Every finding on record at Central Baptist Village

Based on interview and record review, the facility failed to provide written notice of the facility's bed-hold policy to the resident and/or resident representative at the time of transfer to the hospital or within 24 hours of transfer for two (R1, R2) of three residents reviewed for hospital transfers; the facility also failed to complete a discharge summary/recapitulation of stay when R1 and R2 did not return to the facility and were discharged from the facility.Findings include:R1's face sheet documented R1 was Medicare Part A on 04/30/26. R1 was transferred to a local hospital on [DATE]. A physician progress note dated 04/30/26 documented, Patient being transferred to the acute hospital for evaluation of abdominal abscess as the abdomen is getting bigger and hardening. She has stable pain in the abdomen without worsening. Review of R1's clinical record revealed no documented bed-hold notice was provided to R1 and/or R1's representative at the time of transfer to the hospital or within 24 hours of transfer. R1 did not return to the facility. R1 discharged to an Assisted Living Facility after hospitalization. Review of R1's clinical record revealed no completed discharge summary/recapitulation of stay following R1's discharge from the facility.R2's face sheet documented R2 was Medicare Part A on 05/11/26. R2 was transferred to a local hospital on [DATE]. A nursing progress note dated 05/11/26 documented, Patient with reports of weakness, patient is unable to transport to wheelchair. Vital signs taken, see vitals for details. MD made aware. Patient to go to [LOCAL HOSPITAL] ER for further evaluation. Review of R2's clinical record revealed no documented bed-hold notice was provided to R2 and/or R2's representative at the time of transfer to the hospital or within 24 hours of transfer. R2 did not return to the facility. Review of R2's clinical record revealed no completed discharge summary/recapitulation of stay following R2's discharge from the facility.06/15/26 at 2:20 PM, V1 (Administrator) confirmed bed-hold notices were not provided for R1 and R2. The Administrator stated the bed-hold notices were not provided because R1 and R2 were Medicare Part A residents. The Administrator stated, according to company policy, the facility does not issue bed-hold notices to residents who are under Medicare Part A.06/15/26 at 2:45 PM, V4 (Social Services Director) said, they normally complete a recapitulation of the resident's stay along with a discharge summary. V4 stated discharge summaries/recapitulations of stay were not completed for R1 and R2 because the discharges were not planned. Surveyor asked if the summaries were completed once they were made aware that the residents were not returning and V4 said, No.The facility policy titled CBV Bed Hold Policy, reviewed/revised 04/15/25, documented the bed-hold policy needs to be given to the resident and representative when they are transferred or discharged . The policy documented the resident/representative needs to receive written notice within 24 hours in a language and manner they understand. The policy also documented the policy excludes residents on a Medicare stay at CBV.The facility policy titled Discharge Planning, reviewed/revised 04/24/26, documented discharge planning is a service and process provided by the facility to every resident. The policy documented discharge planning prepares the resident for the next level of care and includes arrangements for placement in the appropriate care environment with provisions of necessary services. The policy documented a few days prior to discharge, Social Services opens the CBV Post-Discharge Plan of Care Form and Discharge Summary/Recapitulation of Stay V3 within PCC. The policy further documented Social Services reminds Activities, Dietary, and Nursing interdisciplinary team members to complete and sign their sections of the forms. The policy also documented the nurse enters a Discharge Summary progress note documenting the resident's status at the time of discharge.

Based on observation, interview, and record review the facility failed to perform hand hygiene when providing resident care and failed to ensure staff adhered to Enhanced Barrier Precautions. This applies to 6 of 6 (R3, R4, R6, R44, R81, and R8) residents reviewed for infection control in a sample of 25. Findings include: 1. [DATE] at 11:00 AM, V14 (CNA-Certified Nursing Assistant) and V18 (CNA) provided morning care to R6. R6 had a supra-pubic catheter draining urine into the urine bag. V14 emptied the urine from the urine drainage bag into a urinal. After emptying, V14 did not clean the spout and replaced it in its slot. After discarding the urine into the toilet, V14 removed his gloves, did not perform hand hygiene and put on another pair of gloves. V14 opened R6's soiled diaper, and while wearing the same gloves, reached into his pockets and pulled out a roll of plastic bags, tore off two bags, and placed the roll back in his pockets. V14 turned R6 to her right side, held by V18 (CNA), and wiped off stool from R6's buttocks using a wet towel. V14 did not change gloves or perform hand hygiene, and while wearing the same gloves, V14 opened the bathroom door, went in and brought out another wet towel. V14 cleaned R6's buttocks again. After the perineal care, neither V14 CNA or V18 CNA performed hand hygiene or changed gloves. They dressed R6's in clothes and placed the mechanical lift sling under R6. Without changing gloves or performing hand hygiene, V14 opened R6's room door, went outside and brought in R6's wheelchair. With the same soiled gloves, V14 then removed the foot rest from the wheelchair and placed it on the side, moved the cardiac table aside, placed the mechanical lift near R6 in position, and hooked up the loops of the sling. Then V14 lifted the mechanical lift with the remote control and weighed R6. While still wearing the same soiled gloves, V14 reached into his pockets, took out a pen and paper, wrote down the weight and placed the pen and paper back in his pockets. Together they lowered R6 onto the wheelchair and in the process, the urine bag fell on the floor. V18 opened R6's drawer, took out a comb and combed R6's hair. V14 also wiped R6's face with a wet towel, using the same soiled pair of gloves. Then V18 took R6 out of the room. V14 used the same soiled gloves to tie up the garbage bag and the linen bag and placed both bags onto a pillow that was on a chair next to the bed. At that point, V14 removed gloves but did not wash his hands. V14 took the mechanical lift out of the room, brought in clean linen and placed a draw sheet on R6's bed. V14 tidied bed without gloves. After that he placed the garbage bag and the soiled linen bag that was on the chair onto R6's bed, tidied the bed space, and then took the garbage bag and the soiled linen bag out of the room. On [DATE] at 1:45 PM, V4 (ADON – Assistant Director of Nursing) stated, she educates the nursing staff on how to do their procedures. While emptying the urine bag, they should clean the spout with normal saline before replacing it in the slot. On [DATE] at 10:15 AM, observed V15 (WCN – Wound care nurse) changed the dressing for R6's wound on the right ischium. V15 turned R6 onto her right side. R6 had stool at the anus and around the perineal area. V15 did not wipe the perineal or gluteal area, removed the soiled brief, and placed the fresh disposable brief under R6. V15 changed the dressing without cleaning R6's perineal area and R6 was in the process of passing stool. After changing the dressings for all the wounds, V15 (WCN) tied up the garbage in a plastic bag. With same used gloves, in the right hand V15 picked up the garbage bag and the clean bag with clean box of gloves and hand sanitizer, opened the room by touching the door knob with left hand, placed the bag with clean box of gloves on her treatment cart and discarded the garbage bag. Then re-entered the room, removed PPE (Personal Protective Equipment) and washed her hands. 2. On [DATE] at 11:04 observed V16 (CNA) and V14 (CNA) transfer R4 from bed to wheelchair. After settling R4 in the wheelchair, V16 removed gloves and wheeled R4 out of the room without performing hand hygiene. V14 removed his gloves without performing hand hygiene, removed mechanical lift from the room to outside, and tidied up the bed space. 3. On [DATE] at 1:40 PM, V17 (RN-Registered Nurse) prepared to perform a gastrostomy tube (GT) flush for R3. V17 donned PPE (Personal Protective Equipment) and handled R3's GT. Without changing her gloves and performing hand hygiene, V17 touched the door knob to open the bathroom, filled water in a cup from the sink, and came back to R3. After handling R3's GT again, and wearing the same gloves, V17 opened the bathroom door, replaced the stethoscope and syringe back on the IV pole, and moved the privacy curtain back. On [DATE] at 11:23 AM, V10 (RN) prepared to flush R3's GT. After the procedure and with same soiled gloves on and no hand hygiene, V10 removed the stethoscope from her neck and replaced the syringe into its plastic bag and hung both on the IV pole next to the bed. V10 also handled the cardiac table and opened the bathroom door by touching the door knob while wearing the same soiled gloves. On [DATE] 11:39 AM, V5 (IP-Infection Preventionist) stated hand hygiene must be done before and after using gloves. V5 stated, doors and door knobs must not be touched with soiled gloves. V5 stated staff should not reach into their pockets or touch their own clothes while wearing gloves. V5 stated after emptying the urine from the urine bag, they must clean the spout with a alcohol wipe before replacing it back in its slot. On [DATE] at 12:30 PM, V2 (DON-Director of Nursing) stated, staff must do hand hygiene before and after removing gloves. V2 stated they cannot touch door knobs with gloves or after removing gloves and without performing hand hygiene. V2 stated after any procedure, they must remove gloves, perform hand hygiene and then wear another clean glove for the next procedure. V2 stated before replacing the spout of the urine bag after emptying the urine, they should clean it with alcohol swab. 4. On [DATE], at 12:08 PM, Resident R81 was observed in bed with family present at the bedside. Certified Nursing Assistants (CNAs) V18 and V19 entered the room. V19 placed R81's lunch tray on the overbed table. Both CNAs donned gloves without performing hand hygiene. V18 pulled the privacy curtain around R81's bed. V18 and V19 repositioned R81 and touched her bed linens and incontinence pad to assess whether incontinence care was needed. While still wearing the same soiled gloves, V19 then touched items on R81's lunch tray, and V18 opened the privacy curtain. Both CNAs then removed their gloves and exited the room without performing hand hygiene. They immediately proceeded to distribute meal trays to other residents in the hallway. R81's care plan reviewed on [DATE], indicates a self-care performance deficit related to impaired mobility. Interventions include physical staff assistance for activities of daily living (ADLs), including incontinence care and bed mobility. 5. On [DATE] at 10:55 AM, R44 was bed. V6 (Certified Nurse Assistant/CNA) was rendering incontinence care to R44. R44 had a small smear of bowel movement. V6 cleaned R44's peri-area and then buttock area with her gloved hands. After V6 completed R44's incontinence care, V6 did not change her gloves or perform hand hygiene. V6 then applied a clean incontinence brief to R44. V6 then proceeded to remove R44's gown, assisted with dressing, and placed a mechanical lift sling underneath R44. V6 then lowered R44's bed by touching the control with the same soiled gloves. V6 said she was done and left the room to get assistance with transferring R44. V6 removed her gloves and left the room without performing hand hygiene. R44's care plan reviewed on [DATE], said R44 was dependent on staff assistance with toileting and dressing. 6. R8's Face Sheet shows the following diagnoses: flaccid neuropathic bladder, personal history of urinary tract infections, retention of urine, and dementia. R8's POS (Physician Order Sheet) shows an order dated [DATE] maintain enhanced barrier precautions for indwelling urinary catheter. On [DATE] at 9:50 AM, R8's catheter care was performed by V13 (CNA/Certified Nurse Assistant). V13 emptied R8's drainage bag while only wearing gloves, no gown. Enhanced Barrier Precaution signage noted at entrance to R8's room instructing staff to wear gown and gloves. V13 then provided perineal care for R8. V13 wet towels with water only and wiped R8's left and right groin front to back and left and right inner labia front to back. V13 then turned R8 to her side and cleaned her buttocks by wiping front to back, small bowel movement smear noted. V13 then placed a clean incontinence brief on R8 with the same soiled gloves she provided perineal care with. On [DATE] at 1:36 PM, V2 (DON/Director of Nursing) said staff need to wear gown and gloves when emptying the urinary catheter drainage bag of a resident because that is what is required for enhanced barrier precautions. V2 said there is a risk of cross contamination/carrying germs to another resident if a gown is not worn while emptying a urinary catheter drainage bag. R8's Care Plan last revised [DATE] states resident is on enhanced barrier precautions related to long term use of indwelling urinary catheter. Interventions state staff to wear gown and gloves throughout high/close contact resident care activity including changing incontinence brief and indwelling medical device care. The facility's policy titled Hand Hygiene dated [DATE], said Purpose: Hand hygiene (washing with soap and water or using alcohol-based hand sanitizer) is the most important way to prevent the spread of infections. Germs on hands can transmit dangerous organisms to others .the Five Moments for Hand Hygiene .Before clean/aseptic procedure .After body fluid exposure risk .Before touching a patient .After touching a patient .After touching the patient's surroundings .

Based on observation, interview, and record review, the facility failed to assist residents with feeding in a dignified manner.This applies to 3 of 3 residents (R56, R83, and R79) reviewed for dignity in a sample of 25. Findings include:1. On 8/05/2025 at 12:50 PM, V7 (Registered Nurse/RN) was assisting R56 with her meal in the dining room. V7 mixed R56's served pureed entree food items together. V7 proceeded to feed R56 her mixed pureed meal.On 8/07/2025 at 8:50 AM, R56 was in bed. V8 (RN) was standing over R56 and assisting her with her meal. V8 mixed R56's served pureed entree food items together. V8 said R56 was served eggs, hash brown, and an unknown brownish food item. V8 said R56 consumed 50 % of the main entree.R56's care plan reviewed on 8/07/2025, said R56 was cognitively impaired and required physical staff assistance with eating. R56's care plan did not include mixing all R56's different pureed foods together for meals.2. On 8/05/2025 at 12:20 PM, R83 was in the dining room for lunch. R83 was exhibiting increased anxiety. R83 was attempting to grab her pureed meal items. V7 was assisting R83 with her meal. V7 attempted to redirect R83 and then mixed all R83's served pureed entree food items together. V7 proceeded to feed R83 her mixed pureed meal.R83's care plan reviewed on 8/07/2025, said R83 was cognitively impaired and required physical staff assistance with eating. R83's care plan did not include mixing all the pureed foods together for meals.3. On 8/07/2025 at 8:40 AM, R79 was in bed. V9 (Certified Nurse Assistant/CNA) was assisting R79 with his meal. V9 was standing over R79 and assisting him with his meal.R79's care plan reviewed on 8/07/2025, said R79 was cognitively impaired and required physical staff assistance with eating.On 8/07/2025 at 1:15 PM, V1 (Administrator) said residents with impaired cognition who require assistance with feeding should be treated with dignity. V1 said staff should not stand over a resident or mix pureed food items together when assisting a resident with feeding. The facility's policy titled Resident Dignity dated 3/26/2025, said Purpose: To ensure that residents are cared for in a manner that promotes and enhances quality of life, dignity, and respect.Staff members shall strive to promote resident dignity and to create a positive and enjoyable experience during mealtimes.

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) cares for residents who require assistance with their ADLs.This applies to 2 out of 2 residents (R5 and R64) reviewed ADLs in a sample of 25.The findings include:Findings include: 1. On 8/05/2025 at 10:58 AM, R64 was sitting in her wheelchair in the hallway right outside of her room. Her call light was going off. R64 was observed crying. R64, stated, I have to go to the bathroom, but my roommate is in our bathroom. R64 stated she pressed the call light and is waiting for staff to clean her up but she herself has been waiting a long time to be taken to the bathroom. R64 stated It's been a while I really have to go .I can't wait any longer .someone came and then left .I think I'm going in my pants. At 11:35 AM, R64 was in the day room. Her hair was greasy and not combed. She had hair strands above her lip. R64 said she was blind and wanted the whiskers above her lip shaved. R64 stated staff didn't comb her hair today and staff didn't brush her teeth either when they got her dressed. On 8/06/2025 at 11:26 AM, V2 (DON—Director of Nursing) stated CNAs (Certified Nursing Assistants) are supposed to shave residents. V2 said, During morning care, they will see if they need to be shaved. They also can offer shaving during shower days. V2 stated CNAs should help residents brush their teeth if they need it. V2 stated if a resident's roommate is using the bathroom, then staff should bring the resident to the shower room to use the bathroom in there. V2 stated she does not have a policy on ADL's (Activities of Daily Living). Facility's job description for CNA's (12/2016) shows: Essential job duties:--Assist residents with daily dental and mouth care (i.e., brushing teeth. ). Assist residents with hair care functions (i.e., combing, brushing, shampooing, etc.). Keep hair on female residents clean shaven (i.e., facial hair). R64's face sheet shows the following diagnoses: transient cerebral ischemic attack, unspecified, visuospatial deficit and spatial neglect following cerebral infarction, other abnormalities of gait and mobility, other lack of coordination. R64's most recent MDS (Minimum Data Set) showed for oral hygiene, R64 needs partial assistance. For toileting hygiene, she is dependent. R64 is frequently incontinent of urine and occasionally incontinent of bowel. R64's care plan (6/18/25) shows she has an ADL self-care performance deficit related to weakness, impaired vision and expressive aphasia, secondary to TIA (Transient Ischemic Attack). Intervention: The resident requires physical assistance by staff with personal hygiene and oral care. The resident requires physical assistance by staff for toileting. R64 has bowel and bladder incontinence related to impaired mobility, weakness secondary to TIA and diagnoses of diabetes mellitus and history of CVA (Cerebrovascular Accident). Intervention: Toilet/Check R64 for incontinence every 2 to 3 hours and PRN (As Needed). 2. On 8/05/2025 at 11:25 AM, R5 was seated in the dining room. Her hair appeared greasy and uncombed, and she had noticeable long, thick facial hair on her upper lip. R5 reported that she has requested assistance from staff on multiple occasions for facial hair removal, stating, staff keep saying they will, but never get around to it. R5 said she is unable to manage facial hair removal independently. R5's face sheet lists a diagnosis of need for assistance with personal care, along with a medical history including hypertensive heart disease, diabetes mellitus, generalized muscle weakness, cognitive communication deficit, and anemia. R5's 7/2/2025 Minimum Data Set (MDS) showed she requires staff assistance with self-care tasks. R5's 5/16/25 care plan identified a self-care performance deficit related to impaired mobility. Care /plan interventions direct staff to provide physical assistance with ADLs, including personal hygiene and bathing. Review of R5's Electronic Medical Record (EMR) showed no documented refusals of care or combative behaviors. On 8/06/2025 at 12:43 PM, V2 (Director of Nursing) stated the facility does not have a formal policy regarding ADL provision, adding staff are expected to provide ADL assistance in accordance with each resident's individual care plan.

Based on observation, interview, and record review, the facility failed to apply left and right palm protectors as ordered by physician.This applies to 1 resident (R76) reviewed for range of motion and contractures in a sample of 25.The findings include:On 8/6/25 at 11:41 AM R76 was observed sitting in large activity room with no palm protector on her right hand. Her right hand was closed with fingers extended against palm. On 8/6/25 at 11:46 AM, V8 (LPN/Licensed Practical Nurse) was asked if R76 had an order for palm protectors. V8 said he was not sure and V7 (RN/Registered Nurse) was R76's nurse. On 8/6/25 at 11:49 AM V7 was observed removing R76 from the dining room. V7 (RN) said the CNA (Certified Nurse Assistant) forgot to put R76's palm protectors on this morning. On 8/6/25 at 11:58 AM, V7 wheeled R76 back into dining room for lunch and pointed out to surveyor that she put both R76's left and right palm protector on. Both R76's left and right palm protectors remained on throughout lunch service. On 8/6/25 at 2:19 PM, V12 (CNA) said she was taking care of R76, and it was her responsibility to put her palm protectors on and off, but she forgot. V12 said palm protectors are important because they help prevent worsening contractures and if they are not applied and taken off as ordered. R76's contractures can get worse and R76 can get wounds on her palms from her fingernails. On 8/6/25 at 2:09 PM, V11 (Restorative Aide) said it is her responsibility to put on and take off R76's palm protectors, but she forgot. V11 said R76 is supposed to have the left palm protector put on after she finished breakfast, and the right palm protector does not get put on until later in the day. V11 said R76 is supposed to have both palm protectors off during meals. V11 said it is important to apply and remove palm protectors as ordered because otherwise the contractures can get worse, and application of the palm protectors can become painful for the resident.R76's POS (Physician Order Sheet) shows orders dated 5/30/25:Left Palm protector ON at bedtime and REMOVE in the morning. Right palm protector ON at all times; remove during meals, personal hygiene, and showers. R76's MDS (Minimum Data Set) dated 5/28/25 shows her decision making is severely impaired and she has impairments to both upper extremities. R76's Care Plan last revised 3/11/24 shows she has an ADL (Activities of Daily Living) self-care performance deficit related to impaired cognition and mobility secondary to diagnoses of dementia, stroke, contracture, and possible pain to hands/fingers. Interventions last revised on 1/25/25 include Nursing/Restorative: Splint/Brace Program: Apply right palm protector on at all times, remove during meals, personal hygiene, and showers. Apply left palm protector on at bedtime and off in the morning.On 8/7/25 at 1:36 PM, V2 (DON/Director of Nursing) said the responsibility of putting on and taking off palm protectors falls more on the CNA than the restorative aide, but the physician's order needs to be followed.The facility's undated policy titled, Orthosis states, Purpose: It is the policy of this facility to provide orthosis (such as brace or splints) to all residents who require them. It is overseen by Restorative Nursing.Procedures: Training is provided to all nurses and nursing assistants to assure that the orthoses are being applied as ordered.

Based on observation, interview, and record review, the facility failed to provide catheter care in a manner to prevent urinary tract infections for a resident with an indwelling urinary catheter. This applies to 1 resident (R8) reviewed for urinary catheters in a sample of 25.The findings include:R8's Face Sheet shows the following diagnoses: flaccid neuropathic bladder, personal history of urinary tract infections, retention of urine, and dementia. R8's POS (Physician Order Sheet) showed a 3/21/2024 order of catheter care (clean catheter with soap and water. Start at entry site. Clean catheter every incontinence episode).On 8/6/25 at 12:24 PM, R8 was in her wheelchair in the dining room. R8's urinary catheter drainage bag was in a privacy bag under her wheelchair. The privacy bag was dragging on the floor and had a dried-up white stain on it across the entire width of the bag, about halfway up the bag. On 8/7/25 at 9:50 AM, R8's catheter care was performed by V13 (CNA/Certified Nurse Assistant). V13 emptied R8's drainage bag. R8's urinary catheter privacy bag was attached to her bed and had the same dried white splatter stains as the privacy bag on the wheelchair did that were noted the day before. V13 provided perineal care for R8. V13 wet a towel with water only and wiped R8's left and right groin front to back and left and right inner labia front to back. V13 did not clean urinary catheter tubing. V13 then turned R8 to her side and cleaned her buttocks and a small bowel movement smear was seen. V13 then placed a clean incontinence brief on R8 with the same soiled gloves she provided perineal care with. On 8/7/25 at 12:19, R8 was observed in the dining room in her wheelchair with the urinary catheter drainage bag in the same soiled privacy bag with the white horizontal stain.On 8/7/25 at 12:47 PM, V13 (CNA) said catheter care should be done if a resident has a bowel movement. V13 said she does catheter care with a towel with hot water. V13 said she did not use soap when she provided perineal care for R8. On 8/7/25 at 1:36 PM, V2 (DON/Director of Nursing) said V2 the CNA who provides perineal care on a resident after a bowel movement, should also be cleaning the urinary catheter tubing. On 8/7/25 at 1:44 PM, V4 (ADON/Assistant Director of Nursing) said soap and water are supposed to be used to clean the resident during catheter care because that is the facility policy. V4 said the catheter tubing should be cleaned in one motion, wiping away from the resident down the length of the flexible tubing. V4 said if the privacy bag is soiled with white residue, it should be changed because that means the bag is contaminated. V4 said the privacy bag should never be touching the floor because that is an infection control concern and poses a risk of cross contamination.R8's Care Plan last revised 12/18/24 states resident has an indwelling urinary catheter in place secondary to hypotonic bladder and she takes Methenamine Hippurate due to recurrent urinary tract infections. Interventions include keep catheter tubing and drainage bag off the floor at all times and perform careful perineal care and keep catheter free from crusting, etc. Care Plan last revised on 7/7/25 states resident was taking oral antibiotic on 7/3/25 for 7 days related to urinary tract infection (UTI) and remains at risk for UTIs related to the use of the indwelling urinary catheter. Interventions include check resident at least every 2-3 hours for incontinence. Wash, rinse, and dry soiled areas.The facility's policy titled, Catheterization last reviewed 3/31/25 states, Policy Statement: Use of indwelling catheters (Foley) is discouraged unless required to monitor output in seriously ill residents. Procedure:2. General Guidelines: e. Never let any part of the drainage system touch the floor.

Based on observation, interview, and record review the facility failed to aspirate gastric contents to check the placement of a resident's gastrostomy tube (GT). This applies to 1 of 1 (R3) residents reviewed for GT care in a sample of 25.Findings include:On 8/5/25 at 1:40 PM, V17 RN (Registered Nurse) used a large syringe and pushed 10-15 ml of air through R3's GT and auscultated her abdomen to check the placement of the tubing.On 8/6/25 at 11:23 AM, V10 (RN) used a large syringe and pushed 15 ml air into the GT and auscultated R3's abdomen with a stethoscope. V10 stated she heard the gurgling sound of the air being pushed in. V10 then pushed 160 ml water with the syringe into the GT as per orders. V10 stated the facility had taught them to check for GT placement in this manner.R3's 4/24/2025 care plan showed, check for tube placement and gastric contents prior to beginning feeding. R3's physician orders showed a 4/6/25 order to check G-tube placement before feeding and medication administration every shift.On 8/7/25 at 12:30 PM V2 (DON-Director of Nursing) stated facility has not revised their policy since 2013. V2 stated, facility will investigate it and revise their policy.Facility policy on enteral feeding was dated 2/9/13. The policy was reviewed on 4/4/25 yet was not revised to the current standard of practice.

Based on observation, interview and record review the facility failed to administer medications as ordered. There were 30 opportunities with 3 errors resulting in a 10% error rate. This applies to 1 of 5 residents (R17) observed in medication pass.The findings include:Findings include:On 08/06/2025 at 9:20 AM, V10 (Registered Nurse/RN) prepared R17's 8:00 AM scheduled medications. R17's prepared medications did not include tablets of spironolactone 25 mg (milligram) tablet, vitamin B12 1000 mcg (microgram) tablet, or the furosemide 40 mg tablet. V10 said she forgot to include the medications as ordered. On 08/07/2025 11:50 AM, V4 (Assistant Director of Nursing) said nurses received medication administration training routinely to ensure safe administration of medications. V4 said V10 should have checked R17's EMAR (Electronic Medication Administration Record) to ensure all scheduled medications were prepared and administered as ordered. On 08/07/2025 11:25 AM, V2 (Director of Nursing/DON) said nurses were expected to check medication rights prior to administering medications to ensure resident safety. R17's Order Summary Report showed orders for vitamin B12 1000 mcg 1 tablet, furosemide 40 mg 1 tablet, and spironolactone 25 mg 1 tablet to be administered at 8:00 AM daily. The facility's policy titled Administering Oral Medications showed The purpose of this procedure is to provide guidelines for the safe administration of oral medications.Check the label on the medication and confirm the medication name and dose with MAR.

Based on the interviews and record reviews, the facility failed to provide the required staff assistance for bed mobility and ambulation for dependent residents as per the MDS (Minimum Data Set) assessment. This applies to 2 of the 3 residents (R1 and R2) reviewed for resident falls and injuries in a sample of 3. The Findings Include: 1. R1 is an [AGE] year-old female admitted on the dementia floor on 8/18/22 with an admitting diagnosis, including vascular dementia and multiple sclerosis. On 12/31/24 at 9:25 AM, R1 was observed in her bed and was unable to move her lower extremities except wiggling toes. On 12/31/24 at 9:25 AM, R1 stated, I had a fall to the right side of my bed. My leg didn't move the way I want to. I don't remember what my CNA was doing at that time. A review of R1's fall risk assessment dated [DATE] document that R1 is high risk for fall. A review of the R1's ADL (Activities of Daily Living) care plan document interventions including the resident requires physical assistance by staff to turn and reposition when in bed. A review of the MDS (Minimum Data Set) dated 11/6/24 document that R1 is dependent on bed mobility requiring two or more helpers to complete the activity. A review of the reportable document that the facility reported a fall for R1 on 11/14/24 while V3 (Certified Nursing Assistant/CNA) was providing care to R1. On 12/31/24 at 10:10 AM, V3 stated, I was on orientation when I provided care to R1, and R1 had a fall on 11/14/24. On 11/14/24, I entered R1's room to prepare her for mechanical lift transfer. I was alone in R1's room. I put clothing on her and the sling under her for mechanical lift transfer. I was on her left side and turned her to the right side to tuck in the sling. R1's leg was shaky and twitchy, and her leg slid over the side of the bed, and R1 slid down on her buttocks. I was supposed to work with V7 (CNA), but V7 was out with another resident. On 12/31/24 at 11:20 AM, V7 stated, I am not sure why V3 turned R1 by herself. I told her to wait for me, but she was overconfident that she could do it. On 12/31/24 at 11:10 AM, V2 (Director of Nursing/DON) stated, During the two weeks of orientation, the new CNA (V3) works with a mentor to practice skills, learn processes, and learn the resident's habits. I don't know why V7 (CNA) wasn't there. The orientee (V3) should have worked with her mentor to prevent R1's fall. On 12/31/24 at 10:45 AM, V8 (Restorative Nurse/RN) stated V3 was supposed to work with another staff member during orientation to practice her skills and learn about resident-specific needs. As per our MDS assessment, R1 requires two-person assistance for bed mobility. 2. R2 is an [AGE] year-old female admitted on [DATE] with an admitting diagnosis including vascular dementia, Alzheimer's disease, and psychosis. A review of R2's fall risk assessment dated [DATE] document that R2 is high risk for fall. A review of the MDS (Minimum Data Set) dated 11/14/24 document that R2 requires partial moderate assistance for ambulation. A review of R2's care plan documents R2 was care planned for her limited mobility with interventions: The resident requires physical assistance by staff to walk as necessary. A review of the reportable documents the facility reported a fall for R2 on 12/12/24 with a laceration on her right eyebrow requiring 3 stitches. On 12/31/24 at 10:55 AM, V5 (Social Service Personal) stated, R2 is unsteady when she walks, and she is supposed to be in her wheelchair with supervision as she tends to stand up abruptly. On 12/12/24, I saw R2 in her wheelchair in the activity room when I passed by the activity room. No staff was present in the activity room to supervise residents. When I was about to exit the unit, I saw her standing and coming out of the activity room and taking a few steps. R2 tumbled down face forward and hit the right side of her forehead, causing a laceration that required three stitches. After R2's fall, I was the first to come to the scene; no nurse, nursing assistant, or activity staff were in the activity room to monitor residents. On 12/31/24 at 11:10 AM, V2 stated that someone should supervise dementia residents in the activity room to prevent falls.

Based on interview and record review, the facility failed to document and track HCP (Health Care Providers) covid test results during a covid outbreak in accordance with their policy. This applies to all 102 residents who reside in the facility. The findings include: The form 671 completed on August 12, 2024, showed a facility census of 102. Upon annual survey entrance conference on August 12, 2024, at 9:30 AM, V1 (Administrator) stated there are 16 covid positive residents on the second floor. On August 14, 2024, at 10:17 AM, V3 (IP-Infection Preventionist)) stated R66 tested positive for covid on August 8, 2024, and was tested by a nurse on the second-floor unit due to displaying symptoms of covid. V3 was unable to provide testing results of HCP (Health Care Providers) who were exposed to R66. V3 stated in response to R66 positive test results, all the residents on the second floor were tested for covid, but HCPs tested themselves and V3 did not have any documentation to validate HCP testing. V3 provided a list of staff who had tested positive for covid, titled Staff Syndromic Surveillance for Covid 19, which showed the first staff member tested positive on July 31, 2024, V25 (the Nurse Educator), who potentially interacted with all staff on both the first and second floors, was tested after displaying symptoms of covid. The next staff on the list who tested positive, on August 2, 2024, was V26 (Rehab/Restorative Nurse), who had potential contact with all residents and staff on the first and second floor, also displayed symptoms of covid at the time of testing. On August 4, 2024, the list showed 2 more staff tested positive, V27 (Social Services staff, for the second floor) and V28 (Social Services staff for the first floor) who both displayed symptoms of covid at the time of testing. The Social Services office is adjacent to V25 's office on the first floor. V25 had to walk past the social services office of V27 and V28 to gain access to his office. The list showed on August 6, 2024, 2 more staff tested positive, 1 more Social Services staff and a Nurse who worked the second floor, both who showed symptoms of Covid at the time of testing. V21 (CNA) tested positive for covid on August 11, 2024. The nursing schedule showed V21 worked on the first floor on August 9, 2024, 48 hours prior to becoming symptomatic and testing positive for covid. V22 (CNA) tested positive for covid on August 11, 2024, and the nursing schedule showed V22 had worked on the second floor on August 9, 2024, 48 hours prior to testing positive for covid. The list titled Resident Syndromic Surveillance for Covid-19 showed on August 14, 2024, four additional second floor residents tested positive for covid, for a total of 21 since August 8, 2024. On August 14, 2024, at 1:50 PM, V4 (Culinary Aide) stated she had served meals from the second-floor satellite kitchen, where residents are still eating in the dining room, both today and last week and has not been tested for covid during that time. On August 14, 2024, at 2:00 PM. V5 (Activity Aide) worked on the second floor, stated no one told me what to do regarding covid testing, all I know is if I don't feel good, I should test myself. On August 14, 2024, at 2:50 PM, while working on the second floor, V13 (CNA) stated she has not tested for covid since the outbreak started. On August 14, 2024, at 2:35 PM, while working on the second floor, V10 (CNA) stated he would go to the office for a covid test only before returning to work after being sick. On August 14, 2024, at 2:30 PM, while working on the second floor, V9 (Nurse) stated you test for covid on your own, if you don't feel good at work, test yourself. On August 14, 2024, at 2:40 PM, while working on the second floor, V11 (Nurse regularly scheduled from agency) stated nobody told me about testing for covid, I test myself whenever I want. On August 15, 2024, at 10:02 AM, V2 (Director of Nursing) identified that V25, (Nurse Educator) had contact with staff on both the first and second floors. V2 stated V26 (Restorative Nurse) had contact with both residents and staff on both the first and second floors. V2 stated V27 is the social services staff for the second-floor residents and V28 is the social services staff for the first-floor residents. V2 stated there were no new covid positive residents identified today on August 15, 2024. On August 14, 2024, at 1:31 PM, V2 (DON) stated she does not have tracking of staff covid testing to validate staff have tested after being exposed to covid 19. V2 stated she thought V3 (IP-Infection Preventionist) did that tracking. On August 14, 2024, at 10:17 AM, V3 (IP) stated it was too much to track the testing of staff, so she just tracked the residents and stated staff just test themselves when they have symptoms. V3 did not provide HCP (Health Care Provider) covid test results for staff who had potential exposure to V25, V26, V27, V28, within 24 hours of their positive covid test. V3 did not provide HCP covid outbreak testing results for the second-floor staff at the time of the outbreak testing for second floor residents on August 9, 2024. The Facility's policy titled Covid 19 testing/mitigation dated March 20, 2024, Purpose .Testing is a valuable tool to help control the spread of Covid-19 through early identification of positive cases and is part of the overall Covid -19 plan .Testing plan and response .b. If one positive staff member or resident is identified the unit is considered to be in outbreak. All staff and residents in the affected unit and potentially exposed should be tested immediately (no sooner than 24 hours after exposure) and then .all exposed staff and residents that previously tested negative should be retested within 48 hours after the initial negative test, and again 48 hours after the second negative test. After the initial testing series testing should continue every 48-72 hours until no new positive cases have been found for 14 days .The definition of a higher risk exposure: An exposure to a staff member to a person with COVID in any of the following circumstances .1. Staff member not wearing either a face mask or respirator .and Implement Source Control Measures .The SARS-Cov-2 virus can spread from individuals who do not have symptoms.

Based on observation, interview and record review, the facility failed to serve portions of Garlic Herb Roasted Pork Tenderloin to residents receiving mechanically altered diets as planned on the approved facility menu. This applies to 5 of 5 residents (R1, R41, R52, R62, and R87) reviewed for portion sizes. The findings include: Resident Summary Report, printed August 12, 2024, shows R1, R41, R52, R62, and R87 were to all be served ground meats at meals. Spread sheet, dated August 12, 2024, shows residents with regular diets were to be served 4 ounces of Garlic Herb Pork Tenderloin and residents receiving Ground Meat or Mechanical Soft diets were to be served ground garlic herb pork using a 4 oz spoodle spoon. On August 12, 2024 at 12:07 PM on the first floor during lunch service, V17 (Food Service Worker) stated he was using a three ounce scoop to serve portions of ground Garlic Herb Roasted Pork Tenderloin to residents. V17 stated he was concerned he did not have enough ground pork product for lunch service to residents, so he changed the serving size from 4 ounces to 3 ounces to have enough ground pork for residents. V17 portioned out one scoop of the ground pork to the following residents on their lunch plates: R1, R41, R52, R62 and R87. On August 12, 2024 at 2:12 PM, V18 (Assistant Food Service Manager) weighed one portion of ground pork which weighed 3.4 ounces total. On August 12, 2024 at 12:21 PM, V18 (Assistant Food Service Manager) stated the ground pork was planned on the menu to have been served with a 4 ounce volume scoop. On August 13, 2024 at 1:25 PM, V19 (Dietitian) stated the portions of ground pork served on August 12, 2024 should have weighed a total of 4 ounces which was the same serving weight planned to be served the residents receiving regular diets in the facility. V19 stated the kitchen utilized standard guidelines to prepare ground meats for ground diets but there were no standardized recipes in use for the menu items. On August 12, 2024 at 12:54 PM, V16 (Executive Chef) stated the food service did not have standardized recipes for the preparation of ground diet items. Facility Garlic Herb Roasted Pork Tenderloin recipe, revised May 15, 2024, shows the recipe standard portion was 4 ounces. Facility policy and procedure Modified Texture Foods, revised January 2024, shows The regular diet menu item will be used to prepare all modified-textured menu items unless otherwise indicated by the menu diet spreads. In the instance a substitute is needed, a comparable menu item will be provided Portions of modified-texture menu items will be provided in the proper amounts according to menu diet spreads Facility Dining Inservice Education Portion Size and Proper Weights, dated April 14, 2023, shows, The diet spreadsheet indicates portion sizes and its corresponding utensil for adequate volume portioning. The spoodles are generally used as a volume portion, with each size representing the volume of the product. We need to ensure that if using a spoodle, the weight of the product matches what is required on the diet spreadsheet Facility document Handhelds, undated, shows handheld conversions for single proteins were to be served as slider sandwiches portioned into a minimum of three individuals portions prior to preparation. Facility diet spreadsheet, dated August 12, 2024, shows no diet spread for finger foods or small portions diets.

Based on observation, interview, and record review, the facility failed to offer/provide residents food substitutions equivalent in nutritive value to the originally planned/served menu items. This applies to 4 of 4 residents (R54, R57, R83, and R96) reviewed for food substitutions. The findings include: On August 12, 2024, V17 (Food Service Worker) plated the following food items on plates for residents during meal service: 1. R54 received a half sandwich (1 piece of bread cut in half) with no cheese and 2 half slices of thinly sliced ham between the half pieces of bread. R54's tray ticket showed R54 was to receive a regular/general diet with no further modifications. 2. R96 received a half sandwich (1 piece of bread cut in half) with no cheese and 2 half slices of thinly sliced ham between the half pieces of bread. R96's tray ticket showed R96 was to receive a regular/general diet with finger foods and small portions. 3. R57 received a half sandwich (1 piece of bread cut in half) with a very thin layer of peanut butter and jelly between the half pieces of bread. R57's lunch tray ticket, dated August 12, 2024, shows R57 was to receive a regular/general diet with a finger food modification. 4. R83 received a half sandwich (1 piece of bread cut in half) with a very thin layer of peanut butter and jelly between the half pieces of bread. R83's tray ticket, dated August 12, 2024, showed R83 was to receive a regular/general diet with finger foods and small portions. On August 12, 2024 at 12:27 PM, V18 (Assistant Food Service Manager) stated the staff used one individual portion cup of peanut butter to prepare the half peanut butter/jelly sandwiches served during the lunch. V18 also stated the staff used one piece of sliced ham which they cut in half to prepare the half ham sandwiches served during the lunch. V18 stated he believed the one slice of ham from the half sandwich weighed less one once of meat. On August 12, 2024 at 12:51 PM, V15 (Food Service Director) examined the half ham sandwiches and half peanut butter jelly sandwiches served to residents as substitutions and stated the ham on the half sandwiches appeared to weigh less than an ounce of meat and the peanut butter/jelly sandwiches appeared to be made with only one individual portion cup of peanut butter. V15 stated unless the residents required small portions the sandwich substitutions should contain protein equivalent to the menu items of the regular entrees served at the meal. On August 12, 2024 at 2:12 PM, V18 (Assistant Food Service Manager) weighed the slice of ham served on one of the half sandwiches during lunch which weighed 0.7 ounces total. Spread sheet, dated August 12, 2024, shows regular portions of the garlic herb pork served at lunch were to be served in 4 ounce weight portions. On August 12, 2024 at 12:54 PM, V16 (Executive Chef) stated the facility food service did not have a spreadsheet diet for finger foods. On August 13, 2024, V19 (Dietitian) stated the menu items served to residents during August 12, 2024 lunch service should have contained three total ounces of protein. V19 stated the substitutions served for the lunch menu entrees should have contained equal protein to the planned menu items served. V19 stated residents requiring finger foods should have received the regular menu items as planned but placed between two slices of bread or on a hot dog bun and served to the residents. Facility policy and procedure Resident Food Preferences, Substitutes, and Portion Sizes, revised September 4, 2023, shows, The dietitian can determine if small or large portions are necessary. Small portions are 2 ounces of protein Sliced ham product detail provided by facility food service shows each slice of ham utilized on August 12, 2024 weighed 0.5 ounces per slice. Peanut Butter plastic portion control cup product detail provided by facility food service shows each portion cup of peanut butter contained 0.75 ounces of peanut butter. Facility policy and procedure Modified Texture Foods, revised January 2024, shows The regular diet menu item will be used to prepare all modified-textured menu items unless otherwise indicated by the menu diet spreads. In the instance a substitute is needed, a comparable menu item will be provided Facility Dining Inservice Education Portion Size and Proper Weights, dated April 14, 2023, shows, The diet spreadsheet indicates portion sizes and its corresponding utensil for adequate volume portioning. The spoodles are generally used as a volume portion, with each size representing the volume of the product. We need to ensure that if using a spoodle, the weight of the product matches what is required on the diet spreadsheet Facility Ham Sandwich Recipe, printed August 14, 2024, shows 2 ounces of ham was to be placed on 2 slices of bread for each whole sandwich. Facility Peanut Butter and Jelly Sandwich recipe, printed August 14,2024, shows 1 ounce of peanut butter (2 Tablespoons) was to be placed on 2 slices of bread for each whole sandwich.

Based on observation, interview, and record review the facility failed to follow a resident's plan of care to prevent and treat the development of facility-acquired pressure wounds for a resident at high risk for pressure wounds. This applies to 1 of 4 residents (R25) reviewed for facility-acquired pressure injuries in the sample 21. The findings include: Face sheet, dated August 14, 2024, shows R25's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting her right non-dominant side, congestive heart failure, vascular dementia, sacroiliitis, spinal stenosis, muscle weakness, venous insufficiency, and need for assistance with personal care. R25's historical skin integrity care plans showed R25 was identified to have a potential for skin impairment related to decreased mobility and incontinence on September 16, 2024. On July 16, 2024, R25 was identified to have developed a new facility-acquired a stage 3 pressure wound on her sacrum related to decreased mobility and incontinence. Intervention, initiated July 16, 2024 and revised on August 12, 2024, shows, Encourage the use of pressure-relieving devices such as specialized mattresses R25's care plan, reviewed August 14, 2024, showed R25 developed a new facility-acquired stage 2 pressure wound on her sacrum related to decreased mobility and incontinence (initiated August 12, 2024). Interventions, implemented August 12, 2024, included encourage the use of pressure-relieving devices such as specialized mattresses, cushions, heel troughs, and other devices and nursing staff to provide assistance to turn/reposition at least every two hours, more often as needed or requested. R25's care plan showed R25 had periods of bowel and bladder incontinence related to impaired mobility requiring staff to check R25 for the need to toilet or for incontinence every 2 to 3 hours. The care plan showed R25 required a mechanical lift device for transfers and the physical assistance of staff to turn and reposition her in bed. On August 14, 2024 at 11:04 PM, R25 was lying asleep in bed with her head of bed slightly elevated. R25 did not have a low air loss pressure relieving mattress in place. On August 14, 2024 at 11:12 AM, V23 (CNA-Certified Nursing Assistant) observed R25 lying in her bed and stated R25 did not have a low air loss mattress in place. On August 14, 2024 at 11:27 AM, V24 (Licensed Practical Nurse) stated R25 had no low air loss mattress on her bed and stated she had no physician order for a low air loss mattress for her pressure injury. On August 14, 2024 at 1:22 PM with V2 (Director of Nursing - DON), V20 (Registered Nurse / Wound Care) stated R25's previously healed pressure wound reopened on August 12, 2024. V20 stated R25's original wound was a pressure wound and stated R25 may have developed the wound because maybe she was on the back too much. When asked why R25 did not have a low air loss pressure relieving mattress V20 stated, I missed it. V2 (DON) stated R25 should have had a low air loss pressure reliving mattress put in place when she developed her initial pressure wounds on July 15, 2024 and R25 should have a pressure relieving low air loss mattress in place since the development of the re-opened pressure wound on August 12, 2024. Nursing progress note, dated July 15, 2024, shows R25 was identified as having an open area/wound on her sacral area, measuring 0.5 cm (Centimeters) in diameter, and requiring foam dressing treatment daily. Initial Skin Observation Tool, dated July 16, 2024, shows R25 was identified to have two newly identified facility-acquired pressure wounds: 1. one pressure wound / suspected deep tissue injury on her right sacrum (0.3 cm x 0.4 cm x 0.0); and 2. second pressure wound on her left sacrum (0.5 cm x 0.5 cm x 0.1 cm) which was identified as a Stage 3 wound. Weekly Wound Assessment, dated July 24, 2024, shows R25's right sacral wound was determined to be healed. The Weekly Wound Assessment, dated July 24, 2024 and intending to identify R25's left sacral pressure wound, shows R25's pressure wound was improving. Weekly Wound Assessment, dated July 31, 2024, shows R25's left sacral pressure wound was healed. Initial Skin Observation Tool, dated August 12, 2024, shows R25 was identified to have a newly developed facility-acquired pressure wound. Facility Policy and Procedure Pressure Area Prevention and Treatment, revised July 8, 2015, shows, Stage I Pressure Areas: .Interventions: 3. Implement pressure relieving devices (water mattress, wheelchair cushions, etc.) . The policy/procedure shows interventions for pressure wounds stages 2, 3, and 4 were expected to include all Stage I interventions.

Based on observation, interview, and record review the facility failed to follow their policy to administer medications as ordered by the physician. There were 33 opportunities with 3 medication administration errors resulting in a 9.09% medication error rate. This applies to 2 of 4 residents (R65, R73) reviewed for medication administration in the sample of 21. The findings include: 1. On August 13, 2024, at 8:59 AM, V14 (MDS/Minimum Data Set Coordinator) prepared R65's morning medications, including one tablet folic acid 800 mcg (micrograms), one tablet gabapentin 300 mg (milligrams), one tablet losartan/hydrochlorothiazide 50/12.5 mg, one tablet metoprolol tartrate 50 mg, one tablet potassium chloride 20 mEq (milliequivalents), one tablet PreserVision eye vitamin, one tablet vitamin B12 500 mcg, and one tablet vitamin D3 50 mcg for a total of eight tablets. V14 also prepared one capful of polyethylene glycol mixed in a cup of water. On August 13, 2024, at 9:08 AM, V14 said she was ready to administer R65's medications and counted nine tablets to be administered to R65. V14 was stopped by the surveyor and asked to compare R65's medications with the medications in the cup. V14 said there was an extra pill in the medication cup which was not one of R65's medications. The pill in the cup was a white oblong pill marked with HH on one side and 327 on the other side. Medicine.com identifies the medication as irbesartan 75 mg (blood pressure medication). R65's Order Summary Report dated August 13, 2024, at 12:09 PM, does not show a physician order for irbesartan. On August 13, 2024, at 9:15 AM, V14 assisted R65 with one sip of the polyethylene glycol mixture. At 9:16 AM, V14 walked away from R65 and threw the polyethylene glycol mixture in the garbage. R65 had not refused the medication. On August 14, 2024, at 2:51 PM, V2 (DON/Director of Nursing) said R65 should not receive medications not prescribed to R65. V2 continued to say V14 should have administered R65's complete dose of polyethylene glycol since R65 did not refuse the medication. 2. On August 14, 2024, at 9:17 AM, V11 (Agency RN/Registered Nurse) prepared R73's morning medications, including one tablet empagliflozin 10 mg. R73's Order Summary Report dated August 14, 2024, showed an order dated March 2, 2024, for empagliflozin oral tablet 10 mg, give one tablet by mouth one time a day related to type 2 diabetes mellitus with hyperglycemia, before breakfast. On August 14, 2024, at 10:24 AM, V11 said R73's medications were administered after R73 ate breakfast. On August 14, 2024, at 2:51 PM, V2 (DON) said R73's empagliflozin should have been given before breakfast, as ordered. The facility's policy titled Medication Administration dated April 10, 2024, showed, Policy Statement: Unless otherwise specified by the physician, medications will be administered within sixty minutes before or after dosing schedule, except before or after meals. Purpose: 1. To provide uniform and efficient practices in safe medication administration. 2. To optimize therapeutic dosage levels. Procedure: 1. Licensed nursing professionals administer medications according to times of administration . 3. Medications ordered to be fine before meals are administered approximately thirty minutes before meal time .

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a manner to prevent cross-contamination for 4 of 4 residents (R15, R35, R83 and R88) reviewed for pureed foods in the sample of 21, and 4 residents outside the sample (R5, R54, R74, and R90). The findings include: On 9/06/23 at 9:02 AM, V10 (puree cook) was making the pureed foods for the lunch meal. V10 was putting 14 chicken breasts in the food processor to puree them for the lunch meal. While picking up some of the chicken breasts, 2 of the chicken breasts touched V10's visibly soiled apron. V10 put the chicken breasts that touched her soiled apron into the food processor with the other chicken breasts, added 2 cups of chicken broth, and turned on the food processor to puree the chicken. V10 added thickener to the food processor and turned it back on. V10 took the lid back off the food processor and put her gloved hand, (that she had used to move the pan the chicken was in, turn the food processor on and off several times, grab the handle of the pan containing chicken broth, and grab the container and the scoop to add thickener) inside the food processor. When V10 brought her hand out, there was pureed chicken on 2 fingers of her gloved hand. V10 turned the food processor on again and finished pureeing the chicken for the lunch meal. On 9/6/23 at 9:42 AM, V11 (Director of Culinary Services) said she was going to in-service V10 on the proper handling of food, using utensils and not letting her apron touch the foods. V11 said V10 should have used utensils to pick up the chicken and check the pureed consistency, and not let the food touch her apron/clothing, to prevent cross-contamination and food borne illness. The facility's document titled Diet Order Tally Report, printed on 9/7/23, showed 8 residents (R15, R35, R83, R88, R5, R54, R74 and R90) received pureed diets. The facility's policy and procedure titled Food Handling Guidelines, with a revision date of 4/12/19, showed Prevention of Food Infection .Minimize hand contact with food by the use of utensils and disposable gloves. The facility's document titled Culinary In-service: Proper Food Handling-Cooks, dated 9/6/23 showed Proper Food Handling with Utensils-In-Service Training for Cooks .Proper food handling minimizes the risk of contamination and foodborne illnesses, safeguarding the health of our residents .Cross-contamination: Prevent cross-contamination by using separate utensils for each food item. This ensures the safety of our residents with dietary restrictions or allergies .Glove Usage: Disposable gloves should be worn when handling ready-to-eat foods but remember that gloves are not a substitute for proper handwashing. Change gloves whenever they become contaminated, torn, or when switching tasks, such as handling raw and cooked foods or touching non-food items, such as your apron, hair, and face. Use of Utensils: Always use utensils like spatulas, tongs, or serving spoons to handle food. Avoid touching food directly with your hands or gloved hands .

Based on observation, interview, and record review the facility failed to ensure a residents indwelling urinary catheter drainage bag was not on the floor for 1 of 2 residents (R50) reviewed for catheters in the sample of 21. The findings include: On 9/5/23 at 1:44 PM, R50 was lying on his back in bed with his bed in the lowest position. R50 had an indwelling urinary catheter, and the drainage bag was attached to the frame of his bed under his mattress The drainage bag was folded over under the bed and partially on the floor. On 9/5/23 at 1:48 PM, V4 RN (Registered Nurse) went into R50's room, looked at his catheter drainage bag, and stated it should not be on the floor because it could become contaminated. On 9/5/23 V2 DON (Director of Nursing) was not available for the survey. V2 was off for the week and could not be interviewed for privacy/dignity concerns. R5 RN (Registered Nurse) was available in the DON's absence. On 9/7/23 at 9:35 AM, V5 RN (Infection Control Preventionist) stated indwelling urinary catheter drainage bags should not touch the floor for infection control reasons. V5 stated the floor is dirty and that gets the bag dirty. Germs climb up the catheter and residents can get urinary tract infections. V5 stated the whole catheter system needs to be kept clean. The Face Sheet dated 9/6/23 for R50 showed diagnoses including right sided hemiplegia, cerebral infarction, dysphagia, speech and language deficits following cerebral infarction, benign prostatic hyperplasia, obstructive and reflux uropathy, retention of urine, urinary tract infection, klebsiella pneumoniae, metabolic encephalopathy, hypertension, hyperlipidemia, seizures, lack of coordination, anemia, polyarthritis, muscle weakness, vertigo, cerebral aneurysm, transient ischemic attack, acute kidney failure, and adjustment disorder. The Physician Orders for September 2023 for R50 showed: Maintain Enhanced Barrier Precautions for indwelling medical device usage (catheter). Indwelling catheter care every shift for urinary retention. The Care Plan initiated 7/19/23 for R50 showed, I have an indwelling catheter related to urinary retention secondary to benign prostatic hyperplasia with urinary obstruction and cerebral vascular accident. Anchor catheter to prevent excessive tension on the catheter. Change catheter every month and as needed; 16 French catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Check tubing for kinks each shift. Discontinue catheter as soon as clinically warranted. Exercise caution with mobility and positioning to avoid accidental removal. Monitor for evidence of catheter blockage; flush catheter per physician order; change catheter as indicated. Monitor for evidence of catheter leakage; flush catheter per physician order; change as indicated; avoid using larger catheter size unless medically justified. Position the drainage system (tubing, collection bag) to facilitate flow of urine. Use collection bag cover while in chair. R50's care plan did not show any intervention in pace for keeping the drainage bag off the floor. The facility's Catheterization policy (3/16/23) showed, Infection/Injury Control: Keep catheter tubing and drainage bag off the floor at all times (use privacy bag for drainage bag when resident is up in wheelchair).

Based on observation, interview, and record review the facility failed to provide a safe transfer for 1 of 1 resident (R107) reviewed for safety and supervision in the sample of 21. The findings include: On 9/5/23 at 10:56 AM, V3 CNA (Certified Nursing Assistant) took R107 in her wheelchair to her bathroom door. V3 had a gait belt around her own waist but did not place the gait belt on R107. V3 assisted R107 to standing by pulling on the back of the resident's pants in an upward motion. V3 told R107 to hold onto the grab bar in the bathroom. R107 was having trouble turning in the bathroom and V3 hooked her arm under R107's arm to turn her. V3 pulled R107's pants and incontinence brief down that was soiled with diarrhea. R107 then plopped down onto the toilet seat. After R107 was toileted, V3 hooked her arm under the resident's arm to have her stand and hold onto the grab bar. V3 then cleaned the resident's buttocks, pulled up a clean incontinence brief and her pants. V3 turned R107 and had her sit in her wheelchair. On 9/5/23 at 11:08 AM, V3 CNA stated R107 is weak sometimes. V3 stated sometimes R107 stands well and sometimes she doesn't. V3 stated she knows R107 and how she stands so she doesn't use the gait belt on her. On 9/6/23 at 12:09 PM, V4 RN (Registered Nurse) stated gait belts are to be used during transfers, ambulation and when a resident falls. V4 stated staff should use a gait belt when transferring a resident from the wheelchair to toilet and from the toilet to a wheelchair because it is still a transfer. V4 stated R107 was at high risk for falling, is shaky, and needs to have a gait belt on when she is being transferred. On 9/7/23 at 9:29 AM, V6 PT (Physical Therapist) stated gait belts are to be used anytime a resident is transferred or walked. V6 stated a gait belt is helpful to prevent falls and is a safety tool for staff to use. If a resident loses their balance the staff can hold onto the belt. V6 stated R107 is a fall risk and needs a gait belt on for all transfers. The Care Plan dated 8/11/23 for R107 showed the following: I have an ADL (activity of daily living) self-care performance deficit related to activity intolerance, confusion due to dementia and limited mobility due to osteoporosis and spinal stenosis of the lumbar region. Personal hygiene - R107 requires physical assistance by staff with personal hygiene and oral care. Toilet use - R107 requires physical assistance by staff for toileting. Transfer - R107 resident requires physical assistance by staff to move between surfaces as necessary; I have limited physical mobility related to weakness. Ambulation - R107 requires physical assistance by staff to walk as necessary. Locomotion - R107 requires physical assistance by staff for locomotion using wheelchair; I am at high risk for falls related to confusion, gait problems, incontinence and unaware of safety needs. Anticipate and meet the resident's needs. Provide a safe environment (even floors; free from spills and/or clutter; adequate, glare-free light; a working and reachable call light; handrails on walls, personal items within reach). The Incident Notes for August 2023 for R107 showed the following: 8/26/23 - Approximately 8:30 AM the nursing student observed R107 sitting on the floor beside her bed with legs extended out. When asked resident what happened, R107 verbalized that she fell while trying to transfer from bed to wheelchair. 8/22/23 - CNA was outside of a resident's room, when she heard something hit the floor and then heard resident scream help. The CNA went to the room and found the resident on the floor, laying on her left side with her head laying on top the leg for the roommate's tray table. 8/14/23 - R107 was noted, by the activity aide, in her room sitting on the floor by the window with her back leaning on the wall and her legs lying straight. R107 said when she was trying to get off from bed her legs got caught on the blanket but blankets are all in her bed. The Minimum Data Set, dated dated dated [DATE] for R107 showed severe cognitive impairment; extensive assistance needed for bed mobility, transfers, dressing, toilet use, and personal hygiene. The Morse Fall Scale dated 8/26/23 for R107 showed she is at high risk for falling. The Face Sheet dated 9/6/23 for R107 showed medical diagnoses including urinary tract infection, extended spectrum beta lactamase resistance, dementia, anemia, hypertension, hyperlipidemia, anxiety disorder, depression, dysphagia, spinal stenosis, venous thrombosis and embolism, atherosclerotic heart disease, and osteoporosis. The facility's Accident & Incident Protocol (3/16/23) showed, Safety belt transfer information - a canvas belt (1/2 inch minimum) 48-54 inches long with safety buckles. It is an assistive device to protect employees and residents from injury. It provides the employee with a device to safely transfer and walk the residents. Place safety belt snugly around residents' waist. Transfer with safety belt: Be certain the belt is properly positioned and secured.

Based on observation, interview, and record review, the facility failed to develop a care plan in a timely manner to address a pressure injury for 1 of 3 residents (R44) reviewed for pressure in the sample of 21. The findings include: On 9/5/23 at 11:22 AM, R44 was sitting in the activity room in her wheelchair. R44 had pressure-relieving boots on both of her feet. R44's Skin/Wound Note dated 5/15/23 showed she had an unstageable DTI (deep tissue injury) to her left heel. The note showed the wound was an intact blister measuring 3.1 cm (centimeters) by 4.6 cm that was dark blue in color. R44's Skin/Wound Note dated 9/1/23 showed R44 still had the pressure injury on that date (over three months later). R44's care plans were reviewed, showing the care plan for her existing pressure injury was initiated on 9/5/23 (the same day the facility's annual survey had begun). A care plan, with a revision date of 7/26/23, was in place showing R44 had the potential for impairment to the integrity of her skin related to incontinence, however, the care plan did not mention her existing pressure injury, or her risk of developing a pressure injury. On 9/07/23 at 12:21 PM, V12 (Wound Nurse) said he just initiated the pressure ulcer care plan for R44 on 9/5/23. V12 said the care plan should be initiated as soon as the problem is identified. V12 said it is important to have the care plan in place, so staff know what the interventions are. The facility's policy and procedure titled Care Planning, with a revision date of 11/19/19, showed the purpose of the policy was to establish a course of action, with input from the resident, resident's family and/or guardian, or other legally authorized representative, the resident's physician, and interdisciplinary team (IDT) that moves a resident toward resident-specific goals .Crafting the how of resident care. The procedure showed a baseline care plan will be established within 48 hours of admission to ensure the resident's immediate care needs are met and maintained. The procedure showed the baseline care plan would remain in place until the IDT team could conduct the comprehensive assessment and develop an IDT care plan. The procedure showed the care plan is developed by the IDT team initially, then quarterly thereafter. The procedure showed care plan meetings will be scheduled within 21 days initially, then quarterly, annually, and significant change reviews thereafter. The procedure showed one of the care areas that need to have a plan of care developed to address concerns was pressure ulcer/injury. The policy and procedure showed 10. Throughout the course of rehabilitation or resident stay in the facility, the identified risk factors, goal, interventions, and outcomes on the care plan will be evaluated and revised as necessary. 11. The problem/strength statements will be dated as they occur. 12. The goal statement should be in measurable terms so progress or decline can be determined and have a review date. 13. Interventions should be written to help meet the goal. The intervention should be individualized to the resident. 14. A discipline or department which will be responsible for the intervention shall be identified. The facility's policy and procedure titled Nursing Services, with a revision date of 6/15/15, showed Nursing Care Plan: The Director of Nursing will see that the nursing needs of the resident are planned, supervised and evaluated by the registered professional nurses, and that a nursing care plan is written and currently updated to meet these needs while respecting the individuality of each resident. The plan will indicate the needed nursing care, how it can best be accomplished, what methods and approaches are most successful, and what modifications are necessary to ensure best results.

Based on observation, interview, and record review the facility failed to ensure privacy was provided for a resident during care for 1 of 1 resident (R47) reviewed for privacy in the sample of 21. The findings include: On 9/5/23 at 11:09 AM, R47 was sitting in her wheelchair in her room waiting to go to the bathroom. V3 CNA (Certified Nursing Assistant) came into R47's room to take her to the toilet. V3 left the door open to R47's room. V3 wheeled R47 into the bathroom, had R47 stand at the grab bar while she pulled down R47's pants and incontinence brief. R47 was incontinent of urine and feces. R47 was assisted to sit on the toilet. The bathroom door was left open while R47 was on the toilet. V3 left the bathroom to get a pad and incontinence brief for R47 and the bathroom door remained open. People were walking in the hallway while R47's bedroom and bathroom door were both open and R47 was on the toilet. V3 went back into R47's bathroom, provided incontinence care, put an incontinence brief, and pulled R47's pants up with both doors open. On 9/5/23 V2 DON (Director of Nursing) was not available for the survey. V2 was off for the week and could not be interviewed for privacy/dignity concerns. R5 RN (Registered Nurse) was available in the DON's absence. On 9/6/23 at 12:09 PM, V4 RN (Registered Nurse) stated, when care is provided for a resident the door to the resident's room should be closed. V4 stated this should be done in case someone walks into the room, so the resident still has privacy and in case someone walks into the room the resident still has privacy. V4 stated it is not okay to have the door to the hall open and bathroom door open when a resident is on the toilet because no privacy is being provided. On 9/7/23 at 9:35 AM, R5 RN (Infection Control Preventionist) stated the door to the resident's room should be closed when care is being provided. It is for the resident's privacy. Having the doors open is a privacy issue. The Face Sheet dated 9/6/23 for R47 showed diagnosis including diabetes mellitus, hypertension, atrial fibrillation, deep venous thrombosis, dementia, vitamin D deficiency, anemia, osteoporosis, incontinence, essential tremor, cataract, and low back pain. The Minimum Data Set, dated dated dated [DATE] for R47 showed extensive assistance needed for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. The Care Plan dated 7/19/23 for R47 showed, R47 has an activity of daily living self-care performance deficit related to tremors on both hands. Ensure resident's privacy when performing and assisting with activities of daily living. The facility's Resident Dignity policy (4/4/223) showed, staff members shall strive to treat residents with dignity and respect. Staff shall strive to promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures (pulling privacy curtain around bed, keeping the door closed during care, keeping the resident covered).

Based on observation, interview, and record review, the facility failed to ensure weekly weights were obtained for 1 of 8 residents (R44) reviewed for nutrition in the sample of 21. The findings include: R44's Admission Record, printed by the facility on 9/7/23, showed she had diagnoses including moderate dementia with behavioral disturbance, anemia, generalized anxiety disorder, psychosis, major depressive disorder, osteoarthritis, and an unstageable pressure injury to her left heel. On 9/5/23 at 12:27 PM, R44 was sitting in her wheelchair, by the entrance to the dining room on the memory care unit. R44 was being assisted and encouraged during the lunch meal by staff. R44 was drinking her juice and coffee. R44 ate less than 25% of the lunch meal. R44's facility assessment dated [DATE] showed she had moderately impaired cognitive skills for daily decision making. The assessment showed R44 had short-term and long-term memory problems and requires extensive assist of one staff member for eating. The assessment showed R44 had a weight loss of 5% or more in the month prior to the assessment, or a loss of 10% or more in the previous 6 months. V9's (Registered Dietitian) Nutrition/Dietary note dated 7/14/23 showed R44 was added to weekly weights due to a 6% weight loss over one month. V9's Nutrition/Dietary note dated 7/19/23 showed R44 had an unintentional weight loss, and she was underweighted. The note showed, Weekly weights obtained as well for weight loss. R44's Nutrition Risk assessment dated [DATE] showed R44 had a poor appetite and refuses foods. The assessment showed R44's average meal intake was between 5%-25%. R44's care plan, revised on 7/19/23, showed she had a potential nutritional risk and inadequate oral intake as evidenced by refusal of meals and significant weight loss. R44's Order Summary Report, printed by the facility on 9/7/23, showed an order for weekly weights, every Wednesday. The order date was 7/14/23, to be started on 7/19/23. The Order Summary Report showed the order for weekly weights was still active. R44's Weights and Vitals Summary Report, provided by the facility on 9/7/23, showed she weighed 134.0 pounds on 3/16/23, and she weighed 116 pounds on 9/6/23 (a loss of 18 pounds, or 13.4%, in the last 6 months). The report showed no weights were obtained for R44 on 8/16/23; 8/23/23; and 8/30/23. On 9/7/23 at 10:06 AM, V13 (CNA) said the residents' weights are documented in POC (Point of care-in the residents' electronic charting). No other place. V13 said the facility does not have any paper documents where the residents' weights are documented. V13 said if a resident's weights were obtained, it would be in POC. V13 said there is a gap in R44's weekly weights from 8/9/23-9/2/23. V13 said she believes the weekly weights should have been done. On 9/07/23 at 10:28 AM, V9 (Registered Dietitian) said staff should still be doing weekly weights for (R44). V9 said it looks like it fell off from August through September. It is important to do the weekly weights so that we have a constant trend of where her weights are going. V9 said there should have been weights done during that time. The facility's policy and procedure titled Weight Monitoring and Dietary Supplements, with a revision date of 5/31/23, showed, Residents will be weighed on admission, and then monthly afterwards, unless a physician orders otherwise.

Based on record review and interview the facility improperly transferred one resident (R4) from a sample of four residents assessed for falls/fractures. This failure resulted in R4 sustaining a fracture of the distal femur. Findings Include: Review of R4's incident report dated 8-8-12 denotes it is conceivable that her (R4) leg twisted during transfer or repositioning, and this, combined with her history, caused the bone to fracture. Review of R4's care plan dated 7-3-12 denotes resident (R4) is noted to require more assistance with activities of daily living and mobility. She is noted to be totally dependent to staff with activities of daily living and mobility and is observed with less energy. Interventions: Assist resident (R4) with all activities of daily living. Two person extensive assist with total mechanical lift transfer. Interview with E6 (Certified Nurse Assistant) on 8-9-12 at 3:45 PM states she and another CNA lifted R4 from the wheel chair to the shower chair. E6 states she did not use the total mechanical lift because she did not want to get the total mechanical lift pad wet. E6 states she washed R4 then she and another CNA (E8) lifted up R4 from the shower chair and put her back in the wheel chair. E6 states she rolled R4 in her wheelchair to her room and then used the total mechanical lift lift to put R4 in the bed for the night on 8-6-12. R4 nurses notes dated 8-7-12 at 9:00 AM denotes R4 was calling out the whole night complaining of pain when repositioned, noted swelling left hip. Doctor notified and X-ray ordered of left hip, thigh and knee. R4 nurse notes dated 8-7-12 at 6:00 PM denotes X-ray results to left leg with femur fracture with order for ortho referral, keep leg immobilized. Facilities policy for resident handling/limited lift denotes resident handling can result in injury to staff or residents. In order to provide safe resident handling/transfers with limited lifting, facility has provided sit to stand and total/mechanical lifts. Resident transfers status will be reviewed during care planning. Resident transfer status will be communicated by indicating the method on the " Resident Care Guide" for the CNA's. A transfer that could harm the resident or staff member should not be attempted. Interview with E1 (Restorative Registered Nurse) on 8-9-12 at 9:20 AM states she assessed R4 to need the total mechanical lift and put it on the care plan and on the resident care guide that is kept in R4's room for the CNA to see. E1 states staff are expected to use the total mechanical lift every time R4 needs to be transferred. Review of R4's care guide denotes Transfers: total mechanical lift. Interview with E5 (Director of Nursing) on 8-9-12 at 4:00 PM states R4 was assessed to need the total mechanical lift and should have been used every time R4 needed transferring. Interview with E7 (Assistant Administrator) on 8-9-12 at 3:30 PM states E5 informed her that E6 was suspended because E6 did not follow the policy and did not use the total mechanical lift. E7 states E6 transferred R4 manually. Review of E6 (Certified Nurse Assistant) employee file denotes disciplinary warning and notice, date of violation 8-6-12. Observed performing an improper lifting technique, resident (R4) designated as total mechanical lift in care plan and clearly stated in the CNA care guide, E6 did not follow designated technique. Interview with Z2 (Medical Doctor) on 8-10-12 at 10:30 AM states R4's fracture is a break in bone upper thigh (femur). Z2 states something caused the fracture, it did not happen on it's own. Z2 states does not know how R4 sustained the fracture because no one told her what happened. Interview with E8 (Certified Nurse Assistant) on 8-10-12 at 8:30 AM states she was in the shower room when E6 asked her to help lift up R4. E8 states me and E6 lifted R4 up by her arms from the wheelchair to stand her up. E6 states another CNA (E9) slid the shower chair behind R4 and then we let her sit down on the shower chair. Interview with E9 (Certified Nurse Assistant) on 8-10-12 at 8:40 AM states E6 asked me to pull R4's pants down while E6 and E8 stood R4 up by the arms. E9 states R4 was almost falling down but that she put the shower chair under her. E9 states R4 was not completely sitting in the shower chair. E9 states that E6 and E8 were on the sides of R4 and they grabbed her legs and arms and scooted her back into shower chair.