Every finding on record at Fountainbleau Lodge

Based on observation, interview, and record review, the facility failed to provide palatable, attractive food at safe and appetizing temperatures. This deficient practice had the potential to affect all residents in the facility. The facility's census was 30.Review of the facility's policy titled, Food Preparation and Service, revised November 2022, showed:- Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices;- Danger zone means temperatures above 41 degrees Fahrenheit ( F) and below 135 F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness;- Did not address holding/serving temperatures of food. During an interview on 09//02/25 at 2:40 P.M, Resident #8 said the food could be better and it was often served cold.During a group interview on 09/02/25 at 3:10 P.M., Resident #8, Resident #11, Resident #22, Resident #23, Resident #28, Resident #29, and Resident #36 said that their food was served cold when they ate in their room. During an interview on 09/04/25 at 10:46 A.M., Resident #5 said that his/her food was often served cold. He/She ordered two hot dogs on 09/01/25, and the hot dogs were cold. He/She ordered a grilled cheese sandwich on 09/02/25, and the cheese was not melted, and the sandwich was cold. Observation on 09/04/25 at 11:05 A.M., of a test tray with a lid to cover the food showed: - A grilled pork chop with a temperature of 112 F;- Stuffing with a temperature of 116 F. During an interview on 09/11/25 at 9:20 A.M., the Dietary Manager said he/she would expect hot food to be hot and at least a temperature of 135 F when served. No residents had reported the hot food was cold when served to them. During an interview on 09/04/25 at 1:45 P.M., the Director of Nursing (DON) and Administrator said they would expect hot food to be served hot.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for three residents (Residents #3, #14, and #23) out of 12 sampled residents. The facility census was 30. Review of the facility's policy titled, Resident Assessment, revised October 2023, showed: - Assessments are completed by staff members who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's strengths and areas of decline; - Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2024, showed: - Code all high-risk drug class medications according to their pharmacological classification, not how they are being used. 1. Review of Resident #3's medical record showed: - admission date of 07/31/25; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) with anxiety (persistent worry and fear about everyday situations); - An order for alprazolam (an antianxiety medication) 1 milligram (mg) by mouth every eight hours as needed for anxiety, dated 08/05/25; - No order for antipsychotic (medications that alter the brain chemistry to help reduce psychotic symptoms like hallucinations, delusions, and disordered thinking) medications. Review of the resident's admission MDS, dated [DATE], showed: - Resident received antipsychotic medications on a routine basis. 2. Review of Resident #14's medical record showed: - admitted on [DATE]; - Diagnoses of dementia, anxiety disorder, dysphagia (difficulty swallowing), major depressive disorder (long-term loss of pleasure or interest in life), and unspecified psychosis (a mental disorder with a severe loss of contact with reality); - An order for buspirone (an antianxiety medication) 5 mg by mouth twice a day for anxiety, dated 05/06/25; - An order for sertraline (an antidepressant medication) 25 mg by mouth daily for depression, dated 08/01/25; - An order to discontinue quetiapine (an antipsychotic medication) 25 mg, dated 06/12/25. Review of the resident's quarterly MDS, dated [DATE], showed: - Received an antipsychotic medication seven out of seven days. 3. Review of Resident #23's medical record showed: - admitted on [DATE]; - Diagnoses of heart failure (an inability of the heart to pump sufficient blood flow to meet the body's needs), anxiety disorder, depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), and dysphagia; - An order for venlafaxine (an antidepressant medication)150 mg by mouth every day for anxiety and depression, dated 05/15/25; - No order for an antipsychotic medication. Review of the resident's annual MDS, dated [DATE], showed: - Received an antipsychotic medication seven out of seven days. During an interview on 09/04/25 at 1:00 P.M., the MDS Coordinator said he/she incorrectly coded the MDS by the resident's diagnoses linked to the medications and not by the medication's drug class. During an interview on 09/04/25 at 1:01 P.M., the Administrator said she would expect medications to be coded accurately on the MDS.

Based on observation, interview, and record review, the facility staff failed to maintain appropriate infection control practices for two residents (Residents #6 and #35) out of five sampled residents. The facility census was 30. Review of the facility's policy titled, Enhanced Barrier Precautions, dated August 2022, showed: - Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multidrug-resistant organisms (MDROs) to residents; - EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply; - Examples of high-contact resident care activities are dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care; - EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Review of the facility's policy titled, Wound Care, dated October 2010, showed: - Use a disposable cloth to establish a clean field on the resident's overbed table; - Place all items to be used during the procedure on the clean field arranged so they can be easily reached; - Wash and dry your hands thoroughly; - Place a disposable cloth under the wound to serve as a barrier to protect the bed linen and other body sites; - Put on exam glove, loosen tape, and remove the dressing; - Pull the glove over the dressing and discard into an appropriate receptacle; - Wash and dry your hands thoroughly and put on gloves; - Use a no-touch technique by using sterile tongue blades and applicators to remove ointments and creams from their containers; - Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound; - Wear sterile gloves when physically touching the wound or holding a moist surface over the wound; - Apply treatment as indicated; - Dress the wound; - Discard the disposable items into the designated container; - Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container; - Remove disposable gloves and discard into a designated container; - Wash and dry your hands thoroughly. 1. Review of Resident #6's Physician Order Summary (POS), dated 09/09/25, showed: - An order to cleanse the gastrostomy tube (G-tube - a feeding tube inserted directly into the stomach through a small opening in the abdomen to deliver nutrition, fluids, and medication when a person cannot eat or drink by mouth) site with soap and water, place a drain sponge at the tube insertions site daily and as needed, dated 09/03/25; - An order for G-tube 60 milliliter (ml) water flush every shift, dated 07/18/25;- An order for EBP as an infection control method that involves wearing gowns and gloves during high-contact care activities to reduce the spread of MDROs related to G-tube, dated 05/29/25. Review of the resident's Care Plan, revised 09/03/25, showed: - On EBP related to the G-tube; - Staff are to follow facility EBP policy and procedure; - Maintain EBP policy for duration of the resident's stay or until the G-tube is discontinued. Observation on 09/03/25 at 1:40 P.M., of the resident's G-tube dressing change and water flush showed: - EBP signage on the resident's door; - Registered Nurse (RN) A did not put on a gown and leaned on the resident's bed to remove the soiled dressing, leaned on the resident's bed to clean around the G-tube, leaned on the resident's bed to place the new dressing, and leaned on the resident's bed to put a roll of tape into the resident's drawer; - RN A failed to wear a gown for high-contact resident care for a resident with an indwelling medical device. 2. Review of Resident #35's POS, dated 08/14/25, showed: - An order for to remove tubigrips (an elasticated tubular support bandage) and socks from the bilateral (both) lower extremities (BLE), wash BLE with mild soap and water, rinse, dry apply skin prep to the red areas, apply lotion to BLE, reapply clean tubigrips and socks every day shift for skin integrity, dated 08/14/25; - An order to clean the right calf wound, right foot wound, and left foot wound with normal saline (a solution of salt and water); apply the compounded antibiotic of clindamycin, mupirocin, and gentamicin per directions, cover with calcium alginate (a type of dressing), cover with a dry dressing change daily and as needed, dated 09/04/25. Observation on 09/03/25 at 10:30 A.M., of the resident's wound care showed: - EBP signage on the door; - RN A removed the soiled dressing on the left foot, did not change gloves, and did not perform hand hygiene, and reached into the clean bag of dressing supplies; - RN A did not change gloves, did not perform hand hygiene, and cleaned the left foot wound; - RN A did not change gloves, did not perform hand hygiene, applied with compounded antibiotic treatment to the wound; - RN A did not change gloves, did not perform hand hygiene, and applied a clean dressing to the wound. During an interview on 09/03/25 at 3:00 P.M., RN A said he/she knew who was on EBP by the signage on the door. Gloves and gown should be worn for EBP. During an interview on 09/04/25 at 1:45 P.M., the Administrator and the Director of Nursing (DON) said they would expect staff to wear gowns during high-contact care for a resident with a G-tube. They would expect staff to change gloves and perform hand hygiene after touching anything dirty.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross contamination and food-borne illnesses. This deficient practice had the potential to affect all residents. The facility's census was 29. Review of the facility's policy, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, revised November 2022, showed: - Food and nutrition service employees follow appropriate hand hygiene and sanitary procedures to prevent the spread of food borne illnesses; - All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing food-borne illnesses; - Employees must wash their hands whenever entering or re-entering the kitchen; - Before coming in contact with any food surfaces; - After handling soiled equipment or utensils; - After engaging in other activities that contaminate hands; - The use of disposable gloves does not substitute for proper handwashing; - Gloves are not required when distributing food to residents at dining tables or when assisting residents to eat, unless touching ready-to-eat food; - Did not address covering and labeling of food. Observations made on 08/06/24 and 08/08/24 between 11:50 A.M. and 12:40 P.M. showed: - Staff wore gloves and with the same gloves, touched door handles, residents' plates, and utensils; - Staff did not sanitize/wash hands between glove changes; - No sanitizer observed on counters or on walls; - Certified Nurse Aide (CNA) I assisted resident with eating, got up from the table, walked around the dining room and refilled other residents' cups, sat back down and continued to assist/feed resident without washing or sanitizing hands; - CNA O and CNA M received trays through the kitchen door, passed them while wearing gloves, returned for more trays, removed gloves, and did not sanitize/wash hands; - CNA M carried bowls with bare hands, with his/her thumbs tucked inside of the bowls; - Dietary Aide P, with gloved hands, took two trays (one in each hand), from the kitchen to the dining room, returned to obtain two more trays, wearing the same gloves, until told by another staff member to wash hands; - CNA N picked up a utensil from the floor, placed it on the bottom of the drink cart, did not wash or sanitize hands, obtained a clean utensil and provided it to the resident; - With bare hands, CNA N touched multiple residents' drink cups by the rim and touched the rim of the cups to the spout of the drink pitcher; - With bare hands, CNA N scooped ice from the ice bucket into multiple residents' cups for refills, touching the cups with the scoop. Observations on 08/07/24 at 3:50 P.M. showed: - A container of sliced tomatoes and onions in the refrigerator with no cover, label or date; - A squeeze bottle of red colored substance in the refrigerator with no label or date; - Two large pans of cooked bratwurst patties placed on top of the warmer, uncovered, with a fly buzzing over the top of them; - Two large trays of fruit cups, in the refrigerator, covered, but not labeled. During an interview on 08/08/24 at 10:30 A.M., the Maintenance Director, who said he/she helped in other areas when needed, said the food that had been placed on top of the warmer should have been covered. During an interview on 08/08/24 at 4:00 P.M., CNA M said there was no hand sanitizer in the dining room and if a resident would drop utensil on the floor, he/she would pick it up, put it away and get a new utensil. During an interview on 08/08/24 at 4:05 P.M., CNA N said there was only hand sanitizer on the walls, there was none in the dining room, but they wore gloves. He/She said that if a resident would drop a utensil on the floor, he/she would pick it up and get a new one. During an interview on 08/08/24 at 5:00 P.M., the Director of Nursing and Assistant Director of Nursing said they would expect hand sanitizer to be available for staff in dining room. The Administrator said staff should perform hand hygiene prior to passing trays, should not cross contaminate, when gloves are removed, hands should be washed before putting on clean gloves and food should be covered, labeled and food preparation area free from pests.

Based on interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for one resident (Resident #26) out of 12 sampled residents. The facility's census was 29. Review of the facility's policy, Comprehensive Person-Centered Care Plans, revised March 2022, showed: - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - The comprehensive, person-centered care plan includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; - Care plan interventions are chosen only after date gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making; - When possible, interventions address the underlying sources of the problem areas, not just the symptoms or triggers; - Assessments of residents are on-going and care plans are revised as information about the residents and the resident's conditions change. 1. Review of Resident #26's medical record showed: - admitted [DATE]; - Diagnoses of: hemaplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles) following nontraumatic intracerebral hemorrhage (bleeding in the brain) affecting right dominate side, cerebral infarction (disruptive bloodflow in the brain) acute kidney disease, (a condition in which the kidneys suddenly can not filter waste from the blood), and chronic kidney disease (long standing disease of the kidneys leading to renal failure); - Physician's Order Sheet (POS), dated 07/02/24, showed an order for dialysis, gather face sheet, POS and dialysis communication form, every night shift, on Tuesdays, Thursdays and Sundays. Review of Resident # 26's care plan, last revised 07/10/24, did not address dialysis. During an interview on 08/08/24 at 5:00 P.M., the Administrator and Director of Nursing said they would expect care plans to include treatments and any changes that may occur with orders or plan of care. 49879

Based on interview and record review, the facility failed to inform the resident and/or resident's representative, in writing, of the facility's bed hold policy at the time of transfer to the hospital for one resident (Resident #1) out of 12 sampled residents and one resident (Resident #13) outside the sample. The facility's census was 29. Review of the facility's Bed-Hold and Return policy, dated October 2022, showed: - Residents/Representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence; - Residents are provided written notices about these policies in advance of any transfer (admission) and at the time of transfer (if an emergency, within 24 hours); - The written bed-hold notices provided to residents/representatives, explain in detail, the duration of the state bed-hold policy, if any, during which the residents permitted to return and resume residence in facility. Review of the facility's Discharge to Hospital Protocol, undated, showed: - Obtain order to send to the hospital of choice for evaluation. Write a telephone order and order in the computer to send to emergency room (ER) for evaluation; - Under resident profile in electronic health record, print the transfer/discharge record to send to the hospital; - Under orders, print medication review sheet with current orders to send to hospital; - Send a purple copy of the purple cardstock Out of Hospital Do Not Resuscitate (DNR) form from the chart; - Have resident sign a copy of the Bed Hold Policy. If the resident is unable to sign this form, contact the responsible party and inform them of this policy. Please document on the form and in the nurses notes that the resident and/or responsible party were notified of this policy. A copy of the signed policy needs to go with the resident and a copy needs to be placed in the chart under admission records. 1. Review of Resident #1's medical record showed: - Transferred to the hospital on 02/25/24 and readmitted to the facility on [DATE]; - No documentation the Resident or Resident's Representative was informed in writing of the facility's bed hold policy at the time of transfer. 2. Review of Resident #13's medical record showed: - Transferred to the hospital on 03/04/24 and readmitted to the facility on [DATE]; - Transferred to the hospital on 05/23/24 and readmitted to the facility on [DATE]; - No documentation the Resident or Resident's Representative was informed in writing of the facility's bed hold policy at the time of transfer. During an interview on 08/08/24 at 10:38 A.M., Licensed Practical Nurse (LPN) A said when a resident is hospitalized , nursing staff complete a bed hold form for the family to sign and print out a transfer/discharge form from the electronic record to go to the hospital with them. Nursing staff also call the family and tell them the resident is being sent out. During an interview on 08/08/24 at 2:20 P.M., the Social Services Designee said the nurse should fill out the Skilled Nursing Facility Holding Room policy, which shows the transfer reason and bed hold policy. She will then look in the chart for documentation to make sure the nurse notified the family. She will then send a letter to the family within seven days which includes the transfer reason and bed hold policy. During an interview on 08/08/24 at 5:00 P.M., the Administrator said he/she would expect residents discharging to the hospital to have the bed hold papers sent per the regulations.

Based on interview and record review, the facility failed to ensure that Nurse Aide (NA) Registry checks were completed prior to the employment start date for seven employees out of a sample of ten employees and failed to ensure their policy addressed checking the NA Registry for all employees prior to employment. The facility also failed to follow their policy to ensure the Criminal Background Check (CBC), Employee Disqualification List (EDL) or Family Care Safety Registry (FCSR) were completed prior to the employment date for one employee out of a sample of ten employees. The facility's census was 29. Review of the facility's Compliance and Ethics-Screening Employees, Contractors and Volunteers policy, dated December 2020, showed: - Employees, contracted individuals and volunteers are screened for violations of fraud, abuse and/or ethics violations prior to employment or engagement; - Background screening and investigations are conducted prior to employment or engagement to ensure that employees, contractors and/or volunteers meet at least the following criteria: Competency evaluations have been met (through the state nurse aide registry for nurse aides). Review of the facility's Licensure, Certification, and Registration of Personnel policy, revised April 2007, showed: - Our facility conducts employment background screening checks, reference checks, license verification and criminal conviction investigation checks in accordance with current federal and state laws; -The policy did not address checking the nurse aide registry for employees other than nurse aides. 1. Review of Certified Medication Technician/Certified Nurse Aide (CMT/CNA) B's personnel file showed: - Hire date of 09/22/23; - The facility failed to check the NA Registry for CMT/CNA B prior to hire date. 2. Review of Housekeeper C's personnel file showed: - Hire date of 11/15/23; - The facility failed to check the NA Registry for Housekeeper C. 3. Review of Licensed Practical Nurse (LPN) D's personnel file showed: - Hire date of 11/28/23; - The facility failed to check the NA Registry for LPN D. 4. Review of Dietary Aide E's personnel file showed: - Hire date of 12/01/23; - The facility failed to check the CBC and EDL list prior to hire date, and failed to check the NA Registry for Dietary Aide E. 5. Review of Registered Nurse (RN) F's personnel file showed:- Hire date of 12/28/23; - The facility failed to check the NA Registry for RN F. 6. Review of LPN G's personnel file showed: - Hire date of 01/03/24; - The facility failed to check the NA Registry for LPN G. 7. Review of Dietary Aide H's personnel file showed: - Hire date of 02/23/24; - The facility failed to check the NA Registry for Dietary Aide H prior to hire date. During an interview on 08/07/24 at 3:35 P.M., the Director of Nursing (DON) said Human Resources (HR) checks the NA Registry and employees can't work until they are cleared. During an interview on 08/08/24 at 5:00 P.M., the Administrator said she would expect the NA Registry to be checked for all employees prior to hire and all employees to have a background check before they are hired.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital, including the reason for transfer, and failed to notify the Office of the State Long-Term Care Ombudsman for two residents (Resident #1 and Resident #15) out of 12 sampled residents and one resident (Resident #13) outside the sample. The facility's census was 29. Review of the facility's Transfer/Discharge policy, dated October 2022, showed: - Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility; - The Transfer/Discharge notice is given as soon as practicable but before the transfer or discharge when the health and/or safety of the individuals in the facility would be endangered due to the clinical or behavioral status of the resident, or an immediate transfer or discharge is required by the resident's urgent medical needs; - Notices are provided in a form and manner that the resident can understand; - Notices of Transfer are provided to the resident and/or resident's representative as soon as practicable before the transfer, and to the long-term care (LTC) Ombudsman when practicable. Review of the facility's Discharge to Hospital Protocol, undated, showed: - Obtain order to send to the hospital of choice for evaluation. Write a telephone order and order in the computer to send to emergency room (ER) for evaluation; - Under resident profile in electronic health record, print the transfer/discharge record to send to the hospital; - Under orders, print medication review sheet with current orders to send to hospital; - Send a purple copy of the purple cardstock Out of Hospital Do Not Resuscitate (DNR) form from the chart; - Have resident sign a copy of the Bed Hold Policy. If the resident is unable to sign this form, contact the responsible party and inform them of this policy. Please document on the form and in the nurses notes that the resident and/or responsible party were notified of this policy. A copy of the signed policy needs to go with the resident and a copy needs to be placed in the chart under admission records. 1. Review of Resident #1's medical record showed: - Transferred to the hospital on 02/25/24, and readmitted to the facility on [DATE]; - No documentation that the resident or resident's responsible party had been notified in writing. 2. Review of Resident #13's medical record showed: - Transferred to the hospital on 03/04/24, and readmitted to the facility on [DATE]; - Transferred to the hospital on 05/23/24, and readmitted to the facility on the same day; - No documentation that the resident or resident's responsible party had been notified in writing. 3. Review of Resident #15's medical record showed: - Transferred to the hospital on 08/01/24, and readmitted to the facility on [DATE]; - No documentation that the resident or resident's responsible party had been notified in writing. During an interview on 08/08/24 at 10:38 A.M., Licensed Practical Nurse (LPN) A said when a resident is hospitalized , nursing staff complete a bed hold form for the family to sign and print out a transfer/discharge form from the electronic record to go to the hospital with them. Nursing staff also call the family and tell them the resident is being sent out. During an interview on 08/08/24 at 2:20 P.M., the Social Services Designee said the nurse should fill out the Skilled Nursing Facility Holding Room policy, which shows the transfer reason and bed hold policy. She will then look in the chart for documentation to make sure the nurse notified the family. She will then send a letter to the family within seven days which includes the transfer reason and bed hold policy. During an interview on 08/08/24 at 5:00 P.M., the Administrator said he/she would expect notification of transfers to be sent per regulation. 46460

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during incontinent care for two residents (Resident #22 and #24) out of two sampled residents. The facility failed to develop and implement a risk management process specific to Legionnaires disease (a type of pneumonia caused by Legionella bacteria), which had the potential to affect all residents, staff and visitors. The facility's census was 29. Review of the facility's policy, Standard Precautions, revised September 2022, showed: - Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease; - Hand hygiene is performed with alcohol-based hand rub (ABHR) or soap and water before and after contact with resident; - Before moving from work on a soiled body site to a clean body site, on same resident; - After contact with items in resident rooms; - After removing gloves; - Hands are washed with soap and water when visibly soiled with dirt, blood or body fluids; - Gloves are worn when handling or touching resident-care equipment visibly soiled or potentially contaminated with blood, body fluids or infectious organisms; - Gloves are changed and hygiene performed before moving from a contaminated body site to a clean body site during resident care; - Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces and before going to another resident; - After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to other residents or environment. 1. Observation of Resident #22 on 08/08/24 at 1:44 P.M. showed: - Certified Nurse Aide (CNA) I and CNA J gathered a container of wipes and a clean brief, entered the Resident's room, and donned gloves without washing hands; - CNA I cleaned the resident's perineal area and placed the used wipe in a plastic bag; - While wearing the same gloves, CNA I reached into the wipes container and obtained another wipe, cleaned bowel movement (BM) off of the resident's buttocks and placed the wipe in the soiled brief; - With the same soiled gloves, CNA I obtained another wipe from the wipes container, cleaned the resident's buttocks area again, placed the used wipe in the soiled brief and folded the brief up; - CNA I rolled up the bed pad and soiled brief, tucked under the resident and did not wash hands or change gloves; - CNA J leaned over the resident with his/her long hair dangling down, touching the resident's legs and bed pad; - With the same soiled gloves, CNA I obtained a wipe from the wipes container, and cleaned the resident's perineal area again and his/her right leg fold; - With the same soiled gloves, CNA I picked up a tube of cream from the resident's table and applied the cream to the inner thighs of the resident; - With the same soiled gloves, CNA I and CNA J rolled the resident onto his/her right side. CNA J pulled out the soiled bed pad and brief, handed them to CNA I to place in bag, removed gloves, and did not wash hands; - With the same soiled gloves, CNA I and CNA J with bare hands, placed a clean brief on the resident and straightened the clean bed pad; - CNA I removed gloves and did not wash hands; - CNA I and CNA J left the room with a bag of soiled linens, trash and did not wash hands until placing in the shower room. During an interview on 08/08/24 at 2:10 P.M., CNA I said he/she would change gloves if they are soiled, if BM gets on them, and when finished with a soiled brief. He/She will change gloves when putting a clean brief on, and wash/sanitize hands before and after care. During an interview on 08/08/24 at 2:10 P.M., CNA J said he/she performs peri care, places clean linens if necessary, redresses resident, throws away trash, removes gloves, and washes/sanitizes hands. 2. Observation of Resident #24 on 08/08/24 at 10:50 A.M. showed: - CNA K gathered wipes and a clean brief, did not wash or sanitize hands prior to entering the room, and donned gloves; - CNA K removed blankets, lowered the resident's pants and folded down the soiled brief; - With the same soiled gloves, CNA K picked up the trash can and moved it closer to the bed; - With the same soiled gloves, CNA K removed four wipes from the container and laid them on the fitted sheet; - With the same soiled gloves, CNA K picked up a wipe from the bed, cleaned the resident's perineal area, repeated steps two more times, then tucked the used wipes into the soiled brief; - As CNA K leaned over the resident wearing a gait belt (a device used for assistance with transfers and walking), the strap was hanging loose and dangled onto the soiled brief on the bed during the duration of incontinent care; - CNA K removed his/her soiled gloves, did not wash or sanitize hands and donned clean gloves; - CNA K rolled the resident onto his/her left side, tucked the soiled brief down, reached for a wipe in the wipes container, cleaned BM off of the resident's buttocks, and reached back into the wipe container two more times to clean the resident's buttocks area; - CNA K tucked the used wipes into the soiled brief, rolled the brief up and placed in the trash can; - CNA K removed gloves, did not wash or sanitize hands, donned clean gloves, then placed a clean brief on the resident; - With the same gloves, CNA K pulled up the resident's pants, bagged the trash, touched the resident's shirt, and pulled the blankets up around his/her chest before washing hands. During an interview on 08/08/24 at 2:20 P.M., CNA K said when providing peri care, he/she puts gloves on and would change gloves after wiping the front, after wiping the back, and before putting on clean clothes. During an interview on 08/08/24 at 5:00 P.M., the Administrator and Director of Nursing said they would expect staff to change gloves and wash hands between dirty and clean and before leaving resident rooms. Review of the facility's policy, Legionella Water Management Program, revised September 2022, showed: - As part of the infection prevention and control program (IPCP), our facility has a water management program which is overseen by the water management team, including The Infection Preventionist (IP), Administrator, Medical Director, Maintenance Director, and Director of Environmental Services; - The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's Disease; - The identification of situations that can lead to Legionella growth are such as construction, water main breaks, changes in municipal water quality, presence of biofilm, scale or sediment, water temperature fluctuations, water stagnation and inadequate disinfection; - Specific measures used to control the introduction and/or spread of Legionella such as temperatures and disinfectants; - Control limits or parameters that are unacceptable and are monitored; - A diagram where control measures are applied; - A system to monitor control limits and effectiveness; - A plan for when control limits are not met and/or control measures are not effective. Review of the facility's water temperature log, dated April 2023 through July 2024, showed: - On 07/01/23, water temperature in room [ROOM NUMBER] was 97.2 degrees ( ) Fahrenheit (F) and room [ROOM NUMBER] was 100.9 F, with no intervention documented; - On 08/01/23, water temperature in room [ROOM NUMBER] was 100.8 F, room [ROOM NUMBER] was 97.6 F and room [ROOM NUMBER] was 100.3 F, with no intervention documented; - In September 2023, water temperature in room [ROOM NUMBER] was 100.8 F, room [ROOM NUMBER] was 97 F and room [ROOM NUMBER] was 100.3 F, with documentation of got it adjusted; - In October 2023, water temperature in room [ROOM NUMBER] was 104 F, with no intervention documented; - On 11/14/23, water temperature in room [ROOM NUMBER] was 104 F, with no intervention documented; - On 12/14/23, water temperature in room [ROOM NUMBER] was 104 F, with no intervention documented; - On 01/12/24, water temperature in rooms [ROOM NUMBERS] were 104 F, with no intervention documented; - On 06/14/24, water temperature in room [ROOM NUMBER] was 103 F, room [ROOM NUMBER] was 104 F and room [ROOM NUMBER] was 103.1 F, with no interventions documented; - On 07/14/24, temperatures in room [ROOM NUMBER] was 97.4 F, room [ROOM NUMBER] was 98.4 F and room [ROOM NUMBER] was 98.5, with no interventions documented. During an interview on 08/07/24 at 10:25 A.M., the Maintenance Director said he didn't know he was supposed to check for Legionella since the facility was on city water, but the temperatures should be no higher than 122 degrees ( ) Fahrenheit (F) and no lower than 95 F. When asked about the lower temperature ranges, he/she said he/she thought it was ok since they had been above 95 F. During an interview on 08/07/24 at 10:55 A.M., the Maintenance Director said he just found out the range should be 105-120 F. During an interview on 08/08/24 5:00 P.M., the Administrator said she would expect the facility to follow the Water Management and Legionella policies, and the water temperatures, in resident areas, should be between 105 and 115 F.

Based on observation and interview, the facility failed to maintain an effective pest control program. This practice affected three residents (Resident #10, #17 and #19) out of 12 sampled residents and had the potential to affect all residents in the facility. The facility's census was 29. Review of the facility's policy, Pest Control, revised May 2008, showed: - The facility shall maintain an effective pest control program; - The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents; - Only approved insecticides are permitted in facility and stored in areas away from food storage; - Maintenance services assist, when appropriate and necessary, in providing pest control services. Observation on 08/06/24 at 10:50 A.M. of Resident #17's room showed a fly landed on the resident's hand, bedspread, and nose. During an interview on 08/06/24 at 10:50 A.M., Resident #17 said the flies were always bad. Observation of the dining room on 08/06/24 at 12:29 P.M. showed a fly buzzed around, landing on a window and a gnat flying around near the doors in the dining room. Observation of the dining room on 08/07/24 at 12:10 P.M. showed two flies buzzed around a table while residents were eating, landing on the residents and on the table. Observation of the dining room during the resident council meeting on 08/07/24 at 3:00 P.M. showed two flies buzzed around residents and had to be swatted away. During the resident council meeting on 08/07/24 at 3:15 P.M., Resident #10 said he/she wished for a fly swatter and Resident #19 said he/she kept one in his/her room. Observations on 08/08/24 between the hours of 8:50 A.M. and 2:23 P.M. showed: - A fly on a resident's table in the dining room; - A fly crawling on the table in front of Resident #17 while eating lunch; - Three flies on the center light/chandelier in the dining room; - A fly on a resident's wheelchair in the dining room; - Three flies buzzed around the nurses station; - A fly buzzed around in the common area by the therapy room, while residents were watching television; - A fly buzzed around a resident in a wheelchair in the hallway near the nurses station on the therapy hall; - A fly buzzed around in the hall outside of room [ROOM NUMBER]; - A fly buzzed around in the hall outside of room [ROOM NUMBER]; - A fly buzzed around in room [ROOM NUMBER]. During an interview on 08/08/24 at 09:30 A.M., Licensed Practical Nurse (LPN) A said the facility has issues with flies and spiders. During an interview on 08/08/24 at 5:00 P.M., the Administrator said she would expect the facility to be free of pests.

Based on observation, record review, and interview, the facility failed to provide protective oversight for one (Resident #1) of four sampled residents, when facility staff left the facility's medication overflow cart unlocked and unattended. Resident #1 gained access to the cart and took two medication cards of gabapentin (a medication used to treat seizures disorder and used for nerve pain) and one card of Metoprolol (a medication used to treat high blood pressure) to his/her room. He/She reported taking 6 pills of Gabapentin and 6 pills of Gabapentin were missing which placed the resident in danger of potential overdose. The facility census was 27. The administrator was notified on 06/11/24 at 10:30 A.M. of an Immediate Jeopardy (IJ) past non-compliance which began on 06/09/24. On 06/10/24, the facility performed education to licensed and certified staff on proper safety of medication carts and the need to keep the cart locked at all times. The IJ was corrected on 06/10/24. Review of the facility policy Security of Medication Cart, dated April 2007, showed: - The nurse must secure the medication cart during the medication pass to prevent unauthorized entry; - Medication carts must be securely locked at all times when out of nurse's view; - When the medication cart is not being used, it must be locked and parked at the nurse's station or inside the medication room. - The policy did not address measures to ensure the medication carts were locked while not in use; - The policy did not address the use of a secondary medication cart designated as the overflow medication cart, it's placement in the hall or it not being monitored at all times. 1. Review of Resident #1's medical record showed: - An admitted [DATE] with diagnoses of brain cancer, depression, anxiety, repeated falls, disorder of the central nervous system, and headaches; - Alert and oriented to person place and time, no cognitive concerns; - Able to make needs known; - Independent with personal care. Review of the resident's June 2024 Physician Order Sheet showed: - An order dated 03/19/2024, pain assessment every shift; - An order dated 03/20/2024, admit to Hospice care; - An order dated 05/08/2024 for Gabapentin 100 mg, two capsules by mouth every eight hours for nerve pain. Review of the facility finalization report of incident, dated 06/10/2024, showed: - After interview with staff and resident it was found that the medication overstock cart was unlocked and not secured at the time the resident opened it and removed medication cards from the cart. Review of the facility camera footage, dated 06/09/2024 at 8:03 P.M., showed: - A medication cart parked in the corner of 100 and 200 hall intersection, across from the nurse's station; - No staff were seen on the video; - The resident walked down the 200 Hall towards the corner of the 100 and 200 hall intersection; - The resident sat down in a chair located in front of the medication cart; - The resident reached behind him/her and opened the second drawer of the cart, looked over his/her shoulder and took an undistinguishable amount of medication cards from the cart; - The resident then closed the drawer and walked towards his/her room to the to the right of the medication cart and out of camera view. During an interview on 06/11/2024 at 9:35 A.M., the Director of Operations (DOP) said on 06/09/2024 at approximately 9:00 P.M. she received a call from the Assisted Living Supervisor (ALS) stating he/she had been monitoring the cameras for the skilled unit and observed the resident sitting down in front of the overflow medication cart located on the 100/200 hall area, removed medication cards from the medication overflow cart and then return to his/her room. The ALS immediately notified Licensed Practical Nurse (LPN) A on the skilled unit to immediately go to Resident #1's room and check to see what he/she had or if the resident had medication cards in his/her possession. LPN A retrieved two medication cards of Gabapentin (60 capsules) of 300 mg of Gabapentin and one card (30 pills) of Metoprolol. Upon interviewing the resident, he/she admitted to ingesting 6 pills of 300 mg Gabapentin capsules and 6 pills were missing. The physician was notified and advised at that dosage, it did not meet the level of overdose and to continue monitor the resident. The DOP said the facility has a very small medication room behind the nurse's station, so the extra cards of medications, or the overflow, must be stored in another cart which is kept in the corner created with the intersections of hallways 100 and 200, and across from the nurse's station. They refer to this cart as the overflow medication cart. The DOP would expect the nurse to only unlock the overflow cart when he/she was working directly from it. Once done, it should be locked. It is sitting across from the nurse's station, so it is more likely to be monitored, however, the nurse's station is not always manned. The DOP was not aware of the last time the medication had been used or checked for being locked. During an interview on 06/11/2024 at 10:00 A.M., the resident said he/she had been in the dining room and was heading back to his/her room. The resident said he/she was in so much pain at that time he/she was desperate because it was not time for his/her as PRN (as needed) pain medication. As he/she neared the corner where the medication cart was stored, he/she saw no one was around. The resident said he/she did not know if the cart would be unlocked, but couldn't remember ever seeing staff lock or unlock it. The resident said he/she made a very stupid mistake and decided to check to see if he/she could get into the cart to find anything to take. The resident said he/she sat down in the chair beside the cart, reached down and tugged on the drawer, which opened easily. The resident said he/she checked over his/her shoulder to make sure no one was around and quickly reached in and grabbed 3 cards of medications. He/She looked only enough to see gabapentin on the card, and he/she knew that was also one of his/her medications. Once in his/her room, the resident saw he/she had taken a card of his/her own medication and took six of the capsules. The resident said there was nothing at the medication cart to stop anyone from reaching in to get some of them, but he/she shouldn't have done it. During an interview on 06/11/2024, at 9:50 A.M., Certified Medication Technician (CMT) C said the medication cart should be always locked. Only the nurses have keys to access the overflow medication cart. CMT C said he/she had never checked because it should always be locked. He/she worked the day of the incident and LPN A was in charge of the overflow cart, maintaining responsibility of the keys. During an interview on 06/11/2024 at 9:45 A.M., Registered Nurse (RN) B said the overflow medication cart should always be locked unless being used to retrieve medications, then re-locked. No one should have to check the cart for being unlocked, as it should never be left that way. Complaint #MO237379

Based on interview and record review, the facility failed to ensure the Quality Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility census was 30. Record review of the facility's QAPI Plan, effective 7/19/17, showed: - The QA&A Committee reports to the executive leadership and governing body and is responsible for meeting, at a minimum, on a quarterly basis, more frequently if necessary; coordinating and evaluating QAPI program activities; developing and implementing appropriate plans of action to correct identified quality deficiencies; regularly reviewing and analyzing data collected under the QAPI program and data resulting from drug regimen review and acting on available data to make improvements; and analyzing the QAPI program performance to identify and follow up on areas of concern and/or opportunities for improvement. 1. Record review of the facility's QAA/QAPI committee meeting notes showed: - No documented QAA/QAPI meetings since 2020. - No documentation of follow up on the facility's open Performance Improvement Projects (PIPs) since 2020. During an interview on 3/9/23 at 2:17 P.M., the Administrator said QAA/QAPI was done quarterly prior to COVID. The Administrator said since COVID, QAA/QAPI have not been done quarterly, but will start up again in March with the new Medical Director and will be done quarterly. During an interview on 3/10/23 at 12:34 P.M., the Director of Nursing said she would expect QAA/QAPI meetings to be held quarterly.

Based on interview and record review, the facility failed to maintain quarterly quality assurance assessment (QAA) committee meetings with the required members. The facility's census was 30. Record review of the facility's QAPI Plan, effective 7/19/17, showed: - The QA&A Committee reports to the executive leadership and governing body and is responsible for meeting, at a minimum, on a quarterly basis, more frequently if necessary; coordinating and evaluating QAPI program activities; developing and implementing appropriate plans of action to correct identified quality deficiencies; regularly reviewing and analyzing data collected under the QAPI program and data resulting from drug regimen review and acting on available data to make improvements; and analyzing the QAPI program performance to identify and follow up on areas of concern and/or opportunities for improvement. Record review showed the facility did not maintain the minimum required quarterly QAA meetings since 2020. During an interview on 3/9/23 at 2:17 P.M., the Administrator said QAA/QAPI was done quarterly prior to COVID. The Administrator said since COVID, QAA/QAPI have not been done quarterly, but will start up again in March with the new Medical Director and will be done quarterly. During an interview on 3/10/23 at 12:34 P.M., the Director of Nursing said she would expect QAA/QAPI meetings to be held quarterly.

Based on interview and record review, the facility failed to follow their policy to complete a Criminal Background Check (CBC) and Employee Disqualification List (EDL - a listing of individuals who have been determined to have abused or neglected a resident) check for nine out of ten sampled staff prior to hire. The facility census was 30. Record review of the facility's Background Screening Investigations policy, revised November 2015, showed: - Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on direct access employees. For purposes of this policy direct access employee means any individual who has access to a resident or patient of a long term care (LTC) facility or provider through employment or through a contract and has duties that involve one-on-one contact with a patient or resident of the facility or provider, as determined by the State for purposes of the National Background Check Program; - The Personnel/Human Resources Director, or other designee, will conduct background checks, reference checks and criminal conviction checks on all potential employees and contract personnel who meet the criteria for direct access employee, as stated above. Such investigation will be initiated within two days of an offer of employment or contract agreement. 1. Record review of Employee A's personnel file showed: - A hire date of 8/17/22; - No documentation of the CBC or EDL check completed within two days of hire. 2. Record review of Employee B's personnel file showed: - A hire date of 2/27/23; - No documentation of the CBC or EDL check completed within two days of hire. 3. Record review of Employee C's personnel file showed: - A hire date of 11/10/22; - No documentation of the CBC or EDL check completed within two days of hire. 4. Record review of Employee D's personnel file showed: - A hire date of 11/18/22; - No documentation of the CBC or EDL check completed within two days of hire. 5. Record review of Employee E's personnel file showed: - A hire date of 6/2/22; - No documentation of the CBC or EDL check completed within two days of hire. 6. Record review of Employee F's personnel file showed: - A hire date of 1/23/23; - No documentation of the CBC or EDL check completed within two days of hire. 7. Record review of Employee G's personnel file showed: - A hire date of 2/9/23; - No documentation of the CBC or EDL check completed within two days of hire. 8. Record review of Employee H's personnel file showed: - A hire date of 8/6/21; - No documentation of the CBC or EDL check completed within two days of hire. 9. Record review of Employee J's personnel file showed: - A hire date of 2/9/23; - No documentation of the CBC or EDL check completed within two days of hire. During an interview on 3/10/23 at 12:34 P.M., the Business Office Manager said CBCs and EDL checks should be done at the time of hire, as well as if an employee is rehired. The Business Office Manager said he/she is still fairly new to the position. During an interview on 3/10/23 at 12:38 P.M., the Administrator said she would expect all background checks and EDL checks would be completed at the time of hire.

Based on interview and record review, the facility failed to ensure the physician responded to the pharmacist's recommendations in regard to the resident's medications for three residents (Resident #5, #14 and #19) out of 12 sampled residents. The facility's census was 30. Record review of the facility's Antipsychotic Medication Use policy, last revised December 2016, showed: - Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; - The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications; - The need to continue PRN (as needed), orders for psychotropic medications beyond 14 days require the practitioner document the rationale for the extended order and the duration of such order be indicated in order; - PRN orders for antipsychotic medications will not be renewed beyond 14 days unless healthcare practitioner has evaluated the resident for appropriateness of that medication; - The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting why the benefits of medication outweigh the risks or suspected or confirmed adverse consequences. 1. Record review of Resident #5's medical record showed: - admitted [DATE]; - Diagnoses of major depressive disorder (long-term loss of pleasure or interest in life) and anxiety disorder (persistent worry and fear about everyday situations); - An order, dated 10/17/22, for duloxetine (an antidepressant medication) 20 milligrams (mg) two capsules to equal 40 mg daily for depression. Record review of the Resident's Progress Notes showed: - On 1/31/23, the Pharmacist recommended a Gradual Dose Reduction (GDR) of 30 mg daily; - On 2/27/23, the Pharmacist sent a reminder that the GDR from 1/31/23 had not been addressed; - No documentation from the physician in regard to the pharmacist's recommendation. 2. Record review of Resident #14's medical record showed: - admitted [DATE]; - Diagnoses of schizoaffective disorder (a combination of symptoms that affect a person's ability to think, feel and behave), traumatic brain injury and depressive disorder; - An order on 8/17/22 for Rexulti (an antipsychotic medication) 0.5 mg one tablet daily for use as an antipsychotic. Record review of the Resident's Progress Notes showed: - On 12/29/22, the Pharmacist recommended a GDR of 0.25 mg daily; - No documentation from the physician in regard to the pharmacist's recommendation. 3. Record review of Resident #19's medical record showed: - An admitted [DATE]; - Diagnoses of anxiety disorder, insomnia (difficulty falling and staying asleep) and major depressive disorder; - An order, dated 11/05/22, for temazepam (a benzodiazepine that can treat insomnia) 15 mg every 24 hours as needed for insomnia at bedtime; - An order, dated 1/03/23, for hydroxyzine (an antihistamine medication that can treat anxiety and tension) 25 mg every night as needed. Record review of the Resident's Progress Notes showed: - On 12/29/22, the pharmacist recommended the physician document rationale for temazepam use after 14 days and indication of duration; - On 1/31/23, the pharmacist recommended the physician document rationale for hydroxyzine use after 14 days and indication of duration; - On 1/31/23, pharmacist requested that recommendation from 12/29/22 be addressed; - On 2/27/23, pharmacist requested that recommendation from 12/29/22 be addressed; - On 2/27/23, pharmacist requested that recommendation from 1/31/23 be addressed; - No documentation from the physician. During an interview on 3/09/23 at 3:30 P.M., the Assistant Director of Nursing (ADON) said the pharmacist had been putting recommendations into the progress notes and not on a report that could have been sent to the physician. She hadn't been made aware of any pharmacy recommendations sent to the facility and therefore, they had not been addressed. During an interview on 3/10/23 at 12:34 P.M., the Director of Nursing (DON) and ADON said they would expect pharmacy recommendations to be sent to the physician and to be addressed in a timely manner.

Based on interview and record review, the facility failed to attempt a Gradual Dose Reduction (GDR) for three residents (Resident #5, #14, and #19) out of 12 sampled residents. The facility's census was 30. The facility did not provide a GDR policy. Record review of the facility's Antipsychotic Medication Use policy, last revised December 2016, showed: - Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; - The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications; - The need to continue PRN (as needed), orders for psychotropic medications beyond 14 days require the practitioner document the rationale for the extended order and the duration of such order be indicated in order; - PRN orders for antipsychotic medications will not be renewed beyond 14 days unless healthcare practitioner has evaluated the resident for appropriateness of that medication; - The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting why the benefits of medication outweigh the risks or suspected or confirmed adverse consequences. 1. Record review of Resident #5's medical record showed: - admitted [DATE]; - Diagnoses of major depressive disorder (long-term loss of pleasure or interest in life) and anxiety disorder (persistent worry and fear about everyday situations); - An order, dated 10/17/22, for duloxetine (an antidepressant medication) 20 milligrams (mg) two capsules to equal 40 mg daily for depression. Record review of the Resident's Progress Notes showed: -No documentation of a GDR since 10/17/22. 2. Record review of Resident #14's medical record showed: - admitted [DATE]; - Diagnoses of schizoaffective disorder (a combination of symptoms that affect a person's ability to think, feel and behave), traumatic brain injury and depressive disorder; - An order, dated 8/17/22, for Rexulti (an antipsychotic medication) 0.5 mg one tablet daily for use as an antipsychotic. Record review of the Resident's Progress Notes showed: - No documentation of a GDR since 8/17/22. 3. Record review of Resident #19's medical record showed: - An admitted [DATE]; - Diagnoses of anxiety disorder, insomnia (difficulty falling and staying asleep) and major depressive disorder; - An order, dated 11/05/22, for temazepam (a sedative that can treat insomnia) 15 mg every 24 hours as needed for insomnia at bedtime; - An order, dated 1/03/23, for hydroxyzine (an antihistamine that can treat anxiety and tension) 25 mg every night as needed. Record review of the Resident's Progress Notes showed: - No documentation from the physician in regard to the rationale for use after 14 days and indication of duration for temazepam or hydroxyzine. During an interview on 3/09/23 at 3:30 P.M., the Assistant Director of Nursing (ADON) said the pharmacist had been putting recommendations into the progress notes and not on a report that could have been sent to physician. She hadn't been made aware of any pharmacy recommendations sent to the facility and therefore, they had not been addressed. During an interview on 3/10/23 at 12:34 P.M., the Director of Nursing (DON) and ADON said they would expect pharmacy recommendations to be sent to the physician and to be addressed in a timely manner.

Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for four residents (Resident #11, #26, #31, and #134) out of 12 sampled residents. The facility census was 30. Record review of the facility's Care Planning - Interdisciplinary Team policy, revised September 2013, showed: - Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident; - A comprehensive care plan for each resident is developed within seven days of completion of the Minimum Data Set (MDS, a federally mandated clinical assessment). Record review of the facility's Comprehensive Person-Centered Care Plans policy, revised December 2016, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - The care planning process will facilitate resident and/or representative involvement, include an assessment of the resident's strengths and needs, and incorporate the resident's personal and cultural preferences in developing the goals of care; - The comprehensive, person-centered care plan will include measurable objectives and timeframes; describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; include the resident's stated goals upon admission and desired outcomes; incorporate identified problem areas; reflect treatment goals, timetables, and objectives in measurable outcomes. Record review of the facility's Using the Care Plan policy, revised August 2006, showed: - The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident; - The Nurse Supervisor uses the care plan to complete the Certified Nurses Aides (CNAs) daily/weekly work assignment sheets and/or flow sheets. 1. Observation on 3/8/23 at 11:45 A.M. and 2:57 P.M. and on 3/9/23 at 9:12 A.M. showed Resident #11's oxygen concentrator on at two liters per minute with the nasal cannula lying on the bed. During an interview on 3/8/23 at 11:45 A.M., Resident #11 said he/she does not usually use oxygen during the day, but uses oxygen every night. Record review of the resident's medical record showed: - An admitted [DATE]; - Diagnoses of acute respiratory failure with hypoxia (occurs when there is not enough oxygen in the blood), respiratory syncytial virus pneumonia (respiratory virus that infects the lungs and breathing passages), chronic obstructive pulmonary disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs), and unspecified systolic and diastolic heart failure (when the heart muscle is weak and can't contract or relax normally); - The quarterly MDS, dated [DATE], showed the resident had shortness of breath or trouble breathing when sitting at rest and received oxygen therapy; - An order for oxygen at HS (hours of sleep), and PRN (as needed) at bedtime and as needed during day shift, dated 3/3/23. Record review of the resident's care plan, dated 10/25/22, did not address oxygen therapy. 2. Record review of Resident #26's medical record showed: - An admitted [DATE]; - Diagnoses of nontraumatic intracerebral hemorrhage (bleeding into the brain in the absence of trauma or surgery); dysphagia following cerebral infarction (difficulty swallowing following a stroke), acute respiratory failure with hypoxia, and pneumonia due to streptococcus group B (infection that inflames air sacs in one or both lungs, which may fill with fluid). Record review of the resident's care plan, dated 7/26/22, showed: - The only focus area, interventions, and goals documented were for code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop); - Did not address any other focus areas, interventions, or goals. 3. Record review of Resident #31's medical record showed: - An admitted [DATE]; - Diagnoses of alcoholic cirrhosis of liver (chronic liver damage leading to scarring and liver failure) with ascites (abdominal swelling caused by accumulation of fluid), portal hypertension (elevated blood pressure in the major vein that leads to the liver), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), cognitive communication deficit (difficulty with thinking and how someone uses language), and need for assistance with personal care. Record review of the resident's care plan, dated 2/20/23, showed: - The only focus area, interventions, and goals documented were for diuretic (causing increased passing of urine) therapy; - Did not address any other focus areas, interventions, or goals. 4. Record review of Resident #134's medical record showed: - An admitted [DATE]; - Diagnoses of COPD, atrial fibrillation (irregular rapid heart rate) and benign prostatic hyperplasia (enlarged prostate gland causing urinary difficulty); -The admission MDS, dated [DATE], showed resident used tobacco. Record review of the resident's care plan, dated 2/28/23, showed smoking not addressed on the care plan. During an interview on 3/10/23 at 12:34 P.M., the Director of Nursing and MDS Coordinator said they would expect comprehensive care plans to reflect the resident's current status and the care plans should be updated quarterly and as needed. 46460 47678

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for one resident (Resident #11) out of 12 sampled residents. The facility census was 30. 1. Record review of Resident #11's medical record showed: - Transferred and admitted to the hospital on 2/3/23 and readmitted to the facility on [DATE]; - Transferred and admitted to the hospital on 1/30/23 and readmitted to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. During an interview on 3/09/23 at 3:03 P.M., the Director of Nursing (DON) said the Social Services Designee (SSD) should be doing the written communication with families and ombudsman and she is not sure that this is getting done. The floor nurse gets everything ready to send the residents to the hospital, but they don't do the written communication. During an interview on 3/09/23 at 3:10 P.M., the SSD said she has not been sending anything to the families in writing regarding transfers to the hospital. She does send the information to the ombudsman regarding transfers and discharges. During an interview at 3/10/23 at 12:34 P.M., the DON said she would expect a resident/resident's representative to be notified in writing of a transfer/discharge. The facility did not provide a policy.

Based on interview, and record review, the facility failed to inform the resident and family or legal representative of their bed hold policy at the time of transfer to the hospital for two residents (Resident #11 and #14) out of 12 sampled residents. The facility census was 30. Record review of the facility's Bed Hold policy, undated, showed: - It shall be the policy of Fountainbleau Lodge to hold a resident's room while they are in the hospital upon request of the family. 1. Record review of Resident #11's medical record showed: - Transferred and admitted to the hospital on 1/30/23 and readmitted to the facility on [DATE]; - Transferred and admitted to the hospital on 2/3/23 and readmitted to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the facility bed hold policy at the time of transfer. 2. Record review of Resident #14's medical record showed: - Transferred and admitted to the hospital on 1/02/23 and readmitted to facility on 1/06/23; - No documentation that the resident (own responsible party) was informed in writing of the facility bed hold policy at the time of transfer. During an interview on 3/9/23 at 3:03 P.M., the Director of Nursing (DON) said the Social Services Designee (SSD) should be doing the written communication with families and she is not sure that this is getting done. During an interview on 3/9/23 at 3:10 P.M., the SSD said when a resident goes out, the nurses usually initiate the process and call the families. The nurses usually ask if residents want their bed held, but it's not being documented. She has the bed hold forms, but she has not been completing them. During an interview on 3/10/23 at 12:34 P.M., the DON said she would expect the bed hold policy to be provided and signed when a resident is transferred. 46460

Based on interview and record review, the facility failed to provide and document that residents received or declined appropriate immunizations. This affected two residents (Resident #5 and #14) out of 12 sampled residents. The facility's census was 30. Record review of the facility's Pneumococcal Vaccine policy, last revised October 2019, showed: - Prior to or upon admission, residents will be assessed for eligibility to receive the Pneumococcal vaccine series and when indicated, be offered the vaccine series within 30 days of admission; - Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission not conducted prior to admission; - Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given or refused), per the facility's physician-approved pneumococcal vaccination protocol. 1. Record review of Resident #5's medical record showed: - admitted on [DATE]; - No record of the pneumococcal (infection caused by bacteria that can range from ear and sinus infections to pneumonia and bloodstream infections) vaccination; - No documentation of refusal for the pneumococcal vaccination. 2. Record review of Resident #14's medical record showed: - admitted on [DATE]; - No record of the pneumococcal vaccination; - No documentation of refusal for the pneumococcal vaccination. During an interview on 3/09/23 at 8:22 A.M., the Assistant Director of Nurses (ADON) said the residents had not received the pneumococcal vaccinations, nor did they have a declination. During an interview on 3/10/23 at 12:34 P.M., the Director of Nurses (DON) and ADON said they would expect residents to be offered influenza/pneumococcal vaccines and have a signed declination if the resident refused.

Based on interview and record review, the facility failed to initiate cardiopulmonary resuscitation (CPR, a procedure to support and maintain breathing and circulation for a person who has stopped breathing and/or whose heart has stopped) for one resident (Resident #1) of 19 residents identified as having a full code status (CPR required in the event of cardiac or respiratory arrest). Staff found the resident unresponsive on [DATE] and failed to initiate CPR and call 911. The resident died in the facility. The facility census was 29. On [DATE] at 4:20 P.M. the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on [DATE]. On [DATE] the facility Director of Nursing (DON) was notified of the incident and an investigation was started. RN A was terminated on [DATE] for failure to document and not following facility policy regarding CPR and resident code status. Facility nursing staff were inserviced regarding documentation and facility CPR and code status policies. The IJ was corrected on [DATE]. Review of the facility's Cardio-Pulmonary Resuscitation policy dated [DATE], showed: -If an individual (resident, visitor or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a) It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exits for that individual, or; b) There are obvious signs of irreversible death (e.g. rigor mortis (stiffening of the joints and muscles of a body a few hours after death). Review of the facility's Do Not Resuscitate Order policy dated [DATE], showed: -Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect; -Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -A Do Not Resuscitate Order (DNRO) form must be completed and signed by the Attending physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record. (Note: Use only State approved DNRO forms. If no State form is required, use facility approved form.). Review of Resident #1's face sheet, showed the following: -admitted [DATE]; -No documentation regarding the resident's code status; -Primary diagnosis [CONDITION(S)] (A-Fib, irregular heart rhythm). Other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, dated [DATE], showed: - Resident #1 had chosen to be a full code status; - Resident #1 able to feed self with setup and supervision. Review of the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's dashboard tab in Point Click Care (PCC) while on site [DATE], showed full code status, dated [DATE]. Review of the resident's progress notes, showed the following: -The most recent entry dated [DATE] as a health status note, with resident at baseline. During an interview on [DATE] at 11:00 A.M., the DON said on [DATE], he/she was notified Resident #1 had passed away around 7:50 P.M. by Registered Nurse (RN) A. RN A asked who he/she needed to contact first in regards to the resident's death and the DON advised to call the family, then call the physician, coroner and funeral home and to document. The DON said she was not aware there were any issues with the incident until it was brought to her attention on [DATE] there was nothing documented regarding the resident's death. When she checked, RN A had not documented anything about the events on [DATE], and an investigation started. In regards to the facility's protocol and code status, the DON said every resident's code status can be found in the computer under the physician orders. A resident's chart should also have a sticker on the outside that notes the code status, which is a blue sticker for full code and a red sticker for DNR. The chart should also contain a signed DNR on a purple sheet of paper under the Advanced Directive tab in the chart. In a second interview with the DON on [DATE] at 3:00 P.M., she said she just started in December and is still learning. The DON said on [DATE], she was told by Certified Medication Technician (CMT) B there was no charting on Resident #1's death. The DON logged in the system from home to see no charting done. At that time she sent a text to RN A and reminded him/her to make sure he/she charted on the resident. RN A called in on [DATE] approximately 45 minutes after his/her scheduled shift had already started. RN A was then terminated on [DATE] for failure to document and not following facility policy and procedure. The DON said RN A should have started CPR as the resident was a full code. During telephone interview on [DATE] at 12:26 P.M., CMT B said he/she was the CMT on duty on [DATE] until 8:00 P.M. CMT B said during the day Resident #1 had been acting more confused and saying he/she hadn't eaten breakfast, but the resident had just eaten dinner. Certified Nursing Aide (CNA) D gave the resident a peanut butter and jelly sandwich, which Resident #1 ate in front of the nurse's station sitting in his/her wheelchair while the aides were getting other residents ready for bed. At approximately 7:45 P.M. while checking blood sugars, CMT B observed Resident #1's hand fall out and kind of slump down. CMT B immediately went to check on the resident. CMT B observed Resident #1 to be unresponsive and ashy in color. CMT B yelled at RN A, who was sitting behind the nurse's station that Resident #1 did not look well. CMT B started shaking the resident and calling his/her name, but the resident did not rouse. CMT B said RN A came around from behind the nurse's station, looked at Resident #1 and said he/she is already gone. RN A touched Resident #1 once and said, again, he/she is gone. CMT B said he/she and RN A took Resident #1 to his/her room and laid him/her in bed. RN A went to make notifications of Resident #1's passing and CMT B went to notify the aides in the building that the resident had passed so they could clean the resident up. CMT B said RN A said the resident was a DNR and no CPR was initiated by RN A. CMT B said he/she did not check the resident's code status and wasn't sure where to look for the resident's code status. CMT B said the next day on [DATE], Licensed Practical Nurse (LPN) I told her about the code status stickers on the resident's chart and she saw that Resident #1 was a full code according to the blue sticker. During a telephone interview on [DATE] at 12:49 P.M., CNA D said on the evening of [DATE], Resident #1 had been confused and saying he/she was hungry and didn't get breakfast, but had just eaten dinner. CNA D gave Resident #1 a peanut butter and jelly sandwich and Cheez-Its to eat and went to assist Nurse Aide (NA) C with a bed bath. CNA D said Resident #1 was sitting in front of the nurse's station in his/her wheelchair while eating, and RN A was behind the desk working. CNA D said NA C went to go grab more washcloths and when he/she came back into the other resident's room told him/her (CNA D) Resident #1 had passed and that CMT B was checking Resident #1. CNA D asked NA C if CPR was being started and NA C told him/her that no CPR was initiated, because RN A said Resident #1 was a DNR. CNA D said he/she had never checked Resident #1's code status. During a telephone interview on [DATE] at 12:55 P.M., NA C said on [DATE] at around 7:20 P.M., Resident #1 was confused and saying he/she didn't eat breakfast, although he/she had just finished supper. CNA D gave Resident #1 a peanut butter and jelly sandwich and crackers while the resident was sitting in front of the nurse's station. NA C was helping CNA D with a bed bath on another resident and exited the room to go grab some more washcloths. NA C said he/she observed Resident #1 with his/her chin to his/her chest and CMT B bent over the resident checking for a pulse. RN A was on Resident #1's left side. NA C asked what was going on and CMT B said Resident #1 is leaving and RN A said yeah he/she is gone and RN A walked back to the nurse's station to call his/her supervisor. RN A said Resident #1 needed to be laid down and NA C asked if anyone needed to start CPR. RN A said no, the resident was a DNR. NA C took the washcloths back to the resident's room that was receiving a bed bath and told CNA D what happened and CNA D asked if CPR was being started. NA C told CNA D that RN A said that Resident #1 was a DNR. After finishing the bed bath, NA C said he/she and CNA D assisted CNA J with cleaning up Resident #1 so he/she would be ready when the funeral home arrived. NA C said he/she never checked Resident #1's code status. During telephone interview on [DATE] at 2:33 P.M., CNA J said he/she was on break and CMT B came and told him/her that Resident #1 had passed. CNA J immediately grabbed his/her blood pressure cuff and went to the resident's room. CNA J tried to get a blood pressure on the resident and then initiated CPR. CNA J said he/she did about 10 compressions before RN A came in and said to stop CPR, because the resident was a DNR and to just get the resident cleaned up. CNA J said he/she is CPR certified and didn't see anything posted by the resident's bed that he/she was a DNR so that is why he/she initiated CPR. He/she said he/she were not trained on where to check code status when hired and had only been there approximately a month. CNA J said on [DATE] while discussing what happened with LPN I he/she was told the resident was a full code. LPN I showed CNA J the blue sticker on the resident's chart. During a telephone interview on [DATE] at 2:41 P.M., RN A said on [DATE] around 7:15 P.M., he/she was sitting at the nurse's station charting on the computer. Resident #1 had been confused and saying he/she didn't have breakfast while sitting in his/her wheelchair in front of the nurse's station. Resident #1 was given a peanut butter and jelly sandwich because he/she kept saying he/she didn't eat and was hungry. RN A said CMT B walked by and said Resident #1 does not look right. RN A said he/she came and looked at Resident #1 and could tell he/she was dying and had one agonal breath (agonal breathing is the medical term for a certain type of gasping for air, usually during a serious medical emergency like a stroke or heart attack). RN A did not check the resident's code status at that point, but assisted CMT B to getting Resident #1 in bed. RN A said he/she then listened with the stethoscope and Resident #1 had no heartbeat and looked gray. RN A said he/she went to go make notifications to family, the physician and coroner. RN A said it was at that point, he/she checked and Resident #1 was a full code, but felt it would have been cruel to start CPR as the resident was already gone and gray. RN A said he/she would initiate CPR if a resident was found struggling to breath. During a second interview on [DATE] at 2:10 P.M., RN A said he/she had only worked at the facility for a week. RN A said he/she is CPR certified. RN A said he/she verified the code status after he/she and CMT B had put the resident in bed Resident #1 was a full code when he/she looked at the sticker on the chart. RN A said he/she did not immediately check the code status or initiate CPR, because the resident just went so quickly and his/her color changed and he/she was already getting stiff by the time he/she was gotten from the wheelchair to the bed. RN A said the resident had dementia. He/she felt Resident #1 was already gone and it would be cruel to start CPR at that time. RN A said he/she assessed Resident #1 after putting him/her back in bed by listening with a stethoscope and found no heart beat and he/she was unable to get a blood pressure reading. RN A also noted mottling. RN A said family was contacted, as well as the physician, coroner and funeral home. RN A said he/she was the only licensed person in the building and just ran out of time to document. RN A said he/she knew the information on Resident #1 needed to be documented. RN A denied ever telling CNA J to stop CPR or what the resident's code status was. Review of the resident's progress notes, showed the following: -No documentation regarding the resident's death, family or physician notifications or notification of when resident's body released to the coroner or funeral home on [DATE]. During a second telephone interview on [DATE] at 2:52 P.M., CMT B said he/she did not personally see CNA J doing CPR on Resident #1 because he/she walked into the room behind RN A, but he/she heard RN A tell CNA J to stop the resident was a DNR. CMT B said he/she only works part time and started approximately [DATE]. He/She trained a few days with another medication technician, but had not been trained on checking code status. CMT B said CNA J told him/her that he/she was trying to do CPR. On [DATE], CMT B and CNA J spoke with LPN I regarding Resident #1's death. LPN I showed the CMT and CNA where to look for a quick reference on the outside of the chart. There was a blue dot on the outside of the chart, which indicated a full code status and the chart showed the resident was a full code. CMT B said that was the first time anyone spoke with him/her where to find a resident's code status. During telephone interview on [DATE] at 11:12 A.M., LPN H said when Resident #1 was transferred from assisted living (ALF) to the skilled side of the facility in [DATE], he/she had orders to be DNR. LPN H said the resident's old orders were to be transferred over from the ALF to the skilled side, but he/she is not good with the computer system, so she asked the DON to transfer over the orders. LPN H said a resident's code status can be found on the chart with the sticker, as well as in the chart if there is a signed DNR or on the electronic medical record (EMR) in the physician orders. During telephone interview on [DATE] at 11:35 A.M., the Administrator and DON said they would expect a resident's code status to be reflected consistently on the resident's care plan, physician orders, resident dashboard on the EMR and sticker on the outside of the chart. The Administrator and DON said there were discrepancies in Resident #1's chart, his/her baseline care plan and transfer sheet identified him/her as a DNR. The colored sticker, the care plan andPOS identified [MEDICAL RECORD OR PHYSICIAN ORDER] . If there is a conflict with code status and nursing unsure of a resident's code status then CPR should be initiated and continued until EMS arrives. Administrator and DON would expect admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to identify a significant weight loss and follow through with interventions to maintain acceptable parameters of nutritional status for two residents (Resident #2 and #9) of 10 sampled residents. The facility census was 32. 1. Record review of Resident #2's quarterly MDS, dated [DATE], showed: - [DIAGNOSES REDACTED]. - Weight loss of 10% or more in the last 6 months; - Required limited assistance of one staff for eating; - A significant weight loss of 5% in one month or 10% or more in 6 months; - The resident weighed 159 pounds (lbs); - Severe cognitive impairment. Record review of #2's physician's orders [REDACTED]. - Admitting [DIAGNOSES REDACTED]. - an order for [REDACTED]., 12:00 P.M., and 5:00 P.M.; - an order for [REDACTED]. - Regular diet. Observation on 9/8/14 from 11:34 A.M. to 12:20 P.M., during the lunch meal, showed: - The resident did not receive milk; - The resident consumed 25 % of the dressing, 25% of the mixed vegetables, and 25% of the turkey; - The resident's fork and knife remained rolled up in the napkin; - Staff did not assist the resident during the meal. Observation on 9/9/14 from 11:51 A.M. to 12:38 P.M., during the lunch meal, showed: - The resident did not receive milk or a health shake; - The resident ate his/her baked beans with his/her hands; - The resident picked at the hamburger meat with his/her hand; - The resident consumed 100% of the baked beans, 25% of the hamburger, 0% of the water, and 0% of the tea; - The resident's fork and knife remained rolled up in the napkin; - Staff did not assist the resident during the meal. Observation on 9/11/14 from 8:20 A.M. to 8:35 A.M., during the breakfast meal, showed: - The resident did not receive a health shake; - The resident consumed 25% of the egg, 100% of the milk, 0% of the orange juice, 100% of the water and 0% of the toast; - The resident ate the eggs with his/her hands; - The resident's fork and knife remained rolled up in the napkin; - Staff did not assist the resident during the meal. Record review of the resident's care plan, last updated 8/28/14, showed:- Staff will assist with feeding the resident during meals prn (as needed); - Set up the resident's tray by opening containers, buttering bread, etc. Record review of the Monthly Weights Book showed: - April 2014, the resident weighed 173 pounds (lbs); - May 2014, the resident weighed 161.4 lbs; - June 2014, the resident weighed 157 lbs; - July 2014, the resident weighed 150.3 lbs; - A weight loss of 6.7% in one month from April 2014 to May 2014; - A weight loss of 9.24% in three months from April 2014 to June 2014. Record review of the Dietician's Progress Notes, dated 7/29/14 and 8/25/14, showed: - April 2014, the resident weighed 165 lbs; - May 2014, the resident weighed 161 lbs; - June 2014, the resident weighed 158 lbs; - July 2014, the resident weighed 150 lbs; - A weight loss of 5% in one month from June 2014 to July 2014. 2. Record review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment required to be completed by the facility staff, dated 7/16/14, showed: - [DIAGNOSES REDACTED]. - Moderate cognitive impairment; - Requires extensive assistance of one staff for eating. Observation on 9/11/14 at 8:15 A.M. showed: - The resident sat at an assisted feeding table with two other residents in the dining room; - 50% of the resident's food remained on his/her breakfast plate; - 50% of the resident's juice and 100% of the resident's milk remained beside his/her plate; - No health shake on the table beside his/her plate. During an interview on 9/11/14 at 8:20 A.M., the resident was unable to answer questions about whether he/she was finished or had had enough to eat. Record review of the resident's POS, dated September 2014, showed: - Pureed diet with nectar thickened liquids; - Add health shakes three times daily between meals; - May offer sips of water without thickening while sitting up. Record review of the Monthly Weights Book showed: - In April 2014, the resident weighed 143.2 lbs; - In May 2014, the resident weighed 134.9 lbs; - In June 2014, the resident weighed 132.2 lbs; - In July 2014, the resident weighed 133.1 lbs - A severe weight loss of 8.3 lbs (5.7%) in 30 days from April to May 2014. Record review of the Dietician's Progress Note, dated 7/29/14, showed: - In April 2014, the resident weighed 138 lbs; - In May 2014, the resident weighed 134 lbs; - In June 2014, the resident weighed 133 lbs; - In July 2014, the resident weighed 133 lbs; - No significant weight change in three months. During an interview on 9/11/14 at 9:50 A.M., CNA A said the resident is fed by the staff. He/she can lean forward to sip from a straw, but if he/she tried to pick up food, it usually doesn't make it to her mouth. During an interview on 9/11/14 at 10:15 A.M., RN L said the resident's supplements are not recorded in the handwritten dietary intake log because they are put into the computer. He/she could not find a record of the resident's supplement intake in the computer. During an interview on 9/11/14 at 9:56 A.M., the Dietary Manager (DM) said he/she gets a printout of the monthly weights from the Director of Nursing (DON) to give to the dietician. The DM said he/she didn't know why the weights on the DON's sheet were different from the ones in the book. He/she said the weights in the monthly weight book at the nurse's station were the most accurate. During an interview on 9/11/14 at 1:40 P.M., the DON said he/she would expect the staff to recognize a significant weight loss and put interventions in place in a timely manner. Record review of the facility's policy for Weight Assessment and Intervention, dated December 2008, showed: - Any weight change of 5% or more will be reported to the dietician immediately in writing by the nursing staff; - Individualized care plans shall address the identified causes of weight loss, goals for improvement, and time frames for monitoring and reassessment; - Interventions for undesirable weight loss shall be based on careful consideration of resident choice and preference, nutrition/hydration needs of the resident, functional factors that may inhibit independent eating, chewing/swallowing abnormalities and the need for diet modifications, medications that may interfere with appetite, chewing/swallowing or digestion, the use of supplementation and/or feeding tubes, and end of life decisions/advance directives.

Based on observation, interview, and record review, the facility failed to use safe transfer techniques for one resident (Resident #15) outside of the 10 sampled residents. The facility census was 32. 1. Record review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, dated 7/30/14, showed: - [DIAGNOSES REDACTED]. - Moderate cognitive impairment; - Requires total dependence on two staff for transfers. Observation on 9/8/14 at 2:10 P.M., showed: - Certified Nurse Aide (CNA) K and CNA N used a Hoyer lift (a mechanical device used to lift and transfer a person) to transfer the resident from his/her wheelchair to the bed; - CNA K and CNA N smashed the resident's left leg between the bar of the lift; - The resident yelled out "OOOO" and complained of his/her left foot hurting; - CNA K examined the resident's left foot and found no visible injury. During an interview on 9/11/14 at 1:40 P.M., the Director of Nursing (DON) said he/she would expect transfers to be done according to the facility's policy. Record review of the facility policy Safe Lifting and Movement of Residents dated October 2009, showed: - Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices.

Based on observation, interview and record review, the facility failed to implement interventions to provide necessary treatment to promote healing of pressure ulcers to one resident's (Resident #1) feet, from six residents reviewed who are at risk for developing pressure ulcers. The facility census was 27. 1. Record review for Resident #1 showed: - According to the physician's orders [REDACTED]. The resident previously lived in the assisted living facility (ALF) side of the facility since 7/22/08. [DIAGNOSES REDACTED]. - In a nurse's note, dated 11/29/10, staff documented the resident's family asked Licensed Practical Nurse (LPN) A to take off the resident's TED hose (compression stockings) and check the resident's toenails. The LPN documented the resident's toenails were growing into her toes, there were indentations to both great toes and indentations to the little toe and second toe of the right foot. The LPN documented the resident had scaly, dried, crusty, flaky skin and dirt covering toes and heels. The resident had a 5 X 6 centimeter (cm) purple, mushy area to the right heel. The left heel had a 5 X 5 cm dark, pinkish, purple area. The left outer ankle had a 2 X 2 cm by 1 X 1 cm scabbed over center surrounded by a 2 X 2 cm pink area. The resident complained of severe pain while trimming toenails and assessment of his/her feet. - The POS, dated 11/10/10, contained physicians' orders for [MEDICATION NAME] (a see through occlusive dressing) every 72 hours to the resident's coccyx and right buttock. - In a nurse's note, dated 11/10/10, staff documented Resident #1 had a 2 X 2 cm by 1 cm deep opened area to the coccyx and a 1 X 1 cm opened area to the right buttocks. - In a nurse's note, dated 12/4/10, staff documented the resident had a 1 X 1 cm pressure ulcer on the right buttock, covered with [MEDICATION NAME]. - In a nutritional assessment, dated 12/7/10, the Registered Dietitian documented the resident had a Stage II (a partial thickness loss of skin layers either dermis or epidermis that presents clinically as an abrasion, blister or shallow crater) wound on his/her buttock and the resident had lost 1.4 pounds. - In a nurse's note, dated 12/9/10, staff documented the application of [MEDICATION NAME] to coccyx with no documentation of where or why. - A monthly summary, dated 12/10/10, showed Resident #1 had a 1 X 1 cm scabbed over pressure area to the right buttock and had bi-lateral soft, purple heels. (This summary is the last documentation regarding the resident's feet and coccyx until 1/7/11 when the feet and the coccyx area were found to be much worse). - The treatment administration record (TAR), dated 11/10/10, directed nursing staff to provide a treatment of [REDACTED]. The TAR showed the treatment had been signed off every 72 hours since 11/10/10. - The plan of care directed nursing staff to assess the resident's skin bi-monthly, The care plan directed nurse aides to monitor the resident's skin condition daily and on shower days and to report any new skin conditions to the charge nurses. Observation of Resident #1 showed: - On 1/19/11 at 10:00 A.M., the resident sat in a wheelchair with four plus [MEDICAL CONDITION] of the left leg and two plus [MEDICAL CONDITION] of the right leg. The resident had a Stage II opened area on the left ankle bone. The pressure ulcer was open and had a pinkish, yellow center. The skin around the outside of the open area was pinkish. The right foot had a Stage III (A full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.) pressure ulcer on the bottom of the resident's right heel. The pressure ulcer was the size of a silver dollar, had a yellowish to pink exudate in the center and had two, one inch long black streaks through the center of the heel wound. - On 1/24/11 at 9:25 A.M., the resident had a [MEDICATION NAME] dressing on the coccyx above the tailbone. There were no wounds visible under this dressing. The resident had an opened wound, the size of a half dollar and reddish pink in color, on the right upper buttock. The wound had two small areas the size of the top of a pencil eraser with yellow slough and exudate. Interviews showed: - On 1/19/11 at 11:30 A.M., LPN B said he/she assessed Resident #1's skin on 12/29/10. The LPN said he/she guessed the reason there was no documentation in the nurses' notes was because, since they chart by exception, on the evening she assessed the resident's skin, the wounds were probably healed. When asked about the wound on the resident's coccyx, he/she said it was probably healed too. - On 1/19/11 at 12:45 P.M., the DON said the LPN should have called the resident's physician on 11/29/10, gotten a treatment order and the nursing staff should have monitored the resident's feet at least weekly. The DON said it is the facility's policy to assess all the residents' skin at least every two weeks. The DON said the facility accomplishes this by completing a monthly summary and a skin assessment two weeks later. The DON said she did not know why there was no documentation in the nurses' notes describing the size of the wounds to Resident's #1's feet, coccyx and buttock. The DON said she thought the resident's tennis shoes rubbed and caused the pressure ulcers to develop on the resident's feet. The resident had lost weight and the shoes did not fit properly. The DON said the resident would peddle with his/her right foot which rubbed the pressure sore on the right heel. The tennis shoe had a cushioned area on the side of the shoe with a cutout for ankle bones. The DON said she thought the shoe rubbed the ankle bone of the left foot. The DON said the nurse aides were supposed to verbally tell their charge nurse's whenever they found any new skin problems on the residents. - On 1/19/11 at 11:35 A.M., Certified Nurse Aide (CNA) A and CNA B said that Resident #1 usually had both his/her feet wrapped in bandages. The CNAs said the resident's feet had been wrapped in bandages ever since he/she moved to the skilled facility from the ALF. CNA A and CNA B said the resident received his/her shower on the evening shift. CNA A and CNA B said when they saw the resident on the day shift, the resident's feet would already be wrapped with bandages. CNA A said he/she assumed the charge nurses already knew about the sores on the resident's feet because they would be the ones wrapping them with bandages. The CNAs said the charge nurses already knew about the pressure ulcer on the resident's right buttock because they had been putting [MEDICATION NAME] on the coccyx and right buttock. - On 1/24/11 at 2:00 P.M., the DON said that she had questioned all of the charge nurses from every shift and all of them denied they were aware of Resident #1 having a Stage II and Stage III wound on his/her feet. She said they all claimed that they did not wrap the resident's feet in gauze. MO 748