Every finding on record at Cartersville Crossing of Journey LLC

Based on observations, resident and staff interviews, record review, and review of the facility's policy, the facility failed to ensure residents were served food that was palatable to seven of seven residents (Resident (R) 10, R24, R39, R7, R58, R46, and R29) reviewed for food palatability out of 28 sampled residents. This failure had the potential to affect 71 residents who consumed food prepared from the facility's kitchen and could result in residents skipping meals and experiencing weight loss. Findings include: Review of facility's undated policy titled, Menus and Adequate Nutrition,. item five indicated the menus shall reflect input from residents and resident groups. 1. Review of R10's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/09/25 and located in the resident's electronic medical record (EMR) under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. During an interview on 01/05/26 at 1:05 PM, R10 stated the food served at the facility did not taste good. R10 stated she preferred having chicken noodle soup, but it was always cold and tasteless. R10 stated that all meals needed to be improved, not just the chicken noodle soup. 2. Review of R24's quarterly MDS with an ARD of 08/18/25 and located in the EMR under the MDS tab revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. During an interview on 01/05/26 at 1:35 PM, R24 stated the food served at the facility was not consistent. R24 stated that some meals tasted good and other meals did not taste good at all. 3. Review of R39's admission MDS with an ARD of 12/10/25 and located in the EMR under the MDS tab revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. During an interview on 01/05/26 at 1:55 PM, R39 stated the meals were tasteless and bland. 4. Review of R7's quarterly MDS with an ARD of 12/23/25 located in the resident's EMR under the MDS tab indicated R7's BIMS score was 15 out of 15 which indicated R7 was cognitively intact. Interview on 01/05/26 at 12:49 PM, R7 stated that the vegetables on the lunch meal tray tasted bland and the mashed potatoes tasted watery. 5. Review of R58's quarterly MDS with an ARD of 12/23/25 in the EMR under the MDS tab indicated R58's BIMS score was eight out of 15 which indicated R58 was moderately cognitively impaired. Interview on 01/05/26 at 12:51 PM, R58 stated the vegetables on the lunch meal tasted bland. 6. Review of R46's admission MDS with an ARD of 12/15/25 in the EMR under the MDS tab indicated R46's BIMS score was 15 out of 15 which indicated R46 was cognitively intact. Interview on 01/05/26 at 12:54 PM, R46 stated that the hot foods on the lunch tray tasted warm. 7. Review of R29's quarterly MDS with an ARD of 12/19/25 in the EMR under the MDS tab revealed R29's BIMS score was 15 out of 15 which indicated R29 was cognitively intact. Interview on 01/05/26 at 12:56, R29 stated that the meat and vegetables on the lunch tray tasted bland and that she had to use her salt and pepper to season them. On 01/07/26 a test tray was requested in response to R6, R10, R24, R36 and R39's complaints about the facility's food palatability. Observation on 01/07/26 at 1:15 PM revealed the 200 Hallway meal cart which contained the requested test tray left the kitchen. The last resident was served their meal tray at 1:35 PM and the test tray was removed from the meal cart. Present were the Registered Dietitian (RD), the Dietary Director (DD) and the Dietary Manager (DM). The RD utilized a calibrated facility thermometer to obtain temperatures of the food and beverages served on the test tray. The RD, DD, and DM tasted the food served on the requested test tray. Temperature checks and tasting of the food served on the test tray revealed the following: a. The RD, DD, and the DM tasted the meatloaf, and all agreed that it lacked flavor and taste. b. The RD, DD, and the DM tasted the carrots and confirmed they were soggy, watery, and lacked flavor and taste. c. The RD, DD, and the DM tasted the green beans, and all agreed the green beans were mushy and tasteless. d. The RD, DD, and the DM also tasted the chicken noodle soup and agreed that it lacked flavor and taste. During an interview on 01/07/26 at 1:45 PM, the RD stated the kitchen followed the [NAME] (the name of the food distribution company) Cycle Menu recipes and food preparation instructions. The RD stated the [NAME] Cycle Menus were heart healthy and restricted salt, butter, and oils in the recipes. The RD also stated that the facility required the menus to be followed to provide the residents with a heart healthy diet.

Based on staff interview, record review, and review of the facility's policy, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure the required members of the committee attended the quarterly meetings. This failure had the potential to affect all 71 residents who currently live in the facility.Findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI), dated 03/20/25 revealed, Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. Policy Explanation and Compliance Guidelines: l. The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan. 2. The QAA Committee shall be interdisciplinary and shall: a. Consist at a minimum of:i. The Director of Nursing Services; ii. The Medical Director or his/her designee; iii. At least three other members of the facility's staff, at least one of which must be the Administrator, owner, a board member or other individual in a leadership role; and iv. The Infection Preventionist. A review of the sign-in sheet for the first quarter 2025 (January, February, March) QAPI meeting dated 02/19/25 and provided by the facility revealed the Administrator and Medical Director were not present at the meeting. During the QAPI interview on 01/08/26 at 3:20 PM, the Administrator stated, The Interim Administrator at that time and the Medical Director were not available to be at the meeting; however, we went ahead with the meeting anyway. Neither was present either physically or via phone and that is why there are no signatures for them on the sign-in sheet.

Based on staff interviews, record review, and review of the facility's policy, the facility failed to ensure the resident and/or their Resident Representative (RR) received the required written notice of transfer and a bed hold notice which included all the required information upon their emergent transfer to the hospital for four of 47 sampled residents (R) (R6, R7, R38, and R3). This failure had the potential to affect all residents and their RRs of the facility by not having the knowledge of how to appeal the transfer, if desired, and the mailing address of the Ombudsman which could contribute to the possibility of denial of re-admission and loss of the resident's home following hospitalization for any resident transferred to the hospital from the facility.Findings include: Review of the facility's policy titled, Transfer and Discharge (including Against Medical Advice (AMA) dated 03/20/25 indicated, Policy Explanation and Compliance Guidelines.3. The facility's transfer/discharge notice will be provided to the resident and resident's representatives in a language and manner in which they can understand. The notice will include all of the following.3. d. An explanation of the right to appeal the transfer or discharge to the State. f. Information on how to obtain an appeal form. g. Information on obtaining assistance in completing and submitting the appeal hearing request. h. The.mailing address of the representative of the Office of the State Long-Term Care Ombudsman.10. Emergency Transfer to Acute Care.g. Provide a notice of transfer and the facility's bed hold notice policy to the resident and representative. Review of the facility's undated policy titled, Bed Hold indicated, .The resident and a family member or legal representative of the resident will be notified of the Center's Bed Hold policy.upon transfer from the Center. 1. Review of R6's Progress Notes dated 01/02/26 at 7:15 PM, located in the resident's electronic medical record (EMR) under the Progress Notes tab revealed Resident complaints of chest pain with pressure and tightness all over body, shortness of breath and nausea.NP [Nurse Practitioner] orders to send resident to ER [Emergency Room] . Review of Progress Note dated 01/02/26 at 7:50PM, revealed, EMS [emergency medical services] here to pick up resident. Review of R6's SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form dated 01/02/26 and provided by the facility revealed the transfer notice failed to include how to appeal the transfer and the mailing address of the Ombudsman. The facility's Administrator did not provide evidence for the 01/02/26 transfer to the ER, the resident and RR received the Bed-Hold Notice document. 2. Review of R7's Progress Note dated 09/27/25 at 2:18 AM and located in the resident's EMR under the Progress Notes tab revealed, Resident observed sitting on the floor.nurse noted resident's right wrist to be misshapen and swollen, resident was unable to move her fingers and was in a great deal of pain.NP gave an order to send resident to hospital for further evaluation. Review of R7's SNF/NF to Hospital Transfer Form dated 09/27/25 and provided by the facility revealed the transfer notice failed to include how to appeal the transfer and the mailing address of the Ombudsman. Review of the Bed-Hold Notice dated 09/27/25 failed to document whether the resident or RR received the bed-hold notice. 3. Review of R38's Progress Note dated 12/08/25 at 12:40 PM located in the resident's EMR under the Progress Notes tab revealed, Lab result hgb [hemoglobin] 3.8.NP notified and gave order to send to ER .911 here to transport resident to.ER. Review of R38's SNF/NF to Hospital Transfer Form dated 12/08/25 and provided by the facility revealed the transfer notice failed to include how to appeal the transfer and the mailing address of the Ombudsman. Review of the Bed-Hold Notice dated 12/08/25 failed to document whether the resident or RR received the bed-hold notice. 4. Review of R3's Progress Note dated 12/24/25 at 10:33 AM and located in the resident's EMR under the Progress Notes tab revealed, Dr. made rounds and requested resident to be send to ER for eval [evaluation] due to shortness of breath. Progress note dated 12/24/25 at 2:37PM indicated, sent to.ER. Review of R3's SNF/NF to Hospital Transfer Form, dated 12/24/25 and provided by the facility revealed the transfer notice failed to include how to appeal the transfer and the mailing address of the Ombudsman. Review of the Bed-Hold Notice dated 12/24/25 failed to document whether the resident or RR received the bed-hold notice. Record review and interview on 01/08/26 at 10:30 AM, revealed after the review of the transfer notice, the Administrator could not find any evidence on the transfer notice of the appeal rights, the State's LTC Ombudsman's mailing address, or evidence the resident or the RR received the bed hold notice. Interview on 01/09/26 at 11:19 AM, the Administrator confirmed that she had no evidence that the bed hold notice policy was provided to the residents or RRs.

Based on record review and staff interview, the facility failed to ensure resident assessments were accurately completed for one of 47 sampled residents (Resident (R) 80). R80's Minimum Data Set (MDS) assessment did not reflect the resident's hospice status. This deficient practice had the potential to lead to inaccurate reimbursements and unmet care needs for the resident. Findings include: Review of R80's undated admission Record located in R80's electronic medical record (EMR) under the Profile tab revealed R80 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included metabolic encephalopathy, senile degeneration of brain. Review of R80's quarterly MDS, located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/23/25, failed to document that R80 was receiving hospice services. Review of R80's Physician Order located in the EMR under the Orders tab revealed R80 was admitted to hospice care effective 03/19/26. During an interview on 01/07/26 at 12:50 PM, the Administrator stated, The MDS with an ARD of 12/23/25 was improperly coded and did not reflect [R80] as receiving hospice services.

Based on observation, staff interview, and review of the facility policies titled, Sanitation Inspection, Food Safety Requirements, and Resident Refrigerators, the facility failed to keep the kitchen's convection oven, two conventional ovens, stove top's spill pan, and large manual can opener and its base attachment clean. The facility failed to date bread products stored in the kitchen's dry storage area and cover opened food stored in the kitchen's walk-in freezer. In addition, the facility failed to date thawed nutritional supplements and discard food that was spoiled or had expired use by dates that were stored in the facility's kitchen and in the 300-hallway resident refrigerator. This failure had the potential to affect 64 residents who consumed food prepared in the facility's kitchen. Findings include: Review of the facility's policy titled, Sanitation Inspection, dated [DATE], indicated It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with state and federal regulations. Review of the facility's policy titled, Food Safety Requirements, dated [DATE], indicated It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety. Review of the facility's policy titled, Resident Refrigerators, dated [DATE], indicated The facility does not provide a refrigerator in a resident's room. However, it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators .3. (Nursing/ housekeeping) staff shall clean the refrigerator weekly and discard any foods that are out of compliance. Nursing staff shall clean up spills as needed, or refer to housekeeping staff. 4. Residents and staff shall comply with safe food handling and storage principles .c. Foods with use-by dates shall be discarded accordingly. d. Any food with potential concerns (i.e. smell, packaging, appearance, frozen foods are not solid) shall be discarded. 1. Observation on [DATE] from 8:55 AM to 9:35 AM, during the initial kitchen inspection with Dietary Aide (DA) 1 present, revealed the following: a. The kitchen's convection oven and two conventional ovens were unclean with heavy accumulated blackened and dried food spills on their interior cooking compartment. b. The kitchen's stove top spill pan was unclean with a heavy accumulation of burnt on food spills. c. The kitchen's large manual can opener, which was attached to a food preparation table, was unclean with accumulated dried and sticky food substances on its blade and table base attachment. During an interview with DA1 during the initial kitchen inspection on [DATE] from 8:55 AM to 9:35 AM, DA1 confirmed the kitchen's convection oven, two conventional ovens, the stove top's spill pan, and large manual can opener and its base were unclean. DA1 stated the kitchen's food preparation and service equipment should be kept clean. DA1 explained the kitchen's ovens were on the weekly cleaning schedule but had not been cleaned for about three weeks. 2. Observation of kitchen food storage areas on [DATE] from 8:55 AM to 9:35 AM, during the initial kitchen inspection, with DA1 present, revealed the following: a. In the kitchen's dry storage room two packages of thawed raisin bread, three packages of thawed hamburger buns, two packages of thawed hot dog buns, and one package of thawed croissants did not have a use by or expiration date on their package. These undated packages of bread products were stored on bread racks and ready for use. The undated package of croissants was observed to contain 12 croissants that were covered in green mold. b. In the kitchen's walk-in refrigerator 50 thawed, four-ounce nutritional shakes were stored without a thaw date. c. In the kitchen's walk-in freezer one 30-pound box of cauliflower florets and one 144-ounce box of chicken cordon bleu were stored opened and unprotected from possible contamination. During an interview with DA1, during the initial kitchen inspection on [DATE] from 8:55 AM to 9:35 AM, DA1 confirmed the bread products stored on the bread racks in the kitchen were not dated and the undated croissants were molded. DA1 also confirmed the nutritional shakes stored in the walk-in refrigerator were not dated, and the box of cauliflower florets and the box of chicken cordon bleu were stored opened in the kitchen's walk-in freezer. DA1 stated staff were to date and completely close food prior to storage. During an interview on [DATE] at 10:50 AM, the Regional Registered Dietitian (RRD) stated the undated 50 thawed four-ounce nutritional shakes observed in the kitchen's walk-in refrigerator on [DATE] should have been dated by staff when they were removed from the freezer and placed in refrigeration to thaw and should be discarded if not utilized within 14 days. 3. Observation of food stored in the resident refrigerator on the facility's 300 hallway on [DATE] at 3:47 PM, with the Regional Director of Environmental Service (RDEVS) present, revealed the following: a. Observation of food stored in the refrigerator's freezer compartment revealed an opened and undated package of grapes that were discolored, and freezer burnt. Also, stored in this freezer compartment was a container of watermelon cubes which had an expiration date of [DATE]. The watermelon cubes were covered in ice crystals and freezer burnt. b. Observation of food stored in the refrigerator section revealed one four-ounce yogurt with an expired use by date of [DATE] and another four-ounce yogurt with an expired use by date of [DATE]. Also, stored in the refrigerator section were two thawed four-ounce vanilla nutritional shakes and two thawed four-ounce strawberry nutritional shakes that were not dated with a thaw date. During an interview on [DATE] at 3:47 PM, the RDEVS confirmed the grapes and watermelon stored in the 300-hallway refrigerator's freezer compartment were freezer burnt, and the watermelon had an expired use by date of [DATE]. The RDEVS also confirmed the two yogurts had expired use by dates and the four nutritional shakes were not dated that were stored in the 300-hallway refrigerator. The RDEVS was observed to immediately discard all these food items. During an interview on [DATE] at 11:55 AM, the Director of Nursing (DON) stated it was the night shift nursing staff's responsibility to check and monitor the food stored in the 300-hallway resident refrigerator.

Based on staff interview, record review, and review of the facility policy titled, Transfer and Discharge (including AMA [against medical advice], the facility failed to issue two of two residents (Resident (R) 9 and R24) or their responsible party transfer paperwork or to notify the long-term care ombudsman of hospital transfers out of 19 sample residents. This failure could affect the resident and or representative by not receiving the information for the reason of transfer and the resident's right to return to the facility. Findings include: Review of the facility's policy titled, Transfer and Discharge (including AMA [against medical advice]) with an implementation date of 02/01/22, revealed .Emergency Transfers/ Discharges-initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified) .Provide a notice of transfer and the facility's bed hold policy to the resident or representative as indicated . 1. Review of R9's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was initially admitted on [DATE] for long-term care. Diagnoses included type two diabetes mellitus, hypertensive heart disease with heart failure, acute systolic heart failure, syncope and collapse, and a recent diagnosis of non-ST elevation myocardial infarction, a type of heart attack. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident was moderately impaired in cognition. Review of the MISC [Miscellaneous] tab of the EMR revealed there were no documents uploaded reflecting a bed hold form was provided to R9 when she was sent out on 07/17/24 for tingling in her left arm and chest pain. 43353 2. Review of R24's Admission Record in the Profile tab of the EMR revealed an admitted [DATE]. Review of R24's five-day MDS with an ARD of 08/02/24 and located in the MDS tab of the EMR, revealed a BIMS score of five out of 15 which indicated the resident was severely cognitively impaired. Review of R24's Nursing Note, dated 08/30/24 at 5:57 PM and located in the Progress Notes tab of the EMR, revealed Labs reviewed with NP [Nurse Practitioner], new orders received to send to ER [emergency room ] for evaluation, spoke with responsible party and is agreeable with plan of care. Review of R24's Nursing Note, dated 08/30/24 at 6:15 PM and located in the Progress Notes tab of the EMR, revealed emergency medical services (EMS) called and here to transport resident to hospital via stretcher in stable condition. Review of R24's Nursing Note, dated 08/31/24 and located in the Progress Notes tab of the EMR, revealed In hospital . admitted to [Name] Hospital. Review of R24's EMR revealed there was no documentation that a written transfer notice was provided to the resident and/or their representative at the time of the transfer to the hospital on 08/30/24. During an interview on 09/05/24 at 9:48 AM, the Social Services Director (SSD) verified that the facility notified the resident representative by phone that the resident was being sent out and for what reasons. The SSD stated no residents were provided a transfer form when transferred to the hospital for acute care. She stated she was not aware of this requirement or that it was included in the current facility policy.

Based on record review, staff interview, and review of the facility policy titled, Bed Hold Notice Upon Transfer, the facility failed to issue a bed hold notice for two of two residents (Resident (R) 9 and R24) or their responsible party out of 19 sample residents reviewed for bed holds. The failure to provide a copy of the bed hold notice at the time of transfer could lead to them not knowing their rights in the facility. Findings include: Review of the facility's policy titled, Bed Hold Notice Upon Transfer with an implementation date of 02/01/22, revealed .At the time of transfer for hospitalization or therapeutic leave, the leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed . 1. Review of R9's Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed she was initially admitted on [DATE] for long-term care Diagnoses included type two diabetes mellitus, hypertensive heart disease with heart failure, acute systolic heart failure, syncope and collapse, and a recent diagnosis of non-ST elevation myocardial infarction, a type of heart attack. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident was moderately impaired in cognition. Review of the MISC [Miscellaneous] tab of the EMR revealed there were no documents uploaded reflecting a bed hold form was provided to R9 when she was sent out on 07/17/24 for tingling in her left arm and chest pain. 43353 2. Review of R24's Admission Record in the Profile tab of the EMR revealed an admitted [DATE]. Review of R24's five-day MDS with an ARD of 08/02/24 and located in the MDS tab of the EMR revealed a BIMS score of five out of 15 which indicated the resident was severely cognitively impaired. Review of R24's Nursing Note, dated 08/30/24 at 5:57 PM and located in the Progress Notes tab of the EMR, revealed Labs reviewed with NP [Nurse Practitioner], new orders received to send to ER [emergency room ] for evaluation, spoke with responsible party and is agreeable with plan of care. Review of R24's Nursing Note, dated 08/30/24 at 6:15 PM and located in the Progress Notes tab of the EMR, revealed emergency medical services (EMS) called and here to transport resident to hospital via stretcher in stable condition. Review of R24's Nursing Note, dated 08/31/24 and located in the Progress Notes tab of the EMR, revealed In hospital . admitted to [Name] Hospital. Review of R24's EMR revealed there was no documentation that the facility's bed hold policy was provided to the resident or their representative at the time of the transfer to the hospital on 08/30/24. During an interview on 09/05/24 at 9:48 AM, the Social Services Director (SSD) verified that no bed hold notice was provided to R9 or R24 upon transfer to the hospital. The SSD stated the facility notified the resident representative by phone and the resident received the bed hold information in the admission package. The SSD stated no resident was provided a bed hold notice on transfer to the hospital. She stated she was not aware of this requirement.

Based on observations, resident, family member, and staff interviews, record review, and review of the facility policy titled, Weight Monitoring Program, the facility failed to obtain an admission weight, perform re-weights for weight losses of five percent or greater and be evaluated and assessed by the facility's Consultant Registered Dietitian (CRD) and Interdisciplinary Team after experiencing an unplanned significant weight loss for one of two residents (Resident (R) 17) reviewed for nutritional status out of 19 sample residents. The facility's failure placed the resident at risk for further unplanned weight loss. Findings include: Review of the facility's undated policy titled, Weight Monitoring Program, indicated, Definitions: Significant weight change- A weight loss or gain of: +/- [plus or minus] 5 percent [%] in 30 days +/- 7.5 percent in 90 days. +/- 10 percent in 180 days .Weight Monitoring Frequency .b. New Admissions: New admissions will be weighed for a period of four weeks. Initial weight and height will be obtained within 24 hrs. [hours] of admission to the center .f. Re-Weights. Re-weights will be obtained on all weight changes of 5% or more in one month. Re-weights should be obtained within 24 hrs.2. Interdisciplinary Team Interventions: a. Assess ROOT CAUSE of significant weight change . e. Monitoring .new interventions should be considered if current interventions are not successful. Review of the Admission Record located in the electronic medical record (EMR) under the Profile tab revealed R17 was admitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition, fracture of left femur, and anxiety disorder. Review of R17's admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 07/31/24, revealed R17 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated moderate cognitive impairment, required setup or clean-up assistance with eating, and had a weight of 159 pounds. Review of R17's Comprehensive Care Plan, developed by staff on 08/01/24, located in the EMR under the Care Plan tab, indicated Nutrition: The resident is at risk for alteration in nutrition/hydration secondary to: recent surgery for fx'd [fractured] femur, confusion- dx. [diagnosis] severed protein/calorie nutrition. A care plan goal specified, The resident will have no significant weight changes through next review date. Care plan interventions included, Monitor weight as ordered and RD [Registered Dietitian] to evaluate and make diet change recommendations PRN [as needed]. Review of R17's Admission Nutritional Assessment completed by the facility's CRD on 08/06/24, located in the EMR under the Assmnts [Assessments] tab, specified Weight: found documented weight of 134# [pounds]. The assessment also specified, Intervention/ Plan 1. Weekly wt [weight] x 4 to establish baseline. 2. Recs [Recommendations] sent to nursing for 2.0 [kilocalerie] kcal oral supplement po [by mouth] BID [twice a day]. RD will continue to monitor oral intake, diet status, weight trends, and skin integrity. Review of R17's Physician's orders, located in the EMR under the Orders tab, revealed the following orders: -Speech Therapy (ST) Clarification Order: Patient is to receive skilled ST intervention five x week for eight weeks for cognitive intervention. Treatment (Tx) may include compensation strategies, problem solving, safety awareness, thought organization, orientation, memory, and group intervention. This order was initiated on 08/01/24. -Regular diet with thin liquids and chopped meat. This order was initiated on 08/10/24. -2.0 Supplement two times a day 120 milliliters. This order was initiated on 08/12/24. -Remeron Oral Tablet 15 milligrams- Give one tablet by mouth at bedtime for appetite. This order was initiated on 08/15/24. Review of R17's weight record located in the resident's EMR under the Wts [weights]/Vitals tab, revealed the following weights: -No weight documented from 07/31/24 to 08/06/24 -08/07/24: 159 pounds (the first facility weight) -08/14/24: 155 pounds (a four pound and 2.51 percent weight loss since 08/07/24) -08/21/24: 144 pounds (a 15 pound and 9.43 percent significant weight loss since 08/07/24) -08/28/24: 126 pounds (a 33 pound and 20.75 percent significant weight loss since 08/07/24) -09/04/24: 122 pounds (a 37 pound and 23.27 percent significant weight loss since 08/07/24) Review of R17's EMR revealed there was no evaluation or documentation from the facility's CRD from 08/07/24 to 09/03/24 to address the resident's unplanned significant weight loss during this time period. During an observation on 09/02/24 at 11:28 AM, R17 was in her room with Family Member (FM) 1 present. R17 appeared thin and was not feeling well. During an interview on 09/02/24 at 11:28 AM, FM1 stated R17 had been a resident at the facility for about a month and was not eating well and had lost weight. FM1 stated the facility had attempted to provide supplements, but the resident had a poor appetite and would not always drink them. During an observation on 09/02/24 at 12:55 PM, R17 was in her room with her lunch meal and FM1 present. FM1 was encouraging R17 to eat her lunch meal, but the resident shook her head and would not open her mouth when FM1 brought food and beverages to her mouth and encouraged her to eat. During an observation on 09/03/24 at 12:50 PM, R17 was in her room with her lunch meal and FM1 present. FM1 was encouraging R17 to eat her lunch meal, but the resident shook her head and would not open her mouth when FM1 brought food and beverages to her mouth and encouraged her to eat. During an interview on 09/04/24 at 1:40 PM, the facility's CRD stated when she completed R17's admission nutrition assessment on 08/06/24 she could not find an admission weight, or a weight obtained by staff since R17 was admitted to the facility on [DATE]. The CRD explained since she was unable to find a facility weight, she reviewed R17's hospital information and found a hospital weight of 134 pounds and this was the weight she documented on the resident's admission nutrition assessment. The CRD stated she was not informed and was not aware that R17 had a weight documented on 08/07/24 of 159 pounds and the resident had a documented weight of 126 pounds on 08/28/24 which equated to a significant unplanned weight loss during this period. The CRD stated if she had been aware of this significant weight loss she would have evaluated the resident's nutritional status. The CRD stated staff should have obtained an admission weight for R17 and re-weighed the resident on 08/21/24 and 08/28/24 when the resident's weight indicated the resident experienced a significant weight loss of greater than five percent to ensure these weights were accurate. The CRD stated she would have expected staff to inform her of the resident's significant weight loss, so she could have evaluated the resident's nutritional status. The CRD stated she would request for R17 to be weighed and if it was found the resident had experienced a significant weight loss, she would evaluate the resident and implement new interventions to prevent further weight loss. Review of the CRD's 09/04/24 progress note, located in the resident's EMR in the Prog [Progress] Note tab, indicated the resident's weight on 09/04/24 was 122 pounds which equated to a 23.3 percent weight loss since 08/07/24. The CRD's note specified, Weight loss of likely multifactorial reasons to include fluids, weight technique, and true weight loss. The note further specified Intervention/ Plan 1. Weekly wt [weight] x 4 to continue to track weights 2. Continue 2.0 kcal [kilocalorie] oral supplement PO BID. 3. Increase feed assist and monitoring to include going to dining room and one to one meal supervision. 4. Tray house shake BID [twice a day]. RD will continue to monitor oral intake, diet status, weight trends, and skin integrity. During an interview on 09/05/24 at 9:54 AM, the Registered Nurse Supervisor (RNS) confirmed the nursing staff failed to obtain an admission weight for R17 on 07/31/24 and the resident's first documented facility weight of 159 pounds was not obtained by staff until 08/07/24. The RNS also confirmed staff failed to re-weigh R17 on 08/28/24 when the resident's weight was documented as 126 pounds which reflected a significant weight loss. During an interview on 09/05/24 at 10:32 AM, the MDS Coordinator (MDSC) reviewed R17's medical record and confirmed the staff failed to obtain an admission weight for the resident. The MDSC stated she could not determine where she obtained the weight of 159 pounds that she documented on the resident's admission MDS assessment of 07/31/24. The MDSC stated she was not aware R17 had experienced a significant weight loss since her admission to the facility on [DATE]. The MDSC stated she expected staff to notify herself and the facility's CRD when a resident experienced significant weight changes to ensure care plan interventions were implemented as planned and revisions to the resident's care plan could be made if needed by the care plan team. The MDSC stated R17's nutritional care plan was developed on 08/01/24 and no changes had been made to the care plan since 08/01/24 to address the resident's subsequent unplanned significant weight loss. During an interview on 09/05/24 at 11:21 AM, the ST stated R17 was on her case load since around the time she was admitted to the facility for safety precautions. The ST stated initially R17 was feeding herself and eating pretty well. However, during the past week she started to have a decline in her PO (by mouth) intake, started to have to be reminded to swallow and currently did not have much of a desire to eat. The ST stated R17 was currently being assisted with her meals by her daughter, and a change in the resident's oral motor process was noticed yesterday (09/04/24). During an interview on 09/05/24 at 11:47 AM, the Director of Nursing (DON) stated R17 experienced a fall on 08/01/24 and was displaying agitated behaviors, so staff were unable to safely weigh the resident on this date. The DON stated she would have expected staff to obtain an admission weight for R17 as soon as the resident was able to safely allow staff to weigh her and to reweigh R17 when staff obtained a weight that reflected the resident had experienced a significant weight loss of five percent or greater.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Therapeutic Diet Orders, the facility failed to provide food in a form that met the needs which included yogurt at meals as requested for one of two residents (Resident (R) 14) reviewed for food out of 19 sample residents. The facility's failure to provide food in the appropriate form to meet a resident's needs could result in decreased intake and an increased risk of choking. Findings include: Review of the facility's policy titled, Therapeutic Diet Orders, dated 02/01/22, indicated, The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by the physician and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. Review of the Admission Record located in R14's electronic medical record (EMR) under the Profile tab indicated she was admitted on [DATE] and had diagnoses which included diabetes mellitus and gastro-esophageal reflux disease. Review of R14's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 06/25/24, revealed R14 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated moderate cognitive impairment. Review of the Resident Dining Meeting minutes dated 01/30/24, provided by the facility, revealed R14 requested to receive double portions yogurt, cottage cheese, and soup. Review of R14's comprehensive Care Plan, located in the EMR under the Care Plan tab and dated 06/26/24, contained a Focus of Nutrition: The resident is at risk for alteration in nutrition/ hydration secondary to ^ [high] BMI [body mass index], edentulous [lacking teeth] and does not wear dentures. She is very selective of the food she will eat. The care plan's goal specified The resident will tolerate prescribed diet daily through next review date. Care plan interventions included Food preferences provided as available, and RD [Registered Dietitian] to evaluate and make diet change recommendations. During an interview on 09/02/24 at 11:40 AM, R14 stated she was unable to chew some of the food she was served at meals because she did not have any teeth. R14 stated she requested cottage cheese and fruit to be served at meals, but she could not always eat the fruit served because it was too hard for her to chew without any teeth. R14 also stated she had previously requested to be served yogurt at meals because it was easy for her to eat, but the kitchen did not always provide yogurt on her meal trays. Review of R14's current Physician's Orders, located in the EMR under the Orders tab, dated 10/25/23, revealed an order for a no added salt, regular texture, thin consistency diet. Additionally, the following order was written on 08/29/24, Speech Therapy [ST] Clarification: Patient is to be [sic] receive skilled ST 3x [times] a week until 09/27/24 for dysphagia intervention. Tx [treatment] may include: compensation strategies, safe swallow awareness, diet trials, and oral phase intervention. Review of R14's Consultant Registered Dietitian's (CRD) progress note, dated 08/27/24 and located in EMR under the Progress Note tab, specified RD and dietary manager made aware by Ms. [R14's last name] of difficulty chewing certain foods. Current diet order is regular texture. PLAN: 1. Discuss w/SLP [with Speech Language Pathologist]: recommendation for assessment to determine comfort/preferences vs. [versus] true altered texture needs. During an observation on 09/02/24 at 12:57 PM, R14 was served her lunch meal in her room, and she was edentulous. Observation of R14's meal revealed she was served a plate of cottage cheese with large pieces of cubed cantaloupe placed around the cottage cheese and she was not served yogurt with her meal. R14 stated she could not eat the cantaloupe because she could not chew it and did not receive yogurt with her meal as she had previously requested. Review of the meal tray slip served on the resident's meal tray revealed the resident was to receive a regular diet and the tray slip contained a handwritten note which specified cottage cheese with fruit. During an observation on 09/02/24 at 12:58 PM, R14 informed a Certified Nurse Aide (CNA) that she could not eat the cantaloupe that was served on her meal tray and did not receive the yogurt she requested to be served with her meal. The CNA informed R14 that she would get her an alternate fruit in place of the cantaloupe and yogurt. During an observation on 09/03/24 at 12:50 PM, R14 was served her lunch meal in her room and was not served yogurt on her meal tray as she had previously requested. During an interview on 09/04/24 at 8:50 AM, R14 stated she had eaten her breakfast meal, but again did not receive yogurt on her meal tray as she had previously requested. During an observation on 09/04/24 at 12:43 PM, CNA1 served R14 her lunch meal in her room. Observation of R14's meal tray revealed she was not served yogurt on her meal tray. R14 was observed to inform CNA1 that she did not receive yogurt with her meal as she had requested. CNA1 informed R14 that she would get her a yogurt. During an interview on 09/04/24 at 12:50 PM, the CRD confirmed R14 was edentulous and should not receive hard fruits like cantaloupe with her cottage cheese and should receive yogurt as requested with her meals. The CRD stated she would include on R14's tray card to be served soft fruits with her cottage cheese and yogurt with meals. The CRD stated she had recently referred R14 to ST to evaluate her because she was having trouble chewing certain foods. During an interview on 09/05/24 at 11:21 AM, the ST stated R14 was on her current case load, and she was seeing her three times a week. The ST stated she was evaluating R14's ability to eat certain foods because she was edentulous and wanted to remain on a regular diet. The ST stated R14 would not be safe eating hard fruits like cantaloupe and should not receive them because she was edentulous.

Based on observations, policy review, and staff interview, the facility failed to ensure facial hair was covered with beard guards; failed to ensure opened food items in the dry storage area were securely covered, labeled, and dated; failed to maintain sanitary conditions of the kitchen area and equipment. In addition, the facility failed to maintain the sanitary conditions of the resident diet kitchen on the nursing unit. The census was 73. Findings included: 1. A review of policy titled Dietary Employee Personal Hygiene dated 2/1/22, revealed the policy is to utilize guidelines for employee personal hygiene to prevent contamination of food by foodservice employees. Policy Explanation and Compliance Guidelines: 4.a. Hair Restraints-All dietary staff must wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting food. Observation on 1/6/23 from 8:14 a.m. to 9:10 a.m. during initial tour of the kitchen, revealed Dietary Aide DD and Dietary Aide EE, both to have facial hair, walking around the kitchen without a beard guard covering the facial hair. 2. A review of the policy titled Date Marking for Food Safety dated 2/1/22, revealed the policy is to adhere to a date marking system to ensure the safety of ready-to-eat, time/temperature control for food safety and food (special requests), snacks, and supplements that are maintained in the pantry. Observation on 1/6/23 at 8:14 a.m. in the walk-in cooler, revealed a clear gallon sized plastic baggie sitting on bottom shelf, with uncooked strips of meat, identified by Assistant Dietary Manager (ADM) as turkey bacon. The open date was indicated as 12/30/22, but there was no use by date on the product. Observation on 1/6/23 at 8:17 a.m. with the ADM, in the dry storage room, revealed damaged sheetrock on two walls, with sheetrock dust noted on the top of canned foods, and on top of un-secured plastic storage bins. Stored in the un-secured plastic storage bins was one 10 pound (lb) opened bag of pasta egg noodles, with no open date and no use by date; one 50 lb bag of rice, which was not sealed closed, with no open date, or use by date; in a separate plastic bin was one opened bag of spaghetti noodles and one opened bag of ziti noodles, without an open or use by date; on the top shelf of a wire rack was a five lb. bag of opened chocolate cake mix, without an open date or use by date; one 128 ounce (oz) bottle of Worcestershire sauce, with open date of 9/7, but there is no year visible on the bottle, and no use by date. On a stainless-steel worktable beside the serving tray line was a clear plastic baggie with six dinner rolls, that were firm to touch. The baggie was left open. There was no date on the plastic baggie. These items were verified with the Assistant Dietary Manager. 3. A review of the policy titled Food Safety Requirements dated 2/1/22, revealed the policy is food will be stored, prepared, distributed, and served in accordance with professional standards for food safety. Policy Explanation and Compliance Guidelines: 6. All equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination. a. Staff shall follow the facility procedures for dishwashing and cleaning fixed cooking equipment. b. clean dishes shall be kept separate from dirty dishes. A review of the policy titled Sanitation Inspection dated 2/1/22, revealed the policy of the facility is to conduct inspection to ensure food services areas are clean, sanitary, and in compliance with applicable state and federal regulations. Policy Explanation and Compliance Guidelines: number 4. Sanitation inspections will be conducted in the following manner: a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily. b. The Dietary Manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations. Observation on 1/6/23 at 8:30 a.m. adjacent to the tray serving line was a stainless-steel plate stacker, where the clean plates are stored after coming from the dishwasher. The plate stacker was dirty with dust, grime, and dried food particles on the riser, that lifts the plates up. The shelving under the steam table was dirty, had grime buildup and debris on the shelf. 4. Observation on 1/6/23 at 10:37 a.m. of resident diet kitchen/pantry on the nursing unit, revealed a mini fridge with approximately four inches of ice buildup in the freezer section, one opened carton of milk, with no open date, three cups of yogurt, not labeled with residents name and/or room number, four unopened bottles of Ensure nutritional supplements, without resident name and/or room number, a 48 oz. container of opened liquid coffee creamer, with no open or use by date, and one black plastic container of food items, without a name or date on it. There were no temperature logs on the refrigerator. During an interview on 1/6/23 at 11:00 with Dietary Manager (DM), she revealed she has been back as the DM for two months, after being retired for four years. She stated that the Dietary Aides should be wearing beard guards over their facial hair and stated she didn't realize they were not wearing them. She confirmed that the dry storage area was dirty with sheetrock dust and confirmed the plastic storage bins were not latching closed, to protect the food from dust and pests. The DM verified the uncleanliness of the kitchen plate stacker and the shelving of the steam table. She stated that the staff have a cleaning schedule that they are assigned to do daily cleaning tasks, and stated it is her responsibility to make sure the tasks are being completed by the kitchen staff. She stated that maintenance of the resident diet kitchen/pantry is the responsibility of the nursing department.

Based on observations, interviews, and review of facility policies, the facility failed the ensure that essential kitchen equipment was maintained in proper working condition. Specifically, the walk-in freezer was not holding temperature as evidenced by foods not being frozen upon inspection during initial tour of the kitchen; the low temperature dish machine did not reach the proper temperature during the wash cycle after three cycles. The facility census was 73. Findings included: 1. A review of the policy titled Monitoring of Cooler/Freezer Temperature, dated 2/1/22, revealed the policy of the facility is to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety. An observation on 1/6/23 at 8:14 a.m., during initial walk-through of the kitchen, the walk-in freezer temperature reading from the thermometer hanging from a rack in the freezer, had reading of 10 degrees Fahrenheit (F). However, the food items on the left side of the freezer, including one loaf of garlic bread, two bags of frozen mixed vegetables, and one four-ounce cup of ice-cream, were not frozen solid and were soft and mushy upon touch. Both fans in the freezer were blowing at the time of the walk-through. During an interview on 1/6/23 at 8:15 a.m., the Dietary Manager (DM) stated they have had problems with the freezer maintaining temperatures for the past three-four days, and she would notify the maintenance department. She stated after they worked on it, it would work for a short while, and then it wouldn't hold the proper temperature again. 2. A review of the policy titled Sanitation Inspection dated 2/1/22, revealed the policy of the facility is to conduct inspection to ensure food services areas are clean, sanitary, and in compliance with applicable state and federal regulations. Policy Explanation and Compliance Guidelines: number 4. Sanitation inspections will be conducted in the following manner: a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily. An observation on 1/7/23 at 12:46 p.m. with Dietary Cook JJ, revealed the low temperature dish machine temperature gauge located under the dish machine, did not move during the wash cycle. Cook JJ tested the chemical concentration to be 100 parts per million (ppm) after the rinse cycle. During an interview on 1/7/23 at 12:50 p.m., the Dietary Cook JJ stated that the gauge doesn't work at times, because the dish machine competes with the laundry machines for water. During an interview on 1/7/23 at 4:15 p.m., the contracted Registered Dietician (RD) FF revealed the facility has attempted to contact the service provider for the dish machine but has been unsuccessful. She stated that the facility would use disposable dinnerware until the dish machine can be serviced. During an interview on 1/8/23 at 11:00 a.m., the DM stated that the service provider will be coming today to service the low temperature dish machine, regarding temperature gauge not working. During an interview on 1/8/23 at 3:00 p.m., RD FF stated the dish machine temperature gauge is now working.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment throughout the facility related to delay in repairing damaged ceilings in the kitchen dish-room, the resident shower room, and on the 400 Hall. The facility census was 73. Findings included: An observation on 1/6/23 at 8:10 a.m. during initial tour of the kitchen with Dietary Manager (DM), revealed the ceiling in the dish-room was covered with plastic draping over the entire ceiling space. Some parts of the plastic drape were loose and had openings where debris and rodent/pest could enter. There were dishes drying on a rack directly under a portion of the plastic that was gaping open. During an interview on 1/6/23 at 8:10 a.m., the DM stated the water pipes burst on 12/24/22. She stated the burst water pipes also damaged the sheet rock in the dry storage room, which backs up to the dish-room. She stated that she is not sure of the timeline for repairing the ceiling was but stated the sheetrock in the dry storage is being worked on today. An observation on 1/6/23 at 10:47 a.m. in the shower room, revealed the entire ceiling was missing, exposing the pipes, wiring, beams, insulation, rafters, and light fixtures hanging down. Continued observation revealed that outside skylight was visible through the ceiling space from an exhaust vent, located on the roof. An observation on 1/6/23 at 3:03 p.m. on the 400 Hall, revealed a plastic barrier wall in place just past room [ROOM NUMBER]. The plastic barrier is secured as to not allow entrance by unauthorized individuals. During an interview on 1/6/23 at 4:45 p.m., the Director of Nursing (DON) stated that the ceiling in the shower room was damaged during the burst pipes from the 12/24/22 freeze. She stated that the shower room has not been used, and residents are being given bed baths, until the ceiling can be repaired. She stated that she was unsure of what the timeline was for the repairs of the shower room. During further interview, she stated there are not any resident rooms beyond the plastic barrier on the 400 Hall. During an interview on 1/8/23 at 2:46 p.m., the Administrator stated the water pipes burst on 12/24/2022. He stated he is working on the repairs to the structural damage caused by the burst water pipes but does not have an estimated timeframe of when the repair work will be done.

42464 Based on facility policy, medical record review, and staff interviews, it was determined the facility failed to develop a person-centered comprehensive care plan for six of 26 sampled residents (R) (R#54, R#1, R#40, R#16, R#32, and R#57). Findings included: A review of the facility policy, Comprehensive Care Plans, implemented 2/12/22, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident. The care plan would include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychological needs. 1. A review of the medical record revealed R#54 was admitted to the facility on [DATE] with a past medical history of Hypertension (HTN), respiratory failure with hypoxia, cerebral aneurysm/non ruptured, Heart Failure, A-fib, hypothyroidism, dysphagia, bowel and bladder incontinence, and a Deep Tissue Injury (DTI) to the right heel. A review of the Medical Doctor (MD) orders revealed R#54 was prescribed Augmentin Tablet 875-125 MG (Amoxicillin-Pot Clavulanate) on 12/2/22. The resident completed the antibiotic therapy on 12/9/22. A review of R#54's person-centered care plan revealed the resident was not care planned for antibiotic treatment. During an interview with the Wound Care Nurse (LPN GG), on 1/8/23 at 1:36 p.m., she stated R#54's wound was much better than it had been. She indicated R#54's antibiotic therapy was completed and the infection had resolved. 2. A review of the medical record revealed R#1 was admitted to the facility on [DATE] with a past medical history of UTI, weakness, DM II, gout, HTN, A-fib, dementia with behaviors, depression, cervical disc degeneration, polyarthritis, vitamin D deficiency, edema, and GERD. A review of the MD orders revealed the following: 12/28/22 Monurol Packet 3 gram (Fosfomycin Tromethamine) for Urinary Tract Infection (UTI) to be taken by mouth daily. The antibiotics were completed 12/29/22. 12/23/22 Monurol Packet 3 gram (Fosfomycin Tromethamine) for UTI and taken by mouth for four days. The antibiotics were completed 12/27/22. A review of R#1's person-centered care plan revealed R#1 was not care planned for UTI. A review of the laboratory urinalysis (U/A) results dated 12/18/22 revealed a finding of Proteus mirabilis and klebsiella pneumoniae. A review of the Nurse's Notes revealed the following: 12/13/22 at 3:06 p.m. The patient was seen, and the chart reviewed. No complaints. Notified by staff of altered mental status. U/A pending. 12/20/22 at 8:18 a.m. The resident was started antibiotic this morning. No urinary complaints. 12/29/22 at 7:54 a.m. The resident continued antibiotics for UTI. There were no urinary complaints. 12/31/22 at 8:08 a.m. The resident was status post antibiotics. There were no urinary complaints this shift. A review of the Physician's Notes dated 1/4/23 at 7:32 p.m. revealed the resident was seen for a follow up status post antibiotics for UTI and refusal of incentive spirometer. The resident denied dysuria or abdominal pain. 3. A review of the medical record revealed R#40 was admitted to the facility on [DATE] with a past medical history of falls, venous thrombosis, embolism, FX of T11 - T12, rheumatoid arthritis, HTN, MDD, DM II, uterine cancer, breast cancer with right mastectomy. A review of R#40 was care planned for Hospice on 1/7/23. A review of the MD orders revealed R#40 was admitted to Hospice on 12/15/22. 4. A review of the medical record revealed R#16 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, acute kidney failure, hydronephrosis, and bladder neck obstruction. Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive decline. Section H- Bladder and Bowel revealed R#16 has an indwelling catheter. A review of Physician's order dated 8/10/2022 revealed an order for 'Foley catheter #16FR to bsd; may use leg bag for cath as needed.' A review of R#16 care plan last revised 11/11/2022 did not reveal a care plan to address catheter use. 5. A review of the medical record revealed R#32 was admitted to the facility on [DATE] with diagnoses including COVID-19, acute kidney failure, and hypertension. Review of Admission MDS dated [DATE] revealed a BIMS score of 13 out of 15, indicating cognitively intact. Section O-Special Treatments and Programs revealed resident received oxygen therapy while a resident. A review of the electronic medical records (EMR) revealed a Physician's order dated 11/28/2022 for 'O2 (oxygen) 2L (liters) per NC (nasal canula) continuously every shift'. A review of R#32's care plan initiated 11/30/2022 did not reveal a care plan for oxygen therapy. 6. A review of the medical record revealed R#57 was admitted to the facility 1/19/2022 with diagnoses including diabetes mellitus, chronic kidney disease, and acute kidney failure. Review of Quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. A review of Physician's order dated 8/19/2022 revealed an order for insulin lispro pen-injector 100 units/ml (milliliter) inject 18 units subcutaneously with meals for diabetes mellitus. A review of care plan last revised 11/23/2022 revealed no care plan in place to address diagnosis or need for insulin. During an interview with the Minimum Data Set (MDS) Coordinator on 1/8/23 at 10:40 a.m., she stated that she attended a clinical meeting every morning and received a report on any resident changes. She explained that once she was given the information, she initiated a care plan for care in new areas identified. The MDS Coordinator acknowledged R#54 was not care planned for antibiotics therapy, R#1 was not care planned for a urinary tract infection, and R#40 was not care planned for Hospice until 1/7/23. However, she explained the facility had been busy over the last couple of months, and she needed more time to update the care plan. During an interview on 1/8/2023 at 1:55 p.m. with MDS Coordinator revealed she has been very busy and care plans get missed. Stated if the care plan is not there it is because she did not do one. Confirmed R#16 did not have a care plan for catheter use, R#32 did not have a care plan for oxygen therapy, and R#57 did not have a care plan for diabetes mellitus or insulin use. During an interview on 1/8/2023 at 3:29 p.m. with the Director of Nursing, she stated that she was just made aware of issues with care plans. She further stated that she expects care plans to reflect residents overall mental, physical, and medical conditions and confirmed that information that triggers on the MDS should also be care planned.

Based on observation, facility policy, and interviews, it was determined the facility failed to ensure a homelike and comfortable environment for 15 (202, 205, 206, 207, 210, 143, 214, 405, 305, 515, 403, 407, 408, 409, 410) of 44 resident's rooms and one shower room. Findings included: A review of the facility policy, Resident Environmental Quality, implemented 2/1/22, revealed the facility would be maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. An observation of room [ROOM NUMBER] on 1/6/23 at 9:31 a.m. revealed an area next to the resident's bed had a gouged section, exposing the wall to the drywall with paint removed. An observation of room [ROOM NUMBER] on 1/6/23 at 9:35 a.m. revealed the area behind the resident bed had multiple marks that extended up to the overhead wall light. No paint covered the areas. An observation of room [ROOM NUMBER] on 1/6/23 at 9:36 a.m. revealed no hot water was accessible from the tap for five minutes. It was determined the hot water valve was not turned on. An observation of room [ROOM NUMBER] on 1/6/23 at 9:43 a.m. revealed an area near the grab bar next to the resident bed that had unpatched holes. An observation of room [ROOM NUMBER] on 1/6/23 at 9:47 a.m. revealed an area on the wall to the left of the door with multiple large areas where the drywall was exposed, and the paint was missing. An observation on 1/6/23 at 9:48 a.m. in room [ROOM NUMBER]-B, there were two medium sized patches of scuff marks and missing paint, approximately 5 long and 2 wide on the left wall, at bed level. An observation of room [ROOM NUMBER] on 1/6/23 at 9:53 a.m. revealed an area on the wall to the left of the entrance with multiple marks and missing paint. Additionally, the sprinkler head was missing pieces, leaving a ceiling hole. An observation on 1/6/23 at 10:47 a.m. in shower room, revealed entire ceiling missing with exposed wires, beams, rafters, insulation, and light fixtures hanging down. An observation on 1/6/23 at 12:09 p.m. in room [ROOM NUMBER], resident in bed B complained the water faucet on the bathroom sink was loose and needs to be replaced. Faucet was loose and wobbly. An observation on 1/6/23 at 1:12 p.m. in room [ROOM NUMBER], there was approximately 2x3 metal plate at top of ceiling above light switch, missing covering, visibly exposing some wires, a low Broda chair was being stored in bathroom, with sling in chair with food particles. Both residents state the chair does not belong to them, and residents in adjoining bathroom do not use that chair either. An observation of room [ROOM NUMBER] on 1/6/23 at 9:58 a.m. revealed an area near the window where the paint had been stripped off after something hanging on the wall had been removed or torn down. Additionally, an area lower on the wall had gouges and missing paint. An observation on 1/7/23 at 8:18 a.m. in room [ROOM NUMBER], there was approximately 15 holes on walls in bathroom where screws from towel rods and soap dispensers were removed. An observation on 1/7/23 at 8:20 a.m. in room [ROOM NUMBER], there was no hot water in the room at the hand washing sink. Water ran four minutes and never got warm. An observation on 1/7/23 at 8:22 a.m. in room [ROOM NUMBER], there was no hot water in the room at the handwashing sink. Water ran 3.5 minutes and never got warm. This resident was on COVID isolation. There was no trash bag liner in the trash can, used disposable gowns were being placed on a chair inside the room. An observation on 1/7/23 at 8:24 a.m. in room [ROOM NUMBER], there was no hot water in the room at the handwashing sink. Water ran 3.5 minutes and never got warm. This resident was on COVID isolation. An observation on 1/7/23 at 8:28 a.m. in room [ROOM NUMBER], there was no hot water in the room at the handwashing sink. Water ran 3.5 minutes and never got warm. This resident was on COVID isolation. During an interview with the resident residing in room [ROOM NUMBER] on 1/6/23 at 9:34 a.m., she stated that she did not like the marks on the wall. She indicated that nobody had ever asked her about the damage or said they would fix it. The resident stated she had been in the room for two weeks, and the room looked the same when she was admitted . During an interview with the resident residing in room [ROOM NUMBER] on 1/6/23 at 9:50 a.m., he stated the walls were damaged when he was admitted . He said nobody had ever asked him about the walls or offered to fix them. During an interview with the Maintenance Director (MD II) on 1/6/23 at 10:40 a.m., he stated he had been the Maintenance Director for two weeks. He acknowledged all the problems in rooms 202, 205, 206, 207, 210, 214, and 215. He stated he turned the hot water in the room because it leaked. He said he had not had a chance to address the leak due to other issues in the facility. He added that he knew cosmetic issues existed in the facility, but he had not had an opportunity to fix them. He said that before a resident is admitted , the rooms are usually assessed and improved before they are placed in the room. He stated the facility had other essential things that needed to be fixed, so he could not ensure the rooms were ready for new admissions or room transfers. During an interview with the Administrator on 1/8/23 at 2:46 p.m., he stated that rooms were expected to be ready for new admission or residents transferring to another room. He noted the facility had a maintenance log at the nurse's station so any staff member could notify maintenance of an issue. He stated the Maintenance Director was new, and the plan when he was hired was to get the log caught up. The Administrator said the pipes burst approximately two weeks ago, and the Maintenance Director had to concentrate on getting the facility utilities back in working order. He added that he knew some of the cosmetic issues were older than two weeks, and he acknowledged that those issues should have been fixed. He explained that he intended to repair the painting and walls as soon as possible. Still, the Administrator stated that he was focusing on restoring the pipes, life safety concerns, and kitchen areas addressed first. 38988

Based on observations, staff interviews, and review of the policy titled Disposal of Garbage and Refuse, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner, creating the potential for harboring pests and insects. Specifically, the side door was open, a blue trash bin was overflowing with bagged garbage, bagged garbage on top of the dumpster, garbage and debris was strewn on the ground and behind the dumpster. The facility census was 73. Findings included: Review of the policy titled Disposal of Garbage and Refuse dated 2/1/22, revealed the policy is the facility shall properly dispose of garbage and refuse. Policy Interpretation and Compliance Guidelines: number 7. Refuse containers and dumpsters kept outside shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters should be kept covered when not being loaded. Surrounding area shall be kept clean so that the accumulation of debris and insect/rodent attractions are minimized. Number 8. Garbage shall not accumulate or be left outside the dumpster. Number 9. The schedule for garbage pick-up should be revised, as needed, based on the volume of refuse. Observation on 1/6/23 at 10:31 a.m. after initial tour of the kitchen area, walking through the dining room, visible through the windows, was the dumpster area, revealed the dumpster area was full of bagged garbage. There was a blue trash bin to the right of the dumpster that was overflowing with bags of garbage, bags were noted piled on top of the dumpster, as well as on the ground in front of the dumpster. Continued observation revealed the ground area around the dumpster had trash on the ground. Observation on 1/7/23 at 2:19 p.m. garbage continues to be piled at dumpster, and on the ground surrounding the dumpster. Observation on 1/8/23 at 9:17 a.m. dumpster area continues to be overflowing, bags on the ground in front of the dumpster, and debris on the ground surrounding the dumpster. Interview on 1/8/23 at 4:30 p.m. with the Dietary Manager, confirmed the trash buildup at the dumpster area. She stated the trash pick-up is scheduled four days per week, and stated she thought they would be emptied today. During further interview, she stated that the housekeeping department was responsible for keeping the area around the dumpsters clean. She stated during further interview that the Dietary staff know not to pile the dumpster so high it overflows, and never should place garbage bags on the ground. She stated there is an overflow dumpster for use when the main dumpster gets full. Interview on 1/8/23 at 4:40 p.m. with the Director of Nursing (DON) confirmed that the housekeeping staff are responsible for maintaining the dumpster area clean and free of debris. Housekeeping Supervisor was not available for interview.

Based on observation, record review, and staff interviews, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for one of 26 sampled residents (R) (R#13) related to the use of oxygen. Findings included: A review of the clinical record revealed R#13 was admitted to the facility on [DATE] with diagnoses that included but not limited to non-hodgkin lymphoma, chronic obstructive pulmonary disease (COPD), bipolar disorder, anemia, dementia, and hypertension (HTN). A review of the Admission MDS assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated moderate cognitive impairment. Section I-Active Diagnoses include chronic pulmonary disease. Section O- was not coded as the resident uses Oxygen therapy. A review of care plan initiated on 11/15/22, revealed that resident has potential for altered respiratory status related to COPD. Interventions to care include give medications as ordered by physician. Observe and document side effects and effectiveness, give nebulizer treatments and oxygen therapy as ordered. Monitor vital signs, skin color, pulse oximetry, airway functioning and degree of restlessness which may indicate hypoxia. A review of the January 2023 Physician Orders revealed an order for Oxygen at two liters (L) via nasal canula (N/C) to keep Oxygen saturation above 88%. An observation on 1/6/23 at 10:15 a.m. R#13 lying in bed with Oxygen in use at 2L via N/C. Nebulizer machine sitting on the bedside table. During an interview on 1/8/23 at 5:44 p.m., the MDS Coordinator stated that she reviews the entire electronic medical record for information about diagnoses, treatment, physician orders, and medications. She stated that she is the only one doing the MDS and she just missed the Oxygen. During an interview on 1/8/23 at 5:55 p.m., the Director of Nursing (DON) stated it was her expectation that all MDS assessments be completed with accurate information related to resident's care.

Based on observations, record review, staff interviews, and facility policy 'Oxygen Concentrator', the facility failed to administer oxygen therapy as ordered for one of seven residents (R)(R#32). Findings included: A review of facility policy 'Oxygen Concentrator' implemented 2/1/22 revealed 'Policy Explanation and Compliance Guidelines: 2. Oxygen is administered under order of the attending physician, except in cases of emergency. 4. Use of the Concentrator: a. The nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal canula etc.).' A review of the medical record revealed R#32 was admitted to the facility on [DATE] with diagnoses including COVID-19, acute kidney failure, and hypertension. Review of Admission Minimum Data Set, dated dated dated [DATE] revealed a Brief Interview for Mental Status score of 13 out of 15, indicating cognitively intact. Section O-Special Treatments and Programs revealed resident received oxygen therapy while a resident. A review of the electronic medical records (EMR) revealed a Physician's order dated 11/28/22 for 'O2 (oxygen) 2L (liters) per NC (nasal canula) continuously every shift'. During an observation on 1/6/23 at 9:33 a.m., R#32 was observed lying in bed with oxygen concentrator in room, however, it was not turned on and resident was not wearing the nasal canula. During an observation on 1/7/23 at 8:37 a.m., R#32 was observed lying in bed with oxygen concentrator at bedside. The oxygen concentrator was not turned on and resident was not wearing the nasal canula. During an observation on 1/8/23 at 10:42 a.m., R#32 was observed lying in bed sleeping. Oxygen concentrator at bedside was not on and resident was not wearing the nasal canula. During an interview on 1/8/23 at 12:27 p.m. with RN AA, she confirmed that R#32 has an order for oxygen, however, she has never seen resident wearing oxygen. She stated that she keeps a check on resident's oxygen saturations, and they are within normal limits. During an interview on 1/8/23 at 12:33 p.m. with Assistant Director of Nursing (ADON) LPN BB, they confirmed R#32 had an order for oxygen, but resident had not worn the oxygen in several weeks. Stated the Physician should have been notified that resident was not wearing the oxygen. During an interview on 1/8/23 at 12:35 p.m. with Director of Nursing, she stated that her expectation is for nurses to follow the Physician's orders. Stated if resident does not need the oxygen or is refusing to wear the oxygen, the Physician should have been notified and documentation should have been done. A review of the medical record revealed no documentation that R#32 refused to wear oxygen.

Based on observations, record review, staff interviews, and policy review, the facility failed to implement an effective Infection Control Program (ICP) to prevent the spread of infections by not ensuring Certified Nursing Assistant (CNA) CC washed/sanitized her hands before and after glove removal during the provision of catheter care, for one of three residents (R) (R#14) with indwelling urinary catheter. In addition, the facility failed to properly store resident personal care equipment. Findings included: 1. Review of the policy titled Catheter Care revised 6/13/22, revealed the policy is to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: 1. Catheter care will be performed every shift and as needed by nursing personnel. Compliance Guidelines: 7. Perform hand hygiene. 8. Don gloves. A review of the clinical record revealed R#14 was admitted to the facility on [DATE] with diagnoses that included but not limited to history of COVID, hypo-osmolality and hyponatremia, syncope, dysphagia, retention of urine, depression, hypertension (HTN), and thrombocytopenia. A review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed R#14 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Section H-revealed resident has a urinary catheter. Review of care plan revised on 1/5/23, revealed that resident has a Foley Catheter for Urinary Retention. Interventions to care include catheter change according to order, change drainage bag, and leg bags weekly as per order, observe urine for change in color/consistency and notify Physician as needed, output monitoring every shift, provide Foley care every shift, Urology consult as ordered. During an observation on 1/8/2023 at 10:30 a.m. with CNA CC in R#14's room, she was observed explaining to resident that she was going to perform catheter care. R#14 consented to this observation. CNA CC pulled the privacy curtain and donned gloves without performing hand hygiene, gathered supplies consisting of four washcloths, and two garbage bags. She went to bathroom and wet the four washcloths with water and applied body wash soap to two of the washcloths and two without soap. She placed the four washcloths on an open trash bag on the residents' bed, and proceeded to open the second bag to place soiled linen in. She raised the residents' gown, spread the labia, and took one of the soapy washcloths and wiped down one side of the labia and down the tubing. She discarded the dirty washcloth in the garbage bag. She used the other soapy washcloth to wipe down the other side of the labia and down the tubing and discarded the washcloth in the garbage bag. Without changing her gloves, she picked up the remaining two washcloths and proceeded with the same technique to wipe the soap off the labia and tubing. She discarded those two washcloths in the garbage bag with the other soiled washcloths. Resident asked CNA CC to dry her private area and apply powder. Still wearing the same pair of gloves, CNA CC went back to the bathroom and obtained a dry washcloth. She dried the residents' perineal area and applied powder, per residents' request. Still wearing the same pair of gloves, she assisted resident out of bed and into her wheelchair. She gathered the dirty linens and exited residents' room, still wearing the same pair of gloves. During an interview on 1/8/23 at 10:38 a.m. with CNA CC, she revealed that she works at the facility through a staffing agency and stated she has worked five to six days per week for approximately eight months. She stated that she does not normally perform catheter for R#14, because she takes care of her own personal care. During further interview, she stated that she does catheter care for residents when they have bowel movements, and stated she changes her gloves when cleaning them. She stated that's the only catheter care she does, other than emptying their bags. She stated that she did not receive training from facility during orientation. During an interview on 1/8/23 at 12:51 p.m. with Director of Nursing, she stated agency staff are provided training skills and competencies in orientation. She stated that she is not sure if the staffing agency provides their own training. During further interview, she stated her expectation is staff are to change gloves when providing care from dirty to clean area of body. 2. During multiple observations in room [ROOM NUMBER] on 1/6/23 at 8:55 a.m., 1/7/23 at 2: 31 p.m., and 1/8/23 at 7:52 a.m., revealed two urinals hanging on the grab bar beside the toilet. The two urinals were un-labeled and un-bagged. There were two bath basins sitting on the shelf above the toilet, that were unbagged on 1/6/23 and 1/7/23. Both bath basins were bagged on 1/8/23. During an observation on 1/6/23 at 9:57 a.m. in room [ROOM NUMBER]A, a nebulizer mask was observed on the bedside table, draped over the machine, and unbagged. During an observation on 1/7/23 at 8:28 a.m. and 1/8/23 at 11:17 a.m. in room [ROOM NUMBER], two unbagged urinals were observed hanging on grab-bar of a female resident room. The resident had no evidence that she ever had a catheter. During an interview on 1/8/23 at 4:37 p.m. with Director of Nursing, she stated that her expectation is that all resident care equipment be labeled and bagged when not in use.

Based on record review, and staff interview, the facility failed to establish documentation of Do Not Resuscitate (DNR) code status in the resident's paper chart for one resident (R) #38 of 34 sampled residents. Findings include: A review of the resident's electronic record revealed a code status of Do Not Resuscitate. The resident was admitted to the facility on [DATE], with a with [DIAGNOSES REDACTED]. A review of the Quaterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Intervview for Mental Status (BIMS) score of 0 of 15, indicating cognitively severely impaired. A review of the physician progress notes [REDACTED]. A review of the Physician order [REDACTED]. A review of the resident's face sheet retrieved from the resident's paper chart revealed FULL CODE status. A review of the resident's paper chart revealed a document titled Physician order [REDACTED]. An interview with Licensed Practical Nurse (LPN) AA on 1/7/19 at 1:15 p.m. revealed if a resident appears with [MEDICAL CONDITION], she would look in the electronic record or the resident's paper chart, for code status guidance, whichever is closest to her at the time. An interview with LPN BB on 1/7/20 at 1:25 p.m. revealed if a resident presented without a pulse, she would look for the resident's code status in whichever chart (electronic chart or paper chart) was closest to her at the time. An interview with the Assistant Director of Nursing (ADON), and Social Service Director (SSD) on 1/7/2020 at 2:00 p.m. revealed that the ADON remembered R#38 having a decline in health and the family deciding to make the resident's code status a DNR. The ADON stated she does not know why the resident's face sheet in the paper chart has not been updated with the correct code status of DNR, or why a new POLST has not been filled out and signed by the RP and Physician to reveal the DNR code status.

Based on observation and staff interview the facility failed to ensure the walk -in cooler was clean and in safe operating condition. The census on 10/15/18 was 70 residents. Findings Include: On 10/15/18 at 10:20 a.m. entered walk-in cooler with Dietary Manager (DM) and Dietary District Manager. A strong odor of something soured was noted. At this time, there was a puddle of water noted on the floor of the cooler at the entrance of the walk-in freezer. There was a black substance noted in the upper right-hand corner of the cooler. During an interview on 10/15/18 at 10:25 a.m., in the walk-in cooler, with the DM, she stated that they try to keep the floor of the walk-in cooler clean but 2 days after cleaning the floor with Clorox the odor is back. She also stated that this has been a problem for over a year. During this time the Dietary District manager, who was present at the time of the interview, made this survey aware that upon lifting his shoe from the floor of the cooler, water fills in leaving a perfect, water imprint of his shoe before seeping back into the floor. Dietary District Manager also stated at this time that he too smells the odor and stated they have been [MEDICATION NAME] and cleaning the floor of the walk-in cooler. During an interview on 10/16/18 at 9:00 a.m. with the Administrator he stated that he had maintenance clean the floor of the walk-in cooler last week. During this time this surveyor reviewed pictures of the walk-in cooler. Administrator stated he will call his boss and get the cooler taken care of immediately. On 10/16/18 at 9:10 a.m. Entered the walk-in cooler with the Administrator. Interview with Administrator at this time revealed he too smells the odor, observed the wet floor, and condensation on the ceiling of the cooler. During an interview on 10/16/18 at 9:12 a.m. with Cook AA revealed that she noticed an unpleasant odor in the walk-in cooler about a month ago and reported it to the DM. During an interview on 10/16/18 at 9:15 a.m. with Dietary Aid BB she stated she has worked in this facility for [AGE] years and the water in the floor, and odor of the walk-in cooler, has been going on for over a year. She stated that the Health Department has written the kitchen up twice for the issues with the cooler. During an interview on 10/16/18 at 9:16 a.m. with Dietary Aid CC she stated she has worked in the facility for [AGE] years and the problem with the walk-in cooler has been going on for well over a year and that it has been reported to the Administrator. During an interview on 10/16/18 at 9:30 a.m. with the Maintenance Director he stated that he vacuumed the water out of the floor of the walk-in cooler last week, and again yesterday, and that both times there was an odor. He stated that he hasn't been in this position very long and can't speak for what it looked like a year ago but stated that there was someone coming today to look at the walk-in cooler and give an estimate to fix it. During an interview on 10/16/18 at 9:45 a.m., with the Administrator, revealed that they are bringing in a temporary cooling system to put the food from the walk-in cooler in so the repairs can be done, and done right. During a phone interview on 10/16/18 at 10:45 a.m. with a Commercial Services, LLC he stated that he came and evaluated the walk-in cooler today and the floor bed is rotten. He stated the water is coming from where the door to the freezer is and is running down into the floor. He stated there is foam between the layers of the floor, and over the years milk has been spilled onto the floor, and the water from the freezer door has damaged the floor and subfloor, and the foam has soaked up all the water and milk causing a terrible odor. He stated the floor has a metal top but with the foam being saturated, when stepping on the metal floor, the water seeps up through the floor from the foam. He stated that this was not something that just happened but would take at least a year or longer to get as bad as the floor is now. Observation on 10/17/18 at 9:30 a.m. revealed the walk-in cooler to be completely emptied. Interview, at this time, with the DM revealed that they now have a truck out back with a cooler that they are keeping their refrigerated foods in until the walk-in cooler has been completely repaired. Review of Purchase Order for walk-in cooler repair from a Commercial Service revealed 1 New Floor for Walk-in Cooler was to be ordered.

Based on observations, record review, staff interviews, review of inservice records, review of manufacturer recommendations, review of facility polices/procedures for cleaning/disinfecting blood glucose meters, the facility failed to ensure an Infection Control Program designed to ensure a safe environment to prevent the development and transmission of disease and infection by failing to ensure the cleaning and disinfecting of glucose meters between resident use for three (3) sampled residents (#1, #6 and #30) and fifteen (15) unsampled residents who received blood glucose monitoring on a daily basis via multiple resident glucose meter use. The failure to clean and disinfect blood glucose meters between residents resulted in the likelihood of an immediate and serious threat to resident health and safety for eighteen (18) residents. Therefore, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident existed from August 09, 2011 until being removed August 11, 2011, at which time the facility had implemented a plan to remove the immediate jeopardy. There were no residents in the building with documented Blood Born Pathogens Findings include: 1. During medication pass on 8/09/11 at 5:09 p.m. with Licensed Practical Nurse (LPN) "AA", a blood glucose monitoring was observed. LPN "AA" removed the glucose meter from a drawer of the medication cart. LPN "AA" gathered supplies, donned gloves, and proceeded to clean the glucose meter with an Alcohol wipe. LPN "AA" then entered the room of resident #1. After completing blood glucose for the resident, gloves were removed and she returned to the medication cart. 2. Continued observation revealed LPN "AA" then applied new gloves and preceded to the room of resident #30. She cleaned and disinfected the glucose meter with a Sani-Wipe Bleach Cloth, dried with a paper towel prior to doing the resident's blood glucose. She completed the blood glucose, removed her gloves and left the room. She returned to the medication cart and placed the glucose meter back in the medication cart drawer. She did not clean and disinfect the glucose meter after use. The above observations revealed that LPN "AA" cleaned the glucose meter with an Alcohol wipe before use for resident #1, then cleaned and disinfected the glucose meter, without allowing it to air dry (per manufacturers guidelines) for resident #30. LPN "AA" did not clean and disinfect the glucose meter with any product prior to storing. Interview with LPN "AA" on 8/9/11 at 5:15 p.m. revealed that glucose meters are cleaned with Alcohol wipes between residents, and periodically cleaned with a Sani Wipe Bleach Cloth. There were two (2) medication carts in use within the facility, and each cart contained one (1) glucose meter. There were eighteen (18) residents with a [DIAGNOSES REDACTED]. 3. Observation of blood glucose monitoring for resident #6 conducted 8/10/11 at 8:15 a.m. revealed LPN "BB" did not clean or disinfect the glucose meter prior to preceding to the room of resident #6. She applied her gloves, completed the blood glucose testing, removed her gloves, returned to medication cart, and stored the glucose meter without cleaning or disinfecting. Interview with "BB" on 8/10/11 at 8:30 a.m. revealed that glucose meters are cleaned between each shift by wiping with Alcohol then using a Sani Wipe Bleach Cloth. Review of inservice documentation, dated 10/08/10, included: Glucose meters should be wiped down before each resident use with Alcohol prep pads and allowed to air dry. After the blood glucose testing is complete the machine should be disinfected, accomplished by using a 1:10 solution of household bleach and water, and air dried before next use. The facility might use commercially prepared wipes that were 5-6% sodium [MEDICATION NAME] solution, or wipes might be prepared by the facility. Based on the attendance sheet, LPN "AA" had attended the 10/08/10 inservice. LPN "BB" was hired after the 10/08/10 inservice and no inservice on this subject had been conducted after the 10/08/10 date. Interview with the Director of Nurses on 8/10/11 at 10:00 a.m. revealed that the above policy was still in effect. Glucose meters should be cleaned before and after each use with a 1:10 bleach wipes, and if those wipes were not available staff should use Alcohol wipes. Glucose meter should remain wet for thirty (30) seconds, and then air dry. She further revealed that no newly hired nurses had been trained since the initial inservice on 10/08/10. According to the manufacture's recommendations, the glucose meter, being used by the facility, should be cleaned by cleaning the outside of the meter with a cloth dampened with soapy water or alcohol (70%-85%). To disinfect the meter, dilute one (1) milliliter (ml) of household bleach (5%-6% sodium [MEDICATION NAME] solution) in 9 ml of water to achieve a 1:10 dilution (final concentration of 0.5%-0.6% sodium [MEDICATION NAME]). Do not clean inside battery compartment, code chip port, or test strip port. The immediate and serious threat to health and safety was determined to have been removed on August 11, 2011, but the associated noncompliance continued in order to ensure the following were maintained by the facility: glucose meters are cleaned and disinfected according to the facility's revised policy and procedure; all licensed staff are inserviced on procedures related to cleaning and disinfecting glucose meters; and the Quality Assurance Program monitors implementation of and compliance with the facility's revised infection control related to cleaning and disinfecting glucose meters. Therefore, the scope and severity of the deficiency was reduced from a "K" level to an "E" level when the facility implemented the following plan of correction: - A revised policy and procedure entitled "Cleaning and Disinfecting Blood Glucose Meters" was reviewed and approved by the facility Administrator, DON and the Medical Director. The revised policy became effective 08/11/11 and was revised in conjunction with CDC and OSHA guidelines, and EPA literature. The policy and procedures purpose was to prevent the transmission of infectious disease as related to blood glucose monitoring systems. The procedure reads: 1) Before each use of the blood glucose meter, the machine should be inspected for debris. 2) The machine should be wiped down, both front and back, with Sani Cloth Bleach Wipe to clean and disinfect the machine. The machine should air dry for one (1) minute before it is used. 3) Do not clean inside the battery compartment, code chip port, or test strip port. Allow the machine to air dry as you prepare to perform the blood glucose testing. 4) When blood glucose testing an individual resident is completed the machine should be cleaned and disinfected by wiping it down both front and back, with a Sani Cloth Bleach wipe. 5) The machine should air dry one (1) minute before the next use. Completed 08/11/2011. - Inservices for all licensed nursing staff were conducted regarding the revised policy and procedures related to blood glucose meter cleaning and disinfecting with accurate return demonstration by nurses in attendance. Training sessions were conducted by the DON on 08/10/2011 at 2:00 p.m., 3:20 p.m., and 11:00 p.m. Staff inservice were repeated on 08/11/11 to include any updates made to policy and procedure. All licensed staff except for one (1) were trained. Completed 08/11/11. (The one licensed staff will be trained to include return demonstration on Monday 08/15/2011 prior to return to duty). - Any new hired licensed staff will be trained on policy and procedure for cleaning and disinfecting glucose machines as part of the skills check off during orientation. Revision to orientation process completed 8/10/11 - The DON will be responsible for monitoring daily upon rounds, and weekly with a formal audit, that the blood glucose monitoring machines are being cleaned and disinfected properly. Weekely audits, with new format and schedule began 8/11/11. - Audits will be incorporated into the facility's Quality Assurance program on a monthly basis. The Administrator will be responsible that the audit materials are conducted. Interviews and observations of the cleaning and disinfecting of the blood glucose meters before, between and after resident use were conducted 08/11/2011 at 12:35 p.m. for two (2) day shift Licensed Practical Nurses (LPN) "BB"and "CC". These observations and verbalizations revealed compliance with the revised facility policy and procedure. Other examples, not related to Jeopardy, of noncompliance of F441: During an interview conducted with the RN Infection Control Nurse "DD" on 08/11/2011 at 10:50 a.m. revealed the facility was not equipped for residents requiring Isolation. If a resident needed Isolation he/she would be kept in their room until transferred out of the building. Universal precautions, and all linen would be bagged until that is accomplished. "DD" further revealed she was unaware of isolation policies or procedures. "DD" revealed that CDC guidelines were used for infection issues. Personal protective equipment (PPE) was available in central supply, gloves and masks, but no gowns. "DD" revealed she had been the Infection Control Nurse for one (1) year, and had not attended any classes or formal training. Interview with the DON on 08/11/11 at 11:45 a.m. revealed examples of when staff should use PPE could be for Flu, and/or[DIAGNOSES REDACTED]. Residents do not have to stay in their rooms. Only gloves are used when incontinent care is preformed. If staff become soiled, they would have to go home and change their clothes. Isolation precautions are done only with a physician order. Based on CDC guidelines, would consult with corporate nurses to make decision for the type of isolation procedures, other than a direct physician's orders [REDACTED]. Review of the Infection Program Overview provided by the DON indicated the facility would designate an individual to manage and coordinate the program and have the authority to determine the need for isolation measures; Residents would be restricted from group activities, including group dining, until two (2) days after resolution of diarrhea or vomiting; The need for isolation precautions and /or PPE would be determined on a case by case basis recognizing the challenges inherent in the Long Term Care Environment.

Based on observations, record review and staff interview, the facility failed to be administered in a manner to ensure staff members were trained appropriately regarding infection control measures, specifically, the need to clean and disinfect glucose meters between each resident. This affected three (3) sampled residents (#1, #6 and #30) and fifteen (15) unsampled residents who received blood glucose monitoring on a daily basis via multiple resident use glucose meters. The failure to ensure staff observed accepted infection control guidelines resulted in the likelihood of an immediate and serious threat to resident health and safety for those eighteen (18) residents. Therefore, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident existed from August 9, 2011 until being removed August 11, 2011, at which time the facility had implemented a plan to remove the immediate jeopardy. Findings include: Interview with the Director of Nurses (DON) conducted 08/11/11 at 11:00 a.m. revealed that she was aware of the revisions to F441 dated July 17, 2009. She indicated that the facility was following it's Infection Control policy for cleaning and disinfecting the glucose meters. Continued interview revealed that the facility was to use Sani-Cloth Bleach Wipe to clean glucose meters and if not available should use alcohol wipes. The Sani wipes were to be used before and after using the meters and allowed to air dry. The Sani wipes contain 1:10 ratio of bleach. Review of an inservice dated 10/08/10 indicated Glucose meters should be wiped down before each resident use with Alcohol prep pads and allowed to air dry. After the blood glucose testing is complete the machine should be disinfected, accomplished by using a 1:10 solution of household bleach and water, and air dried before next use. The facility might use commercially prepared wipes that were 5-6% sodium [MEDICATION NAME] solution, or wipes might be prepared by the facility. According to the manufacture's recommendations, the glucose meter, being used by the facility, should be cleaned by cleaning the outside of the meter with a cloth dampened with soapy water or alcohol (70%-85%). To disinfect the meter, dilute one (1) milimeter (ml) of household bleach (5%-6% sodium [MEDICATION NAME] solution) in 9 ml of water to achieve a 1:10 dilution (final concentration of 0.5%-0.6% sodium [MEDICATION NAME]). Do not clean inside battery compartment, code chip port, or test strip port. The facility failed to have a system in place to ensure current infection control guidelines were implemented for cleaning, and disinfecting glucose meters between resident use. The immediate and serious health and safety was determined to have been removed on August 11/2011, but the associated noncompliance continues in order to ensure the following are maintained by the facility: glucose meters are cleaned and disinfected according to the facility's revised policy and procedure; all residents identified with the potential for blood borne pathogens have an individual glucose meter; all licensed staff are inserviced on procedures related to cleaning and disinfecting glucose meters; and the Quality Assurance Program monitors implementation of and compliance with the facility's revised infection control related to cleaning and disinfecting glucose meters. Therefore, the scope and severity of the deficiency was reduced from a "K" level to an "E" level when the facility implemented the following plan of correction: 1. A revised policy and procedure entitled "Cleaning and Disinfecting Blood Glucose Meters" was reviewed and approved by the facility Administrator, DON and the Medical Director. The revised policy became effective 08/11/11 and was revised in conjunction with CDC and OSHA guidelines, and EPA literature. The policy and procedures purpose was to prevent the transmission of infectious disease as related to blood glucose monitoring systems. The procedure reads: 1) Before each use of the blood glucose meter, the machine should be inspected for debris. 2) The machine should be wiped down, both front and back, with Sani Cloth Bleach Wipe to clean and disinfect the machine. The machine should air dry for one (1) minute before it is used. 3) Do not clean inside the battery compartment, code chip port, or test strip port. Allow the machine to air dry as you prepare to perform the blood glucose testing. 4) When blood glucose testing an individual resident is completed the machine should be cleaned and disinfected by wiping it down both front and back, with a Sani Cloth Bleach wipe. 5) The machine should air dry one (1) minute before the next use. Completed 08/11/2011. 2. Inservices for all licensed nursing staff were conducted regarding revised policy and procedures related to blood glucose meter cleaning and disinfecting with accurate return demonstration by nurses in attendance. Training sessions were conducted by the DON on 08/10/2011 at 02:00 p.m., 03:20 p.m., and 11:15 p.m.. Staff inservice repeated on 08/11/11 to include any updates made to policy and procedure.. All licensed staff except for one were trained during these sessions. Completed 8/11/11. (The one licensed staff will be trained to include return demonstration on Monday 08/15/2011 prior to return to duty). 3. Any new hired licensed staff will be trained on policy and procedure for cleaning and disinfecting glucose machines as part of the skills check off during orientation. Revisions to the orientation program were completed 8/11/11. 4. The DON will be responsible for monitoring daily upon rounds, and weekly with a formal audit, that the blood glucose monitoring machines are being cleaned and disinfected properly. 5. Audits will be incorporated into the facility's Quality Assurance program on a monthly basis. The Administrator will be responsible that the audit material is completed. Observations of the actual staff training conducted 08/10/2011 and 08/11/2011 revealed all licensed day, evening, and night shift staff on duty as well as those called in attended both days. Interviews and observations of the cleaning and disinfecting of the blood glucose meters between resident use were conducted 08/11/2011 at 12:35 p.m. for two (2) day shift Licensed Practical Nurses (LPN) "BB"and "CC". These observations and verbalizations revealed compliance with the revised facility policy and procedure. Cross refer to F441