Every finding on record at Booker T. Washington Skilled Nursing and Rehabilit

Based on record reviews and interviews the facility failed to provide documentation regarding the existence of any written advance directives for 3 (#4, #25, #69) of 8 residents reviewed for Advanced Directives. Findings: Review of the facility's Advance Directives policy (revised 05/31/2023) revealed in part: Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. Resident #4 Review of Resident #4's record revealed an admit date of 05/07/2026 and diagnoses including: displaced intertrochanteric fracture of right femur subsequent encounter for closed fracture with routine healing, type 2 diabetes mellitus with hyperglycemia, and COPD. Review of Resident #4's Advance Medical Directives form signed 05/13/2026 revealed a section of the form which read: Please note whether an Advanced Directive has been executed: was incomplete with no box checked to indicate whether or not an Advanced Directive had been executed. During an interview on 06/09/2026 at 9:15 a.m., S1ADM verified Resident #4's advanced directive was not complete and should be. Resident #25 Review of Resident #25's medical record revealed an admission date of 08/08/2024 with diagnoses that included, in part, primary generalized osteoarthritis, hereditary and idiopathic neuropathy, chronic systolic congestive heart failure, obstructive sleep apnea, anemia, atherosclerotic heat disease of native coronary without angina, and essential primary hypertension. Review of Resident #25's MDS dated [DATE], quarterly, revealed a BIMS score of 13.Review of Resident's #25's advanced medical directives form dated 08/08/2026 revealed a section of the form which read: Please note whether advanced directive has been executed. was incomplete with no box checked to indicate whether or not an advanced directive had been executed. During an interview on 06/09/2026 at 9:15 a.m., S1ADM verified Resident #25's advanced directive was not completed and should be. Resident #69 Review of Resident #69's medical record revealed an admit date of 07/02/2025 with diagnosis that included, in part, hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting left non-dominant side, aphasia following cerebral infarction, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, and unspecified systolic congestive heart failure. Review of Resident #69's quarterly MDS dated [DATE] revealed a BIMS score of 12. Review of Resident's #69's advanced medical directives form dated 08/08/2026 revealed a section of the form which read: Please note whether advanced directive has been executed. was incomplete with no box checked to indicate whether or not an advanced directive had been executed. During an interview on 06/09/2026 at 9:15 a.m., S1ADM verified Resident #69's advanced directive was not completed and should be.

Based on record review and interviews, the facility failed to ensure Safe Smoking Assessments were completed on admit and with each subsequent MDS assessment per policy for 1 (#26) of 1 residents reviewed for smoking. Findings: Review of the facility's Smoking Policy - Residents (revised 03/08/2023) included in part:The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include the ability to smoke safely with or without supervision per a completed Safe Smoking Evaluation or equivalent form. Once a resident is determined to be a smoker, his/her ability to smoke safely will be evaluated upon admission, subsequent MDS and PRN. Based on record review and interviews, the facility failed to ensure Safe Smoking Assessments were completed on admit and with each subsequent MDS per policy for 1 (#26) of 1 residents reviewed for smoking. Findings: Review of the facility's Smoking Policy - Residents (revised 03/08/2023) included in part:The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include the ability to smoke safely with or without supervision per a completed Safe Smoking Evaluation or equivalent form. Once a resident is determined to be a smoker, his/her ability to smoke safely will be evaluated upon admission, subsequent MDS and PRN. Review of Resident #26's record revealed an admit date of 11/07/2025 and diagnoses including: conversion disorder with seizures or convulsions, COPD, epilepsy, and generalized muscle weakness. Review of the facility provided Safe Smoking List revealed Resident #26 was listed as a safe smoker. Review of Resident #26's Baseline Care Plan created 11/07/2026 revealed Resident #26 was a smoker. Review of Resident #26's Safe Smoking Assessments failed to reveal an assessment was performed on admission. Further review failed to reveal Safe Smoking Assessments were performed for Resident #26 with each subsequent MDS assessment. During an interview on 06/09/2026 at 9:48 a.m. S2 DON reviewed the facility Smoking Policy and Resident #26's Safe Smoking Assessments and confirmed Resident #26 should have had Safe Smoking Assessments performed on admission and with each subsequent MDS assessment and did not.

Based on record review and interview the facility failed to ensure a significant change assessment was completed for 1 (#15) of 1 reviewed for significant change assessment. Findings: Review of Resident #15's medical record revealed an admission date of 06/13/2022 with diagnosis that included, in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, aphasia following cerebral infarction, dysphagia following cerebral infarction, acute respiratory failure with hypoxia, chronic kidney disease stage two, peripheral vascular disease with heart failure, chronic diastolic congestive heart failure, unspecified systolic congestive heart failure, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #15's MDS dated [DATE], Section C showed that a BIMS was No (resident is rarely/never understood). Resident had memory problem for short term and long term. Cognitive skills for daily decision making was marked severely impaired. Review of Resident #15's physician orders for June 2026 revealed an order of, Admit to ------- Hospice under routine home care with diagnosis of cerebral infarction, dated 04/16/2026. Review of the care plans for Resident #15 failed to reveal a care plan related to hospice care/significant change. During an interview on 06/09/2026 at 7:50 a.m., S2DON confirmed Resident #15 was admitted to hospice on 04/16/2026 and a significant change assessment was not completed for Resident #15. During an interview on 06/09/2026 at 8:10 a.m., S3MDS Nurse confirmed Resident #15 was admitted to hospice on 04/16/2026. S3MDS Nurse reported she did not complete a significant change assessment after the hospice admit for Resident #15.

Based on record review and interviews, the facility failed to ensure residents' code status wishes for emergency basic life support were consistent and accurate across all areas of residents' medical records for 2 (#4, #78) of 8 residents reviewed for Advanced Directives. The facility failed to ensure the residents' records reflected the residents' wishes to be a DNR. Findings:Review of the facility's Advance Directives policy (revised [DATE]) revealed in part: 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive11. The resident has the right to refuse treatment, whether or not he or she has an advance directive. A resident will not be treated against his or her own wishes. 15. Our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: e. Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. 20. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. 21. The Nurse Supervisor will be required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made. Resident #4 Review of Resident #4's medical record revealed an admit date [DATE] and diagnoses including: displaced intertrochanteric fracture of right femur subsequent encounter for closed fracture with routine healing, type 2 diabetes mellitus with hyperglycemia, COPD, major depressive disorder, PTSD, schizoaffective disorder bipolar type, long term (current) use of insulin, and generalized anxiety disorder. Review of Resident #4's 5-Day MDS assessment dated [DATE] revealed Resident #4 had a BIMS score of 15 indicating the resident was cognitively intact. Review of Resident #4's __POST document signed by Resident #4 on [DATE] and by the physician on [DATE] revealed Resident #4 had chosen DNR/Do Not Attempt Resuscitation (Allow Natural Death), Comfort focused treatment, and no artificial nutrition by tube. Review of Resident #4's electronic medical record revealed the home page displayed a Code Status of Full Code. Review of Resident #4's face sheet revealed the Advance Directive section was marked Full Code. Review of Resident #4's physician orders in the electronic record revealed an order dated [DATE] - Full Code. Review of Resident #4's comprehensive care plan revealed Resident #4 had elected a full code status (date initiated [DATE] revision on [DATE]) with approaches including - inform all care givers of full code status, notify MD and family as soon as possible begin CPR and call 911. During an interview on [DATE] at 8:35 a.m. Resident #4 reported she remembered having a conversation with someone about her code status but did not remember who it was with. Resident #4 reported they had signed a yellow piece of paper indicating they had chosen to be a DNR and did not want anyone to do CPR on them. During an interview on [DATE] at 10:43 a.m., S2 DON reported the facility did not have an actual policy for carrying out a resident's expressed wishes for code status or implementing the choices selected on the __POST document. S2 DON further reported the customary procedure on admission was for the Social Worker to let the DON or ADON know if a resident had chosen to be a DNR so they could follow up with the MD and enter the DNR order. S2 DON reported if a resident was transferred to the Emergency Room, a copy of the resident's face sheet and a copy of their __POST document was sent with them. During an interview on [DATE] at 10:55 a.m., S1 Administrator and S2 DON reviewed Resident #4's signed __POST document and agreed the resident had chosen DNR/Do Not Attempt Resuscitation (Allow Natural Death), Comfort focused treatment, and no artificial nutrition by tube. S1 Administrator and S2 DON further reviewed Resident #4's face sheet and physician orders and confirmed they showed the resident to be a full code. S1 Administrator and S2 DON agreed Resident #4's expressed code status wishes were not consistent across all documents and should be. Resident #78 Review of Resident #78's record revealed an admit date of [DATE] and diagnoses including COPD, Type 2 Diabetes Mellitus, epilepsy, infection and inflammatory reaction due to unspecified internal joint prosthesis, peripheral vascular disease, congestive heart failure, and major depressive disorder. Resident #78's admission MDS assessment including the resident's BIMS score had not yet been completed. Review of Resident #78's electronic record revealed a __POST document electronically signed by Resident #78 on [DATE] and not signed by physician. Further review revealed Resident #78 chose DNR/Do Not Attempt Resuscitation (Allow Natural Death), Comfort focused Treatment, and no artificial nutrition by tube. Review of Resident #78s Advanced Directive acknowledgment signed by the resident on [DATE] revealed a section of the form which read Please note whether an Advanced Directive has been executed had I have a DNR Order selected. Review of Resident #78's hard copy __POST physically signed by Resident #78 on [DATE] and by the physician on [DATE] revealed Resident #78 chose CPR/Attempt Resuscitation (requires full treatment in section B); Section B - chose Comfort focused treatment; section C - chose no artificial nutrition by tube. Review of Resident #78's electronic medical record revealed the home page displayed a Code Status of Full Code Review of Resident #78's face sheet revealed the Advance Directive section was marked Full Code. Review of Resident #78's physician orders in the electronic record revealed an order dated [DATE] for a Full Code. Review of Resident #78's comprehensive care plan revealed Resident #78 was care planned for a full code with approaches including notify MD and family as soon as possible begin CPR and call 911. During an interview on [DATE] at 9:05 a.m., Resident #78 reported they had a conversation with someone when they were admitted about their code status wishes but did not remember who it was with. Resident #78 reported they had told the staff member they did not want anyone trying to resuscitate them, and wanted to be allowed to die naturally and be left alone if they coded. Resident #78 reported they did not remember all of the papers they signed on admission but did remember having the conversation. During an interview on [DATE] at 10:55 a.m., S1 Administrator and S2 DON reviewed Resident #78's printed __POST document showing CPR, Comfort focused treatment, and no artificial nutrition by tube and confirmed it did not match the resident's electronic __POST indicating DNR/Do Not Attempt Resuscitation (Allow Natural Death) or Resident #78's Advance Directive form stating the resident had a DNR order. S1 Administrator and S2 DON further reviewed Resident #78's face sheet and electronic physician orders and confirmed they showed Resident #78 was a full code. S1 Administrator and S2 DON agreed Resident #78's wishes for DNR or full code were not consistent across all documents and should be.

Based on record reviews, observations, and interviews, the facility failed to ensure 2 (#46, #223) of 20 sampled residents received treatment and care in accordance with professional standards of practice by failing to ensure: 1. Resident #46's high blood glucose levels were rechecked as ordered after being administered sliding scale insulin for glucose levels greater than 400, and a Hemoglobin A1C (Glycated hemoglobin- a blood test that measures the average blood sugar level over the past 2-3 months) was obtained every 3 months as ordered; 2. Resident #223's care was coordinated with the Hospice provider regarding the resident's medications. Findings: 1. Review of Resident #46's records revealed an admitted [DATE] with diagnoses including: Type 2 diabetes mellitus, end stage renal disease, and mild-protein-calorie malnutrition. Review of Resident #46's active Physician's Orders revealed orders including: - 05/06/24 - Humalog Injection Solution 100 unit/ml (milliliters)- Inject subcutaneously as per sliding scale before meals and at bedtime related to type 2 diabetes mellitus: if 0 - 200 = 0u (units); 201 - 250 = 3u; 251 - 300 = 5u; 301 - 350 = 7u; 351 - 400 = 9u; 401 - 999 = 11u recheck in 3 hours. If still greater than 400, obtain stat serum glucose and notify MD (medical doctor). -04/22/2024-Hemoglobin A1C every three months (July, October, January, April). Review of Resident #46's March and April 2025 MARs (Medication Administration Records) revealed glucose checks greater than 400 on the following dates and times with insulin administered per the sliding scale: -03/11/2025 at 4:00 p.m. = 413 -03/17/2025 at 4:00 p.m. = 430 -03/19/2025 at 11:30 a.m. = 424 -03/20/2025 at 4:00 p.m. = 497 -03/23/2025 at 11:30 p.m. = 436 -03/24/2025 at 4:00 p.m. = 416 -03/27/2025 at 4:00 p.m. = 482 Further review of Resident #46's March 2025 MAR and nursing notes failed to reveal any rechecks of the resident's glucose after 3 hours as ordered. Review of Resident #46's lab results revealed in part: -Hemoglobin A1C results for 02/27/2025 of 8.5 (reference range 4.0-6.0) -Hemoglobin A1C results for 05/07/2024 of 7.4 Further review of Resident #46's paper chart and electronic health record revealed no other Hemoglobin A1C results. During an interview on 04/02/2025 at 9:38 a.m. S2 ADON(Assistant Director of Nursing) reviewed Resident #46's physician orders, March 2025 MAR, and nursing notes and confirmed Resident #46's glucose was not rechecked after 3 hours as ordered on dates sliding scale insulin was administered for a glucose greater than 400 and should have been. During an interview on 04/02/2025 at 10:35 a.m. S2 ADON reviewed Resident #46's physician orders and lab results and confirmed the resident's Hemoglobin A1C was not obtained every 3 months and should have been. 2. Review of the provider's Hospice Program policy (revised July 2017) revealed in part: 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the Hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: b. administering prescribed therapies, including those therapies determined appropriate by the Hospice and delineated in the Hospice plan of care; d. communicating with the Hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day; 12. Our facility has designated ___name)___(title) to coordinate care provided to the resident by our facility staff and the Hospice staff. (note: this individual is a member of the interdisciplinary team with clinical and assessment skills who is operating within the State scope of practice act). He or she is responsible for the following: a. collaborating with Hospice representatives and coordinating facility staff participation in the Hospice care planning process for residents receiving these services; c. ensuring that the long-term care facility communicates with the Hospice medical director, the resident's attending physician, and other practitioners participating in the provision of care to the resident as needed to coordinate the Hospice care with the medical care provided by other physicians; 13. Coordinated care plans for residents receiving Hospice services will include the most recent Hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being . Review of the provider's Palliative/End-of-Life Care-Clinical Protocol (revised March 2018) revealed in part: Treatment/Management: 1. The physician will order appropriate interventions for symptom relief, including pain management. 4. If Hospice becomes involved, both the attending physician and staff will retain an active role in the resident/patient's care and will not simply defer everything to the Hospice staff and practitioner. Review of the provider's Nursing Facility Services Agreement between the provider and ___ Hospice & Palliative Care effective 08/01/2019 revealed in part: 1.1 Facility Services means those personal care and room and board services provided by Facility as specified in the Plan of Care for a Hospice Patient including, but not limited to assisting in the administration of medicine, to the extent of which Facility is permitted by law in the State or Commonwealth in which Facility is located . 1.9 Plan of Care means a written care plan established, maintained, reviewed and modified, if necessary. The Plan of Care will reflect the participation of the Hospice, Facility, and the Hospice Patient and family to the extent possible. Specifically, the Plan of Care includes drugs and treatment necessary to meet the needs of the Hospice Patient . Article 2 Responsibilities of Facility: 2.1 Provision of Services: Facility shall comply with Hospice Patient's Plan of Care . 2.5 Coordination of Care: Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day. Review of Resident #223's record revealed an admitted [DATE] and diagnoses including: malignant neoplasm of pancreas, malignant neoplasm of liver and intrahepatic bile duct, respiratory failure with hypoxia, chronic pain syndrome, and COPD (chronic obstructive pulmonary disease). Review of Resident #223's Hospice Binder revealed in part: -Hospice nurse visit date 03/20/2025 by S6 Hospice RN (Registered Nurse); -Hospice Certification and Plan of Care with a start of care 03/20/2025 included the following medication orders: -Gabapentin 600mg (milligrams) tablet-1 tablet three times a day for nerve pain, start date 03/20/2025 -Hydrocodone 5mg-acetaminophen 325 mg tablet every 4 hours as needed for pain-start date 03/20/2025 -Ipratropium 0.5mg-albuterol 3mg (2.5mg base)/3ml nebulization soln-3ml inhalation (breathing treatments) every 4 hours for COPD start date 03/20/2025 -Lisinopril 20 mg tablet, 1 tablet by mouth every day for hypertension, start 03/20/2025 -Miralax 17 gm (grams) oral powder packet-1 packet by mouth every day as needed for constipation, start 03/20/2025 -Morphine concentrate 100mg/5ml (20mg/ml) oral solution every 2 hours as needed for pain/shortness of breath, start 03/20/2025 -Oxygen gas for inhalation 2 liters as needed for shortness of breath, start 03/20/2025 -Quetiapine 200mg tablet-1 tablet by mouth every night at bedtime, start 03/20/2025 -Senna with docusate sodium 8.6mg-50mg by mouth twice a day for bowel regimen, start 03/20/2025 Review of Resident #223's active physician's orders, March 2025 MAR, and April 2025 MAR in the facility's electronic health record revealed the following Hospice medication orders were not included in the resident's facility orders and had not been administered: -Gabapentin 600mg tablet-1 tablet three times a day for nerve pain, start date 03/20/2025 -Ipratropium 0.5mg-albuterol 3mg (2.5mg base)/3ml nebulization soln-3ml inhalation (breathing treatments) every 4 hours for COPD start date 03/20/2025 -Lisinopril 20 mg tablet, 1 tablet by mouth every day for hypertension, start 03/20/2025 -Miralax 17 gm oral powder packet-1 packet by mouth every day as needed for constipation, start 03/20/2025 -Quetiapine 200mg tablet-1 tablet by mouth every night at bedtime, start 03/20/2025 -Senna with docusate sodium 8.6mg-50mg by mouth twice a day for bowel regimen, start 03/20/2025. Review of Resident #223's nursing notes from 03/20/2025 to 04/01/2025 revealed no notes relating to unavailable or missing Hospice ordered medications. During an interview on 03/31/2025 at 10:05 a.m. Resident #223 reported she was admitted to the facility from the hospital on 03/20/2025 on Hospice services. Resident #223 reported Hospice had ordered gabapentin and Seroquel when she was admitted , but she still had not received either of those medications. During an interview on 04/01/2025 at 10:25 a.m. S4 Hospice RN reported medication orders were entered into the Hospice electronic health record and the Hospice pharmacy delivered them. S4 Hospice RN reported once the medications were available on-site, the Hospice nurse would write paper orders on the facility's telephone orders forms for the facility nurses to enter into the facility's electronic health record and begin administration. S4 Hospice RN reported when Resident #223 asked him about her Seroquel and Gabapentin one day last week, he verified the Hospice pharmacy had delivered them, and then he and one of the facility nurses looked for but could not locate them. S4 Hospice RN reported he re-ordered the medications at that time and told the facility nurses that when they were delivered, he would return to the facility and write the orders. During an interview on 04/01/2025 at 11:45 a.m. S5 LPN (Licensed Practical Nurse) reported she was the nurse who helped S4 Hospice RN look for Resident 223's Gabapentin and Seroquel, which they were unable to locate. S5 LPN reviewed Resident #223's Hospice Certification and Plan of Care and agreed the resident should have been receiving Gabapentin, Seroquel, Ipratropium 0.5mg-albuterol 3mg, Lisinopril, Miralax, and Senna with docusate since 03/20/2025 and was not. During an interview on 04/01/2025 at 11:50 a.m. S2 ADON reported the facility did not enter orders into the provider's electronic health record based on Hospice Certification and Plan of Care, the Hospice nurse had to write the orders on a telephone order sheet for the facility nurses to enter into the facility's electronic health record. S2 ADON reported when S4 Hospice RN was trying to locate Resident #223's missing medications, she told him that even if they were located or re-ordered and delivered, the staff nurses could not administer them until he wrote the orders on the telephone order sheets. During an interview on 04/01/2025 at 1:35 p.m. S3 Administrator reviewed the facility Hospice policies and reported the charge nurses were the designated staff responsible to coordinate residents' care with Hospice. S3 Administrator reported the charge nurse for Resident #223 was S2 ADON. S3 Administrator reported she had spoken with S4 Hospice RN by phone today, and was informed the medications for Resident #223 were delivered by ___delivery service on 03/24/2025. Video footage for 03/24/2025 reviewed with S3 Administrator revealed a delivery person placing 2 boxes on the floor against the wall adjacent to the nursing station right next to the delivery entrance door on 03/24/2025 at 10:58 a.m. Video further revealed S18 DON (Director of Nursing) picking up the boxes on 03/24/2025 at 1:56 p.m. and placing them on the desk in the nursing station. S3 Administrator reported she remembered seeing 2 boxes on the counter in the nursing station this morning and left the room. S3 Administrator returned to her office on 04/01/2025 at 1:50 p.m. with 2 boxes which she opened in the presence of the surveyor. The first box contained Gabapentin, Seroquel, Ipratropium 0.5mg-albuterol 3mg, Lisinopril, and Senna with docusate for Resident #223. S3 Administrator confirmed Resident #223 should have been receiving Gabapentin, Seroquel, breathing treatments, Lisinopril, Miralax, and Senna with docusate and was not. During an interview on 04/01/2025 at 1:55 p.m. S2 ADON reported the facility had not been provided the Hospice binder for Resident #223 with the Hospice Certification and Plan of Care until 03/24/2025, and became aware of the missing medications at that time. S2 ADON further confirmed facility staff became aware on 03/24/2025 Resident #223 should have been receiving Gabapentin, Seroquel, Ipratropium 0.5mg-albuterol 3mg, Lisinopril, Miralax, and Senna with docusate and was not. During a telephone interview on 04/01/2025 at 3:25 p.m. S6 Hospice RN reported she came to the facility on [DATE] at around 11:00 p.m. to do Resident #223's admission assessment. S6 Hospice RN further reported since it was late at night, she did not have access to Resident #223's complete medical record and did not know what other medications the resident needed at that time, and reported S4 Hospice RN was supposed to do it the next day. S6 Hospice RN reported S4 Hospice RN should have written the medication orders for the facility staff to enter into the facility's electronic health record and apparently did not.

Based on record reviews and interviews, the facility failed to provide nutritional and hydration care and services consistent with the resident's comprehensive assessment for 1 (#69) of 4 (#9, #46, #62, #69) residents reviewed for nutrition. The facility failed to consult the Registered Dietician (RD) for Resident #69. Findings: Review of Facility's Nutrition and Hydration to Maintain Skin Integrity Policy (revised October 2010) revealed: Assessment - Purpose: The purpose of this procedure is to provide guidelines for the assessment of resident nutritional needs, to aid in the development of an individualized care plan for nutritional interventions, and to help support the integrity of the skin through nutrition and hydration. Nutritional Assessment - 1. The dietician and RD, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission/re-admission and as indicated by a change in condition that places the resident at risk for impaired nutrition, 2. Re-assessments will be conducted more often if the resident's condition changes and/or he or she develops risk factors for impaired nutrition .3. Registered Dietician assessments will be completed on residents with wounds, weight loss monthly in order to identify if current interventions are working and to revise these interventions as indicated. Documentation: 8. Care plan interventions that address both nutritional deficits and risk factors. Review of Resident #69's medical records revealed an admitted [DATE] with the following diagnoses, including in part: other sequelae of cerebral infarction, chronic obstructive pulmonary disease with (acute) exacerbation, chronic respiratory failure with hypoxia, unspecified protein-calorie malnutrition, chronic systolic (congestive) heart failure and muscle wasting and atrophy/not elsewhere classified/multiple sites. Review of Resident #69's comprehensive care plan revealed a problem of - the resident has risk for nutritional problem related to moderate protein-calorie malnutrition - RD to evaluate and make diet change recommendations as needed (PRN). Review of Resident #69's Nurse Practitioner (NP) progress notes dated 03/07/2025 revealed: Acute/Follow-Up - Chief Complaint / Nature of Presenting Problem: Lab reviewed with elevated A1c (can help diagnose diabetes) .Plan: New onset type 2 diabetes - .Consult dietician for new onset DM (diabetes mellitus). Review of Resident #69's nurse's progress notes revealed an entry dated 03/07/2025 - Writer received new orders from NP for consult dietician for new onset of DM. Review of Resident #69's medical record failed to reveal RD consult. During an interview on 04/02/2025 at 10:55 a.m. S2 ADON (Assistant Director of Nursing) reported she was unable to produce an RD note for Resident #69. During a telephone interview on 04/02/2025 at 11:25 a.m. S10 RD reported she did not have any documentation requesting a consult for Resident #69.

Based on record reviews and interviews, the facility failed to provide and document sufficient preparation and orientation for 1(#70) of 1(#70) resident reviewed to ensure safe and orderly transfer or discharge from the facility. The facility failed to provide resident #70 or her responsible party with required documents; a discharge summary and plan. Findings: Review of the facility's Transfer or Discharge Preparing a Resident. (Revised December 2016) Policy and Procedure revealed in part: Policy Statement - Residents will be prepared in advance for discharge. Policy interpretation and Implementation 1. When a resident is scheduled for transfer or discharge, office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented. 2. A post discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. 3. Nursing, Social Director and Interdisciplinary Team is responsible for: b. Preparing the discharge summary and post-discharge plan. c. Preparing the medications to be discharge with the resident (as permitted by law). d. Providing the resident or representative (sponsor) with required documents (i.e., Discharge Summary and Plan). Review of resident #70's medical records revealed an admit date of 10/18/2024 and a discharge date of 01/16/2025 with the following diagnoses, including in part: multiple sclerosis, functional quadriplegia, non-pressure chronic ulcer of back with necrosis of muscle, diabetes, muscle weakness, major depression, cognitive communication deficit and hypertension. Review of resident #70's Physician Telephone Order revealed an order dated 01/16/2025 discharge home without all medications. During an interview on 04/02/2025 at 9:10 a.m. S2 ADON (Assistant Director of Nursing) reported she wrote the order dated 01/16/2025 for discharge home without all meds. Review of resident #70's medical records failed to reveal a discharge summary had been completed by the facility. Further review of resident #70's medical records failed to reveal the facility provided the required documents, the discharge summary or discharge plan to resident #70 or her (daughter) responsible party upon discharge. Review of resident #70's discharge summary with S1 ADON revealed the discharge summary was not completed. The discharge summary did not have any information filled out on the form. The discharge summary had written in large letters across the first page see EMAR (electronic medical records). S1 ADON reviewed resident #70's EMAR for notes related to the discharge summary and was unable to find any notes. During an interview on 04/02/2025 at 9:20 a.m. S1 ADON reported resident #70 was a planned discharge. S1 ADON acknowledged resident #70's discharge summary had not been completed.

Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. The facility failed to develop 1 (#69) out of 25 total sampled resident's care plan to include diagnosis and approaches for diabetes mellitus. Findings: Review of Resident #69's medical records revealed an admitted [DATE] with the following diagnoses, including in part: other sequelae of cerebral infarction, chronic obstructive pulmonary disease with (acute) exacerbation, chronic respiratory failure with hypoxia, and unspecified protein-calorie malnutrition. Type 2 diabetes mellitus diagnosis documented on nurse practitioner progress note. Review of Resident #69's comprehensive care plan failed to reveal a problem and approaches for diagnosis of type 2 diabetes mellitus. Review of Resident #69's Nurse Practitioner (NP) progress notes dated 03/07/2025 revealed: Acute/Follow-Up - Chief Complaint / Nature of Presenting Problem: Lab reviewed with elevated A1c .Plan: New onset type 2 diabetes . During an interview on 04/02/2025 at 11:40 a.m. S9 Care Plan Nurse reported Resident #69's care plan did not include a problem or approaches for type 2 diabetes mellitus. During an interview on 04/02/2025 at 2:10 p.m. S3 Administrator acknowledged Resident #69's type 2 diabetes mellitus diagnosis was not on the comprehensive care plan and should be added.

Based on record review, observation, and interview, the facility failed to ensure proper infection control techniques were practiced to prevent urinary tract infection for 1 (#17) of 1 (#17) residents observed during incontinence care. Findings: Review of Resident #17's medical records revealed an admitted [DATE] with the following diagnoses, including in part: other idiopathic peripheral autonomic neuropathy, obesity, age-related physical debility, myalgia/unspecified site, and primary generalized osteoarthritis. Review of Resident #17's MDS (Minimum Data Set) Assessment with an assessment reference date of 02/24/2025 revealed in part: -BIMS (Brief Interview for Mental Status = 05 out of 15 indicating severe cognitive impairment; -required extensive assistance with 2+ persons physical assistance for bed mobility and transfers, and total dependence with 2+ persons physical assistance for toilet use, and was frequently incontinent of bowel and bladder. Observation on 04/01/2025 beginning at 11:25 a.m. revealed S7 CNA (Certified Nursing Assistant) performed incontinence care on Resident #17 assisted by S8 CNA. S7 CNA cleaned the resident's front side perineal area wiping from front to back, repeatedly using the same contaminated section of the cloth before changing to a clean section of the cloth. The resident was turned and S7 CNA was further observed to clean the resident's back side perianal area wiping from front to back repeatedly using the same contaminated section of the cloth used to clean the front side. During an interview on 04/01/2025 at 11:41 a.m. S7 CNA confirmed she did not use a clean section of the cloth for each wipe during Resident #17's incontinence care and should have. S7 CNA further confirmed she used the same cloth to clean both Resident #17's front side and back side and should not have.

Based on observations, interviews and record reviews, the facility failed to ensure assessments were accurate for 1 (#2) of 3 (#1, #2 and #3) sample residents. The facility failed to ensure resident #2's annual MDS (minimum data set) with ARD (assessment reference date) 04/30/2024 accurately reflected resident #2's self-care abilities. Findings: Review of resident #2's clinical records revealed diagnoses of other sequelae of cerebral infarction, gross hematuria, type 2 diabetes mellitus, and dysphagia following cerebral infarction, unspecified dementia, and moderate with behavioral disturbance, hematuria, acute kidney failure, unspecified, chronic kidney disease, and stage 3 chronic kidney disease Review of resident #2's annual MDS with ARD 04/30/2024 revealed Section GG - Functional Abilities Self-Care assessment indicating Resident #2 is independent in his ability to eat, perform oral hygiene, toileting hygiene, self-showering /bathing and dressing upper and lower body. Review of Occupational Therapy Evaluation & Plan of Treatment with Certification Period: 05/10/2024 - 06/08/2024 revealed resident #2 is a fall risk, unsteady when standing and walking. Functional skills assessment - ADL (Activities of Daily Living) & Instrumental ADLs indicates resident #2 requires partial/moderate assistance with eating. Requires substantial/maximal assistance with oral care, transfers, personal hygiene, and bathing/showering, dressing upper and lower body. Further review revealed resident #2's self-care functional score equals 3 (score 0-12; 12 being the highest function). During an interview 05/13/2024 at 09:15 a.m. S3 CNA (Certified Nursing Assistant) reported he does everything for resident #2. S3 CNA reported resident #2 is able to feed himself, he requires assistance with all of his ADL's. S3 CNA reported he dresses resident #2, baths him, and performs his oral care. During an interview on 05/14/2024 at 10:30 a.m. S2 LPN (Licensed Practical Nurse)) reported resident #2 can walk with assistance. S2 LPN reported resident #2 has gotten weaker since his admission and it may be due to him being confused and having dementia. S2 LPN reported resident #2 is unable to perform any ADL care on his own he requires total assistance with all of his ADLs. During an interview on 05/15/2024 at 11:00 a.m. S1 DON (Director of Nursing) reviewed resident #2's annual MDS and acknowledged the assessment was not accurate. S1 DON reported resident #2 was not independent for any of his self-care during the annual MDS assessment. S1 DON reported resident #2 requires assistance with all of his ADLs and this assessment does not give a true picture of his abilities.

Based on record review and interview, the facility failed to ensure a Discharge Minimum Data Set (MDS) assessment was completed timely for 1 (Resident #32) out of 18 (Resident #9, #13, #15, #20, #30, #32, #34, #40, #43, #44, #53, #56, #59, #60, #69, #70, #72, and #73) sampled residents investigated. Findings: Review of Resident #32's medical record revealed Resident #32 was admitted on [DATE] and discharged from the facility on 10/23/2023. Review of Resident #32's Discharge MDS dated [DATE] revealed a completion date of 02/22/2024 and a transmission date of 02/29/2024. Review of Resident #32's medical record failed to reveal a Discharge MDS assessment was completed and transmitted within 14 days after the resident was discharged from the facility. During an interview on 03/06/2024 at 11:20 a.m., S5MDS Coordinator acknowledged Resident #32's 10/23/2023 Discharge MDS was not completed and transmitted within 14 days of discharge and should have been.

Based on observations, interviews and record reviews, the facility failed to ensure a plan of care had been developed for 4 (#56, #69, #70 and #72) residents. The facility also failed to ensure a plan of care had been implemented for 1 (#40 ) resident. This was out a total of 24 sampled residents whose plan of care had been reviewed. The facility failed to: 1. Develop a plan of care for Residents #56, #69, #70 and #72. 2. Implement the plan of care for Resident #40. Findings: Resident #56 Review of Resident #56's medical record revealed an admitted [DATE] with the following diagnoses in part: end stage renal disease, diabetes mellitus type 2 with diabetic chronic kidney disease, dependence on renal dialysis, and congestive heart failure. Review of Resident #56's Quarterly MDS (Minimum Data Set) dated 01/19/2024 revealed Resident #56 had a BIMS (Brief Interview for Mental Status) score of 7 indicating severely impaired cognition. Review of Resident #56's Physician Orders dated 02/29/2024 revealed an order for Clindamycin 300mg (milligrams), give 1 capsule PO (by mouth) tid (three times a day) for an infection for 5 days. Review of Resident #56's MAR (Medication Administration Record) revealed an order for the antibiotic, Clindamycin 300 mg, three times a day for an infection for 5 days with a start date of 02/29/2024. Review of Resident #56's Nurses Notes dated 03/05/2024 revealed Resident #56 was seen on 02/29/2024 with left arm infection and was started on Clindamycin. Review of Resident #56's Comprehensive Care Plan failed to reveal a care plan had been developed for antibiotic use and an infection to left arm. Observation on 03/06/2024 at 12:00 p.m. revealed Resident #56 with a dressing to her left arm. During an interview on 03/04/2024 at 1:22 p.m. Resident #56 reported she was on antibiotics for an infection on her left arm. During an interview on 03/06/2024 at 1:50 p.m. S5 MDS Coordinator, reported Resident #56 was not care planned for antibiotic use or skin/wound/infection and should have been. Resident #69 Review of Resident #69's medical record revealed an admitted [DATE] with the following diagnoses, in part: type 2 diabetes mellitus without complications, major depressive disorder/single episode/unspecified, bipolar disorder/unspecified, other schizoaffective disorders, chronic obstructive pulmonary disesase (COPD) and non-traumatic ischemic infarction of muscle/left upper arm/right upper arm. Review of Resident #69's MDS assessment dated [DATE] revealed medications received: 7/7 days of Insulin injections, received during the last 7 days antipsychotic, antidepressant, and diuretic. Review of Resident #69's Comprehensive Care Plan failed to reveal problem and approaches for type 2 diabetes mellitus, bipolar disorder/medication, depression/medication, hypertension, chronic obstructive pulmonary disesase and anticoagulant therapy. Review of Resident #69's Physician's Orders revealed the following orders: 02/28/2024 - Lantus subcutaneous solution 100unit/ml (milliliter) inject 28 unit subcutaneously at bedtime 02/02/2024 - Insulin Aspart injection solution inject as per sliding scale . 12/21/2023 - Trazadone HCL (hydrochloride) tablet 50mg give 1 tablet by mouth at bedtime - bipolar disorder 11/27/2023 - Coreg oral tablet 6.25mg give 1 tablet by mouth two times a day - hypertension 11/02/2023 - Metformin HCL oral tablet 100mg give 1 tablet orally two times a day 10/30/2023 - Monitor for side effects of antidepressant medication every shift. Monitor for edema related to diuretic therapy every shift. Document 0=none, 1=trace, 2=2+, 3=+3, 4=pitting edema. Notify MD (Medical Director) of 3+ or greater. Monitor for behaviors every shift. 10/26/2023 - Sertraline HCL oral tablet 25mg give 1 tablet by mouth one time a day - major depressive disorder. Seroquel oral tablet 400mg give 1 tablet by mouth one time a day - bipolar disorder. Lasix oral tablet 40mg give 1 tablet by mouth one time a day - COPD. Spironolactone oral tablet 25mg give 1 tablet by mouth one time a day - COPD. Entresto oral tablet 24-26mg give 1 tablet by mouth two times a day - hypertension. Amlodipine Besylate oral tablet 10mg give 1 tablet by mouth one time a day - hypertension. During an interview on 03/06/2024 at 9:30 a.m. S5 MDS Coordinator acknowledged Resident #69 was not care planned for diabetes, major depressive disorder receiving antidepressant, bipolar disorder and other schizoaffective disorders receiving antipsychotics, receiving anticoagulant therapy, chronic obstructive pulmonary disease, and hypertension and should be. Resident #70 Review of Resident #70's medical record revealed an admitted [DATE] with the following diagnoses, in part: cardiovascular accident, essential hypertension, weakness, lack of coordination and abnormalities in gait and mobility. Review of Resident #70's MDS revealed a BIMS score of 14 indicating intact cognition. During an interview on 03/04/2024 at 9:13 a.m., Resident #70 stated, I am doing good except for the pain in my left knee; they have been giving me Ibuprofen but it is not working. During an interview on 03/06/2024 8:30 a.m., S6 LPN (licensed practical nurse) reported Resident #70 had chronic pain to her left knee and had just completed a 5 day regimen of Ibuprofen 600 mg routinely for 5 days and she routinely gets Voltaren gel for left knee pain. Review of Resident #70's Comprehensive Care Plan failed to reveal a problem or approaches related to Resident #70's left knee pain. During an interview on 03/06/2024 at 9:30 a.m., S6 MDS Coordinator reported being made aware of Resident #70's left knee pain. S6 MDS Coordinator confirmed failing to include a problem and approaches in Resident #70's plan of care that addressed Resident #70's left knee pain. Resident #72 Review of Resident #72's medical records revealed an admitting diagnosis of COPD dated 02/01/2024. Review of Resident #72's Physician Orders revealed an order dated 02/01/2024 for O2 (Oxygen) 2L (liters) per NC (nasal cannula). Review of Resident #72's Comprehensive Care Plan revealed an initiated date of 03/05/2024 for emphysema/COPD. Observation on 03/05/2024 at 9:00 a.m. revealed Resident #72 with O2 at 2L per NC. During an interview on 03/06/2024 at 9:50 a.m. S5 MDS Coordinator confirmed Resident #72 had an admitting diagnosis of COPD and should have developed a care plan for COPD and oxygen use on admit and was not. Resident #40 Review of Resident #40's medical record revealed an admitted [DATE] with a diagnosis of but not limited to stage 4 pressure ulcer to sacrum, type 2 diabetes, diabetic neuropathy, cognitive communication deficit, unspecified dementia, muscle wasting and atrophy, and gastrostomy. Review of Resident #40's Quarterly MDS dated [DATE] revealed Resident #40 had a BIMS score of 6 indicating severely impaired cognition. Review of Resident #40's comprehensive plan of care revealed a resolved problem of: I have an unstageable pressure ulcer to my right heel (resolved 11/02/2023). Review of Resident #40's March 2024 Physician Orders revealed an order dated 10/30/2023: Heel Protectors to both feet while in bed. Observation on 03/06/2024 at 8:50 a.m. with S6 LPN revealed Resident #40 did not have on heel protectors while in bed and Resident #40's heels were touching. Further observation revealed Resident #40's heel protectors were in the closet. During an interview on 03/06/2024 at 8:50 a.m. S6 LPN reported the certified nursing assistants should have put Resident #40's heel protectors on while Resident #40 was in bed. During an interview on 03/06/2024 at 10:00 a.m. S2 DON (Director of Nursing) confirmed Resident #40 should have had heel protectors put on while in bed as ordered by the physician. 36665 40193

Based on record review and interview, the facility failed to ensure residents were free of unnecessary medications for 1 (#15) out of 6 (#15, #20, #30, #34, #40, #69) sampled residents reviewed for unnecessary medications. The facility failed to monitor Resident #15 for edema while receiving a diuretic. Findings: Review of Resident #15's Medical Records revealed an admitted [DATE] with the following diagnoses, in part: type 2 diabetes mellitus without complications, congestive heart failure, other symptoms and signs involving the genitourinary system, obstructive and reflux uropathy/unspecified other viral pneumonia. Review of Resident #15's Physician's Orders revealed orders dated 01/05/2024 - Bumetanide oral tablet 1mg (milligram) give 1 tablet by mouth one time a day and Spironolactone oral tablet 100mg give 1 tablet by mouth one time a day. Review of Resident #15's January - March 2024 Medication Administration Records and Treatment Administration Records failed to reveal monitoring for edema. During an interview on 03/06/2024 at 10:35 a.m., S2 DON (Director of Nursing) acknowledged edema was not monitored for Resident #15 for January, February and March while receiving a diuretic.

Based on record reviews and interviews, the facility failed to ensure a resident's medical record was complete and accurately documented in accordance with accepted professional standards and practices for 3 (Resident #9, #43, #60) of 4 (Resident #9, #40, #43, and #60) residents reviewed for wounds. Findings: Review of facility's Wound Care policy with a revision date of November 2017 revealed in part: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Documentation: The following information should be recorded in the resident's medical record: 1. They type of wound care given. 2. The date and time the wound care was given. 3. The name and title of the individual performing the wound care. 8. The signature and title of the person recording the data. Resident #9 Review of Resident #9's medical record revealed an admitted d of 03/31/2023 with the following medical diagnoses, in part: restlessness and agitation, mild protein-calorie malnutrition, muscle weakness, and pain. Review of Resident #9's physician order revealed in part: 02/24/2024 Right buttock: order to cleanse with wound cleanser pat dry, apply Medihoney and calcium alginate, and cover with dry dressing once daily and as needed until resolved. 02/20/2024 Pro-Stat oral liquid, give 30ml (milliliters) by mouth, one time a day, to promote healing. Review of Resident #9's January 2024 TAR (Treatment Administration Record) revealed wound care to right buttock was not documented on the following days: 01/01/2024, 01/06/2024, 01/08/2024, 01/15/2024, 01/17/2024, 01/19/2024, 01/23/2024, 01/26/2024, 01/29/2024, and 01/30/2024. Review of Resident #9's February 2024 TAR revealed wound care to right buttock was not documented on the following days: 02/02/2024, 02/04/2024, 02/06/2024, 02/06/2024, 02/07/24, 02/17/2024, and 02/23/2024. Review of Resident #9's March 2024 TAR revealed wound care to right buttock was not documented on the following days: 03/01/2024, 03/02/2024, and 03/03/2024. During an interview on 03/05/2024 at 3:55 p.m., after reviewing January, February, and March 2024 TARs, S3Corporate Nurse confirmed dates were missing from Resident #9's TAR of Wound Care being performed and the nurses should have documented on the TAR. Resident #43 Review of Resident #43's medical record revealed an admitted [DATE] with the following medical diagnoses, in part: contracture of muscles, multiple sites, type 2 diabetes mellitus, pressure ulcer of left hip, stage 4 and pressure ulcer of sacral region, stage 4. Review of Resident #43's physician orders revealed in part: 02/14/2024 Sacrum: Cleanse wound with wound cleanser, pat dry, apply Bactroban, apply wet to dry Dakin's and cover with dry dressing once daily and as needed until resolved. 01/31/2024 Left Hip: Cleanse wound with wound cleanser, pat dry, apply calcium alginate and collagen, cover with dry dressing once daily and as needed until resolved. Review of Resident #43's January 2024 TAR revealed wound care to sacrum and left hip was not documented on the following days: 01/06/2024, 01/08/2024, 01/15/2024, 01/17/2024, 01/19/2024, 01/23/2024, 01/26/2024, 01/29/2024 and 01/30/2024. Review of Resident #43's February 2024 TAR revealed wound care to sacrum and left hip was not documented on the following days: 02/02/2024, 02/03/2024, 02/04/2024, 02/06/2024, 02/07/2024, 02/14/2024, 02/17/2024, and 02/23/2024. Review of Resident #43's March 2024 TAR revealed wound care to sacrum and left hip was not documented on the following days: 03/01/2024, 03/02/2024 and 03/03/2024. During an interview on 03/05/24 at 3:55 p.m., S3Corporate Nurse confirmed there was missing documentation of wound care for Resident #43 and wound care should have been documented on the TAR. During an interview on 03/06/2024 at 9:00 a.m. S4Treatment Nurse and S1Administrator reviewed and Resident #43's January - March 2024 TARs and acknowledged wound care had not been documented daily and should have been. Resident #60 Review of Resident #60's medical record revealed admitted [DATE] with the following medical diagnoses, in part: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus without complications, peripheral vascular disease/unspecified, congestive heart failure and moderate protein-calorie malnutrition. Review of Resident #60's physician's orders revealed in part: 02/21/2024 - right heel: paint with betadine, wrap foot with dressing once daily and as needed unit resolved one time a day and as needed if dressing is soiled. 02/09/2024 - side of right stomp: cleanse with wound cleanser, pat dry, apply xeroform to side of stomp over bone cover with dry gauze once daily and as needed until resolved one time a day and as needed. Top of right stump: wet to dry with betadine over open area to top of stomp, cover with dry gauze once daily and as needed until resolved one time a day and as needed. 02/06/2024 - sacrum: cleanse with wound cleanser, pat dry, apply collagen and calcium alginate and cover with dry dressing once daily and as needed until resolved. 01/18/2024 - sacrum: cleanse with wound cleanser, pat dry, apply Santyl and calcium alginate and cover with dry dressing once daily and as needed until resolved one time a day. Review of Resident #60's January - March 2024 TARs revealed wound care was not documented on the following days: 01/15/2024, 01/17/2024, 01/23/2024,01/25/2024, 01/26/2024, 01/29/2024, 01/30/2024, 02/02/2024, 02/04/2024, 02/04/2024, 02/06/2024, 02/07/2024, 02/14/2024 and 02/17/2024. During an interview on 03/06/2024 at 1:00 p.m. S3Corporate Nurse acknowledged the documentation for wound care was missing for Resident #60. 40193 44414

Based on record review and interview the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Findings: Review of the Payroll-Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 2, 2023 (January 1-March 31) revealed in part excessively low weekends staffing was triggered as an area of concern. Review of Weekend Staffing Pattern Form provided by S1 Administrator for fiscal year Quarter 2, 2023 (January 1-March 31) revealed 12 dates during the 2nd quarter with deficits in the hours provided versus hours required for care and treatment of residents. Saturday 01/07/2023 hours required=145.7, hours provided=138.07 Sunday 01/08/2023 hours required=145.7, hours provided=138.07 Saturday 01/14/2023 hours required=145.7, hours provided=139.49 Saturday 02/04/2023 hours required=157.45, hours provided=138.68 Sunday 02/05/2023 hours required=157.1, hours provided=146.07 Saturday 02/11/2023 hours required=158.75, hours provided=108.03 Sunday 02/12/2023 hours required=152.4, hours provided=131.10 Saturday 02/18/2023 hours required=157.45, hours provided=124.18 Sunday 02/19/2023 hours required=156.10, hours provided=139.91 Saturday 03/04/2023 hours required=151.4, hours provided=150.49 Sunday 03/05/2023 hours required=151.4, hours provided=135.14 Saturday 03/18/2023 hours required=164.5, hours provided=151.07 During an interview on 07/18/2023 at 1:00 p.m. S1 Administrator reviewed the Weekend Staffing Pattern Form related to fiscal year Quarter 2, 2023 (January 1-March 31) and confirmed there was a deficit in the hours provided according to the hours required for care and treatment of residents. During an interview on 07/19/2023 at 10:30 a.m. S1 Administrator and S3 DON (Director of Nursing) reviewed the Weekend Staffing Pattern Form and confirmed the low staffing for the 12 weekend dates during the 2nd quarter did not meet the hours provided versus hours required for care and treatment of residents.

Based on record review and interviews, the facility failed to ensure an RN (Registered Nurse) was on duty for 8 consecutive hours per day for 1 of 14 days reviewed for RN staffing hours. This deficient practice had the potential to affect all of the 69 residents residing in the facility according to the facility's Resident Census Report. Findings: Review of the Staffing Pattern Form provided by S1 Administrator revealed the facility had no RN coverage for at least 8 consecutive hours on Sunday 07/02/2023. During an interview on 07/18/2023 at 3:00 p.m. S3 DON (Director of Nursing) reviewed the Staffing Pattern Form and confirmed the facility had no RN coverage for at least 8 consecutive hours on 07/02/2023. During an interview on 07/19/2023 at 10:30 a.m. S1 Administrator and S3 DON reviewed the Staffing Pattern Form and confirmed the facility had no RN coverage for at least 8 consecutive hours on Sunday 07/02/2023.

Based on observations, record review and interviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infection as evidenced by staff failing to follow the policy for use of the required Personal Protective Equipment (PPE) for 1 resident (#3) out of 3 (#1, #3, #4) residents on transmission based precautions (TBP). This deficient practice had the potential to affect all of the facility's 69 residents. Findings: Review of the facility Isolation Policy dated September 2022 revealed in part: Policy Interpretation and Implementation: 2. Transmission-Based Precautions are additional measures that protect staff, visitors and other residents from becoming infected. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door . so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC (Centers for Disease Control) precaution(s), instructions for use of PPE, . before entering the room. -Contact Precautions: 1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. 2. Contact precautions are also used in situations .that suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, . 7. Staff and visitors wear gloves (clean, non-sterile) when entering the room. 8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing During an interview on 7/17/2023 at 10:40 a.m. S1 Administrator reported 3 residents were currently on TBP due to a recent scabies outbreak. Review of resident #3's medical record revealed an admitted [DATE] with diagnoses that include in part Hemiplegia following cerebral infarction affecting left non-dominant side, scabies, dysphasia, aphasia, major depressive disorder, cognitive communication deficit, seizures, metabolic encephalopathy, and Alzheimer's disease. Observation on 07/17/2023 at 8:00 a.m. revealed signage posted on resident #3's closed room door indicating TBP were in effect including information on correct PPE use for contact precautions, and a cart with PPE's noted just outside the room door. Observation on 7/19/2023 at 8:30 a.m. revealed S2 CNA (Certified Nurse Assistant) seated and feeding resident #3 wearing an untied yellow protective gown that hung down to her lower chest leaving S2 CNA's torso unprotected. Further observation revealed S2 CNA was not wearing gloves. During an interview on 7/19/2023 at 8:35 a.m. S2 CNA confirmed resident #3 was on contact precautions due to a diagnosis of scabies. During an interview on 07/19/2023 at 8:40 a.m. S1 Administrator donned PPEs and observed S2 CNA feeding resident #3 and confirmed S2 CNA was not following the policy for proper PPE use while caring for a resident on contact isolation and should have been. During an interview on 07/19/2023 at 11:25 a.m. S2 CNA confirmed she was not following the policy for proper PPE use while caring for resident #3 who remained on contact isolation and should have been.

Based on record reviews and interview the facility failed to ensure State Registry verifications were completed prior to hire for 4 [S8 CNA (Certified Nursing Assistant), S9 CNA, S10 CNA, S11 Therapy] of 5 employees whom personnel files were reviewed. Findings: 1. Review of S8 CNA's personnel file revealed a hire date of 03/28/2022. Review of S8 CNA's personnel file revealed Criminal Background and Sex Offender Registry checks were completed on 03/29/2023. Further review of S8 CNA's personnel file revealed Adverse Reaction and CNA Registry checks were completed on 03/31/2022. 2. Review of S9 CNA's personnel file revealed a hire date of 03/22/2023. Further review of S9 CNA's personnel file revealed Adverse Actions and CNA Registry checks were completed on 03/30/2023. 3. Review of S10 CNA's personnel file revealed a hire date of 03/08/2023. Review of S10 CNA's personnel file revealed CNA Registry check was completed on 03/09/2023 and Adverse Actions check was completed on 04/24/2023 4. Review of S11 Therapy's personnel file revealed a hire date of 03/02/202. Further review of S11 Therapy's personnel file revealed Criminal Background and Sex Offender Registry checks were completed on 04/01/2021. During an interview on 04/25/2023 at 12:50 p.m., S1Administrator and S6 Corporate Nurse acknowledged State Registry verification checks had not been completed prior to hire date and should have been.

Based on observations and interviews the facility failed to ensure food was served in accordance with professional standards for food service safety for the 62 residents served a meal tray from the kitchen. There were a total of 62 residents receiving meal trays from the kitchen according to the Resident Census and Conditions of Residents form dated 04/23/2023. Findings: Review of facility's Food Holding and Service Policy revealed in part: Procedure: 7. Take and record temperatures of all hot foods and cold foods at the beginning and at mid-point of tray service . Review of the facility's Daily Food Temperature Monitoring Logs for April 2023 revealed: 04/04/2023 - Temperatures for Dinner meal had not been monitored. 04/14/2023 - Temperatures for Lunch meal had not been monitored. 04/17/2023 - Temperatures for Dinner meal had not been monitored. 04/18/2023 - Temperatures for Dinner meal had not been monitored. 04/19/2023 - Temperatures for Dinner meal had not been monitored. 04/20/2023 - Temperatures for Dinner meal had not been monitored. 04/21/2023 - Temperatures for Breakfast, Lunch and Dinner meals had not been monitored. During an interview on 04/23/2023 at 12:10 p.m. S12 Dietary Manager acknowledged food temperatures had not been monitored every meal and should have been. During an interview on 04/23/2023 at 12:20 p.m. S13 Registered Dietician acknowledged food temperatures had not been monitored every meal and should have been.

Based on record review, observations and interviews, the facility failed to ensure staff practices were consistent with current infection control principles to prevent infection and cross contamination as evidenced by S4 Laundry Attendant's deficient practices during laundry observation. Review of the Resident Census and Conditions form dated 4/23/2023 revealed a census of 68. Findings: Review of the facility's Departmental Laundry and Linen Policy revealed in part the purpose of the procedure was to provide a process for the safe and aseptic handling, washing, and storage of linen. Further review of the policy revealed staff should consider all soiled linens to be potentially infectious and handled with standard precautions, removing protective equipment used during washing procedures when leaving soiled linen area, wash hands after handling soiled linen and before handling clean linen. During an observation of the facility's laundry area on 04/23/2023 at 8:57 a.m. S3 Laundry Attendant explained the laundry process. S4 Laundry Attendant picked up a full red biohazard bag and placed the bag on the floor. S4 Laundry Attendant then pulled a full trash bag from the trashcan. S4 Laundry Attendant failed to remove contaminated gloves and perform hand hygiene prior to retrieving a clean linen cart. While demonstrating the process of removing clothes from the washing machine, S4 Laundry Attendant rolled the cart over piles of dirty laundry. Further observation revealed S4 Laundry Attendant then touched a clean cart of bed linens while continuing to wear contaminated gloves. S4 Laundry Attendant then put a trash bag in the trash can returned to the clean side of laundry area continuing to wear the same contaminated gloves and opened the lint trap doors. During an interview on 04/23/2023 at 9:00 a.m. S4 Laundry Attendant confirmed dirty laundry and red biohazard bags should not have been on the floor. During an interview on 04/23/2023 at 2:45 p.m. S4 Laundry Attendant confirmed he should have changed his gloves and performed hand hygiene after handling contaminated linen and emptying trash prior to accessing clean linens and surfaces. During an interview on 4/23/2023 at 3:00 p.m. S1 Administrator confirmed dirty linen should not have been sorted on the laundry room floor and laundry staff should have removed gloves and performed hand hygiene prior to moving from dirty laundry to clean laundry. During an interview on 04/24/2023 at 7:50 a.m. S3 Infection Preventionist confirmed dirty linen should never be placed on the floor while being sorted. S3 Infection Preventionist further confirmed S4 Laundry Attendant should have removed contaminated gloves and performed hand hygiene prior to handling clean linen or touching clean surfaces. During an interview on 4/24/2024 at 10:30 a.m. S5 Laundry Attendant confirmed she had sorted laundry on the floor in the past when sorting bins were not available. During an interview on 4/24/2023 at 2:45 p.m. S1 Administrator reported dirty laundry that has been sorted should directly be placed in the washing machine and not on the floor.