Every finding on record at Brookdale Trinity Towers

Based on observation, interview, and record review, the facility failed to establish and 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 5 residents (Resident #1) reviewed for infection control practices. The facility failed to ensure Resident #1 had an EBP sign posted outside of his room due to having a Foley Catheter.The facility failed to ensure CNA-B wore the appropriate PPE when providing care to Resident #1.These failures could place residents at risk for cross-contamination and infection.The findings included:Record review of Resident #1's face sheet, dated 07/06/2026, revealed an [AGE] year-old male with an original admission date of 06/03/2026, and a current admission date of 07/03/2026. Pertinent diagnoses included Generalized Weakness and Lack of Coordination. Record review of Resident #1's admission MDS assessment, dated 06/09/2026, revealed a BIMS score of 13, which revealed intact cognition. The admission MDS assessment also revealed Resident #1 had an indwelling catheter. Record review of Resident #1's physician order summary, reviewed 07/06/2026, revealed a current order dated 07/03/2026 for catheter care for indwelling catheter every shift. The physician order summary revealed a current order dated 07/04/2026 for enhanced barrier precautions for urinary catheter. Record review of Resident #1's care plan initiated 06/03/2026, revealed a focus for an indwelling urinary catheter. In an observation of Resident #1's room on 07/06/2026 at 12:16 PM revealed no EBP sign located on the door or wall outside of Resident #1's room, and Resident #1 had his call light on requesting assistance from the CNA to change his brief. CNA was observed entering Resident #1's room to provide assistance without putting on proper PPE prior to entering. In an interview on 07/06/2026 at 12:30 PM, Resident #1 stated he was at the facility for therapy, and he needed help with his ADLs. Resident #1 stated staff only wore gloves when they assisted him with incontinent care and bathing, but they never wore gowns. He stated he was not aware the staff were supposed to be wearing gowns when caring for him.In an interview on 07/06/2026 at 12:40 PM, LVN-A stated he believed the staff had been wearing the appropriate PPE because Resident #1 had orders for PPE, and the staff knew he had a Foley catheter. LVN-A also stated he could not say for sure if staff were wearing appropriate PPE since there was not a sign on the door, but he believed they all knew. LVN-A stated he was not sure why Resident #1 did not have an EBP sign outside of his door, but there should have been a sign since he was on EBP for a Foley catheter, and he thought the admitting nurse was the one who should have put the EBP sign on the door.In an interview on 07/06/2026 at 1:30 PM, CNA-B stated she was the one who had provided incontinent care to Resident #1 earlier, and she did not wear a gown while providing incontinent care because she wasn't aware a gown was needed at the time. CNA-B stated she typically would have looked for the sign on the wall to know if a resident was on EBP, but there was not a sign, and no one had told her in shift report Resident #1 was on EBP. In an interview on 07/06/2026 at 2:00 PM, the DON stated EBP was already in Resident #1's orders, but the admitting nurse forgot to add the sign when Resident #1 was re-admitted . The DON stated some of the staff were unaware they needed to wear PPE because there was not a sign on the door, and it had not been relayed to them the resident was on EBP, but the sign had been added to Resident #1's door, and an in-service regarding EBP procedures and precautions had been started, as well as she was auditing all residents with indwelling medical devices, infections, and/or wounds to make sure they were on proper precautions.Record review of the facility's Enhanced Barrier Precautions, revised March 2026, revealed Policy Overview: Enhanced barrier precautions should be utilized to reduce transmission of multi-drug resistant organisms that employs targeted gown and glove use during high contact resident care activities. Policy Detail: 3. Examples of Care Activities: Taking the resident to the toilet or providing peri care; Having prolonged high-contact with items in the resident's room.; Emptying drainage bag: Use hand hygiene, gown, gloves (high-contact activities). 5. EBPs are indicated with any of the following: Wounds and/or indwelling medical devices.

Based on record reviews and interviews, the facility failed to send a copy of the discharge notice, prior to the discharge, to the representative of the Office of State Long-Term Care Ombudsman for two residents (Resident #1 and Resident #2) of five residents reviewed for discharge. The facility failed to send a copy of Resident #1 and Resident #2's discharge notice, prior to discharge, to the representative of the Office of State Long-Term Care Ombudsman. These failures could have placed the residents at risk of not knowing their rights or receiving the services of the state Long Term-Care Ombudsman. Findings Included: Review of Resident #1 face sheet dated 06/04/26 revealed she was an [AGE] year-old female admitted on [DATE] with diagnosis of dysphagia (difficulty swallowing); hypertension (a chronic condition in which the force of blood against your artery wall is consistently too high); osteoporosis (a bone disease that causes bones to become weak, brittle, and highly susceptible to fractures). In an interview on 06/04/26 at 1:30 pm, Ombudsman stated she had never received discharged notices from the facility. Record Review of Resident #1 Discharge Notice dated 05/27/6 revealed a discharge date of 05/30/26. Record Review of Resident's #1 Discharge summary dated [DATE] revealed a discharge date of 05/30/26. Record Review of Resident's #1 Orders dated 05/29/26 revealed Discharge order dated 05/29/26 from [NAME] MD. Record Review of Resident's #1 Care Plan dated 05/15/26 revealed no Discharge Planning had been implemented. Review of Resident #2's face sheet dated 06/04/26 revealed she was a [AGE] year-old female admitted on [DATE] with diagnosis that included chronic obstructive pulmonary disease (a progressive, incurable lung disease that restricts airflow and making breathing difficult), Acute Respiratory Failure (respiratory system suddenly fails to oxygenate the blood), Syncope (fainting or passing out).In an interview on 06/04/26 at 1:30 pm, Ombudsman stated she had never received discharged notices from the facility. Record Review of Resident's #2 MDS Comprehensive MDS dated [DATE] revealed a BIMS Score of 12. Record Review of Resident's #2 discharged Notice dated 05/04/26 revealed a discharged date of 05/08/26. Record Review of Resident's #2 discharged Summary dated 05/04/26 revealed a discharged date of 05/08/26. Record Review of Resident's #2 Care Plan dated 03/25/26 revealed no Discharge Planning had been implemented. In an interview on 06/04/26 at 2:40 pm, Discharge Planner stated she only notified the Ombudsman of unplanned; she did not notify the Ombudsman of Resident #1 and #2 discharges. In an interview on 06/04/26 at 4:10 pm, Assistant Director of Clinical Services stated, I already know we do not notify the Ombudsman. She stated it was because the Administrator was of the understanding the Ombudsman only needed to be notified of emergencies, unplanned or difficult cases. She stated that facility policy states, the facility is to notify the Ombudsman at the time of discharge notice is provided to the Resident or Resident Representative; or as soon as practicable on an emergency discharge. In an interview on 06/04/26 at 4:45 pm, Administrator stated, Ombudsman not being notified was due to ignorance on my part, oversight on my part. Review of facility policy dated August 2023 entitled Resident Transfer and Discharge reflected: D. Notice before Transfer 2. A copy of the notice should be sent to the representative of the Office of the State Long-Term Care Ombudsman at the time the notice is provided to the resident and the resident representative, or as soon as practicable after an emergency transfer or discharge. The discharge must include:Contact information of the managing local ombudsman and the toll-free number for the Long-Term Ombudsman Program.

Based on Record reviews and interviews, the facility failed to ensure that one resident (Resident #2) of five residents discharged did not receive the required 30-day notice of discharge. The facility failed to ensure Resident #2 was given a 30-day discharge notice. Resident #2 was discharge on [DATE]. The failure could put residents at risk for inappropriate discharge from the facility and cause psychological harm due to feelings of anger and sadness. This failure could place discharged residents at risk of being discharged from the facility causing a disruption in their care and/or services The findings included: Review of Resident #2's face sheet dated 06/04/26 revealed she was a [AGE] year-old female admitted on [DATE] with diagnosis that included chronic obstructive pulmonary disease (a progressive, incurable lung disease that restricts airflow and making breathing difficult), Acute Respiratory Failure (respiratory system suddenly fails to oxygenate the blood), Syncope (fainting or passing out). Record Review of Resident's #2 MDS Comprehensive MDS dated [DATE] revealed a BIMS Score of 12. Record Review of Resident's #2 discharged Notice dated 05/04/26 revealed a discharged date of 05/08/26. Record Review of Resident's #2 discharged Summary dated 05/04/26 revealed a discharged date of 05/08/26. Record Review of Resident's #2 Care Plan dated 03/25/26 revealed no Discharge Planning had been implemented. In an interview on 06/04/26 at 2:40 pm, Discharge Planner stated she only notified the Ombudsman of unplanned; she did not notify the Ombudsman of Resident #1 and #2 discharges. In an interview on 06/04/26 at 2:40 pm, Discharge Planner stated the facility received a discharged notice from the insurance company which gave the facility three days to discharge the resident. She stated she informed the FM of discharge the day she received notification from the insurance company. She stated she gave the FM notification via email and telephone according to the insurance time frame and not the 30-day notice as per facility policy. In an interview on 06/04/26 at 4:10pm, Assistant Director of Clinical Services stated a three-day notice of discharge was given to the FM; facility policy stated the FM or Resident must be given a 30-day discharge notice. In an interview on 06/04/26 at 4:45pm, Administrator stated the discharge was initiated the day the insurance company gave the 3-day notice of benefits ending. She stated the FM was notified of the 3-day notice of discharge and that if they chose to stay until the end of the 30 day notice it would be private pay. Review of facility policy dated August 2023 entitled Resident Transfer and Discharge reflected: F. Timing of Notice 1. Notice should be provided at least 30 days prior to the transfer or discharge. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because: a) The resident's welfare is at risk, and his or her needs cannot be met in the community (i.e., emergency transfers to an acute care facility); or b) The health or safety of others in the community is endangered.

Based on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 6 residents (Resident #1) reviewed for medical records.The facility failed to document the amount of food Resident #1 ate during her 3 meals per day for 10 times from March 1st through March 15th, 2026. This failure could place residents at risk of not receiving proper care or having needs met due to inappropriate documentation.The findings included:Record review of Resident #1's face sheet, dated 05/19/26, revealed a [AGE] year-old female, admitted [DATE] and discharged [DATE]. The pertinent diagnosis included Type 1 Diabetes (chronic autoimmune disease where the body's immune system attacks insulin-producing cells in the pancreas). Record review of Resident #1's admission MDS Assessment, dated 05/06/26, revealed a BIMS score of 13 indicating her cognition was intact. Record review of Resident #1's comprehensive care plan, dated 05/16/26, revealed the focus The resident has Diabetes Mellitus initiated on 04/15/26. An intervention listed for the focus included Dietary consult for nutritional regimen and ongoing monitoring initiated on 04/15/26. Record review of Resident #1's EHR on 05/19/26 revealed several meals had not been documented by staff during March 2026. Resident #1 had only 1 meal documented on 05/02/26, 05/04/26, 05/06/26, 05/07/26, 05/08/26, 05/10/26, 05/11/26, and 05/13/26. Resident #1 had only 2 meals documented on 05/03/26 and 05/09/26. During an interview with CNA A at 9:38 A.M. on 05/21/26, CNA A stated the CNAs recorded the amount of food eaten by residents during their meals in the residents' EHR. CNA A stated if the amount was less than 50% then she reported it to the nurse. CNA A stated it was important to document the amount of food eaten by the residents to help manage their weight gain or weight loss. During an interview with CNA B at 10:14 A.M. on 05/21/26, CNA B stated the CNAs charted the percentage of food eaten during meals in the residents' EHR. CNA B stated if the amount was less than 50% she reported it to the nurse. CNA B stated it was important to document the amount of food eaten by the residents to help manage their weight gain or weight loss. During an interview with the DON at 4:40 P.M. on 05/21/26, the DON stated staff recorded the amount of food eaten by residents for breakfast, lunch, and dinner every day. The DON stated it was typically the CNAs that input the information into the EHR. The DON stated she reviewed Resident #1's food consumption record and found several entries were missing. The DON stated it was important to document how much food was being eaten by the residents to prevent weight loss or weight gain, ensure they received adequate macronutrients, and help manage glucose in residents with diabetes. Record review of the facility policy titled Routine Clinical Documentation, revised 03/26, revealed the following policy: After admission, all services routinely provided to the resident will be documented in the resident's medical record, regardless of payor source.Policy DetailCertified Nursing Assistant (CNA):Daily:Activities of daily livingAmount eaten.Measured intake and output, as indicated

Based on observation and interviews, the facility failed to establish and 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.The facility failed to ensure infusion therapy supplies were stored under sterile conditions in the 4th floor medication storage room.The facility failed to ensure used oxygen equipment was not stored in the 4th floor medication storage room.These failures could place residents at risk of cross contamination and infection.The findings included:An observation of the 4th floor medication room on 04/30/26 at 11:00 am reflected unused IV infusion tubing that had been removed from the packaging laying in the bottom of a drawer that contained various other properly packaged and sterile supplies. This observation also reflected a 340 ml bottle of sterile water used for oxygen humification in the back left corner of the top shelf in the bottom storage cabinet. This bottle was not full and was not in a package. The humidifier bottle had an approximately 18 inch oxygen tubing connected to it at the top that would have connected the humidifier to an oxygen concentrator machine. 1/2 was written in black marker on the end that was not attached to the humidifier. The cabinet shelf contained some oxygen supplies such as nasal cannulas and oxygen masks.In an interview on 04/30/26 at 11:37 am, the ADON stated there should not have been any opened or used supplies in the storage room and she was not sure why they were there or why they had not been discarded. She stated it was everyone's responsibility to ensure used or unsterile supplies were disposed of properly.In an interview on 04/30/26 at 5:40 pm, the IP stated IV infusion tubing was not supposed to be used if it was out of the packaging and sat in a drawer. She stated IV tubing was to be used immediately upon being removed from the packaging. The IP stated, if the IV tubing that was sitting out was used, a lot could happen; bacteria, infection, who knows what all the resident could be exposed to. She stated the humidifier was definitely not supposed to be in the cabinet and should have been disposed of immediately after resident use.Record review of the facility's Cleaning and Disinfection of Resident Care Items and Equipment Policy dated 07/2019 reflected in part: d. ii. Single-use items are disposed of after a single use.7. Disposable resident care equipment and supplies shall be immediately discarded after use.

Based on interviews and record reviews the facility failed to ensure a resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, and maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or the resident preferences indicate otherwise for 1 (Resident #70) of 7 residents reviewed for nutritional status.The facility failed to ensure Resident #70 was weighed weekly for 3 weeks after admission per physician's orders. This failure could place residents at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in quality of life.The findings included:Record review of Resident #70's admission Record reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her pertinent diagnoses included fracture of the superior rim of the left pubis, (a break in one or more of the bones that make up the pelvis), muscle weakness (a sensation of imbalance or difficulty maintaining steady posture while standing or walking), and lack of coordination (difficulty in controlling and executing smooth, purposeful movements). Record review of Resident #70's MDS dated [DATE] reflected a BIMS score of 4 which indicated severe cognitive impairment.Record review of Resident #70's Care Plan dated 04/02/26 reflected she had a nutritional problem or potential nutritional problem which was initiated on 04/02/26 and revised on 04/28/26. The goal was the resident would have no significant weight loss or weight gain through the review date, initiated on 04/02/26 with target date of 04/29/26. Interventions included monitor intake and record, monitor/document/report to MD for s/sx of dysphagia (difficulty swallowing) and provide and serve diet as ordered, initiated on 04/02/26. Record review of Resident #70's Order Summary Report on 04/29/26, reflected the following physician orders: Weight on admission, repeat weekly x 3 weeks ordered on 04/02/26. Regular diet. Refer to diet type for texture. Regular liquids consistency ordered on 04/02/26. Refer to Registered Dietician ordered on 04/02/26. Lasix Oral Tablet 40mg. Give 1 tablet by mouth one time a day for edema started on 04/15/26.Record review of Resident #70's progress notes reflected a physician note dated 04/14/26 that stated in part, The patient was seen sitting in her chair. She reports increased swelling to her legs causing discomfort.Record review of Resident #70's Weight Summary on 04/29/26 reflected an admission weight of 145.0 lbs. on 04/02/26, a weight of 144.2 lbs. on 04/10/26 and a weight of 133.6 lbs. on 04/18/26. The third and final weight was not obtained by facility staff. In an interview on 04/30/26 at 5:55 pm, the ADON stated all residents were weighed on admission by the admitting nurse. She stated the weight orders were entered into the TARS and indicated which residents needed to be weighed and when they needed to be weighed. She stated she and the DON provided oversight and confirmed weights were completed with a generated weight report. The ADON stated she did not know why Resident #70's final weight was not obtained and had to look at her medical record. She stated the facility monitored and kept track of nutritional and medical problems that were triggered by weight fluctuations because it could result in medical complications including death if a resident lost or gained too much weight.Record review of the facility's Weight and Height Policy dated 07/2015 and revised on 02/2018 reflected in part: Policy OverviewResidents should be weighed upon admission/re-admission, weekly for three weeks, and as needed. The resident's height should be obtained and documented upon admission/re-admission or as needed.Policy DetailA. Weight3. Residents will be weighed on admission/re-admission and then weekly for three weeks, monthly or as needed thereafter.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 7 residents (Resident #60) reviewed for care plans. The facility failed to ensure Resident #60's care plan reflected her ADLs with assistance needed.This failure could place the residents at risk of not receiving appropriate interventions and care to meet their needs.Findings included:Record review of Resident #60's face sheet, dated 04/28/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: congestive heart failure (long-term condition that affects the heart's ability to pump blood), major depressive disorder (mental health condition with persistent feelings of sadness, loss of interest, various emotional/physical problems), chronic kidney disease (condition that affects the kidneys' ability to filter waste from the blood), muscle wasting and atrophy (reduction in muscle mass and strength), and unspecified osteoarthritis (progressive, degenerative joint disease that can cause pain, stiffness, and loss of mobility). Record review of Resident #60's MDS assessment, dated 04/16/26, reflected a BIMS score of 3, indicating severe cognitive impairment. The MDS reflected Resident #60 was substantial/maximal assistance for eating and oral hygiene. Resident #60 was dependent for toileting hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Record review of Resident #60's care plan, dated 04/28/26, reflected [Resident #60] had an ADL self-care performance deficit. Date initiated: 04/01/26. Interventions included: preferred bathing on Monday, Wednesday, Friday. Date initiated: 04/01/26. Assist with turning and repositioning during routine care and as needed. Date initiated: 04/06/26. Care plan did not reflect the ADLs with assistance needed. During an attempted interview and observation, on 04/28/26 at 1:15 PM, Resident #60 was asked basic questions and she did not respond. Resident #60 was not interviewable. Resident #60 was not injured or in distress. During an interview, on 04/30/26 at 9:20 AM, the MDS Nurse stated she was not familiar with Resident #60 as she had only been contracted with the facility as of 2-3 days ago. The MDS Nurse stated ADLs and assistance needed should have been included in the care plan. During an interview, on 04/30/26 at 9:40 AM, the ADON stated Resident #60's ADLs should have been in the care plan. The ADON reviewed Resident #60's care plan and she verified the ADLs with assistance needed were not care planned appropriately. The ADON stated there was no negative outcome for Resident #60 because staff were aware of how to care for her as they were familiar with her. The ADON stated the CNAs had tasks to follow and the nurses also followed the orders for Resident #60. The ADON stated care plans were developed and updated as a team effort. The ADON stated it was important for the care plan to be developed accurately so staff knew how to care for the resident. An interview was attempted, on 04/30/26 at 10:45 AM. The DON was unavailable as she was out of the country. A call was attempted and a voicemail was left requesting a callback. Record review of the facility's Comprehensive Care Plan policy, dated November 2017, reflected - Policy: A comprehensive, person-centered care plan will be developed for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that have been identified through a comprehensive assessment 4. Each resident's comprehensive care plan will include: a. Resident goals for care and desired outcomesb. Identified resident issues, conditions, risk factors and safety issues .f. Interventions that will be implemented to enable each resident to meet her objectives.

Based on interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission as required for 1 (Resident#70) of 7 resident records reviewed for assessment. The facility failed to complete Resident #70's comprehensive MDS assessment within 14 days following her admission to the facility on [DATE]. This failure could place newly admitted residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being.The findings included:Record review of Resident #70's admission Record reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her pertinent diagnoses included fracture of the superior rim of the left pubis (a break in one or more of the bones that make up the pelvis), muscle weakness (a sensation of imbalance or difficulty maintaining steady posture while standing or walking), and lack of coordination (difficulty in controlling and executing smooth, purposeful movements).Record review of Resident #70's MDS assessment dated [DATE] reflected a completion and signed date of 04/23/26. In an interview on 04/30/26 at 6:30pm, the Adm stated the MDS was supposed to be completed within 21 days from admission. She stated the facility MDS coordinator left on emergency leave on 04/06/26 and did not return so the facility terminated her for job abandonment on 04/15/26. The Adm stated that an MDS Coordinator from Corporate Office remotely worked on MDS from 04/20/26 to 04/24/26. The Adm stated the facility obtained a contract MDS coordinator on 04/24/26 and her start date was 04/27/26. In an interview on 04/30/26 at 6:24 pm, the contract MDS nurse stated she had only been working at the facility for 2-3 days and she had been advised to refer any questions back to the facility. Record review of the chart that was provided by the facility reflected in part: MDS completion date (ItemZ05008) No Later Than:14th calendar day of the resident's admission (admission +13 days).

Based on observation, interview and record review, the facility failed to review and revise the comprehensive care plan by the interdisciplinary team, for 1 of 7 residents (Resident #7) reviewed for comprehensive care plan revisions. The facility failed to review and revise Resident #7's care plan to reflect she no longer used a catheter.This failure could place the residents at risk of not receiving appropriate interventions and care to meet their current needs.Findings included:Record review of Resident #7's face sheet, dated 04/29/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: unspecified dementia (decline in cognitive function severe enough to interfere with daily life affecting memory loss, language, problem solving, and other cognitive abilities), acute kidney failure (condition that affects the kidneys' ability to filter waste from the blood), hypertensive heart disease (condition caused by prolonged high blood pressure leading to heart damage) , anxiety disorder (uncontrollable worry about everyday issues, affecting daily functioning and quality of life), and retention of urine (inability to completely empty the bladder). Record review of Resident #7's MDS assessment, dated 01/29/26, reflected a BIMS score of 03, indicating severe cognitive impairment. The MDS reflected Resident #7 had an indwelling catheter. Record review of Resident #7's care plan, dated 04/29/26, reflected [Resident #7] had an indwelling catheter related to neurogenic bladder (nerve damage disrupts communication between the brain, spinal cord, and bladder, leading to loss of bladder control and urinary dysfunction). Date initiated: 10/13/25. Date revised: 11/08/25. During an attempted interview and observation, on 04/28/26 at 1:50 PM, Resident #7 was asked basic questions, but she did not respond coherently. Resident #7 was not interviewable. Resident #7 was not injured or in distress. Resident #7 did not have a catheter. During an interview, on 04/30/26 at 9:00 AM, LVN A stated Resident #7's catheter had been removed maybe in January or February 2026, but she was not sure on the date. LVN A stated the catheter was discontinued because Resident #7 tried to pull it out. LVN A stated Resident #7 had been doing well without the catheter and she was able to urinate in her brief without retention. During an interview, on 04/30/26 at 9:20 AM, the MDS Nurse stated she was not sure when Resident #7's catheter was discontinued but the care plan should have been updated to remove the catheter. The MDS Nurse stated she had only been contracted with the facility for 2-3 days and was not sure why Resident #7's had not been revised. The MDS Nurse stated care plans were revised upon completion of MDS assessments and as needed for any changes. During an interview, on 04/30/26 at 9:40 AM, the ADON stated she was not sure when Resident #7's catheter was discontinued but that should have been care planned. The ADON stated the care plan should have been revised to reflect that Resident #7 no longer needed or used a catheter. The ADON stated there was no negative outcome for Resident #7 because staff were aware of how to care for her. The ADON stated the CNAs had tasks to follow and the nurses followed the orders for Resident #7. The ADON stated care plans were developed and updated as a team effort. The ADON stated it was important for the care plan to be updated and revised to reflect information accurately so staff knew how to care for the resident. The ADON stated care plans could even be updated daily or as needed. An interview was attempted, on 04/30/26 at 10:45 AM. The DON was unavailable as she was out of the country. A call was attempted and a voicemail was left requesting a callback. Record review of the facility's Comprehensive Care Plan policy, dated November 2017, reflected - Policy: A comprehensive, person-centered care plan will be developed for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that have been identified through a comprehensive assessment 9. Care plans will be revised as information about the resident and the resident's' condition changes.

Based on observation, interviews and record review, the facility failed to store food in accordance with professional standards for 1 of 1 freezer and 1 of 2 medication storage rooms (4th floor medication room) reviewed for food safety.-The facility failed to ensure food items (raw dinner rolls, breaded chicken tenders, and breaded fish) in the freezer were sealed properly.-The facility failed to ensure resident food items were disposed of according to policy. -The facility failed to ensure the resident food and drink refrigerator in a medication storage room was clean and did not have any food or drink remnants in it. These failures could place residents at risk of complications from food contamination.Findings included:Observations during the initial tour of the kitchen on 04/28/26 at 8:25 AM revealed the freezer had boxes of raw dinner rolls, breaded chicken tenders, and breaded fish that were open and exposed to the air.During an interview, on 04/30/26 at 10:55 AM, DA B stated all kitchen staff were responsible to ensure that all food was sealed and dated. DA B stated she knew that all items in the freezer should be sealed to prevent freezer burn.Observation of the resident food and drink refrigerator in the 4th floor medication storage room on 04/30/26 at 11:00 AM revealed a 16oz container labeled Butter Chicken Soup. On the top of the container there was a yellow sticky note that stated, [Resident Name] [Room number] -Please ask if she wants.? 4/19/2026. There was a sign that stated, Label all food and drink items. Food items will be discarded after 3 days (once opened) on the front of the refrigerator. This observation also revealed a pink colored sticky substance in the bottom left corner of the refrigerator and a yellow colored sticky substance in the bottom right side of the refrigerator.During an interview on 04/30/26 at 11:25 AM, the DM stated all items in the freezer should have been sealed correctly to prevent freezer burn and to prevent contamination. The DM stated it was the responsibility of all kitchen staff to ensure food was sealed correctly as it was a team effort to ensure foods were stored and dated properly. The DM stated he went through the freezer and ensured everything was fixed. The DM stated he will be retraining all staff on proper food storage.In an interview on 04/30/26 at 11:37 am, the ADON stated the soup was past 3 days of the opened date and it needed to be thrown away. She stated it was not acceptable to have spilled stuff in the bottom of the refrigerator. The ADON stated dietary was responsible for the resident food and drink refrigerator, but it was everyone's responsibility to ensure food and drinks were disposed of when they were opened. She stated expired food could cause stomach illness and spilled substances could get on other things and cause cross contamination. Record review of the facility's Food Storage policy, dated 2005 and revised June 2024, reflected in part: Policy: All foods must be stored in a manner that maximizes nutrient retention, quality, and food safety.

Based on observation and interview, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident in 2 of 2 medication rooms (4th floor and 5th floor) reviewed for pharmacy services.The facility failed the ensure expired medication was removed from the 4th floor medication storage room.The facility failed the ensure expired medication was removed from the 5th floor medication storage room.These failures could place residents at risk of not receiving the therapeutic benefit of medications and or adverse reactions to medications.The findings included:An observation of the 4th floor medication room on 04/30/26 at 11:00 am reflected 2 unopened 16 oz bottles of Geri-Tussin (an expectorant- a medication used to thin and loosen mucus) with an expiration date of 2025/07 in a cabinet where backstock OTC (over the counter) medications were stored.An observation of the 5th floor medication room on 04/30/26 at 11:30 am reflected 1 unopened 16 oz bottle of Geri-Tussin (an expectorant- a medication used to thin and loosen mucus) with an expiration date of 2025/07 in a cabinet where backstock OTC (over the counter) medications were stored.In an interview on 04/30/26 at 11:37 am, the ADON stated there should not have been any expired medications in the medication storage cabinet. She stated if expired medications were administered, they may not have the desired effect or could cause illness. The ADON stated the central supply clerk had just received the shipment of that medication from the supply company and stocked it in the medication room but did not see that the Geri-Tussin had expired. The ADON stated when she told the central supply clerk about the expired medication, the supply clerk called the supply company to let them know about the expired medication. She stated the supply company told the supply clerk they were not aware that the medication was expired, but they would send a new shipment of the medication.Record review of the facility's Storage and Expiration Dating of Medications and Biologicals dated 05/10/10 and revised 06/30/25 reflected in part: 10. Facility should ensure medications and biologicals that: (1) have an expired date on the label. are stored separate from other medications until destroyed or returned to the pharmacy or supplier.

Based on interview and record review, the facility failed to ensure the comprehensive care plan was developed and implemented within a timely manner for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 (Resident #1) out of 5 residents reviewed for care plans. The facility failed to add the fall with significant injury, fall mats, and the surgical wound with wound care to Resident #1's care plan. The facility also failed to complete Resident #1's comprehensive care plan within the specified time frame.These failures could place residents at risk for receiving inadequate care and services. Findings included:Record review of Resident #1's face sheet dated 09/10/2025 revealed a [AGE] year-old female with an initial admission date of 08/18/2025 and a current admission date of 09/09/2025. Pertinent diagnoses included Displaced Oblique Fracture of Shaft of Right Femur (a traumatic injury in which the femur breaks diagonally), Orthopedic Aftercare (post-surgical care to aide in recovery), History of Falling, Muscle Weakness, and Unspecified Lack of Coordination.Record review of Resident #1's physician orders revealed an order with a start date of 08/18/2025 for wound care to surgical wound to right femur.Record review of Resident #1's admission MDS assessment dated [DATE], and signed as completed on 08/25/2025, revealed a BIMS score of 03, which revealed severely impaired cognition. The MDS assessment also revealed Resident #1 had a major orthopedic surgical procedure during the prior inpatient hospital stay which required active care during the SNF stay, and Resident #1 had a surgical wound requiring surgical wound care. The MDS assessment also revealed Resident #1 had a fracture related fall in the 6 months prior to admission/entry or reentry. Record review of Resident #1's care plan initiated 08/18/2025 and revised on 09/09/2025 revealed a care plan for risk of falls with interventions to include: keep call light within reach, prompt response to all requests for assistance, encourage appropriate footwear, medication review, OT and PT evaluation, and place bed in low position. There was not a care plan which addressed specifically the fall with major injury, or the surgical wound with wound care. There were also no interventions to address the fall mats in place. In an observation on 09/10/2025 at 9:25 AM Resident #1's bed was observed low to the floor with fall mats on both sides of the bed, and the call light within reach. In an interview on 09/10/2025 at 8:25 AM the Administrator stated Resident #1 typically resided in an ALF, but Resident #1 was admitted to the skilled unit for therapy and care after the fall which caused the fracture requiring surgical intervention. The Administrator stated the MDS nurse was the one who updated and revised the care plan, and she had 21 days from admission to complete it. In an interview on 09/10/2025 at 1:30 PM the MDS nurse stated she was not sure why the fall with major injury or the surgical wound requiring wound care was not on the care plan, but it should have been since it was the reason Resident #1 was admitted . She stated maybe it had not been added yet since the comprehensive care plan was still a work in progress as they have 21 days from admission to complete it. The MDS nurse stated there was a care plan for skin integrity, but she agreed it was for Resident #1's skin breakdown to her buttocks since one of the interventions was to apply a barrier cream. She stated there should have been one specifically for the surgical wound requiring wound care. The MDS nurse stated the care plan was a clinical tool used by staff to determine how to address the residents wants, needs, and care. The MDS nurse reiterated and clarified she had 21 days from admission or 14 days from the date of the comprehensive assessment to finish the comprehensive care plan, then after looking it up, she stated she was wrong, and it was 7 days from the date the comprehensive assessment was completed. She stated Resident #1's comprehensive assessment was completed on 08/25/2025, so her comprehensive care plan should have been completed by 09/01/2025, and Resident #1's still was not completed because she was still adding interventions, such as bed in low position (added 09/09/2025) and fall mats (added 09/10/2025).In an interview on 09/10/2025 at 3:05 PM the DON stated Resident #1 was admitted to the skilled unit for therapy and post-surgical care after a fall which caused a fracture requiring surgical intervention. She also stated she was not sure why the surgical wound requiring wound care was not on the care plan, but it should have been since it was the reason Resident #1 was admitted . The DON stated some things, such as the floor mats, had not been addressed on the care plan because she was under the impression the facility had 21 days from admission, regardless of when the comprehensive assessment had been completed. Record review of the facility's Comprehensive Care Plan Policy, dated November 2017, revealed A comprehensive, person-centered care plan will be developed for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that have been identified through a comprehensive assessment. 1. The Comprehensive Care Plan will describe treatments and services to assist the resident to attain or maintain the highest level of physical, mental and psychosocial wellbeing. 2. The comprehensive care plan is based on a comprehensive assessment which includes, but is not limited to, the MDS, Care Area Assessments, clinical assessments and data collection form, therapy evaluations, psychosocial and cognitive evaluations, physician assessments/consults.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (K2) reviewed and 2 of 2 satellite kitchens (SK4 and SK2) for storage, preparation, and sanitation. 1. Satellite Kitchen 4 (SK4) The facility failed to maintain cleanliness of the steam table holding wells and shelf, that a cleaning schedule was followed, personal items were not kept in the dry storage room, and all staff wore a hair and beard net while in SK4. 2.Satellite Kitchen 2 (SK2) The facility failed to maintain cleanliness of the steam table holding wells and shelf, that a cleaning schedule was followed, and personal items were not kept in the server room, in SK2. 3. Main Kitchen 2 (K2) The facility failed to maintain cleanliness of the steam table holding wells and shelf, the convection oven, the trash cans, a floor blower, and that a cleaning schedule was followed in K2. The facility failed to ensure spices were kept closed throughout the survey to prevent cross contamination. The facility failed to keep trash cans covered when not in use. The facility failed to keep dry storage items tightly sealed in the dry storage area and failed to keep the dry storage room door closed by using a large rat trap as a door stop throughout the survey. The facility failed to store walk-in freezer items properly. The facility failed to ensure personal items were not kept in the service area. . These failures could place residents at risk for food contamination and food borne illness. The findings included: 1. Observation and initial tour of SK4 (satellite kitchen 4th floor) on 02/18/25 at 10:45 am revealed 5 of 5 steam table wells had scaling, flaking, and black dots around the insides at the water line. The bottoms of the steam table wells had pale yellow scaling on them and debris floating in the water. The underside of the shelf above the steam table wells was covered in a dark brown substances, some had the appearance of drips, some were more solid. There were visible personal items in the dry storage area of SK4; a jacket, a 16 oz. partially full bottle of water, and a purse. In another part of the dry storage area, a different purse. There was no signage indicating a designated area for personal items in the dry storage area. In an interview with SERVER 1 on 02/18/25 at 11:05 am regarding SK4, she said there was no cleaning schedule the SK4 used. She said the dark brown substances on the underside of the steam table wells was directly over the food. She said the substances had probably dropped onto the food at some point and that was bad. She said they should not have sent food out because it could make residents sick because of contamination. She said she had never cleaned the underside of the steam table shelf, and she had worked at the facility for 3 years. In an interview with SERVER 2 on 02/18/25 at 11:10 am, she said kitchen staff were supposed to keep their personal items in the DM's office, which was down the hall from SK4, (approximately 20 paces). She said her purse was in the dry storage area but should have been in the DM's office. She said she did not leave her belongings in the DM's office because the lockers did not have locks on them because they were supposed to supply their own locks, and she did not have a lock for a locker. In an interview and observation of the DM's office on 02/18/25 at 11:15 am, revealed there was a tray with thawed raw meat above eggs and liquid eggs in the refrigerator. There was a large rat trap being used to prop the door open in the K2 dry storage area. He said it should not be there because of contamination and denied ever seeing rodents in the kitchen areas. The DM stated he did not know why there was a large rat trap being used to prop the door open in the K2 dry storage area. He did not indicate why the storage area was open. The DM pointed to a stack of 6 empty lockers with no locks, he said kitchen staff stored personal belongings in the lockers. He said nothing when informed the lockers were empty and there were personal items in the dry storage area in SK4. He said he conducted an in-service on personal belongings with his staff last year when the lockers were delivered and placed. He said he was not monitoring the staff. He said there was not another in-service regarding personal items and he did not provide any reminders. He said he was in charge of SK4. He said there was a cleaning schedule, but it just was not posted. He said the process for getting kitchen repairs resolved was to verbally let the MS know. He said there was no log but there was an electronic reporting system that no one used, and he did not know why. He said the MS and department managers utilized a different electronic reporting system. He said he did not know how to use the electronic reporting system. He said he had worked at this facility for 9 years, working his way up to DM. In an interview and observation with the DM on 02/19/25 at 5:55 pm revealed he entered SK4 without a hairnet or beard cover. He said he just went in for a minute. The hairnets were located inside SK4. He said he would move them back outside the door. He said the food carts would knock the container off the wall when the hairnet container was outside the door. He said there was no way to don hairnets before entering SK4 with them being stored away from the door on the opposite wall inside SK4. He said everyone was required to wear hair and beard nets (if indicated) in the kitchen areas to prevent contamination. The DM said nothing when asked why he was not wearing the required hair and beard nets. In an interview with SERVER 1 and observation of SK4 on 02/20/25 at 9:30 am, the steam wells were not clean. She said she did not know what the yellowish and black substances were around the insides. She said it was K2 staff's job to clean them, and they took them yesterday to clean them. She said they did not look clean now. There was no cleaning schedule posted. 2. Observation and initial tour of SK2 (satellite kitchen 2nd floor) on 02/18/25 at 11:35 am revealed 5 of 5 steam table wells had scaling, flaking, and black dots around the insides at the water line. The bottoms of the steam table wells had pale yellow scaling on them and debris floating in the water. The underside of the shelf above the steam table wells was covered in dark brown spots, some had the appearance of drips, some were more solid. There was no cleaning schedule. There was a jacket on a shelf above clean plates in the server room in SK2. In an interview with the DC (dining coordinator) for SK2 on 02/18/25 at 11:40 am, she said she had worked at the facility for 1 year and 8 months. She said there was no cleaning schedule to go by for about 1 1/2 weeks. She said the substance under the shelf above the steam table looked like rust and mold. She said she had never looked there. She said it was a big health hazard because it could drop into the food and make residents sick. In an interview with SERVER 3 for SK2 on 02/18/25 at 11:42 am, he said he cleaned the steam wells weekly. He said, Last week when asked when the steam table wells were last cleaned. He said there was no cleaning schedule. He said he knew the chest type freezer needed to be defrosted and needed a new gasket. He said he did not tell the DC because she already knew. SERVER 3 did not answer but shrugged his shoulders when asked if the steam table wells and shelf looked clean. 3. Observation and initial tour of K2 (main kitchen 2nd floor) on 02/18/25 at 11:45 am revealed 5 of 5 steam table wells had scaling, flaking, and black dots around the insides at the water line. The bottoms of the steam table wells had pale yellow scaling on them and debris floating in the water. The underside of the shelf above the steam table wells was covered in dark brown spots, some had the appearance of drips, some were more solid. There was no cleaning schedule. There was a jacket on a shelf above clean plates in the K2 service area. There was a thick covering of a sticky yellowish substance on the convection oven, trash cans, and floor blower in K2. Eight of 30 16-ounce containers of spices and cornstarch were open to air. Trash cans were not covered and emitted a foul odor. A 10-pound bag of dry pasta was open to air in the dry storage room. The dry storage room door was propped open by a large rat trap as a door stop throughout the survey. In an interview with the EC (executive chef) on 02/18/25 at 11:45 am, she said she had worked at this facility for 8 1/2 years. She said personal items were not allowed in any kitchen area. She said a jacket placed above clean plates on a shelf in the service area was not supposed to be there and it was not a designated area for personal items. She said lockers were provided for staff and staff had to provide their own locks. She said they set up 2 designated drinking areas inside K2, so staff could stay hydrated. She said no one monitored staff for hand washing after touching the drinks and returning to prep areas. She said the grease on the convection oven was from the deep fryer which was right next to the convection oven. She said the grease on the convection oven looked like an accumulation of over a month, because that was how long it had been since it was cleaned. She said the floor blower had a greasy coating on it and she did not know how long it had been that way. She said there were no cleaning schedules to follow. She said it was ok for the thawed raw meat to be in the refrigerator above egg products. She said all dry storage items should be covered or sealed tightly, labeled, and dated including spices and cornstarch because cross contamination could occur and make residents sick if consumed. She said she did not know who left the pasta exposed to air in the dry storage room or how long it had been that way. She said she had no idea who or when the large rat trap was used to prop open the dry storage room door. She said the dirtiness of K2 was a health hazard because there were several opportunities for cross contamination. The EC did not answer when asked what her part was in the education of staff. The EC said the trash cans should be covered when not in use and there was an odor of vomit near one of the uncovered trash cans. She said the uncovered trash could attract gnats, flies, ants, and rodents and having bugs in the kitchen could make people sick. In an interview with the COOK and return visit to K2 on 02/20/25 at 9:30 am revealed the large rat trap was propping the dry storage door open and spices were open to air. There was ice accumulation around the fan in the walk-in freezer, boxes of food were stacked to the ceiling, several boxes of food items were open to air, and the lighting was inadequate. The COOK said boxes were supposed to be at least 6 inches from the ceiling in the walk-in freezer because they could block water hydrants and become a fire hazard. She said everyone was responsible for making sure the boxes of food were sealed tightly to prevent freezer burn and if ice accumulated on the food, it would affect the taste and possibly make the residents sick. She said the product would have to be thrown away if it had ice or freezer burn on it. She said dented pans, such as the food mill, no longer had a good seal and it could harbor bacteria in the crevices and dents and relay it to the residents and make them sick. She said the food mill was used this morning. She said the spices and cornstarch should have been closed tightly to prevent cross contamination. In an interview with the EC (executive chef) on 02/20/25 at 09:45 am, she showed this surveyor a cleaning schedule dated February 2025 with all cleaning and sanitation tasks indicating done. She said she did not monitor staff completion of the tasks. She said, According to the completed cleaning schedule, the kitchen should be spotless. She said the kitchen was far from spotless. In an interview with DSD (dining services director) on 02/20/25 at 10:15 am, he said he started working at the facility 4 months ago and was responsible for the entirety of the satellite kitchens, the main kitchen, and the kitchen staff. He said he knew about the lack of cleaning, training, faulty equipment, old steam wells and carts, shelving, and safety issues. He said he had made lists to submit to MS so he could get it to corporate for approval. He said he first submitted the lists to the ex-administrator within 4 months ago. He said he had notified the current ADM of how bad things were in the kitchen and she was working with him to get things fixed. He said he then submitted the lists to MS on 01/15/25 and corporate denied everything on the list on 02/14/25 and told him the items were supposed to be part of the EC's monthly budget. He said the MS was working on that budget now. He said the process for reporting kitchen items that needed repair, or replacement was to report it to the EC and she would handle it. He said he learned how to use the facility electronic reporting system about a month ago. He said he entered RD (registered dietician) requests, but he could not retrieve them from the electronic reporting system and did not know how to do it. He said the facility was without a DM for about a year. He said he was responsible for monitoring the satellite kitchens and staff. He said the DM (dietary manager) was supposed to monitor healthcare staff and the EC (executive chef) was supposed to monitor main kitchen staff (K2). He said his last conducted in-service with kitchen staff was 01/21/25. He said he did daily walk-throughs in all kitchen areas and found multiple failures but would not say what they were. He said there were no records for any training that he could find. He said his plan was to continue teaching and introduce all kitchen staff to the facility's kitchen training catalog, which he said none of the kitchen staff had ever seen. He said the kitchen did not have proper cleaning solutions or cleaning equipment when he started working here. In an interview with the RD (registered dietician) on 02/20/25 at 12:25 pm, she said she had been at this building since November 2024. She said she talked with the kitchen staff last month about sanitation, tray cards, anything related to kitchen operations, prep, temps, etc. She said she would obtain the training she had conducted. She said she conducted walk-throughs in the kitchen and the satellite kitchens during her visits to the facility. She said she had been conducting process improvement plans (PIPs) on sanitation and equipment. She said the kitchen and satellite kitchens were supposed to be following cleaning schedules. She said the ADM had been helpful in advocating with corporate to get the equipment and supplies needed to improve the kitchen. In an interview with the MS (maintenance supervisor) on 02/20/25 at 2:33 pm, he said he worked at the facility for [AGE] years. He said the process of reporting kitchen repairs or replacement equipment was for them to call the receptionist at the front desk and report it to them because the receptionists had been trained to use the facility electronic reporting system. He said he made walk throughs through all the kitchen areas every Sunday. He said the staff always told him Everything was fine. He said the electronic reporting system had been in place at least 5 years. He said the list the DSD (director of dining services) created and presented to him for approval by corporate was now in the process of being refined by himself. He said he would resubmit it to corporate asset management once he was done refining the list. He said the ADM was made aware of changes before resubmitting the request. He said he had documentation of these exchanges that he would provide. He said he was not aware of the ice build-up, stacked boxes to the ceiling, and lighting in the walk-in freezer, or the rat trap utilized as a door stop for the dry storage room in K2. He said there was a red line placed around the inside of the walk-in freezer to indicate how high the boxes could be stacked. In an interview with the ADM on 02/20/25 at 5:09 pm, she stated performance plans via QAPI (Quality Assurance and Performance Improvement) were initiated on 09/25/24 regarding all aspects of the kitchen and satellite kitchens. She said PIPs (performance improvement plans) included corrective actions for the DM. She said turnover was high in the kitchen probably due to the pay and she had no control over providing higher wages. She said salaries and retention for kitchen staff were also part of QAPI. She said she was working with the MS, RD, and all kitchen staff to improve the quality of food, moral, sanitation and knowledge bases. Record review of in-services for the last 3 months revealed the following: *New Menu Cards/Service/Record Keeping dated 01/21/25 via the DSD included daily meetings and production, record keeping, proper storage, cleaning schedules, and hairnets was added to the page. * Satellite Kitchens, nourishment rooms, labeling and dating for safe storage of food dated 01/30/25 via the RD. *Personal belongings dated 02/19/25 via the DM included personal belongings are to be stored in designated areas: lockers in manager's office, lockers in storage room, lockers in restrooms. Record review of the facility's electronic reporting system requests for the kitchen areas indicated the following: dated *08/05/24 for air conditioner, *09/25/24 for a baseboard, *10/02/24 (x2) for a light switch and relocate, *10/25/24 for steamtable, *01/03/25 for not working, *01/08/25 for air conditioner check, *01/09/25 for assemble, and 01/23/25 for air conditioner. All entries were made by the DM. Record review of corrective action documents on the DM indicated the following: *06/28/17 for poor performance, *10/02/17 for poor performance, *10/04/17 for poor performance, *11/13/23 for poor performance, *10/25/24 for poor performance (final reminder). Further review revealed an action plan for the DM initiated on 01/27/25 indicated Weekly meetings were to be conducted every Monday. Notes from the 02/10/25 meeting indicated the DM was improving. There was no meeting for 02/17/25. Record review of the facility policy revised 01/11/24, titled Equipment Maintenance revealed under policy: The maintenance department is responsible for foodservice equipment maintenance. Procedure: 1. The maintenance department is responsible for inspecting equipment annually, or more often, if needed, to ensure proper working order. 2. The food and nutrition department should notify maintenance if equipment is not working properly. Record review of the facility policy revised 06/2024, titled, Food Storage revealed under policy: All foods must be stored in a manner that maximizes nutrient retention, quality, and food safety. 2. The storerooms and walk-ins should be maintained free from dirt, dust, insects, rodents or any potential sources of contamination. 3. All foods should be stored on storeroom shelving that is no less than 6 inches from the floor and at least 18 inches from the sprinklers on the ceiling. Record review of the facility policy revised 07/11/24, titled, Food Storage revealed 4. Thawing: .Thaw meat preferably by placing in deep pans and setting on lowest shelf in refrigerator. Record review of the facility policy revised 04/06/2023, titled, Dry Storage Chart revealed Cornstarch should be kept tightly closed. Pasta dry-once opened, store in airtight container. Spices and herbs, store in airtight containers in dry places away from sunlight and heat. Record review of the facility policy revised 12/2024, titled, Hair Restraints revealed under policy overview: All associates working in food preparation must wear hair restraints. Under policy detail: 1. All hair must be kept covered. 5. Beards must be covered with a beard restraint. Record review of the facility policy revised 05/18/202, titled, Personal Hygiene/Safety/Food Handling/Infection Control revealed policy: Guidelines for personal hygiene to promote a safe and sanitary department must be followed: 3. Head covering worn: c. Beards, mustaches, or any body hair that may be exposed (i.e., arms) must be covered. 4. Conduct: c. Eating and drinking are not permitted in food preparation and service areas. 5. Designated area for employee personal belongings: a. An area in the director of food and nutrition office or dry storage area may be designated as a separate employee personal belonging area with signage. B. Personal belongings, beverages and/or food may be stored in the designated area. Record review of the facility policy revised 08/31/18 titled, Cleaning Schedules under policy: The food and nutrition services staff shall maintain the sanitation of the food and nutrition department through compliance with written, comprehensive cleaning schedules developed for the community by the director of food and nutrition services or other clinically qualified nutrition professional. Community satellite kitchens will be held to the same sanitary standards as the main kitchen, utilizing a comprehensive cleaning schedule specific to each kitchen.

Based on observation, interview, and record review, the facility failed to maintain all kitchen equipment in safe operating condition for 1 of 1 kitchen (K2) reviewed and 1 of 2 satellite kitchens (SK2) reviewed for safe operating equipment. The facility failed to maintain a chest type freezer with heavy ice build-up on the inside walls, bottom, and lid in SK2. The facility failed to maintain and remove a 4-foot X 3-foot char broiler that did not work, had no griddle on it, and was connected to the gas line in K2. The facility failed to maintain and remove dented holding pans and dented prep equipment (food mill) in K2. The facility failed to maintain the walk-in freezer by not allowing ice accumulation around the fan and low lighting in K2. These failures could cause food-borne illness from equipment not being maintained and/or cleaned effectively. Findings include: Observation and initial tour of SK2 (satellite kitchen 2nd floor) on 02/18/25 at 11:35 am revealed a chest type freezer had heavy ice build-up on the inside walls, bottom, and lid and a removable black substance on the gasket. The walk-in freezer in K2 had full boxes of food stacked to the ceiling and ice partially covering the fan. The walk-in freezer was dimly lit. In an interview with the DC (dining coordinator) for SK2 on 02/18/25 at 11:40 am, she said she had worked at the facility for 1 year and 8 months. She said SERVER 3 was responsible for letting her know when equipment needed repair. She said the process for getting kitchen issues resolved was she or SERVER 3 would verbally tell maintenance. She said the chest type freezer needed to be defrosted for 2-3 weeks. She said the chest type freezer lid needed a new gasket. She said the gasket had been cleaned about 2 weeks ago. She said the gasket had mold on it now. In an interview with SERVER 3 for SK2 on 02/18/25 at 11:42 am, he said he knew the chest type freezer needed to be defrosted and needed a new gasket. He said he did not tell the DC because she already knew. SERVER 3 did not answer but shrugged his shoulders when asked if the freezer looked clean. In an interview with the EC (executive chef) on 02/18/25 at 11:45 am, she said she had worked at this facility for 8 1/2 years. She said the char broiler had not worked for over 2 years and she had been trying to get maintenance to remove it. She said she had brought it up several times to the ADM and MS but had no proof because they relayed maintenance requests and repairs only verbally. She said it was not safe to have the char broiler in that condition because it was missing a griddle, the gas tubes were exposed, and it was still hooked up to the gas line. She said it was a fire hazard. In an interview with the COOK and observation in K2 on 02/20/25 at 9:30 am revealed the dented food mill was dirty with food on a prep cart, there was ice accumulation around the fan in the walk-in freezer, boxes of food were stacked to the ceiling, and the lighting was inadequate. The COOK said boxes were supposed to be at least 6 inches from the ceiling in the walk-in freezer because they could block water hydrants and become a fire hazard. She said dented pans, such as the food mill, no longer had a good seal and it could harbor bacteria in the crevices and dents and relay it to the residents and make them sick. She said the food mill was used this morning. She said the spices and cornstarch should have been closed tightly to prevent cross contamination. In an interview with DSD (dining services director) on 02/20/25 at 10:15 am, he said he started working at the facility 4 months ago and was responsible for the entirety of the satellite kitchens, the main kitchen, and the kitchen staff. He said he knew about the lack of cleaning, training, faulty equipment, old steam wells and carts, shelving, and safety issues. He said there was equipment not tagged out or inoperable such as the char broiler. He said the char broiler had been inoperable for at least 5 years. He said it was still hooked up to gas and that it was a safety issue. He said he had made lists to submit to MS so he could get it to corporate for approval. He said he first submitted the lists to the ex-administrator within 4 months ago. He said he had notified the current ADM of how bad things were in the kitchen and she was working with him to get things fixed. He said the process for reporting kitchen items that needed repair, or replacement was to report it to the EC and she would handle it. He said he learned how to use the facility electronic reporting system about a month ago. He said he did daily walk-throughs in all kitchen areas and found multiple failures but would not say what they were. He said there were no records for any training that he could find. In an interview with the MS (maintenance supervisor) on 02/20/25 at 2:33 pm, he said he worked at the facility for [AGE] years. He said the process of reporting kitchen repairs or replacement equipment was for them to call the receptionist at the front desk and report it to them because the receptionists had been trained to use the facility electronic reporting system. He said he made walk throughs through all the kitchen areas every Sunday. He said the staff always told him Everything was fine. He said the electronic reporting system had been in place at least 5 years. He said he was not aware of the ice build-up, stacked boxes to the ceiling, and lighting in the walk-in freezer, the condition of the chest freezer in SK2, or the char broiler in K2. He said there was a red line placed around the inside of the walk-in freezer to indicate how high the boxes could be stacked. He said he was informed about the chest freezer this morning. He said the facility had no roach problems. He said ants and flies were seasonal. He said there had been no rodent problems in the last few years. He said there were rodents [AGE] years ago when he first got there, but none since. In an interview with the ADM on 02/20/25 at 5:09 pm, she stated performance improvement plans via QAPI (Quality Assurance and Performance Improvement) were initiated on 09/25/24 regarding all aspects of the kitchen and satellite kitchens. She said she was working with the MS, RD, and all kitchen staff to improve the quality of food, moral, sanitation and knowledge bases. Record review of the facility policy revised 01/11/24, titled Equipment Maintenance revealed under policy: The maintenance department is responsible for foodservice equipment maintenance. Procedure: 1. The maintenance department is responsible for inspecting equipment annually, or more often, if needed, to ensure proper working order. 2. The food and nutrition department should notify maintenance if equipment is not working properly.

Based on observation, interview, and record review the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 3 of 12 residents (Residents #15, #33, and #152) observed for infection control practices. The facility failed to post Enhanced Barrier Precaution signs outside the rooms of Resident #'s 15, 33 and 152. These failures could place residents, staff, and visitors at risk of cross contamination and/or infection. Findings included: 1. Record review of Resident #15's face sheet dated 02/20/25 revealed a [AGE] year-old-male with an original admitted [DATE] and a current admitted [DATE]. Diagnoses included Squamous Cell Carcinoma of Skin, Scalp, and Neck (a type of skin cancer that was caused by an uncontrolled growth of abnormal squamous cells). Record review of Resident #15's Admission MDS assessment dated [DATE], section C, Cognitive Patterns, revealed a BIMS score of 14 (cognition intact). Section M of the MDS indicated Resident #15 had one or more unhealed pressure ulcers or injuries, as well as moisture associated skin damage and application of nonsurgical dressing. Section N of the MDS revealed Resident #15 was on an antibiotic. Record review of Resident #15's order summary dated 02/06/25 revealed Resident #15 had an antibiotic ordered for a bacterial infection, as well as wound care to an ulcerating cancer wound to the top of the head. During an observation on 02/18/25 at 5:20 PM LVN C performed wound care on Resident #15 with only gloves and no gown. In an interview with LVN-C on 02/18/25 and 5:30 PM she revealed that no gown was worn due to Resident #15 was not on EBP, but had he been, she would have worn a gown to prevent cross contamination. In an interview with the ADON on 02/19/25 at 9:45 AM, the ADON stated she was not sure what Resident #15's antibiotic was for, but she had known about his open wound that he had been getting wound care for, and the antibiotic was carried over and re-ordered from his hospital stay. 2. Record review of Resident #33's face sheet dated 02/20/25 revealed a [AGE] year-old female with an admitted [DATE]. Pertinent diagnosis included a blister to the right lower leg. Record review of Resident #33's Comprehensive MDS assessment dated [DATE] section C, Cognitive Patterns, revealed a BIMS score of 15 (cognition intact). Section M, Skin Conditions, revealed Resident #33 was at risk of developing a pressure ulcer, but did not have one at the time of asssessment. Record review of Resident #33's care plan dated 02/20/25 listed the focus The resident has potential/actual impairment to skin integrity initiated on 01/26/25 and revised on 02/07/25. A pertinent intervention listed for the focus included: Keep skin clean and dry. Use lotion on dry skin. Do not apply to area of skin breakdown, wound or between toes initiated on 01/26/25. Record review of Resident #33's order summary dated 02/20/25 revealed an active order initiated on 02/14/25 for Cleanse blistered areas to the right anterior and inner lateral leg with normal saline and 4x4 (inch) gauze, pat dry with gauze, apply [skin protective wipe], and leave open to air. 3. Record review of Resident #152's face sheet dated 02/20/25 revealed a [AGE] year-old female with an admitted [DATE]. Pertinent diagnosis included malignant neoplasm of brain (cancerous tumor that originates in or spreads to the brain). Record review of Resident #152's PPS MDS assessment dated [DATE] section C, Cognitive Patterns, revealed a BIMS score of 14 (cognition intact). Section M, Skin Conditions, revealed Resident #152 had a surgical wound. Section N, Medications, revealed Resident #152 was taking an antibiotic. Record review of Resident #152's care plan dated 02/20/25 listed the focus The resident is on IV Medications. Infection of scalp incision initiated on 02/08/25. Record review of Resident #152's order summary dated 2/20/25 revealed an active order initiated on 02/18/25 for Vancomycin HCL (Antibiotic) Intravenous Solution Reconstituted 1 GM. Use 1 gram intravenously every 12 hours for INFECTION. During an observation on 02/19/25 at 11:00 AM of the resident halls, there were no EBP signs posted on Resident #15, #33, and #152's doors. During an observation on 02/20/25 at 10:11 AM inside Resident #152's room, LVN A hooked up the Vancomycin medication to Resident #152's PICC line with gloves only and no gown. In an interview with LVN A on 02/20/25 at 11:26 AM, LVN A stated she was unsure of what the difference between standard precautions and EBP were, but she would find out. LVN A stated she thought EBP was someone with a Foley catheter or wound care, and if a resident was on EBP she should put on both gown and gloves prior to going into the room to provide care. LVN A stated it was the manager or admitting nurse's job to put up the EBP signs and carts. In an interview with the IP on 02/20/25 at 11:17 AM, she stated she had to take a class through the CDC to become the IP and learn about the different precautions. The IP stated that with standard precautions, they were utilized on everyone, anytime you touch anyone, but with EBP, it was more detailed and more enhanced precautions for residents with things such as MDRO infections, oozing wounds, vomiting, diarrhea, Foley catheters, rectal tubes, and other similar things. The IP stated she had not reviewed the EBP policy recently, and generally only worked the weekends, so she was not sure how many residents they had or should have had on EBP. The IP stated that typically, the IP, ADON, or DON determined which residents needed EBP and let the floor nurses know where to place the signs and carts. After reviewing the facility's infection control policy, the IP stated all G-tubes, PICC lines and draining wounds required EBP. In an interview with the ADON on 02/20/25 at 11:41 AM, the ADON stated standard precautions were for residents with infections like C-diff, and EBP was more for residents with Foley catheters, G-tubes, MDROs. The ADON stated the nurses and staff identified the residents on EBP by the signs on the doors, but they also identified which residents required EBP by looking at their residents and reviewing their charts and orders. The ADON stated EBP included gowns and gloves in conjunction with the signs on the doors, and if the proper precautions were not utilized, cross contamination could occur, and infections could be transmitted. In an interview with the DON on 02/20/25 at 11:50 AM, the DON stated EBP was less than contact precautions but more than standard precautions. The DON stated EBP should be utilized with close contact such bathing or doing wound care on residents with open wounds, PICC lines, other lines or tubes. The DON stated that based on their policy, any resident with an open wound, especially if they had an infection and were susceptible, should be on EBP. The DON stated if residents had a PICC line and had MRSA, they should be on EBP. The DON stated it was subjective as to who determined the precautions, but the admissions nurse typically caught it first and placed the resident on EBP. The DON stated the ADON followed up the next morning in morning rounds to make sure everyone was placed on the proper precautions, and if they had an open wound and were getting wound care, such as Resident #15 and Resident #33, they should be on EBP. Record review of the facility's Enhanced Barrier Precautions Policy, dated 09/2022 and revised 02/2025, revealed EBPs should be utilized (in conjunction to standard precautions) to reduce transmission of MDROs that employs targeted gown and glove use during high contact resident care activities. Gloves and gowns may be applied prior to performing high-contact resident care activity; Personal protective equipment was changed before caring for another resident; face protection may be used if there was also a risk of splash or spray. 50969

Based on interviews, observations and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #15 and Resident #30) of 16 residents reviewed for comprehensive person-centered care plans. The facility failed to develop and implement Resident #15's care plan to include oxygen therapy. The facility failed to develop and implement Resident #30's care plan to include oxygen therapy. This failure could affect the resident by placing them at risk for not receiving care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #15's face sheet dated 02/20/25 revealed a [AGE] year-old-male with an original admitted [DATE] and a current admitted [DATE]. Record review of Resident #15's Admission MDS assessment dated [DATE]section C, Cognitive Patterns, revealed a BIMS score of 14 (cognition intact). The MDS did not indicate anything regarding the oxygen or respiratory therapy. Record review of Resident #15's care plan dated 02/19/25 revealed no care plan for oxygen diagnosis, status or equipment. Record review of Resident #15's physician orders dated 02/14/25 revealed order of Oxygen 2 liters via nasal cannula. During an observation of Resident #15 inside his room on 02/18/25 at 8:55 AM and 5:20 PM, Resident #15 was on Oxygen 2 liters via nasal cannula. 2. Record review of Resident #30's face sheet dated 02/20/25 revealed a [AGE] year-old female with an admitted [DATE]. Pertinent diagnoses included unspecified dementia and hypertensive heart disease without heart failure (prolonged high blood pressure damages the heart without causing heart failure). Record review of Resident #30's Comprehensive MDS dated [DATE] section C, cognitive patterns, stated Resident #30's BIMS score was 4 (severe impairment). Further review of Resident #30's MDS revealed section O, special treatments, stated Resident #30 received oxygen therapy while a resident in the past 14 days. Record review of Resident #30's order summary dated 02/20/25 revealed an active order initiated on 02/01/25 for O2 at 2 liters; may titrate to 4 liters. Every shift for hypoxia. Record review of Resident #30's care plan dated 02/20/25 did not list oxygen therapy as a focus and included no interventions related to oxygen therapy in any other focus. During an observation inside Resident #30's room on 02/19/25 at 9:19 AM, Resident #30 received 4 liters per minute of oxygen. An interview was attempted with Resident #30, but she was not interviewable. In an interview with LVN B on 02/19/25 at 9:33 AM, LVN B stated LVNs did not typically update the care plans. LVN B stated the care plan was typically updated by the MDS nurse, the ADON or the DON. LVN B stated the nurses did check the care plans for accuracy or to verify residents' preferences or goals. In an interview with LVN A on 02/20/25 at 11:24 AM, LVN A stated she read residents' care plans to ensure she was updated on the residents she was assigned. LVN A stated any assessments, changes in care, or changes in orders were reflected in the care plan. LVN A stated oxygen treatments should be in the care plan. LVN A stated she never edited the care plans herself. LVN A stated if she saw something wrong with the care plan, she would notify the ADON or DON. LVN A stated if the care plan was wrong then the nurse taking care of the resident may not give the resident the most up-to-date treatment. In an interview with the ADON on 02/20/25 at 11:40 AM, the ADON stated they revised care plans on new admissions, 5 days afterwards, significant changes, and quarterly. The ADON stated the floor nurses let the ADON, the DON, or the MDS nurse know if something new needed to be updated. The ADON stated Resident #15 and Resident #30 should have had their oxygen use in their care plans. The ADON stated if a resident's care plan was not updated then a nurse may not know what the most appropriate care was for a resident. In an interview with the DON on 02/20/25 at 11:57 AM, the DON stated anybody on the interdisciplinary team could edit care plans. The DON stated the care plan contained preferences, precautions, likes, dislikes, and activities. The DON stated that anything related to the individualized care of the resident was put on the care plan. The DON stated that regarding oxygen, the care plans should include they were on oxygen, the amount, the titration, and when and how it was ordered. The DON stated Resident #15 and Resident #30 should have had their oxygen use included in their care plans. The DON stated care plans were updated within 24-48 hours of any new change in the resident. The DON stated care plans needed to be updated so nurses on the floor had the most current information about how to care for the resident. Record review of the facility policy titled Comprehensive Care Plan - SOM dated 11/2017 stated the following: 1. The Comprehensive Care Plan will describe treatments and services to assist the resident to attain or maintain the highest level of physical, mental and psychosocial wellbeing. 2. The comprehensive care plan is based on a comprehensive assessment which includes, but is not limited to, the MDS, Care Area Assessments, clinical assessments and data collection forms, Therapy Evaluations, psychosocial and cognitive evaluations, physician assessments/consults. 3. The Interdisciplinary Team will work in coordination with the resident, the resident's family and responsible party to develop and maintain the comprehensive care plan. 50969

Based on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one of one resident (Resident #198) reviewed for tracheostomy care . 1. The facility failed to ensure Resident #198 had suction equipment, emergency supplies, a spare trach or a care plan specific for tracheostomy care. 2. The facility failed to ensure staff could describe steps to take in the event of an emergency dislodgement of Resident #198's trach. 3. The facility failed to ensure staff were competent in trach care and knowledgeable of equipment needed. These failures could place residents at risk for suffocation and death. The facility Administrator and DON were notified on 11/29/23 at 5:32 PM, that an Immediate Jeopardy situation had been identified due to the above failures. While the IJ was removed on 12/02/23 at 6:08 pm, the facility remained out of compliance at a scope of isolation and a severity level of no actual harm with potential for more than minimal harm. The findings included: Record review of Resident #198's face sheet, dated 11/29/2023, reflected a [AGE] year old male who was admitted to the facility on [DATE]. Resident #198 had diagnoses which included: Subacute Osteomyelitis of the left ankle (a chronic low-grade infection of bone), peripheral vascular disease (circulation disorder), Diabetes type II (high levels of sugar in the blood), Asthma (a respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing), Heart disease, lack of coordination, need for assistance with personal care, tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) and a history of polio (an infectious viral disease that affects the central nervous system). Record review of Resident #198's Care Plan, dated 11/29/23, reflected Resident #198 has impaired airway clearance as a focus, but did not mention a tracheostomy or interventions needed for a tracheostomy. Record review of the facility MDS Matrix, dated 11/28/2023 at 9:44 AM, reflected no indication Resident #198 had a tracheostomy. Record review of Resident #198's medical chart indicated he was assessed on 11/27/2023 by Nurse Practitioner A and she indicated Resident #198 had COPD and had orders for Xopenex nebulizer treatments every 6 hours (helps with breathing easier), Singular daily (used for asthma), Duoneb every 2 hours as needed (used to treat COPD) and albuterol every 6 hours (used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung diseases such as asthma and chronic obstructive pulmonary disease) and budesonide nebulizer treatments twice a day (to prevent symptoms of asthma). Observation of Resident #198 on 11/29/2023 at 9:30 AM revealed LVN G gave a breathing treatment to Resident #198. LVN G attempted to place a mask over Resident #198's mouth and nose for an Albuterol breathing treatment. (Albuterol is a medication that treats lung diseases, such as asthma, where the airways in the lungs narrow, causing breathing troubles or wheezing [bronchospasm]. Observation of Resident #198's room on 11/29/2023 at 9:30 AM revealed no emergency equipment present for tracheostomy care and no equipment present for routine tracheostomy maintenance. During an observation of central supply with the ADON on 11/30/2023 at 1:30 PM the ADON was unable to locate an emergency trach kit. During an interview with LVN G on 11/29/2023 at 8:30 AM, she said she would not have a suction machine available for Resident # 198 unless the Dr. ordered it. LVN G was aware that Resident #198 had a tracheostomy. During an interview with LVN G on 11/29/2023 at 9:15 AM she said she was not trained for tracheostomy care. LVN G said the facility would probably send Resident #198 out if there was an emergency . During an interview with the DON on 12/02/203 at 4:44 PM, she said there should have been a care plan for a tracheostomy when Resident #198 first got to the facility. The DON said she did not know why the admitting nurse did not make one specific for a trach . The DON said they needed a Drs order to put a suction machine in the room, and then said well you could put it in there, but you would need an order to suction the person that has a tracheostomy . The DON said the nurse that admitted the resident did the initial care plan, and then after 14 days the LVN Resident Assessment Instrument (MDS) did it. The DON said the resident only had his initial care plan. The DON said Resident #198 was admitted using information from the care plan received from the hospital along with his admission diagnosis that was acquired from the hospital medical records. The DON said the facility knew his tracheostomy was on his admitting diagnosis when he was admitted . The DON related the admitting nurse said the hospital told her it was an established tracheostomy and did not need care. The DON said it was not true that he did not need care for his tracheostomy. The DON said it should have been automatic that the facility put emergency equipment in his room, and they did not. During an interview with Resident #198 on 11/29/2023 at 12:24 PM, he said he had the trach 8 years. He said his family member cleaned the outer trach every two days and it had not been done for the week he had been at the facility. Resident #198 said his tracheostomy was a size 6, then it was increased to a size 7 to help him breathe better, but when they put a new one in at the hospital 8 days ago, it was a 6 again and he did not know why. Resident #198 said the facility had not done trach care on him since his arrival. Resident #198 said the hospital did suctioning on him before he left (7 days ago) and he had not been suctioned since then . During an interview with the DON on 11/29/2023 at 12:45 PM, she said the facility clinical liaison told her Resident #198 did not need any tracheostomy care. The DON said the trach size was a 7 (it is a size 6). The DON said Resident #198 went back and forth between a 6 and a 7. The DON said there was supposed to be an extra trach available, and there was not an extra one at the facility (there was supposed to be an extra trach and one of the next smallest size available). The DON said she did not hear Resident #198's family member took care of Resident #198's trach until 11/29/2023. The DON said Resident #198 had not been suctioned since his arrival. The DON said any of the nurses could suction him . During a phone interview with the attending physician on 11/29/2023 at 1:02 PM, he said he was aware Resident #198 had a tracheostomy. The attending physician said he did not know what the procedures were for admitting tracheostomy patients to the facility . The attending physician said there were not many, if any facilities that would accept a patient with a trach, and if there was an emergency and no one was well trained at the facility, the resident would have to be hospitalized . The physician said he did not know if the facility had any knowledge of the resident's care and needs. During an interview with Resident #198's nurse practitioner on 11/29/2023 at 1:30 PM, she said there should have been trach supplies at the bedside, even for an old trach, as old trachs could have issues such as getting plugged with mucus and other emergencies. The NP stated she saw the resident twice and did not recall seeing any trach supplies such as oxygen, suctioning or a trach kit in resident's room. The NP stated Resident #198 should have some trach care being performed but the NP was seeing Resident #198 for his primary issues which was a diabetic ulcer on his foot. The NP stated she was not aware Residents #198's family member was managing his trach as she had never seen the resident's family member at the facility and was not aware the facility did not have the correct size Shiley in case of an emergency. A Shiley (Trademark) disposable inner canula helps provide convenient and safe tracheostomy care and maintenance to patients in medical and home care settings. During an interview with the DON on 11/30/2023 at 12:25 PM, she said; Now that I have reviewed the procedure, Resident #198 should have had oxygen , another Shiley (inner tracheostomy tube), a suction machine and a trach emergency kit at his bedside. The resident was not receiving oxygen. The DON said she heard Resident #198's family member did the trach care for the resident but had never met the wife and did not know if care had been done. The DON said Resident #198 had not been suctioned since he had been at the facility. The DON said there was no excuse for that not to happen. The DON said the facility would have called 911 if Resident #198's trach had come out. The DON said all direct care staff completed a competency checklist for tracheostomies upon hire, so staff should know where to look for an emergency trach kit. The DON said an emergency trach kit did not need to be in the crash cart. The DON said the emergency trach kit was kept in central supply. During an interview with the Activity Assistant on 11/29/2023 at 10:25 AM, she said she did not remember getting training for trach care. She did not know what could happen if a trach came out . During an interview with RN A on 11/29/2023 at 10:30 AM, he said he had training for tracheostomies in nursing school 8 years ago. He said a suction machine should probably be in the resident's room and probably an ambu bag and emergency kit. RN A said an extra trach should be somewhere known to staff. During an interview with the physical therapist on 11/29/2023 at 10:35 AM, she said residents with tracheotomies did not need a suction machine in their room. She said she did not know if an emergency kit should be in the room. During an interview with LVN B on 11/29/2023 at 10:40 AM, she said she did not get training for trach care at the facility. She said she would put another trach in if the resident's trach came out, and it depended on where the trach was stored. She said sometimes they were stored in the room, or in central supply. During an interview with ADON (LVN) on 11/29/2023 at 10:27 AM, she said she would replace a trach if it came out. The ADON said a suction machine should be in the resident's room. The ADON said there was an ambu bag available in the crash cart and a trach emergency kit was always available. The ADON said there was training when staff were hired for trach care. During an interview with CNA C on 11/29/2023 at 10:44 AM, she said she did not believe a resident with a trach needed a suction machine in their room. She said she would have to ask where an emergency trach kit was located. During an interview with the Speech Therapist on 11/29/2023 at 10:45 AM, she said she did not think a resident needed an ambubag or emergency kit in their room if they had a trach. She said she had trach training [AGE] years ago when she was a student. During an interview with LVN A on 11/29/2023 at 8:30 AM, she said maybe a resident needed a suction machine and emergency trach kit in their room if they had a trach. She said she had no training for trach care from the facility. During an interview with the DON on 11/29/2023 at 12:45 PM, she said the facility did not have a policy for admitting a resident with a tracheostomy . A record review of the facility Tracheostomy Replacement Competency, dated 2/2020, indicated equipment needed: 1 an appropriate size tracheostomy 2 lubricant 3 Velcro tracheostomy sties 4 scissors 5 gloves 6 ambu bag 7 suction supplies 8 towel 9 syringe Skills described the procedure to safely replace a tracheostomy. A record review of the facility's Tracheostomy Care and Suctioning Competency, dated 2/2020, indicated equipment needed: 1 Tracheal cleaning tray 2 Sterile gloves 3 Suction equipment 4 Complete tracheal tube set (for emergency use) 5 disposable inner cannula of same size 6 Sterile normal saline 7 Sterile nonraveling presplit dressing 8 Clean tracheal ties Skills described the procedure to safely care for a resident with a tracheotomy. A record review of the facility's Suctioning Competency, dated 2/2020, indicated equipment needed: 1 Sterile suction catheter kit 2 Sterile drape 3 Sterile cup 4 Sterile gloves 5 #10 to #16 French catheter 6 Sterile gauze 7 Towel 8 (8) 100 cc sterile saline or sterile water 9 Resuscitation (Ambu) bag with supplemental oxygen 10 PPE Skills described the procedure to safely suction a resident with a tracheotomy. Record review of LVN A's training since hire: indication of tracheostomy care for suctioning (verbal), tracheostomy care and suctioning, and tracheostomy care replacement (verbal). 6/6/2023 A record review of the facility Charge Nurse Skills Checklist, dated 1/2022, indicated each charge nurse upon hire, and at a minimum annually thereafter should complete training for Tracheostomy care and suctioning and Tracheostomy Care Replacement. The facility Administrator and DON were notified on 11/29/23 at 5:32 PM, that an Immediate Jeopardy situation had been identified due to the above failures. On 12/1/2023 at 9:53 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: Verification phase: Resident #198 no longer resided at the facility at the time of the verification phase. No other tracheostomy residents reside at the facility. A total of 34 staff members from various shifts and departments were interviewed on the process of emergency tracheostomy care and tracheostomy care beginning on 12/2/2023 at 10:00 AM. All staff members were able to identify the proper procedures for emergency tracheostomy care and tracheostomy care. -On 11/29/23 a respiratory assessment was completed by the Assistant Director of Clinical Services (ADCS) for resident# 198. RP notified by LVN G. MD notified by director of clinical services. The director of clinical services notifed the healthcare supplier of equipment needed. - Verified on 11/29/23 the ADCS observed resident# 198 demonstrate tracheostomy care utilizing appropriate technique and was able to do return demonstration. - Verified on 11/29/23 the following supplies wer e in Resident 198's room: l).suction machine 2). Replacement Shiley size of the 3) tracheostomy kits, 4) oxygen tank and concentrator,5) Ambu bag, 6)Passy-Muir valve) suction kits 8). - Verified on 11/29/23 a licensed nurse obtained an order for tracheostomy care and revised the care plan for Resident #198. - Verified on 11/29/23 the [NAME] President, Divisional Field Sales and Marketing re-educated the Healthcare Liaison on completing the preadmission screen and verification that tracheostomy supplies are available. - Verified on 11/29/2023 Clinical Services (RDCS) re-educated the DCS and Healthcare Liaison on the admission process, continuity of care related to tracheostomy care, availability of supplies, and potential outcomes. - Verified on 11/29/23 the admitting nurses received re-education from the DCS and ADCS on performing skin assessments and completing orders in the medical record for trach care and supplies (See Attachment A)required at bedside. - Verified on 11/29/23 and 11/30/23 the DCS or designee completed re- education to all licensed nurses on procedures for trach care including emergency interventions such as trach dislodgement, occlusion or respiratory distress, trach supplies (see checklists) and location and placement of orders. See guidelines. On 12/01/23, the DCS or designee observed licensed nurses performing return demonstration for an occlusion, respiratory distress, and dislodgement. Remaining licensed nurses will be trained prior to next shift and upon hire. - Verified on 11/29/23 trach orders will include trach size and trach care. - Verified on 11/29/23 the Central Supply Clerk placed supplies (see Attachment B) for tracheostomy in the respiratory storage room. This will be maintained by the Central Supply Clerk or designee. - Observed on 11/30/23 a third party Respiratory Therapist provided additional training to licensed nurses and the DCS and ADCS. All Licensed Nurses completed this training. Licensed Nurses that were unavailable to attend the Respiratory Therapist training will be trained by the DCS, ADCS, or designee prior to working their next shift and upon hire. - Verified on 11/29/23 and 11/30/23, the Healthcare Administrator (HCA), DCS, or designee re-educated all Licensed Nurses and C.N.A's on potential outcomes; those Licensed Nurses and C.N.A's that were not available by 11/30/23 will receive the re-education prior to their next scheduled shift. - Verified on 11/29/23 and 11/30/23 the ADCS or designee completed re-education to all Certified Nursing Assistants (C.N.A's) and Licensed Nurses on trach care, trach supplies ( see Attachment A) and interventions for dislodgement, occlusion and respiratory distress; those associates not available by 11/30/23 will receive the re-education prior to their next scheduled shift. - Verified on 11/30/23 the DCS created a checklist of trach supplies (see Attachment A) that are kept at bedside for residents that have tracheostomy tubes. The checklist was placed in the nurse's information book - Verified On 12/01/23 the DCS added the emergency tracheostomy checklist (see Attachment B) to the emergency checklist binder to include tracheostomy supplies. - Upon new admissions with tracheostomy tubes will be reviewed the next business day by the Interdisciplinary Team (IDT) (the IDT may include, but not limited to the DCS, ADCS, RAI Coordinator, HCA, Resident Programs and Social Services). This review includes the medical record and verification of tracheostomy orders. Licensed nurse will notify Healthcare Provider as needed for orders. - All Licensed Nurses will complete the Tracheostomy Care re-education and Post Test by 11/30/23; those Licensed Nurses not available on 11/30/23 will receive the re-education and Post Test prior to their next scheduled shift. This re-education will be completed by the DCS, ADCS, or designee. - Verified on 11/30/23 the DCS or designee provided re-education to all skilled Administration, Dining, Housekeeping, Therapists, Maintenance, Resident Programs and C.N.A's on emergency process including signs and symptoms of respiratory distress and when to call for assistance. Those associates not available by 11/30/23 will receive the re-education prior to their next shift. - Verified through record review on 11/29/23 an Impromptu Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director, Executive Director, HCA, RDCS, Regional Director of Operations, District Director of Clinical Services and Healthcare Liaison. On 12/22/23 at 6:08 PM, the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a scope isolation and a severity level of no actual harm with potential for more than minimal harm after the IJ immediacy was removed due to the facility's need to monitor and evaluate the effectiveness of the corrective systems.

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 two residents (R #159 and R #200) reviewed for restorative care. The facility failed to apply knee immobilizer to Resident #159's knee to reduce the risk of further loss of range of motion. The facility failed to back immobilizer to Resident #200's back to reduce the risk of further loss of range of motion. This failure placed residents on restorative nursing care at risk for decline in range of motion, and decreased mobility. The findings: Record review of R 159's #'s Face Sheet dated 11/28/2023, documented a [AGE] year-old female admitted [DATE], with the diagnoses of, fracture of the left patella (knee fracture), heart failure, Diabetes type 2 (insufficient production of insulin in the body), and malignant neoplasm of the breast (breast cancer). Record review of R #159's physician orders 11/16/2023 specified, knee brace on at all times. Frequent ice packs to left knee to reduce pain and swelling. Do not allow left knee to bend if brace is opened up. Record review of R #159's MDS revealed a BIMs score of 7 (Severe Impairment). Record review of R #159's Care Plan dated 11/16/2023 revealed R #159 had an alteration in musculoskeletal status r/t fracture of patella (knee) and interventions were, knee brace to be worn daily as tolerated by patient. Observation on 11/28/23 at 01:29 PM, R # 159's knee immobilizer observed on left knee and was not secured and slid down and knee immobilizer was touching the floor as R #159 sat in wheelchair. Observation on 11/28/23 at 02:11 PM. R # 159's knee immobilizer observed on left knee and was not secured and slid down and knee immobilizer was touching the floor as R #159 sat in wheelchair. Observation on 11/28/23 at 03:05 PM. R # 159's knee immobilizer observed on left knee and was not secured and slid down and knee immobilizer was touching the floor as R #159 sat in wheelchair and knee immobilizer turned backwards. Interview with the DON on 12/02/23 at 02:44 PM stated R #159's knee immobilizer should be kept secure and stated the knee immobilizer is probably too big for R # 159 as she is short and stated that OT (occupational therapy) was working with resident on 11/28/2023 at 1:14PM and maybe it slid off after therapy. The DON stated R #159 came in with that knee brace from hospital and unsure if it was a good fit for R # 159. The DON stated while R # 159 was lying in bed, the knee immobilizer had stayed secured, but when R # 159 would possibly be sitting down, the knee immobilizer could have slid down. The DON stated that if the knee immobilizer is not worn as ordered, it could cause R # 159 to have further complications or possibly reinjury the affected area. On 12/02/23 at 03:03 PM, this surveyor and the DON went into R # 159's room. The DON asked R # 159 if she could show us her knee immobilizer. When R # 159 removed blanket, R # 159 was not wearing knee immobilizer. Resident stated that the knee immobilizer kept sliding down so she decided not to wear it. The DON stated that she would order and new knee immobilizer for the R # 159 after speaking with MD. R # 159 refused to knee immobilizer back on and denied having any pain at that time. 2.)Review of R #200's Face Sheet dated 11/28/23 documented an [AGE] year-old male admitted on [DATE] with the diagnoses of: SPINAL STENOSIS (pressure on the spinal cord and the nerves within the spine), LUMBAR REGION WITHOUT NEUROGENIC CLAUDICATION(M48.061) (Compression of the spinal nerves in the lumbar (lower) spine, ENCOUNTER FOR SURGICAL AFTERCARE FOLLOWING SURGERY ON THE NERVOUS SYSTEM(Z48.811). Review of R #200's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: -is at risk for falls related to impaired mobility -is experiencing pain. -has an alteration in musculoskeletal status. -has an ADL Self Care Performance Deficit related to impaired mobility Review of R #200's Physician's Order dated 11/28/23 did not reveal a back brace included. Review of R #200's Comprehensive Care Plan completed on 11/21/23 did not include the back brace and how the facility would implement the back brace for R #200. Observation of R #200 on 11/28/23 at 10:13 AM this investigator entered and revealed the resident leaning on his left side while sitting on his bed. This investigator noticed that there was a back brace that was set upon a wheelchair on the left side of the bed. This investigator asked R #200 if that was his back brace and R #200 responded saying yes it was. This investigator asked R #200 When he uses the back brace, and R #200 stated that he uses it when he is sitting down. This investigator asked R #200 if the staff help him to put on the back brace and R #200 stated that the staff will help him if he asks them to, but he mostly puts the back brace on by himself. Interviewed Certified Nurse Aide (CNA) A on 11/30/23 at 9:13 AM. The CNA A stated that the staff will assist R #200 with the back brace if he asks for help. CNA A could not remember if R #200 was admitted into the facility with the back brace or not. CNA A stated that R #200 is not dependent on staff for all activities of daily living (ADL). Interviewed licensed vocational nurse (LVN) A on 11/30/23 at 10:13 AM. Upon interview with Licensed Vocational Nurse A (LVN A), the licensed vocational nurse, he stated that he was not sure if the back brace was in his orders. The licensed vocational nurse stated that he assumed the back brace was only used as reassurance by the resident. The licensed vocational nurse did not see or understand why a resident would need to be care planned or have any orders for it if it was only used because the resident wanted it on. Interview the DON on 1130 at 10:46 AM. Upon interview with the DON, stated that she did not remember if the back brace was brought in upon admission or if maybe a family member had brought in the back brace after he was already admitted into the facility. The investigator asked the DON if she had been told by any of the staff that R #200 had the back brace and she stated that nobody had mentioned it to her. This investigator asked the DON if the back brace is something that should be care planned or have an order for, and the DON replied by stating yes, that is something that should be care planned, and she must have made a mistake and missed it. The DON also added that she will get an order for it and added into the care plan immediately. This investigator asked the DON what could potentially happen if adaptive equipment is missed or not care planned? The DON stated that a resident could be harmed by lack of training of a device, or a resident health could decline from not using the adaptive device. The facility failed to do a proper observation of the items and devices that R #200 uses as assistance. The facility failed to get orders and do a proper comprehensive care plan for the resident. The facility did not care plan R#200's back brace when he was admitted into the facility. The facility did not care plan the back brace if it was an assistive device that was brought in after admission. The facility did not get orders, nor did they create goals and interventions for this back brace. Record review of Assisted Devices and Equipment dated January 2020 stated; Policy statement Our facility maintains and supervises the use of assistive devices and equipment for residents. 3. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan. 4. Staff and volunteers are trained on the use of devices and equipment prior to assisting or supervising residents. 5. Residents, family, and visitors are trained, as indicated, on the safe use of equipment and devices. 48118

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food plates. 1. Upon two separate visits to the 4th floor satellite kitchen revealed a worn, distressed looking temperature log binder being placed to lean against the food plates that are served to the residents for their meals every day. This failure could place residents at risk for cross-contamination and food-borne illnesses. 2. The facility failed to ensure staff did not store their personal drinks in the preparation area of the facility kitchen. Findings were: 1. In an observation on 11/28/23 at 10:18 a.m. revealed a refrigerator temperature log binder leaning on top of plates that are used to serve the residents on the 4th floor. In an observation on 11/30/23 at 10:38 a.m. the temperature log binder remained leaning against the plates that are utilized to serve the residents on the 4th floor. In an interview on 11/30/23 at 10:42 a.m. with the Dietary Manager revealed that the binder should not be leaning on the plates and it should be placed in the designated basket at the entrance of the kitchen area. The investigator asked the Dietary Manager what those plates that the binder is leaning on are utilized for. The Dietary Manager responded They are used to serve the residents. I can see the problem with that. I will move it immediately. When the investigator asked where the binder belongs, the Dietary Manager followed by stating There is a basket at the entrance of the kitchen where we are supposed to put it. Record review of the facility's policy Food Receiving & Storage Policy Statement revealed, All food, chemicals, and supplies should be received and stored in a manner that ensures quality and maximizes safety of the food served. 2. Observation on 11/29/23 at 10:47 a.m. revealed in the satellite kitchen, located on the 4th floor of the facility a staff personal item placed on top of the counter in the kitchen by the food warmer . Observation on 11/30/23 at 10:34 a.m. revealed, in the main kitchen, two personal drinks placed on the cutting boards of where the kitchen staff cut and prepared food. In an interview on 11/30/23 at 10:25 a.m., the Dietary Manager said items had a designated area that was sectioned and labeled for the residents to place their items at the main kitchen on the 2nd floor. The kitchen on the 4th floor did not have an area for personal items and the dietary manager stated he would create an area for the staff to place their items that would not interfere with a safe and sanitary environment to prepare food for the residents of the facility. Facility's Foods Brought by Family/Visitors policy dated July 2023 reflected: Policy Interpretation & Implementation 5. No items will be stored next to the plate warmer(i.e binders, clipboards). Food storage, plateware, utensils will remain free of debris and unsanitary conditions for the kitchen and food service equipment. Record review of the facility's policy reflected Personal Items in Kitchen, dated October 2017, revealed: It is the policy of this facility that any food or personal items that are brought to the kitchen by staff must be directed to an area that does not come into contact with the food and the area that is preparing food for the residents. Procedures: .2. Staff need to be aware that if personal items are being placed in areas of the kitchen that are used for handling the food that is prepared for the residents it is not sanitary and could result in sickness.

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 of two of five medication carts (200 and 300 Hall 2nd floor Medication Cart) reviewed for medication storage The facility failed to ensure, 200 and 300 hall medication carts were locked when unattended. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. Findings include: Observation on 11/28/2023 at 1:08 pm revealed two medication carts unlocked. The Charge nurse was observed to be behind the nurses' station. The State Surveyor walked towards the medication carts and was able to open drawers and pull out a variety of medications. Interview on 11/28/2023 at 1:23 pm revealed LVN A took ownership of the unlocked medication cart and went to the nurses' station to work on other tasks she had and forgot to lock the medication cart. LVN A stated if the medication cart should not be unlocked, and all medication carts should be locked at all times when not in use so unauthorize people did not have access to medications located inside the medication cart. LVN A stated she could not remember the last time an in-service was conducted on locking medication cart, but administration was always rounding and making sure medication carts were locked at all times when not in use. Interview with the DON on 11/28/2023 at 1:23 pm revealed medication carts are supposed to be locked at all times as per facility protocol when not in use. Observation and interview on 11/30/23 at 1:30 PM revealed 1 of 3 medication carts unlocked at the entrance of hall 100. There were no residents close to the medication cart or in the hallway, but there were visitors entering and exiting the elevator 4 feet away from where the elevator was parked while unlocked. Five minutes later, LVN A came out from the nurses' station LVN A stated it was her medication cart and was interviewed again about what could happen with medication carts being unlocked. The Licensed Vocational nurseLVN A stated that residents and others could could go into the carts and take things from the cart that do did not belong to them. Interview with the Director of Nursing on 11/30/23 at 1:35 PM the Director of Nursing stated she would do another in-service with the Licensed Vocational Nurse and she understood how dangerous it was to have a medication cart unlocked and forgotten to be locked. Record review of the facility's Medication Cart Use and Storage Policy dated 10/01/2019 reflected: Guidelines Security Line 1. The medication cart and its storage bins are kept locked until the specified time of medication administration.