Every finding on record at Focused Care at Hamilton

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's catheter bag had a privacy cover on. This failure could place residents at risk of feeling embarrassed or cause psychosocial harm and emotional distress.Findings included: Record review of Resident #1's face sheet, dated 08/06/2026, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included acute kidney failure, chronic obstructive pulmonary disease (trouble breathing), hypertension (high blood pressure), and benign prostatic hyperplasia (enlarged prostate affecting the flow of urine). Record review of Resident #1's Quarterly MDS Assessment, dated 06/25/2026, reflected a BIMS score of 14, indicating no cognitive impairment. Resident #1 had an indwelling catheter. Record review of Resident #1's Comprehensive Care Plan, revised 06/12/2026, reflected Resident #1 had an indwelling catheter. Interventions included Position catheter bag and tubing below the level of the bladder and away from entrance room door. During an observation and interview on 08/06/2026 at 9:23 a.m. Resident #1's catheter drainage bag was lying on the floor next to the recliner, by the trash can, and underneath the bedside table without a privacy cover on. Resident #1 stated he always sat in the recliner and the urine bag usually stayed on the floor. He was unaware of the privacy cover and was not concerned about the lack of one. During an interview on 08/06/2026 at 9:33 a.m., CNA C stated she was trained in catheter care and resident rights. CNA C stated catheter urine bags must always have a privacy cover on it to protect a resident's dignity and because no one wants to see someone's urine. She stated it was everybody's responsibility to check to ensure the bag was covered when checking on residents. During an interview on 08/06/2026 at 10:04 a.m., LVN B stated she had only worked at the facility for one month and only received training online. LVN B stated she knew all urine collection bags had to have a privacy cover on them if the resident was out of their room to protect a resident's dignity but did not know what the policy was about privacy covers if the resident was in his own room. LVN B stated it was all nursing staff's responsibility to check the catheter bag and to notify the nurse if there was a problem. During an interview on 08/06/2026 at 10:18 a.m., LVN A stated she had been trained in catheter care and resident rights. LVN A stated they only had one resident with a foley catheter and they were rare. LVN A stated catheter bags should always have a cover on them because that was the resident's right to privacy and dignity, and it could be embarrassing if a urine bag was not covered. LVN A stated she was not aware of Resident #1's urine bag because she was not the resident's primary nurse. She stated it was the responsibility of all nursing staff to check the urine bags anytime they went into the room to provide care. During an interview on 08/06/2026 at 10:57 a.m., the DON stated he was trained in catheter care and resident's rights, although he had just started work at the facility. The DON stated the urine collection bag should always have a privacy cover on it because it was the resident's right and it was a dignity concern. The DON stated they only had one resident with a catheter and he saw a privacy bag on it over the weekend. The DON stated Resident #1 must have taken the privacy cover off because the resident got confused. The DON stated it was everybody's responsibility to check the catheter bag when providing care to the residents. The DON stated Resident #1's urine collection bag not having a privacy cover on it would not meet his expectations. During an interview on 08/06/2026 at 11:28 a.m., the ADM stated the facility did not have a policy on indwelling foley catheter care that addressed having privacy covers on the bags because they did not have many residents with catheters and Resident #1 was the only one. The ADM stated she had not been trained in catheter care as she did not have a clinical background. The ADON and the DON would be responsible for training nursing staff on catheter care, but the ADON left and the DON was new. Her expectation would be that the urine collection bag would always have a privacy cover on it due to resident rights and dignity. The ADM stated she was unaware Resident #1's urine collection bag did not have a privacy cover on it despite her dropping off Resident #1's breakfast tray. This would not meet her expectations. During a telephone interview on 08/06/2026 at 11:54 a.m., Resident #1's FM stated she had seen a blue privacy cover on the foley catheter urine collection bag once, but otherwise, it was always uncovered when she came to visit and she could see the urine. The FM stated she did not know how Resident #1 would feel about the lack of a privacy bag but stated that Resident #1 was concerned about his urine output and sometimes would mess with the bag. The FM stated Resident #1 had some confusion and dementia and could be demanding or refuse care. She was not concerned about the privacy bag. Record review of the facility's policy titled Resident Rights revised December 2016, reflected: Policy StatementEmployees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and ImplementationI. Federal and state laws guarantee certain basic rights 10 all residents of this facility. These rights include the resident 's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity.

Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 5 residents reviewed for quality of care (Resident #1). The facility failed to ensure Resident #1 received appropriate treatment and services to prevent urinary tract infections. Residents #1's foley catheter bag was observed, on 08/06/2026, to be on the floor and then observed not to be hung low to drain with gravity. This failure could place residents with urinary catheters at risk for traumatic removal and catheter acquired infections.Findings included: Record review of Resident #1's face sheet, dated 08/06/2026, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included acute kidney failure, chronic obstructive pulmonary disease (trouble breathing), hypertension (high blood pressure), and benign prostatic hyperplasia (enlarged prostate affecting the flow of urine). Record review of Resident #1's Quarterly MDS Assessment, dated 06/25/2026, reflected a BIMS score of 14, indicating no cognitive impairment. Resident #1 had an indwelling catheter. Record review of Resident #1's Comprehensive Care Plan, revised 06/12/2026, reflected Resident #1 had an indwelling catheter. Interventions included Position catheter bag and tubing below the level of the bladder and away from entrance room door. During an observation and interview on 08/06/2026 at 9:23 a.m. Resident #1's catheter drainage bag was lying on the floor next to the recliner, by the trash can, and underneath the bedside table. Resident #1 stated he always sat in the recliner and the urine bag usually stayed on the floor or was clipped to the bedside table because he always sat in the recliner. He was not concerned about the placement. During an interview on 08/06/2026 at 9:33 a.m., CNA C stated she was trained in foley catheter care. CNA C stated she emptied the urine collection bags. She stated the urine bag should be hung on the side of the bed or side of wheelchair, low where it could drain, and it should never touch the floor because that could lead to cross contamination, which could give the residents an infection or damage if someone ran over the tubing. She stated if she ever saw the bag on the floor, she would move it off the floor, clean it, disinfect it and tell the charge nurse. She stated it was everybody's responsibility to check to ensure the bag was not touching the floor. During an interview on 08/06/2026 at 10:04 a.m., LVN B stated she had only worked at the facility for one month and only received training online. She had been trained in foley catheter care and infection control. LVN B stated it was important for the urine collection bag to be placed below the bladder, draining with gravity, and always kept off the floor to avoid possible infections. LVN B stated it was all nursing staff's responsibility to check the placement of the catheter bag and to notify the nurse if there was a problem with bag placement. During an interview on 08/06/2026 at 10:18 a.m., LVN A stated she had been trained in foley catheter care and infection control. LVN A stated they only had one resident with a foley catheter and they were rare. LVN A stated it was important for the urine collection bag to be placed low enough to allow it to drain with gravity and always kept off the floor to avoid cross contamination, which could lead to infection. LVN A stated she was not aware of Resident #1's urine bag because she was not the resident's primary nurse but stated it was all nursing staff to check the placement of the urine collection bags anytime they went into a resident's room or provided patient care. During an observation on 08/06/2026 at 10:23 a.m., revealed Resident #1's catheter drainage bag was hung on the side of the recliner, clipped to the bedside table at a height that caused the tubing to run upward into the bag, rather than downward. During an interview on 08/06/2026 at 10:57 a.m., the DON stated he was trained in catheter care and infection control, although he had just started work at the facility. The DON stated the urine collection bag should be hung low to drain with gravity and should never touch the floor to prevent infection or harm to the resident if it got pulled. The DON stated it was everybody's responsibility to check to ensure proper placement of the bag when providing care to the residents. The DON stated Resident #1's urine collection bag touching the floor, by the trash can would not meet his expectations. During an interview on 08/06/2026 at 11:28 a.m., the ADM stated the facility did not have a policy on indwelling foley catheter care because they did not have many residents with catheters and Resident #1 was the only one. The ADM stated she had not been trained in catheter care as she did not have a clinical background. The ADON and the DON would be responsible for training nursing staff on catheter care, but the ADON left and the DON was new. Her expectation would be that the urine collection bag would be placed off the floor to avoid concerns with infection control and to prevent the bag from getting dirty, tangled, or pulled which could hurt the resident. The ADM stated she was unaware Resident #1's urine collection bag was touching the floor despite her dropping off Resident #1's breakfast tray. During a telephone interview on 08/06/2026 at 11:54 a.m., Resident #1's FM stated the foley catheter urine collection bag was usually hanging on the trash can beside the recliner but had been seen on the floor several times when she came to visit. The FM stated she would pick up the bag up off the floor and hang it back on the trash can because she knew it needed to be hung low to drain. The FM stated the tubing had been pulled sometime in the past and the resident yelled out in pain. Record review of the facility's policy titled Infection Control revised 10/25/2022 reflected: POLICYThis communities' infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. PROCEDURES5. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities .

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen and one of one nourishment room reviewed for sanitation. 1. The facility failed to properly store closed and dated food in the refrigerator. 2. The facility failed to ensure the Nourishment Room was properly cleaned and items were correctly labeled and dated. These failures could place residents who were served from the kitchen at risk for health complications and foodborne illnesses, and decreased quality of life. Findings included: Observation on 09/25/24 at 09:16 AM observed two trays with condiments in the fridge stacked on top of each other without dates or labels. Observed milk and juice in cups without labels and spilled milk on the tray. Observed Hershey's syrup without dates and labels. Observation on 09/25/24 at 10:51 AM revealed a pan with butter type substance sitting out on the stove not under heat or refrigeration storage. Observation on 09/25/24 at 9:19 AM revealed 12 glasses of water sitting out uncovered next to the water filling station. No dates or labels were present. Observation on 09/25/24 at 11:15 AM revealed a stack of serving trays sitting under the dishwasher next to chemicals that were labeled dishwasher detergent. Observation of the Nourishment Room on 09/25/24 at 9:30 AM found two refrigerator bins with around 25 nectar thick vanilla shakes with no facility label or date and a mozzarella string cheese bag opened with cheese sticks packaged with an incorrect label stating cran apple with a use by date of 08/24. Observed personal food items including an energy drink, soda, ranch dressing, creamer, opened water bottle, and grape jam in Nourishment Room fridge with no dates or labels on them. An observation was also made of a dirty rag and spoon soiled with unknown brown substance sitting in the sink. Observation on 09/26/24 at 02:58 PM revealed ADM cleaning out and labeling items in the nourishment room refrigerator after interviews began of items not being labeled. During an interview with the DM on 9/27/24 at 2:51 PM she stated that all refrigerators were her responsibility to maintain. She stated it was her expectation that staff members keep their personal use items in the staff break room. She stated all items should have an expiration date of three days when they're opened. She does not expect dirty dishes to be stored or washed in the nourishment room. She stated that trays should be stored on top of the juice machine and not underneath the dishwasher next to chemicals. She expected that all drinks will be Saran wrapped or covered immediately after they're done pouring and that they should be labeled and dated and stored in the refrigerator. She stated that negative outcomes for improper storage or failing to maintain a clean environment/ equipment was contamination of the resident's food . During an interview with the ADM on 9/27/24 at 3:00 PM she stated that she expected the nourishment room to follow the posted rules. She took personal responsibility for the nourishment room and that the undated food and dirty dishes were unacceptable and out of policy. She says that she expected the DM to oversee all operations in the kitchen including proper food storage. She stated a potential negative outcome of not following the guidelines for proper storage, labeling and dating, and cleanliness was that it could make the residents sick . Review of undated facility policy posted on refrigerator states Items must have the resident's name and date on it. Food items are only good for three days then must be disposed of. House shakes must have a date on every container. Expiration date of 15 days once removed from the freezer. Review of facility policy titled Refrigerator and Freezer dated December 2014 stated all food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from the cases for storage use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and used by dates indicated once food is open. Review of facility policy entitled Foods Brought by Family and Visitors dated October 2017 stated that non-perishable foods will be stored in a resealable container with a tight-fitting lid. Intact fresh fruit may be stored without a lid. Perishable foods must be stored in resealable containers with tightly fitting lids and all refrigerator containers will be labeled with residents name the item and use by date. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under [paragraph] (B) and in [paragraph] (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in [paragraph] 3-401.11(B) or reheated as specified in [paragraph] 3-403.11(E) may be held at a temperature of 54 C (130 F) or above; or (2) At 5 C (41 F) or less. 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for one of one kitchen and one of one common areas (common area near the nurse's station) reviewed for pests. 1. Houseflies, spiders, and crickets were seen in the common area by the nurse's station. 2. Insects and spiderwebs were present in the kitchen. This failure could place residents at risk of infection, discomfort, and diminished quality of life. Findings included: Observation on 09/26/24 at 02:28 PM revealed four houseflies flying in the common area near the nurse's station. Observation on 09/25/2024 at 9:10 AM revealed 1 cockroach walked across the floor in the dry storage area of the kitchen. Observation on 09/25/2024 at 10:45 AM revealed that there were multiple spider webs/ spiders and two crickets in the far-right corner of the dry storage area in the kitchen. Observation on 09/25/24 at 1:30 PM revealed one small dead cockroach in the clean dish area of the kitchen. Observation on 09/26/2024 at 2:28 PM revealed a large live spider in the hallway between the resident's room and the nurse's station. Observation on 09/27/2024 at 2:45 PM revealed spider webs and one dead cockroach in the main dining area. Observation on 09/27/2024 at 3:30 PM revealed spider webs and ants in the main conference room. During a confidential interview with eight residents on 9/26/2024 at 10:45 AM, they stated that they see flies around. They stated they believed pest control could be better. During a confidential interview with a confidential resident on 09/25/24 at 1:45 PM she stated that since her room was closest to the nurses' station, flies come in all the time. During an interview on 9/27/24 at 2:51 PM the DM stated that when she saw more than one bug, she wrote it down on the maintenance log to ask the maintenance people to take care of the pests. She stated she made sure that she communicated with the pest control guy when he came and that they swept and mopped all places daily. She said it was her expectation that her employees do not put food down the drain, take the trash out immediately, and make sure the trash cans were covered. She also said she did not leave wet mops out on the floor and ensured that the chemical room was cleaned, and wet rags were removed each day. The DM stated that if pests were around, they could contaminate the products and create an infestation. During an interview on 09/27/24 at 03:12 PM, the DON stated that from a clinical perspective having pests in the kitchen/food service areas, around clean dishes etc. was not sanitary. She stated the pests could get in the food or infect the food resulting in residents getting sick and she expected the kitchen staff to maintain sanitary conditions. During an interview on 09/27/24 at 03:31 PM, the ADM stated that they have the pest control guy on speed dial and he would be there within two hours, if they called him. She stated that they have been working on the bug problem, but it wasn't fixed yet. The ADM said it was her expectation that staff keep everything clean which included keeping the resident's bedside tables clean and ensuring that housekeeping was keeping the floors clean. The ADM stated a potential negative impact of pests in the facility were that it could make residents sick or uncomfortable and bugs would stress people out. Review record review of maintenance requests logs from 03/31/24 to 09/15/24 revealed that 12 out of 20 maintenance requests were due to pests in the facility. The pest complaints included scorpions, spiders, ants, roaches, and bed bugs. Review of record titled Notice of Pest Control Treatment provided by the ADM as the facility pest control contract stated that treatment services are provided on the 1st Thursday of every month by [pest control company]. Review of pest control invoices from April 2024 to September 2024 reflected the company treated the facility on 04/11/2024, 05/02/2024, 05/06/2024, 05/13/2024, 06/13/2024, 06/21/2024, 07/15/2024, 08/28/2024, 09/19/2024, 09/24/2024 with the most recent including bed bug treatment but did not reflect treatment for crickets, cockroaches, or flies. Review of facility policy dated 02/01/2017 and titled Pest Control reflected the following: our policy is that our facility maintains an effective pest control program. The facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review the facility failed to ensure the cleanliness of kitchen equipment, per manufacturer's instructions, for 1 of 1 ice machines reviewed for food safety requirements. The facility failed to ensure the ice machine was descaled and failed to ensure a plastic bin that held an ice scooper was free from scale buildup. This failure placed all residents at risk for illnesses related to prolonged exposure to scale. Findings include: Review of AM AIDE DAILY CLEANING LIST, undated, reflected a weekly schedule of EQUIPMENT TO BE CLEANED. A B was observed to be initialed next to the task WIPE DOWN ICE MACHINE IN HALLWAY. No date was observed on the sheet to indicate which week the task had been completed. Observation of the ice machine on 12/4/23 at 10:47 AM revealed white-colored streak marks on the left side, right side, and in the crevice of the door of the machine. A plastic, blue container was observed attached to the left side of the ice machine, and appeared to be coated with the same, white-colored substance. Inside the plastic, blue container, a silver ice scooper was observed. At the bottom of the container, the same white substance was observed. During an interview and observation on 12/4/23 at 11:53 AM, the DFS identified the white-colored substance to be lime and the streaks to have been caused by hard-water. The DFS stated a part of staff's weekly cleaning schedule includes cleaning the ice machine, which includes de-liming the machine. She stated the machine was rented, and the facility's responsibility was to maintain the outside of it. She stated initials on the AM AIDE DAILY CLEANING LIST indicated the task was completed. During an interview on 12/4/23 at 1:36 PM, the DFS reiterated that the facility had lime build-up from hard water. She stated staff should have been cleaning the ice machine daily, but they were not educated to do so. She stated she reached out to the company from whom they rent the ice machine from for service and planned to in-service staff on cleaning the ice machine and the container that holds the ice scooper using the de-scaling products that were available at the facility. She stated she also planned to update the AM AIDE DAILY CLEANING LIST to include cleaning the container that holds the ice scooper. The DFS added that facility policy stated to clean the ice machine according to manufacturers instructed; she provided the policy and manufacturer's instructions. She stated she was responsible for ensuring completion of the cleaning tasks and stated that the lime had the potential to negatively affect residents if ingested but did not identify specific risks. During an interview on 12/4/23 at 1:47 PM, the DON stated she was unsure about specific requirements related to cleaning the ice machine but stated staff have reported cleaning the ice machine every night. During an interview on 12/4/23 at 2:06 PM with the ADM, she stated the ice machine was recently serviced unrelated to lime concerns, but for a water leak. She stated she had contacted the facility's corporate maintenance person on, 12/4/23. Corporate maintenance stated staff water conditioner should have been added to the filters to prevent lime build-up. In the meantime, he stated visible lime should have been wiped by using a calcium lime remover. The ADM stated this product was available and accessible in the kitchen and used 1x per week. She stated the facility conducted weekly audits which included reviewing kitchen tasks, but the ice machine had not been identified as an area of concern. She stated the risks of not ensuring the ice machine was clean was that it could fall into the ice and ingested by residents. Review of Section 4: Maintenance of manufacturer's instructions for the ice machine, titled Descaling and Sanitizing, revised 12/19, reflected the following: Exterior Cleaning Clean the area around the ice machine as often as necessary to maintain cleanliness and efficient operation. Use cleaners designed for use with stainless steel products. Sponge any dust and dirt off the outside of the ice machine with mild soap and water. Review of facility policy, titled Sanitization, last revised October 2008, reflected the following: Ice machines and ice storage containers will be . cleaned . per manufacturer's instructions and facility policy.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food safety. Several items in and from the kitchen (salad, salad dressing, croutons, milk, juice, pudding, and a diabetic bedtime snack) were not labeled or dated. The MAINT walked through the kitchen twice without a hair restraint. Kitchen equipment (deep fryer, refrigerator, freezer, sneeze guard)) was not clean. Insect pests (fruit flies, house flies, crickets, and a cockroach) were present in the kitchen. These failures placed residents at risk of food-borne illness. Findings included: Observation on [DATE] at 08:30 AM revealed a gallon plastic zipper bag of croutons in dry storage not labeled or dated. It also revealed a freezer with crumbs and food particles accumulated on the shelves and bottom floor of the machine. It revealed a refrigerator containing cups of milk, cups of juice, souffle cups of mayonnaise-based salad dressings and mustard, a sandwich, green bean salad, and many single servings of Caesar salads, none of which were labeled or dated. The MAINT walked into the kitchen through the back door and out of it through the door into the dining area with no hairnet or beard net on. He wore a baseball cap and had very short hair, but his beard was long and full. Further observation revealed the sneeze guard over the serving trays was dirty with a film dripping down it and dried particles of food on it. The deep fryer was covered in crumbs and other food particles. The front of both ovens and all refrigerators and freezers were covered in food particles and drips of filmy substance. Observation on [DATE] at 10:34 AM revealed the MAINT walked through kitchen again with no hair or beard restraint. Observation on [DATE] at 10:50 AM revealed that a swarm of fruit flies emerged from the foot-pedal wastebasket next to one of the kitchen's handwashing sinks when the pedal was depressed. There was an expired cricket under one of the drying racks for clean dishes and another underneath the commercial dishwasher. There was an expired American cockroach as well as an accumulation of crumbs and food particles on the cart used to carry the dishwashing racks. During an interview on [DATE] at 11:41 PM, the RD stated she had only been to the facility on ce and was only consulting temporarily. She stated she had not trained any of the kitchen staff but had only begun reviewing resident charts and inspected the kitchen. She stated she was at the facility the month prior and had determined some of the equipment had not been clean, but there was no sign of pest activity and no foods not labeled or dated. She stated she was not aware of what training had been done. She stated she would send via email documents from her visit including the kitchen sanitation checklist she used, but these were not received. During an interview on [DATE] at 01:37 PM, the DM stated the meal preparation for [DATE] was done the night before on [DATE] by a brand-new employee. She stated she had not had the time to fully and properly train the new employee. She stated that was why the items were not labeled and dated in the dry storage and refrigerator. The DM stated she had gone over the rules when the employee first started, but she had not been able to provide oversight, because she had not worked on the weekend. When asked about the cleaning schedule for the kitchen, she stated there was a daily schedule, but they had been so shorthanded that they had not been able to complete the cleaning schedule. The DM clarified the cleaning was getting done, but the paper schedule was not documented. When asked why so many areas in the kitchen were not clean if the staff were completing the work, she stated they had been especially short-staffed that weekend. The DM stated she had seen American cockroaches (which she called waterbugs), and they had always died when professional pest control came to the building. When asked about the fruit flies in the wastebasket, she stated she had no idea how that had occurred. She stated she pulled the bag out after it occurred, and the bag smelled as if there were a banana peel in the bag. She stated she had never seen that happen before. The DM stated she monitored for compliance with food storage and preparation rules by training her staff but reiterated that she had not been able to provide monitoring recently due to having to work as a cook and dietary aide. The DM stated kitchen sanitation was an infection control issue and could impact the residents negatively if not maintained. During an interview on [DATE] at 02:08 PM, the DON stated she never entered the kitchen to look at it herself, and the oversight for kitchen compliance was performed by the administrator, who was on vacation for the week. The DON stated she did see the monthly report from the dietitian during QAPI meetings, and she did not recall the kitchen inspections ever receiving a score lower than 90%. The DON stated a potential negative impact on residents was they could get sick if they ate food that was left out too long or expired and could have a reaction if they ingested an improperly labeled food to which they had an allergy or intolerance. Review of facility policy dated [DATE] and titled Food Receiving and Storage reflected the following: Foods shall be received and stored in a manner that complies with safe food handling practices. 1. Food services, or other designated staff, will maintain clean food storage areas at all times. 2. All foods stored in the refrigerator or freezer will be covered, labeled and dated with use by date.

Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for six of 16 residents (Residents #9, 18, 19, 23, 26, and 43) reviewed for activities. 1. Residents #9, 18, 19, 23, 36, and 43 spent nearly all their waking hours in the common area near the nurse's station, not receiving activities. 2. Residents #9, 18, 19, 23, 26, and 43 had no person-centered activity program or activities tailored to their specific needs and preferences. These failures placed residents at risk of depression and diminished quality of life. Findings included: Review of the undated face sheet for Resident #9 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, generalized anxiety disorder, depression, and senile degeneration of the brain. Review of the admission MDS assessment for Resident #9 dated 05/05/23 reflected a BIMS score of 00, indicating severely impaired cognition. The section on Activity Preferences reflected Resident #9 found it very important to listen to activities she liked, do activities she liked, and participate in religious services. Review of the care plan for Resident #9 dated 04/27/23 reflected the following: ACTIVITIES: Resident will attend daily activities of her choice. Resident will enjoy activities three times per week over the next 90 days. 1. Post Monthly Calendar in room. 2. Activities Director to discuss/monitor for preferences. 3. Remind/Encourage to attend and assist to activities as needed. 4. Provide for in room activities as needed and required. 5. Respect resident's rights to refuse to attend activities. Review of the quarterly activity assessment for Resident #9 dated 07/24/23 and completed by the AD reflected the following: She will come and visit with us during bingo and Bible study. She enjoys picture books, (famous country singer), music, and visiting at the nurses station. Review of activity progress notes for Resident #9 dated 03/31/23 to 07/26/23 reflected no activity notes. Review of the undated face sheet for Resident #18 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of neurocognitive disorder with Lewy bodies (a type of dementia characterized by changes in sleep, behavior, cognition, movement, and regulation of automatic bodily functions) and age-related physical debility Review of the significant change MDS for Resident #18 dated 01/18/23 reflected a BIMS score of 00 indicating severely impaired cognition. The section on Activity Preferences reflected staff assessed Resident #18's interests as listening to music, being around animals, doing things with groups of people, participating in favorite activities, spending time away from the nursing home, and spending time outdoors. Review of the care plan for Resident #18 with a target date of 09/18/23 reflected the following: ACTIVITIES: Resident will attend daily activities of her choice. Resident will enjoy activities three times per week over the next 90 days. 1. Post Monthly Calendar in room. 2. Activities Director to discuss/monitor for preferences. 3. Remind/Encourage to attend and assist to activities as needed. 4. Provide for in room activities as needed and required. 5. Respect resident's rights to refuse to attend activities. Review of the quarterly activity assessment for Resident #18 dated 06/12/23 and completed by the AD reflected the following: Resident comes outside and listens to music with the group when the weather is nice. Mostly 1:1s. She is a beautiful, talented lady, who has had the most adventurous life so far. Piano, pilot, motorcyclist, real renaissance woman. Review of activity progress notes for Resident #18 dated 03/31/23 to 07/26/23 reflected no activity notes. Review of the undated face sheet for Resident #19 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, ataxia, and severe protein-calorie malnutrition. Review of the annual MDS for Resident #19 dated 09/28/22 reflected she was too cognitively impaired to participate in the assessment. The section on Activity Preferences reflected staff assessed Resident #19's interests as listening to music, being around animals, participating in favorite activities, and participating in religious services. Review of the care plan for Resident #19's target date 09/05/22 reflected the following: ACTIVITES: Resident will Attends activities of choice. Enjoys visiting with staff and peers. Resident will enjoy activities three times per week over the next 90 days. 1. Post Monthly Calendar in room. 2. Activities Director to discuss/monitor for preferences. 3. Remind/Encourage to attend and assist to activities as needed. 4. Provide for in room activities as needed and required. 5. Respect resident's rights to refuse to attend activities. Review of the quarterly activity assessment for Resident #19, dated 06/26/23 and completed by the AD reflected the following: She comes outside with us to listen to music. Likes to visit with friends at the nurses station. Likes music. Review of activity progress notes for Resident #19 dated 03/31/23 to 07/26/23 reflected no activity notes. Review of the face sheet for Resident #23 reflected a [AGE] year-old female admitted on [DATE] with a diagnosis of dementia with behavioral disturbance. Review of the annual MDS for Resident #23 dated 06/13/23 reflected a BIMS score of 1, indicating severely impaired cognition. The section on Activity Preferences reflected Resident #23 found it very important to participate in activities she liked and religious services. Review of the care plan for Resident #23 with a target date of 09/18/23 reflected the following: ACTIVITIES: Resident will attend daily activities of her choice. Resident will enjoy activities three times per week over the next 90 days. 1. Post Monthly Calendar in room. 2. Activities Director to discuss/monitor for preferences. 3. Remind/Encourage to attend and assist to activities as needed. 4. Provide for in room activities as needed and required. 5. Respect resident's rights to refuse to attend activities. Review of the quarterly activity assessment for Resident #23, dated 05/26/23 and completed by the AD reflected the following: She will attend activities for a minute, but soon decides to leave. She does enjoy one on one activities. She likes music, parties, balloons, and stuffed animals. Review of activity progress notes for Resident #23 dated 03/31/23 to 07/26/23 reflected no activity notes. Review of the undated face sheet for Resident #36 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, Alzheimer's disease, mood disorder due to known physiological condition, and anxiety disorder. Review of the significant change MDS for Resident #36 dated 03/02/23 reflected a BIMS score of 1, indicating severely impaired cognition. The section on Activity Preferences reflected staff assessed Resident #36's interests as listening to music, being around animals, doing things with groups of people, participating in favorite activities, spending time outdoors, and participating in religious services. Review of the care plan for Resident #36 dated 10/05/22 reflected the following: ACTIVITIES: Resident will attend daily activities of her choice. Resident will enjoy activities three times per week over the next 90 days. 1. Post Monthly Calendar in room. 2. Activities Director to discuss/monitor for preferences. 3. Remind/Encourage to attend and assist to activities as needed. 4. Provide for in room activities as needed and required. 5. Respect resident's rights to refuse to attend activities. Review of the quarterly activity assessment for Resident #36, dated 05/29/23 and completed by the AD reflected the following: She loves coming to activities. Sitting outside, listening to music, and parties. Review of activity progress notes for Resident #36 dated 03/31/23 to 07/26/23 reflected no activity notes. Review of the undated face sheet for Resident #43 reflected a [AGE] year old admitted to the facility on [DATE] with diagnoses of Cerebral Palsy (a disorder of movement, muscle tone, or posture caused by damage to the developing brain during pregnancy or at the time of birth), aphasia (loss of ability to understand or express speech), epilepsy (a condition characterized by seizures), gastrostomy (placement of intra-abdominal feeding tube), muscle wasting and atrophy, abnormalities of gait and mobility, dysphagia (difficulty swallowing), and cognitive communication deficit amongst other diagnoses. Review of admission MDS for Resident #43 dated 11/23/23 reflected a BIMS score was not obtained due to the resident being unable to participate in the assessment. This section of the MDS also reflected Resident #43 was rarely or never understood and had severely impaired daily decision-making skills. Review. The section on Activity Preferences reflected staff assessed Resident #43's interests as listening to music, keeping up with the news, doing things with groups of people, participating in his favorite activities, spending time outdoors, and participating in religious services. Review of the care plan for Resident #43 dated 11/20/22 reflected the following: ACTIVITIES: Resident will attend daily activities of his choice. I will enjoy activities three times a week over the next 90 days. 1. Post Monthly Calendar in room. 2. Activities Director to discuss/monitor for preferences. 3. Remind/Encourage to attend and assist to activities as needed. 4. Provide for in room activities as needed and required. 5. Respect resident's rights to refuse to attend activities. Review of activity progress notes for Resident #43 dated 03/31/23 to 07/26/23 reflected no activity notes. Observation on 07/24/23 from 08:30 AM to 10:28 AM revealed Residents #9, 18, 19, 23, 36, and 43 seated in the common area by the nurse's station with the television on but no other activities or interaction occurring for them. Observation on 07/24/23 from 01:14 PM to 3:03 PM revealed Residents #9, 18, 19, 23, 36, and 43 seated in the common area by the nurse's station with the television on but no other activities or interaction occurring for them. Observation on 07/25/23 from 08:27 AM to 12:00 PM revealed Residents #9, 18, 19, 23, 36, and 43 seated in the common area by the nurse's station with the television on but no other activities or interaction occurring for them. Observation on 07/25/23 from 01:56 PM to 03:15 PM revealed Residents #9, 18, 19, 23, 36, and 43 seated in the common area by the nurse's station with the television on but no other activities or interaction occurring for them. During an interview on 07/26/23at 09:15 AM, the AD stated he did not maintain activity logs for residents. He stated the closest thing he had to something like that was a list of bingo scores for the residents who came to bingo. The AD stated the residents who sat in the common area by the nurse's station were Residents #9, 18, 19, 23, 36, and 43, and they did not participate in bingo or any other group activities. The AD stated there were no activities just for them. The AD stated he spent most of his time on group activities and walking around the building checking in with people to make sure they were happy. He stated he was responsible for the activities program, but it felt like most of his job was to be a friend to the residents. During an interview on 07/26/23 at 02:08 PM, the DON stated the residents who sat in the common area most of the day were Residents #9, 18, 19, 23, 36, and 43. She stated those six residents had in common that their cognition was very impaired, and they did not talk with others anymore or express any specific desires. The DON stated the day before, on 07/25/23, the AD had [NAME] Resident #36 out onto the porch for a snow cone at about 03:30 PM, after the surveyor observations had concluded. The DON stated that was the only time she was aware of that any of the six residents in question had been engaged in activities. The DON stated she thought the AD took residents for a walk around the block sometimes in the mornings. She stated she did not think Resident #43 had been on the morning walks. The DON stated other than the walks and the one time Resident #36 went outside for a snow cone yesterday, the only thing those residents ever had to do was watch television shows and movies in the common area. The DON stated there was not any resident-specific programming for those residents. She stated she did not monitor that aspect of resident care and did not know what the administrator monitored. She stated the administrator was on leave for the week. The DON stated she knew they had quarterly care plan meetings where they talked about activity preferences, but that was as much as she knew about the issue. The DON stated a potential negative impact to residents might be feeling alone or depressed and becoming socially withdrawn. Review of facility's policy dated 04/2020 and titled Life Enrichment Activity Guidelines reflected the following: The community will provide, based on the comprehensive assessment and care plan, and the preferences of each resident, and ongoing program to support residents in their choice of activities, but facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support, the physical, mental, and psycho, social well-being of each resident, encouraging both independence and interaction in the community. The life enrichment director/coordinator is responsible for maintaining appropriate departmental documentation. 1. Our activity programs are designed to encourage maximum individual participation that are geared to the individual residents needs based on resident interviews. Interviews for activity preferences are conducted within the first 14 days, annually, and with significant change in condition. 6. Our Activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident and include, as a minimum: a. Activities that stimulate the cardiovascular system and assist with range of motion, such as exercise, movement to music, wheelchair basketball/volleyball, etc., are offered 5 to 7 times per week. b. Intellectual activities that are mentally stimulating, such as current events, trivia, word, games, book reviews, educational, movies, etc. Are provided 5 to 7 times per week. c. Weather permitting, at least one activity a month as hell away from the facility. d. Weather permitting, outdoor activities, are held on a regular basis. f. Spiritual programming is scheduled to meet the religious needs of the residents. i. Creative and expressive activities, such as arts and crafts, ceramics, painting, drama, creative writing, poetry, in music, are available on a regular basis to meet the needs of residents. j. Social activities are scheduled to increase self-esteem, to stimulate interest and friendships, and to provide fun and enjoyment. Activities include, but are not limited to, daily coffee, so sure, birthday and holiday parties entertainment, candlelight, dinner, country, breakfast, cultural, and theme events. 6. Individualized and group activities are provided that: a. Reflect the schedules, choices, and rights of the residents; b. Are offered at hours convenient to the residents, including the evenings, holidays, and weekends; c. Reflect the religious and cultural interests, hobbies, life experiences, and personal preferences of the residents; d. Appeal to men and women, as well as those of various age groups, residing in the facility. 47375 47795

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 3 of 16 residents (Residents #12, 18, and 19) reviewed for pureed diets. Residents #12, 18, and 19 all received pureed meals not prepared according to professional standards or the recipe. This failure placed residents at risk of weight loss and aspiration. Findings included: Review of the undated face sheet for Resident #12 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of diverticulitis of intestine (An inflammation or infection of the pouches formed in the colon), gastroesophageal reflux disease, and dementia. Review of the quarterly MDS assessment for Resident #12 dated 05/11/23 reflected a BIMS score of 15, indicating minimal cognitive impairment. Review of the section titled Swallowing/Nutritional Status reflected coughing or choking during meals or when swallowing medication and complaints of difficulty or pain with swallowing. Review of the care plan for Resident #12 dated 11/11/22 reflected the following: NUTRITION: Resident is on a Regular carb controlled PUREE Diet with Regular Liquids. Resident uses weighted silverware for all Meals. Resident will have adequate nutrition and fluid intake over the next 90 days. Dietary Manager to monitor/discuss food preferences. o Monitor and document intake. o Offer snacks within diet. o Serve diet as ordered and offer substitute if less than 50% is eaten. o Weigh every month and PRN - report 5% loss/gain to MD and responsible party. Review of the physician orders for Resident #12 dated 11/10/22 reflected the following: Carb Controlled diet, Pureed texture, Regular consistency (May have pleasure foods as tolerated) for MEALS. Review of the undated face sheet for Resident #18 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of neurocognitive disorder with Lewy bodies (a type of dementia characterized by changes in sleep, behavior, cognition, movement, and regulation of automatic bodily functions), age-related physical debility, gastroesophageal reflux disease, and Parkinson's disease. Review of the significant change MDS for Resident #18 dated 01/18/23 reflected a BIMS score of 00 indicating severely impaired cognition. Review of the section titled Swallowing/Nutritional Status reflected no difficulty in swallowing. Review of the care plan for Resident #18 dated 03/08/23 reflected the following: NUTRITION: Resident is at risk for nutritional impairment R/T Dx Dementia with Lewy Bodies, Dx Parkinson's. Dx GERD She is on a Regular PUREE DIET and Thin liquids Resident is at risk for malnutrition. The resident will comply with recommended diet for weight reduction daily through review date. Administer medications as ordered. Monitor/Document for side effects and effectiveness. o (Resident #18) needs a calm, quiet setting at meal times with adequate eating time. She prefers to eat in the ding room. Encourage (Resident #18)'s socialization and interaction with table mates during meals. o Invite (Resident #18) to activities that promote additional intake. o Monitor/document/report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. o Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. o Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. o OT to screen and provide adaptive equipment for feeding as needed. o Provide and serve supplements if eats less than 50% of meal. 8/17/20 RD recommendation House supplement 2.0 90ml BID x30 days. o Provide, serve diet as ordered. Monitor intake and record q meal. Review of the physician orders for Resident #18 dated 02/28/23 reflected the following: Regular diet, Pureed texture, Regular consistency for meals. Review of the undated face sheet for Resident #19 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, dysphagia, and severe protein-calorie malnutrition. Review of the annual MDS for Resident #19 dated 09/28/22 reflected she was too cognitively impaired to participate in the assessment. Review of the section titled Swallowing/Nutritional Status reflected no difficulty in swallowing. Review of the care plan for Resident #19 target date 03/06/23 reflected the following: NUTRITION: Resident is on a REGULAR PUREE Diet with Regular Liquids House Sakes TID Chocolate magic cups at lunch and supper. Offer sweet snacks at 10am 2pm HS. Offer sugar salt pepper butter for flavor enhancement with all meals. Resident has malnutrition. Resident will have adequate nutrition and fluid intake over the next 90 days. Dietary Manager to monitor/discuss food preferences. o House shake TID between meals and st HS to provide supplemental protein/energy. o Monitor and document intake. o Offer snacks within diet. o Resident has had a 10% weight loss in the last 6mths o Resident has had a 7.9% wt decrease in 180 days. o Resident is on RED CUP program d/t resident has malnutrition o Serve diet as ordered and offer substitute if less than 50% is eaten. o Weigh every month and PRN - report 5% loss/gain to MD and responsible party. Review of the physician orders for Resident #19 dated 02/24/23 reflected the following: Regular diet, Pureed texture, Regular consistency for Meals. Observation on 07/24/23 at 10:33 AM revealed CK A creating pureed dishes from the daily lunch meal, which was angel hair pasta, chicken parmesan, and mixed vegetables. She added chicken broth concentrate to the chicken parmesan and the noodles to add moisture. Review of the undated facility recipe for angel hair pasta puree reflected the following: Place portions in blender. Blend until smooth. Add water (1/2 c/5 servings) and dry milk (1 tbsp/serving). Blend until smooth. Review of the undated facility recipe for chicken parmesan puree reflected the following: Remove from the regular prepared recipe the portions needed into a food processor. Processed to a fine texture. For every five portions needed, prepare a slurry with three tablespoons thickener and 1.25 cups hot liquid. Mix well with a wire whip. Add one half of the slurry to meat mixer; reprocess 30 seconds. Reheat to 165 Fahrenheit and serve with a number six scoop. Review of the chicken broth concentrate reflected that one serving was 1.5 teaspoons and contained 600 mg/26% of the recommended daily allowance of sodium. Observation on 07/24/23 at 12:32 PM revealed Residents #12, 18, and 19 were each served a plate containing the pureed pasta and chicken parmesan. They ate the food without complaint. Observation on 07/24/23 at 12:50 PM revealed the pureed pasta was congealed into a single lump that stuck to the spoon and would not be separated. The taste of the pureed pasta was so salty as to be unpalatable. The texture of the pureed chicken parmesan was grainy and not smooth, and the taste was so salty as to be unpalatable. The DON observed the pureed food visually and stated the texture was not acceptable for residents who required pureed foods. During an interview on 07/24/23 at 01:41 PM, the RD stated she had only been to the facility on ce the previous month and could not remember the exact date, had done a kitchen inspection and reviewed a few resident charts, and she had not done any staff training or observed purees being made. When the purees were described to her, she stated they were not made correctly and had too much sodium and were probably not smooth enough. During an interview on 07/25/23 at 10:52 AM, the DM stated she had observed the texture of the pureed pasta and chicken parmesan from 07/24/23, and they were not prepared correctly. She stated she did not know why the items had not been properly prepared, as she had provided CK A training in preparing purees. She stated she had been extremely short-staffed in the kitchen and had been working as a cook, so she had not been able to monitor for compliance. She stated that a potential negative impact on residents with pureed diets was they might choke or aspirate on their food. During an interview on 07/26/23 at 02:08 PM, the DON stated the administrator was on leave. She stated she did not visit the kitchen and had not reviewed the purees for consistency. She stated she had not thought she would need to monitor for compliance with altered texture diets, because she thought the DM was doing that, but she might need to monitor more closely. The DON stated the purred foods should have been smooth in texture, and the wrong texture could have resulted in the resident choking. Review of facility policy dated October 2017 and titled Therapeutic Diets reflected the following: Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for one of one kitchen and one of two common areas (common area near the nurse's station) reviewed for pests. 1. Houseflies were seen in the common area by the nurse's station, landing on residents and their food. 2. Insect pests (fruit flies, house flies, crickets, and a cockroach) were present in the kitchen. This failure placed residents at risk of infection, discomfort, and diminished quality of life. Findings included: Observation on [DATE] at 01:56 PM revealed five or six houseflies flying in the common area near the nurse's station. Residents #9, 18, 19, 23, and 36 were seated in the common area, and the flies continually landed on the residents' hands, faces, hair, and clothing. Resident #9 was eating a snack, and the flies landed on her food. Observation from 1:56 PM to 2:30 PM revealed Resident #9 brushing flies away from her food, face, and hands almost constantly. At 02:20 PM, a fly landed on the lip of Resident #18 and stayed there for five full minutes. At 02:24 PM, Resident #23 said Go away, flies! While this was occurring, RN B and LVN C were seated at the nurse's station in front of computers and never acknowledged the flies or resident reaction to the flies. Several staff members walked back and forth through the area and no staff ever acknowledged or attempted to rid the area of the flies. Observation on [DATE] at 10:50 AM revealed that a swarm of fruit flies emerged from the foot-pedal wastebasket next to one of the kitchen's handwashing sinks when the pedal was depressed. There was an expired cricket under one of the drying racks for clean dishes and another underneath the commercial dishwasher. There was an expired American cockroach on the cart used to carry the dishwashing racks. Observation on [DATE] at 02:50 PM revealed several houseflies in the common area, landing on resident faces, hair, hands, and clothes as well as surveyor faces, hands, hair, and clothes. During a confidential interview, seven anonymous residents stated the facility did not do anything about the flies in the building. They stated there are fly swatters available, but they never saw the staff used the fly swatters. They stated they hated the flies becuse they were disgusting and annoying. During an interview on [DATE] at 01:19 PM, the HKS stated every once in a while, the flies got out of hand in the building. He stated he did not have a role in addressing pests in the building. The HKS stated the procedure any time there were pests sightings was to write the sighting in the maintenance log book, and the MAINT would address the issue. The HKS stated he knew there were fly swatters at the nurse's station, but he had not noticed any flies in that area. He stated he was constantly shooing flies off the residents and their food, but he had not done anything to try to remove the flies from the area. The HKS stated he had considered bringing his salt gun to the facility to kill flies individually, but he had not done it because he worried it would make more mess. When asked what a possible impact could be of flies in resident areas, the HKS stated he thought flies were nasty. He stated it was similar to if a cat walked in their litter box and then walked in on the kitchen counter. He stated with flies, they did not know where the fly had just been or what filthy material it had just landed on, so they did not know what it carried onto the residents or their food. During an interview on [DATE] at 01:51 PM, the MAINT stated the facility had a much worse issue with flies a month or two ago, and he had worked on it. He stated he had found two new products that were very effective, and the conditions had improved. The MAINT stated he had not sprayed any of the new product in the common area near the nurse's station. He stated no one had told him there was an issue with flies in that area of the facility, and he had not noticed any. During an interview on [DATE] at 02:08 PM, the DON stated her expectation was for staff to keep flies away from the food if they were around. The DON stated there was a fly swatter at the nurse's station, and they could control any bothersome flies with that. She stated she had not spoken to or trained her staff about what to do if there are flies in resident areas. The DON stated potential negative impacts of the presence of insect pests on the residents was the pests were annoying, gross, and unclean. Review of pest control invoices from [DATE] to [DATE] reflected the company treated the facility on [DATE], [DATE], [DATE], [DATE], [DATE], and )[DATE]. There was no mention of any pest sightings or targeted treatments. Review of facility policy dated [DATE] and titled Pest Control reflected the following: Our facility shall maintain an effective pest control program. This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Maintenance services assist, when appropriate and necessary, and providing pest control services.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet resident's mental and psychosocial needs for 2 of 8 residents (Residents #7 and 13) reviewed for care plans. The facility failed to update care plans as evidenced by: 1. Resident # 7's care plan did not reflect goals and interventions for a new onset of behaviors 2. Resident #13's care plan did not reflect current needs or preferences related to the behavior of wandering. This Failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being. Findings included: Review of Resident # 7 face sheet dated 7/26/23 revealed a [AGE] year-old male admitted on [DATE] with diagnosis that include Bipolar Disorder, unspecified (A mood disorder in which a person doesn't meet the criteria for bipolar disorder with the symptoms similar to bipolar but the full criteria are not met), Adjustment disorder with depressed mood (a psychological response to an identifiable stressor, leading to emotional or behavioral symptoms) Review of Resident #7's Quarterly MDS assessment dated [DATE] revealed at BIMS score of 15 on a scale of 0-15 which suggest cognitively intact. Behavioral pattern revealed no Hallucinations, delusions, physical, or verbal behavior disturbances, refusal of care or wandering noted. Assessment revealed resident is not currently taking any antipsychotic medication and currently on medication for depression. Review of Resident #7's Care plan for Behaviors initiated 12/16/2021 and revised on 06/03/2022 Revealed that recently discovered voyeur behavior was not updated. Review of Resident # 7's Progress notes dated 7/7/23 revealed Type: Behavior Note Text: Resident was discovered outside of a female residents' window. When asked to move from the window resident states I have to fasten my pants I had to urinate right there. When this nurse informed resident that is not acceptable behavior, he became angry and started cursing staff stating I have the right to go anywhere I want to. Review of Resident # 13 face sheet dated 7/26/23 revealed a [AGE] year-old female with an admitted [DATE]was diagnosed with Unspecified dementia, mild, (age-related cognitive decline-), unsteadiness on feet (a balance symptom of postural instability when upright) , other reduced mobility ( mobility to use transportation is reduced due to physical disability, sensory, locomotive, permanent or temporary ) Review of Resident # 13 Quarterly MDS dated [DATE] revealed a BIMS of 0 on a scale of 0-15. A score of 0 can suggests severe impairment. Assessment revealed the resident had delusions and wandering behavior during the assessment period. Assessment revealed resident is on a daily antidepressant drug. Review of Resident # 13 Care Plan BEHAVIORS: Resident resides on the facility memory care unit d/t wander/elopement risks r/t History of attempts to leave facility unattended, Date Initiated: 02/23/2022 Revision on: 02/23/2022 Interview with DON on 7/26/23 at 2:08 pm stated that the facility does not currently have a memory unit and has not had one in the past that she is aware of. DON stated care plans are initiated by the admitting nurse and the comprehensive and updating of the care plan is the responsibility of the MDS Nurse (currently MDS nurse is out on medical leave) . The team has a meeting weekly to discuss resident conditions and issues and the care plan should be updated at that time. Behaviors that are documented in the medical record by the nurse should generate on the 24-hour report and trigger the team of care plan needs. Her expectation is the care plans reflect the care the resident is receiving and should be updated as the resident needs change. There can be a potential negative outcome for the resident if the care plans do not reflect a resident's conditions their needs may not be met. Review of Policy Comprehensive Care Plan effective 1/20/2021 revised 4/25/2021 revealed the care plan is revised every quarter, significant change of condition, annual or as the resident conditions changes on an individualized basis.

Based on interview and record review the facility failed to ensure residents had the right to be free from misappropriation of resident property for one resident (Resident #1) reviewed for misappropriation of property. CNA A used Resident #1's debt card to setup a cash app account and took $935.00. This failure could place residents at risk for exploitation. Findings include: Review of Resident #1's face sheet dated 6/15/2023, reflected a [AGE] year-old male admitted to the ALF side of this facility on 10/20/2022 with diagnoses that included alcoholic Cirrhosis of the Liver (scarring and damage to the liver), Chronic Obstructive Pulmonary Disease (progressive lung disease), Osteoarthritis (degeneration of joint cartilage and the underlying bone), Muscle Wasting and Atrophy (thinning, weakening loss of muscle) and chronic kidney disease. Review of Resident #1's MDS, undated, reflected a BIMSs score of 15 indicating no cognitive impairment. Interview with the AD on 6/14/2023 at 10:15 AM revealed Resident #1 was a resident on the SNF side of their facility from 7/8/2022 until 10/20/22 when he moved to the ALF side She stated Resident #1 reported a problem with his bank account on 6/6/2023 to the BOM. The BOM took Resident #1 to his bank on 6/7/2023 and while there Resident #1 discovered CNA A had been making withdrawals from his bank account to her cash app since January of 2023. The AD stated an investigation revealed that Resident #1 never had a cash app account and didn't even know what it was. She stated CNA A made withdrawals from Resident #1's bank account from January 2023 to May of 2023 for $935.00. The AD stated the bank cancelled his debit card immediately. When Resident #1 returned to the facility, the facility called the police and reported the incident to the state agency. During the AD's investigation, they discovered Resident #1 had given CNA A his debit card information back in October of 2022 to buy a TV, which was installed in Resident 0#1's ALF room. The AD stated CNA A had worked at the facility from 9/16/2021 to 4/12/2023. She stated she worked until right after Easter of 2023 and then stopped showing up for work and no one could reach her. The AD stated she ran into the CNA on 6/4/2023 at a local store and asked her if she still needed a job. The AD stated when the CNA A stated yes, she had her come to the facility on [DATE] to fill out an application. CNA A completed orientation on 6/6/23, and then worked the overnight shift from 6/6/2023 to 6/7/2023. The AD stated when they found out about the missing money on 6/7/2023, CNA A was stopped on her way into work on the evening of 6/7/2023, asked about the missing money and stolen debit card information, then suspended immediately and terminated the next day. The AD stated when CNA A was confronted she started to cry and said she was going to pay the money back, that Resident #1 was her friend. Interview with the BOM on 6/14/2023 at 12:14 pm revealed Resident #1 came to her on 6/6/2023 and stated there was something wrong with his bank account that he was getting insufficient fund fees. The BOM stated she took Resident #1 to his bank the next day, 6/7/2023, and the bank showed them where withdrawals had been made from his account to a cash app account with CNA A's name on it. She stated the resident told the bank he had not authorized those withdrawals, so the bank cancelled his debit card. They came back to the facility, and she reported this to the AD and the AD started an investigation. Interview with Resident #1 on 6/15/23 at 2:55 PM revealed he had been on the skilled nursing side of the facility until 10/20/22 .He stated he had made friends with CNA A while on the SNF side. He stated he asked CNA A to purchase him a TV after he moved to the ALF side from the SNF side of the facility somewhere around the end of October 2022. He stated he put his debit card on the counter at the nurse's station and CNA A went online to Walmart and ordered him a TV. Then she went and picked it up a few days later and gave it to him and he had the maintenance man install it. Resident #1 stated last week he started having problems with his bank account, so he went to the BOM, and she took him to the bank the next day. He stated he noticed his account was overdrawn. Resident #1 stated when he got to the bank he found out about all the missing money and the cash app transfers that CNA A had taken. He stated he wasn't going to press charges because he thought she was his friend, but after seeing how much money she had taken he decided to press charges. He stated he was very upset that it happened and felt very embarrassed that he was taken advantage of like that by someone he thought was a friend. He stated he started to wonder if she might have done it to someone else, that's why he decided to report it to the police. He stated the police came out the next day and talked to him and he told them what happened with the TV. He also stated the bank had told him his last payment to the facility had not cleared. He stated the bank had refunded about $814 of his money and everything is alright now. He stated he didn't even know what a cash app account was until he went to the bank with the BOM and had never authorized CNA A to take his money. During an interview with the AD on 6/15/2023 at 4:56 PM she stated the in-services she provided for review had a pink highlighted dot on them where CNA A's signature and name were to confirm she had received the in-services on Resident Rights and Abuse and Neglect. AD went through 3 different in-service topics and pointed out the highlighted dots by CNA A's signature/name. Record review of in-service dated 4/11/2022 on Resident Rights policy revealed CNA A signature on the in-service. Record review of in-service dated 4/11/2022 on Abuse and Neglect policy revealed CNA A signature on the in-service. Record review of in-service dated 5/31/2022 on Resident Rights policy revealed CNA A signature on the in-service. Record review of facility policy Resident Rights dated December 2006 revealed: Employees shall treat all residents with kindness, respect and dignity. Further, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c.) be free from abuse, neglect, misappropriation of property and exploitation. Record review of facility policy Abuse dated 1/27/2020 revealed: The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property. Further, The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure. Also, The facility has in place policies and procedures to aid in the prevention of abuse, neglect, mistreatment, involuntarily seclusion and misappropriation of resident property.

Based on interviews and record reviews, the facility failed to ensure the resident environment remains free of accidents and hazards for one (1) resident (Resident #2) reviewed for accidents and hazards. The facility failed to ensure a warm compress was safely prepared and it burned Resident #2. This failure could place residents at risk of pain, injuries, and hospitalization . Findings include: Review of Resident #2's face sheet dated 6/14/2023 reflected a [AGE] year-old female resident admitted on [DATE] with diagnoses that included: Chronic Kidney Disease - Stage 3, Congestive Heart Failure (chronic condition in which the heart doesn't pump blood correctly), Parkinson's Disease (brain disorder causing uncontrolled movements, balance and coordination issues), Atrial Fibrillation (heart rhythm disorder), Intervertebral Disc Disorder (a breakdown of discs in the bones of the spine causing pain) , Spinal Stenosis (narrowing of the spinal canal), and Osteoarthritis (degeneration of joint cartilage and the underlying bone). Review of Resident #2's MDS dated [DATE] revealed a BIMS of 15 indicating Resident #2 had no cognitive impairments. Review of Resident #2's orders dated 6/15/2023, revealed no orders for warm compress therapy. Review of Resident #2's Care Plan dated 4/14/2023 revealed resident was at risk for skin breakdown due to fragile skin and stated SKIN 5/27/23 burn incident. Where resident noted to have small white discoloration area to her left outer thumb index finger on her left hand is stinging .large, discolored area to left buttock. Review of Resident #2's progress note dated 5/27/23 at 21:30 (9:30 PM) by LVN B: Late Entry: Called to room by CNA to assess resident d/t warm compress overheating. Resident states It just felt really warm, and I knew I needed to get it off of me. I knew I couldn't get out of bed fast enough, so I grabbed it and tried to throw it off the bed. Assessment completed and resident noted to have small white discolored area to her left outer thumb. She states her index finger on [NAME] is stinging, no visual skin issues noted. Resident has a large, discolored area to left buttock, denies symptoms of burn. Review of Progress note dated 5/28/2023 at 1:35 AM revealed: No redness or sign of irritation or burn noted to hip or back. No assessment of thumb or fingers noted. Progress note dated 5/28/2023 at 4:13 PM revealed: No redness noted on buttocks. Resident states that area does not hurt. No assessment to thumb or fingers noted. Review of Hospice RN G's visit notes dated 5/27/2023, revealed Resident #2 reported a pain score of 5, on a 0-10 score and indicated she was uncomfortable because of pain. The visit notes indicated the location of Resident #2's pain was Right thumb, right pointer finger, coccyx (bony area at the base of the lower back) and lower back and was described as burning. On the visit notes under the Integumentary section (skin) the notes indicated a skin assessment was done and PT has burned area to right thumb, right pointer finger, coccyx areas. Further in the visit notes RN G's notes indicated LVN B assisted this nurse of pulling back dressings to assess areas. Patient has 2 small dressings to left buttocks and these areas were assessed. Skin appears slightly red but intact. Facility had applied Medi honey ointment when treating burned skin so these area do have some brownish discoloration due to the ointment. Patients Left thumb and pointer finger has band aids in place which were pulled back for assessment. Left thumb has a pea sized blister and pointer finger has slight red area. All skin areas that were burned appear to have mild burns with skin intact. During an interview on 6/14/2023 at 1:40 PM, the DON stated she doesn't know if the facility has a process or procedure for using warm compresses, but she will get with ADON and find out . During an interview on 6/14/2023 at 1:54 PM the MD stated when asked about using a microwave to heat warm compresses, No, that is contrary to their policy to warm things in the microwave and use it. He stated, there may not be a specific policy on it, but it is not best practice. He further stated the compress could be too hot or not hot enough. If it was not hot enough it could not be therapeutic and if it was too hot it could burn the patient - they could get a thermal burn or thermal injury. The MD stated no one from the facility had reached out to him for an order for Resident #2 to have warm compress therapy. He stated the hospice agency Resident #2 has services with has a standing order for premade heating pads, similar to the type you can buy over the counter like Salon Pas. He stated he was aware that Resident #2 had some redness to her finger/thumb but not aware of any blisters. During an interview on 6/14/2023 at 2:09 PM, LVN B stated Resident #2 had been complaining of back pain and did not want any pain medications so Resident #2 asked for a heating pad. LVN B stated the facility did not carry heating pads, so she heated up a towel in the microwave and had done it 3-4 times throughout the day on 5/27/2023. She stated she had not received any training on hearting up compresses and was not sure if there was a facility policy on it but it was acceptable practice as far as I know. She stated she had not reached out to the doctor for an order or guidance. She stated her understanding was that later that evening , CMA E heated the compress up in the microwave and it later caught fire . She stated she was called to the room by CNA H and assessed Resident #2 for burns, did not find any skin breakdown or blisters on her back, so she cleaned the area on her back off an applied Medi honey. She stated Resident #2 did complain of burning her pointer finger and thumb, and later that evening she saw a white area on Resident #2's thumb and she treated it with cool compresses and Medi honey. She stated she had not delegated the task of heating of the compress and did not give directions to CMA E. She stated Resident #2 asked CMA E to warm it up and CMA E went and did it. She stated CMA E may have seen her warming up the compress in the microwave earlier in the day, but she had not given CMA E any instructions. During an interview on 6/14/2023 at 2:45 PM, ADON C stated LVN B called her in the evening on 5/27/2023 and told the events of Resident # 2 requesting a warm compress and it caught on fire. ADON C stated LVN B told her that she had instructed CMA E to warm up the compress in the microwave and take it to Resident #2. ADON C stated she also spoke with the hospice nurse a little while later, and she said there were no physical injuries at that point. ADON C stated she didn't know if the facility had a policy for heat therapy but that they normally request that the Therapy Department do heat therapy. She stated their practice was to use a damp towel, warm it up and wrap in another towel. She stated they don't do it very often, but when therapy is not here, sometimes they do. She stated there had been no training on warm compresses, it was just nursing knowledge and it used to be common practice. During an interview on 6/14/2023 at 3:02 PM, LVN D stated she was working a double shift on 5/27/023 and was at the nurse's station when she overheard CMA E talking to LVN B about a resident wanting a compress heated up. She stated she heard LVN B tell CMA E to heat it up for a minute to a minute and a half in the microwave. She stated CMA E heated it up in the microwave and took it down the hall to Resident #2. She stated she did not recall every getting nay any training on warm compresses at the facility but has done it throughout her career, but never at this facility. During an interview on 6/15/2023 at 12:52 PM, CMA E stated Resident #2 had her light on and when she went in the room, Resident #2 asked her to heat up the compress. The compress was in the chair, and it was a towel in a plastic bag. She stated she took it back to the nurse's station and told LVN B that resident needed a warm compress. She stated LVN B instructed her to warm it up in the microwave for a minute to a minute and a half and take it back down to Resident #2. CMA E stated she had never done any compresses before which is why she asked LVN B for directions. She stated she had never received training on warm compresses. During an interview on 6/15/2023 at 1:23 PM, RHD F stated the Therapy Department uses heat therapy with residents and they use a heat pack hydrocollator. It warms to a set temperature of 152 degrees. It is moist heat, and the packs sit inside a pool of warm water and then they pull them out, put them in a special wrap and place them on the resident. He stated only Therapy uses them and they are kept in the therapy room so that their use can be supervised. He stated the therapy team has received training on the proper use of the hydrocollator and they can use heat therapy Monday thru Friday when therapy is available. RHD F said he spoke to the resident the next morning on 5/28/2023 when she came for therapy and Resident #2 denied pain or tenderness at that point and there were no signs/symptoms of pain or injury during her therapy session. He stated he had taken a look at Resident #2's back but denied looking at Resident #2's fingers. During an interview on 6/15/2023 at 1:55 PM, Hospice RN G stated she was notified of the incident with Resident #2 about 8:52 PM on 5/27/2023. She stated she came out to the facility about 9:15 PM to assess Resident #2. She stated Resident #2 was alert and oriented and recounted the details of the event to her. She stated Resident #2's finger and thumb were red; the left thumb had a pea sized blister, and the pointer was just slightly red. She stated the area on Resident #2's back where the compress had been sitting was just barely red and not hardly noticeable. She stated Resident #2 complained of pain of a 5 on a 1-10 scale at that time to her left thumb and left pointer finger. She states Resident #2 had band aids on her finger when she arrived, and she removed them to assess resident and then reapplied fresh band aids. She gave no further orders or treatment interventions - she instructed nursing staff to leave the band aids in place until the following morning and then leave the areas open to air. During an interview on 6/15/2023 at 2:18 PM, CNA H stated she was working the evening of 5/27/2023 and answered Resident #2's call light when it came on. She stated she wasn't sure of the time but it was sometime around 9-9:15 PM. She stated she went to Resident #2's room and the resident told her the compress was burning her . She pulled the compress out from behind Resident #'2s back and it was smoking. She stated she threw the compress on the floor, and then she saw flames. She stated she stomped it out on the floor and them then picked up the compress and put it in the sink and ran water on it. She made sure Resident #2 was okay and then she went and got LVN B. CNA H stated she has provided warm compresses to resident before but has not received any training on how to do it. She stated she has done it for a long time, and she will either run the towel under warm water or put a wet towel in the microwave for about 30 seconds. She stated she then takes it to the room and has the resident touch it to be sure it is not too warm and then she will monitor it for a little while after she puts it on to make sure it doesn't get too hot. She stated earlier that day she had seen LVN B prepare a warm compress for another resident and LVN B did it the same way she had told CMA E to do it. During an interview on 6/15/2023 at 4:56 PM the AD stated she had checked with corporate, and the facility did not have a policy or procedure for warm compresses. She stated they have discontinued use of warm compresses and have begun in-servicing all staff. A facility policy on Accidents and Supervision was verbally requested but not provide by the time of exit.

Based on interview and record review, the facility failed to notify the resident's representative when there was a significant change in the resident's medical condition for one of four residents reviewed for notification of changes. (Resident #1) The facility did not notify Resident #1's representative when she was transported to the emergency room after a fall which resulted in a significant injury. This failure could place residents at risk for not having their family or legal representative notified of not receiving relevant medical information when a significant change occurs. Findings included: Review of the Face Sheet for Resident #1 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet reflected Resident #1's family member was her responsible party with their contact information listed. Review of Resident #1's MDS assessment dated [DATE] reflected a BIMS of 15 out of 15, indicating intact cognitive response. Review of Resident #1's care plan with a revision date of 12/10/2021 reflected Falls: The resident is (Moderate risk for increased falls and fractures as evidence by: HX of falls and impaired vision. Goal- the resident will be free from falls over the next 90 days. Care Plan also reads: 02/05/2022 Resident observed laying face down on the floor, Resident stated she fell out of her wheelchair while she was trying to go to the rest room. Resident was assisted to her chair. Cleansed wound with normal saline to assess the severity of wound. Noted approximately an inch long gaping wound to right side of head. Bruise to right side of head noted. Called 911 to transfer resident to ER for higher level of care. Resident returned From ER with C2 FX. Returned with 6 staples to right side of forehead. Review of incident report dated 02/05/2022 at 0330 reflected Resident #1 had an unwitnessed fall with nursing description as: Resident was observed laying face down on the floor; Resident description as: resident stated she fell out of her wheelchair while she was trying to go to the restroom. Immediate action taken: Resident was assisted to her chair. Cleansed wound with normal saline to assess the severity of the wound. Noted approximately an inch long gaping wound to right side of head. Bruise to right side of head noted. Called 911 to transfer resident to ER for higher level of care. Agencies/People notified: physician and family member. Person preparing report: RN A. Review of Resident #1's incident progress notes dated 02/05/2022 reflected the following: During CNA round, resident was observed laying on the floor face down. This nurse was notified and resident was assisted by to her chair. Noted blood on right side of head. Cleansed wound with normal saline and noted approximately an inch long gaping wound to right side of forehead along with bruise. Resident complaint of back pain. Resident is alert and orientedx3 to person, place and time. No loss of consciousness noted. Called 9-1-1 at 0350. Ambulance arrived at 0403 and report given to ambulance personnel. Resident was transferred to ER in stable condition. Author: RN A. Review of Resident #1's progress notes dated 02/06/2022 reflected the following: resident returned from OBS at local hospital, smiling, states she is glad to be back, staple in place on right forehead, wearing C-Collar as per instructions, assisted back to her room to her recliner, call light in reach, reviewing orders to update EMR In an interview on 03/01/2022 at 1232PM, Resident #1 stated she fell quite sometime ago and was sent to the hospital. She stated she receive stitches on her head and a collar brace. She stated her family member did not know about her fall until the ER doctor phoned and informed him of her discharge back to the facility. She stated she and her family member were upset that the facility did not make notification to the family member because the facility has always called the family with any changes in her condition. In an interview on 03/01/2022 at 135PM, Resident #1's family member stated that this is the worst fall Resident #1 has ever had and he was not notified. He stated he is notified in every change like medications, weight, diet, and falls. He stated he was so shocked when the ED doctor phoned him to tell him Resident #1 was being released back to facility and he asked him released for what? Family member stated he was so upset that he was not notified and went back through his calls to see if he missed any and he did not. He stated he called the Administrator and she was shocked as well and stated she would look into it and make sure this does not happen again. In an interview on 03/01/2022 at 257PM, RN A stated she was notified of Resident #1's fall by a CNA who was making rounds on 02/05/2022 about 330AM. She stated she assessed and checked vitals for Resident #1 and decided she needed a higher level of care due to the open wound on the right side of her forehead. She stated she phoned 9-1-1, the physician, the ADON, and the family. When asked who she spoke with when the family was contacted, she stated she did not know who she spoke with. To be honest, I don't remember if I called the family. She stated family is supposed to be contacted for anything out of the ordinary and she is not sure if she called the family because she does not recall. In an interview on 03/01/2022 at 306PM, the DON stated she had never directly supervised RN A because she is an agency nurse and works the overnight shift 1-2 times per week. She stated when a resident has a fall, their policy is to contact the family, PCP, DON, and administrator and she expects the policy to be followed. She stated if it is not documented anywhere, it did not happen. In an interview on 03/01/2022 at 317PM, the Administrator stated she was aware that a family member was upset because he was not notified of a resident fall and an ED transport. She stated she did apologize to him and does not know why he was not notified because this is not our policy. She stated her expectations were for all parties to be notified regardless of what time it is because this was a severe fall. Review of policy with a revision date of December 2016 and titled transfer or Discharge, Emergency reflected the following: Policy Statement: Emergency transfers or discharges may be necessary to protect the health and/or well being of the resident(s). 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: e. Notify the representative (sponsor) or other family member

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 16 residents reviewed for medication allergies [REDACTED]. The facility failed to review and transcribe Resident #42's allergy list in the electronic medical record following readmissions from the hospital on [DATE] and [DATE]. The facility continued to administer [MEDICATION NAME] (Ace Inhibitor), resulting in Resident #42 developing [MEDICAL CONDITION] (anaphylactic shock) requiring hospitalization and intubation on [DATE]. This failure resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was lowered, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need for monitoring the implementation of their corrective actions. This facility failure placed residents with medication allergies [REDACTED]. Findings include: Record Review of Resident #42's Face Sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses of [MEDICAL CONDITION] Fibrillation, Hypertension, [MEDICAL CONDITION], Dysphagia, and Non-Traumatic [MEDICATION NAME] Hemorrhage. Record Review of Resident #42's Physical/Paper Medical Charts reflected Discharge Instructions dated [DATE] and [DATE] from an ER physician at a local ER were the same and included the following allergy list: Ace Inhibitor-[MEDICAL CONDITION], [MEDICATION NAME]-Rash, Darvon-Rash, [MEDICATION NAME]-Not Specified, [MEDICATION NAME]-Rash, [MEDICATION NAME]-Not Specified, [MEDICATION NAME]-Swelling, and [MEDICATION NAME] HCI-Rash Record Review of Order Summary Report for Resident #42 dated [DATE] reflected [MEDICATION NAME] (Ace Inhibitor) 30mg to be given one time a day ordered on [DATE]. Record Review of Resident #42's Electronic Medical Record reflected allergies [REDACTED]. Record Review of Medication Administration Records for Resident #42 reflected [MEDICATION NAME] (Ace Inhibitor) administration for the months of (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) 2019, and discontinued on [DATE]. Record Review of Communication with physician progress notes [REDACTED].#42's right lower lip swelling. Response from Primary Care Provider on [DATE] at 3:11 PM reflected: He (Resident #42) needs to go to the ER (emergency room ) for evaluation if this is [MEDICAL CONDITION]. A note from the Interim DON revealed that on [DATE] at 4:11 PM, a phone call was received from the primary care physician's nurse to monitor resident and send to emergency room if worsens. Record Review of Resident #42's Discharge Report from an out of town medical center dated [DATE] reflected a primary [DIAGNOSES REDACTED]. The admitted reflected [DATE] with a discharge date of [DATE]. Discharge Summary Notes by a hospital physician reflected Resident #42 had been transferred from a local ER to the medical center in another city on [DATE] for suspected allergic reaction with facial swelling and difficulty breathing. Resident #42 received 2 IM [MEDICATION NAME] and [MEDICATION NAME] (used to control a severe reaction). [MEDICATION NAME] was discontinued, and he was intubated and sedated prior to transfer to the larger out of town medical center. When Resident #42 arrived there, he was admitted to Medical Intensive Care Unit (MICU). He was extubated on [DATE]. Discharge orders reflected, He (Resident #42) is to avoid [MEDICATION NAME] and all Ace Inhibitors forever. Review of [MEDICATION NAME].com on reflected the following elements: [MEDICATION NAME] is a drug of the angiotensin-converting enzyme (ACE) inhibitor class used primarily in treatment of [REDACTED]. It is also used for preventing kidney and eye complications in people with diabetes. Its indications, contraindications, and side effects are as those for all ACE inhibitors. Review of Drugs.com/[MEDICATION NAME] reflected the following elements: [MEDICATION NAME] Side Effects: Get emergency medical help if you have signs of an allergic reaction to [MEDICATION NAME]: hives; severe stomach pain, difficult breathing; swelling of your face, lips, tongue, or throat. You may be more likely to have an allergic reaction if you are African-American. On [DATE] at 10:07 AM, an interview with Resident #42's family member revealed that in an unknown time frame, but less than six months ago, Resident #42 received a medication he was allergic to and almost died . The family member stated the allergy was not a new allergy at the time of the anaphylactic shock and that she had reported the allergy to the facility at admission. On [DATE] at 12:07 PM, the DON stated she was not aware of the incident prior to the surveyor's arrival. She stated her first day at the facility was around that time, and she did not investigate the incident. She stated she was not sure how the discharge instructions from a local ER for Resident #42 dated [DATE] and [DATE] were missed by the facility. On [DATE] at 10:00 AM, the Pharmacist Consultant stated in interview that she was not aware Resident #42 had an allergy to Ace Inhibitors. She stated she relied on the Electronic Medical Record and did not look at the physical/paper charts. She stated that it was high probability that Resident #42 had built up a toxicity to [MEDICATION NAME] (Ace Inhibitor) and that could have led to anaphylactic shock ([MEDICAL CONDITION]). She stated she was not aware that the incident on [DATE] was due to an identifiable allergen administered to resident On [DATE] at 2:30 PM, an interview with the interim DON (at the time of the incident) revealed that she thought the allergy to Ace Inhibitors was a new allergy. She stated she had never seen the discharge instructions in Resident #42's chart from the local hospital dated [DATE] and [DATE]. When asked for hospital records from Resident #42's emergency room visits on [DATE] and [DATE] that should have been faxed to the facility from the hospital, she stated they were still looking in medical records for them. When asked about progress notes from nurses at the facility she stated there were none. On [DATE] at 11:00 AM, interview with Resident #42's Primary Care Provider, who is also the facility's Medical Director, revealed that he was also the Chief Medical Officer at the local hospital. He stated that there was obviously a transition hand off problem with multi-faceted failure. He stated that the form from the local hospital was the form that went with Resident #42 at discharge from the emergency room and was computer generated, and listed allergies [REDACTED]. He stated he did not have a clear answer as to why Resident #42 kept receiving a medication he was allergic to, but transition should be a priority for resident safety and the hospital and that the facility had a problem. On [DATE] at 1:23 PM, Licensed Vocational Nurse (LVN) A stated she had been a nurse at the facility for almost a year and that when a resident goes to the emergency room , the charge nurse will do a nurse-to-nurse report for any updated orders on re-admit. When asked about the Discharge Instruction forms dated [DATE] and [DATE] she stated the nurses do not read them, and that they just place them in the physical/paper chart. She stated she did not know what to do with them and had never been told. When asked how she would know if someone had a new allergy after going to the ER, she stated, I guess from the nurse-to-nurse report, that is a good question. She stated she had never seen any paper that would list a new allergy. She stated that Resident #42 had been showing signs of his tongue swelling off and on for over a week prior to the facility sending him to the emergency room . She stated he was moved to her hall, and once again his oxygen saturation dropped, and his tongue swelled, and she immediately sent him to the ER. She stated the family reported he had been on an Ace-inhibitor before and had the same reaction prior to his admission to the facility. She stated she did not know when that was. On [DATE] at 10:29 AM, the DON stated in interview that they did not have or could not find any documentation from Resident #42's visits to the emergency roiagnom on [DATE] and [DATE]. The facility Administrator was notified on [DATE] at 4:40 PM that an Immediate Jeopardy had been identified due to the above failure. The following Plan of Removal was submitted by the Administrator and accepted by the survey team on [DATE] at 5:45 PM. Plan of Removal submitted by the facility: All Admission/Discharge/Readmission orders [REDACTED]. Director of Nurses and/or designee will compare discharge orders/admitting orders with information entered into Point Click Care/electronic medical record each morning in the daily clinical meeting to verify correct transcription of orders/allergies [REDACTED]. Attached Resident Admission/readmission list will be utilized as a reminder to input/verify allergies [REDACTED].>All currently employed nurses will receive inservicing on this practice. All newly hired nurses will be inserviced on this practice. 100% audit of all current records will be completed with focus on allergies [REDACTED].>The facility also developed a checklist addressing specific Admission Items, including the following: Enter allergies [REDACTED]. Enter Orders. Be sure to verify . Complete a Med Reconciliation Worksheet for any meds with potential issues, adverse reaction/allergy, or need further clarification (like no diagnosis). Physician notified. The survey team monitored the current Plan of removal as follows: Interviews were conducted with staff regarding inservices conducted by the facility on [DATE] and [DATE]. The inservices were titled Drug Interaction''(appropriate response-notifying MD), Allergy Documentation, (second nurse verifying admitting nurse recording medication allergies [REDACTED]. On [DATE] at 3:45 PM interview with LVN B revealed that she was aware of the new system and had received education on the new system in place for allergy identification for residents returning from the hospital. On [DATE] at 1:40 PM interview with LVN A revealed that she had received education on the new system in place for allergy identification for residents returning from the hospital. On [DATE] at 2:30 PM interview with RN A revealed that she had received education on the new system in place for allergy identification for residents returning from the hospital. On [DATE] at 10:00 AM, the Director of Clinical Operations was observed conducting and inservice with three licensed nurses regarding identification of allergies [REDACTED]. On [DATE], the Administrator was informed the IJ was lowered. However, the facility remained out of compliance at a severity of actual harm that was not an Immediate Jeopardy with a scope of a pattern due to the facility required time to monitor their Plan of Removal.

Based on observations, interviews and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public in resident rooms, hallways and the main conference room. There were pervasive urine odors in 6 of 12 rooms sampled for the annual survey. The carpet was stained and worn beyond normal expectations. There was a strong unpleasant odor noted in the main conference room, and throughout the facility hallways. This failure placed 38 residents and the public at risk for unsanitary environmental conditions. Findings include: Observation on 5/6/19 at 9:15 AM upon entry to the facility a strong unpleasant odor was noted. Observation on 5/6/19 at 9:33 AM outside room [ROOM NUMBER] and inside room [ROOM NUMBER] revealed a pungent ammonia-like odor throughout. Observation on 05/06/19 revealed a strong unpleasant odor in the main conference room, which is used by staff, residents and families. There was a fabric covered chair in the room which had a strong ammonia odor. Observations on 5/6/19 through 5/9/19 revealed 6 of 12 sampled rooms had strong pervasive urine odors. The rooms had worn soiled carpet. The carpet had areas which were wrinkled and frayed. (Rooms 104, 106, 115, 118, 127 and 131). Observation on 05/06/19 at 10:01 AM revealed room [ROOM NUMBER] had a strong urine odor. Observation on 05/06/19 at 10:11 AM revealed room [ROOM NUMBER] had a strong urine odor. Observation on 05/06/19 at 10:30 AM revealed room [ROOM NUMBER] had a strong urine odor. Interview with RN A on 05/07/19 revealed that Resident #38 had a recent change of condition and resulted in not knowing where the restroom is, therefore urinating on the floor of the bedroom and bed. Observation on 05/08/19 at 11:59 AM revealed room [ROOM NUMBER] had a strong urine odor, the mattress had dark brown circular stains. There was a room air purifier machine labeled with the resident's name plugged in and turned on. The carpet was stained, had wrinkles and frayed areas. Interview with the Administrator on 05/06/19 at 3:00 PM revealed that the chair which was in the conference room, had previously been in a resident's room. The Administrator stated she would have the chair removed. The Administrator stated that several months ago there was a resident who occasionally came to the conference room and urinated near the window onto the floor and wall area. She stated that the area had been cleaned but the odor at times is still present. The Administrator stated that there have been discussions with the corporate office about removing all carpet from the facility and replacing with hard flooring, which would be easier to keep clean. Observation on 5/08/19 at 2:30 PM when walking down the hallway toward Zone 2, a strong urine odor was noted and there was tile on flooring and not carpet. During interview with the Administrator on 5/8/19 at 2:35 PM, when asked if she smelled the odor in hallway, she stated she did notice an odor stronger in that area.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for 1 of 5 residents reviewed. (Resident #29) The mattress on Resident #29's bed had dark urine stains, deep circular indentations at the center of the mattress and a strong, pervasive urine odor. This facility failure places incontinent residents at risk for skin breakdown and/or improper support. Findings include: Review of Resident #29's admission Face Sheet dated 4/21/17 revealed a [AGE] year-old male with [DIAGNOSES REDACTED]. Review of Resident #29's Minimum Data Set ((MDS) dated [DATE], revealed he is usually understood-has difficulty communicating some words or finishing thoughts but is able if prompted or given time. He usually understands others- misses some part/intent of message but comprehends most conversation. He had a Brief Interview for Mental Status (BIMS) score of three (a score of 0-7 indicates severely impaired cognition). Resident #29 requires two-person physical assist for toileting, changing pad and for personal hygiene needs. Review of Resident #29's care plan dated 2/20/19 revealed that he was at risk for skin breakdown related to incontinence, and impaired physical mobility. The care plan reflected the resident is incontinent of bladder and bowel related to dementia, he is unable to participate in a toileting program related to impaired cognition, and has a self-care performance deficit related to dementia. Observation on 5/06/19 at 12:05 PM and 2:20 PM revealed Resident #29's bed contained soiled wet bedding with a large yellowed circle in the center of the bed, and a strong urine odor noted. Observation on 5/08/19 at 11:30 AM revealed Resident #29's bed with a standard foam mattress, no sheets, the mattress covering was stained with multiple dried dark brown circular stains. There were 2 large circular indentations (approximately two to three inches deep) at the center of the mattress. The mattress covering was crispy to the touch. The foam mattress appeared very worn and flattened. During an interview on 5/08/19 at 11:45 AM, LVN B stated that CNAs are to spray soiled mattresses with disinfectant, let air dry, and then make the bed with fresh linens. She said that it is hard to find extra mattresses to replace an old mattress, but that she could turn in a work order requesting the mattress be replaced. During an interview on 5/08/2019 at 11:55 AM, CNA A stated that he could turn in a work order to maintenance to have the mattress replaced. He said that he was unsure if there were any available newer mattresses. Interview with the DON on 5/09/19 at 10:50 AM revealed that it is her expectation that CNAs are to bag soiled linens immediately and are to inform the charge nurse or the DON when a mattress is worn, and/or soiled beyond a normal cleaning, so that the request for a new mattress can be logged into the maintenance book. Observation on 05/09/2019 at 9:55 AM revealed that a newer, unstained mattress without indentions had been placed on Resident #29's bed.

Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of a resident's admission that includes the instructions needed to provide effective and person-centered care for 5 of 16 residents reviewed for baseline care plans. (Resident #'s 25, 27, 28, 42, and 194) The facility failed to develop and implement a baseline care plan, or in lieu of a baseline, a comprehensive care plan within 48 hours of admission for 5 newly admitted residents. This facility failure placed five newly admitted residents at risk for not receiving continuity of care and communication among nursing home staff, increased resident safety and safeguard against adverse events that are most likely to occur right after admission. Findings include: A. Review of Resident #194's Face Sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #194's assessments revealed as of 5/9/19, no baseline care plan and/or comprehensive care plan had been completed. B. Review of Resident #28's Face Sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #28's assessments revealed no baseline care plan had been developed as of 5/9/19. A comprehensive care plan had been initiated on 9/18/18. C. Review of Resident #42's Face Sheet revealed [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #42's paper and electronic chart revealed a blank baseline care plan in the front of paper chart, undated. A comprehensive care plan was initiated on 1/16/19. D. Review of Resident #25's Face Sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #25's assessment revealed no baseline care plan had been developed as of 5/9/19. A comprehensive care plan was initiated on 3/19/19. E. Review of Resident #27's Face Sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #27's assessment revealed no baseline care plan had been developed. The comprehensive care plan was initiated on 05/08/19. An interview with DON on 05/8/19 at 10:29 AM revealed that she was not certain who created and reviewed baseline care plans but she thought it might be the DON. She stated that she had not been following up on them and reviewing baseline care plans. She stated that Resident #194 has not been reviewed for care plan. She stated verbal communication is what nurses had used to communicate care with nurse aides. She stated that the MDS Coordinator was the one completing care plans but she had left three weeks prior to survey. She stated the MDS Coordinator was the only one that updated the care plans. Interview with the Interim DON on 05/09/19 at 2:30 PM revealed there was no baseline care plan for or care plan for Resident #194.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet resident's physical, mental, and psychosocial needs for 10 of 16 residents reviewed for care plans. (Resident #'s 6, 14, 15, 25, 27, 28, 31, 32, 38 and 42) A. Resident #14's care plan did not address admission to Hospice services. B. Resident #15's care plan failed to address a risk for elopement and use of a wander guard alarm. C. Resident #31's care plan did not address pain and/or interventions. D. Resident #32's care plan did not address admission to Hospice services. E. Resident #27's care plan did not address the resident's frequent refusal of showers. F. Resident #28's care plan did not address risk for falls and the intervention of a bed alarm. G. Resident #6's care plan did not address monitoring for side effects of a [MEDICAL CONDITION] drug. H. Resident #25's care plan did not address activities. These failures could place all residents in the facility at risk for their medical, physical, and psychosocial needs not being met. Findings include: A. Resident # 14's Face sheet with an admission date of [DATE] revealed a [AGE] year-old female with [DIAGNOSES REDACTED]. Review of Resident #14's MDS assessment dated [DATE] revealed Resident 14's cognition was cognitively intact with a BIMS Score of 15 (Score 13-15 indicates cognitively intact; Score 8-12 indicates cognition moderately impaired; and Score 0-7 indicates cognition severely impaired). Review of Resident #14's Physician orders [REDACTED]. Review of Resident #14's care plan dated 02/20/19 revealed no revision addressing admission to Hospice services. Resident #15's Face Sheet with an admission date of [DATE] revealed an [AGE] year-old female with [DIAGNOSES REDACTED]. Review of resident #15's MDS assessment dated [DATE] revealed Resident #15's cognition was severely impaired with a BIMS Score of 6 (Score 13-15 indicates cognitively intact; Score 8-12 indicates cognition moderately impaired; and Score 0-7 indicates cognition severely impaired). Review of Resident #15's care plan dated 01/23/19 showed no evidence of elopement risk or use of a wanderguard alarm. Review of Resident #15's Physician orders [REDACTED]. C. Review of Resident #31's Face Sheet dated 12/28/18 revealed a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed Resident #31's cognition was cognitively intact with a BIMS Score of 13 (Score 13-15 indicates cognitively intact; Score 8-12 indicates cognition moderately impaired; and Score 0-7 indicates cognition severely impaired). Review of Resident #31's Physician orders [REDACTED]. Review of Resident #31's care plan dated 01/19/19 revealed no evidence of identified pain. Resident #31 has requested pain medication almost everyday, sometimes twice a day, (ordered every 6 hours). [MEDICATION NAME] is a scheduled medication order. D. Review of Resident #32's Face Sheet dated 12/12/18 revealed an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #32's re-admit orders from hospital dated 5/01/2019 reflected orders for Hospice Care. Review of Resident #32's Care plan dated 1/15/19 revealed no evidence of being admitted to Hospice Services on 05/01/19. E. Review of Resident #27's Face Sheet dated 04/17/19 revealed an [AGE] year-old female with [DIAGNOSES REDACTED]. Review of Resident #27's care plan dated 5/8/19 revealed no evidence of Resident #27 frequently refusing showers. Observation on 05/06/19 at 2:20 PM revealed Resident #27 with brown matter under fingernails, hair and face oily in appearance. Interview on 05/06/19 at 2:25 PM with CNA B revealed that Resident #27 frequently refuses showers. F. Review of Resident #28's Face Sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #28's care plan dated 9/18/18 revealed no documentation or implementation for risk for falls or for actual falls. Observation of Resident #28's room on 5/6/19 at 10:41 AM revealed a bed alarm on the bed. Interview with CNA A on 5/7/19 at 9:40 AM revealed that Resident #28 did have a bed alarm for her room due to her trying to transfer herself and multiple falls in the past. G. Review of Resident #6's Face Sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Physician order [REDACTED]. Apply 1ml to skin of wrist or neck. The order was dated with a start date of 1/19/19 with no end date. The same physician orders [REDACTED]. Review of Resident #6's Care Plan with an initiated date of 9/14/18 did not address [MEDICAL CONDITION] medications. H. Review of Resident #25's Face Sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #25's Care Plan initiated on 3/24/19 had a multiple choice drop-in care plan for activities with choices not selected as of 5/7/19, not addressing activity focus and activities that Resident #25 may enjoy or participate in. Interview with the DON on 5/8/19 at 10:29 AM revealed she had not been following up on care plans and reviewing care plans. She stated verbal communication is what nurses had used to communicate care with nurse aides. She stated that the MDS (Minimum Data Set) Coordinator was the one completing care plans but she had left three weeks prior to survey. She stated the MDS Coordinator was the only one that updated the care plans. She stated falls, prevention of falls, diets, ADLs, and all areas of resident care should be care planned.

Based on interview and record review, the facility failed to review and revise the person-centered care plan for three of sixteen residents reviewed for comprehensive care plans. (Resident #'s 14,15 and 42) The facility failed to revise the Comprehensive Care Plan for Resident #14. The facility failed to revise the Comprehensive Care Plan for Resident #15 The facility failed to initiate or complete a Comprehensive Care Plan for Resident #42. This facility failure placed all residents at risk for not receiving continuity of care and communication among nursing home staff. Findings include: Review of Resident #14's Face Sheet revealed a [AGE] year-old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #14's paper and electronic chart revealed that she was admitted to Hospice on 04/21/19. The comprehensive care plan was not updated to reflect the admission to Hospice. Review of Resident #15's Face Sheet revealed a [AGE] year-old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #15's Physician order [REDACTED]. Review of Resident #15's care plan dated 01/23/19 showed no evidence of elopement risk or use of a wanderguard alarm. Review of Resident #42's Face Sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #42's paper and electronic chart revealed a blank baseline care plan in the front of paper chart, undated. A comprehensive care plan was initiated on 1/16/19. An interview with DON on 5/8/19 at 10:29 AM revealed care plans where not being updated since the MDS (Minimum Data Set) Coordinator had left, 3 weeks prior. DON stated that nurses communicated with staff (including nurse aides) verbally and the MDS Coordinator revised and updated care plans. Interview with Interim DON on 5/9/19 at 2:30 PM revealed no other documentation could be found for Resident #42. Review of facility policy titled Care Plans, Comprehensive Person-Centered, and dated (MONTH) (YEAR) reflected the following elements: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. ( .) 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well being; e. Include the resident's stated goals upon admission and desired outcomes; 12. The comprehensive, person-centered care plan is developed within seven (7) days of completion of the required comprehensive assessment (MDS). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 13 residents reviewed for personal hygiene assistance. (Resident #29) Resident #29 was observed in bed with a strong urine odor noted. Resident #29's family reported that on multiple occasions the resident has been found sitting in soiled disposable briefs and having a strong urine odor. This facility failure placed residents requiring incontinent care at risk for infection and/or a decreased quality of life. Findings include: Review of Resident #29's Face Sheet with an admission date of [DATE] revealed a 92-yr-old male with [DIAGNOSES REDACTED]. Review of Resident #29's MDS dated [DATE] revealed he is usually understood-has difficulty communicating some words or finishing thoughts but is able if prompted or given time. He usually understands others-misses some part/intent of message but comprehends most conversation. His BIMS score was 3. (A score of 0-7 indicates severely impaired cognition). Resident #29 requires two-person physical assist for toileting, changing pad and personal hygiene needs. Review of Resident #29's care plan dated 2/20/19 revealed he was at risk for skin breakdown related to incontinence and impaired physical mobility. The care plan reflected the resident is incontinent of bladder and bowel related to dementia, he is unable to participate in a toileting program related to impaired cognition and has a self-care performance deficit related to dementia. Observation on 5/06/19 at 10:10 AM revealed Resident #29 in bed, with a strong urine odor. Observation on 5/06/19 at 12:05 PM revealed Resident #29 in the dining room. Observation of Resident #29's bed revealed soiled, wet linens with a large yellow circle in the center of the bed, and a strong urine odor. Interview with CNA A revealed Resident #29's family requested he not be awakened before 10:00 AM. CNA A stated Resident #29's briefs are changed about 5:30 AM, checked again about 6:30 AM and then not again until he is assisted up for the day around 10:00 AM. Interview with Resident #29's family member on 05/07/19 at 2:00 PM revealed they had noticed a very strong urine odor in the resident's room. The family member stated that they had requested the resident not be gotten out of bed at 5:30 AM, but that he should be out of bed when he awakens or at least by 10:00 AM. They stated that on multiple occasions they have found Resident #29 sitting in urine and feces-soaked briefs, and that urine had been observed dripping off of the wheelchair seat. The family member stated that on one occasion she found the resident wearing soiled/wet briefs, and that it took over an hour for staff to come and change him. Interview with the DON on 5/09/19 at 10:50 AM revealed that it is her expectation that incontinent care rounds be made every 2 hours, incontinent care be performed as needed to prevent skin breakdown, and to be sure residents are clean and odor free. Review of the facility grievance log revealed a grievance dated 3/03/19 stating that Resident #29 was found in bed at 11:30 AM soaked head to toe with urine.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident #4) of six residents reviewed for pain management. The facility did not reorder Resident #4's narcotic pain medication, [MEDICATION NAME] 10/325 milligram (mg) causing the resident to miss an undetermined number of doses of medication (on a scale of one to ten with ten being worse, her pain was seven) to control the pain from a recent bilateral knee replacement surgery. This deficient practice had the potential to contribute to uncontrolled pain management for 6 residents identified by the facility taking medication for pain management. Findings include: Review of Resident #4's Physician orders [REDACTED]. the medication [MEDICATION NAME] 10/325 milligrams (mg); one tablet orally every four hours as needed. (Diagnosis: [REDACTED].; take one to two tablets orally every four hours as needed ([DIAGNOSES REDACTED]. Review of Resident #4's admission Minimum Data Set Assessment ((MDS) dated [DATE] reflected a BIMs (brief interview for mental status) score of 15. (cognitively intact) Pain: "frequently" with an intensity rating of seven. ("zero being no pain and ten as the worst pain you can imagine.") Review of Resident #4's initial (current) Care Plan reflected: Pain-resident has complaints of acute pain related to recent surgery for [REDACTED]. Assess effects of pain, evaluate effectiveness of pain management interventions. Review of Resident #4's pain assessment dated [DATE] reflected "describe pain- aching, burning" "what makes the pain better? pain medication" The pain scale was rated at a seven. Review of Resident #4's Interdisciplinary Discharge Plan/Summary reflected: admitted [DATE]/ discharge date [DATE]. Reason for discharge and Diagnosis: [REDACTED]. In a telephone interview on 8/10/12 at 10:45 am, Resident #4 stated she discharged from the facility because she was unable to get her pain medication. Resident #4 stated the facility did not reorder her [MEDICATION NAME]. Resident #4 stated she received her last two pills at 7:00 pm on 7/23/12 and she could not understand why someone did not order them at that time. Resident #4 stated she requested pain medication again at 11:00 pm that evening and Licensed Vocational Nurse) LVN C entered her room and told her she did not have any more. Resident #4 stated LVN C handed her two blue pills and said "here, take these." Resident #4 stated she was not told what the pills were, but assumed it was Tylenol (over the counter pain reliever) because of the color. Resident #4 stated she needed the pain pills every four hours to control her pain and had been requesting her pain medication regularly every four hours. Resident #4 stated when she spoke to her physician, he said he wondered why the facility did not contact him when they realized they were out of the medication. Resident #4 stated she was in a lot of pain, the pills she was given did not help, and she left the facility the next day because she was so upset. Resident #4 was unable to recall the exact time she left the facility, but went to the pharmacy and was given her medication. Resident #4 stated she reported the incident to her daughter who reported it to the facility. Review of Resident #4's individual narcotic record reflected 60 [MEDICATION NAME] were received on 7/18/12. The narcotic record reflected a notation for 7/23/12 at 7 pm and was crossed off with a zero (indicating there were no tablets left). In an interview on 8/10/12 at 12:00 pm, the Director of Nurses (DON) stated when a medication gets low, it should be faxed or called in to the pharmacy. The DON stated it its the responsibility of the 6 am to 6 pm shift because of the limited pharmacy hours, but if the evening shift notices the medication is running low, the order should be faxed. The DON stated she has worked on the floor and Resident #4 had been taking her pain med's every four hours. The DON stated she spoke to the physician and he was very upset no one had called him. The DON stated LVN C should have contacted her, the Assistant Director of Nurses (ADON) or the physician. The physician was contacted by the surveyor, but did not return phone calls. In an interview on 8/10/12 at 12:10 pm, the Administrator stated the DON, physician or herself should have been notified that Resident 4's medication was not available. The Administrator stated the pharmacy will deliver emergency medications. The Administrator stated the physician is on call 24/7. The Administrator stated LVN C should have known to follow the physicians orders and get the medication that was needed. In a telephone interview on 8/10/12 at 1:45 pm, LVN C stated she was off the day before (7/22/12)and when she got to work that afternoon of 7/23/12, she realized Resident #4 was out of pain medication. LVN C stated it was a very busy night, and when Resident #4's husband approached her to let her know she was requesting pain medication, she called the pharmacy to place an order. LVN C stated she had no pain medication to give Resident #4, so she gave her Tylenol, thinking [MEDICATION NAME] had Tylenol in it, so it would be okay. The LVN stated she knew Resident #4 did not have a physician's orders [REDACTED]. LVN C stated later during the night, she opened Resident #4's door to her room but did not enter and did not hear any noise. LVN C assumed Resident #4 was sleeping. LVN C stated she placed a call to the ADON, but there was no answer. LVN C stated she did not call the physician, DON, or Administrator. Review of an employee witness statement dated 7/23/12 and signed by LVN C reflected"on July 23/2012 I was the nurse in charge of Resident #4. It was a busy day when they asked (she and the husband) for her pain medications. I took her the last two pills of the bubble card, but I thought we had a new one. Later at 11:00 pm when she asked for pain pills, I realized we were out of medication. I gave her a Tylenol 500 mg." In an interview on 8/10/12 at 2:00 pm, the ADON stated she did not receive any phone message on the evening of 7/23/12 from LVN C. In an interview on 8/10/12 at 2:35 pm, the DON stated Resident #4 "fell through the cracks" The DON stated the ADON administered the prior dose of Resident #4's pain medication, and should have known to order, but assumed there was another card of medication, "there's always another card." Review of Resident # 4's nurses notes dated 7/22/12 and 7/23/12 reflected no documentation of pain or pain medication availability. Review of a facility policy titled Medication Ordering and Receiving form Pharmacy Provider dated 9/2010 reflected the following: "Ordering and Receiving Controlled Medications: 5) a. If one or more refills or a partial fill quantity remains and medications are not automatically refilled by the pharmacy, refills are written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy a minimum of 3 days in advance of need to assure an adequate supply is on hand." A facility acquired list documented 6 residents that were currently on medication for pain management. Per Administrator the facility census was 56.

Based on interviews and record review, the facility failed to provide routine and emergency drugs for one (Resident #4) of six residents reviewed for pain management when they failed to reorder a pain medication in a timely manner. The facility did not reorder Resident #4's narcotic pain medication, Hydrocodone 10/325 milligram (mg) causing the resident to miss an undetermined number of doses of medication to control her pain (on a scale of one to ten with ten being worse, her pain was seven) from recent bilateral knee replacement surgery. This deficient practice had the potential to contribute to uncontrolled pain management for 6 residents identified by the facility taking medication for pain management. Findings include: Review of Resident #4's Physician orders [REDACTED]. the medication Hydrocodone 10/325 milligrams (mg); one tablet orally every four hours as needed. (Diagnosis: [REDACTED].; take one to two tablets orally every four hours as needed ([DIAGNOSES REDACTED]. Review of Resident #4's admission Minimum Data Set Assessment ((MDS) dated [DATE] reflected a BIMs (brief interview for mental status) score of 15. (cognitively intact) Pain: "frequently" with an intensity rating of seven. ("zero being no pain and ten as the worst pain you can imagine.") Review of Resident #4's initial (current) Care Plan reflected: Pain-resident has complaints of acute pain related to recent surgery for [REDACTED]. Assess effects of pain, evaluate effectiveness of pain management interventions. Review of Resident #4's pain assessment dated [DATE] reflected "describe pain- aching, burning" "what makes the pain better? pain medication" The pain scale was rated at a seven. Review of Resident #4's Interdisciplinary Discharge Plan/Summary reflected: admitted [DATE]/ discharge date [DATE]. Reason for discharge and Diagnosis: [REDACTED]. In a telephone interview on 8/10/12 at 10:45 am, Resident #4 stated she discharged from the facility because she was unable to get her pain medication. Resident #4 stated the facility did not reorder her Hydrocodone. Resident #4 stated she received her last two pills at 7:00 pm on 7/23/12 and she could not understand why someone did not order them at that time. Resident #4 stated she requested pain medication again at 11:00 pm that evening and Licensed Vocational Nurse) LVN C entered her room and told her she did not have any more. Resident #4 stated LVN C handed her two blue pills and said "here, take these." Resident #4 stated she was not told what the pills were, but assumed it was Tylenol (over the counter pain reliever) because of the color. Resident #4 stated she needed the pain pills every four hours to control her pain and had been requesting her pain medication regularly every four hours. Resident #4 stated when she spoke to her physician, he said he wondered why the facility did not contact him when they realized they were out of the medication. Resident #4 stated she was in a lot of pain, the pills she was given did not help, and she left the facility the next day because she was so upset. Resident #4 was unable to recall the exact time she left the facility, but went to the pharmacy and was given her medication. Resident #4 stated she reported the incident to her daughter who reported it to the facility. Review of Resident #4's individual narcotic record reflected 60 Hydrocodone were received on 7/18/12. The narcotic record reflected a notation for 7/23/12 at 7 pm and was crossed off with a zero (indicating there were no tablets left). In an interview on 8/10/12 at 12:00 pm, the Director of Nurses (DON) stated when a medication gets low, it should be faxed or called in to the pharmacy. The DON stated it its the responsibility of the 6 am to 6 pm shift because of the limited pharmacy hours, but if the evening shift notices the medication is running low, the order should be faxed. The DON stated she has worked on the floor and Resident #4 had been taking her pain med's every four hours. The DON stated she spoke to the physician and he was very upset no one had called him. The DON stated LVN C should have contacted her, the Assistant Director of Nurses (ADON) or the physician. The physician was contacted by the surveyor, but did not return phone calls. In an interview on 8/10/12 at 12:10 pm, the Administrator stated the DON, physician or herself should have been notified that Resident 4's medication was not available. The Administrator stated the pharmacy will deliver emergency medications. The Administrator stated the physician is on call 24/7. The Administrator stated LVN C should have known to follow the physicians orders and get the medication that was needed. In a telephone interview on 8/10/12 at 1:45 pm, LVN C stated she was off the day before (7/22/12)and when she got to work that afternoon of 7/23/12, she realized Resident #4 was out of pain medication. LVN C stated it was a very busy night, and when Resident #4's husband approached her to let her know she was requesting pain medication, she called the pharmacy to place an order. LVN C stated she had no pain medication to give Resident #4, so she gave her Tylenol, thinking Vicodin had Tylenol in it, so it would be okay. The LVN stated she knew Resident #4 did not have a physician's orders [REDACTED]. LVN C stated later during the night, she opened Resident #4's door to her room but did not enter and did not hear any noise. LVN C assumed Resident #4 was sleeping. LVN C stated she placed a call to the ADON, but there was no answer. LVN C stated she did not call the physician, DON, or Administrator. Review of an employee witness statement dated 7/23/12 and signed by LVN C reflected"on July 23/2012 I was the nurse in charge of Resident #4. It was a busy day when they asked (she and the husband) for her pain medications. I took her the last two pills of the bubble card, but I thought we had a new one. Later at 11:00 pm when she asked for pain pills, I realized we were out of medication. I gave her a Tylenol 500 mg." In an interview on 8/10/12 at 2:00 pm, the ADON stated she did not receive any phone message on the evening of 7/23/12 from LVN C. In an interview on 8/10/12 at 2:35 pm, the DON stated Resident #4 "fell through the cracks" The DON stated the ADON administered the prior dose of Resident #4's pain medication, and should have known to order, but assumed there was another card of medication, "there's always another card." Review of Resident # 4's nurses notes dated 7/22/12 and 7/23/12 reflected no documentation of pain or pain medication availability. Review of a facility policy titled Medication Ordering and Receiving form Pharmacy Provider dated 9/2010 reflected the following: "Ordering and Receiving Controlled Medications: 5) a. If one or more refills or a partial fill quantity remains and medications are not automatically refilled by the pharmacy, refills are written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy a minimum of 3 days in advance of need to assure an adequate supply is on hand." A facility acquired list documented 6 residents that were currently on medication for pain management. Per Administrator the facility census was 56.

Based on observation, interview and record review the facility failed to establish infection control measures to prevent the transmission of infection and disease by blood borne pathogens for 4 of 11 diabetic residents observed for glucose fingersticks (#s 3, 7, 8 and 10) when individual lancing pen devices were used on multiple residents to obtain blood for glucose tests. Resident #3 had [DIAGNOSES REDACTED].coli. (Each of these three [DIAGNOSES REDACTED]. Fingerstick devices (lancing pen devices) touch the skin and come in close proximity to blood with every use. Even if the lancet itself is changed between each use there is potential for blood to contaminate the pen device. Blood borne pathogens such as Hepatitis B, Hepatitis C and Human-Immunodeficiency Virus (HIV) could potentially be transmitted from one person to another. An Immediate Jeopardy (IJ) was identified on 10/05/11. While the IJ was removed prior to exit on 10/06/11, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not Immediate Jeopardy and a scope of Pattern. This deficient practice placed residents #3, #7, #8 and #10 at risk of contracting blood borne infections and had potential to affect 14 diabetic residents identified as requiring use of a lancing pen device to obtain blood by fingerstick for blood glucose testing. Findings included: 1. Record review of Resident #7's Record of Admission in the current clinical record revealed she was [AGE] years old and was admitted to the facility on [DATE]. She had a [DIAGNOSES REDACTED]. During medication pass observation on 10/05/11 at 7:10 a.m. LVN B was observed performing a fingerstick for blood glucose testing on Resident #7. LVN B took the case containing the glucometer and lancing pen device to the Nurses' station. She removed these items and laid them on the counter. LVN B did not clean the glucometer or the lancing pen device prior to use. She inserted a lancet into the lancing pen device, cleaned the resident's left third finger with alcohol, performed the stick, placed the test strip into the glucometer and ran the glucose test. She removed the used lancet from the lancing pen device and laid it on the used alcohol wipes on the counter. She wiped the outside of the meter with a Clorox wipe. She put the glucometer back into the case and placed the lancing pen device in the equipment tote, gathered the used alcohol wipes and lancet and placed them in a sharps container in her carrying tote. She did not clean the lancing pen device. During an interview immediately following the above observation LVN B was asked if the lancing pen devise belonged to Resident #7. She said the lancing pen device did not belong to any one resident; she said that normally she would have individual lancing devices, but that she was out. She said it was used on all the diabetic residents that required fingerstick glucose testing. 2. Record review of Resident #10's Record of Admission in the current clinical record revealed he was [AGE] years old and was admitted to the facility on [DATE]. He had a [DIAGNOSES REDACTED]. During medication pass observation on 10/05/11 at 7:15 a.m. LVN B was observed performing a fingerstick for blood glucose testing on Resident #10. LVN B took the case containing the glucometer and lancing pen device to the Activity room. She removed these items and laid them on the table. LVN B did not clean the glucometer or the lancing pen device prior to use. She inserted a lancet into the lancing pen device, cleaned the resident's left second finger with alcohol, performed the stick, placed the test strip into the glucometer and ran the glucose test. She removed the used lancet from the lancing pen device and laid it on the used alcohol wipes on the table. She wiped the outside of the meter with a Clorox wipe. She put the glucometer back into the case wiped the outside of lancing pen device with a Clorox wipe and placed lancing pen device in the tote, gathered the used alcohol wipes and lancet and placed them in a sharps container in her carrying tote. 3. Record review of Resident #3's Record of Admission in the current clinical record revealed he was [AGE] years old and was admitted to the facility on [DATE]. He had a [DIAGNOSES REDACTED].coli. (Each of these three [DIAGNOSES REDACTED]. During medication pass observation on 10/05/11 at 7:30 a.m. LVN B was observed performing a fingerstick for blood glucose testing on Resident #3. LVN B took the case containing the glucometer (with Resident #3 ' s name on it) and lancing pen device (the same lancing pen device used on prior Residents) to his room. She removed these items and laid them on the over-bed table. LVN B did not clean the glucometer or the lancing pen device prior to use. She inserted a lancet into the lancing pen device, cleaned the resident's right ring finger with alcohol, performed the stick, placed the test strip into the glucometer and ran the glucose test. She removed the used lancet from the lancing pen device and laid it on the used alcohol wipes on the table. She wiped the outside of the meter with a Clorox wipe. She put the glucometer back into the case, wiped the outside of the lancing pen device with a Clorox wipe, gathered the used alcohol wipes and lancet and placed them in a sharps container in her carrying tote. 4. Record review of Resident #8's Record of Admission in the current clinical record revealed he was [AGE] years old and was admitted to the facility on [DATE]. He had a [DIAGNOSES REDACTED]. During medication pass observation on 10/05/11 at 7:45 a.m. LVN B was observed performing a fingerstick for blood glucose testing on Resident #8. LVN B took the case containing the glucometer and lancing pen device to the Activity room. She removed these items and laid them on the table. LVN B did not clean the glucometer or the lancing pen device prior to use. She inserted a lancet into the lancing pen device, cleaned the resident's right ring finger with alcohol, performed the stick, placed the test strip into the glucometer and ran the glucose test. She removed the used lancet from the lancing pen device and laid it on the used alcohol wipes on the table. She wiped the outside of the meter with a Clorox wipe. She put the glucometer back into the case, wiped the outside of the lancing pen device with a Clorox wipe, gathered the used alcohol wipes and lancet and placed them in a sharps container in her carrying tote. The failure to ensure that a lancing pen device was not used on multiple residents to obtain blood, for blood glucose tests, resulted in the identification of an IJ (Immediate Jeopardy) of which the facility Administrator, and Director of Nurses (DON) were informed on 10/05/11 at 9:55 a.m. During an interview with the Administrator, and DON on 10/05/11 at 10:05 a.m. they all stated they were unaware that lancing pen devices were not supposed to be used on multiple residents. The DON said the company orders disposable, one-time-use lancing devices. She said Clorox wipes (an EPA-registered, hospital-grade disinfectant cleaner) are supposed to be used to clean the glucometer before and after each use. Information posted by the Center of Disease Control, updated 08/26/10, at website http://www.cdc.gov/injectionsafety/Fingerstick-DevicesBGM.html contained the following: "The shared use of fingerstick devices is one of the common root causes of exposure and infection in settings such as long-term care (LTC) facilities, where multiple persons require assistance with blood glucose monitoring. Risk for transmission of blood borne pathogens is not limited to LTC settings but can exist anywhere multiple persons are undergoing fingerstick procedures for blood sampling. For example, at a health fair in New Mexico earlier this year, dozens of attendees were potentially exposed to blood borne pathogens when fingerstick devices were reused to conduct diabetes screening. Recommendations Anyone performing fingerstick procedures should review the following recommendations to ensure that they are not placing persons in their care at risk for infection. ? Fingerstick devices should never be used for more than one person. ? Auto-disabling single-use fingerstick devices should be used for assisted monitoring of blood glucose. These recommendations apply not only to licensed healthcare facilities but also to any setting where fingerstick procedures are performed, including assisted living or residential care facilities, skilled nursing facilities, clinics, health fairs, shelters, detention facilities, senior centers, schools, and camps. Protection from infections, including blood borne pathogens, is a basic requirement and expectation anywhere healthcare is provided." The facility submitted an action plan to remove the immediacy dated 10/05/11 to the regional office consisting of the following actions: 1) Removing all lancet pen device(s) for single use from the carriers used for supplies, medication room, medication carts and from central supply and placed in the bio-hazard room on 10/05/11 by 3:30 p.m.. 2) The Medical Director, was notified on 10/05/11 at 10:31 a.m. regarding the potential risk of exposure to Hepatitis C via multi-use of a lancet device on other diabetic residents. Medical Director was again notified of possible exposure to MRSA and E.coli through the same means and requested further advisement on testing that may be required. Nursing staff will follow additional orders as notified by physicians. 3) An incident report was completed on all residents with a [DIAGNOSES REDACTED]. The primary physicians, families and residents will be notified per our Policy and Procedure. This will be completed by 10/05/11. 4) All staff has been in-serviced by Director of Nursing and or designee on 10/05/11 at 2:00 p.m. and 4:30 p.m. and or before returning to work on proper use of lancet devices. All staff has been in-serviced on Infection Control and the spread of pathogens, and Universal Precautions to prevent the spread of disease. All staff has been given a post test on in-service and must score 80 or above to show they understand subject and material they were in-serviced on. This action plan was verified to have been completed on 10/05/11 at 4:54 p.m. as follows: 1) One-time-use disposable lancing devices are on hand in medication cart, treatment cart and supply totes. 2) No lancet pen devices were found in the medication cart, the medication room, supply totes or central supply. 3) In services were conducted with the facility nurses at 10/05/11 regarding not using lancing pen devices for finger sticks due the possibility of residents being exposed to blood borne pathogens. 4) Interviews were conducted on 10/05/11 with facility nurses to confirm that in services were conducted and nurses understood what type of lancing device to use and the rational for not using a lancing pen device on multiple residents. While the IJ was lowered on 10/06/11 at 9:43 a.m., the facility remained out of compliance at a severity level of potential for more than minimal harm that is not Immediate Jeopardy and a scope of Pattern as the facility must monitor their action plan over time to ensure that the corrections for this issue are effective. There were 14 diabetic residents requiring use of a lancing device to obtain blood by fingerstick for blood glucose testing according to the list provided by the facility DON on 10/05/11 at approximately 9:55 a.m.