Every finding on record at Cabot Health and Rehab, LLC

Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined the facility failed to ensure that the resident's transfer or discharge was reported to the ombudsman for two (Resident #75 and Resident #77) of two residents reviewed. The findings include: Resident #75 Review of Resident #75's Medical Diagnosis revealed diagnoses which included respiratory failure, congestive heart failure (CHF) and atrial fibrillation. Review of Resident #75's admission Record revealed the facility admitted Resident #75 on 02/20/2026. Review of Resident #75's Medicare 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/2026 revealed Resident #75 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of Progress Notes dated 02/21/2026 revealed Resident #75 was admitted to the nursing home on [DATE] from [Named] hospital for skilled services with severe abdominal distention, low fluid output and pain. The Progress Notes revealed Resident #75 was transferred to the hospital emergency room [ER] for a higher level of care with no plan to readmit on 02/21/2026. Review of the facility's Ombudsman Report dated January 2026 to May 2026, revealed no documentation for Resident #75's discharge/transfer to the ER on [DATE]. During an interview on 05/20/2026 at 2:05 PM, the Business Office Manager [BOM] stated, the facility did not send Resident #75's discharge transfer information to the Ombudsman because Resident #75 was in a skilled bed at that time. Resident #77 Review of Resident #77's Medical Diagnosis revealed diagnoses which included kidney failure, colon cancer and type II diabetes. Review of Resident #77's admission MDS with an ARD of 01/26/2026, revealed Resident #77 had BIMS score of 14, which indicated the resident was cognitively intact. Review of Resident #77's Care Plan initiated on 01/28/2026, revealed Resident #77 wished to transfer to live at another facility and would require post discharge home health for physical therapy, occupational therapy and speech therapy. Review of the facility's Ombudsman Report dated January 2026 through May 2026, revealed no documentation for Resident #77 that indicated the resident discharged /transferred to [named] facility for Long Term Care (LTC) on 02/24/2026. Review of Progress Notes dated 02/23/2026 by the Social Worker, revealed plans were made for Resident #77 to discharge on [DATE] to [Named] LTC facility and [Named] LTC facility would provide Durable Medical Equipment (DME) and transportation. During an interview on 05/20/2026 at 1:43 PM, the Administrator stated Residents #75 and Resident #77 did not require a bed hold, because they were skilled care and they do not pay for bed holds so they do not have to report that to the Ombudsman on the monthly report. This surveyor requested a facility discharge/transfer policy. During an interview on 05/20/2026 at 1:53 PM, the BOM stated a monthly report was sent to the Ombudsman that showed all residents that were transferred to the hospital. The BOM stated that residents that transferred to other nursing home facilities were not on the Ombudsman Report. The BOM stated that Resident #77 was not placed on the Discharge Transfer Report when transferred to [Named] LTC facility because the resident was in a skilled bed. The BOM stated, I do not know the purpose of the Ombudsman Report. This surveyor asked the BOM for a copy of policies addressing discharge/transfers. During an interview on 05/20/2026 at 2:13 PM, Medical Records Staff provided a copy of the Nursing Provider Discharge Summary for Resident #77 dated 02/24/2026 and Order Summary Report, dated 2/24/2026 was used for medication reconciliation. Medical Records Staff stated the documents were sent to Resident #77's new facility, and not to the ombudsman office. During a follow-up interview on 05/20/2026 at 2:37 PM, the BOM stated, the facility did not have a discharge/transfer policy, and provided a Department of Human Services [DHS] Memorandum to nursing facilities regarding Notification to Ombudsman of Transfers and Discharges. The BOM reviewed the document with this surveyor. The document revealed an event occurs when the facility discharges a resident from the facility or transfers a resident to the Emergency Room. The BOM confirmed, Resident #75 discharged to the Emergency Room, and Resident #77 discharged to [Named] LTC facility. The BOM stated, the Ombudsman was not notified because Resident #75 and Resident #77 were in skilled care.

Based on observations, interviews, and facility policy review, it was determined that the facility failed to prepare, distribute, and serve food under sanitary conditions. Specifically, the facility failed to ensure that dietary staff performed hand hygiene in between tasks for three (3) of three (3) staff (Dietary Aide #1, Dietary Aide #2 and Cook) observed in the kitchen. The findings are: A review of a facility policy titled Handwashing dated 05/15/2020, indicated, Purpose: To remove contamination after entering the kitchen, touching bare human body parts, using the toilet, coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating or drinking, handlining soiled utensils or equipment, during food preparation, when switching between raw food and working with ready to eat food, before donning gloves for working with food, and after engaging in other activities that contaminate the hands A review of a facility policy titled Safe Food Handling Practices dated 10/23/2019, indicated, Policy: All food is purchase, stored, prepared, and distributed in a clean, safe, and sanitary manner while promoting safe food handling in compliance with state and federal guidelines. Procedure: Employees wash their hands when entering the kitchen and before handling food. Employees do not touch dishware or flatware where food is placed. During an observation on 12/09/24 at 11:36AM, Dietary Aide [DA] #2 entered the kitchen and walked to the restroom. Upon exiting the restroom DA #2 did not wash hands and placed gloves on both hands. Dietary Aide #2 began putting up clean dishes coming out of the dishwasher. During an observation on 12/09/24 at 12:06PM, Dietary Aide #1 placed both hands into shirt pockets. Dietary Aide #1 picked up lids then began placing the lids on the glasses prepared with tea. During an observation on 12/09/24 at 12:09PM, observed Dietary Aide #1 with left hand in the left shirt pocket. DA #1 picked up a coffee cup, obtained coffee then put a lid on the coffee cup. DA #1 handed the cup of coffee through the kitchen window to a resident. During an observation on 12/09/24 at 12:12PM, observed [NAME] take a pen out of shirt pocket. The pen did not work, and the [NAME] went to the office and obtained a pencil. The [NAME] removed the aluminum foil from the cornbread and obtained the temperature of the cornbread at 119.7 degrees. The [NAME] wrote the temperature down then walked over to the sink to wash hands. The [NAME] continued to obtain food temperatures. During an observation on 12/09/24 at 12:30PM, while serving chicken and dumplings, the [NAME] picked up all bowls with thumb on the top of the bowl and the hand on the bottom of the bowl. The [NAME] placed thumb on top of every bowl served. During an observation on 12/10/24 at 9:54 AM, Dietary Aide [DA] #1 was preparing dessert. DA #1 grabbed the phone out of the right pocket of shirt and looked at the phone. DA#1 placed phone back in shirt pocket and wiped both hands on front of shirt. DA #1 continued to prepare dessert. During an interview on 12/10/24 at 3:07 PM, the Dietary Manager confirmed handwashing should be completed when entering the kitchen, between dirty and clean tasks, handling ready-to-eat foods, and anytime an employee touches their face, their person or phone. During an interview on 12/11/24 9:59 AM, the [NAME] confirmed handwashing should be performed when you leave the line during meal service, when you go from one station to another, and if using gloves after gloves are removed prior to starting another task. The [NAME] confirmed that hands should have been washed after obtaining the pencil from the office. During an interview on 12/11/24 10:05 AM, DA #1 confirmed putting hands in shirt pockets and removed phone from shirt pocket. DA #1 confirmed hands should have been washed prior to doing any food services. DA #1 confirmed that not washing hands can cause cross contamination.

Based on record review, interviews, and facility document review, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) for 1 (Resident #52) of 8 sample mix residents. The findings are: On 12/9/24 at 9:29 AM, the surveyor observed Resident #52 lying in bed on their back at a thirty-degree (30') angle with eyes closed. Oxygen (O2) concentrator present in the room and running at two (2) liters per minute (LPM) through a nasal cannula with humidification. Tubing, humidification, and storage bag date 12/03/2024. Review of Resident #52's Medication Administration Record (MAR) for November 2024, did not provide an area to document oxygen use. Review of Resident #52's Baseline Care Plan dated 11/04/2024 noted in section 4. Health Conditions: A. Health Conditions/ Special Treatments: 1a. Oxygen therapy- while a resident. Review of Resident #52's Order Summary Report dated 11/05/2024, noted change O2 tubing, clean filter and O2 cabinet, date all tubing every Monday night on 11-7 shift and for maintenance, O2 at two to four (2-4) LPM though nasal cannula. No directions specified for order. Review of Resident #52's Nursing Skilled Charting dated 11/05/2024 at 11:00 AM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2; 9. O2 via NC. Review of Resident #52's Nursing Skilled Charting dated 11/06/2024 at 11:37 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/07/2024 at 12:27 AM, noted in section H. Respiratory 1. Pulmonary assessment 3) Shortness of breath (SOB) on exertion 7a. Oxygen therapy- while a resident; 8. O2 at 2 lpm; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/07/2024 at 4:10 PM, noted in section H. Respiratory 1. Pulmonary assessment 3) Shortness of breath (SOB) on exertion; 7a. Oxygen therapy- while a resident; 8. O2 at 2-4; 9. O2 through NC PRN. Review of Resident #52's Nursing Skilled Charting dated 11/07/2024 at 7:17 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/07/2024 at 11:04 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC PRN. Review of Resident #52's Nursing Skilled Charting dated 11/08/2024 at 2:30 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2-4; 9. O2 through NC PRN. Review of Resident #52's Nursing Skilled Charting dated 11/08/2024 at 11:17 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Care Plan dated 11/08/2024, noted the resident has shortness of breath (SOB) with O2 use. O2 as needed (PRN), as per Medical Doctors (MD) orders. Review of Resident #52's Nursing Skilled Charting dated 11/09/2024 at 12:42 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/09/2024 at 6:56 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 110/9/2024 at 11:39 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/10/2024 at 9:58 AM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/10/2024 at 6:22 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Admission/ Medicare 5 Day Minimum Data Set (MDS) with an Assessment Reference Date of 11/10/2024, noted Section J1100. Heath Conditions Shortness of Breath (dyspnea) z. None of the above; Section O0110. Special Treatments, Procedures, and Programs C1. Oxygen while a resident no. Review of Resident #52's Nursing Skilled Charting dated 11/11/2024 at 8:27 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through nasal cannula. Review of Resident #52's Nursing Skilled Charting dated 11/11/2024 at 11:17 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Medication Administration Record (MAR) for December 2024, did not provide an area to document oxygen use. During an interview with Resident #52 on 12/09/24 at 10:03 AM, the resident stated, I don't know why I'm getting oxygen. I was getting it in the hospital and came here with it. On 12/10/24 at 8:20 AM, the surveyor observed Resident #52 lying in bed on their back at 30-45' angle with eyes closed. Oxygen concentrator present in the room running at 2 LPM through nasal cannula with humidification. Oxygen tubing, humidification bottle, and storage bag are all dated 12/10/2024. During an interview with Licensed Practical Nurse (LPN) #4 on 12/12/2024 at 11:42 AM, she confirmed that Resident #52 had received continuous oxygen since admission. LPN #4 revealed the resident became short of breath with any movement. LPN #4 confirmed there was no place on the Medication Administration Record (MAR) to document daily oxygen use. The LPN confirmed the daily nursing skilled charting notes documented the resident receiving oxygen from 11/5/2024 through 11/11/2024. During an interview with the Minimum Data Set (MDS) Coordinator on 12/12/2024 at 11:46 AM, she confirmed Resident #52 had an order for oxygen since 11/5/2024. The MDS Coordinator confirmed Resident #52 had oxygen use noted on the daily nursing skilled charts noted from 11/5/2024 through 11/11/2024 and should be noted on the resident ' s Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 11/10/2024. She confirmed section J of the MDS was not documented accurately as it should note the resident had shortness of breath with exertion as noted on the nursing skilled charting on 11/07/2024 in section H's part of the pulmonary assessment.

Based on observation, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 6 (Residents #52, #38, #60, #3, #44, and #377) of 15 sample mix residents reviewed for care plan. The Findings are: 1. On 12/09/24 at 9:29 AM, the surveyor observed Resident #52 lying in bed on their back at a thirty-degree (30') angle with eyes closed. Oxygen (O2) concentrator present in the room and running at two (2) liters per minute (LPM) through nasal cannula with humidification. Tubing, humidification and storage bag were dated 12/03/2024. Review of Resident #52's Medication Administration Record (MAR) for November 2024, did not provide an area to document oxygen use. Review of Resident #52's Baseline Care Plan dated 11/04/2024, noted in section 4. Health Conditions A. Health Conditions/ Special Treatments 1a. Oxygen therapy- while a resident. Review of Resident #52's Order Summary Report dated 11/05/2024, noted change O2 tubing, clean filter and O2 cabinet, date all tubing every Monday night on 11-7 shift and for maintenance, O2 at two to four (2-4) LPM though nasal cannula. No directions specified for order. Review of Resident #52's Nursing Skilled Charting dated 11/05/2024 at 11:00 AM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2; 9. O2 via NC. Review of Resident #52's Nursing Skilled Charting dated 11/06/2024 at 11:37 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/07/2024 at 12:27 AM, noted in section H. Respiratory 1. Pulmonary assessment 3) Shortness of breath (SOB) on exertion 7a. Oxygen therapy- while a resident; 8. O2 at 2 lpm; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/07/2024 at 4:10 PM, noted in section H. Respiratory 1. Pulmonary assessment 3) Shortness of breath (SOB) on exertion; 7a. Oxygen therapy- while a resident; 8. O2 at 2-4; 9. O2 through NC PRN. Review of Resident #52's Nursing Skilled Charting dated 11/07/2024 at 7:17 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/07/2024 at 11:04 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC PRN. Review of Resident #52's Nursing Skilled Charting dated 11/08/2024 at 2:30 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2-4; 9. O2 through NC PRN. Review of Resident #52's Nursing Skilled Charting dated 11/08/2024 at 11:17 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Care Plan dated 11/08/2024 noted the resident has shortness of breath (SOB) with O2 use. O2 as needed (PRN), as per Medical Doctors (MD) orders. Review of Resident #52's Nursing Skilled Charting dated 11/09/2024 at 12:42 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/09/2024 at 6:56 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/09/2024 at 11:39 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/10/2024 at 9:58 AM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/10/2024 at 6:22 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/11/2024 at 8:27 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through nasal cannula. Review of Resident #52's Nursing Skilled Charting dated 11/11/2024 at 11:17 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Medication Administration Record (MAR) for December 2024, did not provide an area to document oxygen use. During an interview with Resident #52 on 12/09/24 at 10:03 AM, the resident stated, I don't know why I'm getting oxygen. I was getting it in the hospital and came here with it. On 12/10/24 at 8:20 AM, the surveyor observed Resident #52 lying in bed on their back at a 30-45' angle with eyes closed. Oxygen concentrator present in the room running at 2 LPM through nasal cannula with humidification. Oxygen tubing, humidification bottle and storage bag are all dated 12/10/2024. During an interview with Licensed Practical Nurse (LPN) #4 on 12/12/2024 at 11:42 AM, she confirmed that Resident #52 has received continuous oxygen since admission. LPN #4 revealed the resident became short of breath with any movement. LPN #4 confirmed the order summary report did not note whether the resident was to receive oxygen as needed (PRN) or continuous. The LPN confirmed the daily nursing skilled charting notes documented the resident receiving oxygen from 11/05/2024 through 11/11/2024. LPN #4 confirmed Resident #52 ' s Care Plan noted the resident as receiving oxygen PRN, but the order summary report did not note PRN. During an interview with the Minimum Data Set (MDS) Coordinator on 12/12/2024 at 11:46 AM, she confirmed Resident #52 had an order for oxygen since 11/05/2024 and that the order did not say if the oxygen was to be continuous or as needed. The MDS Coordinator confirmed Resident #52 had oxygen use noted on the daily nursing skilled charts noted from 11/05/2024 through 11/11/2024. The MDS Coordinator confirmed Resident #52's care plan was not documented accurately. 2. A Review of an Admission Record indicated the facility admitted Resident #3 with admitting diagnosis of Alzheimer's Disease (disease that destroys memory and mental functions). The quarterly MDS, with an Assessment Reference Date (ARD) of 12/02/2024 revealed Resident #3 had a BIMS score of 15, with indicated the resident was cognitively intact. Review of Resident #3 ' s Care Plan, revealed multiple areas, in Intervention where black box warnings did not reveal details to monitor. Black box warning and medication were referenced in the Care Plan but no warnings for symptoms to monitor. 3. A Review of an Admission Record indicated the facility admitted Resident #38 with diagnoses of cerebral infarction due to occlusion or stenosis of the right middle cerebral artery (stroke), embolism and thrombosis of artery (blood clot), pain, major depressive disorder (depressed mood or loss of interest affecting daily life), peripheral vascular disease (narrow blood vessels are reducing blood flow to limbs), atrial fibrillation (irregular heart beat upper chamber of heart beats out coordination from lower chambers, and hypothyroidism (the thyroid does not produce enough thyroid hormone). The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/05/2024, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Review of Resident #38 ' s Care Plan, revealed multiple areas in intervention, where black box warnings did not reveal details to monitor. Black box warning and medication such as a blood thinner initiated on 2/14/2024, an ACE inhibitor initiated on 2/14/2024, a beta blocker initiated on 2/14/2024, s synthetic version of the principal thyroid hormone initiated on 6/24/2020, and antidepressant initiated on 12/05/2023, and an opioid agonist initiated on 8/07/2024 were referenced in Care Plan. No warnings for symptoms to monitor. 4. A Review of an Admission Record indicated the facility admitted Resident #60 with diagnoses of rheumatoid arthritis (inflammatory response that usually affects joints), insomnia (trouble falling or staying asleep), depression (depressed mood), anxiety disorder (feeling of worry or fear that is strong enough to affect one's daily activity) , chronic pain, intervertebral disc degeneration to the lumbosacral region with discogenic back pain and lower extremity pain (changes in the disc due to ageing or trauma and the disc has break down and separate from the bone), wedge compression fracture of fifth lumbar vertebra (broken bone collapses and causes a wedge appearance). The quarterly MDS, with an ARD of 11/19/2024, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated that the Resident was not able to finish the assessment. Further investigation in Section C of the MDS revealed memory was okay with moderate impairment with daily decision-making ability. Review of Resident #60 ' s Care Plan revealed that multiple areas in intervention, where black box warnings did not reveal details to monitor. Black box warning and medication such as a nonsteroidal anti-inflammatory medication initiated on 10/18/2023, a nonsteroidal anti-inflammatory medication initiated on 04/04/2024, an antidepressant initiated on 10/18/2023, an atypical antipsychotic medication initiated on 10/18/2023, and an antidepressant initiated on 10/18/2023, were referenced in the Care Plan. No warnings for symptoms to monitor. 5. Review of Resident #44's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/19/2024, noted the resident had active diagnoses of depression, heart failure, anxiety, pain, imaginary (phantom) limb syndrome with pain, acquired absence of right leg above the knee, acquired absence of left leg below the knee, heart failure. It also noted the resident receives, antianxiety, antidepressant, and an opioid. Review of Resident #44's Order Summary Report dated 12/11/2024 revealed the resident had orders for a prescription medicine used to treat depression, anxiety, nerve pain, fibromyalgia and chronic pain, oral capsule delayed response particles 60 milligrams (mg) give 1 capsule by mouth in the morning related to anxiety; a loop diuretic oral tablet 20 mg, give 3 tablet by mouth in the morning related to heart failure; a benzodiazepine medication oral table 1 mg give tablet by mouth four times a day related to anxiety; an opioid agonist (concentrate) oral solution 20 mg/ milliliter (mL) give 0.5 mL by mouth every 3 hours as needed for pain; an opioid agonist indicated for the relief of moderate to severe acute and chronic pain extended release (ER) oral tablet 30 mg give 1 tablet by mouth three times a day related to phantom limb syndrome with pain; an antidepressant oral tablet 50 mg give 0.5 tablet by mouth at bedtime for symptoms of insomnia. Review of Resident #44's Admission MDS with an ARD of 09/19/2024, noted the resident received, antianxiety, antidepressant, and an opioid. Review of Resident #44's Care plan dated 09/25/2024, does not note black box warning details for antidepressants, antianxiety, diuretic, hypnotic, and opioid. 6. Review of Resident #377's Medicare 5-Day MDS with an ARD of 12/08/2024, noted the resident had active diagnoses of high blood pressure (hypertension), diabetes mellitus (DM); fracture of right bone in pelvis (Pubis), pain, and depression. It also noted the resident received insulin, antidepressant, opioid, hypoglycemic (including insulin). Review of Resident #377's Order Summary Report dated 12/02/2024, noted an opioid agonist oral Tablet 50 mg give 1 tablet by mouth every 6 hours as needed for Pain - Moderate; a GLP-1 agonist that lowers blood sugar (0.25 or 0.5mg/dose (DOS)) under the skin (subcutaneous) solution Pen-injector 2 mg/3mL inject 0.5 mg subcutaneously one time a day every Saturday related to Type II diabetes mellitus; a blood pressure medication oral tablet 80 mg give 1 tablet by mouth one time a day for hypertension; an antidepressant oral tablet 100 mg give 1 tablet by mouth at bedtime for insomnia; an antidepressant oral tablet 25 mg give 1 tablet by mouth one time a day for depression; a nonsteroidal anti-inflammatory medication oral tablet 15 mg give 1 tablet by mouth one time a day for Pain. Review of Resident #377's Care Plan with a date of 11/22/2024, does not document black box warnings details. During an interview with the Minimum Data Set (MDS) Coordinator on 12/12/2024 at 11:46 AM, she confirmed that Resident #44 and Resident #377 do not have black box warning details in their care plans. The MDS Coordinator confirmed the purpose of black box warning details are to alert the staff of a medication interaction. 51477

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to ensure that nutritionally balanced meals were provided for the residents for 1 of 1 meal observed. The findings are: During an observation on 12/09/24 at 1:02 PM, the [NAME] asked the Dietary Manager (DM) to open more green beans to be cooked because there were not enough green beans to finish serving the residents. The DM confirmed there were no more green beans to cook and opened a can of spinach. The DM placed a partial can of spinach on the stove and placed a portion of the spinach in the microwave to cook. The DM obtained spinach temperature on the stove at 140.4 degrees. The DM removed spinach from stove and placed it on the steam table. The [NAME] began to serve spinach for the rest of the trays needed. During an observation on 12/09/24 at 1:19 PM, the [NAME] requested the dietary aide to make more puree chicken and dumplings, spinach, and bread. During an interview on 12/10/24 at 3:07 PM, the DM confirmed the kitchen ran out of pureed food and out of green beans. The DM confirmed the menu was not followed by using spinach. The DM confirmed the kitchen ran out of food because they did not confirm the number of meals needed for the day. During an interview on 12/11/24 09:59 AM, the [NAME] confirmed the kitchen ran out of food for lunch on 12/09/24, due to not cooking enough food and the kitchen did not order enough green beans for the meal. The [NAME] confirmed not preparing enough pureed food for all the residents needing a pureed meal due to having incorrect numbers. The [NAME] confirmed she did not follow the menu. During an interview on 12/11/24 11:42 AM, the Dietary Consultant (DC) confirmed the facility did not follow the menu and ran out of food due to not verifying the number of residents requiring meals for the day. The Dietary Consultant confirmed the facility did not order enough green beans which required the facility to cook spinach.

Based on observations, interviews, and record review, the facility failed to ensure pureed food was blended to a smooth consistency to meet the needs of residents who required a pureed diet during one (1) of one (1) meal service observed. The findings are: A review of a facility policy titled Therapeutic and Modified diets dated 08/24/2020, indicated, Purpose: To ensure residents receive foods with the appropriate textures and nutrient contents as prescribed by the physician to promote treatment and plan of care. Modified Consistency: Residents who require a modified consistency diet may be at risk for developing a foodborne illness due to the increased number of food handling steps required when preparing pureed and other modified consistency foods During an observation on 12/09/2024 at 11:49AM, pureed bread was prepared using milk, cornbread, white bread and milk. The consistency was thick and was not pudding like. During a concurrent observation and interview on 12/09/2024 at 12:18PM, pureed green beans were a thin runny consistency, and the [NAME] verbalized the pureed green beans were still a little thin. During an interview on 12/09/2024 at 1:20PM, the [NAME] confirmed the pureed bread that was served was too thick and not a pudding consistency. The [NAME] verbalized the bread had been in the oven prior to being placed on the steam table. The [NAME] verbalized the longer bread sits on the stem table it will thicken up and should not have been served.

Based on observation and interview it was determined that the facility did not ensure the survey inspection book was kept in a place where residents and family members could reach the book without asking. The findings are: On 12/11/2024 at 10:07 AM, during the resident council meeting Resident #7, Resident #49, Resident #61, and Resident #65 indicated that they did not know where the survey inspection book was located. On 12/11/24 at 10:12 AM, the survey inspection book was observed behind the nurse's station in a rack. The survey inspection book was not where the residents could reach it. During an interview on 12/11/2024 at 10:14 AM, the Director of Nursing (DON) indicated that the survey inspection book was kept behind the nurse's station. The DON indicated that a resident would not be able to reach the survey inspection book if they were in a wheelchair. On 12/11/24 at 3:00 PM, the survey inspection book was observed behind the nurse's station in a rack. The survey inspection book was not where the residents could reach it. On 12/12/24 at 10:14 AM, the survey inspection book was observed behind the nurse's station in a rack. The survey inspection book was not where the residents could reach it. During an interview on 12/12/24 at 10:18 AM, the Administrator indicated that the survey inspection book was located around the nurse's station. The Administrator indicated the inspection book used to be located where the residents could reach it. The Administrator indicated the inspection book was moved behind the nurse's station where the residents could not reach it because the residents would take it or move it. The Administrator indicated that she would have to make another survey book if the residents take it.

Based on observation, interviews, record review, and facility document review, it was determined that the facility failed to ensure a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) within 14 calendar days after admission to identify issues needed for comprehensive care plan development for 1 (Resident #52) of 8 sample mix residents. The findings are: On 12/9/24 at 9:29 AM, this surveyor observed Resident #52 lying in bed on their back at a thirty-degree (30') angle with eyes closed. Oxygen (O2) concentrator was present in the room and running at two (2) liters per minute (LPM) through a nasal cannula with humidification. Tubing, humidification, and storage bag were date 12/03/2024. Review of Resident #52's Medication Administration Record (MAR) for November 2024, did not provide an area to document oxygen use. Review of Resident #52's Baseline Care Plan dated 11/04/2024 noted in section 4; Health Conditions A. Health Conditions/ Special Treatments, 1a. Oxygen therapy- while a resident. Review of Resident #52's Order Summary Report dated 12/09/2024, noted change O2 tubing, clean filter and O2 cabinet, date all tubing every Monday night on 11-7 shift and for maintenance, O2 at two to four (2-4) LPM through nasal cannula. No directions specified for order. Review of Resident #52's Nursing Skilled Charting dated 11/05/2024 at 11:00 AM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2; 9. O2 via NC. Review of Resident #52's Nursing Skilled Charting dated 11/06/2024 at 11:37 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/07/2024 at 12:27 AM, noted in section H. Respiratory 1. Pulmonary assessment 3) Shortness of breath (SOB) on exertion 7a. Oxygen therapy- while a resident; 8. O2 at 2 lpm; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/07/2024 at 4:10 PM, noted in section H. Respiratory 1. Pulmonary assessment 3) Shortness of breath (SOB) on exertion; 7a. Oxygen therapy- while a resident; 8. O2 at 2-4; 9. O2 through NC PRN. Review of Resident #52's Nursing Skilled Charting dated 11/07/2024 at 7:17 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/07/2024 at 11:04 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC PRN. Review of Resident #52's Nursing Skilled Charting dated 11/08/2024 at 2:30 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2-4; 9. O2 through NC PRN. Review of Resident #52's Nursing Skilled Charting dated 11/08/2024 at 11:17 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Care Plan dated 11/08/2024, noted the resident has shortness of breath (SOB) with O2 use. O2 as needed (PRN), as per Medical Doctors (MD) orders. Review of Resident #52's Nursing Skilled Charting dated 11/09/2024 at 12:42 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/09/2024 at 6:56 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/09/2024 at 11:39 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/10/2024 at 9:58 AM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Nursing Skilled Charting dated 11/10/2024 at 6:22 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Admission/ Medicare 5 Day Minimum Data Set (MDS) with an Assessment Reference Date of 11/10/2024, noted in Section O0110, Special Treatments, Procedures, and Programs C1. Oxygen while a resident no. Review of Resident #52's Nursing Skilled Charting dated 11/11/2024 at 8:27 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through nasal cannula. Review of Resident #52's Nursing Skilled Charting dated 11/11/2024 at 11:17 PM, noted in section H. Respiratory 7a. Oxygen therapy- while a resident; 8. O2 at 2L; 9. O2 through NC. Review of Resident #52's Medication Administration Record (MAR) for December 2024, did not provide an area to document oxygen use. During an interview with Resident #52 on 12/09/24 at 10:03 AM, the resident stated, I don't know why I'm getting oxygen. I was getting it in the hospital and came here with it. On 12/10/24 at 8:20 AM, Surveyor observed Resident #52 lying in bed on back at 30-45' angle with eyes closed. Oxygen concentrator present in room running at 2 LPM through nasal cannula with humidification. Oxygen tubing, humidification bottle and storage bag are all dated 12/10/2024. During an interview with Licensed Practical Nurse (LPN) #4 on 12/12/2024 at 11:42 AM, she confirmed that Resident #52 had received continuous oxygen since admission. LPN #4 revealed Resident #52 would become short of breath with any movement, but that the Physician ' s Order did not note why Resident #52 was receiving oxygen. LPN #4 confirmed the order summary report did not note whether the resident was to receive oxygen as needed or continuous. LPN #4 confirmed there was no place on the Medication Administration Record (MAR) to document daily oxygen use. LPN #4 confirmed the daily nursing skilled charting notes documented Resident #52 received oxygen from 11/05/2024 through 11/11/2024. During an interview with the Minimum Data Set (MDS) Coordinator on 12/12/2024 at 11:46 AM, she confirmed Resident #52 had an order for oxygen since 11/05/2024 and that the order did not say if the oxygen was to be continuous or as needed. She confirmed the Physician ' s Order did not note why the resident was receiving oxygen and that there needed to be an indication as to why the resident was receiving oxygen. MDS Coordinator confirmed Resident #52 had oxygen use noted on the daily nursing skilled charts from 11/05/2024 through 11/11/2024 and should be noted on the residents Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 11/10/2024. She confirmed section J of the MDS was not documented accurately as it should note the resident has shortness of breath with exertion as noted on the nursing skilled charting on 11/07/2024 in section H's part of the pulmonary assessment. The MDS Coordinator confirmed Resident #52's Care Plan was not documented accurately.

Based on interview and record review, it was determined that the facility failed to ensure resident Care Plan meetings were attempted every quarter for one (Resident #38) of one resident reviewed for Care Plan meetings. The findings include: On 12/12/2024 at 2:20 PM, the Minimum Data Set (MDS) Coordinator stated they spoke with the facility consultant, the facility does not have a policy for Care Plan meetings. Review of an Admission Record indicated that the facility admitted Resident #38 with a diagnosis of cerebral infarction due to occlusion or stenosis of the right middle cerebral artery (stroke). The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/05/2024, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the Resident had moderate cognitive impairment. During an interview on 12/09/2024 at 2:54 PM, Resident #38 stated I ' ve been to one [Care Plan] meeting in the last 5 years. During an interview on 12/11/2024 at 8:34 AM, the MDS Coordinator stated Resident #38 has not had a care plan meeting this year and that notification was sent in October or November of this year with no response from family. Resident #38 had a BIMS score of 11 and communication impairment and would get frustrated when not understood. The MDS coordinator stated they could have a care plan meeting with Resident #38 if the resident wanted one. Review of Resident #38 ' s Miscellaneous Files revealed the last known Care Plan Meeting Summary performed on 05/10/2023. During an interview on 12/12/2024 on 3:26 PM, the MDS Coordinator verified notification was only sent out to the family and not to the Resident.

Based on observation and interview, it was determined that the facility failed to remove facial hair for 1 (Resident #69) of 4 sampled residents reviewed for activities of daily living. The findings are: A review of an Order Summery Report indicated that Resident #69 had a diagnosis of dementia. The significant change Minimum Date Set (MDS) with an Assessment Reference date (ARD) of 9/09/2024, revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment and required supervision for personal hygiene. Review of Resident #69's Care Plan initiated 09/08/2024, revealed that Resident #69 required supervision to partial assistance by one staff for personal hygiene. On 12/09/24 at 10:18 AM, Resident #69 was observed sitting in a wheelchair outside the resident ' s room. Resident #69 had facial hair on the resident ' s chin and above the upper lip. On 12/09/24 at 10:25 AM, Resident #69 was observed in the resident ' s room. Resident #69 had facial hair on the resident ' s chin and above the upper lip. On 12/09/24 at 2:00 PM, Resident #69 was observed in bed. Resident #69 had facial hair on the resident ' s chin and above the upper lip. On 12/11/24 at 8:45 AM, Resident #69 was observed sitting in a wheelchair outside the resident ' s room. Resident #69 had facial hair on the resident ' s chin and above the upper lip. On 12/11/24 at 10:46 AM, Resident #69 was observed sitting in a wheelchair outside resident ' s room. Resident #69 had facial hair on the resident ' s chin and above the upper lip. On 12/11/24 at 10:55 AM, Certified Nursing Aide (CNA) #3 indicated that Resident #69 gets facial hair shaved on shower days. CNA #3 indicated that Resident #69 had facial hair on the resident ' s chin and upper lip. CNA #3 indicated that she did not know why Resident #69 had not been shaved. On 12/12/2024 at 2:30 PM, the Administrator stated the facility did not have a policy on activities of daily living.

Based on interview and record review it was determined that the facility failed to carry out interventions after a fall for 1 (Resident #2) of 4 sampled residents reviewed for falls. The findings are: A review of an Order Summery Report indicated that Resident #2 had a diagnosis of osteoarthritis of both knees. The significant change Minimum Date Set (MDS) with an Assessment Reference date (ARD) of 09/25/2024 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated that Resident #2 has had a fall with a major injury. Review of Resident #2's Care Plan revised 12/11/2024 revealed that Resident #2 had a fall on 10/24/2024. Interventions included to submit a therapy request for possible services. The Care Plan revised on 12/11/2024, indicated that Resident #2 had an unwitnessed fall. The intervention was to refer to therapy for an evaluation. A review of Resident #2's hospital records dated 09/19/2024 indicated Resident #2 had a fall with a nasal fracture. A review of a facility incident report dated 10/24/2024 indicated Resident #2 had an unwitnessed fall. Interventions included submitting a therapy request for possible services. A review of a Facility Incident Report dated 11/11/2024 indicated that Resident #2 had an unwitnessed fall. Interventions included referring to therapy. During an interview on 12/12/24 at 9:20 AM, the Physical Therapy Assistant indicated that a communication form was received from the DON when there was a need to evaluate a resident for possible services. She indicated after she completes her evaluation the form is sent to billing for payment. She indicated that she did not have a request for a therapy evaluation for 10/24/2024, and 11/01/2024 for Resident #2. On 12/12/24 at 10:00 AM, the Therapy Notes received from Physical Therapy Assistant were reviewed. The notes were dated for the period of 9/21/2024-10/20/2024. There were no notes dated 10/24/2024, and 11/01/2024 for Resident #2. On 12/12/2024 at 10:30 AM, the Physical Therapy Assistant (PTA) indicated she did not have any referrals for Resident #2 for 10/24/2024 and 11/01/2024. During an interview on 12/12/24 at 11:03 AM, the Director of Nursing (DON) indicated that a therapy form should have been completed for Resident #2 when the fall occurred on 10/24/2024 and 11/01/2024. The DON indicated that Resident #2 did not have a therapy evaluation form for 10/24/2024 or 11/01/2024. During an interview on 12/12/24 at 11:09 AM, the MDS coordinator provided a form titled Rehab Communication Form dated 11/01/2024. The form indicated that Resident #2 refused a therapy evaluation and restorative. The MDS Coordinator indicated that she wrote on the form that the resident refused therapy. The MDS coordinator indicated that the form was given to the Business Office Manager. The MDS coordinator indicated that she did not give the form to the therapy department. During an interview on 12/12/2024 at 11:15 AM, Resident #2, stated I have a lot of falls because I have polio. Resident #2 indicated the staff had not asked about a therapy evaluation. Resident #2 indicated not having refused to have a therapy evaluation or any therapy to help prevent falls. On 12/12/2024 at 2:30 PM, the Administrator stated the facility did not have a policy on falls.

Based on observation, interviews, record review, and facility document review, it was determined that the facility failed to ensure that an accurate Physician ' s Order was in place for oxygen for 1 (Resident #52) of 1 sample mix residents who received oxygen. The findings are: On 12/09/24 at 9:29 AM, this surveyor observed Resident #52 lying in bed on back at a thirty-degree angle with eyes closed. Oxygen (O2) concentrator present in the room and running at two (2) liters per minute (LPM) through a nasal cannula with humidification. Tubing, humidification, and storage bag date 12/03/2024. Review of Resident #52's Medication Administration Record (MAR) for November 2024, did not provide an area to document oxygen use. Review of Resident #52's Baseline Care Plan dated 11/04/2024 noted in section 4. Health Conditions A. Health Conditions/ Special Treatments 1a. Oxygen therapy- while a resident. Review of Resident #52's Order Summary Report dated 12/09/2024 noted change O2 tubing, clean filter and O2 cabinet, date all tubing every Monday night on 11-7 shift and for maintenance, O2 at two to four (2-4) LPM though nasal cannula. No directions were specified for the order. Review of Resident #52's admission/ Medicare 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ADR) of 11/10/2024, noted Section O0110. Special Treatments, Procedures, and Programs C1. Oxygen while a resident, no. Review of Resident #52's Medication Administration Record (MAR) for December 2024, did not provide an area to document oxygen use. On 12/10/24 at 1:59 PM, review of Resident #52's Care Plan dated 11/8/2024 noted the resident had shortness of breath with oxygen (O2) use. Oxygen (O2) as needed (PRN), as per Medical Doctors (MD) orders. During an interview with Resident #52, on 12/09/24 at 10:03 AM, the resident stated, I don't know why I'm getting oxygen. I was getting it in the hospital and came here with it. On 12/10/24 at 8:20 AM, this surveyor observed Resident #52 lying in bed on back at 30-45' angle with eyes closed. Oxygen concentrator present in the room running at 2 LPM through nasal cannula with humidification. Oxygen tubing, humidification bottle and storage bag were all dated 12/10/2024. During an interview with Licensed Practical Nurse (LPN) #4 on 12/12/2024 at 11:42 AM, she confirmed that Resident #52 had received continuous oxygen since admission. LPN #4 revealed Resident #52 became short of breath with any movement, but that the Physician ' s Order did not note why Resident #52 was receiving oxygen. LPN #4 confirmed the order summary report did not note whether the resident was to receive oxygen as needed or continuous. LPN #4 confirmed there was no place on the Medication Administration Record (MAR) to document daily oxygen use. During an interview with the Minimum Data Set (MDS) Coordinator, on 12/12/2024 at 11:46 AM, she confirmed Resident #52 had an order for oxygen since 11/05/2024 and that the order did not say if the oxygen was to be continuous or as needed. She confirmed the Physician ' s Order did not note why the resident was receiving oxygen and that there needed to be an indication as to why the resident was receiving oxygen.

Based on observation, record review and interview, the facility failed to ensure leftover food items were discarded to maintain food quality; foods stored in the freezer, refrigerator, and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; failed to ensure dented food cans were promptly removed/ discarded to prevent the growth of bacteria; failed to properly clean and sanitize food thermometer between raw ground meat and cooked meat; failed to properly store frozen raw beef in freezer to prevent cross contamination; failed to removed expired food items to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen. The findings are: 1. On [DATE] at 2:16 PM, the following observations were made on a shelf in the refrigerator: a. A polystyrene foam container labeled cheese with a date of [DATE]. b. One gallon of soy sauce without an open date. c. Sliced cheese in open plastic bag not sealed. d. A twenty ounce bottle of ketchup without a receive date. e. A one gallon container of Italian dressing without a receive date. f. A thirty-Two ounce bottle of lemon juice without an open date. g. An individual bowl of sweet potatoes with lid no identifier or date. h. A forty ounce jug of thickened orange juice without an open date. i. A forty-six-ounce jug of apple juice concentrate without a receive date, and an expiration date of [DATE]. j. A forty-six-ounce jug of thickened sweet tea no open date. k. A forty-six-ounce jug of thickened sweet tea no open date, and an expiration date of [DATE]. l. A container of tomato soup with an expiration date of [DATE] with an open date of [DATE]. m. A five pound container of cottage cheese with no open date. n. A five pound container of cottage cheese with no receive date. o. A fifteen pound box of raw bacon no open date on box and bag is not sealed 2. On [DATE] at 2:36 PM, the following observations were made on a shelf in the freezer: a. box of fully cooked turkey sausage no open date and bag not sealed b. box of donuts without a receive date 3. On [DATE] at 2:41 PM, raw ground beef tubes and fully cooked pulled chicken in a bag stacked on top of each other in a metal pan on counter near the dish washing area in prep area. The meat was noted to be thawed. Dietary Employee #3 said it was there since 12:00 PM when she went over to check on her things. DE #3 took the temperature of the pulled chicken with a temperature of 39 degrees Fahrenheit. 4. On [DATE] at 2:42 PM, a 10-pound tube of ground beef meat' s (#1) temperature was 46 degrees Fahrenheit and a second 10-pound tube of ground beef meat (#2) temperature of 40 degrees Fahrenheit 5. On [DATE] at 2:43 PM, obtained another piece of chicken and the internal temperature was 36 degrees Fahrenheit. 6. On [DATE] at 2:41 PM Dietary Employee #3 used a clean thermometer to obtain the internal temperature of the pulled chicken 7. On [DATE] at 2:42 PM, DE #3 removed the thermometer from the chicken and inserted it immediately into the end of the ground beef tube 8. On [DATE] at 2:42 PM, DE #3 removed the Thermometer from the ground beef tube #1 and inserted the thermometer into the ground beef tube #2 9. On [DATE] at 2:43 PM, DE #3 removed the thermometer from the ground beef tube and rinsed the thermometer in the sink under running water and then inserted it back into the pulled chicken 10. On [DATE] at 2:44 PM, the Surveyor asked the DE #3, How should meat be stored to thaw? DE #3 stated, Meat should be taken out of the freezer and placed in the refrigerator to thaw. 11. On [DATE] at 2:45 PM, DE #3 rinsed the thermometer and scrubbed with an alcohol prep pad prior to obtaining the temperature of cream of potato with bacon soup. The temperature obtained was 62 degrees Fahrenheit. 12. On [DATE] at 2:50 PM, the Surveyor asked DE# 3, How should the thermometer be cleaned in between uses? DE#3 stated, The thermometer should be cleaned with alcohol swabs and hot water. 13. On [DATE] at 2:51 PM, DE #3 placed the ground beef and pulled chicken in the refrigerator from the counter that had been thawing on the counter since 12:00 PM. 14. On [DATE] at 2:52 PM a bag of diced beef sirloin tips stored in refrigerator above cheese, riblets and toast. 15. On [DATE] at 2:54 PM, the Surveyor asked the Dietary Manager How should meat be stored in the refrigerator? The Dietary manager stated, Cooked chicken on top, 2nd shelf precooked fritters, 3rd shelf raw fish and pork, 4th shelf raw beef and chicken. 16. On [DATE] at 2:58 PM, DE#3 placed thawed potato soup in the refrigerator 17. On [DATE] at 3:00 PM, the following observations made in the milk cooler: a. peach Cheesecake bar without prepare date b. ground hamburger meat in a metal pan stored on the shelf with milk, in pan was a 5 pound and 10 pound roll of ground hamburger meat 18. On [DATE] at 3:02 PM, a bag of onion rings were undated in a sealed bag in the freezer. 19. On [DATE] at 3:06 PM, the following observations were made in the dry storage: a. Two 50 ounce cans of chicken noodle soup dented. b. A one gallon can of dark kidney beans. c. Seven 46-ounce jug of Thickened sweet tea with Lemon with an expiration date of [DATE]. d. Three 46-ounce jug of Thickened sweet tea with Lemon with an expiration date of [DATE]. e. One 46-ounce jug of Thickened Cranberry Juice with an expiration date of [DATE]. 20. On [DATE] at 3:10 PM, the Surveyor asked the Dietary Manager, What is the process for dented cans? The Dietary manager stated, We store dented cans to the side. The Surveyor asked, How often is the cans checked for dents? The Dietary Manager, stated, We check them on truck day.

Based on observations, interviews and record review the facility failed to ensure that 2 Residents (Resident #26 and #320) were properly clothed and covered in common areas. This failed practice was a violation of res resident's right to have dignity. The Findings are: 1. Resident #26 had a diagnosis of dementia without behavior disturbance, psychotic disturbance, mood disturbance and anxiety. According to Significant Change Minimum Data Set (MDS) with Assessment Reference Date (ARD) 4/17/23 resident required extensive assist with dressing. It was documented Quarterly MDS with ARD 10/9/23 Resident 26 had a Brief Interview of Mental Status (BIMS) of 3. Resident #26 required staff to assist with choosing simple comfortable clothing. A. On 12/05/23 at 2:30 PM, Surveyor observed Resident #26 sitting by nurses' station wearing a shirt that could be seen thru and did not have on a brassiere undergarment. B. 12/05/23 2:37 PM, Surveyor observed Activity Director Assistant (ADA) observed walking with Resident#26 away from the nurse's station. C. 12/05/23 02:37 PM, the Surveyor asked (ADA) does resident pick out her own clothing? The ASA stated, No. The Surveyor asked do you see anything wrong with her shirt? The ADA stated, Yes, it is see through I just saw that. I was about to take her room and change it. 2. Resident #320 had a diagnosis of unspecified dementia, unspecified severity, without behavior disturbance, mood disturbance, and anxiety. According to Admission MDS with ARD 11/22/23 Resident #320 had a Brief Interview for Mental Status (BIMS) of 3. Resident #320 was care plan for ADL self-care performance deficit related to weakness history of stroke, in continence, and history of falls. A. On 12/06/23 at 9:10 AM, Surveyor observed 2 Certified Nursing Assistant (CNA)s transporting Resident #320 to the shower room. There was a flat sheet wrapped around the Resident that did not fully cover him leaving his buttock exposed. B. On 12/06/23 at 9:10 AM, once resident was in shower room Surveyor asked CNA #3? to walk to the back of resident and tell me what you see? CNA #3 stated It's not down far enough. C. On 12/06/23 at 9:15 AM, Surveyor asked CNA #3 what is the process for transporting a resident to the shower room? CNA #3 said we put the resident on the chair in the room, make sure they are covered, and push them to the shower room. The Surveyor asked, why do you make sure that the residents are covered? CAN #3 stated, It's a dignity issue. E. On 12/7/23 at 4:00 PM, Administrator provided a policy titled Resident Right documented . procedures stated that each resident in the facility has the right to: (34) To be treated with consideration, respect and full recognition of dignity and individuality.

Based on record review and interview, the facility failed to accurately record on the resident assessment to ensure the Minimum Data Set [MDS] accurately reflected section for special treatments, procedures, and programs including oxygen to facilitate the ability to plan, coordinate, and provide necessary care for 1 (Resident #23) of 6 Sample Residents (R#2, R#23, R#39, R#53, R#55, R#64) receiving oxygen therapy. The facility failed to have a procedure in place to monitor activities of daily living [ADL] decline in Residents. The facility failed to ensure the Minimum Data Set [MDS] assessment accurately reflected a level II Preadmission Screening and Resident Review [PASARR] evaluation with recommendations to facilitate the ability to plan, coordinate and provide necessary care for 1 (Resident #31) of 1 sampled resident requiring a level II PASARR. The findings are: Resident #23 with diagnoses of Chronic Respiratory Failure with Hypoxia (below normal level of oxygen in your blood. Minimum data set [MDS] with an assessment reference date [ARD] on 09/24/2023 and a brief interview for mental status [BIMS] of 12. A Care Plan with a revision date of 03/27/2023 documented, .Resident #23 has potential for shortness of breath, Dyspnea, and other complications due to Respiratory Failure .oxygen at 2 liters nasal cannula as needed to maintain oxygen level above 90% % (change tubing per order as Needed) . Physician Orders: Date 07/26/2023 Oxygen: 2 liters/minute per nasal cannula as needed for chronic obstructive pulmonary disease [COPD] to keep O2 (oxygen) sats (saturation) at 90% or above. A Physician Order with a date of 07/06/2023 . Oxygen at 2 Liters via nasal cannula as needed to maintain oxygen level above 90% as needed for Shortness of breath/decreased oxygen saturation related to {COPD}. Per record review of Resident #23's Quarterly MDS with an assessment reference date [ARD] of 09/24/2023 section O0100 Special Treatments, Procedures and Programs did not reflect oxygen therapy. On 12/05/2023 at 2:00 PM, Resident #23 said she wears 2 liters of oxygen at night. Resident #23's concentrator is set on 3.5-4 liters, and nasal cannula is in the floor. On 12/05/2023 at 2:03 PM, the Surveyor observed Resident #23's closet care plan documenting Resident #23 is on 2 liters oxygen as needed prn. On 12/05/2023 at 4:30 PM, Licensed Practical Nurse [LPN] #1 confirmed oxygen setting was on 3.5-4 liters. LPN #1 said Resident #23 changes her oxygen settings. The Surveyor asked if LPN #1 where it is documented on the care plan that Resident #23 changes the oxygen settings. On 12/05/2023 at 4:37 PM, The Surveyor asked the Director of Nursing [DON] where it states that Resident #23 changes oxygen settings on the care plan. The DON said she was going to ask the minimum data set [MDS] nurse for assistance. On 12/05/2023 at 5:00 PM, the MDS nurse provided a Clinical Care Plan Detail documenting .Resident takes her oxygen off at times without alerting staff. She will throw it onto the floor or the bed. Resident noted to change oxygen settings at times. On 12/07/2023 at 5:05 PM, the Surveyor asked the MDS nurse to help locate where the MDS nurse found that Resident #23 changed oxygen settings at times on the care plan, and when it was added. The MDS nurse said told the surveyor she added it to the care plan about 30 minutes ago. On 12/07/23 at 10:05 AM, the Surveyor asked the MDS Nurse to check the Quarterly MDS for 09/24/2023 for oxygen therapy. The MDS nurse said, There is no documentation of oxygen. The MDS nurse looked at progress notes and said told there is no documentation that resident used any oxygen within 7 days of 09/24/2023. On 12/07/23 at 10:25 AM, the Surveyor reviewed vital signs for oxygen therapy documented the following: 1. On 09/17/2023 at 1:51 PM, 95% oxygen via nasal cannula 2. On 09/18/2023 at 3:18 PM, 96% oxygen via nasal cannula 3. On 09/19/2023 at 6:43 PM, 94% oxygen via nasal cannula 4. On 09/21/2023 at 1:56 AM, 97% oxygen via nasal cannula 5. On 09/21/2023 at 1:13 AM, 92% oxygen via nasal cannula 6. On 09/22/2023 at 1:47 AM, 94% oxygen via nasal cannula 7. On 09/24/2023 at 2:02 PM, 97% oxygen via nasal cannula On 12/07/23 at 2:13 PM, the MDS nurse was asked to review vital signs records and noted documentation of oxygen use from 09/17/2023-09/24/2023. The MDS confirmed Resident #23 was on oxygen within 7 days of the recent quarterly MDS with an ARD of 09/24/2023. On 12/07/23 at 10:10 AM, the Surveyor asked the MDS nurse what procedures were being used to monitor for Resident ADL declines since the MDS changes in October 2023. The MDS nurse said, we look at changes of condition, certified nursing assistants [CNA]s are verbal and tell me. On 12/07/23 at 2:15 PM, the Surveyor asked the MDS nurse what procedure is being used to monitor for ADL declines. The MDS nurse told the Surveyor she spoke with her consultant, and nothing has changed. The facility looks at tasks and compares them to the previous MDS and tasks. On 12/07/23 at 3:45 PM, the Surveyor asked the Administrator for the MDS policy. On 12/07/23 at 4:00 PM, the Administrator said they do not have a MDS policy, and the facility follows the resident assessment instrument [RAI] manual. On 12/08/2023 at 08:45 AM, the Director of Nursing [DON] was asked what staff members are responsible for coding to the MDS. The DON said the MDS nurse, and dietary and social work code to a portion of this assessment. Resident #31 had a diagnosis of paranoid schizophrenia, other specified anxiety disorders, delusional disorders, major depressive disorder, and anxiety disorder according to the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/23. On 12/5/23 at 7:15 PM, a review of Resident #31 ' s records Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 01/17/23 documented that resident was not considered by the state as level II PASSRR. On 12/06/23 at 3:30 PM, asked if Resident #31 is a level II PASARR patient. The MDS nurse looked at the list from her office and stated Yes, he is. The Surveyor asked how Resident #31's PASARR II was documented on question A 1500 of the Annual MDS? The MDS nurse stated, It was answered incorrectly. DON is Resident #31 considered by the state to be level II PASSR? The DON said yes.

47916 Based on observation, record review and interview, the facility to ensure the environment was free of potential accident hazards by failure to ensure manufacture guidelines were followed when using a lift for transfer assistance affecting 1 (Resident #25) of 6 sampled (Residents #10 #25, #31, #32, #35, #46) requiring a lift for transfer assistance. The facility failed to ensure interventions were implemented to attempt to prevent falls as evidenced by Resident #64 falling. The findings are: Resident #25 with a diagnosis of Alzheimer ' s disease, dementia, and neurocognitive disorder. A significant minimum data set [MDS] with an assessment reference date [ARD] 0f 11/27/2023, and a staff assessment for mental status [SAMS] shows moderately impaired memory problems. The Resident requires total assistance with bed bed mobility, eating, transfers, dressing and personal hygiene. Review of care plan (05/24/2023, Revision) .Resident has an activity of daily living [ADL] self-care performance deficit r/t Alzheimer's, Confusion, Dementia, Immobility . Transfers: Resident is a mechanical lift, x 2 staff assistance. Transfers: Total dependence, mechanical lift for all transfers, two staff must assist . On 12/05/23 at 2:30 PM, Certified Nursing Assistant [CNA] #4 and CNA #5 observed with Resident #25 positioned into a sitting position, straps in place. CNA #4 was observed locking the casters on the lift and resident was raised out of the Geri chair at the bedside. CNA #4 unlocked the casters and rolled resident over to the bed and lowered Resident #25 to the bed. On 12/05/23 at 2:39 PM, CNA #4 was asked what the process is for moving a resident with a lift. CNA #4 said to position the resident on a lift pad with the straps between the resident's legs, make sure resident is in a sitting position, lift and place in bed. The Surveyor asked CNA #4 to explain the process when using the casters in a locked position. CNA #4 told the Surveyor the wheels are locked when the resident is lifted for resident stability. On 12/08/23 at 8:45 AM, the Surveyor asked the Director of Nursing [DON] what procedure staff are expected to use when transferring residents with a lift. The DON said educate the Resident, safety pins of lift, place lift pad properly, attach sling to the lift, two staff members lift with one to lift and one to guide, and place resident in the bed. The Surveyor asked when should wheels on the lift be locked. The DON said wheels should be locked when Resident gets to the location they are being placed. The Surveyor asked if the wheels should be locked when lifting the resident. The DON told the Surveyor she would have to get back to the Surveyor on that. e. On 12/08/2023 at 8:54 AM, the Surveyor asked for a lift policy, and manufacture guidelines. f. On 12/08/2023 at 09:55 AM, the DON said staff should not lock the wheels when raising residents on the lift. g. On 12/08/2023 at 9:55 AM, the DON provided the policy titled Two Person Lift documenting the steps to lift a resident. The policy does not apply. h. On 12/08/2023 at 09:55 AM, the DON provided the lift equipment guidelines (05/11, Revision) . 8 Transferring the patient 8.1 . Warning . lift equipment does not recommend locking the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. lift equipment does recommend that the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed or any stationary object . On 12/08/2023 at 12:48 PM, The Administrator provided an in-service titled Safe Transfers using the Lift documenting . Date: 10/14/2022 . Ensure to never lock the rear wheels when lifting the individual. Doing so could cause the lift to tip and endanger the resident and CNA. Ensure that the rear wheels are unlocked during lifting & transferring to allow the [NAME] to stabilize itself . On 12/05/23 at 2:00 PM, the Surveyor observed Resident #64 with a splint to left wrist. The Surveyor asked Resident #64 was asked what happened to her wrist. Resident #64 stated, I fell . On 12/O7/23 the Surveyor read the Incident Description with an Effective Date of 11/6/23 070 Heard resident yelling help, went to residents' room where I found her on the floor, lying on her left side, between her bed and her roommate's bed. Resident had a laceration on her left eyebrow and her right wrist. Bruising to left side of face. Left wrist appears dislocated. Immediate Intervention: Sent to ER [emergency room ], Bed alarm to be placed to notify staff when resident is attempting to get up Vitals: 126/72,62, 18, 97.6. b. Review of Care Plan: The resident has had an actual fall with injury 10/12/23 - UW [unwitnessed] Fall Injury 11/6/23 - UW Fall - Injury Date Initiated: 12/06/2023 Created by: [Named](Licensed Practical Nurse Revision on: 12/06/2023. Revision by: [Named] (Licensed Practical Nurse) c. A Minimum Data Set with an Assessment Reference Date 11/9/23 documented falls. d. A nurses note dated 11/6/23 at 17:31 [05:31 PM] documented, Resident back from the emergency room post fall. Skin Assessment completed. Laceration above left eye, skin adhesive present. Treatment to monitor for signs and symptoms of infection. Bruising around the left eye. Bruising noted to L [left] elbow, L hand, L wrist and L forearm. L wrist splint put in place. Bruising noted to R [right] wrist and skin tear to R wrist under thumb. Edges approximated and strips put in place. Bruising noted to L hip. Bruising also noted to R knee. 3+ pitting edema noted to BLE [bilateral lower extremities]. No other issued noted at this time. On 12/7/23 at 1:35 PM, the Surveyor asked Certified Nurse Assistant (CNA) to look on the Resident #64 ' s bed for a bed alarm. The CNA stated, she's never had a bed alarm. The Surveyor asked the CNA how they would know what intervention should be put in place for a fall. The CNA stated, On the closet care plan (CCP). She opened the closet door and there had not been any interventions put in place on the CCP. On 12/7/23 at 1:47 PM, the Director of Nursing (DON) was asked to look in the Electronic Record (ER) for the interventions from Resident # 64's falls. The DON stated, We put a low bed and winged mattress in place. The Surveyor asked to see in the paperwork where the interventions were put in place. There was not a follow up from the Director of Nurses/Designee in the ER. The DON stated, I wrote it on the Incident and Accident (I&A). In the I &A under Immediate Action it was documented, assessed patient, V/S (Vital Signs) taken and sent to the ER .Resident was previously placed in lowest position in a very low bed, however resident raised her bed and stood up by herself and began to take steps. Resident had low bed and winged mattress. The Surveyor asked the DON for interventions that were put in place. The DON stated, A fall mat from the first fall. The Surveyor asked the DON to explain how a fall mat could prevent a fall. The DON stated, It can't, but might prevent an injury. On 12/08/23 at 10:20 AM, the Surveyor asked the Administrator if the fall was unwitnessed with no witnesses how did they know that Resident #64 fell ? The Administrator said the roommate saw it. During interview Resident #64 ' s roommate stated, she was asleep and she heard a noise and woke up to Resident #64 in the floor with her bed raised high. The roommate stated, No I did not see her fall. On 12/08/23 the administrator provided a form titled, Incident and Accident (I&A) Policy that showed, All I & A's occurring in this facility will be investigated and reported to the Administrator and Director of Nursing.

48977 Based on observations, interviews and record review, the facility failed to follow the oxygen safety policy by not posting cautionary and safety signs indicating the oxygen in use 1 Resident (Resident #10) for the use of oxygen therapy of 1 sampled resident. The facility failed to complete a comprehensive care plan for 1 Resident (Resident #23) and failed to follow physician orders for 1 Resident (Resident #53). Findings are: Resident #10 had the following diagnosis dyspnea, chronic obstructive pulmonary disease, shortness of breath, acute respiratory failure with hypoxia. According to Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/2/23 Resident was receiving oxygen therapy 2 liters via nasal cannula for shortness of breath as needed. According to Quarterly (MDS) with (ARD) 10/30/23 Resident was receiving oxygen therapy while a resident. On 12/05/23 at 3:19 PM, Resident #10 was receiving oxygen at 2 liters via nasal cannula and there is no oxygen sign on or around door. On 12/05/23 at 6:05 PM, Resident #10 was receiving oxygen at 2 liters via nasal cannula and there is no oxygen sign on or around door. On 12/05/23 at 6:07 PM, Resident #10 was receiving oxygen at 2 liters via nasal cannula and there is no oxygen sign on or around door. On 12/05/23 at 6:07 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 is there a resident in this room receiving oxygen? LPN #1 stated, yes. Is there an oxygen in use sign on the door? LPN #1 stated, no. Should there be an oxygen in use sign on the door? LPN #1 stated, yes. On 12/07/23 at 2:20 PM, the Surveyor asked the Director of Nursing (DON) if a resident is receiving oxygen, how would I know if a resident was on oxygen therapy before I entered the room? The DON stated, There would be a sign on the door. The Surveyor asked, if a resident is on oxygen therapy should there be a sign on the door? the DON stated, yes. On 12/7/23 at 4:00 PM, the Administrator provided Surveyor with an Oxygen Safety Policy documenting . prior to administering oxygen, Oxygen in Use sign must be posted on the outside of the room entrance door. Resident #23 with diagnoses of chronic respiratory failure with hypoxia, cerebral infraction, chronic atrial fib. Minimum data set [MDS] with an assessment reference date [ARD] on 09/24/2023 and a brief interview for mental status [BIMS] of 12. A Care Plan with (03/27/23, Revision) Resident has potential for shortness of breath, dyspnea, and other complications due to respiratory failure .oxygen at 2 Liters via nasal cannula as needed to maintain oxygen level above 90% (change tubing per order and as needed. A Physician Order with a date of 07/06/2023 . oxygen at 2 Liters via nasal cannula as needed to maintain oxygen level above 90% as needed for Shortness of breath/decreased oxygen saturation related to acute exacerbation of Chronic Obstructive Pulmonary Disease. On 12/05/2023 at 2:00 PM, during interview Resident #23 said she wears 2 liters of oxygen at night. Resident #23's concentrator is set on 3.5-4 liters, and nasal canula is in the floor. On 12/05/2023 at 2:03 PM, Resident #23's closet care plan showed Resident #23 is on 2 liters oxygen as needed prn. On 12/05/2023 at 4:30 PM, Licensed Practical Nurse [LPN] #1 confirmed oxygen setting was on 3.5-4 liters. LPN #1 said Resident #23 changes her oxygen settings. The Surveyor asked if LPN #1 could show Surveyor where that is documented on the care plan that Resident #23 changes oxygen settings. On 12/05/2023 at 4:37 PM, the Surveyor asked the Director of Nursing [DON] if the DON find where Resident #23 changes oxygen settings on Resident #23's care plan. On 12/05/2023 at 4:45 PM, the Director of Nursing [DON] told the Surveyor she was going to ask the minimum data set [MDS] nurse for assistance. On 12/05/2023 at 5:00 PM, the MDS nurse provided a Clinical Care Plan Detail documenting .Resident takes her oxygen off at times without alerting staff. She will throw it onto the floor or the bed. Resident noted to change oxygen settings at times. On 12/07/23 at 5:05 PM, the Surveyor asked the MDS nurse for help locating where the MDS nurse found that Resident #23 changed oxygen settings at times on the care plan, and when it was added. The MDS nurse told the surveyor she added it to the care plan about 30 minutes ago. On 12/04/23 at 2:00 PM, Resident #53 was lying in bed with oxygen on via nasal cannula at 3 liters per minute (LPM) with a date of 12/3/23 on the tubing. Upon checking orders for correct LPM there were no orders for oxygen. On 12/05/23 at 5:17 PM, Resident #53 had oxygen on at 3 lpm via nasal cannula. No orders were noted in portal. On 12/05/23 at 5:18 PM, it was documented by Medical Records Licensed Practical Nurse an order for O2 (oxygen) at 2 LPM (Liters per minute) via NC (nasal cannula) PRN (as needed) for shortness of Breath at 12/5/2023 15:45. On 12/05/23 at 5:18 PM, the Surveyor asked the Medical Records Licensed Practical Nurse if she had put in the order for oxygen on Resident #53. The Medical Records Licensed Practical Nurse stated, Yes I did the DON told me to do it because he didn't have an order for oxygen. On 12/07/23 at 1:47 PM the Surveyor asked the Director of Nurses to explain the process of administering oxygen. The DON stated, Place it on the resident. The Surveyor asked the DON if a physician's order was necessary prior to administering the oxygen. The DON stated, yes . On 12/07/23 at 4:00 PM, the Administrator provided a titled, Oxygen Safety that showed, oxygen therapy is administered to the resident only upon the written order of a licensed physician. On 12/07/23 at 4:00 PM, the Administrator provided a form titled, Physician Services that showed, all medications administered to the resident must be ordered in writing by the residents attending physician.

Based on observation and interview, the facility failed to ensure that the medication cart for 100 Hall was locked and secured at the nurses station when the nurse was not in eyesight of the medication cart. This failed practice affected 10 sampled Residents (#3, #21, #23, #26, #34, #39, #53, #55, #64, and #170), and had the potential to affect 47 Residents in the facility that are capable of ambulating or self-propelling in the facility. The findings are: a. On 12/07/23 at 2:46 PM, the Surveyor observed the 100 Hall cart unlocked and unattended. The Surveyor asked Licensed Practical Nurse (LPN) #2 what is wrong with the medication cart? LPN #2 said it is unlocked for restocking. b. On 12/07/2023 at 2:48 PM, the Surveyor observed the narcotic box was locked, and easily assessed and counted the top drawer with LPN #2. The top drawer of the medication cart contained the following: 1. 2 insulin pens 2. 1 Lidoderm 3. 4 insulin vials 4. insulin syringes 5. 43 bottles of OTC meds 6. 4 prescriptions 7. 10 eye drops c. On 12/07/2023 at 2:50 PM, the Surveyor asked the Director of Nursing [DON] why the medication cart need to be locked. The DON stated, To keep residents from any risk of ingesting medications that are not for them. d. On 12/08/2023 at 11:08 AM, the Administrator provided the policy titled Medications, Storage of documenting .General Guidelines . 6. Compartments containing medications are locked when not in use. Trays or carts used to transport such items are not left unattended. Only authorized personnel will have access to the keys .

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the nutritional value of the pureed food items to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 12 residents who receive a puree diet, as documented on a list 12/07/2023 at 04:40 PM. The findings are: 1. On 12/06/23 at 11:00 AM, cooked lima beans without bean juice placed in food processor with hot water and pureed. 2. On 12/06/23 at 11:31 AM, 16 servings of meatloaf placed in food processor and then added water and pureed. 3. On 12/06/23 at 1:08 PM, DE #2 was asked, What was mixed with the pureed lima beans and meatloaf? DE #2 stated, hot water. The Surveyor asked, Why was stock not used as the recipe required. DE #2 stated, It would have been cold if stock was used. 4. On 12/06/23 at 1:11 PM, the Surveyor asked the Dietary Manager, Why does the recipe include the puree ingredient of broth? Dietary manager stated, To add extra flavor Dietary manager stated, Sometimes we use stock, juice off veggies, or water. 5. On 12/06/23 at 1:35 PM, the Dietary Manager provided the recipes for the pureed lima beans and pureed meatloaf. The pureed lima beans called for the ingredients of lima beans, stock chicken, and food thickener. The pureed glazed meatloaf called for glazed meatloaf, food thickener, and water or stock.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. The findings are: 1. On 12/6/23 at 11:00 PM, the following observations were made of the steam table and foods prepared and served. a. 12/06/23 11:31 AM, staff pureed 16 servings of meatloaf with hot water from the faucet. The pureed meatloaf was found to be thick, lumpy and not smooth. This pureed meatloaf was served to the residents. b. On 12/6/23 at 11:00 AM, staff pureed cooked lima beans in the food processor with hot water from a faucet. The lima beans were found to be thick, lumpy with pieces of beans and not smooth. These pureed lima beans were served to the residents. c. 12/06/23 1:05 PM, the Surveyor asked Certified Nursing Assistant (CNA) #6, how should puree foods be when served? CNA #6 stated, Smooth with no lumps. The Surveyor asked CNA #6 to describe the puree that was being fed to residents. CNA #6 stated, It could probably be done better. On 12/06/23 at 1:08 PM, the Surveyor asked Dietary Employee #2 what should be the consistency of pureed foods? DE #2 replied, It's supposed to be as mashed potatoes. The Surveyor asked DE #2 to describe how the puree appears. DE #2 stated, It looks gritty. The Surveyor asked DE #2 what is mixed with the pureed lima beans and meatloaf? DE #2 stated, hot water. The Surveyor asked, why is stock not used as the recipe required? DE #2 stated, It would have been cold if stock was used. On 12/06/23 at 1:11 PM, the Surveyor asked the Dietary Manager, to describe how the puree appears. The Dietary Manager stated, It's done how our dietary lady likes it. The Dietary Manager was asked, why does the recipe include the puree ingredient of broth? The Dietary Manager stated, To add extra flavor. Dietary manager stated, Sometimes we use stock, juice off veggies, or water.

Based on observation, record review, and interview, the facility failed to report an injury of unknown origin for 1 (Resident #64) of 10 (Residents #18, #70, #37, #61, #65, #10, #19, #60, #64 and #50) sampled residents who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #64 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan dated 2/28/22 documented, .The resident is at risk for impaired skin integrity related to decreased physical mobility, left side weakness/paralysis secondary to [CONDITION(S)] [[CONDITION(S)]], incontinence, prolonged sitting/lying . Identify/document potential causative factors and eliminate/resolve where possible . Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] b. The Incident Audit Report dated 08/09/22 at 11:55 PM provided by the Director of Nursing (DON) on 10/12/22 at 2:57 PM documented, .Was called to resident's room as resident was found on floor . lying on left side . Resident examined for cuts, scrapes, abrasions, skin tears, or bruising . Location of injury . left elbow . Resident complains of left shoulder and elbow pain . There was no documentation of a skin tear on the report. c. The Incident Report dated 8/10/22 provided by the DON on 10/12/22 at 3:15 PM documented, .Night shift reports he was called to resident's room as resident was found on floor . Examined for cuts, scrapes, abrasions, skin tears or bruising . left shoulder and arm x-ray . No injuries observed post incident . There was no documentation of a skin tear on the report. d. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat dry. Apply collagen and foam dressing Q [every] T [Tuesday], Th [Thursday], Sat [Saturday] and PRN [as needed] soiling/dislodgement . Order Date 08/14/22 . Discontinued Date 08/27/22 . Cleanse open lesion to left elbow with Theraworxs. Pat dry. Apply stimulen powder and foam dressing Q M [Monday], W [Wednesday], F [Friday] and prn soiling/dislodgement . Skin Tear L [left] elbow. Cleanse with Theraworxs. Cover with foam bordered dressing M, W, F and PRN for Skin Tear .Active 10/8/22 07:45 [AM] . e. The Weekly Skin Audits from 09/04/22 to 10/09/22 documented the following weekly skin assessments: 1) 09/4/22, there was no documentation of any skin issues to the left elbow. 2) 09/11/22 documented, .Blanchable redness to left elbow . 3) 09/25/22 documented, .Beefy red circular open area approximately 1cm to left elbow. Treatment in place . 4) 10/02/22 documented, .Dry intact scab formation to left elbow . 5) 10/09/22 documented, .Dressing in place to left elbow skin tear . f. On 10/10/22 at 10:10 AM, Resident #64 had a transparent film adhesive dressing to the left elbow with red drainage observed. g. On 10/10/22 at 10:10 AM, the Surveyor asked Resident #64, How did you injure your elbow? He stated, I don't remember. h. On 10/12/22 at 1:00 PM, Resident #64 had a bordered foam dressing to the left elbow dated 10/11/22 and a bordered gauze dressing to the left forearm dated 10/11/22. The Surveyor asked Resident #64, How did you injure your arm? He stated, I'm not sure. I can't remember. i. On 10/12/22 at 1:45 PM, the Surveyor asked the Treatment Nurse, Can you tell me about [Resident #64's] skin tear to the left elbow? She answered, I came in on Monday and someone told me he had a bandage on his elbow. The night shift nurse must have put that dressing on there. I don't know what happened. j. On 10/12/22 at 2:57 PM, the DON stated, I accidentally deleted an incident report from the computer, but the Administrator was able to print it. When I realized I had deleted the report, I redid it. I will bring you a copy of the one I did. The Surveyor asked the DON to clarify what the numbers in the Injury section meant. She answered, Let me go check. The Surveyor asked, Do you know how the resident was injured? She answered, I will have to call the nurse who works weekend nights. I don't know. k. On 10/12/22 at 4:45 PM, the Surveyor asked the DON, Were you aware of any injuries to [Resident #64's] left elbow prior to Monday morning at 10:10 AM? She answered, No. The Surveyor asked, Was an investigation done to determine what may have caused the injuries? She answered, We are working on that now. The treatment nurse is busy, and she is getting really stressed out. The Surveyor asked, Was the resident representative or the physician notified of the injuries? She answered, I am not sure. l. On 10/13/22 at 8:25 AM, Resident #64's Medical Record contained no record of any recent injury to the left elbow or left forearm prior to 10/9/22, no record of an investigation for the injuries and there was no documentation of notification to the medical provider or the family. m. On 10/13/22 at 9:50 AM, the Surveyor asked the Treatment Nurse, If you find a new skin injury on a resident, what do you do? She answered, I would assess the wound. I would call the provider to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Surveyor asked, Should you have looked to see if there was an Incident Report for the areas on [Resident #64's] left elbow and arm? She answered, Yes. The Surveyor asked, What do you do if the injury is of unknown origin? She answered, We have to investigate it. Report to the provider, the family, the DON and the Administrator. n. The facility policy titled, Incident and Accident Investigating and Reporting, provided by the Administrator on 10/11/22 at 9:40 AM documented, .All Incidents and Accidents will be reported (immediately or as soon as practicable) to the Administrator and the Director of Nursing . As soon as practicable, the attending physician and family representative will be notified of the incident and accident . The Charge Nurse, or Designee, will conduct an immediate investigation of the incident or accident, complete the appropriate sections of the Incident and Accident Reporting form and sign the form . The Administrator will determine whether the incident or accident is reportable to state agencies or law enforcement . If patient neglect, abuse, or misappropriation of property is reported, the Administrator and the Director of Nursing will conduct an immediate investigation .

Based on observation, record review, and interview, the facility failed to investigate an injury of unknown origin for 1 (Resident #64) of 10 (Residents #18, #70, #37, #61, #65, #10, #19, #60, #64 and #50) sampled residents who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #64 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan dated 2/28/22 documented, .The resident is at risk for impaired skin integrity related to decreased physical mobility, left side weakness/paralysis secondary to [CONDITION(S)] [[CONDITION(S)]], incontinence, prolonged sitting/lying . Identify/document potential causative factors and eliminate/resolve where possible . Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] b. The Incident Audit Report dated 08/09/22 at 11:55 PM provided by the Director of Nursing (DON) on 10/12/22 at 2:57 PM documented, .Was called to resident's room as resident was found on floor . lying on left side . Resident examined for cuts, scrapes, abrasions, skin tears, or bruising . Location of injury . left elbow . Resident complains of left shoulder and elbow pain . There was no documentation of a skin tear on the report. c. The Incident Report dated 8/10/22 provided by the DON on 10/12/22 at 3:15 PM documented, .Night shift reports he was called to resident's room as resident was found on floor . Examined for cuts, scrapes, abrasions, skin tears or bruising . left shoulder and arm x-ray . No injuries observed post incident . There was no documentation of a skin tear on the report. d. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat dry. Apply collagen and foam dressing Q [every] T [Tuesday], Th [Thursday], Sat [Saturday] and PRN [as needed] soiling/dislodgement . Order Date 08/14/22 . Discontinued Date 08/27/22 . Cleanse open lesion to left elbow with Theraworxs. Pat dry. Apply stimulen powder and foam dressing Q M [Monday], W [Wednesday], F [Friday] and prn soiling/dislodgement . Skin Tear L [left] elbow. Cleanse with Theraworxs. Cover with foam bordered dressing M, W, F and PRN for Skin Tear .Active 10/8/22 07:45 [AM] . e. The Weekly Skin Audits from 09/04/22 to 10/09/22 documented the following skin assessments: 1) 09/4/22, there was no documentation of any skin issues to the left elbow. 2) 09/11/22 documented, .Blanchable redness to left elbow . 3) 09/25/22 documented, .Beefy red circular open area approximately 1cm to left elbow. Treatment in place . 4) 10/02/22 documented, .Dry intact scab formation to left elbow . 5) 10/09/22 documented, .Dressing in place to left elbow skin tear . f. On 10/10/22 at 10:10 AM, Resident #64 had a transparent film adhesive dressing to the left elbow with red drainage observed. g. On 10/10/22 at 10:10 AM, the Surveyor asked Resident #64, How did you injure your elbow? He stated, I don't remember. h. On 10/12/22 at 1:00 PM, Resident #64 had a bordered foam dressing to the left elbow dated 10/11/22 and a bordered gauze dressing to the left forearm dated 10/11/22. The Surveyor asked Resident #64, How did you injure your arm? He stated, I'm not sure. I can't remember. i. On 10/12/22 at 1:45 PM, the Surveyor asked the Treatment Nurse, Can you tell me about [Resident #64's] skin tear to the left elbow? She answered, I came in on Monday and someone told me he had a bandage on his elbow. The night shift nurse must have put that dressing on there. I don't know what happened. j. On 10/12/22 at 2:57 PM, the DON stated, I accidentally deleted an incident report from the computer, but the Administrator was able to print it. When I realized I had deleted the report, I redid it. I will bring you a copy of the one I did. The Surveyor asked the DON to clarify what the numbers in the Injury section meant. She answered, Let me go check. The Surveyor asked, Do you know how the resident was injured? She answered, I will have to call the nurse who works weekend nights. I don't know. k. On 10/12/22 at 4:45 PM, the Surveyor asked the DON, Were you aware of any injuries to [Resident #64's] left elbow prior to Monday morning at 10:10 AM? She answered, No. The Surveyor asked, Was an investigation done to determine what may have caused the injuries? She answered, We are working on that now. The treatment nurse is busy, and she is getting really stressed out. The Surveyor asked, Was the resident representative or the physician notified of the injuries? She answered, I am not sure. l. On 10/13/22 at 8:25 AM, Resident #64's Medical Record contained no record of any recent injury to the left elbow or left forearm prior to 10/9/22, no record of an investigation for the injuries and there was no documentation of notification to the medical provider or the family. m. On 10/13/22 at 9:50 AM, the Surveyor asked the Treatment Nurse, If you find a new skin injury on a resident, what do you do? She answered, I would assess the wound. I would call the provider to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Surveyor asked, Should you have looked to see if there was an Incident Report for the areas on [Resident #64's] left elbow and arm? She answered, Yes. The Surveyor asked, What do you do if the injury is of unknown origin? She answered, We have to investigate it. Report to the provider, the family, the DON and the Administrator. n. The facility policy titled, Incident and Accident Investigating and Reporting, provided by the Administrator on 10/11/22 at 9:40 AM documented, .All Incidents and Accidents will be reported (immediately or as soon as practicable) to the Administrator and the Director of Nursing . As soon as practicable, the attending physician and family representative will be notified of the incident and accident . The Charge Nurse, or Designee, will conduct an immediate investigation of the incident or accident, complete the appropriate sections of the Incident and Accident Reporting form and sign the form . The Administrator will determine whether the incident or accident is reportable to state agencies or law enforcement . If patient neglect, abuse, or misappropriation of property is reported, the Administrator and the Director of Nursing will conduct an immediate investigation .