Every finding on record at Hamilton Nursing Home

Based on interview and record review the facility failed to implement an effective Antibiotic Stewardship Program. This deficient practice has the potential to affect all residents in the facility.Findings include:On 9/4/25 at 9:45 A.M during the Infection Control task the Antibiotic Surveillance Program was reviewed with the Infection Preventionist, Registered Nurse (RN) A . Review of the facility's July 2025 Infection control program revealed the following. R40 received an antibiotic (Bactrim DS) for seven days (7/25/25 - 8/1/25) with diagnosis of Urinary Tract Infection (UTI). R40's Infection Report did not include documentation of signs or symptoms of UTI or any urinary lab work. During inquiry RN A confirmed that the facility followed the McGeer's criteria to determine if residents have true infections and should be prescribed antibiotics. RN A said, There is no documentation in the resident's medical record to support the resident had a UTI. There is no lab work. R27 had received an antibiotic (Bactrim DS) for 10 days (7/22/25 - 8/01/25) with diagnosis of Urinary Tract Infection (UTI). R27 did not have an Infection Report. There were no documented signs or symptoms of infection. On 7/18/25 a urinalysis lab report indicated the resident was positive for an infection that was resistive to Bactrim. The report identified a different antibiotic (Nitrofurantoin) as a more effective antibiotic against the infectious pathogen (aerococcus sanguinicola). During inquiry RN A acknowledged that R27's urine culture indicated that the infectious pathogen was resistant to Bactrim. There was no documentation to support this lab report had been reviewed by either RN A or the resident's attending physician (MD B). MD B was also interviewed during this time and said that he reviewed most of the labs through an application on his cell phone. MD B reviewed R27's urinalysis and could not explain why the resident remained on Bactrim. Review of the facility's June 2025 Infection control program revealed the following: R4 had been prescribed an antibiotic (azithromycin) on 6/23/25. This antibiotic prescription was not identified on the June Infection control Report or included in the facility's Infection Rate resulting in June 2025's infection rate to be inaccurate.According to the facility's Surveillance for Infections policy (undated):Policy StatementThe Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions.Policy Interpretation and Implementation1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections.2. The criteria for such infections are based on the current standard definitions of infections.Policy Interpretation and Implementation7. When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification or confirmation. Cultures will be further screened for sensitivity to antimicrobial medications to help determine treatment measures.8. The Charge Nurse will notify the Attending Physician and the Infection Preventionist of suspected infections.a. The Infection Preventionist and the Attending Physician will determine if laboratory tests are indicated, and whether special precautions are warranted.b. The Infection Preventionist will determine if the infection is reportable.c. The Attending Physician and interdisciplinary team will determine the treatment plan for the resident.Gathering Surveillance Data1. The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The Infection Control Committee and/or QAPI Committee may be involved in interpretation of the data.2. The surveillance should include a review of any or all of the following information to help identify possible indicators of infections:a. Laboratory records;b. Skin care sheets;c. Infection control rounds or interviews;d. Verbal reports from staff;e. Infection documentation records;f. Temperature logs;g. Pharmacy records;h. Antibiotic Review; [NAME]. Transfer log/summaries 3. If laboratory reports are used to identify relevant information, die following findings merit further evaluation:c. Positive urine cultures (bacteriuria) with corresponding signs and symptoms that suggest infection;Data Collection and Recording1. For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate:a. Identifying information (i.e., resident's name, age, room number, unit, and Attending Physician);b. Diagnoses.c. admission date, date of onset of infection (may list onset of symptoms, if known, or date of positive diagnostic test);d. Infection site (be as specific as possible .).e. Pathogens.f. Invasive procedures or risk factors (i.e., surgery, indwelling tubes, Foley, etc., fractured hip, malnutrition, altered mental status, etc.);g. Pertinent remarks (additional relevant information, i.e., temperatures, other symptoms of specific infection, white blood cell count, etc.). Also, record if the resident is admitted to the hospital, or expires; andh. Treatment measures and precautions (interventions and steps taken that may reduce risk.1. Using the current suggested criteria for Healthcare-Associated Infections, determine if the resident has a Healthcare-Associated Infection.2. DAILY (as indicated): Record detailed information about the resident and infection on an individual infection report form (e.g., Infection Treatment/Tracking Report, Infection Report Form, or similar form).

Based on observation and record review, the facility failed to provide 80 square feet per Resident in multiple Resident rooms and at least 100 square feet for single Resident rooms, affecting 18 of 28 Resident rooms (#'s 104, 105, 106, 107, 108, 109, 110, 111, 113, 204, 205, 206, 207, 208, 209, 210, 211, and 213).Findings include:Observation of the Resident rooms on 9/2/24 at 10:00 AM, and review of the Facility Bed Count Information sheet revealed the following:ROOM # SQ. FT # OF BEDS # RESIDENTS 104 155 2 2105 153 2 2106 153 2 2107 218 3 3108 221 4 3109 230 3 2110 234 3 2111 153 2 2113 92 1 1204 153 2 2205 153 2 2206 155 2 2207 222 3 3208 285 4 3209 228 3 3210 233 3 2211 150 2 2213 158 2 2Each resident's room was observed. Cognitively intact residents were interviewed. No concerns were observed or reported.

This citation pertains to intake MI00146554. Based on interview, and record review the facility failed to revise a care plan in a timely manner for one resident (R401) out of four residents reviewed for care planning. Findings include: Record review of electronic medical records revealed R401 admitted into the facility on [DATE] with pertinent diagnosis of dementia, psychoactive substance abuse, and neurocognitive disorder. Review of a Minimum Data Set (MDS) assessment for Resident R401, with a reference date of 6/13/2024 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated moderately impaired cognition. Record review of 401's Nursing Evaluation Quarterly dated 6/14/23, documented the following: . Low Wander Risk. Record review of R401's active care plans revealed the following: Focus: R401 is an elopement risk/wanderer stating he don't want to be here. Further review revealed this care plan was initiated on 3/8/23 and cancelled on 8/28/24. Interventions for the care plan were to be ongoing with target date of 12/14/24. On 9/5/24 at 1:20 PM Social Worker B was interviewed and said R401's care plan should have been updated on 6/14/24 to reflect a low risk for elopement. On 9/5/24 at 1:30 PM the Nursing Home Administrator was interviewed and agreed R401's care plan was not updated to reflect a change into low-risk elopement. The care plan should have been updated on 6/14/24. Review of the facility's policy titled Care Plans, Comprehensive Person Centered revised 9/22 revealed in part: Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.

This citation pertains to intake MI00146554. Based on interview and record review the facility failed to provide adequate supervision for one resident (R401) out of four residents reviewed for elopement, resulting in R401 eloping from the facility. Findings include: Record review of facility's Investigation Report (no date), revealed R401 was reported to the Nursing Home Administrator (NHA) not in the facility on 8/14/24 at approximately 11:22 PM. R401 was last seen by staff in the facility at approximately 5:00 PM. There was no guardian authorized leave of absence. Record review of electronic medical records revealed admission into the facility on [DATE] with pertinent diagnosis of dementia, psychoactive substance abuse, and neurocognitive disorder. Review of a Minimum Data Set (MDS) assessment for Resident R401, with a reference date of 6/13/2024 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated moderately impaired cognition. R401 had a guardian under a guardian agency. On 9/5/24 at 10:20 AM R401 was interviewed by phone and stated I went out the front door, I used the code. I don't need to be there and won't go back or any other nursing home. R401 did not explain how he learned the front door code. On 9/5/24 at 10:30 AM Family Member C was interviewed by phone and stated R401 learned the code to the front door and just left the building. Family Member C further said R401 was staying with them. On 9/5/24 at 12:40 PM the NHA was interviewed and said the facility investigation revealed that there were no staff watching the front door during dinner time at approximately 5:00 PM on 8/14/24. The NHA acknowledged that R401 most likely learned the front door code by watching staff leave the building. Staff should be aware of any residents near the front door when imputing the door code to exit the building so that residents do not learn the code and elope. Record review of facility policy Elopement revised 6/23 revealed in part .It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Residents with a history of substance abuse use disorder may be at increased risk for leaving the facility without notification and should be assessed and have care planning interventions.

Based on observation, interview, and record review, the facility failed to: 1. Ensure the dish machine was tested to for proper sanitizing prior to use; 2. Ensure the caulking of the dish machine back splash and hand washing sink were in good repair; 3. Effectively clean surfaces in the kitchen; 4. Ensure food past the use-by-date was not stored with active food stock; and 5. Ensure the ice machine was properly air gapped. These deficient practices had the potential to affect all residents who consumed food from the kitchen. Findings include: On [DATE] at 8:40 AM, during an observation of the kitchen with Dietary Manager (DM) F the following was observed: 1. Meal trays had been set through the low temp/chemical sanitizing dish machine by Dietary Aide (DA) E. DA E said the sanitizing solution had not been checked. When the dish machine sanitizing log was requested, none was available. 2. The caulking on the dish machine back splash and hand washing sink were chipped or missing. DM F said water can get behind there. 3. When the top of the eye washing station was wiped with a wet paper towel, DM F said, I saw dust. 4. Approximately ten slices of American cheese were stored in the reach-in cooler with a use-by-date of [DATE]. DM F said items in the refrigerator should be checked daily and any expired food should be discarded. On [DATE] at 12:05 PM, the drain line from the ice machine located on the second floor was observed to not have the required minimum one-inch air gap (an unobstructed vertical space between the end of the drain line and the flood rim of the floor drain). On [DATE] at 4:00 PM, the Nursing Home Administrator and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not. The 2013 FDA Food Code was reviewed and revealed the following: Section ,d+[DATE].117 Warewashing Machines, Automatic Dispensing of Detergents and Sanitizers. (B) Incorporate a visual means to verify that detergents and sanitizers are delivered Section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Section ,d+[DATE].13 Backflow Prevention, Air Gap: An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch.

Based on observation, interview, and record review, the facility failed to properly dispose of rubbish and maintain cleanliness of the outside garbage area, resulting in a potential for harborage of pests. Findings include: On 8/20/24 at approximately 12:15 PM, the outside dumpster area was observed with Maintenance/Environmental Director (M/ED) A. The two side doors of the commercial dumpster where observed opened. Food debris such as pizza crust, corn cob, and partial hamburger bun, was observed on the ground near the dumpster. A squirrel was observed noshing on the corn cob. M/ED A said the doors of the dumpster should be closed to keep the critters out. A review of the facility policy titled, Garbage and Pest Control, dated 11/30/14, documented in part the following: - Waste and refuse will be handled in a sanitary manner to prevent cross contamination or pest infestation. - The dumpster door must be kept closed at all times. On 8/23/24 at 4:00 PM, the Nursing Home Administrator and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not.

Based on interview and record review, the facility failed to implement an active water management plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the residents in the facility. Findings include: On 8/22/24 at approximately 10:30 AM the facilities building water management plan was requested from the maintenance supervisor (MS). A folder containing a document titled Water safety plan workbook was provided. A review of the facilities water safety plan workbook revealed that the facility assessment worksheet and water testing audits were not completed. A review of the included flow map revealed that it was inaccurate with listing for areas on the 4th floor which do not exist in the two floor facility. On 8/22/24 at 11:17 AM, during an interview, MS was asked to describe the facility's water management system. MS responded that all the sinks have an air gap. MS was asked if the air gaps are to prevent legionella. MS replied yes. The water management workbook was reviewed with the MS. The MS was asked if they were using the testing work sheets or logs. MS responded no maam. MS was asked if they are establishing control limits and monitoring water systems as instructed in the facilities workbook. MS stated, No, I do not do any testing of the water. MS was asked about the maintenance of the air conditioner units. MS explained that they do not do any preventative maintenance of the air conditioning units other than cleaning the filters. MS confirms that the workbook states that air conditioner units cause a significant risk of legionella, and that the workbook states preventative maintenance should be done and documented. MS was unable to provide documentation of air conditioner filter cleaning. On 8/22/24 at approximately 12:00PM a facility policy titled (Facility Name) Nursing Home Emergency Preparedness Guide Water Management Program was provided which stated the following: Policy: It is the policy of the facility to ensure that the facility has a plan that reduces the risk of growth and spread of legionella and other opportunistic pathogen in the building water systems. Fundamental information: Legionnaires disease is a severe form of pneumonia that often requires hospitalization and is fatal in about 10% of cases, and in 25% of healthcare associated cases. Legionnaires disease is caused by legionella bacteria. There are at least 60 different species of legionella, and most are considered capable of causing disease. Transmission: While legionella is found in natural [NAME] environments it can become a health concern in human made water systems (e.g. plumbing system of large buildings, cooling towers, certain medical devise) where conditions allow it to multiply and come in contact with vulnerable persons. People contract legionella by inhaling aerosolized water droplets containing the bacteria or, less commonly, by aspiration of contaminated drinking water. Cooling tower. Transmission can over via: Shower heads. Plumbing systems. Certain medical devices. Decorative foundations. Risk factors: Age > [AGE] years of age. Smoking. Chronic lung disease, such as emphysema or COPD. Immune system disorders due to disease or medication. Systemic Malignancy. Underlying illness, such as diabetes, renal failure or hepatic failure. Procedure: 1. Complete the CDC worksheet to identify building at risk for legionella growth and spread to identify needs for a water management program. Create the water management team. Identify and document the building description, including location, age, uses and occupants and visitors including the water system description (general summary, uses of water, aerosol-generation devices (e.g. hot tubs, decorative fountains, cooling towers) and process flow diagram. Identify vulnerable areas in the system and create a diagram to visually pinpoint areas for monitoring and control. Identify control measures, including points in the system where critical limits can be monitored and where control can be applied. Confirm procedures are in place, including verification steps to show that the program is being followed as written and validation to show that the program is effective. Document collection and transport methods and which lab will perform the testing if environmental testing is conducted. Water heaters should be maintained water temperature per the federal guidelines and document. Prevention measures include: check shower heads for dripping water and rust. Keep shower heads clean and change as needed and document. Clean ice machine according to (Facility Name) Nursing Homes ice machine cleaning schedule, document and ensure is not excessive standing water. On 8/22/24 at 3:39 PM, during an interview, the Administrator was asked to describe the facility's water management plan. The administrator explained that MS takes care of that and stated, did you talk to (MS) and did (they) show you the plan?. The Administrator stated, I know that we do not do any water testing unless there is a problem. The administrator was informed that the water management toolkit was not being utilized or implemented. Administrator was observed looking through the workbook and stated, I don't see it here. The Administrator was asked if the workbooks instructions should be followed and was asked what components should be included in the facilitys water management plan. The Administrator stated, It should include whatever the instructions say. I'm just trying to think why MS wouldn't have it. We just went through this last year. I'll have to ask MS if this is all we are supposed to use.

Based on observation and interview, the facility failed to maintain facility grounds in a clean and appealing manner. Findings include: On 8/20/24 at approximately 12:15 PM, the backyard of the facility was observed with Maintenance/Environmental Director (M/ED) A. Approximately 40 feet of outdoor planters were positioned along the outside of the building underneath residents' windows. There were four additional planters positioned along the sidewalk. The planters were visible from residents' rooms and the first-floor dining/activity room. The planters had not been maintained and contained weeds that had grown to be at least five feet tall. When M/ED A was queried about how residents might feel looking out their window at the overgrowth, he stated, It's not good. Also, along an exterior wall in the backyard, a downspout was detached about two feet from the gutter. On 8/22/24 at 11:50 AM, M/ED A said the weeds were at least five feet tall and there was no excuse for them to have grown like that. On 8/23/24 at 12:44 PM, the Nursing Home Administrator (NHA) said that maintenance employees should go out there and cut the weeds down. On 8/23/24 at 4:00 PM, the NHA and Director of Nursing was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not.

Based on observation, interview, and record review the facility failed to administer an accurate dose of medication (MiraLAX laxative) during an observation of medication administration (Med. Pass) for (R12). Findings included: On 8/21/2024 at 9:02 a.m., an observation was made with Licensed Practical Nurse (LPN) H 's morning med. Pass to R12 on the (100's Hallway). During a preparation of R12's morning meds by LPN H it was observed LPN H poured some powdered medication (MiraLAX Laxative) in a pill cup (measurement of 30 milliliters) by holding the pill cup up in the air without measuring the amount poured. LPN H then place the cup of powered medication with other medications already prepared on the medication cart and place the container of the medication back into the cart. As LPN H started to dilute the cup of powdered medication by pouring the medication into a cup of water was interrupted before doing so and was asked the measurement of the medication poured. LPN H said it should be one Scoop which comes to seventeen grams. LPN H said I am assuming it's the same as the cup size. LPN H said the scoop to measure that came with the medication had fallen on the floor about a couple of days ago. LPN H was asked should the medication be given if the measurement of one scoop (17 grams) was unknown. LPN H said I been giving it using the cup and I think the 30 milliliters cup is the same. After asking LPN H a second time should the medication be given without knowing the equivalent of one scoop, LPN H agreed and did not give the medication. On 8/21/2024 at 9:27 a.m., In the Hallway of unit 100, LPN H stated, I am ready to give the MiraLAX. LPN H measured the MiraLAX by using a purple cap which came with the medication calibrated for a measurement of seventeen grams and the equivalent of one scoop as ordered. LPN H was asked was the thirty milliliters pill cup the equivalent of one scoop. LPN H stated, No, it's measured half of the pill cup. LPN H said the pill cup was doubled the amount of the bottle cap measurement. LPN H said the resident had been getting double the amount ordered. According to the electronic medical record, R12 was initially admitted into the facility on [DATE] and readmitted into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, congested heart failure, and vascular dementia. R12's annually Minimum Data Set (MDS) with a reference date of 7/13/2024 indicated R12 had moderately cognition impairment with a BIMS (brief interview for mental status) score of 07/15. Review of the Physician's Orders start date of 6/11/2024 documented, MiraLAX Oral Powder 17 grams/Scoop give 1 scoop by mouth one time a day for prophylaxis (constipation). Review of the medication administration record revealed signatures indicating the medication was given daily. On 8/23/2024 at 1:02 p.m. the Director of Nursing (DON) was interviewed regarding the accurate measurement of the MiraLAX and the measurement of a prescribed medication. The DON said the nurse should not assumed the dosage of any medication and didn't need the scoop because everyone knows the purple cap on the bottle comes with the measurement of seventeen grams like it was ordered. According to the facility's 01/23 Medication Administration General Guidelines Policy: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so.

Based on interview and record review, the facility failed to adequately assess factors potentially related to weight status change for one high risk resident (R40) receiving 100% of his nutritional requirements through a feeding tube. Findings include: A review of the Admission Record for Resident #40 (R40) documented an original admitted [DATE] and readmitted [DATE]. R40's diagnoses included adult failure to thrive (FTT), unspecified protein-calorie malnutrition (PCM), Parkinsonism, and gastrostomy tube. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A review of R40's weight measurements documented in part the following: 2/9/24: 149.6# 3/8/24: 148.8# 4/19/24: 130# 5/14/24: 128.4# 6/14/24: 116.2# 7/12/24: 121# 8/15/24: 120# R40 experienced approximately 20% weight loss in six months. A review of nutrition notes and assessments documented in part the following: 1. A 4/19/24 progress note: Resident discussed at Nutrition at Risk meeting. Weight loss noted, awaiting reweigh. MD ordered MBS (modified barium swallow procedure) and fluids. 2. A 5/2/24 nutrition risk assessment: NPO (receiving nothing by mouth) on tube feeding: Jevity 1.5, two cartons three times daily. Provides 2133 - 2160 kcal/day. Resident readmitted with a peg tube and weight loss. Current feeding meets estimated needs. Monitor weight, healing and tube feeding tolerance 3. A 5/24/24 nutrition note: Resident discussed at Nutrition at Risk meeting related to weight loss 7.7% past 30 days. He now is meeting all estimated nutrition/hydration needs via enteral feeding. Some weight fluctuations noted since readmission. MD ordered labs. Continue current plan. 4. A 5/31/24 nutrition note: Resident continues to display significant weight loss. Vomiting and peg tube replacement noted past week. Current tube feeding order meets estimated needs. Monitor for tube feeding tolerance. 5. A 8/17/24 nutritional risk assessment: Jevity 1.5, two cartons three times daily. Provides 2133 - 2160 kcal/day. Resident readmitted . Current feeding meets estimated needs. Monitor weight and tube feeding tolerance. On 8/23/24 at 9:54 AM, an interview and record review were conducted with Registered Dietitian (RD) C. RD C said all residents on a tube feeding were considered high risk and are weighed weekly. In general terms, residents on a tube feeding receive a quarterly assessment unless there is a change in the resident's status, such as change in skin condition, weight fluctuation, intolerance to the tube feeding, or when they return from the hospital. The nurses monitor for tolerance to the tube feeding. RD C does not monitor tolerance to their feeding unless something comes up. RD C calculated R40's caloric needs to encourage gradual weight gain by using the calculation of 30 kcal/kg body weight plus an additional 500 kcal daily. R40 caloric needs were estimated to be 2136 kcal/kg per day. R40's Jevity 1.5 prescription provided 2133 kcal daily. RD C acknowledged that R40's current tube feeding order exceeded his nutritional needs and should promote gradual weight gain. RD C said she did not assess why R40 was not gaining weight. RD C said an assessment regarding a lack of weight gain would include an evaluation of diagnoses that impact an ability to gain weight such as alcoholism, PCM, Parkinson, FTT, and dementia. RD C said she would also evaluate if R40 was receiving his tube feeding as ordered. A review of R40's Medication Administration Records (MAR) documented the following: Zero ml of Jevity 1.5 was administered at 6:00 AM on 6/19/24, 6/20/24, 6/24/24 7/4/24, and 6:00 PM on 6/23/24. Only 240 ml of Jevity 1.5 was administered at 6:00 PM on 6/4/24, 6/5/24, 6/11/24, 6/12/24, 6/13/24, 6/14/24, 6/18/24, 6/19/24, 6/20/24, 6/21/24, 6/25/24, 6/26/24, 6/27/24, 6/28/24, 7/1/24, 7/2/24, 7/18/24, 7/30/24, 8/1/24, 8/2/24, 8/6/24, and 8/8/24. After reviewing R40's MARs, RD C acknowledged she was unaware R40 was not getting the full amount of prescribed Jevity 1.5. RD C said it was her expectation that R40 received the amount of formula prescribed. RD C said if it had been investigated earlier, questions could have been asked about why R40 was not receiving the amount of tube feeding formula prescribed. On 8/23/24 at 11:34 AM, the Director of Nursing said it was her expectation that residents on tube feedings receive their tube feeding according to the registered dietitian's recommendations and physician orders. A review of R40's clinical record did not document nursing progress notes regarding why R40 did not receive the full amount of prescribed tube feeding between 6/4/24 and 8/22/24 as previously documented. The DON said there should have been some documentation when the resident did not receive the full amount of tube feeding formula. On 8/23/24 at 4:00 PM, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not.

Based on interview and record review, the facility failed to notify physician of a low lab level in a timely manner for one resident (R55) reviewed for death in the facility. Findings include: A review of the Admission Record for Resident #55 (R55) documented an original admission to the facility on [DATE] and readmission on [DATE]. R55 died in the facility on [DATE]. R55's diagnoses included epilepsy. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment. Physician's orders documented R55's was prescribed divalproex (Depakote: an anti-seizure medication) 250 mg - 1 tab by mouth twice daily from [DATE] to [DATE] for epilepsy. Review of R55's seizure disorder care plan documented, Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. During record review and interview on [DATE] at 12:06 PM with the Director of Nursing (DON) the following was noted: 1. Laboratory collection received [DATE] documented a Valproic Acid (lab test for Depakote levels) of 18.5. The reference range for Valproic Acid was 50.0 - 100.0). 2. Nurse's note dated [DATE]: Physician reviewed abnormal labs, order for Stat Depakote/valproic level, (lab company) telephoned, no answer, voice message left and order requisitions faxed, confirmation received. Physician updated. Resident does not display any deviation from baseline cognition/functioning or seizure activity at this time. 3. Physician changed resident's order for divalproex sodium 250 mg to two tablets by mouth twice daily on [DATE]. The DON said the physician should have been notified of the valproic acid lab results when we received them. There was a delay in letting the doctor know. On [DATE] at 1:13 PM, Physician B said, When I noticed the valproic acid level I changed the Depakote dose. On [DATE] at 4:00 PM, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not.

Based on observation and record review, the facility failed to provide 80 square feet per Resident in multiple Resident rooms and at least 100 square feet for single Resident rooms, affecting 18 of 28 Resident rooms (#'s 104, 105, 106, 107, 108, 109, 110, 111, 113, 204, 205, 206, 207, 208, 209, 210, 211, and 213). Findings include: Observation of the Resident rooms on 8/23/24 at 10:00 AM, and review of the Facility Bed Count Information sheet revealed the following: ROOM # SQ. FT # OF BEDS 104 155 2 105 153 2 106 153 2 107 218 3 108 221 4 109 230 3 110 234 3 111 153 2 113 92 1 204 153 2 205 153 2 206 155 2 207 222 3 208 285 4 209 228 3 210 233 3 211 150 2 213 158 2 Each resident's room was observed. Cognitively intact residents were interviewed. No concerns were observed or reported.

Based on observations, interviews, and record review the facility failed to: (1) effectively clean and sanitize food service equipment, (2) effectively maintain food service equipment, and (3) effectively maintain the food production kitchen physical plan,t effecting 63 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and increased ambient air temperatures. Findings include: On 08/21/23 at 10:15 A.M., An initial tour of the food service was conducted with Dietary Manager A. The following items were noted: The mechanical ventilation hood, located above the (griddle, stove, oven), was observed non-functional. The food production kitchen was also observed extremely hot! Staff members were also observed perspiring profusely. The 2017 FDA )Food and Drug Administration) Model Food Code section 4-301.14 states: If a ventilation system is inadequate, grease and condensate may build up on the floors, walls and ceilings of the food establishment, causing an insanitary condition and possible deterioration of the surfaces of walls and ceilings. The accumulation of grease and condensate may contaminate food and food-contact surfaces as well as present a possible fire hazard. The Superior three-door reach-in cooler interior light bulb was observed non-functional. Dietary Manager A stated: I will have maintenance replace the bulb. Dry Storage Room: 2 of 4 overhead light bulbs were observed non-functional. The 2017 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. The microwave oven was observed missing the pull handle to open the unit. Dietary Manager A stated: I will have maintenance repair the unit. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. The Coffee Machine was observed soiled with accumulated and encrusted food residue. The backsplash, undersplash, dispensing spouts, and drip trays were also observed heavily soiled with accumulated and encrusted food residue. The [NAME] stand mixer was observed soiled with accumulated and encrusted food residue. The backsplash and spindle guard were also observed soiled with accumulated and encrusted food residue. Dietary Manager A stated: We never use the mixer. The Butcher Block table top was observed soiled with accumulated and encrusted food residue. The Butcher Block surface was also observed unsealed and absorbent (porous). The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Dry Storage Room: 1 of 2 overhead light assembly plastic protective lens covers were observed loose-to-mount (dangling from the light assembly). The 2017 FDA Model Food Code section 6-202.11 states: (A) Except as specified in (B) of this section, light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; or unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. The entire food production kitchen flooring surface was observed extremely worn and missing in several locations. Numerous vinyl flooring tiles were also observed missing, adjacent to the mechanical dish machine. The Janitor Closet flooring surface was observed extremely worn, cracked, missing. The Janitor Closet mechanical return air ventilation was observed non-functional. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. On 08/21/23 at 01:15 P.M., Food Production Kitchen ambient room temperatures were monitored utilizing an Etekcity Lasergrip1080 Infrared Thermometer. The following temperatures were recorded: Oven/Stove/Griddle - 127.5 degrees Fahrenheit Mechanical Dish Machine - 101.0 degrees Fahrenheit Cold Air Supply Grill - 92.8 degrees Fahrenheit Mechanical Ventilation Hood - 106.5 degrees Fahrenheit On 08/21/23 at 01:20 P.M., The mechanical ventilation hood assembly, located directly over the oven/stove/griddle, was observed non-functional. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. On 08/21/23 at 01:06 P.M., Three white Lifetime eight-foot resin tables were observed heavily soiled with accumulated and encrusted food residue, adjacent to the table perimeter within the Main Dining Room. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 08/22/23 at 12:13 P.M., Food Production Kitchen ambient room temperatures were monitored utilizing an Etekcity Lasergrip 1080 Infrared Thermometer. The following temperatures were recorded: Oven/Stove/Griddle - 109 degrees Fahrenheit Mechanical Dish Machine - 96.8 degrees Fahrenheit Cold Air Supply Grill - 92.1 degrees Fahrenheit Mechanical Ventilation Hood - 107 degrees Fahrenheit On 08/22/23 at 12:30 P.M., The mechanical ventilation hood assembly, located directly over the oven/stove/griddle, was observed non-functional. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. On 08/22/23 at 02:00 P.M., Record review of the Policy/Procedure entitled: Food Preparation Appliance Cleaning dated 07/2023 revealed under Policy: Small appliances (such as mixers and food processors) will be cleaned and sanitized after each use. On 08/22/23 at 02:15 P.M., Record review of the Policy/Procedure entitled: Cleaning and Sanitation of Food Service Areas dated 07/2023 revealed under Policy: The food service staff will maintain the sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. On 08/22/23 at 02:30 P.M., Record review of the Policy/Procedure entitled: Malfunctions and Repairs dated 07/2023 revealed under Policy: All malfunctions and repairs are reported to the food service manager and maintenance department.

Based on observations, interviews, record reviews,, the facility failed to provide a pest free environment (flies) for 1 (#60) of 19 sampled residents, effecting 63 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident discomfort. Findings include: On 08/22/23 at 02:10 P.M., Record review of the facility Pest Control Contract dated November 2022 revealed the following: We will provide service at your location twice per month. Service is to inspect and/or treat all common areas, kitchens, laundry rooms, administrative offices, and shipping and receiving areas. All patient rooms will be serviced by request. Free callback service will be provided as needed for contract-covered pests. Our services will cover the control of all common pests, such as rats, mice, roaches, silverfish, ants, sowbugs, pill bugs, and earwigs, as well as occasional invaders, such as crickets, centipedes, ground beetles, millipedes, and spiders. Control is defined as the periodic elimination of existing infestations and the limitation of re-infestation within practical limits. The control of pharaoh ants and carpenter ants. Fleas, bees, wasps, bed bugs, termites, pest birds, live animal removal, flying insects, mosquitoes, special power spraying and dusting, ULV treatments, pest proofing and building clean-outs will be provided at an additional cost. On 08/22/23 at 02:15 P.M., Record review of the facility Pest Control In-Service Sign-In Sheet dated (no date) revealed (Name of the Pest Control Technician) performed treatment services on 08/07/23 at 03:50 P.M. On 08/22/23 at 02:30 P.M., Record review of the facility Pest Control Company Completed Service Invoice dated 08/07/2023 revealed under Technician Notes: I checked and inspected throughout property perimeter, no new issues to report .I checked kitchen, storage, laundry, and maintenance shop .I placed extra glue traps at 1st floor nurse station for reported mice activity. No live or signs seen. On 08/23/23 at 11:05 P.M., An interview was conducted with Resident #60 regarding the environmental conditions within his room. Resident #60 stated: You see the flies over there by the air conditioner. Resident #60 also stated: We have flies in here all of the time. 46865 On 8/21/23 at 8:28 A.M., during medication administration for Resident #60, four flies were observed flying and landing on both Resident #60's bedding and his legs. On 8/22/23 at 2:09 P.M., an additional observation of Resident #60 was made during medication administration. Resident #60 was resting in bed with both legs elevated. A black scab, the size of a quarter, was seen on their left shin. One of the four flies in Resident #60's room landed on the scab and was present on the scab for one to two mintues. Following that one to two mintue time period, a second fly landed on top of the fly present on Resident #60's scab. When a fly lands on top of another fly in the manner that was observed, it means that the two flies are mating.

This citation pertains to intake MI00129934. Based on observations, interviews, and record reviews, the facility failed to effectively maintain ambient room temperatures between 71-81 degrees Fahrenheit effecting 63 residents, resulting in the increased likelihood for resident dehydration and discomfort. Findings include: On 08/21/23 at 03:20 P.M., Ambient room temperatures were monitored utilizing an Etekcity Lasergrip 1080 Infrared Thermometer. The following temperatures were recorded: Basement Conference Room: 81.7 - 82.0 degrees Fahrenheit * Resident room [ROOM NUMBER]: 82.5 - 84.0 degrees Fahrenheit * Resident room [ROOM NUMBER]: 85.0 - 88.9 degrees Fahrenheit * Resident room [ROOM NUMBER]: 84.5 - 85.8 degrees Fahrenheit * Resident room [ROOM NUMBER]: 84.2 - 84.7 degrees Fahrenheit * Resident room [ROOM NUMBER]: 84.5 - 87.0 degrees Fahrenheit * Resident room [ROOM NUMBER]: 84.7 - 88.9 degrees Fahrenheit * Resident room [ROOM NUMBER]: 85.1 - 88.3 degrees Fahrenheit * Resident room [ROOM NUMBER]: 84.1 - 85.7 degrees Fahrenheit * Resident room [ROOM NUMBER]: 82.5 - 82.8 degrees Fahrenheit * Bathtub room [ROOM NUMBER]: 84.6 - 85.8 degrees Fahrenheit * Resident room [ROOM NUMBER]: 83.3 - 84.2 degrees Fahrenheit * Resident room [ROOM NUMBER]: 81.4 - 82.0 degrees Fahrenheit * Resident room [ROOM NUMBER]: 83.4 - 83.8 degrees Fahrenheit * Resident room [ROOM NUMBER]: 85.0 - 87.0 degrees Fahrenheit * Resident room [ROOM NUMBER]: 86.4 - 87.1 degrees Fahrenheit * Resident room [ROOM NUMBER]: 86.3 - 87.4 degrees Fahrenheit * Resident room [ROOM NUMBER]: 83.1 - 86.5 degrees Fahrenheit * Bathtub room [ROOM NUMBER]: 84.7 - 85.4 degrees Fahrenheit * (*) Note: SOM (State Operations Manual) Appendix PP Section F584 states: The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- S483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81 F On 08/24/23 at 01:45 P.M., Record review of the Policy/Procedure entitled: Quality of Life - Homelike Environment dated 05/2017 revealed under Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Record review of the Policy/Procedure entitled: Quality of Life - Homelike Environment dated 05/2017 further revealed under Policy Interpretation and Implementation: (h) comfortable and safe temperatures (71-81 degrees Fahrenheit).

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 63 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased illumination, and decreased air quality. Findings include: On 08/22/23 at 03:20 P.M., A common area environmental tour was conducted with Environmental Services Director C. The following items were noted: Basement Staff Breakroom: The microwave oven interior was observed heavily soiled with accumulated and encrusted food residue. Auxiliary Office: The microwave oven interior was observed heavily soiled with accumulated and encrusted food residue. MDS (Minimum Data Set) Office: The microwave oven interior was observed etched and scored on the interior unit door. On 08/22/23 at 03:56 P.M., An interview was conducted with Environmental Services Director C regarding the facility maintenance work order system. Environmental Services Director C stated: We have a manual work order system. Environmental Services Director C additionally stated: We have two maintenance work order log books. One at each Nurses Station. On 08/23/23 at 08:40 A.M., A common area environmental tour was continued with Environmental Services Director C. The following items were noted: First Floor First Floor Nurse Station: 1 of 2 chairs were observed (etched, scored, particulate). Beige colored duct tape was observed on the countertop edge. The duct tape was severely worn, torn, etched. The laminate surface was also observed cracked, chipped, and/or missing in several locations. Soiled Utility Room: The plastic overhead light lens cover was observed (etched, scored, cracked). The interior surface of the light lens cover was also coated with dead fly carcasses and accumulated dust/dirt deposits. The exterior surface of the specimen refrigerator was additionally observed soiled with accumulated dust/dirt deposits. The exterior surface of the specimen refrigerator was further observed chipped and severely corroded. The specimen refrigerator was also observed without an internal thermometer to ensure appropriate temperature. Treatment Room: The ceiling drywall surface was observed unfinished with drywall tape dangling from the surface. Bathtub room [ROOM NUMBER]: 1 of 2 overhead light fixtures were observed non-functional and missing the protective plastic lens cover. The commode seat was also observed loose -to-mount. The commode base caulking was additionally observed (etched, cracked, missing). Restroom: The overhead light fixture was observed missing the protective plastic lens cover. Janitor Closet: The flooring surface was observed severely (worn, etched, scored, soiled, missing). Bathtub room [ROOM NUMBER]: The commode base caulking was observed (etched, cracked, missing). Restroom: The overhead light fixture was observed non-functional. Second Floor Restroom: The hand sink faucet was observed loose-to-mount. The toilet tissue dispenser was also observed broken. Bathtub room [ROOM NUMBER]: The commode seat was observed loose-to-mount. The commode base caulking was also observed heavily soiled and stained. 1 of 2 overhead light fixtures were further observed non-functional. Janitors Closet: The flooring surface was observed severely (worn, etched, scored, soiled, missing). Replace the flooring surface!! Bathtub room [ROOM NUMBER]: The commode base caulking was observed (etched, stained, soiled, cracked, missing). Restroom: The commode base caulking was observed (etched, stained, soiled, cracked, missing). Second Floor Nurse Station: Black colored duct tape was observed on the countertop edge. The duct tape was severely worn, torn, etched. The laminate surface was also observed cracked, chipped, and/or missing in several locations. On 08/23/23 at 10:25 A.M., An environmental tour of sampled resident rooms was conducted with Environmental Services Director C and Maintenance Technician D. The following items were noted: 100: The restroom commode base caulking was observed (etched, scored, stained, missing). 102: The restroom over sink light fixture was observed non-functional. 1 of 2 commode grab bars were also observed loose-to-mount. 104: The air conditioning unit filter was observed soiled with accumulated dust and dirt deposits. The Bed 1 privacy curtain exterior surface was also observed soiled with accumulated dust, dirt, and soil deposits. 108: The air conditioning unit filter was observed heavily soiled with accumulated dust and dirt deposits. 110: The air conditioning unit was observed missing the filter panel. 112: The restroom return-air exhaust ventilation grill was observed soiled with accumulated dust and dirt deposits. 201: The restroom door lock assembly was observed broken and loose-to-mount. 206: The air conditioning unit filter was observed heavily soiled with accumulated dust and dirt deposits. 207: The air conditioning unit filter was observed heavily soiled with accumulated dust and dirt deposits. 210: 1 of 3 overhead light fixtures were observed non-functional. The air conditioning unit filter was also observed heavily soiled with accumulated dust and dirt deposits. The hand sink faucet assembly was further observed loose-to-mount. 211: The restroom commode base caulking was observed (etched, stained, particulate, missing). 212: The restroom over sink light assembly was observed non-functional. The restroom bathtub interior surface was also observed (chipped, cracked, particulate). Note: The bathtub contained a shower head (only shower head within the entire building). The commode base caulking was further observed (stained, cracked, particulate, missing). On 08/23/23 at 01:45 P.M., Record review of the first floor Maintenance Work Order Log for the last 90 days revealed no specific entries related to the aforementioned maintenance concerns. On 08/24/23 at 01:45 P.M., Record review of the Policy/Procedure entitled: Quality of Life - Homelike Environment dated 05/2017 revealed under Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Record review of the Policy/Procedure entitled: Quality of Life - Homelike Environment dated 05/2017 further revealed under Policy Interpretation and Implementation: (2) The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: (a) clean, sanitary, and orderly environment.

Based on observation, interview, and record review, the facility failed to properly sanitize a glucometer and cleanse patient care equipment (blood pressure cuff, temporal scanning thermometer, and pulse oxygen meter) for three residents (R60, R52, and R28) out of six residents reviewed for infection control during medication administration, resulting in the potential for cross-contamination of germs between residents. Findings include: On 8/22/23 at 8:28 AM during medication administration for R60, Licensed Practical Nurse (LPN) E took R60's vital signs using blood pressure cuff, temporal thermometer, and pulse oxygen meter. After administering R60's medication, LPN E put the patient care equipment back on the medication cart without cleansing the equipment. On 8/22/23 at 9:03 AM LPN E administered medication to R52 and took R52's vital signs using the same blood pressure cuff, temporal scanning thermometer, and pulse oxygen meter that was used on R60. After administering R52's medication, LPN E put the patient care equipment back on the medication cart without cleaning the equipment. On 8/22/23 at 11:57 AM LPN E took R28's blood sugar using a glucometer machine. After testing R28's blood sugar, LPN E sanitized the glucometer with an alcohol pad. On 8/22/23 at 12:15 PM during an interview with LPN E regarding cleaning and sanitizing patient equipment and glucometers, he said he forgot to cleanse the patient care equipment that was used on multiple residents. LPN E said he should have cleansed the equipment in between uses for each resident. LPN E said there were Sani wipes to cleanse the glucometer machine and not an alcohol pad. On 8/23/23 at 11:08 AM during an interview with the Director of Nursing (DON), the DON state that it is her expectation and per policy that the equipment being used on multiple residents should be disinfected in between uses. On 8/23/23 at 1:11 PM during an interview with the Director of Nursing (DON), she said LPN E should have cleansed the glucometer with Sani-wipes (purple top container). Also, the DON said if the glucometer is not sanitized properly the machine could transmit germs to another resident that it is used on. A review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, with a revised date of October 2018 revealed, Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. A review of the policy titled, Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System, with a revised date of December 2017 revealed, Environmental Protection Agency (EPA) registered disinfectant product may be used to clean and disinfect the blood glucose meter .Super Sani-Cloth Germicidal Disposable Wipe.

Based on observation and record review, the facility failed to provide 80 square feet per Resident in multiple Resident rooms and at least 100 square feet for single Resident rooms, affecting 18 of 28 Resident rooms (#'s 104, 105, 106, 107, 108, 109, 110, 111, 113, 204, 205, 206, 207, 208, 209, 210, 211, and 213). Findings include: Observation of the Resident rooms on 8/23/23 at 1:00 PM, and review of the Facility Bed Count Information sheet revealed the following: ROOM # SQ. FT # OF BEDS 104 155 2 105 153 2 106 153 2 107 218 3 108 221 4 109 230 3 110 234 3 111 153 2 113 92 1 204 153 2 205 153 2 206 155 2 207 222 3 208 285 4 209 228 3 210 233 3 211 150 2 213 158 2

This citation pertains to intake MI 948 Based on interview and record review the facility failed to perform a complete physical assessment for one (R23) of two residents following an incident of resident-to-resident abuse, resulting in the potential for unaddressed physical complications resulting from the altercation. Findings include: On 5/25/22 at 10:00 AM during the initial tour R23 was observed sitting in a wheelchair in his room. The surveyor asked R23 if it was all right if he was asked a few questions. R23 shook his head yes. R23 was asked if he remembered getting into a fight with another resident that used to be in his roommate. R 23 looked up at the surveyor and stated yes he was talking smack (a slang term for speaking inappropriately to someone) to me. R23 refused to say anything else regarding the incident. A record review was conducted on 5/27/22 at 9: 43 AM. According to an incident report written on 12/21/21, at approximately 6:45 PM R23 was hit in the nose by the fist of another resident. Following the event LPN (E) observed blood under the nose of R23. After separating the residents, LPN (E) performed a pain and skin assessment on R23. According to the investigation report and nurse progress notes, R 23 received no additional post incident physical assessment on 12/21/21 or the following days. R23 was initially admitted to the facility on [DATE] with relevant diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS (minimum data set) with a reference date of 3/28/22, R23 scored 13/15 on the BIMS (Brief Interview Mental Status), indicating cognitively intact thought processes. On 5/27/22 at 10:59 AM, an interview was conducted with the Administrator regarding the lack of follow-up vital signs, neuro checks, etc. following the resident-to-resident incident. The Administrator stated, the former Director of Nursing noted the lack of follow-through with physical assessment and educated the nurse involved. According to the Administrator nurse (E) is no longer employed at the facility. The administrator acknowledged the minimal physical assessment following R23 receiving a strike to the nose from another resident as a concern. The administrator provided the surveyor a policy regarding incident investigations. The document entitled: Accidents and Incidents- Investigating and Reporting, with a revision date of July 2017. The policy interpretation and implementation section of the document indicated the condition of the injured person should be documented to include vital signs and follow-up information.

Based on observation and record review, the facility failed to provide 80 square feet per Resident in multiple Resident rooms and at least 100 square feet for single Resident rooms, affecting 18 of 28 Resident rooms (#'s 104, 105, 106, 107, 108, 109, 110, 111, 113, 204, 205, 206, 207, 208, 209, 210, 211, and 213). Findings include: Observation of the Resident rooms on 5/27/22 at 1:00 PM, and review of the Facility Bed Count Information sheet revealed the following: ROOM # SQ. FT # OF BEDS 104 155 2 105 153 2 106 153 2 107 218 3 108 221 4 109 230 3 110 234 3 111 153 2 113 92 1 204 153 2 205 153 2 206 155 2 207 222 3 208 285 4 209 228 3 210 233 3 211 150 2 213 158 2

This citation pertains to intake MI 839. Based on interview and record review the facility failed to provide adequate supervision to prevent an elopement in 1 of 5 residents (R901) reviewed for safety, resulting in an immediate jeopardy when, 7/14/21 at approximately 11:00 am R901, who was an assessed elopement risk exited through a door the facility staff left open and unsupervise during the unloading of supplies and was missing for two days in an [NAME] residential neighborhood. R901 was not found until 7/16/21 at approximately 1:55 PM when the Advocate (representative for patient rights) from a local hospital called to inform the facility he was at the hospital. This deficient practice had the likelihood of resulting in serious harm, injury, and or death for all 5 residents identified at risk for elopement. Findings Include: Record review on 8/23/21 of R901's face sheet revealed admittance to facility on 10/8/20 with diagnoses of diabetes mellitus, [CONDITION(S)] (mental disorder), and mild cognitive impairment. According to the Minimum Data Set (MDS) dated [DATE]. R901 had impaired cognition and needed supervision with most Activities of Daily Living (ADLs). Record review of Nursing Progress Notes dated 7/14/21 at 13:57 (1:57 PM) documented the following: CNA (certified Nursing Assistant) entered residents' room to deliver lunch tray, resident noted to not be in room, CNA checked resident's bathroom, made rounds throughout unit, and notified nurse that resident was missing. Resident last seen by writer at med pass at 11AM upon med(medicine) administration . Record review of R901's Elopement Care Plan documented the following: I have a high risk for elopement and associated injury related to exit seeking behavior and verbalizations of desire to exit (Date Initiated 10/14/20-Revision: 8/3/2021 . Record review of hospital records dated 7/17/21 at 11:57 AM documented. Final Report: R901 presents with concerns for being found down on the side of the street. Patient is a nursing home resident; patient reportedly left the nursing home on the noon of July 14. Police were out looking for the patient believed him to be in a shelter however today was found near the nursing home outside in the rain. Temperature 89F rectal on arrival. Initial EKG did swho prolonged QTC around 500 however patient was shaking a bed at the time and was still slightly hypothermic The Hospital Assessment indicated R901 had acute hypothermia, acute rhabdomylosis (A breakdown of muscle tissue that releases a damaging protein into the blood, lactic acidosis secondary to acute rhabdomylosis. R901 was admitted to the hospital. During interview on 8/23/21 at 2:15 PM with R901, it was confirmed that he left the facility last month. When asked why he did not return, R901 said, I didn't come back because I was lost. During an interview on 8/23/21 at 1:45 PM with Administrator A, it was confirmed that R901 eloped from the facility on 7/14/21 during a delivery of supplies to the facility. Administrator A confirmed the resident was located on 7/16/21 at approximately 1:55 PM, when a hospital advocate called the facility. Administrator A confirmed that on 7/14/21, R901 was documented in the facility's elopement book at each nursing desk (notebook that contains residents' picture and information). Administrator A stated, Staff members were not monitoring the door appropriately during delivery order. Record review of Elopement Policy revised 1/2019, documented the following: It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the premises of the facility without the knowledge of facility staff. On 8/23/21 at 2:40 PM, Administrator A was notified of the Immediate Jeopardy (IJ) that began on 7/14/21 due to the facilities failure to implement adequate supervision of R901. A written plan of removal for the immediate jeopardy was received and verified on 8/24/21. 1. Resident # 901 was returned to the facility on [DATE] at 22:17. He was unharmed and remains at the facility with no adverse effects from the incident. A full body assessment was completed by the charge nurse. He was placed on a q(every) 15-minute check and is currently on a q 2-hour check. His room was changed to reside in a room closer to the nurse's station. The social worker met with #901 to determine his mode of exiting on 7/14/21. The social worker continues to meet with resident to identify any changes in his psychosocial needs. Upon returning an incident report was filed. The Attending Physician visited resident and reviewed medications on 7/22/21. The Activity Director assessed resident for changes in his desire to go for walks. 2. All residents identified high risk on the elopement program elopement was assessed by the social worker on 7/19/21. All other residents were reassessed for elopement. All residents care plans were reviewed and revised if needed on 7/19/21. All residents upon admission and with significant change will be assessed for elopement. Their care plans will be reviewed and updated with interventions initiated for elopement prevention and placed on the CENAs Kardex. The elopement binder has been reviewed to ensure resident at risk were identified. The facility alarmed doors were checked and monitoring continues by the charge nurses and maintenance staff q day Q shift to ensure proper functioning. The facility conducted an elopement drill on 7/28/21 at 1:30pm. A new protocol was initiated on 7/22/21 for the delivery of stocks to ensure resident are monitored and remain safe. 3. The Elopement Policy and Procedure was reviewed by the Administrator and Social Worker and deemed appropriate. The staff received education in person and by phone on 7/14/21 and 7/15/21. Any staff that was not able to receive the in-service was not allowed to work prior to receiving education. The facility has completed 100% of the staff education on elopement on 7/16/2021. A new protocol was initiated to ensure staff monitors the Front Entrance during delivery. There will be always two staff employees during the delivery. A screener at the front entrance is allowed to assist with door monitoring if needed. The staff will notify the Administrator for any concerns related to malfunctioning door alarms or concerns with the monitoring during delivery of stock. On 7/26/21 all staff scheduled to monitor during delivery of stock received education related to stock delivery before the scheduled delivery date. The facility has completed 100% of the education on the protocol for delivery of stock. 4. The nursing staff completed audits of all door alarms q shift q day. The Maintenance Director/ Designee completed random checks of door alarms. The audits continues daily and at random by charge nurses and Maintenance staff. Any concerns are addressed immediately. At random during unit rounds the Administrator/ Designee will monitor to ensure the staff is following the protocol related to monitoring the door during delivery and the alarm monitoring logs. The Maintenance Director will monitor the door alarm logs and provide staff a one-on-one in-service. Any concerns will be addressed by the Administrator at the QA Committee meeting. The Director of Nursing will address any concerns with the elopement assessment and the CENA Kardex upon admission and quarterly. The Social worker will ensure the elopement binders are current and care plans are reviewed and revised. The Administrator will be responsible to ensure that compliance is sustained Although the immediate jeopardy was removed on 7/26/21, the facility remained out of compliance until 7/28/21, at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. On 8/24/21 State Agency found that the facility was in compliance as of 7/28/21.

Based on observation, interview and record review, the Facility failed to provide the necessary care and services to maintain the highest physical well being in accordance with the nutritional assessments and physician orders [REDACTED].#405, #416, #418) reviewed for swallowing difficulty and nutritional needs out of a total sample of 21 residents when Resident (#405) choked on meat that was served at the wrong texture. Staff performed the [MEDICATION NAME] Maneuver (first aid procedure for dislodging an obstruction from a person's windpipe); (CPR) cardiopulmomary resuscitation; and solicited Emergency Medical Services (EMS) who transported the resident to an area hospital where he was placed on mechanical life support. In addition, the Facility failed to prevent potential choking incidents for Resident #416 and Resident #418 when food and liquids were provided at the wrong texture and/or consistency. This deficient practice resulted in an Immediate Jeopardy and placed all residents at risk for serious harm, injury and/or death. Findings include: The Immediate Jeopardy was identified on [DATE] at 4:30 p.m. and the Administrator was notified at 5:15 p.m., on [DATE], and required to submit a removal plan for the immediate jeopardy. The facility was provided written notification of the Immediate Jeopardy at 10:47 a.m., on [DATE], upon initiation of an extended survey. Findings during the extended survey on [DATE], indicated that the removal plan to correct the Immediate Jeopardy had not been fully implemented and the Immediate Jeopardy was not removed. Subsequent to the continuation of the extended survey the Immediate Jeopardy was removed at 2:20 p.m., on [DATE], however the deficient practice remained at actual harm and the potential for harm that is not Immediate Jeopardy. Resident #405 On [DATE] at 12:20 p.m., a STAT staff call to the dining room was heard over the facility's PA (public address) system. At this time Resident #405 was observed seated in a chair with his lunch meal on the table in front of him. The staff were observed to be talking to the resident and rubbing the chest and back. The resident was placed into a wheel chair and upon exiting out of the dining room the resident was observed to be pale and unresponsive with a fixed wide eyed gaze. Staff were next observed performing chest compressions on the resident in a resident's room. The EMS arrived at approximately 12:32 p.m. and the resident was transported to an area hospital. On [DATE], at 12:25 p.m., the meal served to Resident #405 was observed and the meal ticket on the tray indicated, 'Mechanical Soft Diet. The food items observed on the resident's plate included half dollar sized scalloped potatoes; cooked cabbage which appeared sliced or shredded in pieces ,[DATE] to ,[DATE] inch wide that was cooked with bacon pieces 1 to 2 inches long; and baby back ribs observed as shredded and stringy with multiple lengths to one inch long and various widths; and three visible chunks of meat ,[DATE] to one inch in length and ,[DATE] to ,[DATE] width and depth. Each item filled about a third of the resident's meal plate. A bread roll was also included on the tray. Observation also revealed a piece of what appeared to be cabbage and a half inch long by ,[DATE] to ,[DATE] inch wide orange red colored piece of meat that was observed on a paper napkin on the tray surrounded by a slimy substance. This was at the eleven o'clock position relative to the rim of the plate. On [DATE] at 2:57 p.m., the medical record for Resident #405 was reviewed and revealed the following: A facility Incident Report/ Accident Record for Resident #405 dated [DATE] at 12:35 p.m., indicated: Resident was attempting to eat lunch and began coughing. Nurse 'D' had just sat down to assist with feeding. A Nurse progress note by Nurse 'D' dated [DATE] at 12:30 p.m., indicated. Resident was attempting to eat lunch and began coughing, [MEDICATION NAME] administered X 1, Resident became unresponsive, color pale, CPR started by staff and continued until 911, transfer to hospital. A physician order [REDACTED]. A physician order [REDACTED]. The order was signed by Nurse 'D'. Review of the nutrition/diet care plan in the resident's clinical record with last revision date of [DATE] revealed: will need a therapeutic diet, 1) provide me with a Mechanically altered diet as ordered by physician. Resident #405 was admitted into the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment dated [DATE], indicated a BIMS (brief interview of mental status) score of seven out of fifteen which indicated moderately impaired cognition. The MDS further indicated Resident #405 required supervision with meals and had a [DIAGNOSES REDACTED]. On [DATE] at 3:20 p.m., Nurse 'D' was queried why the diet order was changed from regular with chopped meat to mechanical soft and stated, He (Resident #405) was observed coughing during meals. Nurse 'D' was further queried if mechanical soft meant chopped or ground and stated, Ground. On [DATE] at 3:30 p.m., the DON (Director of Nursing) was queried about the choking incident and asked what she considered was the consistency of the meat observed on the plate of Resident #405 was replied, Chopped up. The DON was also queried what was meant by mechanical soft meat chopped or ground and stated, Chopped. It is interchangeable. On [DATE] at 3:35 p.m., the RD (Registered Dietician) staff 'E' was queried for the menu for the Mechanical Soft texture of the meal served at lunch to Resident #405 and upon review with the RD revealed a Week 1 menu with the entry Baby Back and across the row the word ground appeared in the column under the heading Mech Soft. The RD was then queried as to what ground meant and stated, Pea sized or smaller. On [DATE] at 3:40 p.m., the Administrator was queried related to the choking episode for Resident #405 and stated, CNA (certified nursing assistant) 'F' performed the [MEDICATION NAME] maneuver and bacon came out. On [DATE] at 11:45 a.m., CNA staff 'G' was queried about facility provided education or training received related to residents diets and stated, They showed us the difference between chopped, mechanical soft and pureed chicken. Chopped was small and in squares not bigger than peas. Mechanical soft was ground or finely shredded. Puree looked like applesauce. On [DATE] at 12:04 p.m., Nurse 'H' was queried about facility provided education or training on diet consistency and stated, Chopped was smaller than dice but larger than peas. Mech soft was shredded thinner and longer than peas, maybe a half inch long, like angel hair pasta. Puree like applesauce, finely ground. On [DATE] at 12:23 p.m., Resident #9 was observed to start eating their meal unassisted and nurse 'I' was observed to push the tray across the table away from the resident. Nurse 'I' was queried why this was done and stated, He is a feeder. He don't feed himself. A CNA then came pulled the tray back in front of the resident and assisted the resident to eat. On [DATE] at 2:15 p.m., Nurse 'D' was queried about the choking incident with Resident #405 and stated, I was about six feet away. He was already at the table sitting by himself. I noted he started coughing ,[DATE] times like trying to clear (something). I walked over and called (Resident #405's)name. CNA 'F' was there behind and he kind of stood up and (CNA 'F') gave the [MEDICATION NAME]. He was staring out. A stat call to the dining room was made. He had no response, no breath sounds and no vitals. On [DATE] at 2:25 p.m., CNA 'J' was queried about the incident with Resident #405 and stated, Some cabbage came out with saliva and (Resident #405) was drooling and never responded. On [DATE] at 2:30 p.m., CNA 'F' was queried about the incident with Resident #405 and stated, Another CNA called me over, (Resident #405) was apparently choking and holding the arms out like help me. I immediately stood him up and gave the [MEDICATION NAME] and cabbage came out. He was pale looking and then just went down. CNA 'F' was also queried about the training that the facility had provided regarding diets and replied, Mech soft is real fine, chopped. Shredded into little strips shorter than a pea. CNA 'F' was then queried what the meat and cabbage looked like on Resident #405's plate at the time of the choking incident and stated, Cut up like when you take it off the bone. Bigger than diced. On [DATE] at 1:11 p.m., CNA 'L' was queried about the education the facility provided on food texture and stated, The example had chicken in small squares larger than a pea (but smaller than a set of dice). Mech soft was ground up like taco meat. Puree was like baby food or mashed potatoes. On [DATE] at 1:55 p.m., Cook 'M' was queried about what the consistency of chopped meat should be and stated, Bone off. Ready to chew. From a one inch square to about six inches. Cook 'M' was further queried and stated, Mech soft is a real fine ground like bread crumbs. Puree is like baby food and applesauce. On [DATE] at 1:55 p.m., Cook 'N' was queried about what the consistency of mechanical soft meat and in particular ribs and stated, Mech soft means ground meat, well cooked pork, chopped and then blended, pulsed a couple time, chopped is small small dices, size of a pea. On [DATE] at 4:30 p.m., review of the hospital record for Resident #405 relevant to facility incident on [DATE], revealed the following: On [DATE]: presented to ED (emergency department) as medical code. Patient had reportedly choked at group home and became unresponsive. CPR was started and EMS arrived 15 minutes later. Per EMS report, delivered three shocks and brought to ED; asystole (no pulse) noted and CPR was continued. Respiratory: Intubated (plastic tube inserted via mouth or nose into to the trachea/windpipe to maintain airway and assist breathing), on Ventilator (machine to assist patient to breath.) admitted to ICU s/p [MEDICAL CONDITION] presumed due to aspiration event, with possible foreign body although CXR (chest x-ray) was clear. Unclear if and how patient allegedly choked on food and became unresponsive. Patient in guarded condition. The Patient is critically ill with the following active issues: [MEDICAL CONDITION], presumed due to aspiration event, possible foreign body. Prolonged QT (cardiac irregularity which leads to increased potential for a fatal cardiac irregularity) with potential Torsades (de pointes-special type of [MEDICAL CONDITION] as initiating event. General: Unresponsive, eyes open. Patient condition has high probability for clinically significant or life threatening deterioration and requires the highest level of physician preparedness to intervene urgently. On [DATE]: Was presented to the ED (emergency department) from a NH (nursing home) as a medical code possibly due to [MEDICAL CONDITION]. Cardiology was consulted to rule out any cardiac causes. Impression and plan: Post [MEDICAL CONDITION], most likely secondary to [MEDICAL CONDITION] (being without oxygen), food pieces were found during intubation. Pt (patient) was in asystole on arrival to ED, Chest x-ray showed no acute cardiopulmonary processes, EKG showed no acute ischemic (without oxygen) changes, echo (ultrasound of the heart) showed EF (ejection fraction-how well heart pumps) of ,[DATE]% with impaired relaxation pattern. Given the echo finding and no elevation in trops (troponin-blood cardiac marker) patient will not need an ischemic evaluation at this time. On [DATE]: Neurologic: poor prognostic indicators: myoclonic (muscle contractures) jerks, h/O (history of) decorticate posturing (significant [MEDICAL CONDITION]), no pupil or gag reflex. [MEDICAL CONDITION], likely [MEDICAL CONDITION] (being without oxygen) [MEDICAL CONDITION]. Resident #416 On [DATE] at 2:55 p.m., Nurse 'H' was asked to observe items on the bedside table in Resident #416's room and the following was observed: A dented half liter clear plastic bottle nearly full of clear (without opacity of thickened water). The bottle was identified with the resident's name in black marker and noted as Glacial Mist spring water on the label. A sixteen ounce Styrofoam cup about half to three quarters full of liquid was also on the table. Nurse 'H' was asked to stir the water in the Styrofoam cup and indicated it was lightly thickened. Nurse 'H' then called the resident's wife to query about the bottled water and was heard to tell the wife resident #416 had silent aspiration (a liquid may enter the lungs and not cause one to cough). On [DATE] at 3:00 p.m., Nurse 'H' was queried about thickened liquids for Resident #416 and stated, The wife wants (Resident #416) on regular, but the VA (Veterans Administration) says keep on nectar thick and that yes we're right (not the wife). On [DATE] at 3:25 p.m., Nurse 'H' was queried if lightly thickened meant nectar thick and stated, No. On [DATE] at 4:48 p.m., the DON was queried about the thickened liquids for Resident #416 and stated, There is no order for thickened liquids. It should be nectar thick. On [DATE] at 5:15 p.m., the medical record for Resident #416 was reviewed and revealed: Resident #416 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated moderately to severely impaired cognition with disorganized thinking. The MDS further indicated the need for limited assistance of one person with eating and a mechanically altered diet. A speech therapy note dated [DATE] which indicated, Immediate cough with thin liquids, much better with nectar thick. A speech therapy note dated [DATE] which indicated, Swallow eval completed, discussed with wife complications of thin liquids, inconsistent with cough and chin tuck. A Nutrition Care Plan with last dated [DATE] which indicated, Problem: I have a swallowing difficulty, Goal: no s/s (signs/symptoms) of aspiration. Plan: provide me with nectar thick fluids. A physician order [REDACTED]. Per wife request. A physician order [REDACTED]. D/C (discontinue) Regular ice water at bedside. 2. Nectar thick liquids at all times. A physician order [REDACTED]. An x-ray detail report dated [DATE] which indicated, Reason for study: aspiration. Impression: Diffuse [MEDICAL CONDITION] with no acute parenchymal (tissue and air sacs) disease. On [DATE] at 1:11 p.m., CNA 'L' was queried about thickened liquids and the education on what nectar thick should look like and stated, It should be thick but not like honey. You can still stir it. On [DATE] at 1:20 p.m., Nurse 'H' was queried about the proper consistency of liquids for Resident #416 and stated, I normally give them to (Resident #416). Generally I give water in small cups, about 100 cc (cubic centimeters). The night nurse prepared the cup that day ([DATE]). Nurses prepare the thickened liquids. Resident #418 On [DATE] at 12:28 p.m., Resident #418 was observed sitting outside the door of their room stated, I am waiting for my tray. I asked for the alternate. On [DATE] at 12:50 p.m., Resident #418 was observed sitting a wheelchair in front of and with legs underneath the over bed table. On the plate in front of the resident mashed potatoes were observed between the nine and twelve o'clock position and piece of rib meat at the six o'clock position. The rib piece was about one inch to one and a half inches by width and depth and about five inches long. It appeared as a rectangular block and was covered with an orange color. Resident #418 was able to pick at it with their fingers and pull smaller pieces from the block and placed them into the mouth. Resident #418 stated, It's just the way I like it. On [DATE] at 5:25 p.m., the medical record for Resident #416 was reviewed and revealed: Resident #418 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated intact to moderately impaired cognition with a BIMS score of 12 out of 15 and the need for supervision and set up with eating. A Communication between the consulting dietician and attending physician dated [DATE] which indicated, Resident is edentulous, nursing reports some difficulty with some meals. Recommend downgrade diet to chopped meat and slp (speech) evaluation. A nutrition care plan dated last [DATE] which indicated, I am edentulous I am having difficulty with some meals. I will receive a regular diet, chopped meats as ordered by physician. A Bedside Assessment of Swallowing Function dated [DATE] which indicated, Bridge/Dentures present: No. Patient has difficulties with the following consistencies: Thin Liquids. Swallowing problem observed: Slow oral transit time, Decrease A-P (anterior/front to posterior/back passage of the food) bolus, Decreased sensation. Recommendations: Diet consistency: chopped diced. A speech evaluation dated [DATE] which indicated, [DATE], patient seen with dinner with regular and ground and chopped meat unable to do regular. A physician order [REDACTED]. On [DATE] at 6:05 p.m., The dietary Manager was queried about the entree of un-chopped, un-sliced un-shredded rib meat Resident #418 consumed for lunch and indicated, I gave (Resident #418) a chopped ground turkey. I prepared it myself. We were out of ribs. I prepared it myself. We do have a new dietary aide, staff 'K' (here about a month and a half) that delivered the tray. The following Plan of Correction to remove the immediate jeopardy was submitted by the facility: On [DATE] at approximately 12:30 p.m., resident #405 was observed consuming his lunch meal and began to coughed. The diet resident #405 was consuming consisted of Au Gratin Potatoes (was boiled, cooked tender, then baked and was fork mashable, Cabbage with bacon boiled and cut in Y2 inch pieces (cooked tender and easily mashed with a fork), Barbecue Ribs (cooked to tender, Mech. Altered fork mashable, shredded and served with Barbecue Sauce), Cornbread, and Pineapple upside down cake. The staff nurse in the dayroom assessed resident #405, a stat call to the dining room was made. The [MEDICATION NAME] maneuver was performed on resident #405 observation of piece of cabbage was expelled from resident #405. Resident #405 was immediately removed from the dining room and assisted to bed to further assess his clinical status and was noted without vital signs. Nurses initialed CPR., 911 was notified and resident was transferred to the hospital. Resident #405 currently is in the hospital on Ventilation Support. On [DATE] the Dietary Manager performed a house wide chart audit for 20 of the 61 residents identified who have a potential to be affected by the same deficient practice. Out of the 61 residents 5 have a [DIAGNOSES REDACTED].>Residents with mechanically altered diets and/or a [DIAGNOSES REDACTED]. Dietary and Nursing staff were reeducated on proper consistency of a Mechanically Altered Diet along with reviewing of the meal ticket prior to serving to ensure correct consistency of food on [DATE]. Bowls of meats ground and chopped was utilized to identify the different textures. The staff was educated in recognizing Mechanical Altered diet which consist of food texture which is very tender, small pieces, shredded, chopped or ground and well moistened with gravy, broth or cream sauce. The staff will observe pictures of different textures and sizes of Mechanically Altered meat. Seven (7) Dietary staff, Twenty-four (24) CNA'S and Fourteen (14) nurses received an in-serviced on [DATE]. There are 4 CENAs and 7 part -time nurses that will receive the mandatory in-service on how to properly identify and Mechanically Altered Diet, before allowed to work. No dietary or nursing staff was allowed to work prior to receiving in-service on how to properly identify a Mechanically Altered Diet. The meal trays will be checked by the cook and/or designee at the end of the tray line/prior to serving to ensure the diet is consistent to meal ticket. Any concerns will be addressed immediately and reported to the dietary manager. The dietary manager or designee will check preparation of mechanically altered diets to ensure this potentially deficient practice does not recur. The check will be performed for breakfast, lunch and dinner for daily for 2 weeks, then 3 times a week for 2 weeks, then random checks 3 times a week continuously. During all meal time, the Director of nursing or designee will perform checks of resident's diet and compare the to the physician's orders [REDACTED]. Any concerns will be addressed immediately with a report to the Dietary Manager. The Dietary Manager will report to the Quality Assurance Committee the results of these audits. Resident #418 chart was reviewed by the Dietary Manager for the proper consistency of food. The dietary manager reviewed the care plan to ensure the proper consistency was documented. The dietary manager initiated a protocol for dietary and nursing staff to ensure that Alternate Diet request are provided for the resident requesting an Alternate. When a resident requests an alternate food item, the request will be call to the kitchen staff. The Alternate will be prepared by the dietary staff and delivered to the floor nurse. The charge nurse will double check the diet with the name on the tray prior to delivering to the resident. The charge nurse and dietary staff will sign off on the Alternate log to indicate the resident received the correct diet ordered. The dietary aide will remove the unwanted food item and take back to the dietary department. Any concern will be addressed immediately. The Dietary manager will review the alternate log weekly. On [DATE] the dietary, nursing and activity staff received an in-service on the new system related to delivery of an Alternate Diet to the floor. As of [DATE], 11 nurses, 18 Cenas, 6 dietary staff, 1 social worker and 2 activity staff received the in-service. The log will be monitored by the Dietary Manager daily each meal to ensure the residents are receiving the correct diet as physician's orders [REDACTED]. The Dietary manager will report finding to the Quality Assurance Committee. The Administrator is responsible for sustained continuous compliance of the plan of correction. Resident #416 room was immediate checked for bottled water at his bedside. The Styrofoam cup at the bedside was checked to ensure the consistency was Nectar thick. The water was the nectar thick consistency. Resident #416 Care plan and Care Card was reviewed to indication the consistency of fluids served at meal time and or at the bedside. On [DATE] the dietary manager performed an audit for 6 of the 60 residents identified who have a potential to be affected by the same deficient practice. The audit included a review of the physician's orders [REDACTED]. The 11 nurses, 18 cenas, 6 dietary staff, 2 activity staff, and 1 social worker staff received an in service related to resident receiving thicken liquids per physician's orders [REDACTED]. The charge nurse received a one on one in service on [DATE] related to how to ensure residents receive Thicken Liquids as ordered by the physician. On [DATE], the social worker informed Resident #416 wife to remove all bottled water from resident's room prior to leaving post visit. The staff will perform q 30-minute check of resident #416 room for 1 week, then q shifts for 1 week, then a random for 2 weeks to ensure the proper consistency of water is at the bedside. During shift change and medication pass the charge nurse will observe residents' nightstand to ensure water is the proper consistency. Any concerns will be addressed immediately. During rounds the Director of nursing or designee will perform daily checks for 2 weeks to ensure resident receiving thicken water is placed at the bedside, if no discrepancy noted, random checks will be performed. Any concerns will be addressed immediately with a report to the Dietary manager. The Director of Nursing will report to the Quality Assurance Committee the results of findings. The Administrator is responsible for sustained continuous compliance of this plan of correction. Compliance date [DATE]. ( and )