Every finding on record at Heritage Oaks

Based on observations, resident and staff interviews, and a review of the facility's policy titled Preventative Maintenance Schedules, the facility failed to repair the furniture in one of 43 rooms (room [ROOM NUMBER]) and failed to ensure a homelike environment in four additional rooms (Rooms 101, 102, 103, and 107). Identified issues included a broken bed footboard, cracked and taped windows, holes in walls, loose baseboards, rusty door jambs, a missing bathroom door, and stained ceilings and floors. These deficiencies increase the risk of infection and injury and do not support a safe, clean, and homelike environment.Findings Include:Review of the facility's policy titled Preventive Maintenance Schedules documented the following INTENT: It is the intent of this center that preventive maintenance schedules be developed and implemented to ensure that the building and equipment are maintained in a safe and operable manner.1.Observation and interview with R14 on 04/14/2026 at 9:55 AM revealed that the bed in room [ROOM NUMBER] had exposed broken particles on the right patient side of the footboard. R14 reported that maintenance was aware of the broken area. She stated the footboard had been broken for four months.Observation on 04/14/2026 at 2:49 PM revealed that the bed in room [ROOM NUMBER] continued to have exposed broken particles on the right patient side of the footboard. R14 reported she was told that maintenance ordered a replacement that would take three months to arrive.Observation on 04/15/2026 at 9:15 AM revealed that the room [ROOM NUMBER] bed footboard continued to have a broken area with exposed particles on the right side of the residents footboard.Observation and concurrent interview with the Maintenance Supervisor on 04/16/2026 at 9:41 AM revealed that the room [ROOM NUMBER] bed footboard had a sharp exposed particle on the patient side. He stated he was not sure how long the footboard had been broken. He stated he could not replace the bed because no other electric bed was available. He reported that he ordered the replacement part last month but did not have a receipt of the order.2.Observation on 04/14/2026 at 10:06 AM revealed that room [ROOM NUMBER] had a broken window with tape placed over the cracked area.Observation on 04/14/2026 at 2:54 PM revealed that the window crack was taped to prevent it from spreading, according to R48. The window header was exposed.Observation on 04/15/2026 at 9:59 AM revealed that room [ROOM NUMBER] had tape covering cracks in both the top and bottom windowpanes. The window header remained exposed.Observation and concurrent interview on 04/16/2026 at 9:41 AM with the Maintenance Supervisor revealed that during landscaping, rocks were blown into the window, creating the crack. Tape was placed to keep the crack from spreading. He stated he was unsure how long ago this occurred. He reported that repairs are entered into TELS (electronic maintenance system) but admitted the crack was never entered into TELS, calling it an oversight.3.Observation on 04/14/2026 at 10:37 AM revealed that room [ROOM NUMBER] had a hole in the wall and a baseboard coming off the wall under the window next to Bed B.Observation on 04/14/2026 at 2:43 PM revealed the same hole in the wall and loose baseboard under the window next to Bed B.Observation on 04/15/2026 at 9:56 AM again revealed a hole in the wall and a baseboard coming off the wall under the window next to Bed B.Observation and concurrent interview on 4/16/2026 at 9:41 AM with the Maintenance Supervisor confirmed the hole in the wall and the loose baseboard. He stated a bed had run into the wall. He reported he was not aware of the damage.4.Observation on 04/14/2026 at 10:48 AM of room [ROOM NUMBER] revealed a dark black stain on the ceiling tile above Bed A. A brown stain was observed on the ceiling tile above Bed B. A brown rusty stain was noted on the ceiling tracking. A stain on the floor extended from the dresser under the window to the closet next to Bed B.Observation on 04/14/2026 at 2:48 PM of room [ROOM NUMBER]revealed rusty brown discoloration on the ceiling strips holding the tiles in room [ROOM NUMBER]. A brown substance was observed on the floor under the window. The ceiling tiles above Bed B had a brown stain. A dark black substance was observed above Bed A.Observation on 04/15/2026 at 9:44 AM of room [ROOM NUMBER] revealed a dark black spot on the ceiling tile above Bed A, a brown stain on the ceiling tile above Bed B, and brown rusty spots on the ceiling tracking. A brown stain remained visible on the floor from the dresser, under the window, and to the closet.Observation and concurrent interview with the Maintenance Director on 4/16/2026 at 9:41 AM confirmed the ceiling stains in room [ROOM NUMBER], the floor stain, and the rusty stains on the ceiling tracking. He stated he did not have a routine plan to replace ceiling tiles or ceiling tracking. He admitted the ceiling tiles needed to be replaced and acknowledged he was not aware of the condition, calling it an oversight. He stated he could obtain short tracks to replace or clean and prime the tracking.5.Observation on 04/14/2026 at 10:55 AM of room [ROOM NUMBER] revealed that the baseboard between the exterior door and bathroom entrance in room [ROOM NUMBER] was coming off the wall. The bathroom door was missing. A brown rusty stain was observed along the bathroom door jamb.Observation on 04/14/2026 at 2:42 PM of room [ROOM NUMBER] revealed the same loose baseboard, missing bathroom door, and brown rusty stain on the left side of the door jamb.Observation on 04/15/2026 at 9:50 AM revealed that the baseboard remained loose, the bathroom door was still missing, and a rusty brown stain was present on the left side of the door jamb.Observation and concurrent interview on 4/16/2026 at 9:41 AM with the Maintenance Director confirmed the loose baseboard, rusty stain on the door jamb, and missing bathroom door. He stated the door was removed because the resident could not access the bathroom. He stated the room was set up for two residents. He admitted he was not aware of the loose baseboard or rusty stains. He stated he did not have a scheduled plan to routinely check rooms and that repairs are addressed as they are reported. He stated that anyone-including nurses, certified nursing assistants, and leadership-can enter a repair into TELS. He reported that he becomes aware of repair needs only when they are entered into TELS.Interview on 04/16/2026 at 10:19 AM with the Director of Nursing revealed that the facility utilizes the TELS system for maintenance needs. She reported that anyone, including nursing and certified nursing assistants, can enter repair requests into TELS. She stated that staff should enter repair needs immediately.Interview on 04/16/2026 at 10:40 AM with the Administrator revealed that everyone is responsible for reporting repairs. Repairs are to be entered into the TELS system, which alerts maintenance. Reporting should be completed within the shift unless the repair is an emergency. The TELS program includes a schedule for routine maintenance. All leaders are to evaluate the environment and resident grooming daily, entering rooms with resident permission. Depending on the repair, most can be completed within 8 hours unless outside services are needed. She reported that beds can be swapped out and that a bed would be taken out of service to determine the needed repair.

Based on observations, staff interviews, record review, and review of the facility's policy titled Patient's Plan of Care, the facility failed to develop or implement a comprehensive, person centered care plan for one of 33 sampled residents (R) (R3). This deficient practice had the potential to place R3 at risk for unmet needs, medical complications, and diminished quality of life.Findings Include:Review of the facility's policy titled Patient's Plan of Care documented the following GUIDELINE: Each patient will have a person-centered comprehensive care plan developed and implemented to address the patient's medical, physical, mental, and psychosocial needs while also honoring their preferences and goals.Review of the Quarterly Minimum Data Set (MDS) assessment for R3, dated 03/26/2026, revealed Section C (Cognitive Patterns) with a Brief Interview for Mental Status (BIMS) score of 09, indicating moderate cognitive impairment. Section I (Active Diagnoses) revealed diagnoses including, but not limited to, anxiety, bipolar disorder, muscle weakness, and urinary retention. Section N (Medications) revealed that the resident was receiving an antipsychotic, an antidepressant, and an opioid.Review of the care plan for R3 dated 01/29/2026 revealed that antidepressant use was not addressed.Review of physician orders for R3 dated 12/18/2025 revealed an order for fluoxetine 40 milligrams (mg), one capsule orally daily, for a diagnosis of bipolar depression.Review of physician orders for R3 dated 01/20/2026 revealed an order for trazodone 100 mg, one tablet orally at bedtime, for a diagnosis of insomnia.Review of physician orders for R3 dated 01/20/2026 revealed an order for antidepressant medication use (trazodone). The order instructed staff to observe the resident closely for significant side effects including dry mouth, blurred vision, constipation, urinary retention, hypotension, appetite changes, headache, insomnia, and weight changes. Special instructions included observing sadness, negative comments, depressed mood, rejection of care, and withdrawal.Review of physician orders for R3 dated 02/10/2026 revealed an order for antidepressant medication use (fluoxetine). The order instructed staff to observe the resident closely for significant side effects including dry mouth, blurred vision, constipation, urinary retention, hypotension, appetite changes, headache, insomnia, and weight changes. Special instructions included observing sadness, negative comments, depressed mood, rejection of care, and withdrawal.Interview on 04/15/2026 at 4:31 PM with the Registered Nurse MDS Coordinator revealed that R3's care plan did not address antidepressant use. She confirmed that antidepressants are required to be included in the care plan. She stated that templates were available for antidepressants and for trazodone. She reported that residents are discussed each morning, including review of antipsychotic and antidepressant medications, and that new medications should be added to the care plan.Interview on 04/16/2026 at 10:19 AM with the Director of Nursing (DON) revealed that residents who are prescribed psychotropic medications, antidepressants, and other high risk medications should have these reflected in their care plans. She stated that if a resident receives a new medication, the care plan would be updated during morning meetings or during the weekly team meeting.

Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration-General, the facility did not ensure that medication was administered as ordered by the medical provider for one resident (R7) of 33 sampled residents. This practice had the potential to place R7 at risk for a clogged gastrostomy tube, medical complications, worsening health conditions, and hospitalization.Findings Include:Review of the facility's policy titled, Medication Administration-General, effective date 04/15/2025 under GUIDELINE documented. Medications are administered in accordance with a valid prescriber order. If a medication order is unrelated to the patient's current diagnoses or condition (s), the prescriber is contacted for clarification prior to administration of the medication. The interaction with the prescriber is documented in the nursing notes or elsewhere in the medical record as appropriate.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R7 under Section I (Active Diagnosis) revealed diagnoses that included, but not limited to, hypertension, Cerebral infarction due to thrombosis of right middle cerebral, gastrostomy status, anxiety disorder, gastrostomy infection, and dysphagia.Review of care plan dated 04/10/2026 revealed resident has potential complications related to anticoagulant therapy with interventions to include administer anticoagulants as ordered, monitor lab work as ordered, and observe for signs of active bleeding. Resident requires feeding tube related to dysphagia. She will not exhibit signs of complications from feeding tube or enteral feeding solution. Interventions include check placement and patency of feeding tube before feeding or medication administration.Review of physician order dated 03/13/2026 for R7 for Eliquis (apixaban) 2.5 milligrams (mg) one tablet via g-tube (gastrostomy tube) twice a day. May crush tablet and suspended in 60 ml (milliliters) of water or D5W (dextrose 5% water solution) and deliver immediately through g-tube.Observation and interview on 04/15/2026 at 7:53 AM with Registered Nurse (RN) AA revealed that RN AA crushed medications separately and administered each medication separately for R7. She mixed each medication with 10-15 ml of water. She confirmed that she mixed Eliquis (anticoagulant) in 15 ml of water then administered medication. She confirmed that medication order read to suspend or mix Eliquis in 60 ml of water or D5W. She confirmed that she should follow the order. Interview on 04/16/2026 at 8:54 AM with RN BB revealed that medications can have special instructions that are in the doctor's order. The nurse should follow the doctor's orders. Interview on 04/16/2026 at 10:19 AM with Director of Nursing (DON) revealed that medications can have special instruction that are on the orders. This prints on the order and medication administration record. This part of giving the medication and part of the order. Nurses are to follow physician orders.

Based on observations, interviews, and review of the facility policy titled, Storage Areas, the facility failed to ensure food was not expired, were properly labeled and dated, and were properly sealed in accordance with professional standards for food service safety as required for 52 census residents who received an oral diet. These failures had the potential to lead to food-borne illness among all facility residents. Findings include: Review of a facility's policy titled, Storage Areas, dated [DATE], revealed It is the intent of this center to store food in a manner that maintains quality and safety .Items should be covered, sealed, labeled, and dated appropriately .Food should be properly stored to prevent cross contamination .Food codes and internal tools may be used as a reference for proper dating .Freezer .Area should be kept in good working condition. During an initial kitchen observation on [DATE] at 7:43 am, it was revealed: In the walk-in refrigerator: -An open five-pound carton of cottage cheese with a Best by [DATE]. -An open ten-pound carton of Peeled Hard Cooked Eggs with a Use by 6 [DATE] on the side. There was a sticker on the side of the carton that revealed [DATE] exp [DATE]. -Two opened metal trays of shredded cooked meat covered in plastic wrap. Neither was dated or labeled. -A large container of soup was opened and covered with aluminum foil. It was not dated or labeled. In the walk-in freezer: -A large plastic container of frozen chicken pieces. The container had a sticker that had Prepared Date ,d+[DATE] and Use By ,d+[DATE] on the side of the carton. An undated poster was observed on the wall that revealed Labeling and Dating-Receive Date, Expiration Date, Open Date, Use by Date, and First in First Out. During an interview on [DATE] at 8:07 am, Cook1 stated that cooks and dietary aides had checklists that they were all responsible to follow. Cook1 said that they were all responsible for checking dates and labels on food items. During an additional kitchen observation on [DATE] at 8:30 am, the Dietary Manager (DM) stated that she was responsible for making sure food items were dated and labeled, and that she did that regularly. Upon reviewing the food items in the walk-in refrigerator, she confirmed the meat and soup items should have been dated and labeled. She confirmed the expired food items should have been thrown away. Upon review of the frozen food items, she believed the chicken may have had the wrong dates posted on the carton. The DM removed these food items. During an additional kitchen observation on [DATE] at 12:30 pm with DM, the walk-in freezer was observed to have a leak under the compressor, along the back wall. Ice was observed frozen in a baseball-size chunk along the pipe. Water was observed to have frozen along the tops of cardboard boxes of food below the leak, approximately 18 inches below. An approximate 20-pound cardboard box of garlic knot bread rolls was also observed below the compressor, with the lid ajar. Ice was visible on the top of the cardboard box lid where water from the compressor leak had frozen. The bread rolls were not secured tightly in the plastic bag inside the box, exposing them to the air and the water leak above. During a concurrent interview on [DATE] at 12:35 pm, the DM and Registered Dietitian (RD) were not aware the bread rolls were not properly secured inside the plastic bag in the walk-in freezer, below the water leak. They confirmed the food should have been properly sealed. The DM and RD confirmed that the walk-in freezer had a leak and caused a buildup of ice where food had been stored. They stated they would move items away from the leak until the walk-in freezer was repaired. The RD and DM both confirmed expired food items should have been tossed, and food should always be dated and labeled.

Based on observations, interviews, record review, and review of the facility policy titled, Skilled Nursing Services, Validation of Record Entries/Legal Documentation, the facility failed to apply a physician ordered neck brace displayed on the Treatment Administration Record (TAR) for one of one resident (Resident (R) 48) of 22 sample residents. This failure to apply R48's neck brace could result in further damage to her neck. Findings include: Review of facility's policy titled, Skilled Nursing Services, Validation of Record Entries/Legal Documentation, dated 12/27/2024, revealed It is the intent of this center to maintain accurate, complete and organized clinical information that is accessible for resident care .documentation will follow standards of practice for clinical and legal documentation. Review of R48's electronic medical record (EMR) titled Face Sheet located under the Resident tab, indicated the resident was admitted to the facility on [DATE] with unspecified fracture of T11-T12 [thoracic] vertebra, unspecified displaced fracture of fourth cervical vertebra, and unspecified fracture of first thoracic vertebra. Review of R48's EMR titled Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/6/2025, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. The assessment indicated the residents required extensive assistance from two staff members for bed mobility and transfers. Review of R48's EMR titled Physician Orders located under the Resident tab and dated 12/4/2024, indicated [R48] is to wear neck brace when out of bed. During an observation on 3/30/2025 at 11:30 am, R48 was sitting in the dining room waiting for lunch to be served. R48 did not have on her neck brace. During an observation on 3/30/2025 at 2:30 pm, R48 was observed in the facility entrance area sitting in her wheelchair with no neck brace on. Review of R48's TAR located under the Facility tab of the EMR, dated March 2025, indicated R48 neck brace was applied as ordered during the day and night shifts. Further review of the TAR for 3/30/2025 revealed R48 neck brace was applied. Review of R48's EMR titled Care Plan located under the Resident Assessment Instrument (RAI) tab and dated 12/16/2024, revealed [R48] has complaints of acute pain R/T [related to] has fracture T11-T12 vertebra. During an interview on 3/31/2025 at 11:20 am, Certified Nurse Aide (CNA) 1 stated R48 was supposed to have a neck brace on anytime she was out of bed. CNA1 stated it has been a while since I have seen her wearing it.

Based on observations, staff interviews, and review of facility policies titled, Food and Nutrition, and Cleaning and Sanitizing the facility failed to maintain a clean and sanitary kitchen. The facility also failed to ensure that the ice machine in the main kitchen was clean and sanitized. Specifically, the facility failed to ensure that the deep fryer, floor, stainless steel counter, and oven were clean and sanitized on a routine basis. The deficient practice had the potential to affect 58 out of 58 residents receiving an oral diet. Findings Include: Review of facility policy titled, Food & Nutrition dated November 2016 under; Sanitary Conditions four (4). store, prepare, distribute, and serve food under sanitary conditions. Review of undated facility policy titled, Cleaning and Sanitizing under Procedures: b. cleaning logs/schedules are available for all areas of the kitchen and retail areas. (Dish room, tray line, production, dry storage, walk-ins, freezers, refrigerators, offices, beverage dispensers, cafeteria, etc.) d. cleaning logs/schedules document dates to clean, position that cleans, position that monitors and dates evidencing cleaning. Observation on 2/3/2023 at 7:46 a.m., the initial tour of the main kitchen revealed an observation of the stove top with buildup and debris around burners of gas burning stove. Continued observation of stove revealed the oven door had large amount of brown dried substance from the rim of the door to the middle aspect of the door. Further observation also revealed that the edge of the oven door had a thick layer of black crusted substance noted as well on both doors. Further observation of the oven also revealed on the second oven door there was a thick buildup of a dark brown substance on the left top inside of the door. As well as a thick black substance noted to the base of the oven. The floor to the right of the fryer had a white watery substance noted on the floor that was near a drain cover that was not secured to the floor, the area also had a black substance that was built up around the edges of the drain. The deep fryer was covered in a thick layer of grease in the bottom casing area where the oil is drained. Observation on 2/3/2023 at 7:55 a.m. of the ice machine stored in main kitchen revealed there was a black substance that was noted on the inside of the machine along the bottom and top lip where ice is dispensed. Outside of machine had thick white chalk like substance around the rim of the machine by the hinges as well as to the bottom of the machine along the bottom edge. There was also white chalk like streaks running down the side of the machine on both sides. Observation on 2/3/2023 at 8:00 a.m. of double oven located on the opposite side of the main stove revealed that there was black debris noted on both doors at the top of the doors and the glass portion of the oven doors were covered in a dark brown film with dark brown steaks noted running down the inside of the glass. There was also noted a large baking pan on the base of the oven with black substance in the base of the pan as well as to the base of the oven floor. The outer rim of the oven was covered with a brown greasy substance as well. Observation on 2/3/2023 at 8:05 a.m. of the coffee station revealed there was a white chalky substance noted on the stainless-steel table the coffee dispenser was stored on. During observation it was also noted that the plexiglass (sneeze guard) on the steam table was covered in dried food particles and debris. Observation on 2/3/2023 at 8:10 a.m. of cart stored to the right of the steam table revealed that there were clean plate lids stored on the cart that was covered in debris and dust particles. Dietary staff confirmed that those were the plate warmers that were being used for the residents' food and that they were clean. Interview on 2/3/2023 at 7:55 a.m. with Cook CC revealed that the dietary staff wipes the ice machine down daily and the inside is cleaned monthly as well. Cook CC was unable to disclose when the last time the ice machine bin was cleaned and confirmed observations of ice machine condition at the time of the observation. Further interview with Cook CC also revealed that the deep fryer is cleaned every week by the cook and confirmed the under carriage was not cleaned. Interview on 2/3/2023 at 8:00 a.m. with Cook CC revealed that the main stove oven is not used and had not been used for some time. Further interview also revealed that the double oven located on the other side of the main stove was what the staff used to cook the food. Cook CC also confirmed observations made to the double oven which had a black substance that was built up on the doors of the oven and on the base of the oven floor. Continued interview revealed that the ovens are cleaned monthly, but Cook CC was not able to disclose the last time this oven had been cleaned. Interview on 2/4/2023 at 8:16 a.m. with the Administrator revealed that the expectation for the cleanliness of the main kitchen is that the kitchen should always be kept clean and sanitary. The Administrator was taken to the kitchen and confirmed all observations that were noted during kitchen tours. Further interview also revealed that there are no cleaning schedules that are utilized in the dietary department for staff to follow at this time and will be put in place. The Administrator was unaware of the condition of the main kitchen as well as the status of the ice machine. Further interview revealed that maintenance is responsible for ensuring that the ice machine is clean and in good working condition. Interview on 2/5/2023 at 8:38 a.m., the Maintenance Director revealed that he has been employed at the facility for five months and has not cleaned out the ice machines since being at facility. Further interview revealed that he was not aware that he was responsible for cleaning the ice machine other than the checking the filters and cleaning the machine coils. He also revealed that the machine was scheduled to be cleaned the first part of January 2023. Interview on 2/5/2023 at 8:40 a.m., Certified Dietary Manager (CDM) DD revealed that there was not a cleaning schedule in place for the dietary staff to follow for cleaning of the kitchen at this time. There were sheets that are on the wall in the kitchen that tells each dietary staff member what they are responsible for cleaning, but there was not a sign off sheet to ensure that the task was completed. Further interview also revealed that the dietary staff is to clean the ice machine monthly by removing the ice and cleaning out the bin but there is no sign off sheet that verifies that the machine has been cleaned.

Based on record review, and staff interviews the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for one of 22 sampled residents (R) (R#15). Specifically, the facility failed to ensure that quarterly assessment dated [DATE] accurately captured residents' use of a Foley catheter. Findings include: Review of R#15 Care plan dated 9/13/2022 revealed R#15 has indwelling 18 French Foley catheter with 10 milliliters (ml) bulb in place. She is at risk for urinary complications related to long term catheter use. Review of MDS Quarterly assessment dated [DATE] Section C (Cognitive Pattern) revealed Brief Interview for Mental Status (BIMS) score was 10 indicating that resident did have some cognitive impairment. Section H (Bladder and Bowel) H0100 Appliances there was no indication on assessment of resident having an indwelling catheter in use. Interview on 2/4/2023 at 9:30 a.m., the Assistant Director of Nursing (ADON) revealed that R#15 came into the facility under hospice care and with Foley catheter from home. Further interview also revealed that there was only one resident in the facility with a catheter and the use of the catheter should be indicated on the residents' care plan and the MDS as well. Interview on 2/4/2023 at 10:05 a.m. with MDS Coordinator revealed that R#15 was admitted to the facility under hospice with the Foley catheter. Further interview also revealed that R#15 use of catheter should have been indicated on the Quarterly MDS that was completed on 12/5/2022 and was not due to an oversite. During interview it was determined that the process for the MDS assessments is to assess the resident quarterly and then annually to capture the residents care needs. The Resident Assessment Instrument (RAI) manual is followed for this process.

Based on record review, observations, staff interviews and review of the facility policy titled Admissions/Transfer/Discharge, the facility failed to apply for Level two (2) PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one of nine residents (R) (R#36) that had a positive Level I PASRR for mental illness and diagnoses of bipolar disorder, prior to and on admission to the facility. The deficient practice had the potential to affect R#36 psychological overall health by not providing warranted psychological services. Findings include: Review of facility policy titled, Admissions/Transfer/Discharge reviewed and updated on October 2016 Intent statement revealed: It is the intent of Magnolia Manor facilities to ensure that all residents and/or potential residents are treated fairly and consistently regarding Admissions, Transfers and Discharges and to comply with all State and Federal regulations. The facility policy detailed Admission Procedural Guidelines: 3. Residents admitted from a hospital, other health care facilities or community sources, the following data should be furnished to the facility prior to or upon admission: B. Admitting diagnosis; I. PASSRR MI/MR prescreening documentation (Level I) J. Level II if applicable Review of the record revealed R#36 was admitted with diagnoses that included, but not limited to, bipolar disorder. R#36 had a PASRR Level 1 (one) submitted with status approved, effective date of 7/15/2020. Review of the PASRR Level I application indicated the resident did not have a mental illness, mental retardation, development disability or related condition. R#36 had no Axis 1 diagnosis of dementia, no physical reason that the resident could not benefit from specialized services and no diagnosis of terminal illness. Further review revealed that there was no PASRR Level 2 (two) on the chart, and no application for a PASRR Level 2. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section A- (PASARR and conditions) indicated resident was not evaluated by PASRR and had no Serious Mental Illness. Section C (Cognitive Patterns) - Brief Interview for Mental Status (BIMS) summary score of 15, indicating no severe cognitive impairment. Section E (Behaviors)-indicated no rejection of care and Section I (Diagnosis)- revealed diagnosis but not limited to bipolar disorder. Review of the behavior care plans dated 4/7/2021, 2/1/2022, and 3/7/2022 revealed R#36 has had an increase in behaviors of making false statements and refusing care; demonstrated behaviors towards staff as evidence by being rude, demanding and her unwillingness to help assist with her Activities of Daily Living (ADL) care. Interview on 2/5/2023 at 8:35 a.m. the Social Service Director (SSD) verified that R#36 did not have a PASRR Level 2 and had not been screened for one while at the facility. She revealed their process for PASRR Level 2 screening was If a resident had a PASRR Level One (1) with a mental illness condition but no diagnosis of dementia or Alzheimer disease, they should be screened, or referred for a PASRR level 2 screening, evaluation and services. As soon as they receive the results and get an outcome, if warranted, they schedule the appropriate psych services for the resident. She confirmed that R#36 was a candidate and should have been screened for PASRR level2 related to her psych diagnoses and not having dementia or Alzheimer's diagnoses. She reported services were offered but R#36 refused. Interview on 2/5/2023 at 8:40 a.m. the Director of Nursing (DON) revealed her expectation was that policy and procedures were followed for all residents.

Based on observation, and resident and staff interviews, the facility failed to ensure that one of four residents (R) (R#49) was supervised by licensed staff while consuming medications prescribed by physician. Specifically, R#49 had two white round pills, one pink oblong capsule, and one small round pink pill on the overbed table consuming them independently without licensed staff supervision. Findings include: Record review for R#49 revealed resident was admitted to the facility with diagnoses of Osteoarthritis left shoulder, osteoporosis, osteoarthritis of bilateral knees, urinary tract infection, Pressure ulcer of the sacral region, low back pain, hypercholesterolemia, Benign prostatic hyperplasia, Transient ischemic attack (TIA), Artificial hip joint, generalized muscle weakness, difficulty walking. Medications included Ascorbic acid (vitamin C) 500 Milligrams (mg), Tylenol 325 mg 2 tablets, Zinc 220 mg, Tamsulosin 0.4mg, B complex capsule, Multivitamin with minerals, Saw Palmetto 450 mg. Minimum Data set (MDS) Quarterly assessment dated [DATE] revealed section C (Cognitive pattern) a Brief Interview for Mental Status (BIMS) score of 15 indicating resident is cognitively intact. Continued review of Section G (Functional Status) revealed resident requires extensive assistance with one-person physical assistance with bed mobility, transfers, dressing and personal hygiene. Observation on 2/3/2023 at 9:17 a.m., R#49 was observed to have medication laying on bedside table that had not been consumed which included two white round pills, one pink oblong capsule, and one small round pink pill. Interview on 2/3/2023 at 9:21 a.m., R#49 revealed that the nurse brought the medication to him in a medication cup, and he poured them on the table to take them one at a time. Continued interview with R#49 also revealed that he did not have any knowledge of being assessed to self-administer medications. Interview on 2/3/2023 at 9:27 a.m., Licensed Practical Nurse (LPN) BB stated she thought the resident had already taken the medication before she left the room, and that she usually watches the resident take all of his medications before exiting the room but did not in this instance. Further interview also revealed that there was one zinc tablet, two Tylenols, and a B-12 tablet that was on the residents' bed side table. LPN BB also revealed that there are currently no residents in the facility that self-medicate at this time. Interview on 2/3/2023 at 11:27 a.m., Assistant Director of Nursing (ADON) revealed that currently there are no residents in the facility that are self-medicating and that the nurse should administer the medications to the residents and ensure that the medications are taken before they exit the residents' room. Further interview also revealed that for a resident to self- medicate they must be able to read and complete a medication Administration Record (MAR) that is given to them along with securing their medications in the lock box that is provided to them.

Based on record review, observations, staff interviews, and review of the facility policy titled, Indwelling Catheter Insertion/Removal the failed to ensure that one of one resident (R) (R#15), Foley catheter was placed in a privacy bag and not visible to visitors and residents. The facility also failed to ensure that R#15 had a medical diagnosis for use of catheter and that the physicians order accurately identified the catheter size for use. The deficient practice had the potential to affect the adequate bladder functioning and elimination for R#15. Findings include: Review of the facility policy titled, Indwelling Catheter Insertion/Removal dated March 2014 revealed under Key points: Indwelling catheters shall have appropriate diagnosis warranting use. Procedure guidelines revealed: The following information should be documented in the Nurses; Notes and/or Treatment record: * Size * Type * Volume of sterile water in the balloon * Drainage system used and reasons for choice Review of the record for R#15 revealed that the resident was admitted to the facility with the diagnoses of Atherosclerotic heart disease, hypertensive heart disease, hyperlipidemia, hypo-osmolality, unilateral primary osteoarthritis, anxiety disorder, constipation, Insomnia, Major Depressive disorder, essential hypertension, urinary tract infection, epigastric pain, shortness of breath. Review of R#15 Care plan dated 9/13/2022 revealed R#15 has indwelling 18 French Foley catheter with 10 milliliters (ml) bulb in place. She is at risk for urinary complications related to long term catheter use. Review of Minimum Data Set (MDS) Quarterly assessment dated [DATE] Section C (Cognitive Pattern), revealed Brief Interview for Mental Status (BIMS) score was 10 indicating that resident did have some cognitive impairment. Section H (Bladder and Bowel) H0100 Appliances there was no indication on assessment of resident having an indwelling catheter in use. Observation on 2/3/2023 at 9:48 a.m. revealed Foley catheter noted to bedside drainage facing the door and not stored in a privacy bag. Observation on 2/4/2023 at 8:11 a.m. revealed a second observation of R#15 Foley catheter to bedside drainage and not stored in privacy bag. Observation on 2/4/2023 at 9:00 a.m. revealed a third observation of R#15 Foley catheter to bedside drainage and not stored in privacy bag and not positioned below the level of the bladder. Interview on 2/4/2023 at 9:05 a.m., Certified Nurse Aide (CNA) AA revealed that R#15 catheter should be stored in the privacy bag and always positioned below the level of the bladder. CNA AA confirmed that catheter was not stored properly and should have been. Further interview revealed that the catheter is checked every morning to ensure that the catheter is positioned properly below the bladder and stored in a privacy bag. She continued to state that R#15 catheter was not checked this shift. Interview on 2/4/2023 at 9:15 a.m., Licensed Practical Nurse (LPN) BB revealed that R#15 was admitted to the facility with a Foley catheter from home under hospice care. Further interview revealed that residents' order for catheter did not have the size of the catheter or diagnosis indicated on the physicians' order. LPN BB was unaware of what size catheter R#15 was using. She stated that the hospice nurse is the one that changes the residents catheter monthly as well as if the catheter becomes dislodged. LPN BB checked residents' catheter and it was determined that resident currently had a 16 French (fr.) with 10 cc bulb in use. Interview on 2/4/2023 at 9:30 a.m., Assistant Director of Nursing (ADON) revealed that R#15 came into the facility under hospice care and with Foley catheter from home. Further interview also confirmed that resident did not have a diagnosis for use of the catheter and the hospice provider had been notified of resident not having this diagnosis, however they had not provided the reason for the catheter information to the facility. The ADON also revealed that the size of the catheter was not indicated on the order for R#15, and that it should have been part of the physicians' order.

Based on interviews, record reviews, and review of facility policy titled Food & Nutrition, the facility failed to employ a qualified dietitian to conduct nutritional assessments on residents. This had the potential to affect 54 of 54 residents residing at the facility. Findings include: Review of facility policy titled Food & Nutrition, dated November 2016 revealed Intent: It is the intent of (company name) facilities to meet the daily nutritional and special dietary needs of each resident. Procedural Guidelines: 1. The facility employs a qualified dietician full time, part time, or on a consultant basis. A qualified dietician is defined as a person registered by the Commission of Dietetic Registration or recognized as licensed or certified in the State of Georgia as a dietician or clinically qualified nutritional professional. Review of facility Clinical Dietitian Position Description revealed Principle Duties and Responsibilities include but are not limited to the following: Patient Care; Nutrition Assessment; -Conducts a nutrition assessment when warranted by a patient's needs or conditions. Nutrition screening is completed within 24 hours of inpatient admission according to facility/state/accreditation requirements; Reviews dietary intake for factors that affect health conditions and nutritional risk; Supervises dietetic technicians screening and data collection activities; Evaluates health and disease condition for nutrition related consequences. Additional duties and responsibilities include areas under Nutrition and Diagnosis, Nutrition Intervention, Nutrition Monitoring and Evaluation, Documentation, Communication and Continuation of Care, Compliance, Community Outreach, Business/Supervisory Functions, Performance Improvement and Professional Development. Review of R#49s medical record revealed there is no evidence of a nutritional assessment being completed. A review of R# 3's medical record revealed a 10.70% weight loss in three months with no evidence of a nutritional assessment being completed between March 2021 and June 2021. A review of R# 6's medical record revealed a 11.11% weight loss in six months with no evidence of a nutritional assessment being completed between December 2020 and June 2021. Review of the facility's Dietitian Visit Tracking Log revealed she was last at the facility on 3/6/2020. An interview on 6/16/2021 at 3:00 p.m. with the Dietary Manager, revealed the facility did not currently have a Registered Dietitian (RD). She indicated the Director of Nursing (DON) was currently doing the nutritional assessments. She further reported they have not had a RD since COVID hit in March of 2020. An interview on 6/16/2021 at 3:21 p.m. with the DON confirmed that the facility does not currently have a dietitian and they have contracted with their dietary services vendor to provide RD services. She reported the vendor had someone who was starting in May 2021 but resigned prior to starting. The DON confirmed that the facility has been without a RD since the first week of March 2020 when COVID hit, and that she has not been completing the nutritional assessments for the residents. An interview on 6/16/2021 at 3:51 p.m. with the dietary services vendor's regional dietitian revealed they are working on recruiting a RD for this facility. She reported she is currently working with an agency to secure a RD. It was further reported that the Administrator reached out to them about eight or nine months ago to help the facility obtain a RD. Prior to this the facility had contracted RD services themselves but they have not had one since COVID hit, and they did not allow them in the facility. She indicated it was her understanding that the DON and Nurse Practitioner were doing the nutritional assessments. She confirmed she is a RD but is unable to take over this facility as she is currently documenting on two buildings and is responsible for overseeing six buildings. She further reported it is difficult to assess while not in the building because the facility has not gone fully electronic, and they are required to be physically in the building to perform a proper assessment. An interview on 6/16/2021 at 4:43 p.m. with the Administrator and DON confirmed they have not had a dietitian since the pandemic hit in March 2020. The Administrator confirmed she contacted the regional dietitian of their dietary services vendor to request assistance with obtaining a RD for the facility. She indicated it has been a challenge to have RD services. She confirmed the Dietary Managers do the nutritional assessments. She further reported if they are having difficulty with a nutrition issue they can reach out to the regional dietitian. She indicated they were going to share a RD with another facility, but she resigned in May prior to coming to the facility. She further reported the need for a RD had been identified in their Quality Assurance/Performance Improvement (QAPI) program in August of 2020. An interview on 6/17/2021 at 11:42 a.m. with the Administrator and DON revealed they shut the building down on 3/14/2020. She indicated while they were shut down, the RD was not someone who would come into the building at that time. She indicated she was unable to identify discussions with the Senior Vice President (VP) of Operations because they were just trying to survive COVID. She reported they started working on this in August 2020 because they knew they had to get the service back in place, and once they came through COVID and re-evaluated the facility they determined they had to get the RD in place. She indicated they contacted sister facilities to see if they could help but could not recall when she did this. She reported they did not advertise on any job search platform for the position, they only asked around at different facilities. She reported they know they are to have the services on a RD, and they have focused on these areas. She further reported the regional dietitian was always a phone call away if they felt they could not manage someone, however, she and the DON indicated they have not felt the need to contact her. They further indicated they did not feel it was necessary to contact her for the residents with enteral feeds and wounds. A message was left on 6/17/2021 at 12:28 p.m. for the Senior Vice President of Operations requesting a return call without success.

Based on observation, interview and review of facility policy titled Food Storage the facility failed to appropriately label and date food items in the pantry and walk-in freezer, failed to maintain a clean toaster, failed to properly seal an opened package in the walk-in freezer, and failed to discard food by expiration date. This had the potential to affect 53 of 54 residents receiving an oral diet in the facility. Findings include: Review of policy titled Food Storage dated 2008 revealed 8c. food should be dated as it is placed on the shelves. 8d. Date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold, or discarded will be visible on all high-risk food. 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within three days or discarded. Observation on 6/14/2021 at 11:05 a.m. in the kitchen revealed a heavily soiled toaster. The Production Manager confirmed that the toaster had not yet been cleaned for the day. Observation on 6/14/2021 at 11:07 a.m. of the pantry revealed an open container of pancake mix in a bag without label or date. Observation on 6/14/2021 at 11:10 a.m. of the walk-in freezer revealed two bags of potato wedges, a blue bag with what appears to be peas, a bag of fruit, meat sausages, meat patties, roast, sliced yellow squash, and an unidentifiable meat all without labels and/or dates. Additionally, there was an open bag of potato wedges (hole in the bag), and a piece of cake on a paper plate, wrapped in clear plastic wrap with an expiration date of 6/9/2021. An interview on 6/14/2021 at 11:15 a.m. with the Production Manager who confirmed the items were not labeled or dated and reported the staff are not labeling or dating the food items when they take them out of the boxes. An interview on 6/16/2021 at 3:00 p.m. with the Dietary Manager, confirmed that the products identified were not labeled. She indicated the staff are aware they are supposed to label and date everything that goes in the pantry, refrigerator or freezer. She further reported there is a posted list of different products with their shelf life, and they know to reference this list when putting food items away. She indicated she has instructed them if they are ever in doubt to put three days on it.

Based on staff interviews and review of facility policy titled, Quality Assurance Performance Improvement (QAPI) Plan the facility failed to ensure that the services of a Registered Dietitian (RD) were in place over the past 15 months. The QAPI Committee failed to identify appropriate interventions to secure a Registered Dietitian. The QAPI Committee further failed to evaluate the effectiveness/ineffectiveness of the Performance Improvement Plan (PIP). Additionally, the facility failed to have an effective QAPI Performance Improvement Plan (PIP) in place to ensure the facility had a Registered Dietitian for the facility. The facility census was 54 Residents. Findings include: Review of the facility's Quality Assurance Performance Improvement Q.A.P.I. Plan last reviewed on June 26, 2020, revealed Purpose of our QAPI Plan: All decisions made will be in an effort to improve our core competencies of providing the highest quality of care to our long-term care and sub-acute rehab residents. We will utilize key performance measures such as Quality Indicators/Quality Measures, Five Star reports and ratings, customer-focused resident and family satisfaction surveys, census goals and accounts receivable to gauge the success of our efforts. Addressing Improvement Issues: The Performance Improvement Plan (PIP) are reported to the QAPI Committee adopts the practice into the facilities processes. If the action plan is not successful, the PIP must evaluate their action plan and make changes to reach their established goal(s). Guidelines for Governance and Leadership: Our Administrator ultimately has responsibility for ensuring our QAPI Committee and Plan are in place. The Administrator and/or Director of Nursing will lead the facilities QAPI Committee and QAPI Plan. The Administrator and/or Director of Nursing will report to the Corporate QAPI Steering Committee, VP of Clinical Services and Sr. VP of Operations. QAPI Committee Activities: The QAPI Committee will have responsibility for the following; a. developing and approving the QAPI Plan, that includes measurable objectives based upon the opportunities identified through the review of established criteria for quality assurance; b. documentation will be maintained to support evidence of ongoing program; c. indicators of quality on a priority basis will be developed, reviewed and revised as committee determines; e. assessing information based on indicators established, taking action by PIPs to address opportunities to improve quality. Review of the facility QAPI Agendas from October 2020 through May 2021 indicated a dietary agenda item to focus on weight loss, hydration, and RD Services. However, there was no evidence to show what efforts were being made to fill the RD position. An interview on 6/16/2021 at 4:43 p.m. with the Administrator and DON revealed the need for a RD for the facility is in their Quality Assurance/Performance Improvement (QAPI) plan. The Administrator reported this was added in August of 2020. She indicated this was entered into their QAPI minutes in October of 2020. An interview on 6/17/2021 at 11:42 a.m. with the Administrator and DON revealed while they were in shut down for COVID 19 the RD position was not one that was allowed into the building at that time. She reported they started working on this in August 2020 because they knew they had to get the service back in place. She indicated when they came through COVID and re-evaluated the facility they determined they had to do get the RD in place. She reported they contacted sister facilities to see if they could help but does not remember when she did this. She further reported they did not advertise on any on-line job search platform for the position, or any other advertising method. She indicated they were asking around at different facilities. She reported they know they are to have the services of an RD for the facility. The Administrator reported they have a focused QAPI plan and review of what they look at frequently but did not have any additional documentation related to the RD Performance Improvement Plan (PIP), interventions or efforts to secure a RD for the facility. An interview on 6/17/2021 at 1:30 p.m. with the Medical Director indicated he knew they were looking for a RD, but he did not have any active part in recruiting. He indicated he attends the QAPI meetings, and is at the facility one day per week, and available 24/7. He reported there are not many residents with wounds and tube feeding. They have the standard diets, and the facility depends on the local hospital if needed. He indicated the hospital has a RD and perhaps that person may be interested in moonlighting at the facility. He indicated he had not shared this suggestion with the Administrator. Cross reference F801

Based on interviews and record reviews, the facility failed to follow the care planned interventions for one Resident (R#98) that was care planned to require a Hoyer lift and two-person assistance with transfers. Actual harm occurred when Certified Nursing Assistant (CNA) FF attempted to transfer R#98 from her wheelchair to the bed and both CNA FF and R#98 fell . R#98 received a left intertrochanteric [MEDICAL CONDITION] which required surgery that included an open reduction and internal fixation (ORIF) of the left hip intertrochanteric with a gamma nail fixation. The sample size was 28 residents. Findings include: R#98 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status of 15 indicating that the resident is cognitively intact, Section G documents that the resident required extensive assistance with eating with one person assist, totally dependent with toileting requiring two person assist, totally dependent with personal hygiene requiring one person assist. Further review of this Quarterly MDS revealed that the resident required extensive assistance requiring two-person assistance for bed mobility, the resident is totally dependent for transfers requiring two-person assistance, and that walking in room did not occur. A review of the care plans revealed that R#98 had a care plan for self-care deficits dated 8/21/17, last revised 11/14/17, documents that R#98 was to be transferred using a mechanical lift and two-person assistance. A review of the facility's internal investigation revealed that CNA FF failed to use a mechanical lift and two-person assistance on 2/15/18, to transfer R#98 from her wheelchair to the bed. Interview on 8/30/18 at 9:45 a.m., with the Administrator, revealed that the CNA (CNA FF) was assisting R#98 to transfer from the chair to the bed and failed to use the required mechanical lift and two person assist. As a result of this failure, CNA FF was terminated. A post survey interview on 9/13/18 at 8:58 a.m. with CNA FF revealed that she was working with R#98 on 2/15/18 and was working from 7:00 p.m. through 7:00 a.m. and that she did not follow the care plan for R#98 which documents to transfer R#98 using a Hoyer lift and two-person assistance. A post survey iInterview on 9/27/18 at 11:55 a.m. with the Director of Nursing (DON) revealed that the DON confirmed that R#98 fell as a result of CNA FF failing to use a mechanical lift with two-person assistance to for transfer. The DON also stated that R#98 had been care planned as requiring two person assist with a mechanical lift transfer both before the fall with fracture and after she returned from the hospital.

Based on staff and resident interviews and record review the facility failed to use a Hoyer lift and two person assist, as assessed as requiring, when transferring one Resident (R) (R#98). Actual harm occurred when Certified Nursing Assistant (CNA) FF attempted to transfer R#98 from her wheelchair to the bed and both CNA FF and R#98 fell . R#98 received a left intertrochanteric [MEDICAL CONDITION] which required surgery that included an open reduction and internal fixation (ORIF) of the left hip intertrochanteric with a gamma nail fixation. The sample size was 28 residents. Findings include: Record review revealed that R#98 was admitted with [DIAGNOSES REDACTED]. A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status of 15 indicating that the resident is cognitively intact, Section G documents that the resident required extensive assistance with eating with one person assist, totally dependent with toileting requiring two person assist, totally dependent with personal hygiene requiring one person assist. Further review of this Quarterly MDS revealed that the resident required extensive assistance requiring two-person assistance for bed mobility, the resident is totally dependent for transfers requiring two-person assistance, and that walking in room did not occur. Review of the care plans revealed that R#98 had a care plan for self-care deficits dated 8/21/17, last revised 11/14/17, that documents that R#98 was to be transferred using a mechanical lift and two-person assistance. Review of a Fall Risk Evaluation dated 1/10/18, documents Gait/Balance: 2- N/A (not applicable) not able to perform function. Review of an Occupational Therapy Certificate dated 11/9/16 documents the residents past medical history includes that the facility workers use Hoyer lift to transfer patient to/from hospital bed to electric wheelchair. Review of the facility's internal investigation revealed that a facility staff member, Certified Nursing Assistant (CNA) FF failed to use a mechanical lift and two-person assistance on 2/15/18 to transfer R#98 from her wheelchair to the bed. This failure resulted in the resident sustaining a [MEDICAL CONDITION] femur. There were no witnesses to the incident. The resident was able to confirm the occurrence and that CNA FF did not use a mechanical lift or two persons to assist. Review of a Situation Background Assessment Recommendation (SBAR) form dated 2/16/18 documented the following: Resident c/o (complained of) pain to left hip during transfer from wheelchair (electric) to bed. Sent to ER (emergency room ) for eval/tx. (evaluation and treatment). admitted with left [MEDICAL CONDITION]. (sic) A review of an acute care hospital admitting History and Physical, for R#98, dated 2/15/18, documented that the residents admitting [DIAGNOSES REDACTED]. Review of the X-ray report dated 2/15/18, revealed that R#98 had a left intertrochanteric [MEDICAL CONDITION]. Review of a Computerized Axial Tomography (CT) scan report dated on 2/15/18, revealed that the resident had an acute comminuted displaced [MEDICAL CONDITION] femur involving the femoral neck and the intertrochanteric region. An operative report dated 2/18/18, revealed that R#98 underwent an open reduction and internal fixation (ORIF) of the left hip intertrochanteric fracture with a gamma nail fixation. R#98 was discharged from the hospital and returned to the facility on [DATE]. Interview on 8/28/18 at 11:30 a.m., with R#98 revealed that the resident confirmed with yes/no answers (verbally) and by shaking her head side to side (no) or up and down (yes) that she experienced a fall in (MONTH) (YEAR). She also confirmed that she sustained a fracture of her left hip by pointing to her left hip. An interview on 8/28/18 at 4:30 p.m. with Certified Nursing Assistant (CNA) DD revealed that the CNA's reference a notebook at the nursing station containing Nurse Aide's Information Sheet forms for each resident and that these forms provide information regarding what type of assistance each resident requires. Review of the Nurse Aide's Information Sheet (undated) revealed that R#98 is aphasic (will communicate by nodding or shaking her head), requires total care for bathing, total care for bowel and bladder, total physical assist with meals, has impaired range of motion for both arms and legs, the resident does not ambulate and requires a Hoyer lift with two person assist. Interview on 8/30/18 at 9:45 a.m., with the Administrator, revealed that the CNA (CNA FF) was assisting R#98 to transfer from the chair to the bed and failed to use the required mechanical lift and two person assist. As a result of this failure, CNA FF was terminated. A post survey telephone interview with the sister of R#98 on 9/12/18 at 12:37 p.m. to 1:12 p.m. revealed that she is the responsible party and power of attorney for R#98. She also confirmed that the facility contacted her on the night of 2/15/18 because of an accident involving R#98. She reports that the nurse called her to inform her that they (the staff) had bumped the residents leg and that she was complaining of pain and they were going to send her to the emergency room to be evaluated. The sister stated that she arrived at the facility prior to R#98 departing for the emergency room and that her sister (R#98) told her that a CNA had attempted to transfer her by herself from the chair to the bed and had dropped her. She also complained of pain in her left hip. The sister confirmed that R#98 was admitted to the hospital with [REDACTED]. A post survey telephone interview on 9/13/18 at 8:58 a.m. with CNA FF revealed that CNA FF confirmed that she was working with R#98 on 2/15/18, and was working from 7:00 p.m. through 7:00 a.m. CNA FF stated that she did not follow the care plan for R#98 which documents to transfer the resident using a Hoyer lift and two-person assistance. CNA FF revealed that she had attempted to get assistance from the two other CNA's that were working the front three halls of the facility that night, but that one CNA was in the shower room with a resident and the other CNA was down another hallway working with a resident. CNA FF said that because she had transferred R#98 by herself in the past, she decided to transfer her without assistance on 2/15/18. She also stated that R#98 would get upset if staff didn't provide assistance for her immediately when asked. CNA FF reported that she had R#98 standing up and was attempting to pivot with her and transfer her to the bed when she lost her balance and they both fell to the floor. She states that she left R#98 lying on the floor and went and got the nurse on duty. The nurse and another CNA came back to the room and after examining R#98, the three staff members (two CNAs and one nurse) physically lifted R#98 off the floor and back into the bed. CNA FF confirmed that the facility told her not to return to work until they had investigated the incident and that the facility had terminated her employment on 2/21/18 as a result. A post survey interview on 9/27/18 at 11:55 a.m. with the Director of Nursing (DON) revealed that the DON confirmed that R#98 fell as a result of CNA FF failing to use a mechanical lift with two person assistance to for transfer. The DON also stated that R#98 had been care planned as requiring two person assist with a mechanical lift transfer both before the fall with fracture and after she returned from the hospital. The DON stated that the Nurse Aide Information Sheet are kept in a notebook at the nursing station where they are readily accessible to the CNAs and are updated as changes occur. She stated that they are not dated since they are updated frequently. Review of a Hoyer or Stand up Lift procedure signed by CNA FF and dated 8/28/17 documents that a Hoyer or Stand up lift should be used with residents who are too heavy to lift or who have special needs that would contraindicate a safe one or two person lift. Bullet point #6 Have your partner with you. Two people are required to safely use any lift at Magnolia Manor. The following documentation is above the signature line: Please note that failure to safely use lifts and failure to use two people each time the lift is used could result in injury to a resident or to you and therefore could result in termination of employment.

Based on interviews and record reviews, the facility failed to notify the Physician regarding a change in code status and failed to clearly document the code status for one resident (R) (R#68). The sample size was 28 residents. Findings include: Review of a Social Service Director (SSD) Progress Note dated [DATE] documents the following: Resident expressed concerns about his DNR (Do Not Resuscitate form) that he signed in 2011. Spoke with resident on [DATE] in regard to DNR. Resident was asked to address his concerns so that information can be provided to help him with any further questions. Resident stated that he wants his DNR to be removed from his chart. Resident was asked if he knew what a DNR stood for. Resident was educated and given information about a DNR and CPR (Cardiopulmonary Resuscitation). He stated that he wasn't in his right mind at the time when he signed the DNR back in 2011. Resident prefers to have his DNR removed. Resident expressed that he wants the facility to do all that they can to prolong his life. Resident proceeded to elaborate that he would like to have CPR. Resident has a BIMS (Brief Interview for Mental Status) of 11 (meaning that the resident is moderately cognitively impaired). However, the SSD failed to follow-through with the facility mandated paperwork for the medical record/chart that communicates the resident's wishes to the staff. The chart had conflicting information regarding R#68's current code status. Review of a SSD Quarterly Progress Note dated [DATE] documents that the resident remains a DNR by choice. Review of a SSD Quarterly Progress Notes dated [DATE] documents resident remains a DNR by choice. Review of a SSD Progress Notes dated [DATE] documents resident remains a DNR by choice. Review of the care plan meeting notes dated [DATE] documents resident recently changed from DNR to Full Code. A review of the Quarterly SSD Progress Note dated [DATE] documents R#68 remains a DNR by choice. Review of a SSD note for Advanced Directive Care Plan dated [DATE] notes R#68 has a DPOA (Durable Power of Attorney) and is a Full Code. Review of the medical records reveals care plan meeting notes dated [DATE] stating Code Status: Full Code. Record review of the (MONTH) (YEAR) physician's orders [REDACTED].>Review of a telephone order dated [DATE] and signed by the Physician on [DATE] documents the following: add Do Not Resuscitate to MAR (Medication Administration Record). Interview with the Social Services Director (SSD) on [DATE] at 9:45 a.m., revealed that if a resident wants to change their code status that the SSD provides education and information to the resident regarding DNR and CPR. Once the resident has made a decision then the SSD speaks with the Physician. Further interview with the SSD revealed that then she documents the following in her progress notes: the education that was given to the resident, the resident's final decision, and the discussion with the Physician. The SSD reviewed the chart for R#68 and confirmed that the resident's code status is documented to be Full Code at this time. Further interview with the SSD also confirmed that there was not any documentation of the notification of the Physician or the Responsible Party and that the chart contained conflicting information regarding the code status for R#68. Review of an undated facility policy titled Do Not Resuscitate encompassing pages 119 through 127. Section 10 Procedures for Revocation: A. If the DNR order is requested to be revoked, staff will immediately notify the resident's attending physician, the resident's power of attorney for health care, if one exists, and the resident's representative. B. A request to revoke a DNR order will become effective upon communication of the revocation. The SSD or the nurse will document this revocation in the resident's medical record as well as documenting the persons informed of the revocation. C. The SSD will also remove all documents related to the DNR from the medical record. Copies of the DNR will be labeled as revoked, dated, and signed or marked by the resident or other person designated by the resident in the presence of the resident. The documents will then be filed in the financial file. D. The attending physician is requested to review treatment orders to assure compliance with the resident's request for treatment and care, and to document the resident's revocation of the DNR order.

Based on observation, interview, and record review, the facility failed to maintain a clean laundry area to prevent contamination of clean linen which had the potential to affect all residents in the facility; and failed to ensure hand hygiene was completed after handling contaminated objects prior to assisting a resident. The facility census was 106. Findings include: 1.Observation of the laundry area on 8/2/17 at 2:50 p.m. revealed Laundry Aide (LA) PP allowed 12 sheets to touch the floor during folding. Folding table was not used. Thick dust was on the ceiling, vents, pipes, and exhaust fan. Observation of the laundry area on 8/3/17 at 1:00 p.m. revealed dust on pipe surfaces and vents. Fine dust observed falling onto the clean linen on the folding table. During an interview at this time, the Director of Environmental Services (DES) stated that there was no log or record of cleaning of the actual laundry room. Interview on 8/4/17 at 9:00 a.m., DES informed that he expects the laundry room to be cleaned daily. He explained that maintenance does periodic deep cleaning and vent cleaning and that no log or checklist for these tasks was available. The Dryer Vent: Complete System Cleaning document revealed the exhaust piping was last cleaned on 2/16/17. Review of policy titled Laundry Services dated 2012 documented that all areas should be cleaned on a regular schedule. 2.Observation on 8/4/17 at 10:50 a.m. revealed CNA KK took a bag of trash and a bag of soiled linen out to the laundry room and dumpster without wearing gloves. She opened dumpster and threw the bag of trash into the dumpster; then placed the bag of soiled linen into the soiled linen basket outside of laundry. CNA KK then went straight to room [ROOM NUMBER] where the call light was on. CNA grabbed the resident's water pitcher and left the room; no hand hygiene was observed. During an interview at this time, CNA KK stated that she had hand hygiene training during orientation. During an interview on 8/3/17 at 12:30 p.m. Infection Control Nurse MM confirmed that she expects hand hygiene to done between every resident encounter. She stated that she provides hand hygiene education during orientation and during an in-service in January 2017. Review of the policy titled Hand Hygiene dated 2012 documented that hand hygiene is required when handling any contaminated object.

Based on observations and interviews the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the kitchen and one of two dining rooms and one of two nourishment pantries. The Director of Dining Services (DDS) failed to wear a beard guard while in the kitchen. The refrigerator in one of two nourishment pantries had open, unlabeled and undated food items on three of four days; and an eight-inch-long hair was observed in a microwave oven in one of two nourishment pantries. This had the potential to affect all residents receiving an oral diet. Findings include: 1. The DDS was observed on 07/31/2017 at 12:30 p.m. in the kitchen behind the tray line but not serving. He was noted to have a neatly trimmed beard but not wearing any type of beard guard. When questioned, he stated that their policy does not require a beard guard for neatly trimmed facial hair less than one inch in length. During an interview on on 08/02/2017 at 10:35 AM, the DDS shared an undated policy. The policy was for kitchen staff dress/uniform requirements but did not state the facility name, nursing home company/owner or management company's name. When questioned regarding whose policy it was, DDS said he would double check and obtain a company policy. During an interview on 8/02/2017 at 1:35 PM, the DDS supplied another undated policy titled: Facility Name, Food and Nutrition Services Department Policy and Procedure Manual, Managed per contract by Metz Culinary Management. Page 3 of the policy under section IV. A. vi. states Hair restraints are to be worn at all times in the kitchen. Any facial hair should be kept neat and trimmed to prevent cross-contamination. Section V on page 3 of the policy lists 4 references including ServSafe, USDA.gov, Food Guidance regulations from FDA, and Metz corporation. The DDS revealed that he looks at Serv-Safe regulations first and with his Administrator and his General Manager. The policy referenced above lists Food Guidance regulations from FDA as a reference. An excerpt from the Food Code, U.S. Public Health Service, FDA, 2013 (UCM 0) states: Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. (B) This section does not apply to FOOD EMPLOYEES such as counter staff who only serve BEVERAGES and wrapped or PACKAGED FOODS, hostesses, and wait staff if they present a minimal RISK of contaminating exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLEUSE ARTICLES. During an interview with the DDS on 08/02/2017 at 2:12 p.m., he stated that he was wrong regarding the use of a beard guard for facial hair in the kitchen. He supplied an updated policy (same title as listed above) that now reads: Hair restraints are to be worn at all times in the kitchen. All facial hair will be covered by a beard guard at all times in the kitchen as well. The DDS also had a copy of an order from US Foods for one case of Beard Cover(s) (100/case). The DDS was observed on 8/3/17 at 12:15 p.m. in kitchen with no beard guard. 2. On 7/31/2017 at 12:24 p.m. three nursing staff members were observed serving residents in the Club Room for the lunch meal. A container of ice had a small ice scoop sitting in it with the handle upright. Two of three staff were observed to use the ice scoop & place it back in the container with the handle up not touching the ice. The remaining staff member used the ice scoop and when she placed it back into the container, the ice scoop fell into the container and into the ice itself. During an observation of lunch meal service in the Club Room on 8/3/17 at 12:15 PM an ice scoop was observed in the container with ice; the handle was not touching the ice. Upon interview the DDS said the dietary staff puts ice in a clean container and provides a scoop for the nursing staff to use in the Club Room. When asked, the DDS said the kitchen staff do not put the scoop into the ice container. He placed a clean bowl on the beverage cart for the nursing staff to put the scoop in between uses. He also disposed of the ice and the container that was sitting on the cart. He supplied the nursing staff with a clean container of ice to use for the lunch meal. 3. Observation of the refrigerator in the pantry on 400 hall on 7/31/17 at 11:00 a.m. was observed to have one opened carton of milk and one bowl of what the DDS said is baked beans with no label, date or time. The DDS disposed of the two items. The refrigerator in the pantry on 400 hall on 08/01/2017 at 10:55 a.m. was observed to have two milk cartons opened, not dated, timed or labeled. The refrigerator in the pantry on 400 hall on 8/02/2017 at 9:50 a.m. was observed to have two opened milk cartons with no label, time or date. 4. On 8/04/2017 at 9:11 a.m. the microwave oven in the 400-hall pantry was checked and a dark hair approximately 8 inches in length was lying half in the bottom of the microwave oven under the glass turntable and half outside the microwave oven on the counter surface. There was an accumulation of moisture under the glass turntable where the hair was observed. The DDS was informed.

Based on interview and record review the facility failed to ensure the physician signed and dated all orders in the medical record for eight (R#29, R#58, R#135, F#15, F#109, R#209, R#119, R#193) of 30 resident charts reviewed. Findings include: An interview was conducted with the Administrator on 8/04/2017 at 3:20 p.m. She stated the facility had changed Medical Directors in March of this year, 2017. She further stated the facility thought that if a resident already had an established plan of care under the previous Medical Director, then they could be seen by the Physician's Assistant (PA). She said the survey team would not find physician visits on many records. An interview was conducted with the Director of Nursing (DON) on 8/4/2017 at 4:30 p.m. She stated the Medical Director comes one to two times a week. The other physician who is listed as attending for over 20 residents doesn't come in to see residents but does sign prescriptions for the PA. The PA comes 4-5 days per week. She further stated that skilled residents are visited every 30 days, non-skilled are seen every 60 days but must be seen by a doctor initially. Her understanding was that as long as the prior Medical Director had seen the resident then the PA could see them. When asked how the facility tracks physician visits and who is responsible, she stated Medical Records audits the charts monthly. When asked if the MR person is under the same assumption that the physician's assistant can see the resident and the physician doesn't have to see them, the DON said she couldn't speak for the Medical Records person. The MR person was not available to interview per the DON. 1. R#29 has monthly physician's orders signed only by the PA with no dates documented for the months of June 2017, July 2017 and August of 2017. The monthy Physician order for [REDACTED]. In addition, three of five telephone/verbal orders were not signed by the MD or PA. 2. R#58 has monthly POFs that are signed by the PA but not dated for the months of March 2017 and July of 2017. Other POFs for the months of April 2017, May 2017 and June of 2017 are signed by the PA and dated. There was not any evidence of physician (MD) signature found on the physician's orders reviewed. R#135, R#15, and R#109 all have July 2017 orders signed but not dated; R#209 has July 2017 orders not signed or dated; R#119 has May 2017 orders signed but not dated; and R#193 has June 2017 orders signed but not dated.

Based on interview and record review the faciity failed to ensure that a physician saw each resident within 30 days of admission and every 30 days for 90 days and therafter, at least every sixty days for eighteen of 30 residents. Thirty residents were reviewed for physician visits. The sample size was 40 residents. The census was 107 residents. Findings include: An interview was conducted with the Administrator on 8/04/2017 at 3:20 p.m. She stated the facility had changed Medical Directors in March of this year (2017). She further stated that the facility thought that if a resident already had an established plan of care under the previous Medical Director, then they could be seen by the Physician's Assistant (PA). The Administrator revealed that the survey team would not find physician visits on many records. Interview on 8/4/2017 at 4:30 p.m. was conducted with the Director of Nursing (DON) Which revealed that the Medical Director comes one to two times a week. The other physician who is listed as the attending physician for over 20 residents doesn't come in to see residents but does sign prescriptions for the PA. The PA comes 4-5 days per week. She further stated that skilled residents are visited every 30 days, non-skilled are seen every 60 days but must be seen by a doctor initially. Her understanding was that as long as the prior Medical Director had seen the resident then the PA could see them. When asked how the facility tracks physician visits and who is responsible, she stated Medical Records (MR) audits the charts monthly. The MR person was not available to interview per the DON. Record review revealed that R# 90 was admitted to the facility on [DATE] and was seen by a PA on 5/12/17; she was seen by her Medical Doctor (MD) on 7/14/17. There was not any evidence that the resident was seen by her MD by 6/12/1. The resident did not have a supervising visit from a physician for 63 days. Record review revealed that R#135 was seen by her MD on 2/26/17 and a PA on 6/3/17 and 7/14/17. There was not any evidence that the resident was seen by an MD or PA by 4/26/17, and there was not any evidence that the resident was seen by an MD by 6/26/17. Record review revealed that R#119 was admitted to the facility on [DATE] and was seen by an MD on 5/18/17 and 7/26/17. There was not any evidence that the resident was seen by an MD by 6/18/17 as well. Record review revealed that R#74 was seen by a Nurse Practitioner (NP) on 11/22/16, 2/28/17 and a PA on 4/23/17, 5/19/17 and 7/12/17. There was not any evidence that the resident was seen by an MD by 1/22/17 or by 4/28/17; and there was not any evidence that the resident was seen by either an MD, NP or PA by 6/28/17. Record review revealed that R#15 was seen by a PA on 5/16/17, 7/6/17 and 8/17/17. There was not any evidence that the resident was seen by an MD by 7/16/17. Record review revealed that R#140 was seen by an NP on 2/9/17, a PA on 4/5/17, 4/14/17, 7/14/17 and 7/20/17. There was not any evidence that the resident was seen by an MD by 4/9/17, and there was not any evidence that the resident was seen by either an MD, NP or PA by 6/9/17. Record review revealed that R#141 was seen by an MD on 2/14/17, a PA on 6/2/17 and 8/3/17. There was not any evidence that the resident was seen by either an MD, NP or PA by 4/14/17 and there was not any evidence that the resident was seen by an MD by 6/14/17. Record review revealed that R#161 was seen by a PA on 3/21/17, 3/28/17 and 6/2/17. There was not any evidence that the resident was seen by an MD by 5/21/17 and there was not any evidence that the resident was seen by an MD, PA or NP by 7/21/17. Record review revealed that R#79 was admitted on [DATE] and seen by a PA on 2/2/17, 4/28/17, 6/2/17 and 6/14/17. There was not any evidence that the resident was seen by an MD by 3/2/17 and an NP or PA by 4/2/17. There was not any evidence that the resident was seen by and MD on 5/2/17 and a PA or NP by 7/2/17. Record review revealed that R#117 was seen by an NP on 11/22/16 and a PA on 4/21/17 and 7/6/17. There was not any evidence that the resident was seen by an MD by 1/22/17, and there was not any evidence that the resident was seen by a NP or PA by 3/22/17, and there was not any evidence that the resident seen by an MD by 5/22/17. Record review revealed that R#109 was seen by an MD on 12/24/16. He was seen by an NP on 1/26/17 and 2/28/17. He was seen by a PA on 7/12/17. There was not any evidence that the resident was seen by an MD by 3/26/17, and there was not any evidence that the resident was seen by the NP or PA by 5/26/17 and seen by the MD again by 7/26/17. Record review revealed that R#129 was seen by an MD on 2/21/17 and a PA on 3/28/17, 4/12/17, 4/21/17, 4/25/17, 6/3/17 and 6/29/17. There was not any evidence that the resident was seen by an MD by 5/28/17. Record review revealed that R#26 was seen by an NP on 10/13/16 and 2/14/17. She was seen by a PA on 6/2/17 and 8/3/17. There was not any evidence that the resident was seen by an MD by 12/13/16 and again by 4/14/17. Record review revealed that R#71 was seen by an NP on 8/18/16 and 2/14/17. She was seen by an MD on 2/26/17 and a PA on 6/2/17 and 7/27/17. There was not any evidence that the resident was seen by an MD by 10/18/16 and there was not any evidence that the resident was seen by a NP or PA by 12/18/16. In addition, there was not any evidence that the resident was seen by an NP or PA by 4/26/17 and an MD again by 6/26/17. Record review revealed that R#107 was seen by an NP on 2/28/17 and a PA on 3/8/17, 3/10/17, 3/30/17, 6/3/17 and 8/3/17. There was not any evidence that the resident was seen by an MD by 4/28/17. Record review revealed that R#108 was admitted [DATE]. He was seen by a PA on 5/19/17 and 6/8/17. He was seen by an MD on 7/26/17. There was not any evidence that the resident was seen by an MD by 6/19/17 and there was not any evidence that the resident was seen by a PA or NP by 7/19/17. Record review revealed that R#204 was admitted [DATE] and was seen by a PA on 7/25/17. There was not any evidence that the resident was seen by an MD by 8/19/17. Record review revealed that R#61 was seen by an NP on 11/29/16 and 2/28/17. She was seen by a PA on 6/2/17 and 7/14/17. An MD saw her on 7/26/17. There was not any evidence that the resident was seen by an MD by 1/29/17, and there was not any evidence that the resident was seen by an NP or PA by 3/29/17 and an MD again by 5/29/17. Record review revealed that R#34 was seen by an NP on 11/22/16 and 2/7/17. He was seen by a PA on 5/16/17 and an MD on 7/26/17. There was not any evidence that the resident was seen by an MD by 1/22/17, and there was not any evidence that the resident was seen by am NP or PA by 3/22/17 and there was not any evidence that the resident was seen by an MD again by 5/22/17. Record review revealed that R#192 was admitted [DATE] and seen by a PA on 6/6/17, 6/7/17 and 6/16/17. She was seen by an MD on 7/26/17. There was not any evidence that the resident was seen by an MD by 7/2/17.

Based on observations, record review, and staff interviews, it was determined that the facility failed to address signs of pain and provide pain management as described in the Plan of Care during the provision of pressure sore and wound treatment for one resident (#112) of three residents with pressure ulcers, and to implement interventions for the potential for nutritional impairment for one resident (#37) in a total sample of 38 residents. This failure resulted in actual harm that was not immediate jeopardy for resident #112. Findings include: 1. Resident #112 was admitted into the facility in September of 2011 with [DIAGNOSES REDACTED]. Review of the documentation on the "Licensed Nurse Skin Assessments" dated September of 2012 revealed that resident #112 had no wounds/pressure ulcers. Licensed nursing staff documented on the October, 2012 skin assessment that the resident had red areas in his/her groin and small open areas. On the November 26, 2012 skin assessment, the licensed nurse documented that there was a black area on the right heel and treatment in progress to the scrotum folds. On January 23, 2013 the nurse documented that resident #112 had deep tissue injury on the right heel. There was a care plan, updated on 11/21/2012, to address his/her alteration in skin integrity/pressure ulcer. Pressure ulcer to right medial heel (Deep Tissue Injury). There was an intervention to observe for pain and treat as ordered. The goal included to reduce pain and discomfort. However, during an observation of pressure ulcer wound care and care to the ulcers in the resident's groin area on 02/12/13 at 2:28 p.m., the resident cried out in pain but, the nurse failed to intervene and treat the pain. See F314 for additional information regarding resident #112. 2. Resident #37 had a care plan since 11/06/12 to address his/her potential for nutritional impairment. There were interventions for staff to determine the resident's food preferences and provide as feasible, and to provide health shakes three times a day with meals. However during an observation of the resident's meals on 2/12/13 at 12:45 p.m., and on 2/13/13 at 8:50 a.m. and 12:50 p.m., the resident was not served a health shake. Review of the "Diet History/Food Preference List" form revealed that the form was blank. See F325 for additional information regarding resident #37.

Based on observations, record review, and staff interviews, it was determined that the facility failed to address signs of pain and provide pain management during the provision of pressure sore treatment for one resident (#112), to notify the physician about the registered dietician's recommendations to promote healing of a pressure sore for one resident (#140), and failed to follow up with the physician timely about the status of an infected pressure sore for one resident (#133) of two of four active residents with pressure sores and one closed record with a pressure sore from a total sample of 38 residents. This failure resulted in actual harm that was not immediate jeopardy for resident #112. Findings include: 1. Resident #112 was admitted into the facility in September of 2011 with [DIAGNOSES REDACTED]. Review of the documentation on the "Licensed Nurse Skin Assessments" dated September of 2012 revealed that resident #112 had no wounds/pressure ulcers. Licensed nursing staff documented on the October, 2012 skin assessment that the resident had red areas in his/her groin and small open areas. On the November 26, 2012 skin assessment, the licensed nurse documented that there was a black area on the right heel and treatment in progress to the scrotum folds. On January 23, 2013 the nurse documented that resident #112 had deep tissue injury on the right heel. There was a care plan, updated on 11/21/12, to address his/her alteration in skin integrity/pressure ulcer. Pressure ulcer to right medial heel (Deep Tissue Injury). There was an intervention to observe for pain and treat as ordered. The goal included to reduce pain and discomfort. However, during an observation of pressure ulcer wound care and care to the ulcers in the resident's groin area on 02/12/13 at 2:28 p.m., the resident cried out in pain but, the nurse failed to intervene and treat the pain. During an observation of pressure ulcer wound care and care to ulcers in the resident's groin area on 02/12/13 at 2:28 p.m., when licensed nurse "FF" touched the resident's right heel pressure ulcer to clean it, the resident cried out in pain and jerked his/her right leg back from her. Resident #112 cried out three times during the heel ulcer measurements and application of the ordered [MEDICATION NAME]. At that time, nurse "FF" said that Resident #112 usually complained of pain during the procedure but, not after it. The nurse said that resident #112 had a 1.0 x 0.2 centimeter (cm) opening in his/her left groin fold and a 0.2 cm x 0.2 cm opening in the right groin fold. Resident #112 cried out in pain during the treatment procedures. The resident said expletives and told the nurse that she did not know she was doing. Immediately after the pressure sore treatments were done, nurse "FF" said that resident #112 commonly called out during the wound care procedure and was medicated. Review of the resident's Nurse's Notes and Medication Administration Records (MARs) revealed no documentation that resident #112 was pre-medicated before wound care was performed to his/her heels or groin area. There was no documentation of pain medication having been given related to the pressure ulcer wound care. On 2/13/13 at 9:45 a.m., nurse "FF" stated that she had asked the medication nurse on 2/12/13 to pre-medicate the resident before wound care was done. However, nurse "FF" said that she did not check to ensure that the resident had been given medication prior to her doing the wound cares. Nurse "FF" acknowledged that the resident had cried out in pain and jerked his/her leg during treatment and that she could have stopped the treatment. There was a physician's orders [REDACTED]. However, nurse "FF" also acknowledged that she had used normal saline to clean the wound bed on resident #112's groin and not soap and water as ordered by the physician. Nurse "FF" said that she was responsible to update the care plan about the pressure ulcer on the resident's right heel to reflect the current treatment and not the initialed treatment dated November 2012. In an interview on 2/13/13 at 7:47 a.m., medication nurse "DD" stated that, sometimes resident #112 could tell you when he/she was in pain. Nurse "DD" said that, if the resident was sitting up at the nurse's station and hollered out, he/she could tell nurse "DD" if his/her foot was hurting and could be repositioned and express whether that intervention helped. Nurse "DD" said that resident #112 was not medicated for pain before the wound care was done on him/her on 02/12/13. She said that resident #112 had not complained about pain yesterday before the procedure but, if the resident had complained of pain, nurse "DD" said that she/he would have given the 'as needed' (prn) medication. Nurse "DD" said that she did the wound care treatments if the treatment nurse was off. She said that the last time she did the wound care for resident #112, he/she did not cry out in pain. Review of the February 2013 physician's orders [REDACTED]. During an interview on 2/13/13 at 10:55 a.m., the facility's Medical Director said that he did not want resident #112 to be uncomfortable during dressing changes and it sounded like he/she was (uncomfortable) yesterday. The physician said that resident #112 did curse at staff sometimes whether they were touching him/her or not but, it sounded like he/she was having pain during the treatment yesterday. The physician said that he would address resident #112's pain management. The physician said that he was not aware of any correspondence from the facility by phone or fax related to resident #112's pain management yesterday or today. Review of the "Message to the Physician" that was faxed by the facility on 02/12/13 at 6:30 p.m., and returned to the facility on [DATE] at 7:57 p.m., revealed that the treatment nurse had notified the physician about the open area on the outer edge of the eschar cap on the resident's right heel. However, there was no documentation that the nurse notified the physician about resident #112's level of pain experienced during the dressing change procedure that day. The physician response noted to change the type of dressing from [MEDICATION NAME] open to air to a foam dressing. During an interview on 2/13/13 at 1:00 p.m., the Director of Nursing (DON) stated that the nurse should have stopped the wound care when Resident #112 cried out in pain. 2. Resident #140 was admitted with an unstageable pressure ulcer on his/her sacrum. During a hospitalized from [DATE] to 1/03/13 for pneumonia and [MEDICAL CONDITION], the sacral pressure ulcer was debrided and [DEVICE] treatments begun. On 1/27/13, the facility's Registered Dietician documented a recommendation for "restoring MVI (multivitamin) every day, 500 milligrams (mg) of Vitamin C twice a day, and 220 mg of Zinc every day for 30 days, and one packet [MEDICATION NAME] in 60 milliliters (ml) of water for 90 days to promote wound healing." However, there was no evidence that the physician was aware of those recommendations. During an interview on 2/14/13 at 8:30 a.m., Registered Nurse "BB" confirmed that there was no evidence that the 1/27/13 RD recommendations had been communicated to the physician. After surveyor inquiry, the Director of Nursing provided a "Physician Communication Form" dated 1/27/13 for the physician to consider the RD recommendations. However, the documentation to implement those recommendations was not signed by the Nurse Practitioner until 2/14/13. There was no evidence that the physician had been made aware of those recommendations or that nursing staff had followed up on the 1/27/13 "Physician Communication Form" until 2/14/13. 3. Resident #133 (closed record) was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with a full length knee extension brace/immobilizer on his/her left leg to prevent knee flexion and had a physician's orders [REDACTED]. According to the 10/18/12 Treatment Record, the resident developed a 3.2 centimeter (cm) by 4 cm., closed, deep tissue injury on the plantar aspect of his/her left foot that was caused by the left leg immobilizer. The physician was notified, the immobilizer was cut to prevent pressure and the pressure sore was treated as ordered. On 11/02/12, a communication was faxed to the resident's physician notifying him that the now open pressure sore on the plantar aspect of the resident's left foot had a moderate amount of greenish drainage and that the surrounding tissue was red and [MEDICAL CONDITION]. On 11/03/12, the physician faxed the facility with a request for the resident's medication list. However, there was no indication that licensed/registered nursing staff had followed up with the physician about the greenish drainage from the resident's pressure sore until 10 days later, on 11/12/12, when the physician's family nurse practitioner (FNP) assessed the resident and noted a thick, yellow purulent drainage coming from the pressure sore with redness and swelling of the surrounding skin. At that time, the FNP ordered a wound culture to be obtained and for licensed nursing staff to administer 500 milligrams of [MEDICATION NAME] (an antibiotic) to the resident every day. The resident was discharged home on[DATE]. The pressure sore at that time had decreased in size, had pink granulation tissue, light non-purulent drainage and the surrounding skin was not red or [MEDICAL CONDITION].

Based on record review, hospital History and Physical Final Report review, hospital Discharge Summary Report review, facility Memo of Record review, facility Diet Master form review, and staff interview, the facility failed to ensure that one (1) resident (#1), who had been assessed to need, and ordered per physician's orders [REDACTED]. Resident #1 received a peanut butter and jelly sandwich, choked, was transported to the hospital, placed in the Critical Care Unit on a ventilator, and subsequently died . The failure of the facility to ensure that Resident #1 received food prepared in the appropriate form resulted in serious injury, harm, and death for this resident. Further residents were identified at risk based on review of the Centers for Medicaid Services (CMS) Form 672, which denoted a total of thirty-seven (37) residents who were receiving mechanically altered diets, including pureed and all chopped food. Of these thirty-seven (37) residents, according to review of the facility's Diet Master form, thirteen (13) residents required pureed foods, thus, all thirteen (13) of these residents could have been at potential risk for serious harm. It was therefore determined that an immediate and serious threat to resident health and safety existed on 07/25/2011, and was removed on 08/05/2011, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: Record review for Resident #1 revealed a medical record Face Sheet which documented an admission date of [DATE], and documented multiple [DIAGNOSES REDACTED]. An Accumulative [DIAGNOSES REDACTED]. A hospital History and Physical Final Report form of 01/17/2011, referencing a 01/08/2011 hospital admission directly prior to the resident's admission to the nursing facility, documented that the resident had a history of [REDACTED]. A speech therapy Dysphagia Medial Work-up Form documented Resident #1 to have an oral-phase and pharyngeal-phase swallowing disorder and to be a definite risk for choking. A speech therapy Plan of Treatment form of 01/22/2011 documented, in the Initial Assessment section, that Resident #1 had a profound current level swallowing functional deficit. A subsequent speech therapy Plan of Treatment form of 06/06/2011 documented that the resident continued to have a moderate/severe current level swallowing functional deficit. A Minimum Data Set assessment of 07/19/2011 for Resident #1 documented in Section K, Swallowing/Nutritional Status, that the resident had a swallowing disorder. A 05/23/2011 Physician/Prescriber Telephone Orders form specified that Resident #1 was to have no peanut butter due to a choking hazard, and the July 2011 physician's orders [REDACTED]. A 07/14/2011 Physician/Prescriber Telephone Orders form specified to change the resident's diet to a mechanical soft diet with pureed meats and pureed bread only, and again specified no peanut butter. A Nurse's Notes entry of 07/25/2011 at 10:00 a.m. documented that Resident #1 was observed in the hall choking, and that the [MEDICATION NAME] Maneuver was performed by the nurse, with no results. This Note documented that Emergency Services 911 was called, cardiopulmonary resuscitation was begun, and the resident was transported to the hospital via the Emergency Medical Technicians. A 07/25/2011, 3:00 p.m. Nurse's Notes entry documented that Resident #1 had been admitted to the hospital Critical Care Unit. During an interview with CNA "DD" conducted on 08/05/2011 at 3:15 p.m., CNA "DD" stated that at around 10:00 a.m. on 07/25/2011, she had observed Resident #1 in the hallway in his wheelchair, pulling himself along the wall by the handrail, with a peanut butter and jelly sandwich in his hand. She stated she saw Resident #1 put his hand up to his throat and she saw he was choking, so she attempted the [MEDICATION NAME] Maneuver after looking in his mouth, and called for help. During an interview with Nurse "EE" conducted on 08/05/2011 at 12:50 p.m., Nurse "EE" stated that at approximately 10:00 a.m. on 07/25/2011, she had been in a resident's room on the 300 Hall and had heard a CNA calling for help. Nurse "EE" stated she looked out into the hallway and observed CNA "DD" performing the [MEDICATION NAME] Maneuver on Resident #1. Nurse "EE" stated that CNA "DD" informed her that the resident was choking on a peanut butter and jelly sandwich. Nurse "EE" stated she assumed care of Resident #1 and continued the [MEDICATION NAME] Maneuver, but that no food residue came out. She stated the resident was then repositioned to the floor, the [MEDICATION NAME] Maneuver was again attempted, but the resident had no pulse, so Cardiopulmonary Resuscitation was began. Nurse "EE" stated that during the provision of emergency care to Resident #1, the resident was checked for food debris, and none was observed either on the lips or in the mouth, but that she had smelled peanut butter. Review of the facility's investigative documents related to this choking incident involving Resident' #1 revealed a Memo of Record of 08/03/2011 which documented that at the time of the facility's 07/26/2011 conversation with the resident's family regarding this incident, Resident #1 was in a coma and on a ventilator. This Memo of Record documented that on 07/27/2011, the resident died . This Memo of Record documented that Resident #1 had been found in the hallway apparently choking on a peanut butter and jelly sandwich, and that during the course of the facility's investigation, all staff who were present at the time of the incident had been interviewed. Certified Nursing Assistant (CNA) "AA" had given a statement indicating that at the time the resident was observed choking, Dietary Staff "BB" had stated that she had given Resident #1 a sandwich. However, in a written statement provided by Dietary Staff "BB" during the facility's investigation, she documented that on 07/25/2011, Resident #1 had come to the dietary department indicating he was hungry, so Dietary Staff "BB" obtained a pudding pack and offered it to him, but he refused, so she retrieved the pudding pack and returned to work. The facility also documented, on the Memo of Record, that during an interview conducted on 07/27/2011, Dietary Staff "BB" had denied giving Resident #1 a sandwich, and had reiterated her account of events, as reflected in her written statement. The facility's Memo of Record also documented that during a 07/27/2011 facility interview with Staff "CC", Staff "CC" had supported Dietary Staff "BB"'s statement by stating that she had witnessed "BB" offer a pudding to Resident #1, which he refused, therefore "BB" returned to dietary and Resident #1 left and proceeded down the hallway. During an 08/05/2011, 2:15 p.m. interview conducted during this complaint survey, Dietary Staff "BB" again stated that on 07/25/2011 at around 10:00 a.m., Resident #1 had come to the dietary department door and needed something to eat. She stated she offered him some pudding which he refused, so she returned to preparing meatloaf. The facility's Memo of Record referenced above documented that the facility's review of the investigative findings revealed no definitive evidence to indicate that Dietary Staff "BB" gave Resident #1 the sandwich, but acknowledged that some unknown person had given the resident the sandwich. Additionally, during an interview conducted on 08/05/2011 at 11:15 a.m., Dietary Aide "FF" stated that on the morning of 07/25/2011, she had prepared peanut butter and jelly sandwiches as snacks and had delivered them to the Nurse's Station. She further stated that no one had obtained a sandwich off the tray as she was going from the dietary department to the Nurse's Station desk. In a written statement obtained as part of the facility's investigation into Resident #1's choking incident, Dietary Aide "FF" documented that she had delivered these sandwich snacks to the Nurse's Station at 10:00 a.m. (approximately the same time that Resident #1 had obtained and ingested the peanut butter and jelly sandwich). During an interview with CNA "AA" conducted on 08/05/2011 at 2:55 p.m., CNA "AA" stated that upon receipt of these sandwich snacks on the morning of 07/25/2011, she had signed for the snacks and had placed them behind the Nurse's Station desk. Therefore, peanut butter and jelly sandwiches were available on 07/25/2011, after having been delivered to, and placed in, the unsecured Nurse's Station at 10:00 a.m. Thus, these sandwiches were available for distribution by staff to residents, and were potentially accessible to residents. During an interview with CNA "GG" conducted on 08/05/2011 at 12:10 p.m., CNA "GG" stated that in the past, she had observed Resident #1 removing a sandwich from the snack cart, and she had intervened to prevent the resident from obtaining the sandwich. Based on the above, the facility allowed Resident #1, who had been assessed as having swallowing problems, and who had a physician's orders [REDACTED]. The facility thus failed to ensure that Resident #1 received food in the form designed to meet the resident's needs. The immediate and serious threat to resident health and safety was determined to be removed on 08/05/2011, when the facility completed the following steps: - On 07/26/2011, the facility implemented a procedure by which all snacks will be delivered and stored only in the pantry which is located behind both nurses' station desks. This room is not a resident area, and is a staff access-only area. A licensed nurse will sign the Snack Acknowledgement of Receipt and assure, at the time of delivery, safe storage of snacks in the pantry behind the nurses' station which is not a public area. At no time will snacks/food be left at the desk. This will be monitored by the Charge Nurse during snack times at approximately 10:00 a.m., 2:00 p.m. and 8:00 p.m. A CNA has been assigned to pass snacks on each shift within fifteen minutes of receipt. The Director Of Nursing (DON) will monitor on a weekly basis and report to the Quality Assurance Committee (QA) monthly. - On 07/26/2011, the facility implemented a procedure by which food trays are monitored for correct diets being served to residents. This will be monitored by licensed nursing staff and CNAs during each meal service and documented in a log, and the DON will monitor this log monthly and will report findings at the monthly QA Committee meetings. - On 08/04/2011, the dietary department reviewed the sandwiches and all snacks against physicians' orders to assure compliance. This procedure will be completed on a monthly basis on the first Friday of every month. The Dietary Manager will monitor daily for 30 days, weekly for a month, and monthly for three months. Findings will be reported to the QA Committee Meeting on a monthly basis. - On 08/04/2011, the facility implemented staff hiring and orientation policies which included specific documentation related to residents at risk or potentially at risk during food consumption. All new hires will receive in-service training as part of their initial hiring process. The Diet Safety Competency Checklist will be completed on the first day of orientation and also prior to any new employee participating in meal service which will demonstrate their ability to distinguish proper food items related to physician diet orders. The Staff Development Coordinator will assure that this is completed to assure compliance and that it is meeting the resident's needs. - On 08/04/2011, the facility implemented a procedure by which the Master Snack List will be reviewed weekly in the PAR Committee meeting to assure accuracy to diet orders. Sandwiches, along with all snacks, will be labeled by the dietary department, with labels produced from the Master Snack List, with the resident's name, room number, order, date and snack time. This will be performed for residents who desire sandwiches and have diet orders that do not prohibit such foods. This will be monitored by the Dietary Supervisor daily for 30 days, weekly for one month, and monthly for three months, with these results reported to the PAR Committee weekly. The next review will be 8/10/2011 by the PAR Committee. - On 08/04/2011, the facility implemented a procedure by which a review of all diet order changes will be conducted by the PAR Committee weekly. The carbon copies of all new and revised diet orders are kept on file in the dietary office for reference of diet order setup and revisions made in the software system. The Dietary Supervisor inputs new information into the computer. This PAR review will entail comparing the information currently in the dietary system to the physicians' orders. The Dietary Supervisor will also monitor daily for 30 days, weekly for a month, and monthly for three month. These findings will be reported to the QA Committee Meeting on a monthly basis. - On 08/04/2011, the facility implemented a procedure by which the licensed nurse receiving an original physician's diet order, filed in the resident's medical record, will flag the chart with diet changes so that the chart will be reviewed at the next PAR meeting following the change. The facility's PAR Committee meeting is held every Wednesday morning, with the next meeting being on August 10, 2011. - On 08/04/2011, the facility implemented a procedure by which all diet order changes will be reviewed by the QA Committee meeting monthly. At the end of each month, when physicians' orders are received from the pharmacy, the specific list of all diet orders provided will be reviewed by the DON with the diet list from dietary, physicians' order form, and telephone orders, to determine any variance. This review will be presented at the monthly QA Meeting by the DON. - On 08/04/2011, the facility implemented a procedure by which the snack list of residents and their diets will be reviewed as new orders are received by the dietary supervisor and a member of the licensed nursing staff, and will be reviewed/monitored weekly at the PAR meetings and during monthly QA Committee meetings. The next monthly QA Committee meeting will be on August 25, 2011. The DON and Unit Managers have identified any residents at risk related to their respective diet orders that have exhibited or suspected to share or take food from other residents. These residents will be assigned to eat under direct supervision not only during meals, but also at snack times. No snacks or food from dietary or other locations will be allowed in the possession of these residents without direct supervision. These residents will have this behavioral risk noted in their care plan and care guides. All diets will be added to the care guides that will be monitored and updated as changes occur. This will be monitored by the Restorative Aide daily for thirty days, then weekly for three months, and will be reported to the QA Committee on a monthly basis. - On 08/04/2011, staff in-service training was provided by the Speech Therapist for the different types of diets, their consistency, signs/symptoms of penetration/aspiration and risk/potential hazards with compromised food consumption/incorrect diet order, and the procedures implemented to assure resident safe food consumption. Of the 138 employees, only 12 employees remained as of 08/05/2011. A follow-up mandatory in-service will be provided to all staff on August 11, 2011, then semi-annually thereafter. This program will be provided through the facility's therapy program by the Speech Therapist. This will be monitored by the DON. Additionally, as part of a periodic inservice program, the facility will provide ongoing education to all staff related to the different types of diets, their consistency, signs/symptoms of penetration/aspiration and risk/potential hazards with compromised food consumption/in correct diet order, and all the procedures in place to assure resident safe food consumption. This includes the procedure by which, upon signs/symptoms of newly developing swallowing or chewing problems, a CNA to Nursing to Therapy Communications form/process is utilized. This staff training will also be provided by the Speech Therapist, and will be on-going on a semi-annual basis. - On 08/05/2011, the facility implemented the use of a resident diet order reference book with pictures, which was actually developed as a result of a called meeting of the QA Committee held on August 4, 2011. This meeting was held to review the incident involving Resident #1 and to discuss and review the facility's plan of correction. This diet order reference book will be kept in the dietary department, will be accessible to all staff to use in group settings, will be updated as diet orders change, and will be reviewed in the weekly PAR Committee meetings to assure compliance. Based on the corrective plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on 08/05/2011. However, the effectiveness of these corrective plans could not be fully assessed to ensure ongoing application and completion. The facility had implemented the interventions referenced above and conducted staff inservice training on the modified policies and practices, but the facility will conduct inservice for new staff in an ongoing process. As part of semi-annual inservices, the facility will provide ongoing education to all staff related to the different types of diets, their consistency, signs/symptoms of penetration/aspiration and risk/potential hazards with compromised food consumption/in correct diet order, and all the procedures in place to assure resident safe food consumption. Monitoring will be required to assure that this training is ongoing and has resolved the identified problems for new and existing staff. Additionally, the facility's PAR Committee will monitor, in its weekly meeting, the facility's ongoing corrective plan, to include monitoring of the master snack list, diet order changes as entered into the dietary department software system, review of resident medical records for diet changes and updates. The next scheduled meeting of the facility's PAR Committee was 08/10/2011. Also, the facility's QA Committee met on 08/04/2011 to discuss and review the facility's corrective plan, and will monitor and assess findings of the facility's ongoing monitoring for issues such as compliance with physicians' dietary orders, the accuracy of the resident snack list, the accuracy and appropriate updating of the facility's resident care guides, and the results of the DON's monthly review of the specific list of physicians' diet orders. These interventions are scheduled to be reviewed at the next monthly QA Committee meeting, which will be held on 08/25/2011. Therefore, the non-compliance continues, with the scope and severity level of the deficiency decreased to the "E" level.