Every finding on record at Crossroads of Flowery Branch of Journey LLC, The

Based on staff interviews and record review, the facility failed to ensure the security of all personal funds of residents deposited with the facility. Specifically, the facility failed to maintain a surety bond sufficient to cover the total funds in the resident trust account. This deficient practice had the potential to affect the residents with trust fund accounts managed by the facility. The census was 93 residents.Findings included:A facility policy on surety bonds was requested but not provided.A review of the State of Georgia Department of Community Health Long-Term Care Facility Residents' Fund Bond, dated 11/1/2024, revealed a surety bond for $75,000.00.A review of the Resident Trust Fund statement for 8/1/2025 to 9/1/2025 revealed a balance of $54,268.70 on 8/1/2025, a balance of $89,735.10 on 8/21/2025, a balance of $89,765.10 on 8/29/2025, and a balance of $89,766.98 on 8/31/2025.A review of the Resident Trust Fund statement for 9/2/2025 to 9/30/2025 revealed a balance of $89,766.98 on 9/2/2025, a balance of $92,763.98 on 9/3/2025, a balance of $92,399.48 on 9/9/2025, a balance of $92,176.43 on 9/12/2025, a balance of $92,006.43 on 9/15/2025, a balance of $81,289.91 on 9/16/2025, a balance of $77,745.31 on 9/17/2025, a balance of $75,463.05 on 9/22/2025, a balance of $75,603.05 on 9/23/2025, and a balance of $75,214.29 on 9/24/2025.During an interview on 1/16/2026 at 5:08 pm, the Business Office Manager (BOM) revealed that for resident trust funds, she is responsible for giving the residents cash. She stated she was not sure what a surety bond is. She further stated that she only handles individual resident trust funds and does not look at the whole balance of the account. She confirmed that $89,766.98 was the documented current balance for 8/31/2025 and $89,766.98 was the documented starting balance for 9/2/2025.During an interview on 1/16/2026 at 5:17 pm, the [NAME] President of Operations revealed that the BOM oversees the total amount of the resident trust fund account. He confirmed the amount from August 2025 to Septemebr 2025 was over the surety bond of $75,000. He confirmed that the total amount of the resident trust fund should not go over the amount of the surety bond and that the current surety bond is $75,000.During an interview on 1/16/2026 at 6:09 pm, the Administrator revealed his expectations for the resident trust fund is that the balance should not exceed the surety bond and that if it does, the facility should increase the surety bond.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to develop and implement care plans that describe the resident's medical, nursing, physical, mental, and psychosocial needs for six of 46 sampled residents (R) (R90, R12, R74, R57, R1 and R16).Findings included:A review of the facility's policy titled Comprehensive Care Plans, revised 3/20/2025, revealed that the comprehensive care plan will be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS) assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. The services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Further review revealed, under number five, The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 1. A review of the electronic medical record (EMR) revealed that R90 was originally admitted to the facility on [DATE] and was re-admitted to the facility on [DATE] with pertinent diagnoses, including but not limited to, displacement of nephrostomy catheter, malignant neoplasm of bladder, gram-negative sepsis, acute cystitis with hematuria, acute kidney failure, and chronic kidney disease stage 3.A review of R90's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of seven, which indicated R90 had severe cognitive impairment. During an observation on 1/11/2026 at 3:24 pm, R90 was lying in bed, color pale, eyes closed. He had two urinary bags on either side. The right-side bag has cloudy, dark yellow fluid in it, approximately 50ml (milliliters) volume. The bag on the left side had clear yellow fluid with a volume of approximately 150ml. These bags were attached to the residents' backs (nephrostomy tubes).During an observation of R90 on 1/11/2026 at 5:10 pm, Registered Nurse (RN) AA confirmed that R90 had nephrostomy tubes. A review of R90's most recent comprehensive care plan revealed no mention of a nephrostomy.During an interview on 1/11/2026 at 5:17 pm, the Director of Nursing Services (DNS) confirmed that there is no order for dressing changes or care orders on R90 for the nephrostomy tubes, and the care plan that is present in the electronic medical record was not up to date to reflect care for the nephrostomy tube sites.During an interview on 1/15/2026 at 11:24 am, the Regional Director of Nursing Services revealed that comprehensive care plans should be developed within a week of admission and should be revised with a new medication, a change of condition, and any change in a resident and that care plans should include diagnoses, medications, wounds, skin concerns, resident preferences, code status, risk factors, and specific care needs such as oxygen, dialysis, and nephrostomy care.2. A review of R12's EMR revealed he was admitted to the facility on [DATE]. Pertinent diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, muscle weakness, need for assistance with personal care, contracture, other lack of coordination, stage 2 pressure ulcer of the sacral region, stage 4 pressure ulcer of the left heel, and contracture of the left hand. A review of R12's quarterly MDS dated [DATE] revealed R12 had a BIMS score of one, indicating R12 had severe cognitive impairment at the time of the assessment. A review of R12's physician orders revealed an order dated 11/21/2025 for adaptive/ assistive devices of prevalon boots for offloading. A review of R12's care plan revealed a focus dated 10/31/2025 that documented R12 has a stage 2 wound to sacrum and stage 4 wound to left heel. Goals included, wound will be free from infection and heal within 30 days. Interventions included, but were not limited to, follow wound care treatment as ordered, new order for prevalon boots, and reposition resident every two hours and offload heel. During an observation on 1/11/2026 at 1:14 pm and on 1/12/2026 at 8:15 am, R12 had no pressure-relieving boots on.During an interview on 1/12/2026 at 8:15 am, the Unit Manager confirmed that R12's pressure-relieving boots were not on but should be. During an interview on 1/15/2026 at 11:24 am, the DNS confirmed that if R12 had a care plan intervention of pressure-relieving boots, then they should have been on.3. A review of R74's EMR revealed she was admitted to the facility on [DATE]. Pertinent diagnoses included, but were not limited to, alcohol abuse, depression, insomnia, and unspecified mood affective disorder. A review of R74's physician orders revealed an order dated 12/16/2025 for aripiprazole oral tablet 2mg with instructions to give one tablet by mouth one time a day, an order dated 12/16/2025 for duloxetine Hcl oral capsule delayed release particles 60 mg with instructions to give one capsule by mouth one time a day, an order dated 12/16/2025 for mirtazapine oral tablet 15 mg with instructions to give one tablet by mouth one time a day, an order dated 12/26/2025 for aripiprazole oral tablet 2mg with instructions to give 0.5 tablet by mouth one time a day for mood for 1 week, an order dated 1/4/2026 for aripiprazole oral tablet 2mg with instructions to give 2mg by mouth one time a day, an order dated 1/8/2026 for aripiprazole oral tablet 2mg with instructions to give one tablet by mouth one time a day for mood disorder, an order dated 1/8/2026 for mirtazapine oral tablet 15 mg with instructions to give one tablet by mouth one time a day for depression, and an order dated 1/8/2026 for duloxetine Hcl oral capsule delayed release particles 60 mg with instructions to give one capsule by mouth one time a day for depression.A review of R74's care plan revealed no focus or interventions mentioning a diagnosis or risk factors related to alcohol.During an interview on 1/15/2026 at 11:24 am, the DNS confirmed R74's comprehensive care plan did not include her diagnosis and risk factors related to alcohol, but should have.4. A review of R1's EMR revealed R1 was admitted to the facility on [DATE]. Pertinent diagnoses included, but were not limited to, acquired absence of left leg below knee, acquired absence of right leg above knee, legal blindness, and type 2 diabetes.A review of R1's quarterly MDS dated [DATE] revealed R1 had a BIMS score of 15, which indicates R1 was cognitively intact.A review of R1's physician orders revealed an order dated 11/14/2025 for Humulin subcutaneous solution with instructions to inject 100 units subcutaneously one time a day for diabetes mellitus before breakfast.A review of R1's care plan dated 1/11/2026 revealed a focus initiated on 11/12/2025 revealed a focus of diabetes mellitus. Goals included, The resident will have no complications related to diabetes through the review date. Interventions included, but were not limited to, Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.During an interview on 1/11/2026 at 1:51 pm, R1 revealed he had concerns with his insulin, which has to be given to him before he eats. He has reminded before, but sometimes he does not receive his insulin until after meals.During an interview and observation on 1/12/2026 at 8:32 am, R1 was observed eating breakfast in his room. He stated that he has not been offered his insulin yet.During an interview on 1/13/2026 at 8:09 am, Licensed Practical Nurse (LPN) KK revealed that she has been working at the facility for about a year. When asked about insulin administration, she explained that she usually tries to administer insulin before breakfast. She confirmed that R1 had not been offered or administered his insulin before breakfast today and explained that she was having technical difficulties with her computer when she arrived on the shift.During an interview on 1/15/2026 at 11:24 am, the DNS confirmed R1's care plan intervention for diabetes related to the following physician orders for R1 were not followed, but should have been. The DNS further stated that a potential negative outcome for missing the insulin before meals is hyperglycemia.5. A review of R57's EMR revealed he was admitted to the facility on [DATE]. Pertinent diagnoses included, but were not limited to, cerebral infarction, hemiplegia, and hemiparesis following unspecified cerebrovascular disease affecting the unspecified side.A review of R57's quarterly minimum data set (MDS) dated [DATE] revealed a BIMS of 12, indicating R57 had moderate cognitive impairment at the time of the assessment.A review of R57's physician orders revealed an order dated 7/12/2025 for clopidogrel bisulfate tablet 75 mg with instructions to give one tablet by mouth one time a day for blood clot prevention.A review of R57's care plan dated 7/12/2025 revealed only two focuses: full code and discharge. There was no indication of the level of assistance needed or a mention of R57's usage of anticoagulants.During an interview on 1/15/2026 at 11:24 am, the DNS confirmed that R57's comprehensive care plan only had focuses related to advance directives and discharge, but should have contained more, including the level of assistance and the use of anticoagulants.The DNS further stated that comprehensive care plans should be developed within a week and revised with a new medication, a change of condition, and any change in a resident. The DNS further stated that care plans should include diagnoses, medications, wounds, skin concerns, resident preferences, code status, risk factors, and specific care needs. The DNS confirmed these processes were not followed and stated that staff were not following the facility process for care plans.6. A review of R16's EMR revealed she was admitted to the facility on [DATE]. Pertinent diagnoses included, but were not limited to, displaced fracture of the lateral malleolus of the right fibula, fracture with routine healing, benign neoplasm of the parathyroid gland, unspecified injury of the head, and generalized anxiety disorder.A review of R16's physician orders revealed an order dated 9/25/2025 for Apixaban Oral Tablet 5mg (milligram) (Apixaban); give one tablet by mouth two times a day (anticoagulants).A review of R16's care plan revealed no focus or interventions mentioning a risk factor related to anticoagulant medication administration.An interview on 1/15/2026 at 11:24 am with the DNS revealed that comprehensive care plans should be developed within a week. They should be revised with a new medication, a change of condition, and any change in a resident. Care plans should include diagnoses, medications, wounds, skin concerns, resident preferences, code status, risk factors, and specific care needs.During an interview on 1/16/2026 at 12:19 pm, DNS stated that R16 absolutely should have a care plan related to anticoagulants.

Based on staff interviews, resident interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to provide one of 46 sampled residents (R) (R1) the right to participate in the development of his person-centered plan of care. This deficient practice had the potential to deprive R1's inclusion of personal goals, choices, and preferences in the plan of care.Findings included:A review of the facility's policy titled Comprehensive Care Plans, revised 3/20/2025, documented under section titled Policy Explanation and Compliance Guidelines number one, The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Further review revealed, under number four, The comprehensive care plan will be prepared by an interdisciplinary team, which includes, but is not limited to: e. The resident and the resident's representative, to the extent practicable.A review of R1's electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE]. Pertinent diagnoses included, but was not limited to, acquired absence of left leg below knee, acquired absence of right leg above knee, obesity, insomnia, legal blindness, major depressive disorder, anxiety disorder, and type 2 diabetes.A review of R1's quarterly minimum data set (MDS) dated [DATE] revealed that R1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact.A review of R1's care plan dated 1/11/2026 revealed a focus initiated on 12/1/2025 that stated R1 was resistive to care, occasionally refuses medications related to resident's choice. Interventions included, but were not limited to, allowing the resident to make decisions about the treatment regimen to provide a sense of control and providing the resident with opportunities for choice during care provision.Further review of R1's EMR revealed no documentation indicating R1's attendance or refusal of attendance for the development of the comprehensive care plan.During an interview on 1/16/2026 at 1:54 pm, R1 revealed he had never had a care plan conference, asked what it was, and said he would like to attend one.During a phone interview on 1/16/2026 at 3:08 pm, the Regional Reimbursement Specialist revealed she provides oversight and assistance with MDS Coordinators and updates care plans. She stated that social services and the MDS coordinator are responsible for care plan conferences, and these conferences are documented in the EMR. She further stated she did not locate documentation of a care plan conference for R1.During an interview on 1/16/2026 at 4:33 pm, the Business Office Manager (BOM) revealed that she has been assisting with social services responsibilities as the facility has not had a social services director for several months. She stated that care plan conferences are usually conducted a couple of days after admission, quarterly, annually, or upon request. She stated she was not aware of where care plan conferences are documented and that the social worker did the documentation for care plan conferences.During an interview on 1/16/2026 at 5:44pm, the Director of Nursing Services (DNS) revealed that she expects care plan conferences to be completed within 30 days of admission and quarterly and usually includes nursing, social services, therapy, dietary, activities, and the resident or resident representative. She confirmed she did not see any care plan conference documentation for R1 and was not sure why.

Based on staff interviews, record review, and review of the facility's policy titled Residents' Rights Regarding Treatment and Advance Directives, the facility failed to ensure that the advance directive status was consistently documented in the clinical record for two of 46 sampled residents (R) (R16 and R112).Findings included:A review of the facility policy titled Residents' Rights Regarding Treatment and Advance Directives dated February 2024 revealed under Definitions, Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State, relating to the provision of health care when the individual is incapacitated. Under the section titled Policy Explanation and Compliance Guidelines revealed: .9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.1. A review of R16's medical record (EMR) revealed she was admitted to the facility on [DATE], with pertinent diagnoses including, but not limited to, displaced fracture of lateral malleolus of right fibula, fracture with routine healing benign neoplasm of parathyroid gland, unspecified injury of head, generalized anxiety disorder.A review of R16's Physician Orders reveal an active order for FULL CODE STATUS with date of 9/25/2025.A review of Medical Summary of R16's EMR revealed special Instructions: FULL CODE.A review of R16's care plan revealed: Advanced Directives Do Not Attempt Resuscitation (DNR) with interventions: honor code status directive and keep family informed of change in condition; with a revision date of 9/30/2025.Further review of EMR revealed Physician Orders for Life-Sustaining Treatment (POLST) form with a code status: Allow Natural Death and Do Not Attempt Resuscitation. Signed by R16 on 1/12/2026 and signed by Physician on 1/13/2026.2. A review of R112's EMR revealed she was admitted to the facility on [DATE] with pertinent diagnoses, including, but not limited to, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, anxiety disorder, and major depressive disorder.A review of R112's Physician Orders reveal an active order for FULL CODE STATUS with date of 1/8/2026.A review of Medical Summary of R112's EMR revealed special Instructions: FULL CODE.A review of R112's care plan revealed: Advanced Directives Do Not Attempt Resuscitation (DNR) with interventions: honor code status directive and keep family informed of change in condition. Date initiated: 1/8/2026.Further review of R112's EMR on 1/16/2025 revealed Physician Orders for Life-Sustaining Treatment (POLST) form with a code status: Allow Natural Death and Do Not Attempt Resuscitation. Signed by R112 on 1/12/2026 and signed by Physician on 1/13/2026.Interview with Director of Nursing Service (DNS) on 1/16/2026 at 12:19 pm confirmed that R16's and R112's EMR were not updated consistently with new code DNR. The DNS stated that all EMR entries must be consistent with a code status from the Advanced Directive.

Based on record review, staff interviews, and review of the facility's policy titled Baseline Care Plan, the facility failed to develop a Baseline Care Plan for three of 46 sampled residents (R) (R14, R109, and R90). The deficient practice had the potential for residents' needs to go unmet. Findings included:A review of the facility's policy titled Baseline Care Plan implemented on 2/1/2024, documented under Policy Explanation and Compliance Guidelines: 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident, including, but not limited to: i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders. iv. Therapy orders. v. Social services.3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. 1. A review of R14's Physician Orders revealed an order dated 12/13/2025 for next day labs PT/INR (Prothrombin Time / International Normalized Ratio) one time a day every 1 month starting on the 15th, an order dated 12/10/2025 for anticoagulation medication observation, an order dated 12/11/2025 for Occupational Therapy Clarification Order - Skilled Occupational Therapy 5 times a week, and an order dated 12/12/2025 for Occupational Therapy Clarification Order - Skilled Occupational Therapy 5 times a week. A review of R14's EMR revealed no baseline or comprehensive care plan. During an interview on 1/16/26 at 12:19 pm, the Director of Nursing Service (DNS) confirmed that residents should have a baseline care plan within 48 hours of admission. She stated that currently, corporate employees help nurses with comprehensive care plans, but nurses are responsible for creating a baseline care plan. The DHS also confirmed that there was no care plan for R14 in the EMR. 2. A review of R109's EMR revealed R109 was admitted to the facility on [DATE] with diagnoses including, but not limited to, acquired absence of right leg below the knee, type 2 diabetes mellitus with foot ulcer, dependence on renal dialysis, and end-stage renal disease. A review of R109's EMR revealed no baseline or comprehensive care plan. An interview on 1/12/2026 at 3:06 pm, the DNS confirmed there was no baseline care plan or comprehensive care plan completed for R109. 3. A review of the electronic medical record (EMR) revealed that R90 was originally admitted to the facility on [DATE] and was re-admitted to the facility on [DATE] with pertinent diagnoses, including but not limited to, displacement of nephrostomy catheter, malignant neoplasm of bladder, gram-negative sepsis, acute cystitis with hematuria, acute kidney failure, and chronic kidney disease stage 3. During an observation on 1/11/2026 at 3:24 pm, R90 was lying in bed, color pale, eyes closed. He had two urinary bags on either side. The right-side bag has cloudy, dark yellow fluid in it, approximately 50ml (milliliters) volume. The bag on the left side had clear yellow fluid with a volume of approximately 150ml. These bags were attached to the residents' backs (nephrostomy tubes). During an observation of R90 on 1/11/2026 at 5:10 pm, Registered Nurse (RN) AA confirmed that R90 had nephrostomy tubes. A review of R90's EMR revealed no baseline careplan upon admission related to the nephrostomy. During an interview on 1/11/2026 at 5:17 pm, the DSN confirmed that there was no baseline careplan upon admission for R90 to reflect care for the nephrostomy tube sites.

Based on observations, staff interviews, resident interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to follow physician orders in accordance with professional standards related to insulin, blood testing, and non-pressure related wound care for three of 46 sampled residents (R) (R1, R14, and R53). This deficient practice had the potential to create a diminished quality of care.Findings included:A review of the facility's policy titled Medication Administration, revised on 2/14/2024, revealed under the section titled Policy, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Under the section titled, Policy Explanation and Compliance Guidelines, number 11 revealed, Compare medication source with MAR (medication administration record) to verify resident name, medication name, form, dose, route, and time. b. Administer within 60 minutes before or after the scheduled time unless otherwise ordered by the physician. A review of R1's electronic medical record (EMR) revealed R1 was admitted to the facility with pertinent diagnoses, including, but not limited to, acquired absence of left leg below knee, acquired absence of right leg above knee, legal blindness, and type 2 diabetes. A review of R1's quarterly minimum data set (MDS) dated [DATE] revealed that R1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. A review of R1's physician orders revealed an order dated 11/14/2025 for Humulin (insulin) subcutaneous solution with instructions to inject 100 units subcutaneously one time a day for diabetes mellitus before breakfast, an order dated 11/14/2025 for Humulin (insulin) subcutaneous solution with instructions to inject 80 units subcutaneously one time a day for diabetes mellitus before lunch, and an order dated 11/14/2025 for Humulin (insulin) subcutaneous solution with instructions to inject 80 units subcutaneously one time a day for diabetes mellitus before dinner. A review of R1's care plan dated 1/11/2026 revealed a focus initiated on 11/12/2025 revealed a focus of diabetes mellitus. Goals included, The resident will have no complications related to diabetes through the review date. Interventions included, but were not limited to, Diabetes medication as ordered by the doctor. Monitor/document for side effects and effectiveness. During an interview on 1/11/2026 at 1:51 pm, R1 revealed he had concerns with his insulin, which has to be given to him before he eats. He has reminded staff before, but sometimes he did not receive his insulin until after meals. During an interview and observation on 1/12/2026 at 8:32 am, R1 was eating breakfast in his room. He stated that he had not been offered his insulin yet. During an interview on 1/12/2026 at 8:34 am, the Unit Manager confirmed that she had not given R1 his insulin before breakfast as ordered. During an interview and observation on 1/13/2026 at 8:05 am, R1 was eating breakfast in his room. When asked if he had his insulin yet, he stated no, and further stated that his last insulin was yesterday, before dinner. When asked if he refused any insulin this morning, he stated that he had not been offered it and is still waiting to be offered his insulin. When asked if he had his blood sugar taken this morning, he stated that it had been taken around 5:00 am this morning, and it was over 200. An interview on 1/13/2026 at 8:09 am with License Practical Nurse (LPN) KK revealed that when asked about insulin administration, she explained that she usually tries to administer insulin before breakfast. She confirmed that R1 had not been offered or administered his insulin before breakfast today and explained that she was having technical difficulties with her computer when she arrived on the shift. When asked what his last blood sugar levels were, she stated that it was 249 at 4:26 am. An interview on 1/15/2026 at 11:24 am with the Director of Nursing Services (DNS) confirmed the physician orders for R1 were not followed, but should have been. The DNS further stated that a potential negative outcome for missing the insulin before meals is hyperglycemia (low blood sugar). 2. A review of R14's EMR revealed R14 was admitted to the facility with pertinent diagnoses, including, but not limited to, fracture of unspecified part of neck of left femur, muscle weakness, type 2 diabetes mellitus, endocarditis, pathological fracture, and encounter for other orthopedic aftercare. A review of R14's physician orders revealed an order dated 12/13/2025 for next-day labs PT/INR (Prothrombin Time / International Normalized Ratio) one time a day every 1 month starting on the 15th. During an interview on 1/16/2026 at 12:19 pm, the Director of Nursing Service (DNS) confirmed that the physician ordered a PT/INR blood test on 12/15/2025, but there were no test results in the EMR. She was not able to say why the blood test was not done. 3. A review of the EMR revealed R53 was admitted to the facility with diagnoses that included a non-pressure chronic ulcer of unspecified part of unspecified. A review of the most recent quarterly MDS documented that R53 had a BIMS score of 15, indicating the resident had intact cognition. A review of the Care Plans for R53 revealed that the care plan documented that the resident was to receive wound care treatment daily A review of the Treatment Administration Record (TAR) revealed that wound care should be performed daily for R53. During an observation of R53 on 1/12/2026, it was noted that the wound dressing was dated 1/9/2026. During an interview on 1/14/2026 at 10:05 am, Licensed Practical Nurse (LPN) BB revealed that she assisted with wound care as needed and expressed interest in becoming the facility's wound care nurse. She stated that nursing staff was sometimes overwhelmed and unable to complete ordered wound care, and that she filled in to assist when this occurred. During an interview on 1/12/2026 at 10:10 am, LPN CC revealed that when asked about wound care, LPN CC stated that the Unit Manager was responsible for completing wound care on the unit and typically checked the TAR. She further stated that if she observed a wound requiring a dressing change, she would either complete the dressing change herself or notify the Unit Manager. Interview on 1/12/2026 at 10:00 am with the Registered Nurse (RN) Unit Manager who stated that the assigned unit nurse was responsible for completing wound care treatments. She mentioned that if the unit nurse became overwhelmed or requested assistance, she would provide support and help with wound care. She further acknowledged that she was not aware that wound care treatments had not been completed as ordered. Interview on 1/14/2026 at 10:19 am with the Director of Nursing (DON) revealed that the floor nurse was responsible for completing wound care for residents on the unit. The DON stated that when the floor nurse was overwhelmed, the nurse was expected to inform the Unit manager, who would then assist with wound care or assign another staff member to assist. The DON stated that the expectation was for the floor nurse to complete wound care, and that this responsibility was communicated to nursing staff during orientation.

Based on observations, staff interviews, resident interviews, record review, and review of the facility's policies titled, Oxygen Administration and Medication Orders, the facility failed to obtain physician orders for oxygen therapy for one of 13 residents on oxygen and physician orders for Bi-level Positive Airway Pressure (BiPAP) for one of one resident with a BiPAP Mask. Specifically, the facility failed to obtain physician orders for oxygen therapy for residents (R) (R112 and R50). This failure had the potential to cause respiratory distress and inconsistent care for residents receiving oxygen therapy.Findings included:A review of the facility policy titled Medication Orders, revised 2/14/2024, under the section titled Policy Explanation and Compliance Guidelines, number 5, Specific Procedures for Medication Orders: c. Written Transfer Orders (sent with a resident by a hospital or other health care facility). Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete, or the date signed is different from the date of admission. If the order is unsigned, or signed by another physician, or the date is other than the date of admission, the receiving nurse should verify the order with the current attending physician before medications are administered.A review of the facility policy titled Oxygen Administration, revised 2/14/2024, under the section titled Policy Explanation and Compliance Guidelines, number 2 documented, Personnel authorized to initiate oxygen therapy include physicians, RNs (Registered Nurses), LPNs (Licensed Practical Nurses), and respiratory therapists.A review of R112's electronic medical record (EMR) revealed R112 was admitted to the facility on [DATE]. Pertinent diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, and shortness of breath.A review of R112's physician orders revealed an order dated 1/8/2026 for oxygen at night during sleep, 2L (liters)/min (minute) via nasal cannula every night shift.A review of R112's physician orders revealed an order dated 1/11/2026 for oxygen at night during sleep, 4L/min via nasal cannula every night shift.A review of R112's EMR revealed a hospital Discharge summary dated [DATE] that documented, under Diagnosis and Reason for Visit, Reason for visit: SOB - Shortness of breath; difficulty breathing. A review of the EMR of the Hospital Course noted, During her admission, she was found to have acute respiratory failure secondary to influenza A and COPD exacerbation. Pulmonology followed up and treated her with a course of steroids, antibiotics, Tamiflu, and bronchodilators. With this treatment, she was able to wean off oxygen during the day but continues to require oxygen at night.A review of the EMR revealed, under the section titled Assessment and Plan, number one documented, acute-on-chronic hypoxic respiratory failure. Sp02 dropped to 87% on RA [room air] at one point during the day. Acute resolved, now stable on baseline RA [room air] during the day and 2-4L HS [at bedtime].A review of the EMR revealed, under the section titled Vitals and Measurements, Oxygen flow rate: 4L/min.During an interview on 1/11/2026 at 2:18 pm, R112 stated she was supposed to be sleeping with oxygen, but has not been because she has not been provided an oxygen concentrator, and that has been the case for a couple of nights since her admission to the facility. R112 further stated that last night she woke up at 3:00 am and had a headache and difficulty breathing, which required her to do a breathing treatment this morning. R112 further stated that she has asked her night nurses about it each night for three nights and has not received an answer. She further stated that she usually received 4L per night at the hospital.During an interview on 1/15/2026 at 11:24 am, the DNS revealed the start date of R112's oxygen order was documented as 1/8/2026, the day of R112's admission, and R112 should be receiving the oxygen at night during sleep. The DNS stated the reason for the delay in R112's oxygen is that the staff did not bring R112 her oxygen concentrator at admission.During an interview on 1/16/2026 at 5:59 pm, the DNS revealed that if a resident has an order for oxygen, the facility should provide the resident with oxygen. 2. During a review of the facility policy titled Oxygen Administration, revised 2/14/2024, under the section titled Policy Explanation and Compliance Guidelines, number 2 documented, Personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists. Further review documented under number 9, Types of delivery systems include: e. Bi-level Positive Airway Pressure (BiPAP) Mask--This mask is part of a system that is capable of generating two adjustable pressure levels during inhalation and exhalation.A review of R50's EMR revealed R50 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, acute respiratory failure with hypoxia, obstructive sleep apnea, simple chronic bronchitis, and shortness of breath.A review of R50's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicates R50 had moderate cognitive impairment.A review of R50's physician orders printed on 1/11/2026 revealed no orders for BiPAP.A review of R50's physician orders printed on 1/12/2026 documented, BiPAP settings: ASVAuto Mode Min EPAP- 5cm (centimeters), Max EPAP- 15.0cm Min PS- 4.0cm Max PS- 19.0 Ramp time- 20 min.Further review of R50's physician orders printed on 1/12/2026 documented, Resident to wear BiPAP at night. Document vital signs and oxygen saturation before use. Document if the resident refuses to use BiPAP every night shift.A review of R50's EMR revealed a document titled, Hospital SNF Initial Placement report Paperwork with a print date of 11/7/2025. Under the section titled MD (medical doctor) Progress Note with a date of service of 11/5/2025, the subsection titled Assessment and Plan documented, Patient required BiPAP and high-flow oxygen, with intermittent improvement and subsequent worsening necessitating transfer to (Acute Care Facility) for respiratory distress and increased work of breathing.An observation and interview on 1/11/2026 at 1:16 pm with R50 revealed a BiPAP mask uncovered, unbagged, and on the resident's nightstand. When asked if he uses it, R50 responded that he uses it every night.During an observation on 1/12/2026 at 8:16 am, a BiPAP mask was uncovered, unbagged, and on the resident's nightstand.During an interview on 1/12/2026 at 8:17 am, the Unit Manager confirmed that the BiPAP mask was uncovered and should be placed in a bag.During an interview on 1/15/2026 at 11:24 am, the DNS revealed that BiPAP masks and tubing should be placed in a bag. The DNS further stated that potential negatives outcomes of not following this process could lead to the equipment not being clean and exposure to germs. The DNS further confirmed that the BiPAP orders were added on 1/12/2026 and acknowledged that it was after the observations of the unbagged BiPAP.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure that one of two residents (R) (R9) received care and services for the provision of hemodialysis in accordance with professional standards of practice, including ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. This failure had the potential to cause delays in the identification and treatment of dialysis and related complications, including fluid overload, electrolyte imbalances, and access site complications.Findings included:The facility was unable to provide a dialysis policy. A review of the electronic medical record (EMR) for R9 revealed no communication documents to indicate that information was exchanged with the dialysis center. The record revealed multiple instances of missing or incomplete documentation related to communication between the facility and the dialysis center. A review of R9's physician orders dated 1/12/2026 documented, Location: Right upper extremity AV fistula DO NOT use the access site arm to take blood samples, blood pressure, administer IV fluids, or give injections. 1/12/2026 A review of R9's physician orders dated 1/12/2026 documented, Dialysis: Appointment Monday, Wednesday, Friday. During an interview on 1/12/2026 at 10:21 am, R9 revealed she attended dialysis three times weekly and did not voice concerns regarding her dialysis care or transportation. During an interview on 1/12/2026 at 10:10 am, Licensed Practical Nurse (LPN) CC revealed that when asked about the process for sending the resident to the dialysis center and whether any communication was sent with the resident, she said she believed a book was used for communication, but was not sure. When asked if any documentation of communication was entered into the resident's medical record, she replied that she was not sure. During an interview on 1/16/2026 at 10:55 am, LPN BB revealed that when asked about dialysis resident management, she stated that vital signs were obtained before leaving for dialysis and again upon return from dialysis treatment. She stated that she was unsure whether residents were weighed before and after dialysis, explaining that she had not personally prepared a resident for transport to the dialysis center. During an interview on 1/16/2026 at 11:45 am, Certified Nursing Assistant (CNA) JJ revealed that he was responsible for obtaining resident weights in the facility. He stated that he did not always obtain weights for residents who attend dialysis treatments, explaining that staff generally relied on the weights obtained at the dialysis center. During an interview on 1/14/2026 at 2:40 pm, the Director of Nursing Services (DNS) stated that R9 was expected to have a dialysis communication book that accompanied the resident to and from the dialysis center. The DON further confirmed that there was no documentation in R9's medical record reflecting daily communication with the dialysis center. Following the interview, the DON provided printouts of the dialysis center's vital sign reports for review. During an interview on 1/12/2026 at 3:03 pm, the Unit Manager stated she was unaware of R9's dialysis appointment today. During an additional interview on 1/12/2026 at 3:06 pm, the DNS confirmed that there were no orders for R9's dialysis in the EMR, but confirmed that there should be. The DNS further confirmed that a skin assessment was completed for R9 upon admission, but there was no indication of R9 having a shunt or being a dialysis resident from the skin assessment.

Based on resident and staff interviews, record review, and review of facility policy, the facility failed to report allegations of staff-to-resident abuse to facility administration and/or within two hours to the State Survey Agency (SSA) for two of three residents (Resident (R) 1 and R2) reviewed for abuse out of a total sample of 12. The deficient practice had the potential to place residents at continued risk of abuse.Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 3/5/2024, revealed reporting of all alleged violations . shall be immediate but no later than 2 hours after the allegation is made .1. Review of R1's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the with diagnoses that included but not limited to dementia, anxiety, protein-calorie malnutrition, and muscle weakness. R1 was admitted to hospice care on 07/30/24.Review of R1's Care Plan, dated 11/5/2024 and located under the Care Plan tab of the EMR, revealed a focus of . Fragile Skin: Resident has fragile skin related to the aging process and is at risk for bruising easily and skin tears . Interventions were to notify the physician and responsible party of any changes. Review of R1's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/23/2025 and located under the MDS tab of the EMR, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident could not complete the cognition interview.During an interview on 7/1/2025 at 1:54 PM, the Social Service Worker (SSW) 1, affiliated with the hospice service, stated R1 reported to her on 11/19/2024 that she had been hurt by staff, causing bruising and wounds. SSW1 stated she reported the allegation to the Administrator and the facility Social Service Director (SSD) and filed a report with the Hospice agency. SSW1 stated R1 reported to her again on 3/5/2025 that someone hurt her. SSW1 stated she observed bruising on the resident's left ankle and reported the bruising to the Administrator and to the facility SSD. During an interview on 7/1/2025 at 4:55 PM, the Director of Nursing (DON) stated there were no facility reports or investigation for the allegation reported on 11/19/2024. The DON stated she was aware of the abuse allegation R1 that was reported on 3/5/2025 by the hospice Social Worker regarding R1. The DON stated she had determined the bruise to be related to a fall the resident had on 2/8/2025. The DON could not produce any evidence that the allegation had been reported to the SSA or investigated. During an interview on 7/1/2025 at 5:25 PM, the Administrator stated he was not the Administrator in November 2024. He confirmed that no report of the 11/19/2024 allegation could be located. The Administrator stated they felt the reports from SSW1were retaliatory and that is why they were not investigated or reported and agreed they should have been reported and investigated. During an interview on 7/2/2025 at 10:20 AM, the SSD stated she thought she remembered a conversation about the allegation from R1 on 11/19/2024 but did not report or have any documentation of the incident. The SSD stated she was aware of the allegation reported to the facility on 3/5/2025. The SSD stated she did not report or do an investigation of the allegation because they had determined the bruise looked like an old injury. The SSD could not produce any documentation of the allegation. 2. Review of R2's admission Record, located under the Profile tab of the EMR, revealed she was admitted with diagnoses that included but not limited to heart failure, kidney failure, depression, hypertension, and muscle weakness. R2 was admitted to hospice care on 8/9/2024.Review of R2's quarterly MDS with an ARD 6/5/2025 and located under the MDS tab of the EMR, revealed R2 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact.During an interview on 7/2/2025 at 12:05 PM, R2 stated that she was treated very roughly. R2 stated she had a very sore body and felt like the staff did not care if they hurt her. During an interview on 7/2/2025 at 12:12, Family Member (F) 1 stated that R2 has complained about rough treatment from staff, and he had concerns that staff was unconsciously mistreating R2.During an interview on 7/2/2025 at 3:17 PM, the SSD stated that on 2/28/2025, a Certified Nurse Aide (CNA) had reported to her that R2 had alleged a staff member had held her hand too hard and hurt her. The SSD stated she had documented the allegation in her daily planner but did not report or investigate the allegation. The SSD stated she did not remember who the reporting CNA was. The SSD confirmed she should have reported and investigated the allegation. During an interview on 7/3/2025 at 9:05 AM, the Administrator stated he was not aware that these issues were not reported or thoroughly investigated. The Administrator stated he was concerned that the allegations were not investigated appropriately and agreed that all injuries of unknown origin should be taken seriously and investigated thoroughly.

Based on staff interviews, record review, and review of facility policy, the facility failed to identify and/or investigate allegations of staff-to-resident abuse for two of three residents (Resident (R) 1 and R2) reviewed for abuse out of a total sample of 12. The deficient practice had the potential to allow abuse to continue. Findings include:Review of the facility policy titled, Abuse, Neglect and Exploitation, dated 3/5/2024, revealed, . An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . 1.Review of R1's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed she was admitted with diagnoses that included but not limited to dementia, anxiety, protein-calorie malnutrition, and muscle weakness. R1 was admitted to hospice care on 7/30/2024.Review of R1's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 4/23/2025 and located under the MDS tab of the EMR, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident could not complete the cognition interview.Review of R1's Care Plan, located under the Care Plan tab of the EMR and dated 11/5/2024, revealed a focus of, . Fragile Skin: Resident has fragile skin related to the aging process and is at risk for bruising easily and skin tears . Interventions were to notify physician and responsible party of any changes. Review R1's Change of Condition Evaluation, dated 2/8/2025 and located under the Assessment tab of the EMR, revealed R1 had a fall. It was recorded R1 did not sustain an injury, and there were no changes observed on the skin evaluation.Review of R1's Weekly Skin Assessment, dated 2/12/2025 and located under the Assessment tab of the EMR, revealed R1 did not have any bruises, and her skin was intact. Review of R1's Weekly Skin Assessment, dated 2/19/2025 and located under the Assessment tab of the EMR, revealed R1 did not have any bruises, and her skin was intact. During an interview on 7/1/2025 at 1:54 PM, the Social Service Worker (SSW)1, affiliated with the hospice service, stated R1 reported to her on 11/19/2024 that she had been hurt by staff, causing bruising and wounds. SSW1 stated she reported the incident to the Administrator and the facility Social Service Director (SSD) and filed a report with the Hospice agency. SSW1 stated R1 reported to her again on 3/5/2024 that someone had hurt her. SSW1 stated she observed bruising on R1's left ankle and reported the bruising to the Administrator and to the facility SSD.During an interview on 7/1/2025 at 4:55 PM, the Director of Nursing (DON) stated there were no investigations into the allegation of abuse for R1 reported on 11/19/2024. The DON could not produce any evidence that the allegation had been investigated. During an interview on 7/1/2025 at 5:25 PM, the Administrator stated no report of the allegation for R1 could be located. The Administrator confirmed the allegations should have been investigated. 2. Review of R2's admission Record, located in in the EMR under the Profile tab, revealed R2 was admitted to the facility with diagnoses that included but not limited to heart failure, kidney failure, depression, hypertension, and muscle weakness. Review of R2's quarterly MDS, with an ARD of 6/5/2025 and located under the MDS tab of the EMR, revealed a BIMS score of 13 out of 15, which indicated the resident was cognitively intact.A review of the facility incident report, dated 11/13/2024 and provided by the facility, revealed that a family friend of R2 noted bruising on R2 on 11/10/2024 but did not report it to staff until 11/13/2024. The report indicated the Administrator was notified on 11/13/2024 by staff. The report indicated the bruising was reported to the appropriate agencies and the investigation was started immediately by the Administrator. Further review of the investigation revealed that staff were interviewed about the bruising; however, there was no documented evidence that R2 was interviewed about the bruising. There was no documented evidence that other residents were interviewed. There was no documented evidence that the event was analyzed to determine how the bruising occurred and how to prevent further incidents. There was no documented evidence that staff had been trained or in-serviced on the reporting or investigating injuries of unknown origin. There was no documented evidence on how to protect the resident and any risk factors they might need to address to prevent further incidents. The follow-up report was submitted within the five-day timeframe; however, there was no documented evidence that any follow-up by social services or any measures that were taken to verify any corrective actions were implemented. During an interview on 07/03/25 at 9:05 AM, the Administrator stated he was not aware that these allegations were not thoroughly investigated. The Administrator stated he was concerned that the allegations were not investigated appropriately and agreed that all injuries of unknown origin should be taken seriously and investigated thoroughly.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect a significant weight loss for two of 12 residents (Resident (R) 8 and R5) reviewed. The deficient practice had the potential to result in unmet care needs.Findings include: Review of the facility's policy titled, Conducting an Accurate Resident Assessment, dated 3/20/2025, revealed, . Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status . The physical, mental, and psychosocial condition of the resident determines the appropriate level of involvement of physicians, nurses . dietitians, and other professionals .1. Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R8 was re-admitted to the facility on [DATE] following a hospital stay, which started 3/6/2025. She had diagnoses that included dysphagia (difficulty swallowing).Review of R8's Weight Summary, located under the Wts/Vitals tab of the EMR, revealed R8's weight on 3/22/2025 was 126.0 lbs. R8 weighed 112 pounds (lbs) on 4/4/2025 and weighed 115 lbs on 4/20/2025, representing a significant weight loss of 8.73% (11 lbs).Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/23/2025 and located under the MDS tab of the EMR, revealed R8 scored four out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R8 was severely cognitively impaired. It was recorded that R8 weighed 115 lbs but failed to record a significant weight loss.Review of R8's Care Plan, located in the Care Plan tab of the EMR, revealed a focus area, [Resident] has a potential risk for weight loss related to dysphagia and disease process revised on 10/3/2022. It did not document the significant weight loss.During an observation on 7/2/2025 at 12:38 PM, R8 was observed eating her meal independently. When asked how her meal was, R8 repeated several times that she was skinny and touched her abdomen. 2. Review of R5's admission Record, located under the Profile tab of the EMR, revealed R5 was re-admitted to the facility on [DATE] following a hospital stay which began on 4/19/2024. R5 had diagnoses that included Parkinson's disease and other disorders of the brain. R5 was discharged from the facility to the hospital on 9/22/2024 and did not return.Review of R5's Weight Summary, located under the Wts/Vitals tab of the EMR, revealed R5's weight on 4/23/2024 was 149.2 lbs and on 4/30/2024 was 153 lbs. R5's next weight was 129 lbs on 5/28/2024, representing a 13.54% weight loss (20.2 lbs) in one month.Review of R5's Progress Note, dated 6/4/2024, written by the Nurse Practitioner (NP), and located under the Progress Notes, tab revealed Remeron was ordered for appetite stimulation due to weight loss. Review of R5's Progress Note, dated 7/10/2024 and located under the Progress Notes tab of the EMR, revealed R5 was assisted with all meals, family brought snacks, and the Registered Dietician (RD) was following R5.Review of R5's quarterly MDS, with an ARD of 7/11/2024 and located under the MDS tab of the EMR, revealed R5 scored 14 out of 15 on the BIMS, which indicated R8 was cognitively intact. It was recorded that R5 weighed 122 lbs, but failed to code weight loss.Review of R5's Care Plan, located in the Care Plan tab of the EMR, revealed a focus area, The resident is at risk for altercation in nutrition/hydration secondary to: poor po [oral] intake. 4/24/2024 hospital return-weight gain trend; 8/6/2024 quarterly review- SWL [significant weight loss] with revision date of 8/6/2024. During an interview on 7/2/2025 at 4:20 PM, the RD reported she assisted with the MDS assessments. During an interview on 7/2/2025 at 5:10 PM, the RD confirmed R8's and R5's MDS assessments did not reflect that the residents had a significant weight loss. She stated there was significant weight loss which someone failed to document. During an interview on 7/2/2025 at 6:44 PM, the Director of Nursing (DON) reported she expected the MDS to reflect significant weight loss.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to update care plans to reflect a significant weight loss with current intervention for two of 12 residents (Resident (R) 8 and R5) reviewed. The deficient practice had the potential to result in unmet care needs regarding nutrition. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 3/20/2025, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment .1. Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R8 was re-admitted to the facility on [DATE] following a hospital stay, which started 3/6/2025. She had diagnoses that included dysphagia (difficulty swallowing).Review of R8's Weight Summary, located under the Wts/Vitals tab of the EMR, revealed R8's weight on 3/22/2025 was 126.0 pounds (lbs). R8 weighed 112 lbs on 4/4/2025, representing a significant weight loss.Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/23/2025 and located under the MDS tab of the EMR, revealed R8 scored four out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R8 was severely cognitively impaired. It was recorded that R8 weighed 115 lbs but failed to record a significant weight loss.Review of a 5/24/2025 Weight Change Note, completed by the Registered Dietician (RD) and located in the Progress Notes tab of the EMR, revealed significant weight loss at one and three months and revealed R8 refused the supplement due to dislike of the milky base. The RD recorded she spoke with the nurse practitioner about changing her appetite stimulant to Remeron. The RD recommended replacing the two cal supplement with Ensure Clear three times a day and adding a Magic Cup (fortified frozen dessert) with lunch and dinner.Review of the Order Recap from 3/22/2025 to 7/2/2025 revealed R8 started Remeron on 3/22/2025, and it was increased in dosage on 3/25/2025. R8 continued on the two cal supplement and had no orders for Ensure Clear or Magic Cup. There were no orders for routine weights.Review of R8's Care Plan, located in the Care Plan tab of the EMR, revealed a focus area, [Resident] has a potential risk for weight loss related to dysphagia and disease process, revised on 10/3/2022. Goals, revised on 6/14/2025, included, . nutrition and hydration needs will be met through the next review date . risk of weight loss will be minimized . Interventions included, Administer medications as ordered, revised on 12/27/2016, Invite me to activities that promote additional intake., revised 5/11/2021, Monitor/document/report [as needed] any signs/symptoms of dysphagia, revised 12/27/2016, Obtain and monitor lab/diagnostic work as ordered, revised 5/11/2021, Provide and serve diet as ordered, revised 12/27/2016, RD to evaluate and make diet change recommendations as needed, revised 12/27/1206, and Supplements as ordered, revised 6/16/2021. No new interventions were documented since 6/16/2021.During an observation on 7/2/2025 at 12:38 PM, R8 was observed eating her meal independently. There was no Magic Cup on the tray. When asked how her meal was, R8 repeated several times that she was skinny and touched her abdomen. When asked if she liked or received ice cream or a frozen dessert, she reported she liked it, but it comes and goes.During an interview on 7/2/2025 at 3:40 PM, Certified Nurse Aide (CNA)1 reported R8 fed herself and had a fair appetite but was not much of a breakfast eater. CNA1 was not aware of any weight loss interventions for R8 but stated that Magic Cups were available as other residents received them on their trays.During an interview on 7/2/2025 at 3:41 PM, CNA2 stated that R8 fed herself. When asked about weight loss interventions, CNA2 said R8's diet changed to mechanical soft when she had an issue with her jaw. The diet remained the same over the last several months.2. Review of R5's admission Record, located under the Profile tab of the EMR, revealed R5 was re-admitted to the facility on [DATE] following a hospital stay which began on 4/19/2024. R5 had diagnoses that included but limited to Parkinson's disease and other disorders of the brain. R5 was discharged from the facility to the hospital on 9/22/2024 and did not return.Review of a Nutrition/Dietary Note dated 5/21/2024, located in the Progress Notes tab of the EMR, revealed R5 had a fair appetite, was assisted with meals, and saw speech therapy for dysphagia. R5 triggered MDS for a significant weight gain with weights of 143 lbs on 3/29/2024 and 153 lbs on 4/30/2024.Review of R5's Weight Summary, located under the Wts/Vitals tab of the EMR, revealed R5's weight on 4/23/2024 was 149.2 lbs and on 4/30/2024 was 153 lbs. R5's next weight was 129 lbs on 5/28/2024, representing a 13.54% weight loss in one month.Review of the Progress Notes tab revealed Physician Notes by a nurse practitioner. On 6/4/2024 a note indicated Remeron was ordered for appetite stimulation due to weight loss. On 7/10/2024 a note revealed R5 was assisted with all meals, family brought snacks, and the RD was following R5.Review of R5's quarterly MDS, with an ARD of 7/11/2024 and located under the MDS tab of the EMR, revealed R5 scored 14 out of 15 on the BIMS, which indicated R8 was cognitively intact. It was recorded that R5 weighed 122 pounds (lbs.) but failed to code weight loss.Review of R5's RD Nutrition Assessment, dated 8/6/2024, and located in the Evaluations tab of the EMR, revealed R5 had a significant weight loss and received 2.0 kcal (kilocalorie, a unit of measurement for energy) supplement 90 mL (milliliters) three times a day. The RD recommended adding fortified foods to meals and increasing the supplement to 120 mL three times a day.Review of a Weight Change Note, dated 9/11/2024 and located in the Progress Notes tab of the EMR, revealed R5 had significant weight loss at three and six months. It recorded nutrition interventions were added/increased to include liquid protein 30 mL twice daily and 2.0 kcal supplement 120 mL twice daily. Weekly weights were added.Review of R5's Care Plan, located in the Care Plan tab of the EMR, revealed a focus area, The resident is at risk for altercation in nutrition/hydration secondary to: poor po [oral] intake. 4/24/2024 hospital return-weight gain trend; 8/6/2024 quarterly review- SWL [significant weight loss] with revision date of 8/6/2024. Interventions were all dated 4/10/2024 and included, Alert dietician if indicated, assist and encourage at meals as needed, monitor lab values, and supplements provided as ordered.During an interview on 7/2/2025 at 5:10 PM, the RD confirmed R8's Care Plan did not state she had a significant weight loss. When asked if she would expect the Care Plan to reflect a weight loss with person-centered interventions, the RD stated her understanding was that she was to review the Care Plan and make sure it was current. The interventions were not specific, but the details of them were in her notes in the EMR.During an interview on 7/2/2025 at 6:44 PM, the Director of Nursing (DON) reported she expected the Care Plan to reflect a significant weight loss. She expected that interventions were updated but not necessarily specific. The DON stated she was taught to put in general statements such as supplements as ordered.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to identify a severe weight loss, re-assess nutritional needs, and implement interventions in a timely manner to aid in the prevention of weight loss for two of 12 residents (Resident (R) 8 and R5) reviewed. R8 had a recorded weight loss of 18.65% (percent) in less than three months. R5 had a recorded weight loss of 19.57% in five months. Findings include: Review of the undated facility policy titled, Weight Management Policy and Procedure revealed a weight report which reflected significant weight changes was generated monthly (by the 10th of the month) and reviewed by the dietary manager, Registered Dietician (RD), and Director of Nursing (DON). A significant weight change was defined as 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. Weekly weights were completed for residents exhibiting significant weight changes.1. Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R8 was re-admitted to the facility on [DATE] following a hospital stay, which started 3/6/2025. She had diagnoses that included dysphagia (difficulty swallowing).Review of a Nutrition Note, dated 3/5/2025 (prior to the resident's hospitalization) and located in the Progress Notes tab of the EMR, revealed that she was at risk for inadequate oral intake related to chewing difficulty. She was changed to a mechanical soft diet. R8's supplement (two cal) was increased to 90 milliliters (mL) four times a day.Review of R8's Weight Summary, located under the Wts/Vitals tab of the EMR, revealed R8's weight on 3/22/2025 was 126.0 pounds (lbs). R8 weighed 112 lbs on 4/4/2025, representing an 11.11% weight loss, and weighed 115 lbs on 4/20/2025, representing an 8.73% weight loss in one month. R8 continued to lose weight and weighed 102.5 lbs on 6/9/2025, which was her last recorded weight as of 7/1/2025. This represented an 18.65% (23.5 lbs) significant weight loss in three months.Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/23/2025 and located under the MDS tab of the EMR, revealed R8 scored four out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R8 was severely cognitively impaired. It was recorded that R8 weighed 115 lbs but failed to record a significant weight loss.Review of the Progress Notes and Evaluations tabs of the EMR revealed no documentation of weight loss until a 5/24/2025 Weight Change Note was completed by the RD. The note documented significant weight loss at one and three months and revealed R8 was refusing the supplement due to dislike of the milky base. The RD recorded she spoke with the nurse practitioner about changing R8's appetite stimulant to Remeron. The RD recommended replacing the two cal supplement with Ensure Clear three times a day and adding a Magic Cup (fortified frozen dessert) with lunch and dinner.Review of the Order Recap from 3/22/2025 to 7/2/2025 revealed R8 started Remeron on 3/22/2025, and it was increased in dosage on 3/25/2025. R8 continued on the two cal supplement and had no orders for Ensure Clear or Magic Cup. There were no orders for routine weights.Review of R8's Care Plan, located in the Care Plan tab of the EMR, revealed a focus area, [Resident] has a potential risk for weight loss related to dysphagia and disease process revised on 10/3/2022. Goals, revised on 6/14/2025, included, nutrition and hydration needs will be met through the next review date and risk of weight loss will be minimized. Interventions were last revised in the year 2021.Observations of R8 in her room on 7/1/2025 at 12:30 PM and 12:50 PM revealed R8 seated in her wheelchair with her plate, cover in place, by her on a table. During an observation on 7/2/2025 at 12:28 PM, R8's meal tray was delivered to her room and set up in front of her as she sat in her wheelchair. Staff left to deliver more room trays. At 12:38 PM, R8 was observed eating her meal independently. There was no Magic Cup on the tray. When asked how her meal was, R8 repeated several times that she was skinny and touched her abdomen. When asked if she liked or received ice cream or a frozen dessert, she reported she liked it, but it comes and goes.During an interview on 7/2/2025 at 3:40 PM, Certified Nurse Aide (CNA)1 reported the restorative aide (RA) weighed the residents. CNA1 reported R8 fed herself and had a fair appetite but was not much of a breakfast eater. CNA1 was not aware of any weight loss interventions for R8 but stated that Magic Cups were available as other residents received them on their trays.During an interview on 7/2/2025 at 3:50 PM, the RA reported he weighed residents weekly when they had a weight loss. The RA wrote down the weights and gave them to the DON to record in the EMR. The RD and DON determined who was weighed weekly, and the RD spoke to him about residents with weight changes. He was unable to recall if R8 was weighed weekly and stated he had to check his binder. He thought she may have refused, and he did not want to upset her, so he did not continue them. He was unable to recall the RD speaking with him about any weight loss for R8.During an interview on 7/2/2025 at 4:20 PM, the RD reported she ran a monthly report for one-, three-, and six-month weight losses. The facility was able to reach out to her in between her visits with concerns, and she was in the facility at least one day a week. She reported that the policy was that residents who were high risk were put on weekly weights. The RD reported she had a month to do significant weight change assessments. She assisted with the MDSs and Care Plans. When she had recommendations, she provided them to the DON who put the orders in the EMR. During an interview on 7/2/2025 at 5:10 PM, the RD confirmed R8 had a significant weight loss from 3/22/2025 to 4/4/2025, and she did not record any assessment until 5/24/2025. She confirmed there were no orders for her recommendations regarding supplements on 5/24/2025 and that the Care Plan and the MDS did not reflect the significant weight change.During an interview on 7/2/2025 at 6:44 PM, the DON reported a resident with a significant weight loss was on weekly weights. The DON called the RD with any concerns and spoke to her when she was in the facility, which was at least weekly. The Medical Director and nurse practitioner attended the weekly at risk meetings when residents with significant weight loss were discussed. The RD emailed the DON her recommendations, and the DON put orders into the EMR for supplements provided by nursing. Items such as a Magic Cup, which dietary provided on meal trays, were not ordered. The DON expected the RD to put in a note or evaluation with any significant weight loss. The DON expected a MDS to be accurately coded to reflect a significant weight loss and expected the Care Plan to reflect a significant weight loss. 2. Review of R5's admission Record, located under the Profile tab of the EMR, revealed R5 was re-admitted to the facility on [DATE] following a hospital stay which began on 4/19/2024. R5 had diagnoses that included Parkinson's disease and other disorders of the brain. R5 was discharged from the facility to the hospital on 9/22/2024 and did not return.Review of a Nutrition/Dietary Note dated 5/21/2024, located in the Progress Notes tab of the EMR, revealed R5 had four pressure ulcers, had a fair appetite, was assisted with meals, and saw speech therapy for dysphagia. R5 triggered MDS for a significant weight gain with weights of 143 lbs on 3/29/2024 and 153 lbs on 4/30/2024.Review of R5's Weight Summary, located under the Wts/Vitals tab of the EMR, revealed R5's weight on 4/23/2024 was 149.2 lbs and on 4/30/2024 was 153 lbs. R5's next weight was 129 lbs on 5/28/2024, representing a 13.54% weight loss in one month. R5 continued to lose weight and weighed 120.4 lbs on 9/22/2024.Review of the Progress Notes tab revealed Physician Notes by a nurse practitioner. On 6/4/2024 a note indicated Remeron was ordered for appetite stimulation due to weight loss. On 7/10/2024 a note revealed R5 was assisted with all meals, family brought snacks, and the RD was following R5.Review of R5's quarterly MDS, with an ARD of 7/11/2024 and located under the MDS tab of the EMR, revealed R5 scored 14 out of 15 on the BIMS, which indicated R8 was cognitively intact. It was recorded that R5 weighed 122 pounds (lbs.) and failed to record a weight loss. Review of the Progress Notes and Evaluations tabs of the EMR revealed no documentation of weight loss by the RD until 8/6/2024 when an RD Nutrition Assessment was completed, located in the Evaluations tab. The RD documented a significant weight loss at 90 and 180 days and recorded that R5 received 2.0 kcal supplement 90 mL three times a day. The RD recommended adding fortified foods to meals and increasing the supplement to 120 mL three times a day.Review of a Weight Change Note, dated 9/11/2024 and located in the Progress Notes tab of the EMR, revealed R5 had significant weight loss at three and six months. It recorded nutrition interventions were added/increased to include liquid protein 30 mL twice daily and 2.0 kcal supplement 120 mL twice daily. Weekly weights were added.Review of the Order Summary Report, dated 9/15/2024, and the Order Recap Report from 4/22/2024 to 9/15/2024, located in the Orders tab of the EMR, revealed R5's liquid protein was already ordered at 30 mL twice daily as of 4/10/2024, and the 2.0 kcal supplement was ordered at 120 mL three times daily on 4/10/2024. No changes were made following the recommendations of08/06/2024 and 9/11/2024.Review of R5's Care Plan, located in the Care Plan tab of the EMR, revealed a focus area, The resident is at risk for altercation in nutrition/hydration secondary to: poor po [oral] intake. 4/24/2024 hospital return-weight gain trend; 8/6/2024 quarterly review- SWL [significant weight loss] with revision date of 8/6/2024. Interventions were all dated 4/10/2024.During an interview on 7/2/2025 at 4:20 PM, the RD reported she started at the facility in December and so was unfamiliar with R5. During an interview on 7/2/2025 at 6:44 PM, the DON reported she started in November and so was unfamiliar with R5. She expected timely nutritional assessments after weight loss with interventions. She expected an MDS to be accurately coded to reflect a significant weight loss and expected the Care Plan to reflect a significant weight loss with updated interventions.

Based on staff interviews, record review, review of the facility's policy titled Nurse Aide Training Program, and review of the Alliant Certified Nursing Assistant (CNA) Annual Report, the facility failed to monitor and verify two of 29 CNAs (CNA AA and CNA FF) completed the minimum required training hours during the last review period of February 1, 2023 - January 31, 2024. The facility census was 87 residents. Findings include: Review of the policy titled Nurse Aide Training Program dated February 1, 2022, under the section titled Policy Explanation and Compliance Guideline revealed, 2. Each nurse aide shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year. (b). It is the responsibility of the employee to attend/complete mandatory in-service training to maintain employment with the facility. Review of the Alliant Certified Nursing Assistant (CNA) Annual Report, dated 7/5/2024 for review period 2/1/2023 - 1/31/2024 revealed, a staff development review was conducted on 7/5/2024. Under the section titled, Problems revealed, Two (2) full time CNAs without the required 12 in-service hours per the code of Federal Regulations (42CFR483.35/483.95). Under the section titled, Recommendations revealed, Please submit a plan of correction on how the facility will monitor CNA staff for required in-service hours in the future within 30 days. Under the section titled, Comments revealed, Please ensure that your yearly in-services are not limited to the following but include additional topics on Quality of care, transfers, turning and positioning, incontinent care/skin care weight loss, Alzheimer's, cognitively impaired and dining techniques (feeding, assistive devices .etc.). Under the section titled Staff Review CNA revealed, each CNA who did not meet the Federal in-service requirements with their certification date, certification number, certification expiration date, total of in-service hours completed during the review period. During the review period CNA AA who worked part time completed five hours and thirty minutes (5.50) hours out of the six (6) required minimum, and CNA FF who worked full-time completed one and fifteen hundredths (1.15) hours out of the 12 required hours. Interview on 8/27/2024 at 9:50 am with the Assistant Director of Nursing (ADON) revealed that all of management was responsible for overseeing in-services and education and there was no designated person. The ADON further revealed, she was not aware that CNA AA and CNA FF were not in compliance with their in-service hours, and it was her expectation that all staff should be up to date with their in-service education. Interview on 8/27/2024 at 9:53 am with CNA AA revealed that she was not aware she did not meet the in-service education requirement during the facilities audit period. She stated that she had received training, and thought it was all completed. She stated she would complete the rest of the education that was needed. Interview on 8/27/2024 at 12:41 pm with the Director of Nursing revealed her expectations was that all CNA's were to have their in-service hours completed because it could possibly have a negative outcome if in-service hours were not complete and that could affect the residents safety.

Based on resident and staff interviews, review of resident council minutes, and review of the facility's policy's titled Resident Council Meeting policy, the facility failed to assure that a follow-up was completed and communicate its decisions related to resident concerns and recommendation voiced during resident council meetings. This deficient practice had the potential to have an adverse effect on any resident who voiced a concern and/or recommendation. The facility census was 87 residents. Findings Include: Review of the facility's policy titled Resident Council Meetings, dated 2/2/2022, under the section titled Policy revealed, This facility supports the rights of residents to organize and participate in residents' groups, including a Resident Council. This policy provides guidance to promoting structure, order, and productivity in these group meetings. Under the section titled Policy and Explanation and Compliance Guidelines revealed, 5. The Activity Director shall be designated if approved by the group, to serve as a liaison between the group and facilities administration and any other staff members. (b). The designated liaison shall be responsible for providing assistance with facilitating successful group meetings and responding to written requests from group meetings. 6. The group may appoint a resident to take notes/maintain meetings or may elect that the Activity Director/ designated liaison to take notes/maintain minutes. Meeting minutes may include but are not limited to: (a). Names of residents in attendance; (b). Follow up from previous meetings; (c). Issues discussed; (d). Recommendations from the group to the facility; (e). Name of staff members, speakers, and other guests present in the meetings (as invited by the group to attend). 7. The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the council. Record review of the facility-provided documents titled Resident Council Meeting from 10/2/2023 through 7/9/2024 revealed nine Resident Council meeting minutes handwritten or typed. A continued review of the forms revealed nine (9) incomplete Resident Council Meeting minutes due to an omission of a response to provide evidence that concerns and /or recommendations was thoroughly investigated, and a resolution was obtained to determine resident satisfaction. The form also omitted documentation to show that actual follow-up was made with the complainant to determine complainant or resident satisfaction. During a Resident Council Meeting on 8/27/2024 at 10:09 am, with the following residents in attendance (R26, R44, R25, R69, R66 and R85) all revealed, that they voiced their concerns and/or recommendations, and no one had got back to them with any resolutions or follow-ups. All six of the six residents attending the meeting stated they did not know how to file a grievance or who the grievance official was but believe it to be the Administrator. Interview by phone on 8/27/2024 at 1:26 pm with the Activity Director (AD) revealed that resident council meetings were held every first Monday of every month and if residents or herself was not available they would choose a different day. She further revealed that she hand a copy of the Resident Council Meeting Minutes during the facility monthly Quality Assurance and Performance Improvement (QAPI) meeting to be discussed among the QAPI team. The AD further revealed she verbally let the residents know about the resolutions to their concerns, and confirmed there was no documentation or history of resolutions to residents' concerns. She further stated if an issue could not be resolved then she would go to the Administrator, or she would contact the Ombudsman. She further revealed she was not aware that the resolutions were supposed to be documented. Interview on 8/27/2024 at 2:07 pm with the Director of Nursing (DON) revealed Resident Council Meetings were held once a month and minutes were taken which was managed by the AD. She stated if concerns like food was brought up at the meetings, then it was taken to Dietary Manager or if there were concerns with call lights then it would be brought to her. She further revealed that they do their best to resolve or accommodate the residents' concerns. The DON further revealed she was aware that resolutions to residents' concerns must be documented, and her expectations were that staff must document resolutions.

Based on observations, resident and staff interviews, and review of the facility's policy titled, Maintenance Inspection, the facility failed to maintain the facility in a safe, clean, comfortable, homelike environment as evidenced by six of 56 resident rooms with furniture and/or packaged terminal air conditioners (PTACs) in disrepair. Specifically, rooms A6-2, B10-1, C18-2 had dressers with missing drawers and/or knobs and rooms C13, C15, C18, and C19 had PTACs that leaked water onto the floors. This deficiency had to potential to diminish the quality of life for the residents in rooms with dilapidated furniture and create a safety hazard for residents in rooms with leaking PTAC units. Findings include: Review of the facility's policy titled, Maintenance Inspection, dated 8/1/2022, under the section titled, Policy Explanation and Compliance Guidelines revealed, 1. The Director of Maintenance Services will perform routine inspections of the physical plant using a Maintenance Checklist. 3. All opportunities will be corrected immediately by maintenance personnel. 1. Observation and interview on 8/25/2024 at 2:43 pm with Resident (R) R8 in her room (B10-1) revealed, she was alert and oriented. Observation of the room revealed a dresser which was missing knobs from two of three drawers. She stated the knobs were always missing. Observation of resident rooms on 8/25/2024 beginning at 3:00 pm revealed the following: 2. A6-1: dresser missing the bottom drawer, both knobs from the middle drawer, and one knob from the bottom drawer. 3. C13-2: missing top dresser drawer, dirty PTAC filters. 4. C15: leaking PTAC. 5. C18-2: dresser missing two of three drawers and leaking PTAC. 6. C19: leaking PTAC. Observation and interview on 8/28/2024 beginning at 2:00 pm with the Maintenance Director revealed, he confirmed the aforementioned observations and stated the concerns were his responsibility. He stated the PTACs have been leaking off and on over the last month due to the extreme heat which caused increased condensation that leaked onto some of the floors. He stated the units still work but some of them are not forcing the fluid to the outside. He stated he clean those floors with the wet vac every two to three days. He stated there were no immediate plans to replace any PTACs. He further stated it was difficult to make routine rounds because he worked alone and usually addressed staff concerns right away.

Based on observations, staff interviews, and review of the facility's policy titled, Hand Hygiene, the facility failed to ensure hand hygiene practices were maintained to prevent the potential for infections and cross contamination. Specifically, the facility failed to perform hand hygiene after passing out each meal tray for residents on one of three halls (Hall A) that was observed during lunch. Findings Include: Review of the facility's policy titled Hand Hygiene, dated February 1, 2022, under the section titled Policy revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Under the section titled Policy Explanation and Compliance Guidelines revealed, 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under conditions listed in, but not limited to, the attached hand hygiene table. 3. Alcohol based hand rub with 60% to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. Observation on 8/26/2024 at 12:50 pm revealed, Certified Nursing Assistant (CNA) CC and CNA DD was observed passing out lunch trays to residents on Hall A. CNA CC and CNA DD were observed walking out of room A5 and not using hand sanitizer. Registered Nurse (RN) EE was observed approaching CNA CC and CNA DD and reminded them to use hand sanitizer in between passing meal trays. During continuous observation CNA CC and CNA DD were observed walking out of Room A7 and A10 without using hand sanitizer. Interview with on 8/26/2024 at 12:55 pm with CNA CC revealed she was aware that hand sanitizer was supposed to be used after the passing of each lunch tray. CNA CC revealed she forgot to use hand sanitizer. CNA CC stated she had not received any handwashing hygiene training since she started working at the facility. Interview on 8/26/2024 at 12:57 pm with CNA DD revealed she was aware that hand sanitizer was supposed to be used after the passing of each lunch tray. CNA DD revealed she forgot to use hand sanitizer. CNA DD also stated she had not received any handwashing hygiene training since she had started working at the facility but did learn it during her CNA class training. Interview on 8/27/2024 at 4:49 pm with the Director of Nursing revealed it was her expectation for all CNAs to use proper hand hygiene between dropping off meal trays to residents. She further revealed a possible negative outcome of not following proper hand hygiene as issues with infection control and resident safety regarding germs.

Based on staff interviews, record review, and review of the facility's policy titled Documentation in Medical Record, the facility failed to ensure accurate documentation was completed regarding a change of condition for one resident (R) (R1) out of six sampled residents reviewed for notification of change. Findings Include: Review of the undated facility's policy titled, Documentation in Medical Record under Policy revealed, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Under the section titled Policy Explanation and Compliance Guidelines revealed, 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. Review of R1's medical records revealed diagnoses that included, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, end stage renal disease, major, unspecified dementia, anemia in chronic kidney disease, dysphagia, dependence on renal dialysis. Review of R1's Annual Minimum Data Set assessment dated [DATE] for Section C (Cognitive Patterns) revealed the Brief Interview of Mental status was not conducted related to the resident was rarely/never understood. Review of R1's Hospital ED (Emergency Department) provider Note dated 7/18/2024 at 9:04 am under Medical Decision Making revealed, R1 presented with altered mental status (AMS). Under ED Diagnosis revealed final diagnoses that included, hypernatremia, dehydration, acute respiratory failure, sepsis, pneumonia of both lungs, and fever. Under the Hospital Problems section, the Assessment & Plan that included Septic shock revealed, R1 was presented with fever 104.7, altered mental status, elevated lactic acid 2.2, and leukocytosis. Most likely source in resp (respiratory) nature based on imaging. Initially LP (lumbar punctures) was completed based on high fever as well as AMS but CSF (cerebrospinal fluid) with high glucose and only minimally elevated protein. Review of the facility's 24-hour report dated 7/18/2024 revealed there was no documentation related to R1's change of condition. Review of R1's nurses notes, and Situation, Background, Assessment, and Recommendation (SBAR) report revealed there was no documentation related to R1's change of condition. Review of R1's Progress Notes dated 7/22/2024 at 1:51 pm revealed late entries for a Nurses Note, Physician Note, and SBAR communication was completed after the surveyor had questioned staff regarding the change of condition that resulted with the resident being sent to the ED. Interview on 7/22/2024 at 10:05 am with Nurse Practitioner (NP) CC revealed that she came in on Friday morning and was told by the nurse that R1 was transitioning but did not know how long she had been in that condition. She revealed that she did an assessment that found that R1 was difficult to arouse with rapid breaths. She revealed vital signs were checked and 911 was notified. She revealed that R1 was transported out by EMS wearing an O2 (oxygen) mask. Interview on 7/22/2024 at 11:40 am with the Administrator revealed that an interview was conducted with the nurse who stated that she and NP CC assessed the resident for her change in condition, but she forgot to chart the information. She revealed that further investigation revealed no evidence of documentation of R1's change of condition in R1's medical record, nurses notes, 24-hour report, or SBAR report. She revealed that NP CC revealed that she only wrote an order to send R1 out for evaluation, but not why. She revealed that the Licensed Practical Nurse (LPN) FF and the NP CC have had documentation training and have written late entry notes for the change of condition for the resident. Interview on 7/22/2024 at 1:30 pm with LPN FF revealed that it was change of shift and she thought she had charted everything down. She confirmed she did not see the information in the chart She revealed that she sent all the transfer information with the Emergency Medical Services (EMS) but did not chart information on the SBAR form. Interview on 7/22/2024 at 2:14 pm with CNA HH revealed that he provided care to R1 throughout the night. He revealed that there was something different in the resident's behavior throughout the night. He revealed that when he provided incontinent care to the resident throughout the night, she would fight with him; however, on that night she would fight but not as hard as you usually did. He revealed that the resident was checked on every two hours. He revealed that on his last rounds the resident looked like she was declining. He revealed that he reported it to the nurse, she came and checked on the resident, vital signs were done, sent resident out to ER (emergency room ). Interview on 7/22/2024 at 2:45 pm with the Assistant Director of Nursing (ADON) JJ revealed that she checked the 24-hr report book and there was no information written about the change of condition for R1. She confirmed that there was no documentation in the nurses' notes. She reported that all staff had been trained on the documentation policy.

Based on observations, interviews, and policy review, the facility failed to ensure staff entering the kitchen wore a hairnet, failed to ensure food items were labeled, dated, and discard after Best Use By date, and failed to ensure dietary staff properly used the three-compartment sink to prevent food borne illness. All 92 residents were receiving an oral diet. Findings include: 1. Review of facility policy titled Food Safety Requirements dated [DATE], revealed under 'Policy Explanation and Compliance Guidelines' number 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. Hairnets should be worn. Observation on [DATE] at 8:32 a.m. revealed Certified Nursing Assistant (CNA) KK entered the kitchen and was standing in the food preparation area without wearing a hairnet. Interview on [DATE] at 8:32 a.m. with CNA KK, confirmed that she was in the food preparation area and was not wearing a hair net. She stated that she needed dietary staff assistance and went into the food preparation area to find someone. The CNA revealed that she should have been wearing a hairnet while in the kitchen. Interview on [DATE] at 8:55 a.m. with the Certified Dietary Manager (CDM) revealed that nursing staff are to stand at the kitchen door and ask dietary staff for assistance with resident items or nursing staff is to wear a hairnet if they plan to walk into the kitchen food preparation area. Interview on [DATE] at 10:35 a.m. with License Practical Nurse (LPN) Unit Manager (UM) revealed if nursing staff need to go to the kitchen to request food for a resident, they are to either knock on the door and wait for dietary staff to assist them, or they are to wear a hairnet if they go into the kitchen and in the food preparation area. The LPN revealed that hairnets are available by the kitchen door. 2. Review of the facility policy titled Food Storage: Cold dated [DATE], revealed the Dining Services Director/Cook(s) ensures that all food items are stored properly in covered containers, labeled, and dated and arranged in a manner to prevent cross contamination. Observation on [DATE] at 8:47 a.m. during initial tour of the kitchen revealed in the walk-in refrigerator an open three pound bad of shredded cheddar cheese that was not securely wrapped and had no open date, a clear plastic bag containing sliced deli meat with no label or open date. Further observation revealed a plastic container labeled Sloppy with date of [DATE] and a container labeled Spaghetti Meat with a date of [DATE]. Interview on [DATE] at 8:50 a.m. with dietary cook II verified the shredded cheddar cheese was not wrapped or dated and verified the deli meat was not labeled or dated. The dietary cook stated that items should be wrapped, labeled, and dated in the walk-in refrigerator. Continued interview with the dietary cook revealed the dates on the containers of Sloppy and Spaghetti Meat were the dates they were prepared, and staff are to discard after three days. The dietary cook confirmed that those food items should have been discarded. Observation on [DATE] at 8:58 a.m. of the reach-in refrigerator revealed a one-gallon container of 2% milk with a Best by Date of [DATE]. Observation on [DATE] at 9:00 a.m. of the reach-in refrigerator revealed the one-gallon of 2% milk with Best Use By date of [DATE] remained inside. Continued observation revealed a plastic container labeled Chix Noodle prepare date [DATE] and use by date [DATE]. Interview on [DATE] at 9:00 a.m. with the CDM, verified the 2% milk had a Best by Date of [DATE] and staff should have discarded. The CDM confirmed that the container labeled Chix Noodle had use by date of [DATE] and staff should have discarded. During further interview, the CDM revealed that part of the daily dietary staff cleaning tasks is to check all food storage areas and ensure food items are labeled and dated. The CDM had no explanation why the cleaning sheet indicated that the task had been completed yet expired food items had been found. Review of a facility document titled Dietary Weekly Cleaning Schedule revealed on [DATE] and [DATE] dietary staff initialed that the task of check dates-discard outdated items was completed. Interview on [DATE] at 8:50 a.m. the CDM stated that there is no policy regarding discarding food by expiration, best use by, or use by date. Observation on [DATE] at 9:05 a.m. of the reach-in refrigerator revealed a half gallon container of Whole Cultured Buttermilk with a Best by date of [DATE]. Interview on [DATE] at 9:05 a.m. the CDM confirmed the buttermilk had a Best by date of [DATE] and should have been discarded. The CDM could not explain why the buttermilk had not been discarded. 3. Observation on [DATE] at 11:35 a.m., with dietary cook JJ wash the food processor bowl, blade, and lid in the three-compartment sink. She washed the items in soapy water, rinsed with water, and submerged in quaternary sanitizer solution for ten seconds and placed back on the food processor base to start preparing puree food item. Continued observation revealed a poster hung above the sink which states dishware items are to be submerged in solution for one minute. Interview on [DATE] at 11:35 a.m. with dietary cook JJ, confirmed that she only had the food processor items in the sanitizing solution for a few seconds. Dietary cook JJ stated that she knows that she should have had the items in the sanitizing solution longer. Interview on [DATE] at 11:35 a.m. the CDM revealed she expects staff to follow proper procedure when using the three-compartment sink and submerge dishes in the sanitizing solution for 60 seconds. Interview on [DATE] at 8:50 a.m. the CDM revealed that they do not have a policy that outlines the procedure for using the three-compartment sink. The CDM confirmed that the facility uses a quaternary sanitizing solution and expects staff to follow manufacturers guidelines.

Based on observations and staff interviews, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner, evidenced by overflowing garbage from the dumpster and the area around the dumpster was clean and free of debris. The facility census was 92. Findings include: Observation on 11/5/22 at 9:15 a.m. during tour of the dumpster area, revealed the dumpster was full, and the top lid was not able to be closed, exposing multiple garbage bags. Continued observation revealed the wooded area behind the dumpster had multiple trash items on the ground. Interview on 11/5/22 at 9:15 a.m. with the Certified Dietary Manager (CDM) revealed that the dumpster is scheduled for trash pick-up today. Interview on 11/5/22 at 9:18 a.m. with the Maintenance Director (MD) revealed that he will call the dumpster company to ensure they get trash picked-up today. Observation on 11/6/22 at 9:10 a.m. of the dumpster area revealed dumpster continued to be full; however top lid was closed. Further observation revealed overflow garbage was observed to be in two large gray colored carts. Both carts were filled with garbage bags and neither cart had a lid, exposing the trash bags. One of the carts had two open trash bags exposing the contents which was kitchen trash, evidenced by Styrofoam meal trays used for resident meals. Further observation revealed the wooded area behind the dumpster area continued to have trash on the ground which included three Styrofoam clam shell to go containers, two Styrofoam drinking cups, an empty Diet Coke box, and other various trash items. Interview on 11/6/22 at 9:10 a.m. with the CDM revealed that dietary staff are responsible for picking up trash on the concrete pad the dumpster sits on. The CDM stated that maintenance was responsible for picking up the trash that is behind the dumpster in the woods. She stated she has informed the Administrator of the issue of overflow garbage on several occasions, the last time was about six months ago. Interview on 11/6/22 at 9:20 a.m. with the MD revealed that he tried to call for trash pick-up yesterday, but the company had already closed for the day. He stated that the facility had trash pick-up on Friday, but stated the dumpster filled up fast. During further interview, he stated trash gets picked up daily Monday through Friday, but no pick-up on the weekends. The MD confirmed that the large dumpster remained full and that the two gray colored carts containing trash bags were open with no lids. He stated that maintenance/housekeeping is responsible for ensuring the trash behind the dumpster in the woods is picked up. The MD stated he excepts his staff to pick up the loose trash daily. He confirmed that the trash in the woods should have been picked-up and staff know to pick it up if they see it. Interview on 11/6/22 at 10:55 a.m. with the Administrator revealed she was aware of the overflow issue with the dumpsters. She stated she has contacted the trash company and asked for an extra pick-up day, but stated the company is not able to accommodate at this time. She stated they got a larger dumpster, but the dumpster continues to get full. When asked if she asked for an additional dumpster, have two instead of one, she stated that she had not, it didn't cross her mind but will contact the company and ask for another dumpster.

Based on observation, record review, review of manufacturer's recommendations and staff interview, 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 sanitizing of glucometers between each resident use. This affected two (2) sampled residents, (#17 and #36) and nineteen (19) residents who received blood glucose monitoring on a daily basis via a multiple resident use glucometers. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for these twenty-one (21) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to the resident health and safety existed from March 8, 2011 related to glucometers not being cleaned and disinfected when used for multiple residents until March 10, 2010, when a plan of correction was implemented by the facility to remove the jeopardy situation. Additional concerns, not related to jeopardy, were identified regarding hand washing during the medication pass observation. Findings include: 1. During medication pass on the A-Hall with LPN, "CC", on 3/08/11 from 11:51 a.m. she donned her gloves, took the glucometer out of the medication cart drawer, used the meter to check resident #17's blood glucose level. The nurse returned the glucometer to the medication cart drawer, but did not clean or disinfect the meter after use. In addition, LPN continue to draw up insulin and administer the injection without changing the gloves or washing her hands. Interview with LPN, "CC", on 3/08/11 at 12:08 p.m. revealed she did not clean the glucometer before she went into the resident #17 room, stating that she thinks she might have cleaned it after the last resident, but was unsure. 2. During medication pass task on the B-Hall on 3/08/11 at 12:40 a.m. with LPN "AA" revealed prior to checking a randomly observed resident's blood glucose, she wiped the portal area with a single alcohol wipe (a 2 inch by 2 inch pad containing alcohol). The cleaning consisted of a single swipe across the surface of the top of the meter. After obtaining the blood glucose level, the meter was returned to the medication cart without cleaning or disinfecting. 3. Observation on 3/08/2011 at 11:15 a.m. of Hall-C Licensed Practical Nurse (LPN) "BB" revealed that she cleaned the glucometer with a single wipe from one alcohol prep pad before checking resident #36's blood glucose level. After checking the resident's glucose, she brought the glucometer back to the cart, wiped it again with a clean alcohol prep and placed it in the drawer. Observation of the C-Hall medication cart at that time revealed there were no germicidal wipes of any kind on the cart. Interview on 3/08/2011 at 11:30 a.m. with LPN "BB" confirmed that she was instructed to clean the glucometer before and after use with an alcohol prep. Review of the Cleaning Glucometer between each use with alcohol pads per DON dated 2/08/11 revealed that two (2) of the three (3) nurses attended this in-service and an in-service dated 2/14/11 revealed that three (3) of the three (3) nurses observed and/or interviewed attended this in-service. Staff interview with LPNs "HH", "II", "JJ", "MM" revealed they had received instruction of cleaning glucometers between resident use and they were to use an alcohol wipe. Review of the Administrative Policies and Procedures (provided by the corporate office) on cleaning and disinfecting glucometers, given to surveyors on 3/08/2011 at 10:00 a.m., revealed that the facility should be using an EPA registered detergent/germicide that has a TB/HBV/HIV label or dilute bleach solution of 1:10 concentration. It indicated alcohol was not an EPA registered detergent/disinfectant. Interview with the Administrator, the Director of Nurses and the Infection Control nurse on 3/08/2011 at 1:00 p.m. revealed that they were not aware of what was in the policy. The Infection Control nurse stated that she thought the night shift was responsible for cleaning the glucometers. The DON stated that he taught the staff to clean the glucometers with alcohol before and after use. The Administrator stated that she had not been able to put her hands on their policy and so she had it faxed from corporate at 9:51 a.m. that morning. The facility had twenty-one (21) residents who received daily monitoring of blood glucose levels from once to four (4) times a day. Each of the three (3) medication carts contained one (1) glucometer for use for all of the 21 residents. Review of manufacturer recommendations for maintenance revealed to clean the outside of the meter with a lint-free cloth, dampen with soapy water or [MEDICATION NAME] alcohol (70%-85%). Also, revealed to disinfect the meter, dilute one (1) ml of household bleach in nine (9) ml of water, which is a 1:10 dilution. The final concentration is 0.5-0.6% sodium hypochlorite. Do not clean inside the battery compartment or test strip port. Interview with a Manufacturer Healthcare Professional Representative "JL" on 3/22/11 at 11:10 a.m. revealed all alcohol prep pads are not the same and it can not be determined if they are sufficient or not to disinfect a meter. We (Manufacturer) recommend that you use the cleaning and disinfecting procedures that are located in the product user manual and follow FDA/CDC guidelines. In any health care environment (facility) there is no way to be sure of potential exposure to blood-borne pathogens and therefore, it was recommended that the meters would be cleaned and disinfected between each patient (resident) use. The facility may find they need to amend their policies to ensure sufficient cleaning of meters when they are used for more than one person. The immediate and serious threat to resident health and safety was determined to have been removed on March 10, 2011 but, the associated noncompliance continues in order to ensure the following are maintained by the facility: blood glucose monitors are cleaned and disinfected according to the facility revised policy and procedure: all residents identified with the potential for blood borne pathogens have an individual blood glucose monitoring machine; all licensed staff receive in-serviced on procedures related to cleaning and disinfecting blood glucose monitors; and the facility monitors ongoing implementation of and compliance with the facility's revised infection control policy related to cleaning and disinfecting blood glucose monitors. 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. The revised policy and procedure entitled "Cleaning and Disinfecting Glucometers" was reviewed and approved by the facility Administrator, DON and the Medical Director. The revised policy became effective 3/08/11 and was revised in conjunction with CDC guidelines, EPA literature, and manufacturer's recommendations. The policy and procedure read: Purpose: To prevent the spread of communicable disease and infection as related to multi use blood glucose monitoring equipment. 1.-Place monitor on a clean, dry surface 2.-Wash hands and apply gloves 3.-Use Santi Cloth Plus Germicidal Disposable Cloth (EPA reg. no.: 9480-6) for twenty seconds to clean the front and back of the glucose monitor. Discard cloth after use. 4.-Place monitor in a clean plastic cup to air dry for five (5) minutes, discard cup after use. 5.-After use, clean glucometer again with Sani Cloth Plus Germicidal Disposable Cloth. 6.-Remove gloves and wash hands. Glucometer must be disinfected before and after each use. 2. A new facility policy was developed for residents identified with potential Blood Borne Pathogens such as HIV and Hepatitis to have an individual glucose machine. This machine will be resident specific and will be labeled, bagged and kept in a separate area of the medication cart. Completed 3/09/11. 3. In-services of all licensed nursing staff were conducted regarding the revised policy and procedures related to blood glucose monitor cleaning and disinfecting. The in-services included a return demonstration by all nurses in attendance. Training sessions were conducted by the DON on 3/08/11 at 4:10 p.m., 4:15 p.m., 5:30 p.m., 7:15 p.m., 7:30 p.m., 8:00 p.m., 10:30 p.m. and 11:30 p.m. and on 3/09/11 at 7:40 a.m. There are no licensed staff currently on leave of absence or unavailable to attend the in-services.. All new hires of licensed staff will be in-serviced as part of the orientation process. Completed 3/09/11 4. A copy of the revised policy and procedure was placed on each medication cart. Completed on 3/08/11. 5. Monitoring for compliance to be conducted to be conducted daily by the DON or Clinical Education Manager for two (2) weeks, then weekly for two (2) weeks, and each quarter there after to include all shifts. Monitoring will include observation of return demonstration by twenty five (25) percent of random licensed staff per shift for residents receiving blood glucose monitoring per day. 6. Prevention measures regarding Infection Control and compliance with revised policy will be included in the facility's weekly Patient's at Risk (PAR) committee and preventive measures will also be reviewed each quarter by the Quarterly Assurance Committee. Initial meeting 3/09/11. Observation of the cleaning and disinfecting of the blood glucose monitors between resident use was conducted on 3/09/11 with Licensed Practical Nurses (LPN) "AA", "BB", "CC", "HH", "II" and Registered Nurse (RN) "EE" from 11:22 a.m. until 3:52 p.m. and verification of in-service and return demonstration for LPNs "FF", "GG" and RN "QQ" on 3/10/11 at 6:11-9:45 a.m. These observations revealed compliance with the revised facility policy and procedure. Additional Interviews were conducted with those licensed staff on the night and weekend shifts on 3/09/11 and 3/10/11 to verify attendance at an in-service regarding cleaning and disinfecting of the blood glucose monitors and knowledge of the new policy and procedure. Additional concerns included: During medication pass on the A-Hall with LPN, "CC", on 3/08/11 from 11:51 a.m. she donned her gloves, took the glucometer out of the medication cart drawer, used the meter to check resident #17 blood glucose level. LPN "CC" continue to draw up insulin and administer the injection without changing the gloves or washing her hands. During medication pass on the B-Hall with LPN "AA" on 3/07/11 from 10:22 a.m.-10:28 a.m., she was observed walking out of a residents room with a blood pressure (BP) cuff in her hand, placed the BP cuff on the top of the medication cart, started preparing and administering medication to another resident, without washing her hands. Interview with the Director of Nursing (DON) on 3/9/11 at 10:15 a.m., he indicated that handwashing should occur between residents. That hand sanitizer was on every cart and may be used up to three (3) times then the nurse has to wash her hands. In-services are held every pay day regarding handwashing. Review of the Handwashing in-service dated 2/23/11 revealed that staff are to wash hands between each resident care and that LPN "AA" and "CC" had attended. Review of facility policy, which was provided by the DON on 3/09/11 at 10:40 a.m., revealed that hand washing should occur before preparing or handling medications, after having prolonged contact with a resident and after removing gloves.

Based upon observation, record review and staff interviews, the facility failed to be administered in a manner that ensured staff members were trained appropriately regarding the need to clean and disinfect glucometers between each resident. This affected 21 residents currently in the facility who received daily monitoring of blood glucose levels where mult-use glucometers are used. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for those 21 residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed from March 8, 2011 until March 10, 2011 when a plan of correction was implemented by the facility to remove the jeopardy situation. Findings include: Interview on 3/8/11 at 1:00 p.m. with the Administrator, Director of Nursing (DON) and the Clinical Education Director revealed that the DON was unaware of the revision to F441 dated July 17, 2009 and was that the DON and the Clinical Education Director were not familiar with the facility Policy for cleaning and disinfecting of the blood glucose monitors. Review of the facility policy Cleaning/Disinfecting Glucometers with creation date of 4/30/10 and fax date of 3/08/11, from the corporate office, revealed that alcohol should never be used, as it can damage the LED (light emitting diode) readout and the machine, if no visible soil is present, should be disinfected after each use following the manufacture direction or wipe with a cloth damped with EPA (environmental protection agency) registered detergent/germicide that has a TB ([MEDICAL CONDITION]), HBV ([MEDICAL CONDITION]),[MEDICAL CONDITION](human immunodeficiency virus) label or dilute beach solution of 1:10 concentration, and allow to self dry. At this time the DON revealed that he had an in-serviced and instructed all professional staff to clean the blood glucose monitors with an alcohol wipe before and after use. The facility failed to have a system in place to ensure infection control guidelines were implemented for cleaning and sanitizing blood glucose monitors between residents. The immediate and serious threat to resident health and safety was determined to have been removed on March 10, 2011 but, the associated noncompliance continues in order to ensure the following are maintained by the facility: blood glucose monitors are cleaned and disinfected according to the facility revised policy and procedure: all residents identified with the potential for blood borne pathogens have an individual blood glucose monitoring machine; all licensed staff are in-serviced on procedures related to cleaning and disinfecting blood glucose monitors; and the ongoing implementation of and monitoring of compliance with the facility's revised infection control policy related to cleaning and disinfecting blood glucose monitors. 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. The revised policy and procedure (of 4/2010) entitled "Cleaning and Disinfecting Glucometers" was reviewed and approved by the facility Administrator, DON and the Medical Director. The revised policy became effective 3/08/11 and was revised in conjunction with CDC guidelines, EPA literature, and manufacturer's recommendations. The policy and procedure read: Purpose: To prevent the spread of communicable disease and infection as related to multi use blood glucose monitoring equipment. 1.-Place monitor on a clean, dry surface 2.-Wash hands and apply gloves 3.-Use Santi Cloth Plus Germicidal Disposable Cloth (EPA reg. no: 9480-6) for twenty seconds to clean the front and back of the glucose monitor. Discard cloth after use. 4.-Place monitor in a clean plastic cup to air dry for five (5) minutes, discard cup after use. 5.-After use, clean glucometer again with Sani Cloth Plus Germicidal Disposable Cloth. 6.-Remove gloves and wash hands. Glucometer must be disinfected before and after each use. 2. A new facility policy was developed for residents identified with potential Blood Borne Pathogens such [MEDICAL CONDITIONS] to have an individual glucose machine. This machine will be resident specific and will be labeled, bagged and kept in a separate area of the medication cart. Completion 3/09/10 3. In-services of all licensed nursing staff were conducted regarding the revised policy and procedures related to blood glucose monitor cleaning and disinfecting. The in-services included a return demonstration by all nurses in attendance. Training sessions were conducted by the DON on 3/08/11 at 4:10 p.m., 4:15 p.m., 5:30 p.m., 7:15 p.m., 7:30 p.m., 8:00 p.m., 10:30 p.m. and 11:30 p.m. and on 3/09/11 at 7:40 a.m. There are no licensed staff currently on leave of absence or unavailable to attend the in-services.. All new hires of licensed staff will be in-serviced as part of the orientation process. Completed 3/09/11 4. A copy of the revised policy and procedure was placed on each medication cart. Completed on 3/08/11. 5. Monitoring for compliance to be conducted to be conducted daily by the DON or Clinical Education Manager for two (2) weeks, then weekly for two (2) weeks, and each quarter there after to include all shifts. Monitoring will include observation of return demonstration by twenty five (25) percent of random licensed staff per shift for residents receiving blood glucose monitoring per day. 6. Prevention measures regarding Infection Control and compliance with revised policy will be included in the facility's weekly Patient's at Risk (PAR) committee and preventive measures will also be reviewed each quarter by the Quarterly Assurance Committee. Initial meeting 3/09/11. Observation of the cleaning and disinfecting of the blood glucose monitors between resident use was conducted on 3/09/11 with Licensed Practical Nurses (LPN) "AA", "BB", "CC", "HH", "II" and Registered Nurse (RN) "EE" from 11:22 a.m. until 3:52 p.m. and verification of in-service and return demonstration for LPNs "FF", "GG" and RN "QQ" on 3/10/11 at 6:11-9:45 a.m. These observations revealed compliance with the revised facility policy and procedure. Additional Interviews were conducted with those licensed staff on the night and weekend shifts on 3/09/11 and 3/10/11 to verify attendance at an in-service regarding cleaning and disinfecting of the blood glucose monitors and knowledge of the new policy and procedure. Completion on 3/10/11.