Every finding on record at Elim Park Baptist Home, Inc

Based on clinical record reviews, observations, facility documentation, facility policy and interviews for 13 of 16 sampled residents (Residents #2, Resident #6, Resident #10, Resident #22, Resident #26, Resident #34, Resident #35, Resident #62, Resident #63, Resident #73, Resident #81, Resident #90, and Resident #100) reviewed for infection control, the facility failed to ensure that appropriate Enhanced Barrier Precaution (EBP) infection control practices were implemented per Center of Disease Control (CDC) guidelines for residents with a history of Multiple Drug Resistant Organisms (MDROs) and any indwelling lines, catheters, or wounds, including ensuring Personal Protective Equipment (PPE) was readily accessible at the point of care and based on observation of the environment for 1 of 2 resident units, the facility failed to ensure staff did not transport clean and dirty linen and trash together on the same supply cart. The findings included: 1.Observations and interview on 4/29/26 at 10:35 AM with Resident #35 identified a low air loss mattress in use. During interview, the resident stated he/she had a wound on the coccyx. There was no Enhanced Barrier Precaution (EBP) signage or Personal Protective Equipment (PPE) available in or near the resident's room. Observations during a tour of all resident care units on 4/29/26 at 12:03 PM identified that no EBP signage was observed posted for any resident room in the facility. Observation on 4/29/26 at 1:28 PM identified an orange EBP sign was observed face up on a desk near the computer at the nurse's station between North and South Pines. The sign was not posted at any resident room. 2.Observations on 4/30/26 at 11:34 AM identified Resident #10 receiving bathing and dressing care from Nurse Aide #2 without the use of any PPE. Interview with Licensed Practical Nurse (LPN #1) on 4/30/26 at 12:24 PM identified Resident #10 had a pressure ulcer on the buttocks that would likely not heal due to a history of Methicillin-Resistant Staphylococcus Aureus(MRSA). LPN #1 stated the resident had a feeding tube due to refusal of oral medications and unsuccessful attempts at administration by alternative methods. She also reported physician orders for EBP would be initiated only by a nursing supervisor or the Infection Prevention Nurse. Interview with NA #2 on 4/30/26 at 12:58 PM identified Resident #10 required one staff member for bathing and dressing and two staff for transfers using a mechanical lift. She reported that no PPE or special precautions were needed for the resident care. Interview with the Infection Prevention Nurse (RN#1) on 5/4/26 at 11:02 AM identified residents were placed on transmission based precautions only when information from the transferring facility indicated the need. She stated the facility used EBP only for five specific Multiple Drug-Resistant Organisms (MDROs) listed in its policy and did not implement EBP for residents with wounds or indwelling medical devices unless one of those MDROs was present. RN#1 further stated that only she or a nursing supervisor could initiate EBP orders and that signage and PPE carts would be placed at the door when EBP were implemented. 3.Clinical record review with RN #1 on 5/4/26 at 11:50 AM identified the following resident conditions associated with EBP indications under CDC guidance: Resident #2: Suprapubic catheter, MRSA in nares Resident #6: History of MRSA in urine Resident #62: History of MRSA in nares Resident #73: History of MRSA in wound Resident #90: Central venous access device Residents #22, #34, #35, #63, #81: Draining wounds Resident #10: History of MRSA in nares, draining wound, feeding tube Resident #26: History of Vancomycin-Resistant Enterococci (VRE) in urine, draining wound Resident #100: Feeding tube and multiple draining woundsRN #1 confirmed these residents would be placed on EBP only if another resident with one of the five MDROs listed in facility policy were admitted to their unit. Interview and review current Center of Disease Control (CDC) guidelines on 5/5/26 at 9:53 AM with RN #1 identified RN #1 acknowledged that the facility's EBP policy did not align with current CDC guidance and required revision. She was unable to identify any policy addressing staff floating between units when EBP residents were present. CDC guidelines (Implementation of Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug Resistant Organisms, updated April 1, 2024) state that EBP are indicated for residents colonized or infected with an MDRO when Contact Precautions do not otherwise apply, as well as for residents with wounds or indwelling medical devices. Guidelines note that colonization may persist for extended periods, residents may be unaware of MDRO status, and EBP is not limited to outbreaks or specific organisms. Review of the facility's Enhanced Barrier Precautions policy, dated 5/1/26, indicated that examples of high contact activities requiring gown and glove use included care involving central venous catheters, urinary catheters, feeding tubes, dialysis catheters, and wound care requiring a dressing. 4.An observation on 5/5/2026 at 6:15 AM outside a resident room on the short-term care unit identified a small supply cart with clean disposable incontinent briefs and washcloths on top of the wire cart with trash bags tied to the handles on each end of the cart. One bag contained soiled linens and the other trash. On the bottom rack of the cart were fabric bed pads and a rolled-up blanket. During the observation Nurse Aide (NA #1) came out of the resident room where the cart was parked. After inquiry regarding the cart and contents NA #1 indicated the supplies on top of the cart were clean and the linens on the rack on the bottom of the cart were extra linens found during rounds removed from the rooms. NA #1 further indicated the bags tied to either end of the cart on the handles were trash and dirty linens because she/he was trying to organize and have everything she/he needed available. On 5/05/2026 at 6:35 AM an interview with the 11-7 AM supervisor (RN #2) indicated the dirty and clean linen need to be 3 feet apart. An interview with the Infection Preventionist RN #1 on 5/05/2026 at 6:37 AM indicated there should have been a cart with clean linen. She/he also said the nurse aide should use individual trash bags for each resident and when done in the room bring the bag to the dirty utility room trash bin. The facility policy labeled Linen given onsite notes linen will be provided and handled in such a way to prevent spread of infections. All clean linen carts must be covered when being transported to various linen closets and used/dirty linen should be placed in a plastic bag, tied and brought to the soiled utility room.

Based on observations of the kitchen, review of facility documentation and staff interview, the facility failed to ensure the dietary staff accurately recorded refrigerator and freezer temperatures, dishwasher and pot washer temperatures on the temperature logs when they were found consistently recorded below the acceptable temperature ranges. The facility failed to provide documented evidence of any corrective action for the out-of-range temperatures. The findings included: An observation of the kitchen with the Dietary Manager on 4/30/2026 starting at 9:24 AM identified the following:Recorded temperatures of the refrigerator, freezer, dishwasher and pot washer to be below the acceptable range and without any corrective action recorded from January 2026 through May 30, 2026, identified the following:1.Refrigerator Acceptable temperature standard per the temperature log:Minimum temperature is 34 degrees Fahrenheit (F).Maximum temperature is 40 degrees F. January 20261/13/26 at 11:00AM- 33 degrees F. (1 degree below) no corrective action documented. February 20262/23/26 at 5:00PM- 33 degrees F. (1 degree below) no corrective action documented. March 20263/2/26 at 11:30 AM- 31 degrees F. (3 degrees below ) no corrective action documented.3/8/26 at 11:30 AM- 32 degrees F. ( 2 degrees below) no corrective action documented.3/11/26 at 7:00 PM 32 degrees F. ( 2 degrees below) no corrective action documented.3/16/26 at 11:30 AM- 33 degrees F. (1 degree below) no corrective action documented.3/28/26 at 11:30 AM- 33 degrees F. (1 degree below) no corrective action documented. 2. Freezer Acceptable temperature range standard as per the temperature log:Maximum temperature is 10 degrees F. February 20262/18/26 at 7:00 PM- 11 degrees F. (1 degree above) no corrective action documented.April 20264/1/26 - 38 degrees F. (28 degrees above) no corrective action documented4/4/26- 11 degrees F. ( 1 degree above) no corrective action documented3.Dishwasher- (High temperature machine) Acceptable wash cycle per log is greater than or equal to 150 degrees F.Acceptable rinse cycle per the log is 180 degrees- 194 degrees F. A review of the daily breakfast, lunch, and dinner final rinse temperatures identified the following: January 1 through 31, 2026, recorded range of temperatures were 161-175 degrees F. (5-19 degrees below acceptable standard range). February 1 through 28, 2026, recorded range of temperatures were 161-164 degrees F. (5-16 degrees below acceptable standard range). March 1 through 31, 2026, recorded range of temperatures were 155-167 degrees F. (13-25 degrees below acceptable standard range). April 1 through 29, 2026, recorded range of temperatures were 161-169 degrees F. (11-19 degrees below acceptable standard range). Interview with the Dietary Manager on 4/30/26 at 9:24 A.M. identified the acceptable temperature ranges were correct as written on the temperature logs for staff to refer to and directions to take for corrective action. There were also instructions for the staff to notify the supervisor and document the corrected action taken to bring the device to acceptable range. The Dietary Manager further indicated the staff just do not understand where to look and what to do. The Dietary Manager further indicated dietary staff are responsible for the task. When asked who was responsible for oversight of the staff competency and oversight of the logs, she/he indicated the staff just do not understand though they have been told many times. During the wash cycle an observation noted the gauge reading rinse was not at 160- and 180-degrees F. The Dietary Manager indicated there was a third gauge to the far top right toward the back of the machine(without signage) that was the final rinse temperature that should have been read and recorded. However, dietary staff had been reading and recording only the first 2 gauges which are the wash(within normal limits) and the second gauge was a pre-rinse at a lower temperature. The Dietary Manager indicated although dishwasher temperatures were in acceptable ranges she/he re-educated staff regarding the appropriate gauges to read to record dishwasher temperatures and take corrective action when temperatures are not within acceptable range. On observation the final rinse gauge read 189 degrees F above the acceptable range.The manufacturer (CMA dish machines) specifications provided by the Dietary Manager for the high temperature dishwasher indicated the wash temperature ranged to be 150-160 degrees and the final rinse 180-195 degrees . The manufacturer specifications also indicated a pump rinse to be 150 -160 degrees(the log does not ask to record this temperature). There are 2 gauges at the top middle of the machine with manufacturer signage reading wash and the other rinse.

Based on clinical record review, facility documents, review of policy and staff interviews for the 1of 1 resident reviewed ( Resident # 43) reviewed for falls, the facility failed to ensure staff consistently completed every fifteen-minute checks per the physician's order and per facility practice after the resident sustained falls. The findings include: Resident #43's diagnoses included Alzheimer's disease and dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #43 had severe cognitive impairment. The care plan dated 3/30/2026 indicated Resident #43 was at risk for falls. Interventions included : to encourage appropriate footwear, gripper socks when out of bed at night, providing an uncluttered environment and to keep personal items within reach. A facility Incident Report dated 4/25/2026 indicated Resident #43 had a fall at 9:15 PM at which time the resident was found on the floor in the bedroom with his/her back against a bed. When asked about the fall Resident # 43 was unable to recall how the fall occurred. Additionally, the report indicated actions taken to prevent further falls by directing staff to conduct every fifteen-minute checks on Resident # 43.A physician's order dated 4/27/2026 (with no time) directed to check on Resident #43 every 15 minutes for 3 days. A review of the facility 15-minute observation sheets dated 4/27/2026 and 4/28/2026 ( part of the 15-minute checks intervention from the fall 4/25/2026) identified no documentation from 4/27/2026 at 9:00 PM through 4/28/2026 at 6:45 AM as to where the resident was observed at the time or the staff members initials. Documentation on 4/28/2026 from 7:00 AM through 7:00PM identified inconsistent documentation of resident location observed and initials of the person conducting the 15-minute check with a line drawn from 7:15 AM through 7:45 AM, 8:30 AM through11:45 AM, 12:30 PM through 2:30 PM, 3:15 PM through 6:30 PM and 7:15PM through10:45 PM without indicating Resident #43's location at the time or the staff person's initials who completed the observation. An interview with the Director of Nursing Services (DNS) on 5/4/2026 at 11:08 AM indicated the 15-minute check forms were kept separate from the incident and investigation form packets. The DNS further indicated the 4/27/26 and 4/28/26 forms were missing some documentation, and she/he would find the other 15-minute check forms. An interview and facility document review with the Director of Nursing Services (DNS) on 5/05/2026 at 12:40 PM indicated the date of 4/27/2026 and 4/28/2026 were missing documentation of the observation of Resident #43 every 15 minutes and initials of the staff member completing the task from 4/27/2026 at 9:00 PM through 6:45 AM on 4/28/2026. The DNS also indicated that the staff member who documented on 4/28/2026 should have entered where the resident was located and initialed each 15-minute entry and not drawn a line through. The DNS indicated at 12:48 PM that the facility had no policy and procedure for conducting 15-minute checks as staff only needed to fill out the form.

Based on the tour of the Dietary Department, interviews and facility documentation, the facility failed to ensure open items were dated, failed to identify expiration dates, failed to ensure food was served under sanitary conditions, and failed to ensure correct dishwasher temperatures. The findings included: During a tour of the Dietary Department on [DATE] at 9:15AM with the Dietary Manager and Sous Chef the following was identified: 1a. The walk-in refrigerator was noted to contain an opened 5 pound bag of cheddar cheese (,d+[DATE] full), wrapped with plastic cling, with no date when opened, an opened 5 pound bag of cheddar cheese (,d+[DATE] full), wrapped in plastic, with no open date, an opened 5 pound bag of cheddar cheese (,d+[DATE] full), wrapped in plastic with no open date, an opened 5 pound bag of blue cheese (,d+[DATE] full), wrapped in plastic, with no open date and an opened 5 pound bag of blue cheese (,d+[DATE] full), wrapped in plastic with no open date, an opened 5 pound bag of parmesan cheese (,d+[DATE] full), wrapped in plastic, with no open date and an opened 5 pound portion of pepper jack cheese (,d+[DATE] full), wrapped in plastic, with a white substance accumulating on one end of the cheese, with no open date. In order to observe the expiration date on the packages, the packages had to be completely unwrapped. b. The walk-in refrigerator was noted to contain an opened plastic container of salsa (,d+[DATE] full), with no open date, a second opened plastic container of salsa (,d+[DATE] full) with no open date, an opened jug of BBQ sauce (,d+[DATE] full) with no open date, and an opened jug of hot sauce (,d+[DATE] full) with no open date. c. The first 2-door reach in cooler was noted to have heavy splatter stains on both outer doors. The reach in cooler was noted to contain an unopened 2 pound package of fresh broccoli which contained water and a yellow liquid on the bottom of the bag with no expiration date, 2 metal pans with pureed egg (about 2 pounds) unlabeled, a metal pan with pureed pork (8 ounces) labeled [DATE], a metal pan with pureed oatmeal (8 ounces) unlabeled, a metal pan with pureed pancake (1 pound) unlabeled, and a 2 inch metal hotel pan full of French toast that unlabeled as to when the food was placed in the pans. d. The shelving unit next to the 2-door reach in cooler was noted to contain an opened 5-pound bag of egg noodles (,d+[DATE] full), wrapped in plastic with no date identified for the date it was opened and in order to view the expiration date, the package needed to be completely unwrapped. e. The second 2-door reach in cooler was noted to contain a full metal pan of pureed chicken dated ,d+[DATE], a 5-pound bag of breakfast sausage patties (,d+[DATE] full) with no open date and no expiration date, and a teal colored 32 ounce water bottle (10 ounces full of liquid) identified by the Sous Chef to be a personal water bottle that belonged to one of the weekend cooks. f. The soap dispenser next at the hand washing station was noted to have a large brown colored stain on the dispenser. g. A 25-pound plastic container with thickening powder (half full) was noted to be opened, with no open date or expiration date on the container and heavily soiled on the outside. h. Three 50-pound plastic containers were noted to be splattered and dirty on the exterior, one contained flour with no date as to when the flour was opened and placed in the container or expiration date, one contained panko crumbs with no open date or expiration date, and one with sugar noted to be clumpy with a date of ,d+[DATE]. i. The ice machine door was noted to be open, no scoop was identified in the scoop holder, and the scoop was located stored on a kitchen counter (not covered) across the kitchen. j. On [DATE] at 9:10 AM a walk-through of the dry stock room with the Dietary Manager identified a 25-pound plastic container, unlabeled with a tan powdery substance (,d+[DATE] full) that could not be identified by the Dietary Manager, a 25-pound plastic container with rice flour (,d+[DATE] full) with no open date to identify when the rice flour was put in the container and failed to identify an expiration date, a 25-pound plastic container with semolina (,d+[DATE] full) with no open date to identify when the semolina was put in the container and failed to include an expiration date and a 25 pound plastic container with clam fry (,d+[DATE] full) powder with no open date to identify when the clam fry powder was put in the container and failed to include an expiration date. An opened 10-pound bag of bowtie pasta (,d+[DATE] full) in plastic wrap that lacked a date when opened, an opened 10-pound bag of spaghetti (,d+[DATE] full) in plastic wrap that lacked a date when opened, an opened 10 pound bag of penne pasta (,d+[DATE] full) in plastic wrap with no open date, and an opened 10 pound bag of tavolini pasta (,d+[DATE] full) in plastic wrap with no date when opened. Interview with the Sous Chef on [DATE] at 11:08 AM identified the cooks were responsible for checking the food labels daily and labeling food after it is opened. Interview with the Dietary Manager on [DATE] at 9:10 AM identified that the stock person oversees the dry stock and removing expired items, but currently that position was not filled, and the Sous Chef was intermittently filling in for the position. She further identified the pureed pork dated ,d+[DATE] and pureed chicken dated ,d+[DATE] should have been discarded within 3 days of being stored in the refrigerator. Subsequent to surveyor observation, the container of pureed pork and chicken were discarded by the Dietary Manager. Review of the Labeling Food for Storage Policy identified that by accurately and completely labeling all food for storage, you can minimize the risk of foodborne illnesses. In addition, the label must include following; the name of the product, the date the product was opened, the time the label is completed, the date the product will expire and the initials of the person who completed the label. 2. Observation of the Dietary prep area on [DATE] at 11:25 AM identified [NAME] #1 wearing gloves, plating BLT sandwiches, a personal cell phone was noted to be laying on the counter next to the open bacon. When prompted about phone being on the counter, [NAME] #1 picked it up with her gloved hand and threw it on another counter, then continued to plate the sandwiches without the benefit of hand hygiene or changing her gloves. Interview with the Dietary Manager on [DATE] at 11:09 AM identified per policy no phones or personal belonging should be out on the counter, if an emergency arises gloves should be taken off, then upon return perform hand hygiene and apply new gloves. Interview with the [NAME] on [DATE] at 11:32 AM identified she was aware of the policy on personal belongings on the counter but was waiting for an emergency phone call. She identified she should have kept the cell phone in her pocket, taken off her gloves, washed her hands and taken the call outside of the kitchen. 3a. On [DATE] at 9:30 AM a tour of the dish room with the Dietary Manager identified the gauges on the dish machine that the wash the healthcare units dishes identified the wash temperature read 146 degrees Fahrenheit, the rinse read at 159 degrees Fahrenheit, and final sanitizing read rinse 180 degrees Fahrenheit. Per the manufacturer guidelines posted on the dish machine, washing temperature was to reach 150 degrees Fahrenheit, rinse was to reach 160 degrees Fahrenheit, and final sanitizing rinse was to reach 180 degrees Fahrenheit. b. Observation of the dish room for the healthcare machine on [DATE] at 9:30 AM identified Dietary Aide (DA) #1 removed her gloves after handling the dirty dishes, then applied new gloves to handle the clean dishes without the benefit of hand hygiene in between glove changes. She then stacked wet hot plates and wet hot lids without the benefit of air drying them before storing them. Interview with the DA #1 on [DATE] at 9:40 AM identified that she took off her dirty gloves and applied a clean pair without the benefit of hand hygiene because she believed the gloves were not dirty since she was working with water and was not aware wet dishes should not be stacked Interview with the Dietary Manager on [DATE] at 9:35 AM identified she was not sure if the temperatures were accurate and stated the Dish Washing staff was responsible for the temperatures. She identified that many times they put a thermometer though to check the temperatures, and do not utilize the gauges on the machine. The thermometer provided by the Dietary Manager read 150 degrees Fahrenheit, but the Dietary Manager was unable to identify if the temperature shown was for the wash, rinse, or sanitize temperatures. Interview and Dish Machine Temperature Record review with the Dietary Manager on [DATE] at 9:40 AM identified that temperatures were supposed to be checked at breakfast, lunch, and dinner on both dish machines. Review of the temperature logs for the Healthcare Dish Machine and the Pots and Pans Dish machine noted the temperatures were last documented on [DATE] at 8:00 AM (there was no documentation of temperatures taken for [DATE], [DATE] and [DATE]). Interview with Dish Washer #1 on [DATE] at 9:45 AM identified she was only responsible for taking the temperatures on the dishwasher used for the pots and pans, and checks them at 12:00 PM, and the person working the healthcare dish machine was responsible for taking the temperatures for that machine. Interview with DA #1 on [DATE] at 9:40 AM identified that she did not check the dishwasher temperatures for the healthcare dishwasher, and that was the responsibility of the person assigned as the Dish Washer. Furthermore, she identified she took off her dirty gloves and applied a clean pair without the benefit of hand hygiene because she believed the gloves were not dirty since she was working with water and was not aware wet dishes should not be stacked. Review of the policy and procedure on Handwashing dated ,d+[DATE] identified hands should be washed at the kitchen hand sink station with soap and water after removing gloves. Review of the policy and procedure on Dish Machine Temperatures dated ,d+[DATE] identified a single tank conveyor machine wash temperature should be 150 degrees Fahrenheit, and the final rinse should be 180 degrees Fahrenheit. In addition, a High Temperature Dish machine was to have temperatures recorded during each period of use.

Based on obsevations, staff interviews, record reviews, and review of facility policy for 1 of 4 residents (Resident #18) reviewed for nutrition, the facility failed to appropriately supervise a resident during a meal per the meal ticket and failed to obtain weights per the physician's order, for 1 of 3 residents (Resident #53) reviewed for a skin condition the failed to apply TEDS (compression stockings) according to the physician's order, and for 1 of 2 residents (Resident #72) reviewed for edema, the facility failed to obtain a daily weight daily for a resident with Congestive Heart Failure (CHF) per the facility policy. The findings include: 1. Resident #18's diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and moderate protein-calorie malnutrition. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #18 was severely cognitively impaired, independent with eating, required partial to moderate assistance with bed mobility, and was independent with transfers and ambulation. The Resident Care Plan dated 6/4/24 identified a problem with nutrition. Interventions included appetite stimulant, nutritional supplement, and monitor intake. A. A physician's order dated 8/28/24 directed to provide Resident #18 with a regular diet, regular/thin consistency fluids with pre-cut bite sized pieces and assist with 1 staff. Observations on 9/9/24 at 12:47 PM identified Resident #18 was in the bathroom. Resident #18's meal tray was on his/her over bed table and consisted of a peanut butter jelly sandwich cut diagonally, (not bite-sized), blueberries, and chocolate milk. Resident#18's meal ticket directed supervision at meals and tray set-up. Alerts noted on the meal ticked included aspiration precautions, assist of one, and pre-cut bit size portions. Observation on 9/9/24 at 12:59 PM identified Resident #18 sitting on the side of bed, eating unsupervised. The peanut butter and jelly sandwich was not cut into bite sized pieces and was diagonally cut. The nurse consultant immediately summoned the nurse. Observation and interview with LPN #1 on 9/9/24 at 1:02 PM identified Resident #18's meal ticket directed supervision at meals and tray set-up. Alerts for aspiration precautions, assist of 1, and pre-cut bite sized portions was written on the meal ticket. LPN #1 stated that due to the information on the meal ticket, Resident #18 required supervision during his/her meal intake and indicated that she would remain with the resident to supervise the meal until relieved by another staff member. Observation and interview with NA #2 on 9/9/24 at 1:05 PM identified that she was not aware that Resident #18 required supervision at meals, was an assist of one, was on aspiration precautions, or required bit sized food. NA #2 stated she had delivered the residents tray and only looked at top portion of the slip which noted double portions and failed to read supervision at meals, aspiration precautions, assist of 1 staff, or the pre-cut bite size portions. NA #2 indicated that when she looked at her Resident Care Card (Resident Care Assignment) there was no indication that Resident #18 required supervision, assistance, was on aspiration precautions or needed his/her food cut to bite sized pieces. NA #2 identified that the Resident Care Card was how she knew to care for Resident #18 despite what the meal ticket directed. A subsequent observation on 9/10/24 at 12:34 PM identified that Resident #18's meal ticket still directed supervision of the meal, aspiration precautions, assistance of 1 staff and bite sized pieces. The resident was alone in the room with his/her meal and was eating. Interview with Director of Dietary on 9/12/24 at 1:15 PM identified that her understanding of the policy was if a resident had supervision at meals on his/her meal ticket, then a staff member was to always be with that resident during the meal. Interview with Speech Pathologist on 9/13/24 at 10:30 AM identified that if a residents meal ticket stated supervision, aspiration precautions, and assistance of 1 staff, then a staff member should always stay with that resident when food was available. Interview with Director of Nursing Services on 9/13/24 at 12:39 PM identified that if a resident meal ticket directed supervision, then a staff member should always stay with that resident when food was available. If there was a question about the orders on the meal ticket, then it should be brought to attention of charge nurse, but staff should have remained with Resident #18 until the order could be verified. B. A physician's order dated 6/30/24 directed facility staff weight Resident #18 weekly for 4 weeks. A review of the electronic health record identified although weights were ordered by the physician to be taken on 7/3/24, 7/10/24, 7/17/24 and 7/24/24, weights were only obtained on 7/3/24 and 7/10/24. Interview with LPN #1 on 9/12/24 at 8:10 AM identified that Resident #18's physician directed that weekly weights be obtained every week and that only 2 of the 4 weights on 7/3/24 and 7/10/24 had been completed. LPN #1 was unable to identify why the weights were not taken, but should have been. Review of the Resident Weights and Weight Changes policy dated 3/23/2023 directed, in part, weights may be done more frequently, such as weekly or daily, per the physician order, as a nursing measure, or as a dietician recommendation. 2. Resident #53's diagnoses included heart failure, atrial fibrillation (irregular heartbeat), and abnormalities of gait and mobility. The annual Minimum Data Set assessment dated [DATE] identified Resident #53 was moderately cognitively impaired and required partial/moderate assistance with toileting hygiene and personal hygiene, and walking was not attempted. The Resident Care Plan dated 8/5/24 identified Resident #53 had an altered cardiovascular status related to heart failure and atrial fibrillation. Interventions included diet consult as necessary and to monitor vital signs per protocol. A Nurse Aide (NA) Resident Care Card (Resident Care Assignment) in effect from 9/1/24 through 9/9/24 and last updated 3/27/24 directed TEDS to be applied on Resident #53 in the morning and to be removed in the evening. The physician orders in effect from 9/1/24 through 9/9/24 directed TEDS to be applied on Resident #53 in the morning and to be removed in the evening. Observations on 9/9/24 at 11:49 AM, 9/10/24 at 12:14 PM, 9/11/24 at 10:40 AM, 9/12/24 at 9:27 AM, and 9/12/24 at 1:47 PM identified that Resident #53 was not wearing TEDS. The Electronic Treatment Administration Record (ETAR) from 9/1/24 through 9/12/24 identified that TEDS were signed as being applied on all dates, except for 9/1/24 and 9/10/24. Interview, clinical record review, and observation with LPN #3 on 9/12/24 at 1:47 PM identified that Resident #53 was not wearing TEDS despite having a current order for TEDS to be worn daily. LPN #3 further indicated that the overnight nurse (LPN #6) had documented on the ETAR that the TEDS were applied in the morning on 9/12/24. LPN #3 identified that the overnight nurses were responsible for applying the TEDS and documenting on the ETAR since the application time for the TEDS was 6:00 AM. Interview and clinical record review with LPN #6 on 9/12/24 at 2:18 PM identified that she had documented on the ETAR that the TEDS were applied in the morning on 9/9/24, 9/11/24, and 9/12/24 despite not having applied the TEDS on Resident #53. Additionally, LPN #6 indicated that the overnight NAs were responsible for applying the TEDS and advising the nurse if the resident refused to wear the TEDS. Interview with the overnight NA #6 on 9/12/24 at 2:49 PM identified that he did not apply the TEDS to Resident #53 and that the day NAs were responsible for applying the TEDS. Interview and observation with the day NA #7 on 9/13/24 at 10:00 AM identified that Resident #53 was wearing TEDS. Additionally, NA #7 identified that she had not applied the TEDS to Resident #53 on any days before the morning of 9/13/24 because she was unaware that Resident #53 had to wear TEDS daily. NA #7 further indicated that Staff Development had told her the morning of 9/13/24 that Resident #53 had to wear TEDS daily and provided NA #7 with a pair of TEDS for Resident #53 to wear. Subsequent to surveyor inquiry, the TEDS order was changed on 9/13/24 from an application time of 6:00 AM to an application time of 8:00 AM per Resident #53's request. Interview with the Director of Nursing Services on 9/12/24 at 2:41 PM identified that there was no policy for application of TEDS stockings, but in lieu of a policy, it would be expected that TEDS be applied per the physician's order and that the nurses would verify the application of the TEDS since the nurses were responsible for the TEDS documentation on the ETAR. 3. Resident #72's diagnoses included unspecified diastolic congestive heart failure, stage 3 chronic kidney disease, and essential hypertension. The admission Minimum Data Set assessment dated [DATE] identified Resident #72 was cognitively intact, was independent with eating, and was dependent with toileting, personal hygiene, and transfers. A physician's order dated 8/1/24 directed to monitor Resident #72 one time a day for signs and symptoms of fluid overload, including weights trending up, and notify the physician or Advanced Practice Registered Nurse (APRN) of abnormalities. A physician's order dated 8/14/24 directed to weigh Resident #72 one time a day for CHF and notify cardiology and the physician or APRN if the weight was greater than 3 pounds in one day, or greater than or equal to 5 pounds in one week. The Resident Care Plan dated 8/14/24 identified the resident had congestive heart failure. Interventions included weight monitoring as ordered and to monitor/document/report signs and symptoms of congestive heart failure such as dependent edema of legs and feet, a distended neck vein, and weight gain. Review of the Electronic Medication Administration Record (EMAR) identified that Resident #72's weights were documented as completed during the time period of 8/1/24 to 9/12/24. Review of the clinical record failed to identify weights were recorded on 8/9/24, 8/15/24, 8/24/24, 8/26/24, 8/30/24, 9/5/24, 9/6/24, 9/7/24, 9/8/24, 9/9/24, and 9/10/24 (11 of 43 missed opportunities, 25%). Additionally, the clinical record failed to identify if Resident #72 refused to be weighed on any of these days. Review of the visual/bedside Kardex Report (Resident Care Card/Resident Care Assignment) identified Resident #72 was to be monitored for weight gain of over 2 pounds a day. Interview and record review with Registered Nurse (RN) #1 on 9/11/24 at 10:34 AM identified that the Nurse Aide (NA) was responsible for obtaining the weight for Resident #72, documenting the weight in the computer, and verbally reporting to the nurse. Record review failed to identify that weights were done daily, but should have been. Interview and record review with APRN #1 on 9/11/24 at 11:38 AM identified weights were not done daily as ordered, furthermore APRN #1 stated the weights were not being done because the resident was COVID positive, therefore the resident's weights were on hold. Review of the clinical record failed to identify the daily weights order was on hold. Interview with Nurse Aide (NA) #1 on 9/12/24 at 12:59 PM identified she knew to obtain a resident's weight when she was told by her nurse, weights were done rotating odd and even days on Wednesdays, and that either the total mechanical lift or wheelchair was used to weigh residents. Review of the CHF Residents Policy directed in part that residents identified as having Congestive Heart Failure are weighed daily, and the practitioner is notified of a weight gain greater than 3 pounds. Review of the Resident Weight and Weight Changes Policy dated 3/22/23 directed for regular monitoring of weights to screen residents for significant weight changes. 50179 51101 51102

Based on a tour of the Dietary Department, interviews and facility documentation, the facility failed to provide lunch at appropriate and appetizing temperatures. The findings included: Interview with Resident #27 on 9/9/24 at 1:38 PM identified that vegetables were always cold. Interview with Resident #58 on 9/9/24 at 11:24 AM identified that the food was not hot and some of the food was overcooked, especially the vegetables that are mushy. Interview with Resident #72 on 9/9/24 at 11:55 AM identified that food was often cold. Interview with the Dietary Manager on 9/12/24 at 11:40 AM identified the process to ensure foods were served hot included the cook taking temperatures before taking the food out of the oven, checking the holding temperatures in the hot box, and taking the temperatures of the food when it was being plated. Interview and review of the temperature log with [NAME] #2 on 9/12/24 at 11:45 AM identified cooking temperature were recorded for service dates 9/1/24 to 9/11/24, but the log failed to identify temperatures in the hot box and plated temperatures. In addition, [NAME] #2 identified that two food trucks had already been sent to the units for lunch, he had only checked food oven temperatures, and he was unaware of the requirement to check food temperatures once the food had been plated. On 9/12/24 at 12:01 PM, a test tray for appropriate temperatures was conducted with the Dietary Manager. The lunch meal was plated in the Residential Care (RCH) dining room that serves the resident's residing on the East Wing (residents residing on the sub acute unit). At 12:35 PM, the meal truck arrived on East Wing at 12:39 PM, and at 12:39 PM 3 Nurse Aides were observed to begin passing out the meal trays to residents. The last tray was delivered at 12:43 PM, temperatures were conducted with the Dietary Director at that time, and identified the following: a. The kielbasa's internal temperature was 118.2 degrees Fahrenheit from the surveyor's thermometer and 116 degrees Fahrenheit from the Dietary Manager's thermometer. The Dietary Manager identified the internal temperature should be 145 degrees Fahrenheit. b. The roast beef internal temperature was 132.4 degrees Fahrenheit from the surveyor's thermometer and 130 degrees Fahrenheit from the Manager's thermometer. The Dietary Manager identified the internal temperature should be 145 degrees Fahrenheit. c. The mashed potato internal temperature was 143 degrees Fahrenheit from the surveyor's thermometer and 142 degrees Fahrenheit from the Dietary Manager's thermometer. The Dietary Manager identified the internal temperature should be 165 degrees Fahrenheit. An interview with the Dietary Manager on 9/12/24 at 12:46 PM identified that temperatures for the lunch tray were low because these foods just don't hold their temperature, and she planned on redoing the menus to include items that hold their temperature better. Review of the policy and procedure on Meal Assembly Procedures and Taste/Temperature Record dated 8/22 identified all food items are monitored for temperature and listed on the taste/temperature log.

Based on observations, review of the clinical record, facility policy, and interviews in 1 of 3 dining rooms residents, (Resident #35, Resident #65, and Resident # 430), reviewed for dining services, the facility failed to ensure a dignified dining experience. The findings include: 1. 1. Resident #65's Diagnosis included Alzheimer's dementia, anxiety and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #65 as severely cognitively impaired and required no assistance with eating. Observation on 9/12/24 at 12:15 PM identified Resident # 65 sleeping with his/her lunch meal in front of him/her. NA #4 began assisting Resident #65 with his/her meal and was noted to be standing over, and not at eye level, with the resident. Interview with NA #4 on 9/12/23 at 12:15 PM identified she had been standing over Resident #65 while assisting him/her to eat because her back hurt but subsequent to surveyor inquiry, sat down next to Resident #65 to continue to assist him/her. Interview with Director of Nursing on 9/13/24 at 12:20PM identified that per the facility practice, when NA #4 was assisting Resident #65, she should have been seated and at eye level, not standing over the resident. Review of the Feeding the dependent resident policy failed to identify the position of the caregiver in assisting the resident to eat. 2. a. Resident #35's diagnosis included depression, anxiety, and Parkinson's disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #35 was cognitively intact and was independent for eating Interview with Resident #35 on 9/9/24 at 12:32 PM identified that that it took too long to receive his/her meal. b. Resident # 430's diagnosis included pneumonia, and atrial fibrillation. The admission Minimum Data Set assessment dated [DATE] identified Resident #430 was severely cognitively impaired and did not require assistance with eating. Observations on 9/9/24 at 12:05 PM, identified that although all Resident #430's table mates had been served lunch by 12:05 PM, Resident #430 had not been served until 12:30 PM. Interview with Resident #430's family member identified that it always took too long for Resident #430 to be serviced his/her food. Observations on 9/12/24 at 12:15 PM identified although Resident #430's tablemates received their food by 12:15, Resident #430 had not received his/her meal. Interview with Resident #430s family member on 9/12/24 at 12:15 PM identified he/she had requested a salad to be substituted for lunch at that time as Resident #430 did not like what was on the menu. Further, Resident #430 and his/her family member indicated that it always took staff too long for Resident #430 to be served his/her food and that the family member was upset due to the wait. Observation at 12:30 PM identified Resident #430 had not yet been given his/her salad. Subsequent to surveyor inquiry with the Dietician on 9/12/24 at 12:30 PM she went to the kitchen to check on Resident #430's salad. Resident #430's salad was served to him/her at 12:56 PM (41 minutes) after his/her initial request for a substitution which occurred at 12:15 PM. Interview with NA #4 on 9/12/23 at 12:15 identified that there is always only 1 Dietary Aide available to plate the meal and several NA's delivered and assisted residents with their meals. Interview with Dietician on 9/12/24 at 12:56 PM identified that it took 41 minutes to obtain a salad for Resident #430 because salads are made in the kitchen, so these items take longer to obtain. The Dietician identified that obtaining the food item from the kitchen should take 15 minutes or less and should not take 45 minutes or more to obtain. Additionally, the Dietary Aide that is plating the food being served would be responsible for obtaining the food item from the kitchen as salads were not available in the dining room. Interview with Dietary Operations Manager on 9/12/24 at 1:00 PM identified that it should take 15 minutes to obtain a salad from the kitchen. Additionally, she did not know why it took so long (41) minutes for Resident #430 to receive his/her salad. The Dietary Operations Manager indicated that the Dietary Aide was responsible to ensure that residents receive substitutions. Further, the Dietary Aide plating the food should have stopped plating, left the dining room, went to the kitchen to obtain Resident #430's salad, and then resumed plating meals for the residents who had not yet been served despite making the other residents then wait for their food. Review of the Resident Meal Service policy dated 8/2022 directed, in part, to serve the meal in sequence so all persons at one table are served at the same time. Monitor delivery of meals to Residents to ensure timeliness and appropriateness of service. Additionally, offer all residents participation in meal selection (may include selection of the entire meal or any component of the meal).

Based on interviews, review of the clinical record, and facility policy for 1 of 2 residents (Resident #72) reviewed for edema, the facility failed to notify the physician of a weight gain greater than 3 pounds in 1 day, per the physician's order, for a resident with Congestive Heart Failure (CHF). The findings include: Resident #72's diagnoses included unspecified diastolic congestive heart failure, stage 3, chronic kidney disease, and essential hypertension. The admission Minimum Data Set assessment dated [DATE] identified Resident #72 was cognitively intact, independent with eating, and was dependent with toileting, personal hygiene, and transfers. The Resident Care Plan dated 8/14/24 identified Resident #72 had CHF. Interventions included weight monitoring as ordered and to monitor/document/ report signs and symptoms of congestive heart failure such as dependent edema of legs and feet, distended neck veins, and weight gain. A physician's order dated 8/14/24 directed to weigh Resident #72 once daily for CHF and notify the cardiology and the physician or Advanced Practice Registered Nurse (APRN) if the weight was greater than 3 pounds in one day, or greater than or equal to 5 pounds in one week. Review of Resident #72's weights identified that his/her weight was 203.6 pounds on 8/23/24, no weight was recorded for 8/24/24, and on 8/25/24 Resident #72's weight was 208.2 pounds (a 4.6 pound weight gain). Review of the visual/bedside Kardex Report identified Resident #72 was to be monitored for edema including a weight gain of over 2 pounds a day. Interview and record review with Registered Nurse (RN) #1 identified that Nurse Aides were responsible to obtain weights. Additionally, the facility policy for a resident who had a diagnosis of CHF and gained weight was to update the provider with any weight gain of 3 pounds in one day or 5 pounds in one week. RN #1 identified that the nurses progress notes failed to reflect the weight gain or that the physician or APRN was notified but the provider should have been notified per the order. Interview and record review with APRN #1 on 9/11/24 at 11:38 AM identified she would have expected to have been notified of Resident #72's weight gain per the physician's order but she had not been. Further, APRN #1 indicated that she would have expected an RN assessment of Resident #72 to check for swelling, fluid buildup, and lung sounds but during a review of the clinical record/progress notes, she failed to identify nurses or practitioner progress notes addressing the weight gain. Review of the CHF Residents Policy directed in part that residents identified as having congestive heart failure are weighed daily, and the practitioner is notified of a weight gain greater than 3 pounds. 51102

Based on staff interview, clinical record review, and facility policy for 1 of 5 sampled residents (Resident #63) reviewed for unnecessary medications, the facility failed to ensure an as needed (PRN) psychotropic medication was limited to 14 days per the requirement. The findings include: Resident #63's diagnoses included dementia, hypertension, and a fractured left femur. The admission Resident Care Plan dated 7/8/24 identified Resident #63 was taking a psychotropic medication, Trazodone, (an antidepressant). Interventions included to monitor Resident #63 as related to behavior, cognition, and mood. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #63 was severely cognitively impaired and required extensive assistance of 2 for bed mobility, limited assistance of 2 for transfers, set up/supervision for eating, and that an antidepressant was in use. The physician orders dated 7/8/24 through 8/1/24 directed Trazodone 50 milligrams (mg), administer 0.5 mg every 8 hours as needed for agitation, but failed to include a medication stop date. A pharmacist recommendation dated 7/29/24 identified that Trazodone was required to be reevaluated after 14 days of use and that if therapy was to continue beyond 14 days, to please note the medical justification for the continued use in a progress note and specify the number of days the as needed medication order was to continue. Review of facility census records indicated that Resident #63 was discharged on [DATE] and readmitted to the facility, after a medical leave, on 8/2/24. The readmission physician orders dated 8/2/24 through 9/12/24 directed Trazodone 50 mg, administer 0.5 mg every 8 hours as need for agitation but failed to reflect a stop date. Review of the Medication Administration Record (MAR) dated 8/2/24 to 9/12/24 directed Trazodone 50 mg, administer 0.5 mg every 8 hours as needed for agitation but failed to reflect a stop date. An interview with APRN #1 on 9/12/24 at 1:39 PM identified that Resident #63's order for Trazodone should have only been place for 14 days and that the lack of a stop date when Resident #63 returned from the medical leave on 8/2/24 was an error. APRN #1 identified that all psychotropic medication that were ordered PRN required a stop date which cannot exceed 14 days. Subsequent to surveyor inquiry, Resident #63's order for Trazodone was re-written to include a stop date after 14 days. The facility Psychotropic Medication policy dated 3/22/23 identified that as needed orders for psychotropic drugs are limited to 14 days. If the physician believed that the as needed order should be extended beyond the 14 days, the physician must document a rationale in the medical record.

Based on facility documentation and interviews for the Resident Trust Account, the facility failed to ensure the current Surety Bond was sufficient to cover the current total balance amount in the Resident Trust Account. The findings include: A current Resident Trust Account balance statement dated 9/12/24 identified a balance of $73,524.38. Review of the Surety Bond from the insurance group provider, effective 6/4/2024 thru 6/4/2025, was for $10,000 indicating a shortage of $63,524.38. An interview with Accounts Receivable person on 9/13/24 at 10:06 AM identified she was not aware that the amount of the surety bond was insufficient to cover the Resident Trust Account balance. An interview with the Administrator on 9/13/24 at 12:10 PM identified that the surety bond was for $10,000 and the Resident Trust Account balance was $73,524.38. The Administrator was unaware that the amount of the surety bond was not enough to cover the Resident Trust Account balance and subsequent to surveyor inquiry, was working to obtain a surety bond amount sufficient to cover the balance ($63,524.38) in the Resident Trust Account.

Based on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) reviewed for falls, the facility failed to ensure a gait belt was utilized when ambulating the resident in accordance with facility policy. The finding includes: Resident #1's diagnoses included Alzheimer's Disease, left artificial knee joint, and osteoarthritis. The Minimum Data Set assessment dated [DATE] identified Resident #1 had short- and long-term memory problems, required maximum assistance with toileting, bathing, and dressing, required moderate assistance with transfers and ambulation, and utilized a walker for mobility. The Resident Care Plan dated 10/28/23 identified a self-care deficit, limited physical mobility, and fall risk related to cognitive deficits and decreased functional mobility. Interventions directed for physical therapy and occupational therapy to assess and treat, use appropriate footwear, gripper socks when out of bed, to keep personal belongings within reach and to keep the environment clutter free. The physical therapy evaluation dated 10/28/23 identified Resident #1 was at risk for falls with a history of three (3) falls in the past year and was being evaluated for transfers and mobility. The evaluation indicated Resident #1 was able to follow commands, required moderate assistance to sit at the edge of the bed, and moderate assistance of one person to transfer from a sit to stand position with the rolling walker. The evaluation identified as Resident #1 was being walked to the toilet with the assistance of both the occupational and physical therapists, Resident #1 suddenly fell backwards hitting his/her head on the floor and complained of left foot and head pain. The occupational therapy evaluation dated 10/28/23 identified as Resident #1 was ambulating from the bed towards the toilet with a rolling walker and assistance of two (2), Resident #1's knee buckled and Resident #1 suddenly dropped to the floor hitting his/her head on the floor and complained of left ankle and head pain. The nurse's note dated 10/28 23 identified the charge nurse, Licensed Practical Nurse (LPN) #1, heard a loud bang and gasps from Resident #1's room. Upon entry LPN #1 observed Resident #1 sitting on the floor, Resident #1 fell while working with the occupational and physical therapists, complained of pain to the right knee, posterior head, and left ankle. The resident was assessed by the Nursing Supervisor and the physician directed the resident be evaluated in the emergency department. Review of the hospital clinical record identified Resident #1 sustained a transverse fracture of the medial malleolus with intra-articular extension and a comminuted oblique fracture of the distal fibula with intra-articular extension, Resident #1 was admitted for orthopedic and medical workup pending a decision for surgery. The record identified Resident #1 was seen by ortho on 10/29/23 who placed splints for immobilization, recommended outpatient follow-up for placement of a cast and Resident #1 was discharged to the long term care facility on 10/31/23. Interview with PT #1 on 11/27/23 at 12:15 PM identified that on 10/28/23 in the morning, she along with OT #1 conducted an initial assessment of Resident #1. The assessment included testing of muscle strength, range of motion, transfers, and ambulation. PT #1 identified Resident #1 required minimal assistance to transition from a sit to stand position and initially required under the arm holds bilaterally with support to the back with ambulation. PT #1 indicated during ambulation the support was adjusted to contact guard. PT #1 identified Resident #1 was not wearing a gait blet and the gait belt policy identified anyone requiring assistance of one (1) or two (2) people for transfers and ambulation was supposed to be wearing a gait belt. PT #1 identified that typical practice is for all residents to have a gait belt on unless they are independent when ambulating. Interview with OT #1 on 11/27/23 at 12:45 PM identified on 10/28/23 she along with PT #1 conducted the initial assessment on Resident #1. OT #1 indicated Resident #1 required some assistance to transfer from a sit to stand position and while walking to the bathroom PT #1 and she were on either side of Resident #1, holding Resident #1 at the base of the spine and guiding the walker. OT #1 identified she readjusted her hands to manage the oxygen tubing and Resident #1 was requiring less assistance with ambulation. OT #1 identified she continued to keep a hand on Resident #1 and was very confident with Resident #1's walking ability. OT #1 identified Resident #1 was not wearing a gait belt and she was aware that the facility policy on gait belt use identified Resident #1 should have been wearing a gait belt. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 11/27/23 at 1:10 PM identified she responded to the room after hearing a loud bang, observed Resident #1 sitting on the floor at the foot of the bed with the walker in front of him/her, Resident #1 complained of foot pain and upon removal of the gripper socks, Resident #1 yelled out in pain. LPN #1 identified she contacted the Nursing Supervisor to assess Resident #1 and she identified Resident #1 needed to go to the hospital for an evaluation. Review of the annual mandatory in-services identified in December 2022, PT #1 and OT #1 took the post test on Body Mechanics and Back Care and correctly answered the question identifying that when ambulating a resident that requires assistance the staff must brace their weaker side, use a gait belt and walk at the resident's pace. Review of the facility policy titled Gait Belt Policy, dated 3/22/23, directed that gait belts are to be used when transferring or ambulating a resident that needs the assistance of one (1) or two (2) staff members.

Based on clinical record review, facility documentation, and interviews, for two (2) of three (3) residents reviewed for respiratory services, (Resident #1 and #2), the facility failed to ensure that oxygen tubing was changed in accordance with facility policy. The findings include: 1. Resident #1 had diagnoses that included Congestive Heart Failure (CHF). A Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had severe cognitive impairment and received oxygen on a daily basis. A care plan dated 3/1/23 identified that the resident had CHF and to monitor for signs and symptoms of heart failure and to medicate in accordance with physician's orders. A physician's order dated 3/1/23 directed to administer oxygen at two (2) liters per minute via nasal cannula to keep oxygen saturations above 92%, and to change oxygen tubing weekly every Sunday on the 11:00 PM to 7:00 AM shift. Review of Resident #1's Treatment Administration Record (TAR) from March to April 2023 identified that the oxygen tubing was not signed off as changed on 3/12, 4/9, and 4/23/23. 2. Resident #2 had diagnoses that included CHF and Chronic Obstructive Pulmonary Disease (COPD). An annual MDS assessment dated [DATE] identified that the resident was cognitively intact and received oxygen daily. A care plan dated 4/1/23 identified that the resident had potential for shortness of breath with interventions that included monitoring for signs and symptoms of respiratory distress. A physician's order dated 4/1/23 directed to administer oxygen via nasal cannula 0.5 to 2 liters a minute to maintain oxygen saturation above 92%, and to change the oxygen tubing once a week, every Sunday on the 11:00 PM to 7:00 AM shift. Review of the TAR for April 2023 identified that the oxygen tubing was not signed off as changed on 4/9 and 4/23/23. Interview with the Director of Nurse's on 6/7/23 identified that the nurse's should be changing the oxygen tubing once a week in accordance with facility policy. Review of the oxygen policy identified that oxygen tubing should be changed weekly.

Based on clinical record review, observations, review of facility documentation, and interviews, the facility failed to ensure that water sources potentially contaminated with Legionella were restricted from use in resident care areas, which was identified as corrected on [DATE] when the facility audited the affected units to ensure all water sources were either turned off or a water filter was in place. The finding includes: Resident #1 resided on Northern Pines nursing unit and had diagnoses that included Congestive Heart Failure (CHF). A Minimum Data Set assessment dated [DATE] identified that the resident had severe cognitive impairment and required extensive assistance with Activities of Daily Living. A care plan dated [DATE] identified that the resident had CHF and to monitor for signs and symptoms of heart failure and to medicate in accordance with physician's orders. A nurse's note dated [DATE] identified that the resident had an unwitnessed fall and vital signs revealed a pulse of 143 (normal pulse 60 to 80 beats per minute) and the resident's oxygen saturation was 69% (normal ,d+[DATE]%), the resident was placed on oxygen and sent to the hospital. Review of the hospital paperwork dated [DATE] identified that the resident was admitted to the hospital with community acquired pneumonia, had tested positive for the Legionella, had acute respiratory failure, and was treated with antibiotics. A nurse's note dated [DATE] at 12:39 AM identified that the resident had been readmitted on [DATE] to the facility after a hospital stay for pneumonia. A nurse's note dated [DATE] identified that the resident was experiencing episodes of respiratory distress and was seen by the Advanced Practice Registered Nurse (APRN) and with permission of the family, hospice was notified and a referral was made, the resident was experiencing end of life symptoms and comfort medications were ordered. A nurse's note dated [DATE] at 12:05 AM identified that the resident was found with no respirations or pulse and was pronounced deceased by the Registered Nurse. Review of Resident #1's death certificate dated [DATE] identified that the resident's cause of death was pneumonia. Interview with the Administrator on [DATE] at 2:30 PM identified that on [DATE] the facility was notified that Resident #1 tested positive for Legionella in a urine test on [DATE] at the hospital. Interview with the State Epidemiologist on [DATE] at 2:01 PM identified that Resident #1 had not left the facility for the previous 14-day incubation period, had a positive test for Legionella in the urine, and a chest X-ray that identified pneumonia which indicated that the Legionella was a facility acquired case. Interview with the Administrator on [DATE] at 2:30 PM identified that on [DATE] the facility met with the state agency, and epidemiology, to discuss a plan to restrict water access to the affected part of the building (Northern and Southern Pines) until Legionella test results would be available (approximately 2 weeks). The area of concern for Legionella was the Southern and Northern Pines units where Resident #1 resided, the facility took water samples to test for Legionella and ordered water filters on [DATE] (the water filters act as a physical barrier to trap the bacteria from passing through). When the filters were delivered to the building it was identified that the filters were not compatible with the facility faucets, so new faucets were ordered and until new faucets could be delivered to the facility, the water would be shut off restricting the potentially contaminated water from being used. The facility was able to install a total of 9 water filters on the shower heads and some of the faucets on [DATE]. The administrator identified if the water source did not have a filter, it was shut off. Observations by the state agency on [DATE] at 10:35 AM through 11:10 AM, 5 days subsequent to the facility restricting the water supply on the Southern and Northern pines units, an unsecured tub room on the Southern Pines unit, and bathroom sinks in room [ROOM NUMBER] and room [ROOM NUMBER], all had signs above sink do not use, however, when turned on the sinks had flowing water, all without filters. Observations in room [ROOM NUMBER]'s bathroom identified a shower head with free flowing water without a filter, additionally the shower lacked any signage not to use the shower. All of these areas identified were in resident care areas and all rooms identified were occupied by residents. The facility took immediate action upon surveyor observation on [DATE] and added a filter to the shower head in room [ROOM NUMBER], the water supply to sink in the tub room, and the sinks in room [ROOM NUMBER] and 27 were shut off. The facility also conducted an audit of all rooms on the affected units to ensure that water sources were turned off. Interview and observation of the Southern Pines unit, room [ROOM NUMBER], with the Maintenance Director on [DATE] at 10:39 AM identified that the shower head had a filter, however, he had just placed the filter on the shower head, subsequent to surveyor observation at 10:35 AM. The Maintenance Director identified that the facility had placed the filters on the shower heads immediately on [DATE] (5 days prior) because the water filters were compatible with the shower heads, however, room [ROOM NUMBER] must have been missed. Interview and observation with the Administrator of the shower room on the Southern Pines unit on [DATE] 10:45 AM identified that a sign was placed above the sink that identified do not use, the sink did not have a filter, however, when the sink was turned on by the surveyor, water was free flowing. The Administrator identified that the tub room is a resident care area that residents have access to, and he was unsure why the sink was not turned off on [DATE] (5 days previous to surveyor observation). Interview and observation of rooms [ROOM NUMBERS] on the Northern Pines unit on [DATE] at 11:10 AM identified that although there was a sign above both sinks stating do not use when the surveyor turned on the sinks the water was free flowing. The Administrator identified that both of the sinks were a hard shut off, and that it was possible that the maintenance staff attempted to turn off the sinks of [DATE] but were unable to, and may have forgotten to go back and shut them off. The facility took immediate action upon surveyor observation on [DATE] and added a filter to the shower head in room [ROOM NUMBER], the water supply to sink in the tub room, and the sinks in room [ROOM NUMBER] and 27 were shut off. The facility conducted an audit of all rooms on the affected units to ensure that water sources were turned off. Further interview with the State Epidemiologist (SE) on [DATE] at 12:05 PM identified that Legionella is a bacteria that is spread by inhaling water contaminated with Legionella into the lungs, and any type of running water could lead to an infection. The SE further identified that once the facility was aware of possible Legionella contamination the residents and staff should have not had access to any running water on the Northern and Southern Pines units. The SE stated that any unrestricted water on these units would be very concerning. According to the Centers for Disease Control Legionella is a serious type of pneumonia that is diagnosed by a chest X-ray and a urine test. The Legionella bacteria can be found in any human made building water system, for example shower heads and sink faucets. Legionella grows and multiplies in a building water system and can be transmitted in droplets small enough for people to breath in. On [DATE] the facility was notified that all of the random water samples came back negative for Legionella.

Based on clinical record review, facility documentation review, and interviews for one (Resident #1) reviewed for accidents, the facility failed ensure the intercom system was functioning. The findings include: Resident # 1's diagnoses included oral phase dysphagia, heart failure, Parkinson's disease, unspecified convulsions, catatonic schizophrenia, and anemia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and required supervision with eating. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 had dysphagia with alteration in swallowing safely and effectively, had poor food safety awareness, rushing through meals, and had the potential for choking related to dementia, Parkinson's, and dysphagia. Interventions directed to provide direct supervision for all oral intake, upright 90 degrees for all oral intake and for at least ,d+[DATE] minutes following meals, cue Resident #1 to take small bites of food, chew or swallow prior to the next bite, cue to take small single sips of liquids, cue to alternate solids and liquids and cue for slow rate of intake of meals. The nurse's note dated [DATE] at 3:23 PM identified LPN #1 was notified Resident #1 had coughed while eating the lunch meal and observed Resident #1 sitting up straight with mouth open. LPN #1 provided a few sets of three (3) to four (4) back slaps and asked Resident #1 to cough, but Resident #1 was unable to dislodge the object. The note further identified Resident #1 pointed to throat and LPN #1 gave a few abdominal thrusts while Resident #1 was sitting in the chair and was unable to dislodge object. Resident #1 was helped to stand up and a few more abdominal thrusts were given with the help of NA #1. Resident #1 coughed but was still unable to dislodge object. LPN #1 asked Resident #1 to cough while abdominal thrust was given, Resident #1's lips turned blue, and he/she became limp and was lowered to the floor. The note also identified that LPN #1 left Resident #1 with NA #1 and NA #2, (NA #1 was CPR certified) and ran to call code blue. Interview with LPN #1 on [DATE] at 11:25 AM identified when Resident #1 was eating in the nursing unit dining area, Resident #1 started choking. LPN #1 identified when she attempted to call a code blue from the phone (intercom system) in dining area, she realized the phone had static sounds and she could not call the code blue using the dining room phone. She identified that she had to run to nurse's station to page/call the code blue. She identified that the phone in the unit's dining area was only used to communicate with the facility's kitchen and she did not know it was not working (the phone does not allow calls outside the facility). She further identified that she did not realize that the phone malfunctioned until she tried to call code blue at that time. LPN #1 indicated the unit's dining room telephone failed to function too allow paging the code blue when Resident #1 experienced a choking incident and LPN #1 a choking incident with was unable to call for help. Interview with the Maintenance Director on [DATE] at 1:19 PM identified that communication to the facility's maintenance department is done through email. He identified that the department did not receive any email regarding the phone in the unit's dining not working prior to [DATE], and the facility did not perform monthly checks of the phones to ensure function. He identified that it was discovered that the phone was not when LPN #1 attempted to use it to call for code blue on [DATE] when Resident #1 experienced a choking incident. He further identified that the distance LPN #1 had to go to use the phone at nurse's station was approximately forty feet. Subsequent to the incident on [DATE], the Maintenance Director identified the phone was inspected and identified to have malfunctioned. The Maintenance Director indicated the phone was replaced on [DATE] after the incident. Facility did not provide a policy for surveyor review.

Based on observations, review of facility policy, and interviews, the facility failed to ensure that dietary staff donned hair nets, beard guards and gloves during food prep and failed to ensure food items were properly dated, labeled and discarded at prescribed times and failed to ensure that the sanitizing liquid used to sanitize the food prep equipment and pots were at the appropriate level to disinfect and prevent the possibility of contamination from a microorganism. The findings include: Observation on 6/5/22 at 6:20 AM noted DA #1 (dietary aide) in the process of preparing strawberry and blue berry desserts, DA #1 was noted to use ungloved hands to place blueberries on the top of each dessert cup and was noted to not be wearing a hair net. Interview with DA #1 on 6/5/22 at 6:31 AM indicated he was supposed to wear gloves and a hair net when handling the resident's food. DA #1 immediately donned a hair net and gloves without the benefit of washing hands or using hand sanitizer. Observation in the kitchen on 6/5/22 at 7:15 AM noted Cook #1 in the process of preparing French toast, Cook #1 did not have a beard guard in place and facial hair could be seen around the mask on both cheeks and completely covering the chin and neck area. Interview with Cook #1 on 6/5/22 at 7:16 AM noted he should have had a beard guard on and would get one immediately and noted that his facial hair on the sides of his face and the chin/neck area was at least an inch long. Cook #1 indicated DA #1 must wear gloves when preparing foods including the strawberry and blueberry deserts. Cook #1 indicated DA #1 must wear a hat, hair net, or a cap covering his hair when in the kitchen area and preparing food. A tour of the walk-in refrigerator with Cook #1 on 6/5/22 at 7:25 AM identified: · Two trays of uncooked fish with breadcrumbs on top, and two trays of meat that were uncovered and undated. Cook #1 identified that the fish and meat should have been covered in plastic wrap with a prep date and/or date of when the meat was placed in the refrigerator to unthaw. · A large container labeled beef stew with a date of 5/30/22, Cook #1 indicated the beef stew should have been discarded after three days. · A metal container with shredded carrots dated 5/31/22. Cook #1 indicated prepared carrots should be discarded on day 5 and noted that it was day 6 and the carrots needed to be discarded. · A large metal container filled with applesauce with a date of 5/31/22, Cook #1 indicated it was good for 5 days, but needed to be discarded at the fifth day. · A container of cut up cucumbers dated 5/31/22, which Cook #1 indicated should have been discarded on day three (6/3/22). · A container with meat covered but not dated that Cook #1 identified was short ribs but noted it should have been dated. · A large metal tray on the bottom shelf contained raw chicken that was covered but not dated, with saran wrap not dated. There was also another container of meat that was covered but undated. Cook #1 indicated that all food items should be dated. Interview with the Dietary Manger on 6/6/22 at 10:45 AM indicated dietary staff must wear gloves every day when handling food and they have to wear a hair net and a beard guard if facial hair is over a quarter inch in length. He also noted that hands should be washed before and after donning and doffing gloves. In addition, the Dietary Manager indicated that the food in the walk in refrigerator must be covered and dated when prepared and discarded 3 days after being prepared. Observation on 6/6/22 at 10:40 AM noted Cook #1 wiped the counter down that he used to prepare sandwiches on. A test of the solution used to wipe the counters down identified the solution did not register as having sanitizer. Cook #1 indicated he had filled the water buckets from the three bay sink and indicated that he had not tested the water/sanitizing solution because there were no test strips available. Interview with the Executive Cook on 6/6/22 at 1:35 PM indicated the facility had recently changed chemicals and the facility did not have any test strips to test the 3 bay sink or the red buckets used for surfaces in at least a week. The Executive Cook indicated that he heard that the state was in the facility so on his way to work he asked a friend to borrow some test strips and picked up the test strips on his way to work. Interview with the Executive Cook on 6/7/22 at 12:15 PM indicated the facility had been using the new sanitizing product for 4-6 weeks and he only had one container of testing strips and ran out about a week ago. The Executive Cook indicated the 3 bay sink was being used during the week for washing of the pots and pans while they did not have testing strips. The Executive Cook also noted the company for the chemical was called but could not come out to the facility so he decided to go back to the old sanitizing system until the new company could come out. In addition, the Executive Cook indicated he did have the testing strips for the old sanitizing solution, and it was a different type of testing strip. He indicated he would educate staff on the new sanitizer system because once it was repaired or fixed by the company the dietary staff would go back to using the new product. Interview with the Dietary Manger on 6/7/22 at 12:30 PM indicated the sanitizer chemical should be tested every morning and then the red buckets and the 3 bay sink with the sanitizer water should be emptied and re-filled every 2 hours. The Dietary Manager was aware they did not have testing strips for a week and the sanitized water was not being tested . The Dietary Manager indicated she had been asking for information regarding the new product they were using but had not received anything. The Dietary Manager indicated with this new chemical for sanitizing maybe they may have to test more often and may have to change the sanitized water more often based on the manufacturer recommendations for how long the chemical was good for once it was dispensed for use. Review of the facility's policy regarding Labeling and dating foods identified that all food must be labeled and dated to ensure that all staff are aware of the contents of the package and when it must be used by. Food that left over after meal service must be labeled and dated and used within 2 days. Review of facility's policy regarding Glove use identified that gloves help ensure food safety by creating a barrier between hands and ready to eat foods. Hands should be properly washed, and disposable gloves applied, or sanitized utensils were used to prevent contamination of ready to eat foods from hands. Specific tasks that require wearing disposable gloves include; making sandwiches, cutting fruit, and vegetables for service. The employee needs to change gloves before starting another job. Hands must be washed each time when gloves are changed to start another job. Review of the facility's Personal Hygiene policy identified food handlers must cover hair properly with a hair restraint such as a hair net, cap or hat. Mustaches and beards must be well trimmed, and hair must be properly covered to keep it away from food. Review of the facility Sanitizing Food Contact Services identified any surface that comes in contact with food such as utensils, equipment, cutting boards, and prep tables must be first cleaned and then sanitized, without this important step in our food safety program, food can easily become contaminated. Sanitizing means reducing the number of harmful microorganisms on that surfaces to a safe level. Always wash and rinse surfaces first then sanitize and let solution stand for one minute allowing to air dry. Change the solution when it is visibly soiled, or concentration has dropped below the required level.

Based on observation, review of facility policy, and interviews, the facility failed to ensure dietary staff wore proper fitting facial masks that covered the nose and mouth. The findings include: Observation on 6/5/22 at 6:20 AM noted DA #1 had a face mask on that was on the chin but did not cover his nose or mouth. DA #1 was in the process of preparing desserts during the time of the observation. Interview with DA #1 on at 6/5/22 at 6:31 AM indicated he was aware that his mask should cover his mouth and nose, he immediately pulled his mask up over his nose and mouth. Observation on 6/5/22 at 7:15 AM noted Cook #1's mask was below his nose and only covered his mouth. Interview with Cook #1 on 6/5/22 at 7:16 AM noted he corrected his mask ensuring that it covered his nose. Cook #1 indicated all dietary staff must wear a mask at all times when preparing food and in the kitchen. Interview with the Dietary Manager on 6/6/22 at 10:45 AM indicated that masks worn correctly should cover the nose and mouth area. Review of the education provided by the Dietary Manager identified that the dietary staff was required to properly wear a face mask that covers the nose and mouth due to the Covid -19 virus.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #12) reviewed for respiratory care, the facility failed to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #12 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change Minimum Data Set (MDS) dated [DATE] identified Resident #12 was cognitively intact and required extensive assistance with personal hygiene with one person physical assist. The MDS further identified Resident #12 required extensive assistance of one person physical assist for transfer, dressing, and required oxygen therapy. A Resident Care Plan (RCP) dated 4/13/22 identified Resident #12 has oxygen therapy related to [CONDITION(S)]. Interventions included to administer oxygen according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note dated 6/2/22 at 11:12 PM identified Resident #12 continues on oxygen at 3 Liters and pulse oxygen at 97%. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 6/5/22 at 9:27 AM with the ADNS identified Resident #12 sitting in the wheelchair in room with oxygen concentrator at 3 Liters via nasal cannula (receiving oxygen therapy). Interview with ADNS on 6/6/22 at 2:00 PM identified she has been employed by the facility for approximately 3 weeks. The ADNS identified she was not aware of the issue. The ADNS indicated the license nursing staff would be expected to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the DNS on 6/7/22 at 7:15 AM identified she has been employed by the facility for approximately 4 weeks. The DNS identified she was not aware of the issue. The DNS indicated it is the responsibility of the licensed nursing staff to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility oxygen therapy policy identified to standardize use of low flow oxygen therapy to maintain adequate blood levels as ordered by the physician. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility medications and treatment policy identified medication will be administered when ordered by an authorized prescriber. Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for two of three sampled residents (Residents #12 & #23) reviewed for respiratory care, the facility failed to ensure that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Resident #12's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change MDS assessment dated [DATE] identified Resident #12 was cognitively intact, required extensive assistance of one person for personal hygiene, transfers and dressing. The assessment also identified that the resident required oxygen therapy. The resident care plan (RCP) dated 4/13/22 identified Resident #12 had oxygen therapy related to [CONDITION(S)] with an intervention to administer oxygen according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note dated 6/2/22 at 11:12 PM identified Resident #12 had oxygen at 3 liters and a pulse oxygen saturation rate of 97%. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 6/5/22 at 9:27 AM with the ADNS identified Resident #12 seated in a wheelchair in his/her room with a nasal cannula in place and the oxygen concentrator set at 3 liters (receiving oxygen therapy). Interview with the ADNS on 6/6/22 at 2:00 PM identified she had been employed by the facility for approximately 3 weeks. The ADNS identified she was not aware of the issue and indicated the licensed nursing staff would be expected to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the DNS on 6/7/22 at 7:15 AM identified she had been employed by the facility for approximately 4 weeks. The DNS indicated it was the responsibility of the licensed nursing staff to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS indicated an in-service would be given to the licensed nursing staff. Review of the facility's oxygen therapy policy identified that oxygen therapy should be ordered by the physician and the order should include the liter flow of oxygen, and frequency. 2. Resident #12 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change MDS assessment dated [DATE] identified Resident #12 was cognitively intact, required extensive assistance of one person for personal hygiene, transfers and dressing. The assessment also identified that the resident required oxygen therapy. The Resident Care Plan (RCP) dated 4/13/22 identified Resident #12 has oxygen therapy related to [CONDITION(S)] with interventions that included, administer oxygen according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 6/5/22 at 9:27 AM identified Resident #12 seated in a wheelchair with a nasal cannula in place and oxygen flowing at 3 liters per minute via oxygen concentrator. The oxygen tubing connected to the concentrator was dated 5/23/22 (12 days old). The oxygen tubing connected to the portable oxygen tank was dated 5/2/22 (33 days old). Interview with the ADNS on 6/5/22 at 9:37 AM identified she had been employed by the facility for approximately 3 weeks. The ADNS indicated the oxygen tubing should be changed weekly on Sundays on the 11:00 PM - 7:00 AM shift by the nursing staff. The ADNS indicated an in-service would be given to all licensed nursing staff regarding changing oxygen tubing. Interview with RN #1 (infection control nurse) on 6/6/22 at 9:18 AM identified she had been employed by the facility for approximately 2 1/2 years. RN #1 indicated the facility policy indicated oxygen tubing should be changed weekly on Sundays on the 11:00 PM - 7:00 AM shift by the nursing staff. RN #1 indicated last environmental rounds was performed on March 2022, and the next environmental round is due in June 2022. RN #1 indicated an in-service will be given to all licensed nurses. Interview with the DNS on 6/7/22 at 7:18 AM identified she had been employed by the facility for approximately 4 weeks. The DNS indicated the oxygen tubing should be changed weekly on Sundays on the 11:00 PM - 7:00 AM shift by the nursing staff. The DNS indicated on the Monday prior when she had reviewed the treatment kardex for changing oxygen tubing the licensed nurse had signed the treatment kardex. The DNS indicated she was under the impression that the oxygen tubing was changed. The DNS indicated an in-service would be given to the licensed nursing staff. Review of the facility's oxygen therapy policy dated 6/5/22 indicated that nasal cannulas should be labeled with the date and changed every 7 days on the 11:00 PM - 7:00 AM shift, and as indicated per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Resident #23's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS assessment dated [DATE] identified Resident #23 had intact cognition and required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. The care plan dated 4/6/22 identified Resident #23 had congestive heart failure with the potential for shortness of breath with interventions that included administer oxygen per physician orders. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, change oxygen tubing and label with date every Sunday on the 11-7 shift. The nurse's note dated 5/31/22 at 11:46 PM identified Resident #23 had oxygen via nasal cannula at 0.5 liters. The note further identified that Resident #23 denied shortness of breath and pain. Review of the treatment record for May/2022 identified Resident #23 was on 0.5 liters of oxygen to maintain saturation levels above 92% and check Resident #23 every shift for oxygen saturation level. The treatment record noted that Resident #23's saturation levels were between 92%-98% on 0.5 liters of oxygen. The treatment record also noted, change oxygen tubing and label with date every Sunday on 11:00 PM -7:00 AM shift. The changing of the oxygen tubing was signed off as changed on 5/1/, 5/8, 5/18, 5/22, and 5/29/22. The nurse's note dated 6/1/22 at 11:01 PM identified Resident #23 was unable to titrate off of the oxygen that shift and noted that the oxygen saturation level on room air was 89%. The note further identified that the resident continued on oxygen 0.5 liters per minute to maintain saturation level of 93%. Resident #23's lung sounds were diminished but clear at baseline. Review of the treatment record (TAR) for the period of 6/1/22 - 6/6/22 identified that the oxygen tubing was due to be changed on Sunday 6/5/22 on the 11:00 PM - 7:00 AM shift. Observation on 6/5/22 at 8:55 AM identified Resident #23 had a nasal cannula in place that was connected to a portable oxygen tank located on the back of the wheelchair and the tubing was dated 5/23/22. There was a concentrator located to the right side of the bed with oxygen tubing attached dated 5/23/22. The nasal cannula was not stored in a bag but noted to by lying on the resident's bed. Interview with Resident #23 on 6/5/22 at 8:57 AM indicated he used oxygen 24 hours a day and the tubing was supposed to be changed on Mondays. Resident #23 indicated he was currently on 0.5 liters per minute and noted he/she had worn the oxygen tubing lying across his/her bed last night and took it off this morning when the portable oxygen tubing was applied. Interview and observation with the ADNS on 6/5/22 at 9:05 AM indicated the nasal canula on Resident #23 attached to the portable oxygen was dated 5/23/22 and the concentrator oxygen nasal cannula was dated 5/23/22. The ADNS indicated the oxygen nasal cannulas for both machines should have been changed every 7 days and should have been changed on 5/30/22 (almost 2 weeks ago). The ADNS indicated there would be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADNS after clinical record review indicated there wasn't an order in place and would have to get the facility policy. Interview with the DNS on 6/5/22 at 9:43 AM indicated that her expectation was that oxygen tubing would be changed on a weekly basis on the 11-7 AM shift and as needed. Review of facility's Oxygen Policy dated 6/5/22 identified that the nasal cannulas are to be changed every 7 days on the 11:00 Pm - 7:00 AM shift and as needed per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the policy noted that plastic bags should be labeled with the date and changed every 7 days and when visibly soiled.

Based on review of facility documentation, the facility failed to ensure that staff testing for COVID-19 was conducted in accordance with CMS and CDC guidance. The findings include: Interview with the Director of Nursing Services (DNS) on 9/3/20 at 9:30 AM indicated that the facility was testing all staff in accordance with the guidance and noted that the facility was COVID-19 free. The DNS further identified that she/he felt it was very important to continue staff testing in order to decrease the risk of staff resident transmission. Interview with the Administrator on 9/3/20 at 10:00 AM identified that all the staff were tested on a weekly basis to prevent COVID-19 from entering the facility. The Administrator identified that this is very important to prevent a resurgence of COVID-19. Interview on 9/3/20 at 10:20 AM with the Infection Control Nurse (LPN #1) indicated she/he performed staff testing and was responsible for ensuring that all staff members were tested on a weekly basis. LPN #1 provided a spread sheet with all employee names and the dates of their testing during 8/16/20 through 8/29/20. Interview with the DNS on 9/3/20 at 11:00 AM identified the facility had a staff member that tested positive in June 2020 but did not have any current staff or residents that were positive for COVID-19. The DNS identified that she reviewed the employee testing list on a weekly basis to ensure that all the staff were tested . The DNS further noted that the staff were very good about getting tested on a weekly basis on their scheduled day and time and if an employee was going to be off on their scheduled testing day, then the staff member was supposed get tested on the previous day. The DNS indicated weekly testing of COVID-19 was done by LPN #1 with oversight from the Infection Preventionist RN #1. Review of the employee roster on 9/3/20 with the DNS and LPN #1 identified that during the week of 8/16/20 through 8/22/20 seven employees were not tested for COVID-19 and during the week of 8/23/20 through 8/29/20 thirty-one employees were not tested for COVID-19. Further review noted that all of the employees not tested had worked at least once during the period of 8/16/20 through 8/29/20 and thereafter. Further interview with the DNS on 9/3/20 at 2:00 PM indicated she/he did not realize that many employees were not tested during the week of 8/23 through 8/29/20. The DNS was unable to explain why these staff members were not tested . Further interview with LPN #1 on 9/3/20 at 2:05 PM identified she/he had double checked all the test results and confirmed that the data provided was accurate. LPN #1 indicated that during the week of 8/23 through 8/29/20 she/he was out sick a few days and could not explain why there were 31 employees who were not tested . Further interview with the Administrator on 9/3/20 at 2:20 PM identified she/he was not aware that they were not 100% compliant, but identified that it is a priority to have all the employees tested weekly because they are the ones that would be bringing COVID-19 into the facility and spreading COVID-19 to the residents. A review of the facility's testing report for weekly testing on 9/3/20 identified that for the week of 8/16/20 through 8/22/20 the facility staff testing completion rate was 80% and during the week of 8/23 through 8/29/20 was 60.6%. The facility had a total of 34 employees (none of which had previously tested positive for COVID-19) that were actively working in the nursing home between 8/16 through 8/29/20 and thereafter. The facility failed to conduct staff testing in accordance with CMS guidance, Executive Order 7AAA and Blast Fax 2020-87. The facility policy on Resident and staff testing was requested but not provided.

Based on clinical record review, facility documentation, interviews, and policy review for one of three resident's reviewed for abuse ( Resident #25), the facility failed to ensure that the resident was free from abuse. The findings include: Resident #25 had a [DIAGNOSES REDACTED]. A minimum (MDS) data set [DATE] identified that the resident had moderate cognitive impairment, required extensive assistance with activities of daily living, and did not exhibit any alterations in mood. Review of a reportable event and investigation dated 10/8/19 identified that on 10/8/19 Resident #25's family member had called the facility at 5:30 PM and stated that a Nurse Aide (NA) had pinched the resident in his/her right breast in the hallway earlier in the day. The statement obtained from Resident #25 further identified that he/she was pinched in the right breast by a NA, and that this was not the first time it had happened, but he/she had not told anyone about the first incident. The investigation identified that it was NA#7 that had allegedly pinched the resident. A body audit was performed with no injuries noted. The investigation identified that the facility had substantiated the allegation because of the consistency of Resident #25's recollection of events. Interview with Resident #25 on 10/23/19 at 1:06 PM identified that about 2 weeks ago a NA had pinched his/her right breast while she was sitting in the hallway. Resident #25 further identified that the pinch was painful and made him/her very angry. Interview with NA #7 on 10/23/19 at 11:30 AM identified that on 10/8/19 she did not have any contact with Resident #25, and at no time had she ever pinched Resident #25. Interview with the Social Worker on 10/23/19 at 1:45 PM identified that although the most recent brief interview of mental status (BIMS) score identified that the resident had moderate cognitive impairment, Resident #25 was alert and oriented, had intact short term and long term memory, good recall skills and had no history of accusatory behavior. She further identified that she had done an initial visit with the resident on 10/9/19 after the allegation, and had made subsequent visits to assess his/her mood, and on all of these occasions the Resident's recollection of events remained consistent. Interview with the Director of Nurse's on 10/24/19 at 2:30 PM identified that she had the resident look at several employee photographs to identify the NA who had allegedly pinched him/her, Resident #25 immediately pointed to NA#7 and stated that's her, that girl is evil. The DON further identified that the resident had accuracy and consistency in her recollection of events, so the allegation was substantiated and NA #7 was terminated. Review of the facility policy on abuse identified that each resident has the right to be free from abuse.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews, for one sampled resident (Resident #47) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure that all of the recommendations were implemented. The findings include: Resident #47's [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 was severely cognitively impaired and had a level 2 PASRR. Review of the PASRR summary findings identified that Resident #47 should be evaluated for a [DIAGNOSES REDACTED]. Review of the clinical record failed to reflect an assessment for dementia. An interview with the Director of Social Services on 10/23/19 at 11:40 AM identified that she did not see the actual evaluation of the PASRR level 2 recommendation. The Director of Social Services identified that no one staff member is individually responsible for the oversite of the PASRR recommendations and that it is an interdisciplinary effort. The Director of Social Services identified that RN #3, the MDS coordinator was responsible to ensure that the different departments who were responsible to implement the recommendations were notified to implement their part and that it would be the Nursing Department and/or the Social Service Department who would ensure that an evaluation of dementia was conducted. The Social Service Director identified that she could not recall the specific case. Interview with RN #3, the MDS coordinator on 10/23/19 at 11:46 AM identified that she traditionally gives a copy of the PASRR to the Social Worker, but that she was not sure who ultimately was responsible to ensure PASRR recommendation are implemented and that it is an interdisciplinary effort. Interview with RN #2 identified that she spoke with the psychiatric Advanced Practice Registered Nurse (APRN) and that if a dementia assessment was conducted, it would have been located under the exam section on the 6/4/19 visit. Review of APRN psychiatric note failed to identify a dementia assessment.

Based on clinical record reviews, reviews of facility investigations, and staff interviews for two of six residents in the survey sample reviewed for accidents (R #129 and R#214), the facility failed to ensure an assistive device was used during a transfer resulting in an injury, and/or failed to provide supervision and/or assistance in accordance with the plan of care to prevent falls with injuries. The findings include: 1. Resident # 129 ' s [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated the resident had moderately impaired cognition and required extensive assist with transfer. A resident care plan dated 5/31/13 identified the resident was at risk for falls. Interventions included transfer with assist of 1 and ambulate with a rolling walker and brace to left knee. A Physical Therapy discharge note dated 4/1/13 indicated the resident received therapy from 3/19/13 to 4/1/13. The resident was obese and bilateral knees had a valgus deformity causing him/her to be at greater risk for falling due to instability; more evident in the left knee then the right knee. Resident was fitted for a knee brace that he/she will wear whenever he/she transfers or ambulates short distances with the rolling walker. A physician's orders [REDACTED]. A nurse's note dated 7/24/13 at 11:55 AM indicated R #129 was lowered to the floor and the left foot was twisted. The resident was in significant pain and the left foot/ankle was swollen. Physician was notified and a stat x-ray was ordered. An x-ray report dated 7/24/13 noted probable bimalleolar fractures. Review of a the facility investigation documentation dated 7/24/13 at 11:55 AM indicated R # 129 turned to transfer but started to go down. The nurse aide assisted the resident to the floor. The left foot was twisted as the resident went down. An x-ray showed a left bimalleolar fracture and the resident was transferred to the hospital and admitted . A hospital discharge summary dated 7/26/13 indicated the resident underwent [REDACTED]. An interview on 9/11/13 at 10:13 AM with nurse aide # 4 indicated on 7/24/13, R#129 was holding on to the bar in the bathroom while he/she was doing pericare. The resident could no longer stand and started to fall to the floor. She attempted to hold the resident, but was unable to. The resident's left foot twisted as he/she went to the floor. Nurse aide #4 indicated the resident did not have a left knee brace on and/or did not use a walker at the time of transfer. NA#4 indicated he/she was not the routine caregiver for R # 129 and was not aware the resident needed a left knee brace and/or walker for transfer. An interview on 9/11/13 at 10:40 AM with physical therapist # 1 indicated that although it was not out of character for the resident to refuse care, he/she would have expected the nurse aide to attempt to apply the left knee brace on the resident. He/she was not aware of the resident refusing the left knee brace on a regular basis. He/she indicated the regular caregivers know the equipment needed and what is expected for each resident. An interview on 9/12/13 at 12:35 PM with the DNS indicated the left knee brace for transfer should have been on the nurse aide information sheet (summary). Although there was no documentation in the clinical record, the resident had been refusing the left knee brace. She indicated the physician should have been notified and a therapy referral made for re-evaluation. 2. Resident #214's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as moderately impaired for decision-making skills, requiring extensive assistance of two for most activities of daily living, with functional limitations in range of motion of the upper and/or lower extremities and noted as having frequent pain. An interim care plan dated 6/15/13 identified a problem with falls. Interventions included do not leave (resident) unattended in the bathroom. Review of the clinical record and facility documentation identified that on 8/24/12 at 12:50 P.M. after being left unattended on a toilet by staff, the resident was found lying on the bathroom floor on his/her right side. An initial x-ray of the resident's right side which included the shoulder, humerus, hip, knee, ankle and foot were obtained on 8/24/12 and were all negative for fractures. During the period of 8/24/12 to 8/29/12, the resident continued to complain of pain (i.e. moaning and grimacing) which required narcotic pain medication. On 8/28/12 a second x-ray was obtained and the resident was noted as having a moderately displaced right sub-capital femoral neck fracture of the right hip. On 9/11/13 at 2:15 P.M., 2:30 P.M. and 4:35 P.M. interviews and review of facility documentation with NA #2, RN #2 and LPN #1 indicated that the resident was found on the floor of the bathroom. RN #2 and LPN #1 indicated that when it was determined that the resident had fallen secondary to being left unattended in the bathroom by NA #1 it was upsetting. LPN #1 further indicated that he/she was "mortified" because it had been clearly stated in writing that R #214 was not to be left unattended. On 9/11/13 at 5:20 P.M., an interview and review of facility documentation with NA #1 indicated that he/she had transferred the resident and placed him/her on the toilet without assistance and had only left the resident for a "split second" to go out into the hallway to get a pad for the resident's bed. Although it was noted by NA #1 that he/she was aware that the resident was not to have been left unattended, he/she further responded by stating "oh well, things happen". Subsequent to the resident's fall, on 9/11/13 at 2:00 P.M., interviews and review of facility documentation and portions of NA #1's personnel record with the DON identified that on 8/31/12, NA #1 had been given a final written warning and a three day suspension regarding the event of 8/24/12. It was further noted at the time, that NA #1 was also involved in the resident's previous fall of 6/15/12 at which time the resident was left unattended.

Based on review of clinical records, review of facility documentation, review of facility policies, and interviews for one of three sampled residents, Resident #143, who was reviewed for accidents, the facility failed to maintain a safe environment to prevent accidents. The findings the included: 1. Resident #143 (R #143) had [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] identified that R #143 was severely cognitively impaired, required extensive assistance with most Activities of Daily Living (ADLs), and required supervision for ambulation. The nursing care plan dated 1/25/12 identified that R #143 was at risk for falls secondary to dementia and shuffled gait with interventions that included to monitor R #143 for unsteady gait. Review of the nurses notes dated 2/21/12 at 3:00 PM identified that R #143 was ambulating independently in the hallway with his/her walker when the resident was hit from behind by a laundry cart. R #143 fell face forward and hit his/her head on the ground. Review of facility documentation identified that R #143 sustained injuries that included a cut (laceration) on his/her upper lip, a bloody nose, and a laceration across the bridge of the nose. R #143 was subsequently transferred to Emergency Department (ED) for further evaluation. Review of the interagency referral form from the ED to the facility dated 2/21/12 identified that R #143 had sustained a nasal fracture. Interview with the DNS on 8/1/12 at 3:40 PM identified that on 2/21/12, Housekeeper #1 accidently struck R #143 with a housekeeping cart as the resident was coming out of the dining room. The DNS stated that Housekeeper #1 reported that he/she did not see the resident at the time of the incident. Interview with Housekeeper #1 on 8/1/12 at 5:50 PM identified that the laundry cart was "filled high" and that he/she could not see R #143 on 2/21/12 come from around the corner. Review of Housekeeper #1's personnel file on 8/1/12 identified that the employee received a Safety Corrective Action for striking R #143 with the laundry cart during transportation of laundry on 2/21/12. The corrective action report further identified that the laundry cart was stacked with linens at such a height as to obscure the employee's vision. Subsequent to the 2/21/12 incident, the facility required covers to put on laundry carts to prevent overloading and provided inservice to housekeeping staff/porters not to stack laundry above the top of carts.