Every finding on record at Birchwood Nursing and Rehabilitation

Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum of the director of nursing services, the Medical Director or his/her designee, at least three other members of the facility's staff, at least one of who must be the Administrator, owner, or board member or other individual in a leadership role, and the infection preventionist for 4 of 4 quarterly meetings (09/12/25, 12/11/25, 03/12/26, and 06/11/26) reviewed for Quality Assessment Assurance committee. The facility did not ensure the Administrator attended Quality Assurance and Performance Improvement meetings on 09/12/25, 12/11/25, 03/12/26, and 06/11/26. These failures could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings included:Record review of the facility's Quality Assurance and Performance Improvement Committee sign-in-sheets for 09/12/25, 12/11/25, 03/12/26, and 06/11/26 reflected the Administrator did not sign in for the meetings. During an interview on 08/13/26 at 3:56 PM, the Administrator stated all department heads were required to attend Quality Assurance and Performance Improvement meetings. The Administrator stated, I have missed some of the meetings, however he usually zoomed in from his office. The Administrator stated he was responsible for ensuring he was part of the meetings. The Administrator expressed that not attending the quarterly meetings placed residents at risk because he might miss something that required his attention. Record review of the facility's undated policy titled Quality Assurance Performance Improvement Plan revealed: . 2. Governance and Leadership . the facility administration leads the individual facility Quality Assurance Performance Improvement Program. The administration of the facility is responsible for ensuring the staff is given the equipment that is needed to make an effective program. The steering committee will be made up of the Administrator, DON, Medical Director, facility direct care staff as well as department heads. The Administrator will act as the chairperson.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 5 of 5 residents (Resident #3, #6, #18, #33 and #42) reviewed for infection control.The facility failed to follow their infection control policy for Residents #3, #6, #18, #33 and #42 who were on Enhanced Barrier Precautions (EBP) by not posting signage at the entrance of their rooms. This deficient practice could place residents at-risk for infection due to improper care practices. Findings included:Record review of Resident #3's quarterly MDS, dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood), renal insufficiency (poor kidney function) and obstructive uropathy (when the flow of urine is blocked). Resident #3's BIMS score was 14, indicating intact cognition. Resident #3 had an indwelling catheter. Record review of Resident #3's care plan, dated 04/20/26, reflected Resident is on enhanced barrier precautions with an intervention that included: Posting at the residents room entrance indicating the resident is on enhanced barrier precautions. Record review of Resident #6's quarterly MDS, dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Non-Alzheimer's Dementia (conditions that impair memory, cognition, and daily functioning) and Parkinson's disease (a progressive condition that makes it hard to move). Resident #6's BIMS score was zero, indicating severe cognitive impairment. Resident #6 had a stage 4 pressure ulcer upon admission. Record review of Resident #6's care plan, dated 08/14/26 and revised on 07/10/26, reflected Resident is on enhanced barrier precautions with an intervention that included: Posting at the residents room entrance indicating the resident is on enhanced barrier precautions. Record review of Resident #18's annual MDS, dated [DATE], reflected she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #18's diagnoses included cerebral palsy (a group of conditions that affect movement, balance and posture), epilepsy (brain disorder that causes recuring seizures) and paraplegia (paralysis of lower half of the body). Resident #18's BIMS score was 15, indicating intact cognition. Resident #18 required the use of a feeding tube. Record review of Resident #18's care plan, dated 03/27/24 reflected Resident is on enhanced barrier precautions with an intervention that included: Posting at the residents room entrance indicating the resident is on enhanced barrier precautions. Record review of Resident #33's quarterly MDS, dated [DATE], reflected a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included renal failure (when the kidneys stop working), and neurogenic bladder (loss of bladder function due to nerve damage). Resident #33's BIMS score was 11, indicating moderate cognitive impairment. Resident #33 had an indwelling catheter. Record review of Resident #33's care plan, dated 03/06/26 reflected Resident is on enhanced barrier precautions with an intervention that included: Posting at the residents room entrance indicating the resident is on enhanced barrier precautions. Record review of Resident #42's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included malnutrition (when the body does not get the right amount of nutrients, vitamins and calories). Resident #42's BIMS score was zero, indicating severe cognitive impairment. Resident #42 required the use of a feeding tube. Record review of Resident #42's care plan, dated 05/07/25, reflected Resident is on enhanced barrier precautions with an intervention that included: Posting at the residents room entrance indicating the resident is on enhanced barrier precautions. Observation on 08/11/26 at 9:41 AM revealed no EPB signage or PPE outside Resident #18's room. Observation on 08/11/26 at 10:24 AM revealed no EBP signage or PPE outside of Resident #6 and Resident #42's room. A white bin with clear drawers filled with PPE was located inside the room. Observation on 08/11/26 at 10:27 AM revealed no EBP signage or PPE outside Resident #3 or Resident #33's rooms. Interview on 08/11/26 at 1:11 PM, the Wound Nurse stated EBP signage was posted above resident beds and not on the outside of doors. He stated at some point, corporate made the change and now all signage was inside the room. He stated before he does wound care for Resident #18, he sets up his supplies, takes them into the room, and then puts on the PPE before he does the treatment. The Wound Nurse stated there was no risk to the resident because the signage was posted above the bed. Interview on 08/11/26 at 3:25 PM, the DON stated if EBP signage was posted on the outside of the resident doors, it could be confusing, since a lot of rooms had two residents, and that was why signage was above the bed for the resident who needed it. The DON stated for residents on EBP, staff were to don (put on) PPE inside the room, even if the bin was outside the room. The DON was unaware that the facility EBP policy and resident care plans reflected signage was to be posted on the entrance to the room. She stated there was no risk because the signage was still there and it made more sense to have it posted near the head of the bed. She stated she would revise the infection control policy and care plans. Record review of the facility's Enhanced Barrier Precaution policy, effective 04/01/2024, reflected, in part: .Communication to StaffThe facility will utilize postings outside the room and [Name of Electronic Health Record software] to communicate to staff if a resident requires EBP.

Based on interviews and record reviews the facility failed to ensure residents were not admitted to the facility, unless the State mental health authority had determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission that, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility[KS4.1] for 1 Resident (Resident #3) of 5 residents reviewed for PASARR Screening. The facility failed to ensure Resident #3 had a complete and accurate PASARR screening prior to admission. This failure could place residents at risk of being misplaced or not receiving services available to them. Findings included:Record review of Resident #3's quarterly MDS assessment, dated 06/19/26, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of other symptoms and signs involving the musculoskeletal system and diagnoses of bipolar disorder (mental health condition that causes extreme shifts in mood and activity levels) and age-related cognitive decline. His BIMS score was 14, indicating he was cognitively intact. His Functional Ability assessment indicated he required minimal assistance with his ADLs. Record review of Resident #3's care plan, dated 07/15/26, reflected he had mood problems related to his Bipolar Disorder, and impaired cognitive function. The resident also used anti-psychotic and anti-anxiety medications. No focus for dementia noted. Record review or Resident #3's PASRR Level 1 Screening, completed by the referring entity on 03/22/26, indicated on Section C that he had a primary diagnosis of dementia, no history of mental illness, intellectual disability, or developmental disability. In an interview on 08/11/26 at 9:32 AM Resident #3 stated he received good care overall; he had few complaints about his care. He stated he did speak about his feelings with someone every month. He stated he was satisfied with his treatment at the facility. In an interview on 08/12/26 at 12:00 PM the MDS Coordinator stated she was unaware Resident #3's PASARR submitted by the referring hospital was not accurate. She stated she was also unaware she was responsible for contacting the referring hospital to request a corrected PASARR. She did not know she should have submitted a corrected PASARR, if the hospital refused or failed to correct the PASARR. She stated she did not routinely review resident diagnoses for new or existing diagnoses. She stated she learns of changes needed to the MDS during the morning stand-up meetings. She stated the risk of an inaccurate PASARR could be the resident not receiving specialized services they were entitled to. In an interview on 08/13/26 at 10:30 AM the DON stated the MDS was responsible for care plan changes, MDS updates, and PASARR updates. The DON stated that most of that information is covered during the morning stand-up meetings. New admissions were reviewed by the nursing staff as well as the MDS coordinator to ensure all paperwork is in place and is accurate. She stated the risk of inaccurate forms could be the resident not receiving the care they required. Review of the facility's undated policy PASRR Level 1 Screen Policy and Procedure reflected: It is the policy of {the facility} to obtain a PL1 screening form from the referring entity prior to admission to the {nursing facility}. 3. The facility will review the PL1 screening form for completion and correctness prior to admission and submit the PL1 form per regulations.

Based on observation, interview, and record review the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 2 residents (Resident #42) reviewed for range of motion. The facility failed to ensure Resident #42 had a carrot (soft, cone shaped device) applied to the left hand per physician orders for contracture management. The failure could place residents at risk for decline in range of motion, decreased mobility, pain, and worsening of contractures. Findings included:Record review of Resident #42's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses that included encephalopathy (damage or disease that affects the brain). Resident #42's BIMS score was zero, indicating severe cognitive impairment. Record review of Resident #42's care plan, dated 02/25/26 reflected Alteration in musculoskeletal (the bones, joints and muscles of the body ) status r/t contracture (structural changes to soft and connective tissues that causes them to stiffen, tighten and contract) of upper extremity. Resident has a contracture device. With an intervention that included Contracture device per MD order/facility policy. Record review of Resident #42's physician orders reflected the following: - Contracture Device to Left Hand---Check Q Shift For Placement every shift for Dx: Contracture, start date 02/24/26. - Glove to right hand to assist in prevention of resident scratching skin, check skin daily under glove to ensure no skin damage, start date 03/04/26. Observation and interview on 08/11/26 at 10:24 AM, Resident #42 was lying in bed and was not able to answer any questions. Resident #42's left hand appeared contracted, and no device was in the left hand. A blue carrot was observed in Resident #42's right hand. No glove was noted on Resident #42's right hand. Interview on 08/12/26 at 9:32 AM, CNA H stated Resident #42 was to wear a glove on the right hand and a carrot in the left hand. She stated the carrot was so he would not contract more and she said anybody that provided care, like the CNA and nurse, was responsible to ensure he was wearing the glove and carrot. She stated a CNA called in yesterday and the ADON worked as the aide on the hall on 08/11/26. Interview on 08/13/26 at 10:42 AM, the ADON stated a CNA called in on Tuesday (08/11/26) and she worked on the floor as Resident #42's aide that day. She stated Resident #42 was supposed to have the carrot in the left hand and glove to the right at all times. The ADON said the nurse was responsible for ensuring they were in place and to sign it off on the TAR. She said if Resident #42 did not use the carrot his fingers could end up digging into the palm of his hand and cause skin issues. She said the glove was used on the right hand to prevent him from scratching. Interview on 08/13/26 at 1:04 PM, LVN A stated Resident #42 was to wear a carrot on the left hand and glove on the right. She stated the nurse was responsible for making sure the carrot was in place and the Wound Nurse was responsible for ensuring the glove was in place. LVN A stated she must have missed putting in the carrot on Tuesday (08/11/26) and stated sometimes Resident #42 takes it out of his left hand. She stated on the 10-6 shift last night, the carrot got messed up during peri care and was sent to the laundry. She stated she placed the carrot back in Resident #42's left hand at the start of her shift this morning and he did not have one overnight. LVN A stated the risk of not having the device in place was Resident #42's fingernails could go into his palm. Interview on 08/13/26 at 3:25 PM, The DON stated nurses were responsible to ensure Resident #42's carrot and glove were in place. She said CNAs were to alert the nurse if they noticed he was not wearing them. The DON stated if the carrot was not in place, Resident #42 could get skin damage to the palm of his hand. She stated the glove was more of an intervention to keep Resident #42 from scratching his skin. Record review of the facility's Immobilization Devices, Splints/Slings /Collars/Straps policy, undated, reflected the following: .5. If a handroll is used 1. Position the handroll between the fingers and palm of hand 2. Do not hyperextend the joints when inserting the handroll.13. Cloth devices can be washed when soiled. If continuous uses is required, an extra device will be kept on hand for application.

Based on observation, interview and record review, the facility failed to ensure that licensed nurses had the specific competencies, and skill sets necessary to care for residents' needs, for 1 of 2 residents (Resident #42) reviewed for nursing services. The facility failed to ensure all licensed nurses were provided with training on the use of g-tube (tube inserted into the stomach through the abdomen to deliver food, water and medication) de-cloggers (a thin, flexible plastic device used to clear clogged feeding tubes). This failure could place residents at risk of being cared for by insufficiently trained staff, resulting in serious injury or harm.Findings included:Record review of Resident #42's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses that included encephalopathy (damage or disease that affects the brain) and malnutrition (when the body does not get the right amount of nutrients, vitamins and calories). Resident #42's BIMS score was zero, indicating severe cognitive impairment. Resident #42 required the use of a feeding tube.Record review of Resident #42's care plan, dated 01/09/25 and revised on 04/02/25, reflected The resident requires tube feeding and is on a NPO diet. Resident receives all medications via PEG tube. Resident Receives a protein supplement.Record review of Resident #42's physician orders reflected the following: - NPO diet NPO texture, NPO consistency, all nutrition given enterally via g-tube, start date 01/08/25. - Enteral Feed Order every shift free water flush q 4 hour with 130 mls of water to run concurrently with enteral feeding. - total 780 mL free water, start date 01/13/25.- Enteral Feed Order two times a day Flush tube with 60ml water before and after feedings, start date 03/18/26.- Enteral Feed Order two times a day Isosource HN @65ml/hr X 22 HOURS via PEG tube, start date 03/18/26.Observation and interview on 08/13/26 at 9:45 AM, LVN E stated if a g-tube was clogged she would try to unclog it by working with the tube and try to get water to go down, but if that did not work, she would use a de-clogger. LVN E showed an enteral feeding tube clog remover size 20-22 Fr. 39.5 cm. in the supply room. She stated the green ones (size 20-22 Fr.) were for Resident #42 and three boxes were observed on the shelf. In a follow up interview on 08/13/26 at 10:28 AM, LVN E stated she had been trained and had used de-cloggers for a long time. When asked if she was trained by the facility, she stated she had not been checked off but was shown how as it was demonstrated to her by the MDS Nurse. She stated the MDS Nurse used a de-clogger on Resident #42 about 2 weeks ago. LVN E stated she had used a de-clogger on Resident #42 about one week ago.Interview on 08/13/26 at 10:42 AM, the ADON stated she ordered medical supplies for the facility which included de-cloggers for g-tubes. She stated if a g-tube was clogged they could push on the tube to see if any of the residual would come out, but other than that they would use the de-clogger. The ADON stated they come in a box of ten and she had ordered them about 2-3 times lately. She stated she and the DON were responsible to train the nurses how to use them and they had a check off sheet they used. She said when they trained the nurses they went over how to use the de-clogger by turning the device counterclockwise, then clockwise, then pull it back out and discard. She stated it was not moved up and down. She stated the device could go deep [into the stomach] if it was not used correctly. Interview on 08/13/26 at 11:02 AM by phone with LVN F was unsuccessful and a message was left. Interview on 08/13/26 at 11:02 AM, the MDS nurse stated she did not work on the floor and had never unclogged a g-tube. She stated she had not used a de-clogger on Resident #42 and did not demonstrate how to use one for LVN E. When asked if she had been trained on how to use one, the MDS Nurse pulled out instructions on how to use a de-clogger from her pocket and read them off. She stated she was trained verbally just now by the DON. Interview on 08/13/26 at 12:23 PM, the Medical Director stated when a g-tube was clogged, staff could try a saline flush, and if that did not work they could use a de-clogger. He stated he does recommend staff use them and he has standing orders for their use. He stated he was aware de-cloggers were being used for Resident #42. He said complications could include the feeding tube being ruptured or tissue damage.Interview on 08/13/26 at 11:19 AM, the DON stated when a g-tube was clogged, her expectation was that staff check the tubing to see if it was clamped, try flushing with water, and if they could not visually see what was clogging it they could use a de-clogger. The DON stated nurses were trained on their use by her or the ADON upon hire and annually. She stated she verbally trains them and uses a de-clogger she has in her office to demonstrate holding the tube and using the de-clogger to twist counterclockwise and clockwise. She stated it was never an up and down motion. Interview on 08/13/26 at 1:11 PM, the Wound Nurse stated he had not been trained on the use of a g-tube de-clogger. He stated that was nothing he dealt with and if he noticed a pump was beeping or might be clogged he would check the tubing to make sure it was not kinked, but other than that he would go get the charge nurse. He stated he does not do any g-tube care because that was not in his scope and had not been trained or observed for skills check off. Interview on 08/13/26 at 12:52 PM by phone with LVN G was unsuccessful and a message was left.Interview on 08/13/26 at 1:52 PM, LVN A stated when a g-tube was clogged she would use warm water because sometimes the formula builds up. She said if that did not work, they had de-cloggers and the ADON had showed her how to use one. She stated the de-clogger was guided and not pushed into the feeding tube until resistance was met and up and down motion was used to unclog the tube. She stated she had not used a de-clogger on Resident #42. LVN A stated the risk was possible damage if going all the way into the stomach.Interview on 08/13/26 at 2:27 PM, when asked where on the skills check off list was removing clogs in g-tubes, the DON stated it does not specifically say that on the sheet. In a follow up interview on 08/13/26 at 3:25 PM, the DON stated she spoke with LVN E and told her the ADON had seen her use the de-clogger and checked off her sheet. The DON stated the nurses may not know when they were being checked off, but they were trained. She stated from now on she would watch the nurses perform the skill and check them off. The DON stated the risk was the feeding tube could be damaged or the area where the tube was going in [to the stomach] could be damaged. She stated she had trained the Wound Nurse, but he did not do g-tube care and she stated the MDS Nurse never works on the floor.Record review of Licensed Nurse Proficiency Audit did not indicate any skills or procedures for unclogging g-tubes, however reflected the following, in part: Nursing skills .G. G-tube 2. Treatment procedures A. G-Tube flushes B. Enteral feedings. Further review of the The skill check off sheets were marked as satisfactory for all skills for the following staff:- LVN E on 04/14/26- Wound Nurse on 02/25/26- MDS Nurse on 03/31/26- LVN G on 12/17/25- LVN A on 12/04/25No skills check off list was provided for LVN F.Record review of the facility's Gastrostomy Tube Care policy, undated, and Medication Administration and General Guidelines policy, dated 2025, did not reflect any procedure for unclogging g-tubes. Record review of a document titled Removing Clog - Enteral Tube undated and unreviewed provided by the facility reflected, Purpose To achieve patency (open, not blocked) of gastric and/or jejunostomy enteral tubes.Policy The clog remover will be used to achieve patency of a tube that has become clogged with semi-solid[KS17.1] formula. The clog remover should be disposed of after a single use.Instructions: Blocked Gastric or Jejunostomy Tube1. Determine the length in centimeters of the gastric or jejunostomy tube by viewing the measurements on the tube or using a measuring device to measure the length of the exposed tube.2. Determine the French size of the enteral tube.5. Insert the clog remover until the blockage is reached and rotate the wand clockwise and counterclockwise to break the clog. Do not attempt to force the clog remover through the entire blockage.6. Once the clog is clear, flush tube with 30-60 cc's of water.7. Discard clog remover and document results.

Based on observations, interviews, and record reviews the facility failed to ensure each resident received, and the facility provided food that accommodated resident intolerances, and preferences and appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice for 1 (Resident #16) of 5 residents reviewed for diabetic diet preferences. The facility failed to provide Resident #16 with her food preference of a low-calorie sweetener diabetic meal tray. This deficient practice could place residents at risk for unstable blood sugar, poor food intake, weight loss, and not having their nutritional needs met. Findings included: Record review of Resident #16's quarterly MDS Assessment, dated 07/16/26, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE], with BIMS score of 15 indicating cognition was intact. Resident #16 had active diagnosis that included chronic kidney disease (kidneys lose nearly all their filtering ability), Diabetes Mellitus (high blood sugar), Hyperlipidemia (high cholesterol), and Malnutrition (imbalance between the nutrients the body needs and what it receives). Resident #16 is independent with her eating. Record review of Resident #16's Care plan initiated on 05/24/24 reflected Resident #16 had Diabetes Mellitus (high blood sugar). Goal: Resident #16 will have no complications related to diabetes. Interventions included Dietary consult for nutritional regimen and ongoing monitoring. Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen. Monitor compliance with diet and document any problems. Notify the charge nurse for any non-compliance with diet. Offer substitutes for foods not eaten.Care plan continued with Resident #16 potential risk for malnutrition. Resident is on a regular diet with thin liquids. Resident #16 received a protein supplement. Goal: Resident #16 will maintain stable weight and nutritional parameters. Interventions included monitor and document meal intake, monitor resident's labs, notify the doctor with any negative findings, abnormal labs, or resident non-compliance, offer diet as ordered by the physician, update food preferences as needed. Record review of Resident #16's orders revealed:Insulin Glargine Solution 100 UNIT/MLInject 20 unit subcutaneously one time a day for Diabetes related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONSActive 3/21/2026Regular Diet, Active 07/26/26 Interview on 08/11/2026 at 11:05 AM, Resident #16 stated the only concern she had was that she was a diabetic and she wished the facility would be careful of the meals they served. Resident #16 stated she received insulin in the mornings before breakfast and blood sugar check at night before bed. Resident #16 explained her blood sugar readings were over 200 before bed and that concerned her. Resident #16 stated she had asked her nurses to have more diabetic friendly meals, however they continued to provide her with food items that will spike her blood sugar levels. Interview and observation on 08/11/2026 at 12:15 PM revealed Resident #16 was provided with meal ticket labeled regular a chicken leg quarter, green beans and macaroni and cheese. Resident #16's plate was eaten at 50% with majority of macaroni and cheese left on the tray. According to Resident #16 she just ate a little of each item, in order to have eaten something.Interview and observation on 08/12/2026 at 12:05 PM revealed Resident #16 was provided with meatloaf, cabbage, blackeye peas, cornbread, and pie. Observation of Resident #16's tray revealed she ate less than 50%. According to Resident #16 this tray was not appropriate for her diet because she was diabetic.Interview and observation on 08/13/2026 at 12:00 PM revealed Resident #16 in her room eating lunch which included beef roast, carrots, potatoes, and cake with icing. Resident #16 had eaten about 40% of her meal leaving the carrots, potatoes, and had removed most of the icing off the cake to the side. Resident #16 stated she ate some of the meat and a few carrots, however none of the potatoes because the meal they served was not fit for a person with diabetes. Resident #16 stated she had repeatedly asked for meals fit for a diabetic, and not all the sugar and the starch. Interview and observation on 08/13/2026 at 12:20 PM, Dietary Manager revealed she was not aware Resident #16 had a diagnosis of high blood sugar. Observation of Resident #16's meal ticket revealed Resident #16 was on a regular diet, her tray revealed 40% of meal eaten. The Dietary Manager stated, we do have diets specifically for persons that have diabetes. According to the Dietary Manager, Resident #16 being a person with diabetes should have alternate deserts like fruit, and smaller food portions The Dietary Manager stated it is not ok that she is being served a regular tray because it could result in complications with her health, unstable vitals, and problems that can affect her quality of life. The Dietary Manager stated the nursing staff were responsible for communicating by a communication sheet, indicating when a resident had meal preferences. Interview on 08/13/2026 at 1:07 PM with LVN A revealed Resident #16 was a diabetic and had been since admission in 2024. According to LVN A Resident #16 has had good numbers since March 2026 when her insulin was increased to 20ml. LVN A further explained, if numbers are consistently higher in the evenings, that should be communicated to the physician to see if he wanted to change up her insulin intake. LVN A stated Resident #16 had not reported to her that she would like to have an alternate diet due to her blood sugar readings. LVN A stated the facility did not have a specific diet for people with diabetes. LVN A further stated, all residents were served the same meals, education was provided to residents about their diagnosis, it was up to the resident to decide whether or not to eat what was provided on the meal trays. LVN A stated it was the nurses' responsibility to notify the physician of resident vitals, resident concerns with their blood sugar levels, diet, and food preferences. LVN A stated it was also the nurses' responsibility to communicate with the Dietary Manager when residents wanted to change their meal preferences. LVN A stated Resident #16 was not at risk of complications because her blood sugar readings had not reached over 300. LVN A stated furthermore Resident #16 ate what she wanted and her blood sugar levels were treated with insulin. Interview on 08/13/2026 at 1:22 PM with CNA B revealed she was not aware that Resident #16 was a person with diabetes diagnosis, that she only worked at the facility as needed. CNA B stated Resident #16 had not reported issues with her meal trays. CNA B stated she noticed Resident #16 did not complete her meals at 100% but had not reported that to the nurse because she thought Resident #16 just did not like the food being served. CNA B stated she was responsible for reporting to the nurse if there were any concerns with residents not eating, not doing so could lead to weight loss. Interview on 08/13/2026 at 2:14 PM with LVN C revealed Resident #16 has reported to her meals were not fit for persons with diabetes, however I have not reported this because I thought she was already on a dietary restricted meal plan. LVN C stated she did monitor Resident #16's blood sugar at bedtime and noticed it consistently in the 200 range. LVN C stated she had not thought of reviewing her diet. LVN C stated she as a nurse was responsible for communicating with the Dietary Manager Resident #16's request and concerns for receiving a diabetic friendly meal tray. LVN C stated not doing so could place Resident #16 at risk of not receiving the type of foods she would like to eat, high insulin levels, and unmanaged blood sugar levels. Interview on 08/13/2026 at 3:25 PM with the DON revealed Resident #16 did have a diagnosis of Diabetes Mellitus (high blood sugar). The DON stated Resident #16 had never mentioned any concerns to her about the meals that were served to her. According to the DON, she expected the nursing staff to discuss with residents any dietary concerns and requests and report them to the Dietary Manager and the physician. According to the DON resident diets should be discussed at least quarterly during care plan meetings, risk included her not being served a preferred diet. Interview on 08/13/26 at 4:58 PM with the Dietician revealed Resident #16 had a diagnosis of Diabetes Mellitus (high blood sugar), however was not on her radar for any concerns. The Dietician reported preference sheets were to be completed quarterly by the Dietary Manager; she was not sure when the last sheet was completed however if resident wanted or requested to have a dietary meal fit for persons with diabetes, she can have it because it was available. The Dietician stated Resident #16's levels were not too bad, however if she was a diabetic she should have been on the LCS meals prior to today. Record review of facility policy titled Food Preference List, dated 2012, reflected the followingInformation should be obtained by interview with all new residents with diet orders within 3 days of admission and updated annually or as needed. If the resident can't provide information, try to get the information from family, friends, or by observing meal habits.Tray cards are to be updated at least quarterly and reflect appropriate information from food preferences. Generally, the dislikes are the most relevant on the tray card.Write the resident's name, room number, and date that the food preferences were obtained.Fill in the current order.Check the food the resident likes or dislikes.Write in consistency of meat and vegetables preferred.List any comments.Check preferred serving size.List favorite foods and breakfast preferences . Record review of facility policy titled Diet Orders/Diet Manual, dated 2012, reflected the following: The Dietary Service Department is to be informed of any of the changes listed below in a timely manner:Change of DietChange in Resident's Dietary NeedsPhysicians will be asked to order only those diets appearing on the daily spreadsheet. If another diet is requested, such as (Low Concentrated Sweets (LCS)) the registered dietitian will be contacted.The nursing -dietary communication form is initiated by nursing with the original sent to dietary and the copy put on the chart.Dietary must be informed in writing of any diet order change and when a resident is not in the facility at meal times .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for food and nutrition services.The facility failed to ensure staff who entered the kitchen wore hair restraints. This failure could place residents at risk of food contamination and food borne illness. Findings included:Observation on 08/12/2026 at 11:33 AM revealed, in the kitchen, while the [NAME] was taking temperatures of food, the Activity Director entered the kitchen to grab a utensil from the other side of the steam table and did not have a hair restraint on. The Dietary Manager asked her to leave the kitchen and stated she should have had a hair restraint covering her hair. Interview on 08/13/2026 at 2:37 PM, the Dietary Manager stated her expectation was any time a staff member entered the kitchen they were to have a hair net. She stated she had a sign on the door to remind staff, and hair restraints were available in the drawer right before entering the kitchen. She stated she was responsible for ensuring staff wore hair restraints and started an in-service. She said if not worn, food served to the residents could be contaminated. Interview on 08/13/26 at 3:08 PM, the Activity Director stated she was supposed to wear a hair restraint when going into the kitchen so hair will not get into the food. She stated there was some available in the drawer before entering the kitchen. She said she put one on the day before yesterday but just was not thinking of it when she went into the kitchen during lunch [on 08/12/26]. Interview on 08/13/26 at 3:25 PM, the DON stated her expectation was all staff wear hair restraints while in the kitchen. She stated the risk to residents was the food could be contaminated. Record review of the facility's Dietary Service Policy & Procedure Infection Control , revised 04/09/25, reflected: .Procedure:1.b. Clean hair is required. It is to be covered with an effective hair restraint.

Based on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #108) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #108 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings include: Record review of Resident #108's face sheet, dated 06/17/25, reflected Resident #108 was an [AGE] year-old male, readmitted to the facility on [DATE] with a diagnosis of pneumonitis (inflamed lung tissue) due to inhalation of food and vomit. Record review of Resident #108's quarterly MDS assessment, dated 04/29/25, reflected Resident #108 made himself understood and understood others. Resident #108's BIMS score was 4, which indicated his cognition was severely impaired. Record review of Resident #108's SNF Beneficiary Protection Notification Review reflected Resident #108 was receiving Medicare Part A services starting on 02/02/25, and the last covered day of Part A services was 03/09/25. During an interview on 06/18/25 at 10:14 a.m., the MDS Coordinator stated she was responsible for ensuring Resident #108 was issued a SNF ABN. The MDS Coordinator stated Resident #108 had 40 skilled benefit days remaining. The MDS Coordinator stated the form should have been issued if the resident had skilled benefit days remaining and was being discharged from Part A services and continued in the facility. The MDS Coordinator stated Resident #108 representative was informed of the services that might not be covered but it was not documented on a SNF ABN form. The MDS Coordinator stated it was important for the resident to receive the form so he would know what he was responsible for paying. During an interview on 06/18/25 at 10:44 a.m., the Administrator stated the MDS Coordinator was responsible for ensuring the SNF ABN was completed. The Administrator stated he expected the SNF ABN to be handed out if the resident had days remaining in the facility. The Administrator stated it was important for the resident to receive the form so they would know what they were responsible for. During an interview on 06/17/25 at 3:50 p.m., the Regional Compliance Nurse stated the facility did not have a policy regarding SNF ABN.

Based on interview and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's mental and physical condition for 2 of 17 residents (Resident #12 and Resident #17) reviewed for assessments. 1. The facility failed to complete a Significant Change in Status MDS Assessment after Resident #17 admitted to hospice services on 04/12/2025. 2. The facility failed to complete a Significant Change in Status MDS Assessment after Resident #12 admitted to hospice services on 02/26/2025. These failures could place residents at risk of having inaccurate assessment, not having individual needs met and decreased quality of life. Findings included: 1. Record review of a face sheet dated 06/18/2025 indicated Resident #17 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included encephalopathy (brain disease, damage, or malfunction that causes an altered mental state) and unspecified protein-calorie malnutrition (condition where not enough essential nutrients are consumed which can lead to significant health issues, including muscle and fat loss, impaired immune function, and overall decline in health status). Record review of Resident #17's Order Summary Report dated 06/18/2025 indicated he had an order to admit to hospice services with an order date of 04/12/2025. Record review of Resident #17's care plan with a date initiated of 04/14/2025 indicated he had a terminal prognosis and received hospice services. Record review of Resident #17's electronic health record did not indicate a Significant Change in Status MDS Assessment was completed after Resident #17 admitted to hospice services on 04/12/2025. Record review of the Texas Medicaid Hospice Program Individual Election/Cancellation/Update Form 3071 indicated hospice services were started 04/12/2025. During an interview on 06/17/2025 at 2:43 PM, the MDS Coordinator said she was responsible for completing the MDS assessments for the residents. The MDS Coordinator said she did not complete a Significant Change in Status MDS Assessment for Resident #17 because she did not think he needed one. The MDS Coordinator said Resident #17 admitted to hospice services, but he did not have a change in his condition. The MDS Coordinator said she missed completing the Significant Change in Status MDS Assessment on Resident #17. The MDS Coordinator said it was important for the Significant Change in Status MDS Assessments to be completed as required so the state and staff knew about the change in the resident's condition. 2. Record review of Resident #12's face sheet dated 06/17/25, indicated an [AGE] year-old female who initially admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and post-traumatic stress disorder (mental disorder that develops from experiencing a traumatic event). Record review of Resident #12's quarterly MDS assessment dated [DATE], indicated she was understood and understood others. Resident #12 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #12 received hospice care. Record review of Resident #12's comprehensive care plan revised on 03/05/25, indicated Resident #12 had a terminal prognosis and/or was receiving hospice services. The care plan interventions included if resident was receiving hospice services, to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical needs were met. Record review of Resident #12's order summary report dated 06/17/25, indicated she had an order to admit to [hospice company] for Alzheimer's/dementia with an order start date of 02/26/25. Record review of Resident #12's electronic health record did not indicate a Significant Change in Status MDS Assessment was completed after Resident #12 admitted to hospice services on 02/26/2025. During an interview on 06/17/25 at 2:53 PM, the MDS Coordinator said Resident #12 admitted to hospice services in February 2025. She said she was responsible for completing the Significant Change in status MDS assessments. She said a Significant Change in Status MDS assessment should have been completed for Resident #12 within 14 days of her being admitted to hospice. She said she had not been educated on completing a Significant Change in Status MDS assessments when a resident was admitted to hospice services. She said she thought the resident had to have 2 qualifying changes in status to warrant a Significant Change in Status MDS assessment. She said she was not aware being admitted to hospice services only required one change in status. The MDS Coordinator said there was no risk to Resident #12 not having a Significant Change MDS assessment completed. During an interview on 06/17/2025 at 3:48 PM, the Regional Reimbursement Nurse said a Significant Change in Status MDS Assessment should be completed within 14 days of a resident's admission to hospice services. The Regional Reimbursement Nurse said the MDS Coordinator was responsible for completing the MDS assessments as required. The Regional Reimbursement Nurse said she did not oversee the MDS Coordinator she was just her corporate support, and she was new to the position. The Regional Reimbursement Nurse said she was not aware the MDS Coordinator had not completed the Significant Change in Status MDS Assessments. The Regional Reimbursement Nurse said not completing a Significant Change in Status MDS Assessment did not affect the residents. During an interview on 06/18/2025 at 11:35 AM, the Administrator said the MDS Coordinator was responsible for completing the MDS assessments as required. The Administrator said he expected the MDS Coordinator to complete the MDS assessments on time and when appropriate. The Administrator said it was important for the Significant Change in Status MDS Assessments to be completed as required for continuity of care. During an interview on 06/18/2025 at 11:39 AM, the ADON said the facility did not have a policy on completion of the MDS assessments. The ADON said they followed the RAI manual. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated October 2023, indicated, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident.

2. Record review of Resident #41's face sheet, dated [DATE], reflected Resident #41 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included psychotic disorder with delusions (a disconnect from reality, where an individual holds strongly to false beliefs that are not based in reality). Record review of Resident #41's annual MDS assessment, dated [DATE], reflected Section A1500 (Preadmission Screening and Resident Review (PASRR)) asked Is the resident currently considered by the state level II PASRR process to have serious mental ill ness and/or intellectual disability or a related condition? This section was marked 0 which meant No. Section A.1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions did not have A. Serious mental illness, B. Intellectual Disability, or C. Other related conditions checked. Resident #41 sometimes made himself understood, and sometimes understood others. Resident #61 had a BIMS score of 3, which indicated his cognition was severely impaired. Record review of Resident #41's comprehensive care did not address PASRR in the care plan. Record review of the PASRR Level 1 Screening form, dated [DATE], reflected Resident #41 had no evidence or indicator of mental illness. During a telephone interview on [DATE] at 3:36 p.m., the PASRR Manager stated if a diagnosis was added that was not previously there, she expected a Form 1012 and a new PASRR Level 1 Screening to be submitted to alert the local authority that the resident required a PASRR evaluation because of a qualifying diagnosis. The PASRR Manager stated the MDS Coordinator was responsible for ensuring a Form 1012 and a new PASRR Level 1 Screening was submitted. The PASRR Manager stated it was important for the residents to be screened for PASRR to ensure their evaluated for eligibility and services. During an interview on [DATE] at 3:50 p.m., the Regional Compliance Nurse stated the facility did not have a policy regarding PASRRs. During an interview on [DATE] at 10:14 a.m., the MDS Coordinator stated she was responsible for ensuring that the local authority was notified of the new diagnosis. The MDS Coordinator stated when Resident #41 was admitted he had no psychiatric diagnoses or medications but two weeks later he received a new order for Zyprexa (psychiatric medication) and a diagnosis of Psychotic Disorder due to behaviors. The MDS Coordinator stated either a Form 1012 or another PASRR Level 1 Screening should have been submitted to alert the local authority of change in PASRR status. The MDS Coordinator stated, it was missed. The MDS Coordinator stated it was important for the residents to be screened for PASRR to ensure their evaluated for eligibility and services. During an interview on [DATE] at 10:44 a.m., the Administrator stated he expected the MDS Coordinator to submit either a Form 1012 or a new PASRR Level 1 Screening to notify the local authority of the new mental health diagnosis. The Administrator stated it was important for the residents to be screened for PASRR to ensure their evaluated for eligibility and services. Based on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 2 of 8 residents (Resident #12 and Resident #41) reviewed for PASRR. 1. The facility failed to refer Resident #12 for PASRR review following new mental illness diagnosis of posttraumatic stress disorder (mental disorder that develops from experiencing a traumatic event) on [DATE]. 2. The facility failed to refer Resident #41 for PASRR review following a mental illness diagnosis of psychotic disorder with delusions (a disconnect from reality, where an individual holds strongly to false beliefs that are not based in reality) on [DATE]. These failures could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: 1.Record review of Resident #12's face sheet dated [DATE], indicated an [AGE] year-old female who initially admitted to the facility on [DATE], with diagnosis of post-traumatic stress disorder, onset date of [DATE]. Record review of Resident #12's quarterly MDS assessment dated [DATE], indicated she was understood and understood others. Resident #12 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS indicated Resident #12 had an active diagnoses of post-traumatic stress disorder. Record review of Resident #12's comprehensive care plan revised on [DATE], indicated Resident #12 had a history of trauma that may have a negative impact. The trauma was related to loss of [family member #1] while in the care of her older [family member #2], resident's [family member #2] died in her 20's from measles, [family member #3], [family member #4], and [family member #5] died in a wreck and [family member #6] died in a diabetic coma. The care plan interventions included to monitor for escalating anxiety, depression, sleep disturbance, substance abuse, or suicidal thoughts and report immediately to the physician and to the mental health care provider if applicable. Record review of Resident #12's PASRR Level 1 screening dated [DATE], indicated No if there was evidence Resident #12 had a mental illness, intellectual disability, or developmental disability. Record review of Resident #12's order summary report dated [DATE], indicated she had an order for prazosin 1mg give one capsule daily at bedtime for nightmares/PTSD with an order start date of [DATE]. Record review of Resident #12's medication administration record dated [DATE]-[DATE], indicated she had received one capsule of prazosin 1mg daily at 7:00PM. Record review of Resident #12's EMR on [DATE] did not reveal a Form 1012 (Mental Illness/Dementia Resident Review) completed or a new PASRR Level 1. During an interview on [DATE] at 2:53 PM, the MDS Coordinator said Resident #12 did not require a new PASRR Level 1 or a Form 1012 to be completed because PTSD was not a mental illness. She said she looked at the PASRR Evaluation form and PTSD was not listed as a qualifying diagnosis for mental illness therefore a new PASRR Level 1 or a Form 1012 was not needed. During an interview on [DATE] at 3:35 PM, the PASRR Program Manager said if a resident had a new mental diagnosis a Form 1012 was to be completed to determine if further screening was needed. He said PTSD was a qualifying diagnosis for mental illness. He said the MDS Coordinator was responsible for completing a new PASRR Level 1 or a Form 1012. He said it was important for those to be completed for an individual with a mental illness. He said by not completing a new PASRR Level 1 or a Form 1012, the resident could have been eligible for PASRR services and would not receive them. During an interview on [DATE] at 3:41 PM, the Regional Reimbursement Nurse said the diagnosis of PTSD was not specifically stated on the PASRR level 1 or the Form 1012 so she could see how it could have been missed. She said she would have completed a new PASRR Level 1 or a Form 1012. The Regional Reimbursement Nurse said it was important to complete a new PASRR Level 1 or a Form 1012 to see if the resident qualified for PASRR services. She said if the resident did qualify, she could have missed receiving those services. She said the MDS Coordinator was responsible for completing a new PASRR level one or a Form 1012. The Regional Reimbursement Nurse said other Regional Reimbursement Nurses and herself completed quarterly audits to ensure PASRRs were being completed.

Based on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 5.56%, based on 2 errors out of 36 opportunities, which involved 1 of 6 residents (Resident #43) reviewed for medication administration. The facility failed to ensure MA A administered Resident #43's Artificial Tears and followed the physician's order for Resident #43's Moxifloxacin Ophthalmic Solution (antibiotic eye drops) on 06/17/2025. These failures could place residents at risk of not receiving therapeutic effects of their medications and possible adverse reactions. Findings included: Record review of a face sheet dated 06/18/2025 indicated Resident #43 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (deterioration of memory, language, and other thinking abilities with behaviors) and candidiasis of skin and nail (fungal infection of skin and nail). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #43 understood others and was understood by others. The MDS assessment indicated Resident #43's BIMS score was a 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #43 used an antibiotic. Record review of Resident #43's Order Summary Report indicated the following orders: Artificial Tears Ophthalmic (eye) Solution 1 % Instill 1 drop in both eyes five times a day with a start date of 02/16/2024. Moxifloxacin (antibiotic) Ophthalmic Solution 0.5 % Instill 1 drop in left eye four times a day with a start date of 02/16/2024. Record review of Resident #43's June 2025 MAR indicated her Moxifloxacin 0.5% solution scheduled for 7:00 AM and Artificial Tears scheduled at 9:00 AM were administered by MA A. Record review of Resident #43's care plan last reviewed 04/24/2025 indicated she had an eye infection related to candidiasis of the eye to give therapeutic ointments, drops as ordered by the physician. During an observation of medication administration on 06/17/2025 starting at 7:45 AM, MA A administered one drop of Moxifloxacin 0.5% solution in both of Resident #43's eyes and did not administer Resident #43's Artificial Tears. During an interview on 06/17/2025 at 10:18 AM, MA A said she administered Resident #43's Moxifloxacin in both eyes because she misread the order. MA A said she got caught up in trying to get Resident #43's medications together and forgot to administer Resident #43's Artificial Tears. MA A said when she administered medications she should check the prescription with the computer, ensure it was the right resident, amount, time, and how many times the medication was given. MA A said it was important to administer medications as ordered because something could go wrong with the resident and their health. During an interview on 06/18/2025 at 11:15 AM, the DON said the ADON and herself monitored the nurses and medication aides to ensure they were administering medications correctly by conducting the annual check offs and as needed. The DON said if medications were not administered per the doctors' orders the problem or reason the medication was intended for was not going to be resolved. During an interview on 06/18/2025 at 11:35 AM, the Administrator said he expected for medications to be administered per the doctors' orders and for there not to be any mistakes. The Administrator said the DON and ADON were responsible for monitoring to ensure medication errors did not occur. The Administrator said medication errors could affect any residents in the facility. During an interview on 06/18/2025 at 11:50 AM, the ADON said she helped monitor the nurses and medication aides to ensure they administered medications correctly. The ADON said a couple times a month she randomly observed them when they administered medications to ensure they were doing it correctly. The ADON said MA A had only been a MA for about two weeks. The ADON said she had checked off MA A on medication administration, and she had done fine. The ADON said if the residents did not receive medications per the doctors' orders it could be detrimental to their health because they would not be receiving what they needed. Record review of the facility's undated policy titled, Medication Administration and General Guidelines, indicated, Medications are administered as prescribed, In accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so .Checklist for completing proper steps in the administration of medications .Adheres to the 6 rights of Medication Administration: 1) Right Dose 2) Right Route 3) Right Resident 4) Right Medication 5) Right Time 6) Right Documentation .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #107) reviewed for infection control. The facility did not ensure LVN B performed hand hygiene while providing wound care to Resident #107. This failure could place residents at risk for cross contamination and the spread of infection. Findings included: Record review of Resident #107's face sheet, dated 06/18/25, reflected Resident #107 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included hypothyroidism (thyroid gland doesn't produce enough thyroid hormone). Record review of Resident #107's admission MDS, dated [DATE], reflected Resident #107 made himself understood and understood others. Resident #107's BIMS score was 9, which reflected her cognition was moderately impaired. Resident #107 had an open lesion other than ulcers, rashes, and cuts. Record review of Resident #107's comprehensive care plan, revised on 05/13/25 reflected Resident #107 had potential/actual impairment to skin integrity related to lesion on right cheek. The care plan interventions included avoid scratching, keep hands, and body parts from excessive moisture, encourage good nutrition/hydration and keep skin clean and dry. Record review of Resident #107's order summary report, dated 06/18/25, reflected an active physician's order to clean wound to right side of face with normal saline (wound cleanser), apply xeroform gauze (wound dressing) and cover with gauze island (wound dressing) with border one time a day and as needed for wound healing with a start date 05/16/25. During an interview and observation on 06/17/25 at 8:13 a.m., LVN B applied a set of gloves and gathered wound care supplies from treatment cart. LVN B doff (off) and don (on) new gloves without cleansing her hands or using hand sanitizer. LVN B cleaned the wound with normal saline, doff gloves and don gloves without cleansing her hands or using hand sanitizer. LVN B dried the wound using a gauze, doff and don new gloves without cleansing her hands or using hand sanitizer. LVN B applied a xeroform gauze to the wound and finished up the wound care. LVN B stated she should have performed hand washing between gloves changes. LVN B stated I don't know when asked why she did not perform hand hygiene. LVN B stated it was important to perform hand hygiene between glove changes to prevent the spread of infection. During an interview on 06/18/25 at 10:27 a.m., the DON stated she expected LVN B to sanitize her hands between each glove changes. The DON stated she was the Infection Control Preventionist, and she monitored by annual check off and random spot checks. The DON stated if there was an issue noted staff was in-service on the spot. The DON stated she has never had any issues with LVN B providing wound care. The DON stated it was important to perform hand hygiene to prevent the spread of infection. During an interview on 06/18/25 at 10:44 a.m., the Administrator stated he expected hand hygiene to be performed between gloves changes. The Administrator stated the DON was responsible for monitoring and overseeing. The Administrator stated it was important to ensure infection control practices were followed to prevent the spread of infection. Record review of a licensed nurse proficiency audit dated 01/03/25 reflected LVN B had been checked off on proper handwashing technique. Record review of the facility's undated policy titled, Fundamentals of Infection Control Precautions reflected . A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions . 1. Hand Hygiene . After removing gloves .

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 1 shower rooms on the secured unit and 1 of 2 dining rooms (main building) reviewed for physical environment. 1. The facility did not ensure the dining room did not have cobwebs and crane flies on the ceiling and walls. 2. The facility failed to ensure the shower in the secure unit did not have pink and black grime on the walls. These failures could place the residents at risk for decreased quality of life and infection due to unsanitary conditions. The findings included: 1. Record review of the face sheet, dated 05/08/2024, revealed Resident #50 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, without behavioral disturbances (group of symptoms that affects memory, thinking and interferes with daily life) and diabetes mellitus (high blood sugar). Record review of the Admission MDS assessment, dated 04/19/2024, revealed Resident #50 had clear speech and was understood by the staff. The MDS revealed Resident #50 was able to understand others. The MDS revealed Resident #50 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #50 thought it was very important to do things with groups of people. The MDS revealed Resident #50 was independent with eating. Record review of the comprehensive assessment, initiated on 04/10/2024, revealed Resident #50 had an ADL self-care deficit and was at risk for malnutrition. The interventions included: monitor and document meal intake and provide supervision assistance with eating as needed. During an interview on 05/06/2024 beginning at 11:17 AM, Resident #50 stated her only concern at the facility was the cafeteria. Resident #50 stated there were dead flies on the ceiling and walls in the dining room above the candy bar sign. Resident #50 stated the flies had been there since she admitted to the facility. Resident #50 stated she had reported it to multiple staff members and asked them to clean it, but it had not been cleaned. During an observation on 05/06/2024 at 11:44 AM, two crane flies were hanging from cobwebs above the sign in the main building dining room. There were numerous cobwebs on the walls and ceiling. During an interview on 05/06/2024 beginning at 12:07 PM, Resident #50 was in her room sitting up in a wheelchair with her meal tray in front of her. Resident #50 stated she used to eat in the dining room, but she told staff about the cobwebs and flies, and nothing got fixed so she removed herself. During an observation on 05/07/2024 at 12:21 PM, two crane flies were hanging from cobwebs above the sign in the main building dining room. There were numerous cobwebs on the walls and ceiling. During an interview on 05/08/2024 beginning at 2:08 PM, the Housekeeping Supervisor stated she had only been in the supervising position for 2 days. The Housekeeping Supervisor stated she was unsure who was responsible for ensuring the dining room had no cobwebs or bugs on the ceiling and walls. The Housekeeping Supervisor stated she was unaware there were cobwebs and bugs on the walls and ceiling. The Housekeeping Supervisor stated it should not have been liked that. The Housekeeping Supervisor stated it was important to ensure the walls and ceiling were cleaned especially in the dining room, so the cobwebs or bugs did not fall into the food. The Housekeeping Supervisor stated she would not have wanted it like that in her own home. During an interview on 05/08/2024 beginning at 3:05 PM, the Administrator stated the housekeeping staff were responsible for cleaning from the ceiling to the floor every day. The Administrator stated the housekeeping staff had a deep cleaning schedule that had not been followed well since they were in between supervisors. The Administrator stated the person over housekeeping was coming to the facility to provide training to the current staff. The Administrator stated he was currently responsible for ensuring the dining room was cleaned but after training the Housekeeping Supervisor would have been responsible. The Administrator stated it was important to ensure the dining room walls and ceiling had no cobwebs or bugs for cleanliness and to maintain a homelike environment. 46892 2. During an observation on 05/07/2024 at around 10:38 AM, the shower on the secured unit had pink grime on the grout on one of the side walls towards the bottom and black grime on the grout starting about mid area of the wall down to the corner. During an interview on 05/07/2024 at 10:40 AM, the Housekeeping Supervisor said she was new to the position that it was her second day as supervisor. The Housekeeping Supervisor said the showers should be cleaned every other day unless they had a shower scheduled that day. The Housekeeping Supervisor said the last time the shower in the secure unit should have been cleaned was the day before yesterday (05/05/24). The Housekeeping Supervisor said Housekeeper C should have cleaned it. The Housekeeping Supervisor said she had not had time to clean the showers because they were very short staffed. The Housekeeping Supervisor said it was important to clean the showers to keep bacteria down, prevent infections, and for sanitation and because it was a public shower. During an observation of the shower in the secure unit and an interview on 05/07/2024 at 10:49 AM, Housekeeper C said she was not sure if the pink and black grime on the walls would come off, but she would try to clean it. Housekeeper C said the Housekeeping Supervisor and herself were responsible for cleaning the showers. Housekeeper C said she cleaned it a couple days ago and it should have been cleaned Sunday (05/05/24) by the Housekeeping Supervisor. Housekeeper C said it was important for the showers to be cleaned to keep them sanitary and not have bacteria growing. During an interview on 05/08/24 at 12:00 PM, the Administrator said the showers should be cleaned daily. The Administrator said he provided oversight to housekeeping. The Administrator said he rounded daily around the facility and had not noticed the pink and black grime. The Administrator said it was important for the showers to be clean so infections would not occur. Record review of the facility's undated policy titled, Resident Rights, indicated, .Safe environment- The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide .2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior .

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 residents (Resident #13) reviewed for incontinence. The facility failed to ensure Resident #13 was provided proper incontinent care. These failures could place residents at risk for urinary tract infections and a decreased quality of life. Findings included: Record review of a face sheet dated 05/07/24 indicated Resident #13 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia in other diseases classified elsewhere unspecified severity with other behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life with behaviors). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #13 was sometimes understood by others and sometimes understood others. The MDS assessment indicated Resident #13 had a BIMS score of 00, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #13 was always incontinent of urine and was frequently incontinent of bowel. The MDS assessment indicated Resident #13 required partial/moderate assistance with toileting and substantial/maximal assistance with personal hygiene. Record review of Resident #13's care plan last reviewed 04/25/2024 indicated she required the assistance of 1 staff for toilet use. Resident #13's care plan indicated she had potential for pressure ulcer development to provide incontinent care after each episode and apply moisture barrier. Record review of Resident #13's Order Summary Report dated 05/08/2024 indicated Amoxicillin-Potassium Clavulanate tablet 875-125 mg give 1 tablet by mouth every day and evening shift for bacterial infection related to urinary tract infection for 10 days with a start date of 05/08/2024. During an observation on 05/07/2024 at 10:37 AM, CNA B provided incontinent care with LVN A. CNA B put on gloves and removed Resident #13's brief. Resident #13 had a bowel movement. CNA B wiped Resident #13 and with the same wipe that had stool on it wiped her again from front to back. CNA B grabbed another wipe and did the same thing. CNA B did not use a clean wipe or clean area on the wipe when wiping Resident #13's peri area. After wiping Resident #13's peri area, CNA B removed one glove and grabbed a clean brief and applied it with her ungloved hand. CNA B did not change gloves and perform hand hygiene prior to applying the clean brief. CNA B finished removed her other glove and washed her hands. During an interview on 05/07/2024 at 10:44 AM, CNA B said when she provided incontinent care to Resident #13, she should have changed both of her gloves before applying the clean brief and should have only wiped once instead of multiple times with the same wipe. CNA B said she was in a hurry, and she was nervous so that's why she had not done that. CNA B said she was trying to flip sides on the wipe but was unable to. CNA B said she should have changed gloves and only wiped once because it could cause urinary tract infections. During an interview on 05/08/2024 at 10:43 AM, LVN A said the charge nurses were responsible for ensuring the CNAs provided proper incontinent care. LVN A said she noticed CNA B did not change gloves at the appropriate times and wiped more than once with the same wipe. LVN A said she tried to prompt CNA B, but she did not hear her. LVN A said the same wipe should not be used multiple times to prevent the stool from causing a urinary tract infection. LVN A said gloves should be changed to get rid of the dirty. During an interview on 05/08/2024 at 12:06 PM, the Administrator said the expectations were for the CNAs to follow the policy for incontinent care and do it as they were supposed to do it. The Administrator said the DON was responsible for providing oversight for the CNAs. The Administrator said it was important for proper incontinent care to be performed to help eliminate urinary tract infections. During an interview on 05/08/2024 at 12:29 PM, the DON said when providing incontinent care, the CNAs should wipe once and throw the wipe away and get a new one. The DON said gloves should be changed between the dirty and clean, and the CNAs should wash their hands in between glove changes. The DON said the ADON, herself, or designees visually watched the CNAs provide incontinent care at least once a quarter if not more to ensure they performed incontinent care properly. The DON said it was important to provide proper incontinent care because the residents could get an infection. Record review of the facility's policy titled, Perineal Care, effective date 05/11/2022, indicated, . This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition . 11) Don gloves and all other PPE per standard precautions i. Choose your PPE by considering the type of exposure, the durability and appropriateness for the task 12) Soak towels in a washbasin filled with warm water (make sure it is at a comfortable temperature) and facility approved cleansing agent or remove an adequate number of pre-moistened cleansing wipes . Female resident: Working from front to back, wipe . Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke .21) Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area . 24) Doff gloves and PPE 25) Perform hand hygiene . Important Points . Do not wipe more than once with the same surface . Always perform hand hygiene before and after glove use .

Based on observation, interview, and record review the facility failed ensure each resident receives and the facility provides food that accommodates residents' food preferences for 1 (Resident #29) of 14 residents reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to honor Resident #29's preference for double protein portions. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of a face sheet, dated 05/08/2024, indicated Resident #29 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect your mood), and abnormal weight loss. Record review of an order summary report dated 05/08/2024 indicated Resident #29 had an order for regular diet, regular texture, double protein portions with meals with an order start date of 01/10/2024. Record review of Resident #29's quarterly MDS assessment, dated 03/11/2024, indicated Resident #29 understood others and made himself understood. Resident #29 had a BIMS score of 15, which indicated his cognition was intact. Resident #29 was independent for eating. Record review of the care plan last revised on 09/27/2023 indicated Resident #29 was at risk for malnutrition and was on a regular diet with thin liquids, and double protein portions with meals. The care plan interventions included, encourage 3 or less snacks/day as tolerated, serve diet as ordered and food serve supervision to monitor and discuss food preferences. Record review of the lunch meal ticket dated 05/06/2024 for Resident #29 indicated Resident #29 was on a regular diet and should have received double protein portions. During an observation on 05/06/2024 at 12:00 p.m., Resident #29 was sitting at the table in the dining room. The DON served Resident #29's meal tray with only one slice of meat loaf. The surveyor showed the DON that Resident #29 did not receive double protein portion. During an interview on 05/06/2024 at 1:00 p.m., Resident #29 stated he did not eat a lot of vegetables and he preferred double meat. During an interview on 05/08/2024 at 12:48 p.m., [NAME] D stated she was responsible for ensuring residents received the correct portions. [NAME] D stated she thought the piece that was given to Resident #29 was big enough for double portions, but she should have given two slices to equal double portions. [NAME] D stated he received double protein (meat) portions because he did not like vegetables. [NAME] D stated it was important to ensure Resident #29 received the correct portion to prevent weight loss. During an interview on 05/08/2024 at 12:59 p.m., the Dietary Manager stated [NAME] D was responsible for ensuring Resident #29 received the correct portions. The Dietary Manager stated Resident #29 only eats the protein (meat) and did not like vegetables or starches. The Dietary Manager stated two slices of meat loaf should have been served. The Dietary Manager stated she was responsible for overseeing by monitoring lunch meals. The Dietary Manager stated she had not noticed this issue in the past, but staff had been verbally in-serviced. The Dietary Manager stated it was important for their food preferences and meal tickets to be followed to prevent weight loss. During an interview on 05/08/2024 at 2:45 p.m., The DON stated she was responsible for checking the trays to ensure the proper diet has been served. The DON stated Resident #29 should have had double protein portions on his tray. The DON stated she thought the piece was bigger than a regular portion until surveyor pointed it out that it was the same portion as the resident next to him. The DON stated it was important for Resident #29's food preference to be followed to make sure he was getting the nutrition and calories that he needs since he preferred meat instead of vegetables and starches. The DON stated this failure put Resident #29 at risk for weight loss. During an interview on 05/08/2024 at 2:56 p.m., the Administrator stated he expected for the meal tickets and for food preferences to be followed. The Administrator stated the nurse should be checking the meal tickets for accuracy. The Administrator stated the Dietary Manager was responsible for ensuring the residents were served according to their meal tickets and preferences. The Administrator stated it was important for their food preferences and meal tickets to be followed because it was their right, and wellbeing. Record review of the facility's undated policy, titled Resident Meal Service and HS Snack, indicated, 9. If a resident request larger amount of food for all meals, a large portions diet can be ordered and served. For occasional request a double portion of any meal component may be offered

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #13) reviewed for infection control. The facility failed to ensure CNA B changed gloves and performed hand hygiene while providing incontinent care to Resident #13. The facility failed to ensure CNA B used a clean wipe when cleaning Resident #13's peri area. These failures could place residents and staff at risk for cross contamination and the spread of infection. Findings included: Record review of a face sheet dated 05/07/24 indicated Resident #13 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia in other diseases classified elsewhere unspecified severity with other behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life with behaviors). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #13 was sometimes understood by others and sometimes understood others. The MDS assessment indicated Resident #13 had a BIMS score of 00, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #13 was always incontinent of urine and was frequently incontinent of bowel. The MDS assessment indicated Resident #13 required partial/moderate assistance with toileting and substantial/maximal assistance with personal hygiene. Record review of Resident #13's care plan last reviewed 04/25/2024 indicated she required the assistance of 1 staff for toilet use. Resident #13's care plan indicated she had potential for pressure ulcer development to provide incontinent care after each episode and apply moisture barrier. Record review of Resident #13's Order Summary Report dated 05/08/2024 indicated Amoxicillin-Potassium Clavulanate tablet 875-125 mg give 1 tablet by mouth every day and evening shift for bacterial infection related to urinary tract infection for 10 days with a start date of 05/08/2024. During an observation on 05/07/2024 at 10:37 AM, CNA B provided incontinent care with LVN A. CNA B put on gloves and removed Resident #13's brief. Resident #13 had a bowel movement. CNA B wiped Resident #13 and with the same wipe that had stool on it wiped her again from front to back. CNA B grabbed another wipe and did the same thing. CNA B did not use a clean wipe or clean area on the wipe when wiping Resident #13's peri area. After wiping Resident #13's peri area, CNA B removed one glove and grabbed a clean brief and applied it with her ungloved hand. CNA B did not change gloves and perform hand hygiene prior to getting the clean brief and applying it. CNA B finished removed her other glove and washed her hands. During an interview on 05/07/2024 at 10:44 AM, CNA B said when she provided incontinent care to Resident #13, she should have changed both of her gloves before applying the clean brief and should have only wiped once instead of multiple times with the same wipe. CNA B said she was in a hurry, and she was nervous so that's why she had not done that. CNA B said she was trying to flip sides on the wipe but was unable to. CNA B said she should have changed gloves and only wiped once because it could cause urinary tract infections. CNA B said changing gloves and performing hand hygiene was important to prevent the spread of infection. During an interview on 05/08/2024 at 10:43 AM, LVN A said the charge nurses were responsible for ensuring the CNAs provided proper incontinent care. LVN A said she noticed CNA B did not change gloves at the appropriate times and wiped more than once with the same wipe. LVN A said she tried to prompt CNA B, but she did not hear her. LVN A said the same wipe should not be used multiple times to prevent the stool from causing a urinary tract infection. LVN A said gloves should be changed to get rid of the dirty. During an interview on 05/08/2024 at 12:06 PM, the Administrator said the expectations were for the CNAs to follow the policy for incontinent care/hand hygiene and do it as they were supposed to do it. The Administrator said the DON was responsible for providing oversight for the CNAs. The Administrator said it was important for the CNAs to change gloves, perform hand hygiene, and wipe properly during incontinent care to eliminate urinary tract infections and infection. During an interview on 05/08/2024 at 12:29 PM, the DON said when providing incontinent care, the CNAs should wipe once and throw the wipe away. The DON said the CNAs should get a new one, and gloves should be changed between the dirty and clean. The DON said the CNAs should wash their hands in between glove changes. The DON said the ADON, herself, or designees visually watched the CNAs provide incontinent care at least once a quarter if not more to ensure they performed incontinent care properly. The DON said it was important to change gloves, use clean wipes, and perform hand hygiene when providing incontinent care because the residents could get an infection. Record review of the facility's undated policy titled, Hand Hygiene, indicated, You may use alcohol-based hand cleaner or soap/water for the following .after removing gloves . Record review of the facility's policy titled, Perineal Care, effective date 05/11/2022, indicated, . This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition . 11) Don gloves and all other PPE per standard precautions i. Choose your PPE by considering the type of exposure, the durability and appropriateness for the task 12) Soak towels in a washbasin filled with warm water (make sure it is at a comfortable temperature) and facility approved cleansing agent or remove an adequate number of pre-moistened cleansing wipes . Female resident: Working from front to back, wipe . Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke .21) Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area . 24) Doff gloves and PPE 25) Perform hand hygiene . Important Points . Do not wipe more than once with the same surface . Always perform hand hygiene before and after glove use .

Based on observation, interview, and record review the facility failed to follow their own established smoking policy for 1 of 2 smoking area (main building) reviewed for smoking policies. The facility did not ensure cigarette butts were disposed of in a metal container. This failure could place residents at risk of an unsafe smoking environment. The findings included: Record review of the smoking policy, revised 11/01/2017, revealed Ashtrays will be a metal container with a self-closing cover device into which ash trays may be emptied . During an observation and interview on 05/06/2024 between 11:30 AM and 11:39 AM the main building smoking area had a plastic-lined trashcan. There were approximately 30 red-tipped cigarette butts at the bottom of the plastic-lined trashcan. The Housekeeping Supervisor was in the smoking area. The Housekeeping Supervisor stated she was responsible for emptying the ashtrays and the red metal trashcan. The Housekeeping Supervisor stated she emptied the cigarette butts in the metal ashtrays into the red metal trashcan and then emptied the red metal trash can into the plastic-lined trashcan. During an interview on 05/08/2024 beginning at 2:08 PM, the Housekeeping Supervisor stated she had only been in the supervising position for 2 days. The Housekeeping Supervisor stated she was unsure who was responsible for emptying the cigarette butts in the red metal trashcan. The Housekeeping Supervisor stated no one asked her to do it, she just started emptying the red metal trashcans. The Housekeeping Supervisor stated she was unsure if the cigarette butts should have been emptied into the plastic-lined trashcan but that was where she had been emptying the cigarette butts. During an interview on 05/08/2024 beginning at 3:05 PM, the Administrator stated the cigarette butts in the red metal trashcan should not have been emptied into the plastic-lined trashcan. The Administrator stated the Maintenance Supervisor was responsible for emptying the cigarette butts and was unsure why the Housekeeping Supervisor was doing it. The Administrator stated it was important to ensure the cigarette butts were disposed of properly to prevent a fire.

46892 Based on observations, interviews, and record review the facility failed to ensure residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 2 of 2 residents (Resident # 9 and Resident #15) reviewed for dialysis. The facility failed to have a physician's order for dialysis for Resident #9. The facility failed to ensure nursing staff monitored Resident #15's central venous catheter used for dialysis (a long, flexible tube inserted into a vein in your neck, chest, arm, or groin and leads to a large vein that empties into your heart and is used as a dialysis access) for signs and symptoms of infection and for the dressing to be intact. The facility failed to ensure the dialysis clinic was notified that Resident #15's central venous catheter dressing was loose and needed to be changed. These failures could place residents at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: 1. Record review of Resident #9's, undated, face sheet indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #9 had a history of schizophrenia (affects a person's ability to think, feel and behave clearly), type 2 diabetes (the way the body processes blood sugar) and stage 3 kidney disease (mild to moderate kidney damage and kidneys are less able to filter waste and fluid out of your blood). Record review of Resident #9's quarterly MDS dated [DATE] indicated he had a BIMS score of 13 which indicated the resident was cognitively intact. Resident #9 had not rejected care and had a diagnosis of renal insufficiency. The MDS had not indicated dialysis was received. Record review of Resident #9's order summary report dated 04/11/2023 indicated to assess dialysis device location in left arm for positive bruit and thrill every shift for hemodialysis. The physician orders did not indicate Resident #9 received dialysis, the name of the dialysis facility or the days Resident #9 was scheduled to attend dialysis. Record review of Resident #9's care plan dated 04/20/2022 indicated Resident #9 had a history of needing dialysis and had a dialysis port. Resident #9 refused dialysis frequently despite education. The goal indicated Resident #9 would have no complications related to the dialysis port. The interventions included to monitor for dry skin and apply lotion as needed, not to draw blood or take blood pressure in arm with graft, monitor labs and report to the doctor as needed and monitor/document/report to MD PRN any signs or symptoms of infection to access site. Record review of Resident #9's progress notes dated 3/14/23 to 4/6/23 indicated the resident refused dialysis and the primary physician and family member were notified. During an interview on 04/12/23 at 09:59 AM, the Facility Administrator at the Kidney Care facility indicated Resident #9 had refused dialysis on several occasions and he attempted to contact the Administrator at the SNF on optioning a withdraw. The facility Administrator stated Resident #9's dialysis seat days were Tuesday, Thursday, and Saturday at 12:15 PM. The facility Administrator stated if residents refused dialysis more than 30 days, they would look at other options and he had tried to set up a meeting with the nephrologist and Resident #9 on 03/09/2023 and Resident #9 refused to attend. During an interview on 04/12/23 at 8:56 AM, LVN A stated any of the nursing staff could write an order for dialysis and the days the resident attendant should be specified on the order. LVN A stated the importance of having an order for dialysis was to make sure staff were aware of the resident's needs and because an order was needed for resident to be able to attend dialysis. LVN A stated it was the responsibility of the DON to check over all the resident orders. During an interview on 04/12/23 at 12:36 PM, the ADON stated Resident #9 should of had an order for dialysis and the charge nurse that took the order was responsible for completing the order. The ADON stated orders are checked at random by herself and the DON, but not all of them are checked. The ADON stated the dialysis order was important because that was where staff communicated the dialysis days for the resident and if they did not have an order they might have overlooked or missed an appointment. During an interview on 04/12/23 at 9:22 AM, the DON stated the process for dialysis residents was to make sure staff found out the days and times of the residents scheduled appointment and the name of the dialysis facility when they are admitted . The DON stated she would care plan dialysis and make sure there was an order. The DON stated the ADON and herself were responsible for making sure nursing staff knew who to call (dialysis facility and staff member) and the information should have been on the physician order, and it would have been put on a communication form given to the nursing staff when resident first started. The DON stated if there was no order in Resident #9's chart, then he could have missed one of his scheduled dialysis days. During an interview on 04/12/23 at 12:11 PM, the Administrator stated the DON was responsible for making sure Resident #9 had an order for dialysis. The Administrator stated nursing staff was responsible for asking Resident #9 to go to dialysis on all of his scheduled days until he was discharged from the dialysis clinic. The Administrator stated he expected Resident #9 to have an order for dialysis, so that nursing staff did not miss anything going on. The Administrator stated, collaboration important with the clinic to provide the best care. The Administrator stated he expected Resident #9's dialysis schedule and dialysis facility information to have been documented somewhere, but he did not know exactly where the nurses should document it. 2. Record review of Resident #15's face sheet dated 04/12/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease with (acute) exacerbation (chronic inflammatory lung disease that causes obstructed airflow from the lungs), essential (primary) hypertension (high blood pressure), and end stage renal disease (kidney failure). Record review of the quarterly MDS assessment dated [DATE], revealed Resident #15 was understood by others and was able to make self-understood. Resident #15 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment revealed Resident #15 received dialysis while a resident at the facility. Record review of Resident #15's care plan with a target date of 05/18/2023 revealed a focus of the resident needed dialysis related to renal failure with the goal of the resident would have immediate intervention with any signs and symptoms of complications from dialysis occurred through the review date, and an intervention to check and change dressing daily at the access site and document. Record review of the order summary dated 04/10/2023 revealed Resident #15 had an order to not touch the dialysis port in the left subclavian (central venous catheter inside the vein on the left chest area) and if a problem was observed to call the dialysis center, the dialysis center was to change the dressing when needed. Resident #15 did not have an order to monitor the central venous catheter for signs and symptoms of infection and for the dressing to be intact. Record review of the Treatment Administration record for the month of April 2023 did not reveal Resident #15's central venous catheter was being monitored by the nurses for signs and symptoms of infection and for the dressing to be intact. During an observation and interview on 04/10/2023 at 10:13 AM, Resident #15 stated her dialysis treatments were on hold due to her possibly regaining her kidney function. Resident #15 stated her last dialysis treatment was on 03/30/2023, but she still had her central venous catheter in place. Resident #15's central venous catheter was located on her left chest area. The dressing to the central venous catheter was undated, not completely adhered and the white dressing had a brownish tinge to it. When Resident #15 moved the loose dressing lifted and exposed the exit site (area where the catheter comes out from underneath the skin). Resident #15 stated the facility staff did not check the central venous catheter daily. Resident #15 stated the dressing sometimes was loose due to getting wet when she showered. Resident #15 stated the dialysis clinic was responsible for changing the dressings. During an observation on 04/11/2023 at 8:27 AM, Resident #15 central venous catheter dressing was undated, loose and had the same brownish tinge to it. During an interview on 04/12/2023 at 9:41 AM, RN B, the nurse at the dialysis clinic, stated the dressing to the central venous catheter was changed by the nurses at the dialysis clinic. RN B stated the dressing should not have gotten wet and it should be intact. RN B stated if Resident #15's central venous catheter dressing got wet or was loose the nurses at the facility should have contacted the dialysis clinic. RN B stated to her knowledge the nursing home facility staff had not contacted the dialysis clinic to notify them Resident #15's dressing was loose and not intact. RN B stated the central venous catheter dressing not being intact could result in Resident #15 getting an infection. During an interview on 04/12/2023 at 8:55 AM, LVN A stated she was not monitoring Resident #15's central venous catheter. LVN A stated Resident #15 told her over the weekend her central venous catheter was bothering her so she looked at it since her dressing was loose. LVN A stated she assessed the area that day and there were no signs and symptoms of infection. LVN A stated she did not document this anywhere, and she did not notify the dialysis clinic that Resident #15's central venous catheter dressing was not intact. LVN A stated she should have documented this. LVN A stated she did not know why she had not notified the dialysis clinic, but she should have notified the dialysis clinic. LVN A stated the nurses should be monitoring the central venous catheter for the dressing to be intact and for signs and symptoms of infection and documenting it on the treatment administration record. LVN A stated she had not received any training regarding how to care for residents on dialysis, what to monitor, and when to contact the dialysis clinic. LVN A stated the ADON, DON, and the charge nurse were responsible for documenting the monitoring of Resident #15's central venous catheter on the treatment administration record. LVN A stated the central venous catheter dressing not being intact placed Resident #15 at risk for an infection. During an observation and interview on 04/12/2023 at 9:14 AM, Resident #15 stated the facility transported her to the dialysis clinic yesterday (04/11/2023) afternoon and the dressing to the central venous catheter was changed by the dialysis staff. Resident #15's dressing to the central venous catheter was white and adhered on all sides to her skin. During an interview on 04/12/2023 at 9:21 AM, the DON stated Resident #15 should have had an order to monitor her central venous catheter for signs and symptoms of infection, for the dressing to be intact, and for no redness or swelling to the site. The DON did not know why Resident #15 did not have the order. The DON stated the nurses were responsible for documenting the monitoring of the central venous catheter in the treatment administration record. The DON stated if there were any issues with the central venous catheter or the dressing was not intact the nurses should have notified the dialysis clinic for instructions. The DON stated she had instructed the nurses to call the dialysis center for any issues with the dialysis access. The DON stated not monitoring the central venous catheter and the dressing not being intact placed the resident at risk for getting an infection. During an interview on 04/12/2023 at 12:11 PM, the Administrator stated the DON was responsible for ensuring Resident #15 had an order to monitor her central venous catheter. The Administrator stated he expected the nurses to monitor all the dialysis access sites to provide the best care possible to the residents. The Administrator stated he expected the nurses to contact the dialysis clinic if there were any issues with the residents' access sites. The Administrator stated not checking Resident #15's catheter access site placed her at risk for infection and dislodgment. During an interview on 04/12/2023 at 12:36 PM, the ADON stated the nurses were responsible for monitoring Resident #15's central venous catheter for no signs and symptoms of infection and for the dressing to be intact. The ADON stated the nurses should have been documenting this on the treatment administration record. The ADON stated the DON and herself were responsible for making sure the nurses monitored and documented on Resident #15's central venous catheter. The ADON stated she was working the floor a lot and had not been able to review Resident #15's treatment administration record. The ADON stated the nurses should have contacted the dialysis clinic to notify them Resident #15's central venous catheter dressing was not intact. The ADON stated not monitoring Resident #15's central venous catheter placed her at risk for getting a severe infection because the central venous catheter went directly into her bloodstream. Record review of the facility's policy titled, Dialysis, last revised November 2013, indicated, .review and confirm the physician's order for dialysis . The policy did not address care of the central venous catheter.

Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 12 residents (Resident #35) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #35's diagnoses on the MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #35's face sheet dated 04/11/23 indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #35 had a diagnoses which included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), type 2 diabetes (the way the body processes blood sugar) and hypertension (force of the blood against the artery walls is too high). The face sheet indicated Resident #35 had an onset of pneumonia (infection that inflames air sacs in lungs and fill with fluid) on 12/08/22, infection of the skin on 01/10/22 and sepsis (life threatening complication of an infection) on 12/08/2022. Record review of Resident #35's quarterly MDS dated [DATE] indicated Resident #35 had a BIMS score of 3 which indicated severe cognitive impact. The MDS indicated a diagnosis of pneumonia, septicemia, and wound infection in the last 7 days. Record review of Resident #35's order summary report dated 04/11/23 did not indicate the use of antibiotics or wound care for Resident #35. Record review of Resident #35's care plan dated 04/27/21 indicated Resident #35 had the potential for pressure ulcer development. Interventions included to administer treatment as ordered, do not massage over bony prominences, and use mild cleansers for peri-care and washing. The care plan did not indicate Resident #35 had pneumonia, an infected wound or septicemia. Record review of Resident #35's weekly skin assessment dated [DATE] did not indicate any wounds. Record review of Resident #35's weekly skin assessment dated [DATE] did not indicate any wounds. Record review of the nursing progress notes from 03/10/23 to 03/21/23 did not indicate Resident #35 had pneumonia, septicemia, or a wound infection. During an interview on 04/12/23 at 9:10 a.m., the MDS coordinator stated it was her responsibility to make sure the diagnosis was correct on Resident #35's MDS. The MDS coordinator stated it had been correct on the MDS for the previous 3 years and she just missed it this time because she was in a rush. The MDS coordinator stated regional did not double check the MDS assessments unless they were flagged or had an increase in payment. Regional nurses only checked the MDS assessments quarterly and at random. The MDS coordinator stated the importance of making sure the MDS assessments were correct was to ensure adequate payment, make sure it was a true picture of the resident and their needs, and quality measures. The MDS coordinator stated if the MDS assessment was not correct it could result in quality measure impairment, or the payment could be wrong. During an interview on 04/12/23 at 9:22 AM, the DON stated the MDS coordinator was responsible for making sure the MDS assessments were correct. The DON stated she reviewed the MDS assessments at random and signed them when they are completed. The DON stated if the MDS was not correct, it could impact payment and Resident #35 could have looked like he was not getting the correct medications or treatment. During an interview on 04/12/23 at 12:11 PM, the Administrator stated the MDS coordinator was responsible for completing the MDS assessments and he expected them to be done correctly. The Administrator stated if the MDS assessments were not correct, it could impact resident care, but it should not take them long to figure out it was marked incorrectly. Record review of the facility's policy titled, Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy dated 2/2021 indicated . the RN signs the assessment certifying that each section was completed by the appropriate person and the individual is qualified to determine the accuracy of the portion of the resident's assessment completed.

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (nurse's cart) reviewed for storage of medications. The facility failed to ensure the nurses' cart was locked when unattended. This deficient practice could place residents at risk of medication misuse and diversion. Findings include: During an observation on 04/11/2023 at 10:31 a.m., LVN A left the nurses' cart unlocked and out of sight, facing Resident #101's room, while checking Resident #101's blood sugar. During an observation on 04/11/2023 at 10:47 a.m., LVN A left the nurses' cart unlocked and out of sight, facing Resident #1's room, while administering Resident #1's medication. During an interview on 04/11/2023 at 10:51 a.m., LVN A stated she should have locked the nurses' cart prior to going in Residents #101 and #1's room. LVN A stated, I get so nervous when state watches me. LVN A stated this failure allowed residents, staff, and visitors access to other residents' medication. During an interview on 04/12/2023 at 9:08 a.m., the DON stated she expected medication carts to be locked when unattended. The DON stated the nurses were responsible for monitoring their own cart. The DON stated she was responsible for training staff on securing/storage of medications. The DON stated she did random checks throughout the day to ensure medication carts were locked when unattended. The DON stated she did not notice any issues during her random checks. The DON stated this failure allowed anyone access to residents' medication. During an interview on 04/12/2023 at 12:36 p.m., the Administrator stated he expected medication carts to be locked when unattended. The Administrator stated this failure could put residents at risk for indigestion of medications. Record review of the facility's Medication Administration Procedures policy, last revised in 2003, revealed . 5. During the medication administration process, the unlocked side of the cart must always be in full view of the nurse 8. After the medication administration process was completed, the medication cart must be completely locked, or otherwise secured

Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior throughout the facility. The facility did not maintain the sewer system for one month after being aware it was not functioning properly. This failure resulted in water with raw sewage flooding resident use areas including the kitchen. An Immediate Jeopardy (IJ) was identified on 9/21/16. The IJ was removed on 9/23/16; however the facility remained out of compliance at a widespread potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective actions, perform a professional cleaning of the kitchen and dining room, and correct plumbing issues causing the sewer back-up. This failure could place the census of 49 at risk of possible infection from living and eating food prepared in an area with raw sewage. Findings included: During observations on 9/21/16 the following was noted: *at 3:14 p.m. a professional plumber's snake (a metal cable that can be advanced into the plumbing system/pipe to clear a clogged area) was seen to the right of the front entrance of the building; *at 3:25 p.m. there were wet blankets and towels against the wall connected to the dining room for approximately 5-6 feet. *at 3:34 p.m. the kitchen had gray water under: the dishwasher, steam table, a tea cart near the mixing bowl, a black rubber mat at end of steam table. A shop vac was next to the dishwasher, whitish/gray water with food particles was in the sink next to the dishwasher, and a mop bucket with dirty water was near the tea maker. The complete dinner meal was prepared and left in the steam table for the evening meal service and there was food debris on the steam table lids that covered the food. During an observation and interview on 9/21/16 at 4:05 p.m., the evening cook was mopping the floor in the kitchen. The mop water was dark gray to black coming from the floor as she mopped. The Dietary Manager (DM) said the water on the kitchen floor was sewage water that had backed up from the dishwasher drain. The DM said the evening meal was prepared and placed on the steam table at 3:30 p.m., to be served at 5:00 p.m. The DM said she cooked the morning and lunch meals and served residents while sewer water was standing on the floor of the kitchen and dining room. The DM said she knew she should have made other arrangements for meal service for the residents and she would not eat from the kitchen. She said she should have used pre-packaged emergency food for the meals. During an interview on 9/21/16 at 4:45 p.m., after surveyor intervention, the DM said she was not going to serve the meal she had already prepared and was going to obtain sandwiches for the evening meal. During an observation on 9/21/16 the following was noted: *at 3:35 p.m. the clean out drain (outside) Hall #3 had a strong feces odor, copious amounts of used toilet paper, and black material resembling human fecal material lying on the side walk. The sidewalk had pooled, strong feces smelling black water with toilet paper throughout for 6-8 feet. *at 3:40 p.m., the sidewalk and clean out drain for halls 5 and 6 had a strong feces odor, black material resembling human feces with toilet paper laying throughout. *at 3:43 p.m. the medication room had three soaked pads, five blankets and multiple towels around the baseboards of the cabinets and brown water was on the floor. *at 3:48 p.m. the DON's office had wet carpet pulled back with missing tiles; *at 3:49 p.m. a shop vac was outside of the maintenance supervisor's office; During an interview on 9/21/16 at 3:40 p.m., the maintenance supervisor said the sewage back-up occurred that morning at 7:30 a.m. He said he arrived at the facility at 8:00 a.m. and there was sewer water in the kitchen, dining room and Hall #3 and 4. He said the sewer back-up came from the kitchen's dishwasher drain and came out into the dining room, and into Halls #3 and #4. He said the water was sewer water and had a sewage smell. The maintenance supervisor said today's back-up problem started on 9/20/16. He said a plumber was at the facility the day before and unclogged the blockage in the sewer line, but the system became reclogged. He said water was flowing through the plumbing system without problems now. He said the facility had another back up from the sewer line in Room 101 approximately 1 week ago due to a pipe breaking. He said there were on-going problems with the plumbing system since July. He said the plumber's snake had punched a hole through a blockage in the pipes and when the snake was brought back out it had mud on it. He said this indicated another possible break in the plumbing system. The maintenance supervisor said the floor was cleaned with a disinfectant, but was unable to produce a MSDS on the chemical. During an observation on 9/21/16 the following was noted: *at 3:51 p.m. the laundry room had clothes piled up, spilling out of the laundry barrels and smelled of urine. There were two full trash bags of wet clothes on the floor on the clean side of the laundry. During an interview on 9/21/16 at 3:59 p.m., Housekeeping/Laundry G said she took 14 loads of laundry and washed them at a laundry mat in another town because the sister facilities were not available until 5 p.m. She said she had brought back two bags of wet washed clothes, but needed to be dried. She said she laid them on the floor on the clean side of the laundry. *at 4:05 p.m. the shower room on Hall #5 smelled of feces and urine; *at 4:30 p.m. the beauty shop closet had black mold-like substance on the walls. During an interview on 9/21/16 at 3:15 p.m., the administrator said the plumber's snake (to the right of the front entrance of the building) was present because the facility had a blocked sewer pipe and it was used to unblock it earlier that morning. She said the facility had a blockage of the sewer on Halls #3 and #4 earlier that day, and a past blockage on Hall # 2 where the cast iron pipe had to be replaced. She said the backed-up water was extracted from Halls #3 and #4 and outside in the clean outs for the kitchen. The administrator said the building had plumbing problems all over the building due to the old cast iron pipes and the plumber would be coming back next Monday or Tuesday to run a camera through the system to evaluate the extent of the problem in the plumbing system of the facility. She said the problem with the showers and resident commodes was hit and miss, and some were working and some were not. She said the backed up water only affected the employee's offices on Hall #4, but was cleaned up and the only commode affected was in the employee break room. She said the laundry aide took the laundry to a sister facility for the linens and resident's clothes to be washed. She said there was no longer a problem with the resident's commodes or showers at this time because the plumbing issue was unclogged and water was flowing freely in the pipes. During an observation and interview on 9/21/16 at 3:30 p.m., there were three wet floor signs placed in the halls and two in the dining room where the wet blankets and towels were. The ADON said the water backed up from the kitchen and went out around the wall edges of the dining room, Halls #3 and #4 earlier that morning. She said the staff put towels and blankets down to protect the residents. She said the floors were mopped and sanitized and no longer had water on them. During an interview on 9/21/16 at 3:45 p.m., CNA F said she was told during report on 9/21/16 at 2:00 p.m. that all residents would have to use the secured unit's front bathroom and shower due to the plumbing issues. CNA F said two days ago all the toilets were filling up and overflowing. During an interview on 9/21/16 at 3:48 p.m., LVN E said the facility experienced the sewer backing up four times since August. LVN E said on 8/17/16 and 8/18/16 the residents could not take showers due to drainage problems. During an observation and interview on 9/21/16 at 4:00 p.m., Resident #8 said he could not use his commode and had not showered for several days. During an interview on 9/21/16 at 4:05 p.m., Resident #3 said the showers were not working for 4 weeks. She said they overflowed and had cold, putrid smelling water. She said there were towels, sheets and blankets in the dining room, in her bathroom and at the bottom of the dining room walls that morning. During an interview on 9/21/16 at 4:20 p.m., CNA K said there were four episodes of flooding in the past week. She said the kitchen, the front shower rooms, and Hall #3 was flooded this morning. She said Residents #2 and #4's bathrooms flooded also. CNA K said there was flooding since last Tuesday (9/13/16) and the current flooding started yesterday. She said the administrator told them, If you tell state, they (administration) will kick our butts. During a phone interview on 9/21/16 at 4:40 p.m., Plumber #1 said three weeks ago Hall #1 was clogged up. He said the next week the whole building went down, but he was able to clear it. He said he told them to get someone involved this week to evacuate the residents because the sewer system had failed. He said he kept putting his plumber's snake through the sewer pipes today, but he kept bringing up mud. Plumber #1 said this was an indication of system failure and the floors would have to be torn up to get to the pipes. He said the residents could not live in that type of situation. During an observation and interview on 9/21/16 at 4:50 p.m., the regional maintenance supervisor was present to help evaluate the sewer problem. He said the administrator told him sewer water was coming into the building. He said if any water came out of any drain, it was sewer water. During an interview on 9/21/16 at 5:00 p.m., the administrator said the first plumber (#1) recommended digging up the facility floors with a team of workers to fix the plumbing. She said she consulted the cooperate office today concerning the flooding issues. The administrator said she considered evacuation to sister facilities, but decided not to when the second plumber (#2) opened a pipe. The administrator said she was unsure if the company would spend the money on the facility's plumbing issues. Maintenance Invoices dated 7/25/16, 8/05/16, 8/29/16, 9/14/16, and 9/20/16 indicated Plumber #1 was at the facility for repair of the plumbing/sewer system. The job invoices indicated the facility's plumbing system backed up several times and the plumber continued to have mud pulled back on the plumber's snack. The invoices indicated there was a removal and repair of the broken pipe under Room 101's bathroom. The administrator and DON were notified on 9/21/16 at 5:03 p.m. that an Immediate Jeopardy situation was identified due to the above failures. During an interview on 9/21/16 at 5:08 p.m., Resident #5 said he was unable to have his shower today due to plumbing issues. During an interview on 9/21/16 at 5:17 p.m., Resident #2 said he took a shower this morning, but the water kept rising over his feet. He said there were problems in the shower drain. During an interview on 9/21/16 at 5:18 p.m., Resident #7 said he took a shower yesterday and the water would not go down the drain. He said the nurse aide had to turn off the water and stop the shower. During an observation and interview on 9/21/16 at 5:30 p.m., Resident #4 said he was not able to use his toilet today because of plumbing issues. His restroom had white blankets surrounding the base of the toilet. During observations on 9/21/16 at 6:40 p.m., the following was noted: *the employee break room sink had dirty water standing in the basin of the sink *Room 36's toilet had brown material resembling human feces. The toilet would not flush. *Room 37's toilet flushed slowly requiring two flushes *Room 38 had a bedside commode with a large amount of urine and feces. *Room 42's toilet had a foul smelling brown material resembling human feces. The toilet flushed, but required two flushes due to slowness *Room 43's toilet flushed slow requiring two flushes; *Room 46's toilet flushed slow requiring two flushes; *Room 50's toilet had foul smelling brown material resembling human feces and the toilet required two flushes due to slowness; *The Shower room on Hall 4 had dark brown material around the edges of the shower. The shower had a foul smell. There was a dirty wash cloth and towel lying in the floor. During an interview on 9/21/16 at 6:40 p.m., the DON said the shower flooded yesterday and needed cleaning. The Plan of Removal (POR) was accepted on 9/21/16 at 7:30 p.m. and included: *Medical Director called about IJ on 9/21/16.and an off-cycle QA meeting set up for the a.m. of 9/22/16. *The hall corridor floors, handrails and resident rooms were to be disinfected with a bleach solution on 9/21/16. *The kitchen and dining room were to be disinfected with a bleach solution on 9/21/16. *All toilets to be checked to ensure they are flushing properly on 9/21/16. *The dish-washing machine in the kitchen will be draining properly and there will be no gray water in the kitchen or dining area on 9/21/16. *The DON to in-service staff on checking resident sinks, toilets, and showers to ensure they drain properly. Any drainage problems will be reported to the Administrator immediately. *The facility will maintain a plumber's snake on site to assist in any plumbing/drainage issues on 9/21/16. *Monthly QA meetings will review monitoring of Infection Control to ensure compliance on 9/21/16. On 9/22/16 at 10:15 a.m., the surveyors were unable to confirm the POR was implemented sufficiently to remove the IJ. During an interview on 9/22/16 at 10:15 a.m., the administrator said the facility had another back-up of water in the kitchen that morning after breakfast was served. She said there was a blockage found between the facility's sewer system and the city's. She said the kitchen, Halls #3 and #4's (floor, baseboards and handrails) were sanitized with a 10% bleach solution last night and the kitchen was mopped with a bleach solution this morning. During an interview on 9/22/16 at 10:25 a.m., Plumber #2 said his company recommended running cameras down the pipes to evaluate what work was needed. During an interview on 9/22/16 at 10:30 a.m., the regional maintenance supervisor said the main drain was not draining from the facility to the city pipe system. During an interview on 9/22/16 at 10:30 a.m., the FSS said the kitchen was cleaned with a 10% bleach solution last evening and breakfast was cooked and served to the residents that morning. She said when the dishwasher was run, the drain began to back-up again and flooded the kitchen only. She said the kitchen shut down and she ordered outside food for lunch. During an interview on 9/22/16 at 10:15 a.m., the administrator said the QA meetings to review monitoring of Infection Control began that morning with the medical director, to discuss issues related to sewer back-up that could cause resident infections, how they would monitor, and report to QA monthly. During a phone interview on 9/22/16 at 1:48 p.m., the Medical Director said he was called last night about the QA/IJ issues and he called the administrator this a.m. to discuss further QA issues. He said no resident had been sick in the last 6 months related to the environmental problems. During observations on 9/22/16 at 1:50 p.m., the following areas were clean and free of sewer water and odor: Medication Room; Resident #2 and #4's bathrooms; commodes on each hall were flushing without problems; shower rooms on Halls 3/4 and 1/2; and laundry room. During interviews on 9/22/16 at 2 p.m., CNAs L and N; housekeepers O and M; ADON; DON; LVN P; and the administrator said they participated in the cleaning of Halls #3 and 4 (floors, baseboards and side rails), the kitchen, the dining room, the medication room, and the resident's rooms that were affected by the sewer back-up: During an observation and interview at 2:20 p.m., a professional plumbers snake was stored in the facility's maintenance/storage shed. The maintenance supervisor said the regional maintenance man said the plumber's snake could be theirs permanently. During an observation and interview on 9/22/16 at 2:32 p.m., a restoration company removed the baseboards from Halls #3 and #4, from the dining room, and kitchen. The administrator said the company was contracted to provide professional cleaning to the kitchen, dining room and hall #3 and #4. She said the company would be working through the night to complete the process. During an interview on 9/22/16 at 2:42 p.m., Resident #4 said his commode was flushing without problems and his shower did not have any back-up issues today. During an interview on 9/22/16 at 4:20 a.m., the maintenance supervisor said Plumber #2 went through a third of the sewer system with the camera and found a grease build up between the facility's main connections with the city's sewer system. He said the plumber sent for a jet stream cleaner to break up the clogged area and would be working into the night to complete the camera surveillance and cleaning. *Two in-service records dated 9/21/16 indicated all 59 staff were in-serviced on checking sinks, toilets and showers for proper drainage and to report any plumbing issues to administration immediately. The surveyors confirmed the facility had implemented the POR sufficiently to remove the IJ on 9/23/16 by: During an interview on 9/23/16 at 8:45 a.m., the FSS said the kitchen and the dining room walls were cleaned and treated with a chemical by the restoration company last night and were waiting for their report to resume cooking in the kitchen. During an observation on 9/23/16 at 8:48 a.m., the dining room walls, the kitchen and Halls #3 and #4 had industrial fans pointed at them to dry the treatment performed on the walls. The walls were white and clean. During an interview on 9/23/16 at 9:08 a.m., regional maintenance supervisor said the restoration company cleaned all areas (kitchen, dining room, Halls #3 and #4) identified and their cleaning procedure met code standards. He said the facility completed the camera surveillance of the facility ' s sewer system and no other problems were found. He said the plumbers and the city were cleaning the clog at the main site and developed a plan for future prevention. On 9/23/16 at 11:25 a.m., the administrator, regional administrator, regional DON, and ADON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a widespread potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective actions. A CMS form 672 dated 9/21/16 indicated the census was 49.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for 1 of 6 residents reviewed for incident/accidents. (Resident #6) The facility did not ensure Resident #6 wore his smoking apron while smoking. Resident #6 required supervision while smoking and was to wear a smoking apron for safety. Resident #6 dropped ashes onto his thigh while smoking and developed a second degree burn. This failure could place 4 residents who smoked at risk for burn injuries. Findings included: Consolidated physician orders dated September 2016 indicated Resident #6 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A physician order for [REDACTED].#6's right thigh with normal saline and apply skin prep until healed. The most recent MDS dated [DATE] indicated Resident #6 usually made his needs known and usually understood others. Resident #6 required total assistance with ADLs. The most recent care plan dated 9/13/16 indicated Resident #6 had a potential for burns related to smoking, the potential for ruined clothing related to burn holes or blackened marks, and the potential for fire and burns to self and/or others. The care plan indicated that Resident #6 was to be supervised while smoking to minimize any safety risks. Resident #6 was to have staff light his cigarettes, wear a smoking apron when smoking, and report to the charge nurse if he burned himself or his clothing while smoking. A smoking safety evaluation dated 9/18/16 indicated Resident #6 was deemed unsafe to smoke and must be closely supervised. The additional comments indicated Resident #6 wore a smoking apron and was supervised during all smoke breaks. An incident report dated 9/21/16 at 11:45 a.m. indicated Resident #6 dropped a hot ash from his cigarette onto his right leg. The report indicated a physician order for [REDACTED]. The incident report indicated a skin assessment was done by LVN D and Resident #6 had a 1 cm blister to his right thigh area. During an interview on 9/26/16 at 10:30 a.m., LVN D said she worked on 9/21/16. LVN D said the DON brought Resident #6 to her from the dining room and said Resident #6 had burned his leg and told her to assess it. She said Resident #6 had an approximately 1cm x 1 cm red area that was starting to blister to his right upper thigh. LVN D said CNA B reported Resident #6 was not wearing a smoking apron on 9/21/16 and he did not know where it was. LVN D said the DON told her she did not know where the smoking aprons where. LVN D said she did not look for the smoking aprons. During an observation and interview on 9/22/16 at 3:05 p.m., Resident #6 was sitting in his wheel chair in the dining room waiting to go smoke. Resident #6 had a quarter sized burn hole to his jogging pants to the right upper leg area. Resident #6 said he smoked yesterday (9/21/16) and hot ash fell on his right leg and burned through his pants and burned his leg. Resident #6 said he did not have a smoking apron on and had not worn one in two weeks. Resident #6 said (unknown) staff told him his apron was lost. During an observation and interview on 9/23/16 at 9:04 a.m., Resident #6 had a 1cm x 1 cm fluid filled blister to his right upper thigh. The regional nurse assessed Resident #6 with the state surveyor and agreed the area was a fluid filled blister to the burn site of Resident #6's right upper thigh. During an interview on 9/22/16 at 3:45 p.m., CNA B said he took Resident #6 out to smoke on 9/20/16 and 9/21/16 at 11:30 a.m. and 1:00 p.m. CNA B said Resident #6 did not wear a smoking apron because he could not find one. CNA B said he did not witness Resident #6 get burned. CNA B said he told the DON on 9/21/16 that Resident #6's smoking apron was missing. During an interview on 9/23/16 at 9:01 a.m., the DON said Resident #6 approached her in the dining room during lunch 9/21/16 and said he burned his leg while smoking and wanted her to look at it. The DON said Resident #6 said it was still burning. The DON said she had the charge nurse look at his leg and Resident #6 had a small 1 cm x 1 cm red area on his right upper thigh. The DON said Resident #6 was not wearing an apron, but should have been wearing one. During an interview on 9/23/16 at 9:15 a.m., LVN A said she assessed Resident #6's right thigh this morning and it had a 1 cm x 1 cm fluid filled blistered area at the site of the burn. LVN A said Resident #6 should always wear a smoking apron when smoking. During an interview on 9/23/16 at 8:55 a.m., the administrator said she had three smoking aprons for residents to wear. She said Resident #6 refused to wear a smoking apron at times. The administrator said she was unaware of the cigarette burn to Resident #6's thigh until after surveyor intervention. During an interview on 9/23/16 at 9:12 a.m., CNA C said Resident #6 was to wear a smoking apron while smoking, but she had not been able to find one in the last few days. The smoking policy dated February 2013 indicated the following: *all residents who smoke will be supervised; and *a smoking safety evaluation will be completed for all residents who smoke on admission, change of condition, and quarterly. The policy did not address smoking aprons. The Black/Hawks Medical-Surgical Nursing 7th edition, page 1439, figure 52-6 burn injury classification according to depth of injury indicated the appearance of a 2nd degree burn surface would be wet, shiny, and weeping, have blisters and the wound would blanch with pressure. The wound would be painful and very sensitive to touch and air currents. A list provided by the ADON on 9/23/16 indicated there were 4 residents who smoked and required supervision at all times and 1 resident who required a smoking apron.