Every finding on record at Forest Acres Post Acute

Based on observation, interview, record review, and facility policy review, the facility failed to maintain an effective pest control program involving Residents (R)7, R13, and R34, for 3 of 28 sampled residents. Findings included: Review of a facility policy titled, Pest Control, revised 06/2026, indicated, Our facility shall maintain an effective pest control program. Review of an admission Record revealed the facility admitted R7 on 09/04/2024. According to the admission Record, the resident had a medical history that included but was not limited to a diagnosis of paraplegia. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/12/2026, revealed R7 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Review of an admission Record revealed the facility admitted R13 on 04/09/2025. According to the admission Record, the resident had a medical history that included but was not limited to a diagnosis of hemiplegia and hemiparesis following cerebral infarction. Review of a quarterly MDS, with an ARD of 04/21/2026, revealed R13 had a BIMS score of 15 out of 15, which indicated the resident had intact cognition. During a concurrent observation and interview on 07/13/2026 at 11:27 AM, R7 stated their room had cockroaches present since their admission. R7 stated they killed cockroaches daily and found cockroaches in their bed and on their face. The surveyor noted there was a cockroach crawling on the baseboard near the air conditioning unit in the resident's room. During a concurrent observation, of R7's room, and interview on 07/13/2026 at 11:40 AM, Licensed Practical Nurse (LPN)6 was asked to move a fall mat propped against the wall close to the observed cockroach. LPN6 verified it was a cockroach that was observed. The surveyor noted there were more than 10 cockroaches of various sizes crawling near the base board and on the floor where the fall mat had been propped against the wall. R7 stated the blankets must be shaken out to prevent the cockroaches from getting on them. During an interview on 07/13/2026 at 11:43 AM, Certified Nursing Assistant (CNA)7 acknowledged the presence of cockroaches in R7's room. During an interview on 07/13/2026 at 11:46 AM, the Administrator acknowledged she was not aware of the issue and stated there should not be pests in the residents' rooms. During an interview on 07/13/2026 at 2:34 PM, R13, who shared a room with R34, stated they informed the therapy and facility staff that there were cockroaches in their room. R13 stated the cockroaches were bad at night in the bathroom, and they always had to look before they used the toilet. R13 stated their family purchased them bug spray and traps to keep in their room. During an interview on 07/13/2026 at 2:54 PM, R7 stated the facility staff knew about the cockroaches. R7 stated the roaches made them feel uncomfortable and paranoid and expressed concern that a roach could be on their legs, and they would not know because they were paralyzed in their lower extremities. During an interview on 07/14/2026 at 3:17 PM, R13's family member (FM) acknowledged they saw cockroaches in the resident's room. R13's FM stated the resident was upset about the cockroaches, and the cockroaches were more active at night. During an interview on 07/15/2026 at 11:16 AM, Physical Therapy Assistant 15 stated R13 reported there were cockroaches in their room at night. During an interview on 07/15/2026 at 2:30 PM, LPN6 acknowledged the cockroaches had been present in R7 and R13's room and she reported the concern to the Maintenance Director. LPN6 acknowledged that on 07/13/2026 was the first time she had ever seen the cockroaches be that bad in the resident's room. During an interview on 07/15/2026 at 11:14 AM, CNA10 stated she had to kill roaches in R7 and R13's room. During an interview on 07/15/2026 at 3:23 PM, the Maintenance Director stated about a month ago, CNA7 told him about cockroaches in R7 and R13's room. During an interview on 07/16/2026 at 2:31 PM, the Director of Rehabilitation stated R13 expressed concerns with cockroaches being in their room. During an interview on 07/16/2026 at 3:00 PM, the Housekeeping Supervisor acknowledged roaches had been present in numerous rooms on the 1st floor to include R7 and R13's room. During an interview on 07/17/2026 at 11:48 AM, the Director of Nursing acknowledged pests should not be in a resident's room.Review of an admission Record revealed the facility admitted R34 on 06/23/2026. According to the admission Record, the resident had a medical history that included but was not limited to a diagnosis of end stage renal disease. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/30/2026, revealed R34 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident had intact cognition. During a concurrent interview and observation of R34's room on 07/14/2026 at 8:45 AM, the surveyor noted there were two roaches crawling around the toilet. R34 stated that while being assisted with care in their room, there had been multiple sightings of roaches in the bathroom and sleeping area. R34 stated the nursing staff had been made aware of the roach presence in their room. During an observation of the bathroom that adjoined R34's room on 07/16/2026 at 9:10 AM, multiple roaches scattered out of the torn opening in the middle of the floor. During an interview on 07/16/2026 at 11:13 AM, CNA10 confirmed the presence of roaches in the facility and stated the facility had an ongoing pest problem. During an interview on 07/16/2026 at 11:57 AM, the Maintenance Director stated he was not aware of roach sighting in the bathroom as no one had reported the problem to him.

Based on interview, record review, and facility policy review, the facility failed to refer Resident (R)89 and R90 to the appropriate state-designated authority for a Level II preadmission screening and resident review (PASARR) evaluation and determination when the resident was diagnosed with a new mental illness diagnosis for 2 of 3 sampled residents reviewed for PASARR. Findings include: Review of a facility policy titled, PASARR, revised 03/2019, indicated, 1. All individuals are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review process. The policy specified, c. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (l) The nurse notifies the social services department/designee when a resident is identified as having a possible (or evident) MD, ID or RD. (2) The social worker/designee is responsible for making referrals to the appropriate state-designated authority. 1. Review of an admission Record indicated the facility admitted R90 on 01/30/2019 . According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of bipolar disorder and generalized anxiety disorder. Per the admission Record, R90 received a diagnosis of delusional disorder on 02/19/2020 and depression on 10/01/2021. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2026, revealed R90 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had active diagnoses to include anxiety disorder, depression, bipolar disorder, and psychotic disorder. Review of R90's medical record revealed no evidence the facility referred the resident to the appropriate state-designated authority for a Level II PASARR evaluation and determination when the resident was diagnosed with delusional disorder on 02/19/2020 and depression on 10/01/2021. During an interview on 07/16/2026 at 10:34 AM, the Social Services Director (SSD) stated she began working in the facility in 11/2025. The SSD stated if a resident had a new serious mental illness diagnosis during their stay she would add it to their current PASARR in the system and resubmit it to the state. The SSD stated for residents who had been in the facility prior to 11/2025, she would review their PASARRs during the resident's quarterly care plan meeting to ensure the PASARR was up to date and to determine if any changes needed to be made. The SSD stated she was in the process of reviewing R90's PASARR. Per the SSD, since she began working in the facility, R90 had a quarterly care plan meeting, but she did not review the resident's PASARR. The SSD acknowledged R90 should have had another PASARR when the resident was diagnosed with delusional disorder and depression. During an interview on 07/17/2026 at 12:28 PM, the Director of Nursing stated she deferred PASARR questions to the SSD. During an interview on 07/17/2026 at 3:04 PM, the Administrator stated R90 did have some new diagnoses and she was unsure why the resident's PASARR was not updated. The Administrator stated the facility hired a new SSD and she might have missed the resident's new mental illness diagnoses. During a follow-up interview on 07/17/2026 at 3:58 PM, the Administrator stated she reviewed R90's medical record and reported the resident did have qualifying diagnoses that should have been added to their PASARR Level I for resubmission but it was missed.2. Review of an admission Record indicated the facility admitted R89 on 02/03/2020. According to the admission Record, the resident had a medical history that included but was not limited to a diagnosis of type 2 diabetes mellitus. Per the admission Record, R89 received a diagnosis of bipolar disorder and anxiety disorder on 08/01/2025. Review of R89's Care Plan Report, included a focus area initiated on 01/19/2026, that indicated the resident was at risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social or spiritual well-being, related to diagnoses of major depressive disorder, bipolar disorder, and anxiety. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 04/26/2026, revealed R89 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had active diagnoses to include anxiety disorder, depression, and bipolar disorder. Review of R89's medical record revealed no evidence the facility referred the resident to the appropriate state-designated authority for a Level II PASARR evaluation and determination when the resident was diagnosed with bipolar disorder on 08/01/2025. During an interview on 07/16/2026 at 10:34 AM, the Social Services Director (SSD) stated she began working in the facility in 11/2025. The SSD stated if a resident had a new serious mental illness diagnosis during their stay she would add it to their current PASARR in the system and resubmit it to the state. The SSD stated for residents who had been in the facility prior to 11/2025, she would review their PASARRs during the resident's quarterly care plan meeting to ensure the PASARR was up to date and to determine if any changes needed to be made. Per the SSD, since she began working in the facility, Resident #90 had a quarterly care plan meeting on 05/06/2026, but she did not review the resident's diagnoses or PASARR. The SSD acknowledged Resident #89 should have had another PASARR when the resident was diagnosed with bipolar disorder on 08/01/2025. During an interview on 07/16/2026 at 12:44 PM, the Director of Nursing stated she deferred all questions related to the completion of a PASARR to the Administrator, but expected the SSD to follow the facility practice for the completion of PASARRs. During an interview on 07/17/2026 at 8:37 AM, the Administrator stated if a resident obtained a relevant diagnosis after admission, the relevant diagnosis should be added to the PASARR and resubmitted to the state. The Administrator stated R89's new diagnosis of bipolar disorder should have been added to the PASARR in 08/2025 and resubmitted to the state.

Based on observation, interview, record review, and facility policy review, the facility failed to provide nail care for Resident (R)9 and R86), for 2 of 3 sampled residents reviewed for activities of daily living. Findings included: Review of a facility policy titled, Fingernails/Toenails, Care of, revised 02/2018, indicated, Purpose The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 1. Review of an admission Record revealed the facility admitted R9 on 04/30/2026. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of type 2 diabetes mellitus with hyperglycemia, muscle weakness, depression, lack of coordination, and weakness. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/02/2026, revealed R9 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident had moderate cognitive impairment. The MDS indicated R9 required substantial/maximal assistance with personal hygiene. During a concurrent observation and interview on 07/13/2026 at 10:36 AM, R9's fingernails on their left hand were long, with a brown substance underneath the nails. R9 stated their fingernails had not been cleaned or trimmed. During a concurrent observation and interview on 07/13/2026 at 2:23 PM, R9 had long fingernails on their left hand, with a brown substance underneath the nails. R9 stated the staff had not offered to clean their nails. During an observation on 07/14/2026 at 10:03 AM, 07/15/2026 at 9:43 AM, 07/16/2026 at 11:10 AM, and 07/17/2026 at 9:04 AM, R9 had long nails on their left hand, with a brown substance underneath the nails. During an interview on 07/15/2026 at 2:30 PM, Licensed Practical Nurse (LPN)6, assigned to care for R9, stated nurses were responsible for the cutting of a resident's nails who had diabetes and the certified nursing assistants (CNA) were responsible for ensuring a resident's nails were clean. LPN6 stated she was unaware that R9 needed nail care. During an interview on 07/17/2026 at 12:08 PM, the Director of Nursing (DON) stated she expected a registered nurse to cut and/or trim the nails of a resident who had diabetes and for the CNAs to clean a resident's nails as needed. During a concurrent interview and observation on 07/17/2026 at 3:45 PM, the DON observed R9's nails on their left hand and stated nail care should be provided for R9. During an interview on 07/17/2026 at 3:45 PM, the Administrator stated she expected the nursing staff to monitor a resident with diabetes nails and to resolve any concerns identified. 2. Review of an admission Record revealed the facility admitted R86 on 05/22/2026. According to the admission Record, the resident had a medical history that included but was not limited to a diagnosis of heart failure. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date of 06/02/2026, revealed R86 had a Brief Interview for Mental Status score of 13 out of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for personal hygiene. Review of R86's Care Plan Report included a focus area initiated on 05/24/2026, that indicated the resident was at risk for activity of daily living/mobility decline and required assistance related to a diagnosis of heart failure. During a concurrent observation and interview on 07/14/2026 at 10:07 AM, R86 was in their room and the resident's fingernails were observed at a length that extended one quarter inch to one half inch beyond the tip of the nailbed, with debris underneath the nails. R86 stated they would like to have their fingernails trimmed. According to R86, they told staff that their fingernails needed to be trimmed. During an observation on 07/15/2026 at 9:39 AM and 07/15/2026 at 12:58 PM, R86 was in their room and the resident's fingernails were observed at a length that extended one quarter inch to one half inch beyond the tip of the nailbed, with debris underneath the nails. During a concurrent observation and interview on 07/15/2026 at 2:45 PM, R86 was lying in their bed and the resident's fingernails extended one quarter to one half inch beyond the tip of the nailbed. Certified Nursing Assistant (CNA)2 stated she noticed the length of the resident's fingernails, but did not offer nail care and did not report the length of the resident's nails to the nurse. During an concurrent interview and observation on 07/15/2026 at 2:47 PM, Licensed Practical Nurse (LPN)1 observed R86's fingernails and stated the resident's nail on their thumb and third finger of the resident's right hand needed to be trimmed, and the first four fingernails on the left hand should be trimmed. LPN1 stated that since R86 was not a diabetic, staff should offer to trim the resident's fingernails. During an interview on 07/16/2026 at 12:50 PM, the Director of Nursing stated she expected staff to offer nail care, and if a resident refused the refusal should be documented. During an interview on 07/17/2026 at 9:16 AM, the Administrator stated nail care should be provided with baths/showers if the care was needed. The Administrator stated that staff should ask the resident if they wanted the care, and if there was no contraindication with the scope of practice the staff member should provide the care. The Administrator stated she expected staff to offer nail care if the staff noticed a resident's nails were too long.

Based on observation, interview, record review, and facility policy review, the facility failed to provide Resident (R)89 enteral tube feeding formula as ordered and failed to label the tube feeding formula bottle with the resident's name, date, time, and infusion rate for 1 of 3 sampled residents reviewed for tube feeding. Findings included: Review of a facility policy titled, Enteral Nutrition, revised 11/2018, indicated, Adequate nutritional support through enteral nutrition is provided to residents as ordered. Review of an admission Record revealed the facility admitted R89 on 02/03/2020. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of dysphagia and attention to gastrostomy. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 04/26/2026, indicated R89 had a Brief Interview for Mental Status score of 0 out of 15, which indicated the resident has severe cognitive impairment. The MDS indicated eating was not attempted due to a medical condition or safety concerns and the resident had a feeding tube. Review of R89's Care Plan Report, included a focus area initiated 02/21/2025, that indicated the resident needed a feeding tube and had a potential for complications of a feeding tube use related to a diagnosis of dysphagia due to cerebrovascular accident. Interventions directed the staff to administer the tube feeding formula, hydration, and flushes per order (initiated 02/11/2025). Review of R89's Order Summary Report with active orders as of 07/15/2026, revealed an order dated 07/25/2025, for enteral feed order every shift of Glucerna 1.5 by way of a gastrostomy tube at 65 milliliters per hour (mL/hr). Per the order, the enteral feed order should infuse daily from 8:00 PM until 1430 mL had been infused. Review of R89's medication administration record for the timeframe 07/01/2026 - 07/31/2026, revealed no evidence to indicate the staff documented/monitored the amount of tube feeding formula infused during each shift. During an observation on 07/14/2026 at 5:00 PM, R89 was observed lying in bed, with the head of the bed elevated and their enteral tube feeding of Glucerna 1.5 infusing at 65 ml/hr. During an observation on 07/15/2026 at 12:25 PM, R89 was observed lying in bed, with the head of the bed elevated and no enteral tube feeding of Glucerna 1.5 was infusing. During a concurrent observation and interview on 07/15/2026 at 9:33 PM, R89 was observed lying in bed, with the head of the bed elevated and no enteral tube feeding of Glucerna 1.5 was infusing. Licensed Practical Nurse (LPN)5 stated R89's enteral tube feeding did not infuse for two hours during her shift from 7:00 PM to 7:00 AM that began on 07/15/2026. LPN5 reviewed the physician's orders for R89 and stated R89 had a physician's order to start Glucerna 1.5 at 8:00 PM. LPN5 stated she would start the enteral tube feeding late since it was already 9:40 PM because she did not check the physician's orders for R89 when she started the shift at 7:00 PM. During a concurrent interview and observation on 07/16/2026 at 9:45 AM, the Director of Nursing (DON) observed the enteral tube feeding for R89 and noted the tube feeding formula bottle did not contain the resident's name, date and time the product was hung by the nurse, and the infusion rate. The DON stated she expected the nurse to record that information on the bottle of enteral tube feeding formula. During an interview on 07/16/2026 at 11:30 AM, the Registered Dietician stated he expected nursing staff to follow the physician's order that specified R89 should receive 1430 mL of enteral tube feeding formula per day for nutritional support. During a follow-up interview on 07/16/2026 at 12:25 PM, the DON stated she expected the nurse to read and follow the physician's order and verify the amount of enteral tube feeding formula infused based on the remaining product in the bottle and the amount infused as recorded on the pump. During an interview on 07/17/2026 at 8:37 AM, the Administrator stated nursing staff should follow the physician's order to provide the enteral tube feeding formula as ordered.

Based on interview, record review, and facility policy review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) Level 1 Screening was accurate for one (Resident (R) 114) of four residents reviewed for PASARR. This created a potential failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate prior to admission. Findings include: Review of R114's undated Admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, schizophrenia, and major depressive disorder. R114 did not have a diagnosis of dementia or intellectual disability. Review of R114's Orders located in the EMR under the Orders tab indicated the resident was prescribed doxepin for depression, sertraline for depression, and aripiprazole for paranoid schizophrenia. Review of R114's Care Plan dated 03/25/25, located in the EMR under the Care Plan tab revealed Psychosocial- Well-being: Resident is at risk for psychosocial well-being concerns related to anxiety, diagnosis of Depression, Schizophrenia. Goal: Will have psychosocial needs Met and will minimize risk for decline in mood and behavior/psychosocial well-being. Interventions included Encourage friends and family to visit and observe for tearfulness, increased agitation, and decreased participation in care. Review of R114's PASARR Level I form provided by the facility, dated 03/18/25, documented R114 did not have a diagnosis of mental illness and was not prescribed any psychotropic medications. During an interview on 05/14/25 at 1:52 PM with the Social Service Director (SSD), the SSD confirmed R114's PASARR Level I was inaccurate and stated, I don't know how I let that one slip through. The SSD said the process is once the PASARR is uploaded it is reviewed to ensure it matches with the diagnoses. If it is inaccurate then she would resubmit it for review of PASARR level II. During an interview on 05/14/25 at 2:27 PM with the Administrator, the Administrator revealed he expected the residents' PASARRs to be audited on admission to ensure they are accurate, and services are provided.

Based on review of the facility policy, record reviews, and interviews, the facility failed to ensure Resident (R)78 was free from neglect. Specifically, the facility failed to properly assess and provide care and services to prevent the loss of a limb for 1 of 1 residents. On 02/14/24 at 5:49 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 02/14/24 at 5:49 PM, the Administrator and the Director of Nursing (DON) were notified that failure to provide care and services for a resident to prevent the loss of a limb constituted Immediate Jeopardy (IJ) at F600. On 02/14/24 at 5:49 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 11/10/23. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 02/15/24 at 1:13 PM, the facility presented an acceptable IJ Removal Plan. On 02/15/24 at 5:00 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F600 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Recertification Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, states under Policy Statement, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Review of the facility policy titled, Abuse and Neglect -Clinical Protocol, states, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Also abuse includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well- being. 2. Neglect as defined means, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of R78's Face Sheet revealed R78 was admitted to the facility on [DATE] with diagnoses including, but not limited to: right below knee amputation, severe protein calorie malnutrition, muscle wasting and atrophy, type 2 diabetes mellitus and lack of coordination. Review of R78's medical record revealed R78 was hospitalized from 02/04/24 through 02/13/24, due to the neglect of the facility to provide care and services to prevent skin breakdown, deterioration of the muscle, bone exposure and loss of his left lower extremity. R78 received a left, below the knee amputation on 02/06/24. It is documented that R78 was walking with a prosthesis when admitted to the facility on [DATE]. Further review revealed, R78 was able to get to the restroom on his own, and bath himself. R78 would also change his bed linens, and bag the soiled linen. It was also documented that R78 liked to wear a sock on his left leg. The Hospital Report dated 02/04/24 at 3:52 PM documented, the facility reportedly noticed the wound today after removing his socks which he had on for a week, signed by the emergency room physician. Review of R78's Skin Worksheets revealed the following: a Skin Worksheet dated 11/10/23 which indicated the left lower extremity is discolored. No open areas. On 11/25/23 the Skin Worksheet revealed discoloration to the left lower extremity. The Skin Worksheet dated 12/09/23, 12/16/23 and 01/06/24 indicates no discoloration or open areas to R78's left lower extremity. Review of the Skin Worksheet dated 01/27/24 which is titled, Body Audit, indicated dry skin to R78's lower left extremity, still no open areas documented. Review of the Skin Worksheet dated 02/03/24 indicated a wound to R78's left lower extremity, and documents that the Nurse Practitioner (NP) needs to look at it. At this time it is open. R78 sent out to hospital on 02/04/24 and his left leg is amputated below the knee on 02/06/24. Review of R78's Comprehensive Plan of Care dated 09/26/23, revealed a focus area, Activities of Daily Living (ADL) self care deficit related to physical limitations. The goal states, Will receive assistance necessary to meet ADL needs, dated 09/26/23. Interventions include: Acknowledge the patients right to refuse care/services but continue to offer assistance as needed, dated 10/25/23. Assist to bathe/shower as needed. dated 09/26/23. Assist with daily hygiene, grooming, dressing, oral care and eating as needed, dated 09/26/23. Resident is sometimes non-compliant with assistance. Provide education about the risks associated with the denial of services, dated 02/04/24. Resident's preference is to remain independent for ADLs not allowing anyone to see his skin, dated 02/04/24. Further review of the Plan of Care revealed another focus area: At risk for alteration in skin integrity related to impaired mobility, bowel incontinence, and indwelling catheter, dated 09/22/23. Resident does not have use of Foley catheter. The goal states, Skin will remain intact, free from erythema, breakdown, excoriation, or bruising. The interventions include. Encourage to reposition as needed; use assistive devices as needed, dated 10/05/23. Observe skin condition with ADL care daily; report abnormalities, dated 10/05/23. Resident's preference is to remain independent for ADLs not allowing anyone to see his skin. Provide education about the risks associated with the denial of services, dated 02/04/24. Review of R78's Nurses note dated 02/04/24 at 12:01 PM states, Resident has an open wound on his left foot showing bone or tendon, will send him out to the hospital. Review of R78's Nurses Note dated 02/04/24 at 12:45 PM states, Late entry from yesterday, 02/03/2024. Resident asked the janitor to take his sock off which he had on for one week. Janitor tried but the sock was stuck to the resident's left lower extremity. The janitor told me that the resident wanted me to cut his sock off. I looked at it and it was stuck. I removed the sock by putting saline on it. I notified the Nurse Practitioner, she advised to put it in the Provider's Book, which I did. Resident wanted to get another sock on it. I advised him not to. I advised that I will wrap it up. I cleansed the wound with wound cleanser, patted it dry with gauze. Soaked gauze with betadine and covered the wound with it and wrapped the wound with kerlex gauze bandage wrap. Review of R78's Progress Notes revealed progress notes revealed the following: 09/26/24, Under skin assessment it states, Inspection and palpation, no rash, right stump excoriation, hyperpigmented lower extremities dark in color. Left medial scar from the groin to the lower leg. Hypopigmented vitiligo noted to the chest, back and neck. On 10/02/23 at 10:30 AM seen by NP2, and the skin assessment states, Inspection and palpation, no rash, lesions or jaundice, nails normal. On 10/08/23 at 9:45 AM seen by NP2, skin assessment states, Inspection and palpation, no rash, lesions, or jaundice. Nails, normal. On 10/10/23 at 3:45 PM seen by NP3, skin assessment states, Inspection and palpation, no jaundice. Nails normal. On 10/14/23 at 3:30 PM seen by NP3, skin assessment states, Inspection and palpation, good turgor and no jaundice. Nails normal. On 10/16/23 at 8:45 AM seen by NP2, skin assessment states, Inspection and palpation, no rashes or jaundice. Nails normal. On 10/28/23 at 4:16 PM seen by NP2, skin assessment states, Inspection and palpation, no jaundice. Nails normal. On 11/01/23 at 11:15 AM seen by NP2, skin assessment states, Inspection and palpation, no rash, lesions, or jaundice. Nails normal. On 11/15/23 at 9:15 AM seen by the Physician. skin assessment states, Inspection and palpation, no rash, hyperpigmented lower extremities dark in color. Left medial scar from the groin to the lower leg. Hypopigmented vitiligo noted to the chest back and neck. On 01/13/24 at 12:00 PM seen by NP2, skin assessment states, Inspection and palpation, no lesions, jaundice, or rash. Nails normal. On 01/25/24 at 12:30 PM seen by NP2, skin assessment states, Inspection and palpation, no lesions, jaundice, or rash. Nails normal. On 01/27/24 at 10:45 AM seen by NP2, skin assessment states, Inspection and palpation, no lesions, jaundice, or rash. Nails normal. On 01/28/24 at 11:15 AM seen by NP2, skin assessment states, Inspection and palpation, no lesions, jaundice, or rash. Nails normal. On 01/28/24 at 3:15 PM seen by NP1, skin assessment states, Inspection and palpation, no lesions, jaundice or rash. Nails normal. On 02/04/24 at 2:45 PM seen by NP1, no skin assessment documented on progress note. Resident sent out to the hospital for evaluation of left lower extremity. No documentation could be found to ensure any of the nurse practitioners had looked at R78's left lower extremity. During an interview on 02/14/24 at 8:00 AM, R78, when asked about the care he is receiving, stated, No, they are not doing anything for me. During the interview R78 continued to reiterate that the facility staff were not taking care of him. During an interview on 02/14/24 at 10:55 AM, the Wound Care Nurse stated, He [R78] was admitted in September, and he did not have any sores or wounds on his leg. The Wound Care Nurse further stated, His [R78] leg was discolored on admission, he [R78] was not getting any treatments to his left leg at all. During an interview on 02/14/24 at 11:45 AM, Registered Nurse Unit Manager (RN1) stated that R78 was ok on admission and R78 had no skin issues. RN1 further stated the facility was in the process of changing from paper to the computer system at that time. RN1 concluded that the resident would refuse care at times. RN1 stated, He [R78] would not let us look at his body nor his foot. During an interview on 02/14/24 at 12:58 PM, Licensed Practical Nurse (LPN)2 stated she did a body audit on 01/20/24. LPN1 revealed that R78 refused to let her check his left lower extremity. LPN1 stated she documented it under the skin and comprehensive assessments. LPN1 further stated that R78 would let her look at his bottom and privates but not his feet. LPN1 concluded that she did not tell anyone about his refusals. During an interview on 02/14/24 at 1:03 PM, Certified Nursing Assistant (CNA)1 revealed that she has worked at this facility for [AGE] years and has been a CNA for three years. CNA1 stated they would just set up his bath water and sometimes he would agree to go to the shower. CNA1 further stated there were no wound or sores on his left leg or foot. CNA1 stated his leg was skinny and she noticed no odor. CNA1 concluded, If I tried to wash him he would say that he could do it himself. During an interview on 02/14/24 at 1:09 PM, CNA2 revealed that she has worked at this facility for [AGE] years. CNA2 stated that R78 had no complaints of pain, he would get himself up every day with no assistance and get into a wheel chair. CNA2 stated she did notice that his leg was skinny, but had no odor. She stated that he would not let you see his body, he wanted to do everything for himself. During an interview at an unspecified date and time, the Nurse Practitioner (NP)1 stated that no one had told her that there was a new wound, once they reported it I saw him the next day. NP1 denies any odor and that most of the time he was up in the wheel chair with a blanket over his head. He had no fever at all. NP1 stated that they do an annual head to toe assessments. NP1 mentioned a communication book at the desk and there was no documentation of a new wound documented in the book for this resident. NP1 further stated the resident will decline help from staff and ask them to get out of his room. He can be nasty. He did not get looked at completely due to his behaviors. He has not been seen by psych and she stated she does not know his background. During an interview on 02/15/24 at 11:50 PM, NP2 stated she had not physically seen the resident's foot at all. She stated it was a vascular issue, no odor at all. NP2 went on to say that monthly and annually the doctor or the nurse practitioner will look at their skin and do a head-to-toe assessment. NP2 concluded the staff and techs will bring any acute skin issues to their attention by writing it in a communication book at the desk and then the physician will address any issues. During an interview on 02/15/24 at 2:20 PM, the attending Physician who is also the Medical Director (MD), stated that when he saw the resident's left leg it was only discolored, no open wounds or odor. The MD stated he first saw his left lower extremity on 09/26/24 when the resident was first admitted . He also mentioned the communication book at the nurse's desk, and stated that if the nurse sees any skin issues they will write it in the communication book. He went on to say that the nurse practitioner sees the residents more than he does. On 02/15/24 at 1:13 PM, the facility provided an acceptable Allegation of Compliance which documented the following: Immediate actions taken: NP was notified of the wound once staff were aware and she evaluated and resident was sent to the ER for further evaluation. Investigation was initiated immediately into the development of the wound and lack of documentation. QAPI initiated to address lack of documentation regarding, his skin assessments, his preferences, and refusals to allow staff to assess his skin and lack of care planning of his preferences and refusals. 100% audit of all residents in the facility complete on 02/05/2024 to ensure there were not other wounds in the facility that staff were unaware of. Educations initiated on 02/24/2024 for all licensed nurses and CNAs regarding skin assessments, baths, and assessing skin during baths, ensure baths are given as scheduled, ensuring resident refusals and preferences are all care planned appropriately. ADHOC QA Meeting held on 02/15/2024. Members present: Administrator, Director of Nursing, Regional Director of Clinical Services, the Social Services Director, the MDS, Care Plan Coordinator, and the Medical Director. Root cause of issue related to wound development and staff unaware: lack of documentation in medical record to support resident refusals to allow staff to assist with bathing or dressing or to assess his skin and lack of documentation on his care plan related to his refusals or his preferences. Audits of 100% of residents in facility completed on 02/05/2024 to ensure no other wounds in facility that staff were unaware of. There were no new wounds identified. Education was initiated with all licensed nurses and CNAs to include completion of body audits, documentation of refusals and resident preferences to include care planning. MDS education, completion of shower sheets to be completed by the CNA with each bath/shower. Education to ensure nurses and CNAs document any and all refusals of care as well as preferences. Any nurses left at this point will receive the education prior to next shift worked. Education initiated with 100% of staff on 02/14/2024 to review abuse and neglect policy and reporting. Any staff who were unable to be reached will have education complete prior to next shift worked. Audits will be complete M-Fri by the administrative nursing team to maintain a master list of residents and their bath schedules to ensure baths given as scheduled and that shower sheets were complete by CNA and any f/u was obtained. Review of all body audits that were due the previous day will be reviewed daily Monday through Friday during the daily clinical meeting by the Administrative to ensure that they were complete and any f/u needed was complete. Review of the eTAR will be reviewed daily during clinical meeting by Administrative nursing team for discrepancies and or missing documentation. Any refusals or variances in skin integrity noted on body audits and or shower sheets will be f/u to ensure any notifications and or communication needed with provider or nursing management and any further education needed for staff. QAPI committee will meet weekly to ensure all data from the previous week will be reviewed to determine effectiveness of the initial education and of the ongoing action plan. Documentation of this meeting should include the names of all parties present, topics that were discussed, minutes and any action items that were created as a result of a particular meeting. Administrator along with QAPI committee will determine need for continued monitoring and any adjustments needed to the plan. The above components have been implemented and complete as of 02/15/2024 by 10:00 AM.

Based on observations, interviews and review of facility policy, the facility failed to ensure proper temperature of the food was maintained upon delivery to residents rooms. Furthermore, the facility failed to ensure food was appetizing and palatable. Findings include: Review of the facility policy titled Food and Nutrition Services (Revised October 2017) states, .each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preference of each resident. Food and Nutrition Services, 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. During an observation on 02/13/24 at 1:00 PM, of a test tray, after the last tray was served, revealed food temperatures taken by the Dietary Manager (DM). The results are as follows: Potatoes - 130 degrees Fahrenheit, Broccoli - 120 degrees Fahrenheit, and mechanical chopped chicken - 125 degrees Fahrenheit. During an interview on 02/15/24 at 8:18 AM, the DM revealed they have a new Director of Nurses (DON) and Administrator, and they will work together to assist with the issue of proper food temperatures. The DM revealed as soon as trays hit the unit, Certified Nurses Assistants (CNAs) should start passing them out to residents. If no one immediately starts passing trays the temperature of the food will drop if not immediately passed out. The DM also revealed she would speak with the Administrator and DON to work on the process of getting drinks poured in the kitchen prior to passing trays on the halls. The DM stated they use to have them announce when trays were on the hall, but no longer do this. The DM further stated they could possibly start announcing this again so all hands can be on deck. The DM concluded the temperature of the food that was taken on 02/13/24 was down because it took a while for them to pass trays.

Based on observation, interview, and review of facility policy, the facility failed to ensure an ongoing antibiotic stewardship program. Findings include: Review of facility policy titled Antibiotic Stewardship (Revised December 2016) states Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Antibiotic Stewardship, 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. 5. When a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic /anti-infective orders. 11. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if the antibiotic therapy should be started, continued, modified, or discontinued. 12. Before a nurse removes and antibiotic from the facility emergency supply of medication, he or she will check for the right drug, right strength, allergy information and use of warfarin, along with the following: a. The nurse will contact the pharmacist if not familiar with the antibiotic dose or drug-drug interactions; b. The pharmacy removal slip for the dose(s) removed will be completed; and c. As soon as clinically appropriate, the prescriber will be asked to review converting parenteral antibiotics to an oral formulation. Review of the facility policy titled, Infections-Clinical Protocol (Revised March 2018) states Monitoring and Follow-up, 1. The nursing staff and physician or provider will monitor the progress of a resident with an infection until it is resolved (i.e., no further significant clinical signs or symptoms). 6. The physician or provider will evaluate the duration of any antibiotic treatment and will identify whether antibiotics can be stopped (for example, if an individual with an uncomplicated infection is afebrile and asymptomatic at least 48 hours). 7. The physician or provider will identify and address possible complications of antibiotic treatment including adverse drug reactions, allergic reactions, drug interactions, and antibiotic-related colitis or diarrhea. During an interview on 02/15/24 at 9:12 AM, the Infection Control Preventionist (ICP) revealed, I started last January and switched jobs in August. The Director of Nursing has been doing it since the change. The previous DON did it from August until she quit at the end of October or beginning of November and the new DON took over in December. The ICP revealed she and the Social Worker completed documentation after the previous DON left and before the new DON started. When the new company took over there was no way to track because we only had Point Click Care, PCC. The ICP stated, I stopped monitoring in August when I changed jobs, the previous DON was monitoring, I am not sure where the papers are. I don't do infection tracking because I am the unit manager now. During an interview on 02/15/24 9:43 AM, the Director of Nursing (DON) confirmed that the ICP is the person who is the certified ICP for the facility. The DON stated that there is no one else certified and that no one is consistently assigned to monitor infection control at this time. In regard to missing documentation in the tracking and trending of all infection's notebook, The DON stated that the ICP was the interim DON when she got here and was responsible for that as well. The DON reviewed the notebooks provided by the ICP and stated that they should contain infection control tracking, trending, and monitoring and agreed that there was no documentation since July of 2023.

Based on review of facility policy, observations and interviews, the facility failed to ensure medications and biological's, that were expired, were removed from medication carts and treatment carts. The expired medications were observed in 3 of 5 medication carts and in 1 of 1 treatment cart. Findings include: Review of the undated facility policy titled, Medication and Labeling and Storage, states, Medication Storage: 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated or deteriorated medications or biological's, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. During an observation on 02/12/24 at 12:10 PM, of the treatment cart on the back hall revealed: One tube Skintegrity Hydrogel 4 ounces, manufactured by Medline expired on 07/2023. One bottle of AMT Wound Care 2 ounces with Lot #15038-01 expired on 12/2023. One bottle of Anti-perspirant 1.5 ounces, Manufactured by Medline with Lot #60538 expired on 10/2023. One bottle of Anti-perspirant 1.5 ounces, Manufactured by Medline with Lot #60440 expired on 10/2023. One bottle of Anti-perspirant 1.5 ounces, Manufactured by Medline with Lot #60692 expired on 11/2023. One jar of Hydrocortisone Cream 1 pound, with Lot #LL2336 expired on 08/2023. Curity Plain Packing Strips with Lot #18E110162 expired on 04/2023. Comfitel Silicone Contact Layer Dressing, 6 dressings 3 x 4 with Lot #E20160127 expired 01/26/2021. Opticell 4.25 x 4.25 squares, sterile, Manufactured by Medline with Lot #W056844 opened and placed back on the treatment cart for use and no longer sterile. Skintegrity Hydrogel 2 x 2 squares, Manufactured by Medline with Lot #18475 expired on 08/2022. One Curad Xeroform Petrolatum Dressing with Lot #6052236004, sterile, opened and partially used and placed back on the treatment cart for use and no longer sterile. During an interview on 02/12/24 at 12:15 PM, the Director of Nursing (DON) confirmed the above biological's and medications were expired and removed from the treatment cart. During an observation on 02/12/24 at 1:00 PM, of the Hall 1 back medication cart revealed the following: One bottle of Bisacodyl 5 milligrams tablets Manufactured by Gericare with Lot #441V02 expired on 01/24/2024. One box of Even Care Glucose Control Solution, Manufactured by Medline with Level 1 and Level 3 solution was opened on 09/2023. The package insert states, Discard any unused control solution 90 days after first opening or after expiration date, whichever comes first. The medications and biological's on the Hall 1 back medication cart were confirmed as expired and removed from the cart by Registered Nurse (RN)2. Due to incomplete review of the Hall 1 back medication cart on 02/12/24, a continuation of the review on 02/14/24 at 6:47 AM of the cart revealed: One bottle of Calcium Citrate 100 coated tablets with Lot #13286 expired on 01/24/2024. One Glargine Insulin pen was opened and in use with no open date. During an interview on 02/14/24 7:00 AM, Licensed Practical Nurse (LPN)4 confirmed the expired medication and the insulin pen with no open date and removed them from the medication cart. During an observation on 02/14/24 at 7:30 AM of the Hall 2 front/back cart revealed the following: One bottle of Timolol 22.3-68.1 eye drops was expired on 01/27/2024 and still in use for the resident receiving them. The box was wet due to the leaking eye drops and the label was also wet. The expired eye drops were confirmed by LPN2 and removed from the medication cart.

Based on record reviews and interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for Resident (R)80 for dialysis for 1 of 1 resident. The facility further failed to ensure 2 assessments were coded correctly and no missing OBRA assessments for Resident A and Resident B for 2 of 2 residents reviewed on a monthly missing OBRA assessment report. Findings include: Review of the transmission report for Resident A and Resident B indicated a warning, monthly, on the missing OBRA assessment report for the facility. The discrepancies were not corrected, so the error kept occurring on the missing assessment report month after month when the report was generated by the facility. During an interview on 02/15/24 at 10:45 AM, the MDS Assessment Coordinator stated that the two names kept coming up on the, Missing OBRA Assessment, report monthly, but she could not figure out why or what the discrepancy was. She stated that today, 02/15/24, the MDS regional nurse was in the facility and she had her to look at it, and it was corrected.

Based on observations, record reviews and interviews the facility failed to ensure Resident #167 (167) was free from unnecessary psychotropic medications for 1 of 5 residents reviewed for unnecessary medications. The findings included: The facility admitted R167, a [AGE] year old, with diagnoses including, but not limited to, dementia without behavioral disturbance, hematemesis, conjunctivitis of the right eye and diabetes mellitus type 2. No other diagnoses were listed in the medical record for R167. An observation on 02/13/2024 at 09:21 PM revealed R167 in a hospital gown, resting in bed. An observation on 02/14/2024 at 10:15 AM revealed R167 in a hospital gown, resting in bed. An observation on 02/15/2024 at 03:45 PM revealed R167 in a hospital gown, resting in bed. Review on 02/13/2024 at 12:03 PM of the physician orders for R167 included: Haloperidol (Haldol) 2 milligrams q6 hours as needed for agitation ordered 01/29/2024. Haloperidol (Haldol) 2 milligrams by mouth 2 times daily. Lorazepam 0.5 milliliters by mouth every 4 hours as needed for anxiety. Morphine 0.25 milliliters (5 milligrams) tid (3 times daily), maximum daily amount is 15 milligrams. Morphine 0.25 milliliters every 4 hours as needed for pain maximum daily amount is 30 milligrams. Zofran 4 milligrams by mouth, disintegrating tablet every 8 hours. Prilosec 40 milligrams by mouth 2 times daily before a meal. No behaviors and no pain documented in the medical record for R167. During an interview on 02/14/2024 at 04:12 PM with the Medical Director and he stated that this resident is PACE, a resident that a room is rented by the hospital and their physicians see those residents. So he could not speak to the unnecessary medications for R167. Review of the behavior and pain monitoring for R167, revealed no documentation of any behaviors nor any pain.

Based on review of facility policy, observations, interviews, and record review, the facility failed to ensure a medication error rate less than 5 percent. Specifically, an insulin pen was not primed prior to administering 4 units of insulin and an insulin pen was not primed correctly prior to administration. The medication error rate is 7.41 percent for 2 of 27 opportunities for error. Findings include: Review of the undated facility policy titled, Administering Medications, states under the Policy Statement, Medications are administered in a safe and timely manner, and as prescribed. Review of the Lispro Insulin package insert states, The pen must be primed before each injection to make sure the pen is ready to dose. It is important to make sure insulin comes out, and is visualized when the dose button is pressed and the air is removed. To properly prime the insulin pen, remove the cover and wipe the hub with an alcohol wipe. Apply a needle and remove the cover. Holding the pen vertically, dial 2 units and press the dose button, make sure you see insulin escape the needle. If you do not see insulin escape the needle, dial 2 more units and press the dose button. Continue at least 3 times and if you still do not see insulin escape the needle then replace the needle and start the process of priming over again. Once the pen is primed, dial up the correct dose. Then you are ready to administer the insulin. During an observation on 02/14/24 at 8:00 AM, revealed Licensed Practical Nurse (LPN)6 failed to prime the insulin pen before administering the 4 units as ordered with meals, 3 times daily. During an interview on 02/14/24 at approximately 8:00 AM, LPN6 stated that she did not know that she needed to prime the pen each time insulin was administered. LPN6 stated that she thought it was only primed the first time the insulin pen was used. During an observation on 02/14/24 at 8:40 AM, revealed LPN2 failed to correctly prime an insulin pen. LPN2 took the cap off the pen, applied the needle and then dialed up 2 units and held the pen horizontally and did not watch to see if insulin escaped the needle. During an interview on 02/14/24 at approximately 8:40 AM, LPN2 confirmed that she had not primed the insulin pen correctly.

Based on observations, interviews, and review of facility policy, the facility failed to follow sanitation and proper food handling to prevent foodborne illnesses. Specifically, the facility failed to ensure the ice scoop was covered and not left in the container of ice. Furthermore, during the lunch meal, brownies and mandarin oranges were not covered during transport to resident's room. Findings include: Review of the undated facility policy titled Meal Distribution states, Meals are transported to the dining locations in a manner that ensures proper temperature, maintenance, protects against contamination, and are delivered in a timely and accurate manner. Meal Distribution, 3. All foods that are transported to dining areas that are not adjacent to the kitchens will be covered. During an observation of lunch service on 02/13/24 revealed the following: At 12:56 PM, an uncovered plate of brownie was taken from the cart and delivered to room [ROOM NUMBER] approximately 15 feet down the hallway. At 12:58 PM, Certified Nursing Assistant (CNA)4 delivered a lunch tray with an uncovered brownie to room [ROOM NUMBER] approximately 24 feet down hallway. At 12:59 PM, CNA4 used a plastic scoop that was left inside a plastic container that contained ice/water. At 1:03 PM, a tray with a dessert bowl of mandarin oranges was uncovered and taken to room [ROOM NUMBER] approximately 24 feet down the hallway. During an interview on 02/13/24 at 1:04 PM, CNA4 stated that the plastic ice scoop should not be left in the container of ice and that she should have disinfected her hands between scooping ice and delivering resident's lunch trays, which could cause cross contamination. CNA4 indicated that she had disinfected her hands between delivering trays. During an interview on 02/15/24 at 8:18 AM, Dietary Manager (DM) revealed the rack with desserts could be Saran wrapped and the entire dessert cart if there was not a top on it. The DM further stated, I can see taking it from the cart to the room uncovered is an issue, so going forward we will make sure the desserts are covered prior to taking them to the hall.

Based on review of facility policy, observations and interviews, the facility failed to ensure staff used proper hand hygiene during meal service, for 1 of 2 observations of meal service. Findings include: 49800 Review of the facility policy titled, Handwashing/Hand Hygiene, (Revised October 2023) states, This facility considers hand hygiene the primary means to prevent the spread of healthcare- associated infections. Indications for Hand Hygiene, 1. Hand hygiene is indicated: e. after touching the resident's environment; 2. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations. During an observation on 02/13/24 at 12:52 PM, Certified Nursing Assistant (CNA)4 delivered a food tray to room [ROOM NUMBER]-2. CNA4 did not practice proper hand hygiene prior to taking the food tray in or scooping ice into glass for tea. During an observation on 02/13/24 at 12:59 PM, CNA4 did not practice proper hand hygiene after delivering a food tray to room [ROOM NUMBER] and prior to using plastic scoop that was left inside the resident's room. During an interview on 02/13/24 at 1:04 PM, CNA4 revealed the plastic scoop should not be left in the container of ice and that she should have practiced proper hand hygiene between scooping ice and delivering residents lunch trays, which could cause cross contamination. CNA4 indicated that she had disinfected her hands between delivering lunch trays. 49818

Based on review of the facility policy, record review, and interviews, the facility failed to treat Resident (R)2 and their Resident Representative (RR) with dignity and respect. 1 of 2 residents reviewed for dignity. Findings include: Review of the facility's undated policy titled, Respect, Dignity, Right to have Personal Property revealed the resident has a right to be treated with respect and dignity. R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to; type 2 diabetes, congestive heart failure, and chronic kidney disease. Review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/22 revealed R2 has a Brief Interview of Mental Status (BIMS) score of 6 out of 15, indicating cognitive impairment. An interview on 03/16/23 at 12:05 PM with R2 revealed At this time right now, I currently have no issues with staff at the facility, but in the past have had issues with a nurse, (Licensed Practical Nurse (LPN)1). She would provide me care, but always would have a bad attitude about caring for me. It's been several times that she has been disrespectful to me. I told my RR about it and she came to the facility and LPN1 was rude to her in front of me as well. After that incident, my RR filed a complaint with the facility and LPN1 is no longer allowed to work on this unit. A phone interview on 03/16/23 at 1:20 PM with R2's RR revealed, I've been on the phone with R2 and have overheard LPN1 speak in a disrespectful tone towards R2. There have also been times where I called the facility to get updates about R2's care because she was behaving strangely. When R2 acts like that, she normally has a urinary tract infection(UTI). When I asked about this before, LPN1 was rude to me on the phone as well and laughing with other staff members instead of talking with me. I live out of state, but when I got a chance to visit R2, I also got to speak with LPN1 and she was disrespectful towards me as well, while R2 was in the room. I was trying to follow up about some medications for R2 and LPN1 was rude to me and walked away from me while I was trying to ask basic questions. I told Administration about LPN1 and since they are no longer allowed to work with R2, I am okay. However, I worry about how LPN1 speaks to other residents in the facility. An interview on 03/16/23 at 3:10 PM with LPN1 revealed that they could recall having a conversation with R2's RR and denied all accusations of being rude to the RR, R2, or any other residents at the facility. During the exit of the interview, LPN1 stated in a rude tone I don't know why you are asking me about this, that woman does not know what she is talking about because she has dementia and is confused. LPN1 then proceeded to slam the door of the conference room and shouted loudly in a rude tone to another staff member I didn't even do anything. Review of a witness statement written by LPN1, dated 02/23/23 at 2:22 PM revealed She asked if the resident had a UTI or had a lot discharge and I told her that there was nothing that I observed, but I completed an order for a Urine Analysis (UA). The door was closed, I stayed in the room, and told her I would let the Doctor know. I might have been talking to someone else and caught me off guard (when asked if laughing with other staff while on phone calls with Resident Representatives). An interview on 03/16/23 at 5:49 PM with the Administrator and Director of Nursing (DON) revealed that staff are expected to treat residents and their representatives with dignity. The DON and Administrator further stated that during staff interviews, they determined LPN1 had been rude/disrespectful to other staff at the facility and placed LPN1 under a verbal warning related to her professionalism.

Based on observations, record reviews and interviews, the facility failed to assure that commodes were working in two resident bathrooms for 1 of 3 Residents (R) reviewed during the complaint survey. Findings include: R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to osteomyelitis and overactive bladder. R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to urea cycle metabolism disorder and Alzheimer's disease. On 1/23/23 at approximately 10:40 AM, during initial tour, a random check of bathrooms revealed that the bathroom commodes of R1 and R2 were not flushing. R1 stated that she had repeatedly told staff that the commode occasionally flushes once and then runs, taking forever to fill the tank before being able to flush again. R2 stated that he did not remember how long since his bathroom commode would flush, that he had told staff about the problem but it has never been fixed. R2 stated that he usually uses a bathroom elsewhere in the facility, or just uses his commode even though it will not flush. On 1/23/23 at approximately 12:43 PM, the commodes for R1 and R2 were checked again by the Surveyor and neither commode was flushing. On 1/23/23 approximately 1:03 PM, the Maintenance Director stated that when he finds out about a commode problem, he sometimes writes it down on a piece of paper or someone has entered into TELS (a building management platform). In either case a record of repairs is not retained. On 1/23/23 at approximately 1:13 PM, the Maintenance Director and Surveyor went to the bathroom for R2 and found fecal matter and toilet tissue in the commode. The Maintenance Director was unable to make the commode flush and stated that it was broken. On 1/23/23 at approximately 1:19 PM, the Maintenance Director and Surveyor went to the bathroom for R1 and found the commode running, but not filling the tank with water and the Maintenance Director stated that the fill mechanism was broken or not attached. On 1/23/23 at approximately 2:19 PM, the Maintenance Director had not provided repair records for either of these two commodes, although he recalled having worked on the commode in bathroom of R1. On 1/23/23 at approximately 1:24 PM, the Administrator stated that needed repairs are either recorded in a book at the nursing stations or entered into TELS, but was unsure how records were otherwise maintained or if the book was being used.

Based on observations, interviews and review of the facility's Meal Service policy, the facility failed to ensure that staff knocked on resident's door for permission prior to entering the Resident's room. 1 of 2 units observed. The findings include: A random observation on 10/26/20 at approximately 12:05 PM revealed a Certified Nursing Aide enter room [ROOM NUMBER] without knocking and a Licensed Practical Nurse enter room [ROOM NUMBER] without knocking. An interview on 10/26/20 at approximately 12:11 PM with Certified Nursing Aide (CNA)#2 revealed the CNA acknowledged he/she entered the resident's room without knocking and stated the resident was a little hard of hearing. An interview with Licensed Practical Nurse (LPN) #1 revealed the LPN acknowledged he/she entered the resident's room without knocking because the resident could see him/her from the door. An observation on 10/27/20 at approximately 3:31 PM revealed a staff member entering room [ROOM NUMBER] without knocking. A interview on 10/27/20 at approximately 3:35 PM with CNA #3 revealed the CNA acknowledged he/she entered the resident's room without knocking and further stated he/she normally knock on the door and identify his/herself. A review of the facility's Meal Service policy, revealed under Procedure: In Patient room [ROOM NUMBER]. Knock on door, request entrance, and identify patient. Random observation on 10/28/20 at approximately 11:20 AM revealed CNA #1 entering room [ROOM NUMBER] without knocking. This was confirmed on interview with CNA #1.

Based on observations and interviews, the facility failed to ensure the high temperature dishwasher was at the appropriate temperature prior to washing the facility's dining ware and failed to ensure the unit refrigerators were free from black stains around door seal and sticky substances on shelves. 1 of 1 main kitchen and 2 of 3 unit refrigerators observed. Eighty-eight residents had the potential of being effected. The findings include: An observation and interview on 10/27/20 at approximately 2:14 PM revealed several industrial dish trays with dining ware had already gone through the high temp dishwasher. The dishwashing temperature on the machine was noted at 155 degrees. The Certified Dietary Manager (CDM) stated the hot washer temperature should have been at 160. The dish washer temperature remained at 155 degrees when two additional dish trays with glasses and plates had gone through. Two dishwashing staff and the Certified Dietary Manager (CDM) who were present during observation commented the gauge on the dishwasher was stuck. Neither the two dishwashing staff nor the CDM made an effort to re-wash the dining ware that had gone through the dishwasher at the temperature of 155 while the surveyor was present. Neither the CDM or two dishwashing staff verbally stated we need to re-wash the dining ware that had gone through. At approximately 3 PM, the CDM provided the manual for the high temperature dish washer that indicated the washing temperature should be at 160 degrees. An interview on 10/28/20 at approximately 8:06 AM with the CDM revealed Eco Lab had been monitoring the dishwasher temperature. The last documented Eco Lab visit was on March 2020 due to pandemic. The CDM confirmed the dishwasher was at 155 and further stated he/she nor staff indicated the dishes should have been rewashed after the dishwasher temperature got at 160 degrees. An observation and interview on 10/28/20 of the unit refrigerator on the 200 unit revealed a puddle of water on the glass shelves, small black specks in water puddles on the bottom shelf and red stain on back wall of the compact size refrigerator. Registered Nurse (RN) #2 confirmed the observation. RN #2 stated the nurses are responsible for checking the temperature and that house keeping was responsible for keeping the unit refrigerators clean. An observation and interview on 10/28/20 at approximately 8:23 AM with the Maintenance/Housekeeping Manager confirmed the observation and stated he/she cleans the unit refrigerators once a week but does not keep documentation on when he/she cleans them. An observation and interview on 10/28/20 at approximately 8:32 AM of the 100 unit back hall unit full size refrigerator revealed the sticky yellow substance on the back bottom shelf above the vegetable/fruit crisper, under the crisper there was a large amount of sticky discoloration and there was a black substance in and on/around the molding/rubber seal of the refrigerator door. RN #1 and House Keeping Aide #1 confirmed the observation.

Based on observations, staff interviews, the facility's policy entitled COVID-19 Policy/Plan for Facilities, record review, and review of staff screening logs, the facility failed to: 1) provide appropriate screening for one (1) of one (1) staff member and two (2) of two (2) transporters; 2) ensure isolation carts were stocked with personal protective equipment for three (3) of three (3) carts observed; 3) ensure one (1) of one (1) staff member (Employee #1) washed their hands when they entered and exited resident rooms to prevent the spread of infection; 4) ensure staff were aware of isolation precautions for one (1) of four (4) residents (Resident # 4); and 5) ensure six (6) of 43 residents remained six (6) feet apart and practiced social distancing. The finding included: 1. During an observation on 4/21/20 at 9:35 a.m., Employee #6 entered the facility without being screened. Employee #2 was responsible for screening visitors and staff. Two (2) ambulance employees (Transporter #1 and #2), came into the facility to transport a resident to an appointment. Employee #2 did not take either of the transporter's temperature and did not record answers to the screening questions. Transporter #1 requested his temperature be taken. There was no thermometers available to test temperatures. When a thermometer was provided, Employee #2 was unaware of how to operate the device. A review of the facility's COVID-19 Sign In/Out Log Form, for the above observations, revealed Employee #6 member's name, but no screening or temperature was recorded. In additon, the federal surveyor was not screened per the facility policy and CDC recommendations when she entered the facility. Review of the facility policy updated 3/28/20 entitled, COVID-19 Policy/Plan for Facilities revealed, Temperatures of staff will be taken with no person permitted to work with a temperature greater than 99.0. All staff will complete the Staff Log and be screened for potential concerns prior to reporting to resident areas. Staff logs now include temperatures at exit as well. During an interview with the Administrator and Director of Nursing (DON) on 4/21/20 at 1:00 p.m., the DON communicated staff had been trained to complete the screening questions and have their temperature taken every time they came into the facility. She said she expected the screening to be completed as required. 2. During the initial tour of facility on 4/21/20 at 10:03 a.m., Resident #'s 1, 2, and 3 doors were open. An isolation cart was outside each of the resident's rooms. The carts contained a stethescope and gloves. The cart outside Resident #1's room, also contained gowns. No additional personal protective equipment (PPE) was in the carts. There was a sign that read, See Nurse before entering room on the doors, but no signage indicating PPE should be worn in the room. Review of the medical records for Resident #'s 1, 2 and 3 revealed they were each on Contact Isolation. During an interview with the Infection Control (IC) Nurse on 4/21/20 at 10:35 a.m., she stated all isolation room doors should be kept closed, and all necessary PPE should be stored in the isolation carts. The IC Nurse indicated all residents that returned from a hospital stay were placed on droplet precautions. She further stated PPE was available and should be worn when caring for Resident #'s 1, 2, and 3. She added, the carts should have contained the necessary items. During an interview with the DON and the Administrator on 4/21/20 at 12:38 p.m., the DON said staff had been trained on isolation procedures. The DON indicated each resident on isolation precautions should have PPE outside their rooms and staff should wear the required items. 3. During an observation on the 200 front hallway on 4/21/20 at 11:35 a.m., Employee #1 entered Resident #1's room with a food tray. Employee #1 entered the room wearing only a mask. She repositioned Resident #1's bedside table using her bare hands, and placed the resident's meal tray on the table. She did not wash or sanitize her hands before or after she touched the table or before she left the room. She was observed delivering meal trays to seven (7) rooms. She did not wash/sanitize her hands before she entered or exited the rooms, or before she went into the next room to prevent the spread of infection. During an interview with the DON and the Administrator on 4/21/20 at 12:38 p.m., the DON said staff members were trained on the isolation procedures as well as handwashing procedures. The DON communicated she expected employess to wash and/or sanitize their hands. 4. Resident #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the tour of the Patient Under Investigation Unit (PUIU), on 4/21/20 at 11:15 a.m., an isolation cart was observed outside Resident #4's room. The cart contained a stethoscope and gowns in the top drawer and gloves on top of the cart. There was no other PPE in the cart. Employee #3 was observed entering and exiting Resident #4's room without wearing PPE. During an interview with Employee #3 on 11/21/20 at 11:20 a.m., the employee stated she was unsure what PPE was required when entering the resident's room and would need to follow up with the nurse. During an interview the charge nurse on the PUIU on 11/21/20 at 11:25 a.m., she stated she was unsure of the type PPE required for Resident #4 and would need to follow up. Failure to follow isolation precautions increases the risk of the spread of infection. During an interview with the DON and the Administrator on 4/21/20 at 12:38 p.m., the DON said staff should be aware of the isolation procedures for all residents. She further communicated the unit nurses should communicate with other staff members about resident specific requirements for PPE and the requirements should be followed. 5. During an observation on the first floor back unit at 4/21/20 at 10:50 a.m., six (6) residents were observed sitting approximately two to three feet apart from each other watching a television program. The residents did not wear a face mask, and did not perform hand hygiene after they touched chairs and tables in the room, which increased the risk for the spread of infection. During an interview with Employee #5 on 4/21/20 at 11:01 a.m., she confirmed the residents were sitting too close together, and the residents should practice social distancing. She further stated residents should have worn a mask when they were outside of their rooms. Review of the facility's educational training material revealed nursing staff members had been provided education related to Infection Control. Further review of the training material revealed residents could come out of their rooms, but should practice social distancing and remain six (6) feet apart, according to the guidance from the Centers for Disease Control. During an interview with the DON and Administrator on 4/21/20 at 1:20 p.m., revealed they were unaware staff were allowing residents to sit together in the television room area.

Based on record review and interview, the facility failed to ensure residents and/or their representatives received in writing and in a language they could understand the reason for transfer to the hospital for 2 of 3 residents reviewed for hospitalization . The facility failed to provide a written Notice of Transfer that included the reason for transfer for Residents #7 and #65. The findings included: The facility admitted Resident #7 on 11/2/18 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 3/31/19 indicated the facility transferred Resident #7 to the emergency room due to pneumonia. The resident was hospitalized and re-admitted to the facility on [DATE]. Further review of the medical record revealed Resident #7 was admitted to the hospital on [DATE] due to [MEDICAL CONDITION] activity with re-admission to the facility on [DATE]. There was no documentation in the medical record to indicate the facility sent a written Notice of Transfer with the resident or sent a written notification for the reason for the transfer to the resident's representative at the time of the transfers and admissions to the hospital. The surveyor requested documentation related to the written Transfer Notices for the hospitalization s. The facility provided a copy of a form entitled, Facility Initiated Discharge Letter indicating Resident #7 would be discharged [DATE] and 7/28/19 respectively. The form indicated this was a Notice of Discharge. Review of the form indicated the reason for the resident's transfer to the hospital was not included on the form. During an interview on 8/14/19 at approximately 12:30 PM, the Director of Nursing and Business Office Manager reviewed the forms and confirmed that this was the form the facility sent upon transfer, and no other written Notice of Transfer was provided. The facility admitted Resident #65 on 4/12/19 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 5/28/19 revealed the facility transferred Resident #65 to the hospital due to decreased blood pressure and oxygen level with increased heart rate and temperature. The facility readmitted Resident #65 on 6/6/19. Further review of the medical record indicated Resident #65 was admitted to the hospital on [DATE] due to abnormal vital signs with re-admission to the facility on [DATE]. There was no documentation in the medical record to indicate the facility sent a written Notice of Transfer with the resident or sent a written notification for the reason for the transfer to the resident's representative at the time of the transfers and admissions to the hospital. The facility provided a copy of a form entitled, Facility Initiated Discharge Letter which indicated Resident #65 would be discharged from the facility 4/9/19 and 7/28/19 respectively. The form indicated this was a Notice of Discharge. Review of the form indicated the reason for the resident's transfer to the hospital was not included on the form. During an interview on 8/14/19 at approximately 12:30 PM, the Director of Nursing and Business Office Manager reviewed the forms and confirmed that this was the form the facility sent upon transfer, and no other written Notice of Transfer was provided.

On the day of the complaint inspection, based on observations, interviews and record reviews the facility failed to ensure 1 of 3 resident's care plans were reviewed and revised with adequate interventions to prevent falls/injuries from occurring. Residents #1's care plan was not updated with adequate interventions to prevent injuries. The findings included: The facility admitted Resident #1 on 5/29/2009 with [DIAGNOSES REDACTED]. The resident's annual MDS (Minimum Data Set) dated 3/18/2010 and 3/18/2011 coded the resident as requiring total assistance with transfers and bed mobility with 2+ persons for support during those activities. She was coded as requiring total assistance with dressing, hygiene and bathing. The resident was coded as cognitively impaired with difficulty in decision-making. Review of the resident's nurse's notes dated 3/18/11 at 11 PM stated, "Resident fell out of bed and onto floor while CNA was providing care. CNA stated she rolled the resident to change her sheet and she kept rolling and fell to the floor face down... Resident was bleeding from laceration on corner of left eye... and hematoma on left side of forehead... MD (Medical Doctor) notified. Ordered Vitamin K shot in left thigh. Patient was sent out to hospital on 911 call." Resident #1 returned from the emergency roiagnom on [DATE] at 5:30 AM with a sutured laceration at the corner of her left eye. Review of the comprehensive care plan initiated 8/19/2010, failed to include in the approaches that the resident required 2-person assist with bed mobility. The approaches for the Activities of Daily Living (ADL) only included, "dependent on staff to bathe shower; dependent on staff with daily hygiene, grooming, dressing oral care; Mechanical lift." The CNA care tool failed to address the need for 2-person assist with bed mobility. Cross Refers to F-323 as it relates to the facility's failure to review and revise the care plan with appropriate interventions to prevent injuries.

On the day of the complaint inspection based on record review and interviews, the facility failed to provide supervision to prevent accidents for 1 of 3 residents reviewed for incidents/accidents. Resident #1 sustained a fall from her bed while receiving care from Certified Nursing Assistant (CNA) #1, certified on 1/24/2011 and employed by the facility 2/23/2011. CNA #1 was still in orientation when the incident occurred. The findings included: The facility admitted Resident #1 on 5/29/2009 with [DIAGNOSES REDACTED]. The resident's annual MDS (Minimum Data Set) dated 3/18/2010 and 3/18/2011 coded the resident as requiring total assistance with transfers and bed mobility with 2+ persons for support during those activities. She was coded as requiring total assistance with dressing, hygiene and bathing. The resident was coded as cognitively impaired with difficulty in decision-making. Review of the comprehensive care plan initiated 8/19/2010, failed to include in the approaches that the resident required 2-person assist with bed mobility. The approaches for the Activities of Daily Living (ADL) only included, "dependent on staff to bathe shower; dependent on staff with daily hygiene, grooming, dressing oral care; Mechanical lift." Review of the resident's nurse's notes dated 3/18/11 at 11 PM stated, "Resident fell out of bed and onto floor while CNA was providing care. CNA stated she rolled the resident to change her sheet and she kept rolling and fell to the floor face down... Resident was bleeding from laceration on corner of left eye... and hematoma on left side of forehead... MD (Medical Doctor) notified. Ordered Vitamin K shot in left thigh. Patient was sent out to hospital on 911 call." Resident #1 returned from the emergency roiagnom on [DATE] at 5:30 AM with a sutured laceration at the corner of her left eye. The physician progress notes [REDACTED]. Sent out to ER (emergency room ) due to head trauma while on Coumadin... 1. Hematoma L (left) forehead 2. Laceration to L forehead sutured by ER (emergency room ) 3. Hematoma to R (right) thigh." Review of the facility's conclusion of the investigation of the incident revealed, "...The CNA turned the resident to face the window. The CNA had the clean linen and brief underneath the resident's back. The CNA then walked around to the other side of the bed to turn the resident over. The resident rolled off the bed onto the floor... On 3/21/11 the CNA provided a demonstration of the incident. The ending result was the CNA did not ensure that there was enough room on the side once she turned the resident... The resident returned to the facility the same day with 4 sutures to the eye laceration. The resident was also placed on a wider mattress..." Review of CNA #1's employee file, revealed the CNA was certified on 1/24/2011 and hired by the facility on 2/23/2011. During an interview with the Administrator on 6/23/2011 at 9:00 AM, she stated the CNA was in orientation at the time of the incident. The Administrator stated the CNA's orientation had been extended to ensure the CNA met the facility's expectation related to patient care. In an interview with the surveyor on 6/30/2011at 7:45 AM CNA #1 confirmed that she was in training at the time of the incident. She stated that the CNA responsible for her training her was not in the room at the time of the incident. There were no witnesses to the incident. CNA #1 stated that Resident #1 was on her back and that she positioned her on her right side. "I was on her left side, as I was going around the right side, she rolled out of bed." CNA #1 was a newly certified CNA in orientation at the facility. At the time of the incident the CNA was not supervised when providing care for Resident #1 identified by the facility as needing the assistance of 2 people for bed mobility.

On the days of the complaint inspection, based on observations, record review and interviews, the facility failed to provide care that met professional standards of practice for 2 of 3 sampled residents reviewed for standards of practice related to urinary tract infections and for 4 of 4 sampled residents reviewed for standards of practice related to aspiration precautions. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Record review on 09/13/2010 revealed the following Nurse's Note: 08/13/2010 at 6:00 PM that stated, "Speech only slightly garbled today. Hx (history) UTI (urinary tract infection) in the past. New order received for UA/CS (urinalysis/culture and sensitivity) Stat in AM.... 08/14/201 at 6:50 AM In and out cath (catheterization) to obtain urine specimen for UA and CS STAT in AM; pt (patient) tolerated procedure well... 08/15/2010 at 2:00 PM Pt with garble speech appears confused unable to coordinate hands to mouth. Placing hands in plate rather than spoon to eat with. Chest congested. BP (blood pressure) 114/63 p (pulse) 68 R (respirations) 18 unlabored. MD (medical doctor) notified ordered [MEDICATION NAME] Bid (twice a day) and chest x-ray given. Schedule CT (computerized tomography) of head at hospital... Late entry for 08/15/2010 12:30 AM MD here to see resident... 08/16/2010 11:40 AM Resident unable to coordinate hand movement. Garbled like speech. Tongue hanging out of mouth. Resident not herself call RP (responsible party). RP would like for resident to be evaluated. MD notified. Resident sent to hospital..." Record review on 09/13/2010 of the hospital admission history and physical dated 08/16/2010 at 3:33 PM revealed an admission assessment and plan that stated, "Urinary tract infection..." On 09/13/2010 a review of the laboratory studies revealed no results for the STAT UA/CS ordered by the physician for the AM of 08/14/2010. In an interview with the surveyor on 09/14/2010 the Director of Care Delivery (DCD) for 1 Front stated that she had discovered that the urinalysis had not been done when she came in to work on Monday morning, 08/16/2010; that the urine was left in the refrigerator. The nursing staff failed to assure that the lab picked up the urine on 08/14/2010. The facility admitted Resident #3 on 07/31/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Review of the Lexington Medical Center urinalysis results dated 08/05/2010 had a note that stated, "wait for C and S". The culture and sensitivity results were available on 08/07/2010 but not obtained by the facility until 08/09/2010, treatment was started 2 days after the test results were available. In an interview with the surveyor on 09/14/2010 the DCD for 1 Front stated that she discovered that the hospice nurse carried the urine to the wrong lab and as soon as this was discovered the resident was treated. The DCD stated that the urinalysis results were usually received within 24 hours of the collection date and the culture/sensitivity results was received within 48 hours of the collection date. The nursing staff failed to followup on a urinalysis done on 08/05/2010 until 08/09/2010, four days after the urine was sent to the lab. As stated in paragraph one, the facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Observation on 09/13/2010 at approximately 3:00 PM of Resident #1's room revealed a white Styrofoam cup dated 09/11/2010 filled with water. In an interview with the surveyor on 09/13/2010 at 3:30 PM Licensed Practical Nurse #1 confirmed the date on the cup and the liquid. LPN #1 stated that a Speech Therapist had been working with Resident #1 and she was to have thickened liquids only. "The cup must have been left by the weekend staff." Record review on 09/13/2010 revealed a hospital transfer summary dated 08/23/2010 with discharge [DIAGNOSES REDACTED]. The physician ordered on [DATE] Speech-Language Pathology 5 days per week daily with precaution listed as aspiration; a pureed diet with nectar thick liquids was prescribed. Review of Resident #1's care plan revised 08/31/2010 listed as a focus area "Alteration in nutritional status r/t (related to) therapeutic mechanically altered diet with thicken liquids. On 09/14/2010 at 8:15 AM Resident #1 was observed in the dining room independently eating a pureed breakfast and drinking thicken water. The facility admitted Resident #2 on 03/10/2008 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed physician's orders [REDACTED]. Review of Resident #2's care plan revised 09/13/2010 listed as a focus area "History of weight loss r/t receives daily diuretic and has dx (diagnosis) of dysphagia..." On 09/14/2010 at 8:20 AM Resident #2 was observed in the dining room independently drinking thicken juice at breakfast. Additional review revealed the facility admitted Resident #3 on 07/31/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a telephone order dated 08/26/2010 for a pureed diet with nectar-like thick liquids. Review of Resident #3's care plan revised 08/26/2010 listed as a focus area "Nutrition: potential for weight loss related to dementia is also a diabetic; therapeutic mech (mechanically) alt (altered) diet with nectar thicken liquids..." On 09/13/2010 at approximately 3:15 PM Resident #3's granddaughter stated that her grandmother was unable to drink unassisted. The facility admitted Resident #4 on 05/19/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a physician's orders [REDACTED]. Review of Resident #4 care plan initiated 08/12/2010 listed as a focus area "Feeding tube use with potential for complications also received ordered liquids and PO (by mouth) diet..." On 09/14/2010 at 10:00 AM Resident #4 stated that he needed help with drinking and eating. Aspiration precautions were not care planned as a focus area for Residents #1, #2, #3 and #4 and observations on 09/13/2010 and 09/14/2010 revealed no system to identify residents who were at risk for aspiration. Review of the Certified Nurse Aide (CNA) Kardex failed to list Resident #1 as at risk for aspiration; Residents #2, #3 and #4 were noted on the CNA Kardex as at risk for aspiration. The PIW (patient intervention worksheet) used by the CNAs did not include aspiration precautions for Residents #1, #2, #3 and #4. In a face-to-face interview with the surveyor on 09/14/2010 at 1:00 PM Speech Therapist #1 stated that any resident receiving nectar thick liquids should be on aspiration precautions, that she taught the CNA individually about aspiration precautions when she worked with the residents. When asked if she taught every shift she stated, "No." The Speech Therapist stated she was concerned about posting information at the bedside due to it being personal information about the resident. In face-to-face interviews with the surveyor on 09/14/2010 CNAs #1, #2 and #3 stated they would position the resident upright and give them small bites. The CNAs could not recall an inservice related to aspiration precautions. In reviewing the CNA Kardex monitor with the surveyor CNA #3 was not sure if the CNA Kardex addressed aspiration precautions, until she saw aspiration precautions on the monitor.

On the days of the complaint inspection based on record review and interviews the facility failed to provide appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents reviewed for urinary tract infections. On 08/13/2010 the physician ordered a STAT urinalysis and culture/sensitivity for Resident #1 to be done on 08/14/2010; the urine obtained by an in and out catheterization was left in the refrigerator, the test was not performed and treatment was delayed. Resident #1 was admitted to the hospital on [DATE] with a urinary tract infection. Resident #3's with increased blood sugars and a low grade temperature had a urinalysis and culture/sensitivity done on 08/05/2010, which was carried to the wrong lab, treatment was delayed for 4 days. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Record review on 09/13/2010 revealed the following Nurse's Note: 08/13/2010 at 6:00 PM that stated, "Speech only slightly garbled today. Hx (history) UTI (urinary tract infection) in the past. New order received for UA/CS (urinalysis/culture and sensitivity) Stat in AM.... 08/14/201 at 6:50 AM In and out cath (catheterization) to obtain urine specimen for UA and CS state in AM; pt tolerated procedure well... 08/15/2010 at 2:00 PM Pt with garble speech appears confused unable to coordinate hands to mouth. Placing hands in plate rather than spoon to eat with. Chest congested. BP (blood pressure) 114/63 p (pulse) 68 R (respirations) 18 unlabored. MD notified ordered [MEDICATION NAME] Bid (twice a day) and chest x-ray given. Schedule CT of head at hospital... Late entry for 08/15/2010 12:30 AM MD here to see resident... 08/16/2010 11:40 AM Resident unable to coordinate hand movement. Garbled like speech. Tongue hanging out of mouth. Resident not herself call RP. RP would like for resident to be evaluated. MD notified. Resident sent to hospital..." Record review on 09/13/2010 of the hospital admission history and physical dated 08/16/2010 at 3:33 PM revealed an admission assessment and plan that stated, "Urinary tract infection. We will initiate [MEDICATION NAME]. The last two urine cultures had produced fluoroquinolone resistant species. The patient was given [MEDICATION NAME] in the ER, although these were both acceptable [MEDICATION NAME] given the patient's unspecified [MEDICATION NAME] history, we will refrain cephalosporins and initiate carbapenem therapy pending final culture. 2. Altered mental status secondary to problem 1..." On 09/13/2010 a review of the laboratory studies revealed no results for the UA/CS ordered by the physician STAT in the AM on 08/13/2010. In an interview with the surveyor on 09/14/2010 the Director of Care Delivery for 1 Front stated that she had discovered that the urinalysis had not been done when she came in to work on Monday morning, 08/16/2010; that the urine was left in the refrigerator. The facility admitted Resident #3 on 07/31/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Review of the Lexington Medical Center urinalysis results dated 08/05/2010 had a note that stated, "wait for C and S". The culture and sensitivity results were available on 08/07/2010 but not obtained by the facility until 08/09/2010, treatment was started 2 days after the test results were available. In an interview with the surveyor on 09/14/2010 the Director of Care Delivery for 1 Front stated that she discovered that the hospice nurse carried the urine to the wrong lab and as soon as this was discovered the resident was treated.