Every finding on record at High Shoals Health and Rehabilitation

Based on observation, interviews, and record reviews, the facility failed to ensure respiratory equipment was maintained in a clean and sanitary manner for one resident (R) (R20) of 19 sampled residents reviewed for respiratory care. This deficient practice had the potential to expose respiratory equipment to environmental contamination and increased the risk of respiratory complications and infection. Findings include:Review of the electronic medical record (EMR), revealed that R20 was admitted to the facility with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD), Alzheimer's disease, and dementia with agitation. Review of the care plan for R20, revealed that the resident had a care plan problem identified as respiratory difficulties/risk for further decline related to COPD. The care plan goal indicated the resident would not require hospitalization as a result of respiratory changes during the review period. Interventions included administering medications and treatments as ordered to address the resident's respiratory condition and maintain respiratory stability.Review of physician orders for R20, revealed an active physician's order for Albuterol Sulfate 2.5 mg (milligrams)/3 mL (milliliters) nebulizer solution, with instructions to administer one nebulizer treatment four times daily as needed for shortness of breath or wheezing. An observation on 06/09/2026 at 1:30 PM, revealed R20 was observed lying in bed and observation of the resident's bedside area revealed a nebulizer mask resting uncovered/unbagged on the dresser. An observation of R20 on 06/10/2026 at 12:00 PM, revealed the nebulizer mask remained uncovered/unbagged and exposed to the environment.An interview on 06/11/2026 at 9:15 AM with Licensed Practical Nurse (LPN) FF, she stated that nebulizer masks and tubing should be stored in a blue protective bag when not in use to maintain cleanliness and prevent contamination.An interview on 06/11/2026 at 9:25 AM with the Director of Nursing (DON), the DON confirmed that nebulizer masks should be stored in a protective bag or other protective covering when not in use to maintain cleanliness and reduce the potential for contamination. The DON stated that her expectation was that nebulizer masks and associated tubing be stored in the protective bag whenever they were not actively being used by the residents.During a follow-up interview on 06/11/2026 at 10:45 AM, the DON stated that the facility did not have a specific policy regarding the storage of nebulizer masks.

Based on observations, staff interviews, and review of the facility's policy titled, Transmission-Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airborne), the facility failed to follow Enhanced Barrier Precautions (EBP) by not using the required personal protective equipment (PPE) during catheter care for one of 12 residents resident (R) (R71) on EBP. This had the potential to increase the risk of infection transmission to residents and staff.Findings include:A review of the facility's policy titled, Transmission-Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airborne), last updated 12/27/2025, revealed under the Policy section .Enhanced Barrier Precautions are indicated for patients with any of the following; .-Wounds and /indwelling medical devices even if the patient is not known to be infected or colonized with a MDRO (Multidrug resistant organism)-Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact activities that provide opportunities transfer of MDRO to staff hands and clothing. MDRO's may indirectly transferred from patient-to-patient during high contact activities. Nursing home patients with wounds and indwelling medical devices are especially at high-risk of both acquisition and colonization of DDROs. The use of gown and gloves for high-contact patient care activities is indicated, when Contact Precautions do not apply, for nursing home patients with wounds and /or indwelling medical devices regardless of MDRO colonization as well as for patients with MDRO infection or colonization.Review of the electronic medical record (EMR) revealed R71 was admitted to the facility with diagnoses of uropathy (a blockage in your urinary tract that slows or stops urine flow), bladder neck obstruction and chronic indwelling Foley catheter in place.Review of the quarterly MDS (Minimum Data Set) dated 03/19/2026 for R71 revealed a Brief Interview for Mental Status (BIMS) score of 15 in Section C (Cognitive Patterns), indicating intact cognition. Section H (Bladder and Bowel) identified the presence of an indwelling urinary catheter. Section I (Active Diagnoses) identified obstructive uropathy as an active diagnosis.Review of physician orders for R71 dated 09/30/2025 revealed multiple orders related to Foley catheter care and maintenance. Orders included an indwelling urinary catheter to bedside drainage (18 French, 30 cc balloon), assessment of catheter function and abdominal distention three times daily, catheter replacement every 30 days, catheter replacement as needed for malfunction or dislodgement, flushing the urinary catheter with 30 milliliters (mL) normal saline every Thursday, and flushing with normal saline as needed for clogging. There is also a referral to urology.Review of the care plan for R71, dated 06/08/2026, revealed interventions related to Foley catheter use and urinary elimination. The catheter care plan was originally initiated on 09/29/2025 and reviewed and continued 03/03/2026. The care plan included monitoring for signs and symptoms of urinary tract infection, providing perineal care after incontinent episodes, assessing for bladder distention and urinary complications, performing catheter care and changes as ordered, observing for signs of infection, utilizing enhanced barrier precautions, and ensuring catheter tubing was secured and maintained below the level of the bladder. Goals included preventing urinary tract infections (UTIs) and other complications related to incontinence and catheter use. Further review of the care plan for R71 revealed Enhanced Barrier Precautions (EBP) were care planned as an intervention related to catheter use and skin breakdown/wound care.An observation on 06/10/2026 at 11:30 AM of Licensed Practical Nurse (LPN) AA performing a Foley catheter flush for R71, revealed LPN AA did not don (put on) a gown prior to the procedure and utilized gloves only. During the procedure, LPN AA was observed leaning forward over R71's bed and made contact with R71 while not wearing a gown.An interview on 06/10/2026 at 11:30 AM with LPN AA, LPN AA acknowledged that a gown should have been worn due to the close contact provided during the procedure.During an interview on 06/10/2026 at 12:20 PM, the Infection Preventionist (IP) nurse stated her expectation was that staff utilized appropriate PPE to protect residents with wounds and indwelling urinary catheters while care was provided.

Based on observations, staff interviews, record reviews, and review of the facility's policy titled Pharmacy Services - Medication Administration: General, the facility failed to follow professional standards of nursing practice for two of 39 sampled Residents (R) (R386 and R17). Specifically, the facility failed to document an explanation for a missed dose of enoxaparin (a blood thinner used to prevent and treat blood clots) for R386 and failed to follow prescribed blood pressure parameters outlined in a physician's order and to ensure that an antihypertensive medication was transcribed accurately for R17 observed during medication administration. Findings include: Review of the undated facility policy Pharmacy Services - Medication Administration: General under the Intent section revealed, To facilitate that medications are administered as prescribed, in accordance with good nursing principles. Under the section titled Guidelines revealed, . The joint responsibility of the center and the pharmacy is to facilitate accurate medication administration . Medications are . administered with a valid prescribed order . If a dose of regularly scheduled medication is withheld, refused, or given at an alternate time . the nurse or CMA should document an explanation of each instance in the permanent medical record. 1. Review of medical records revealed, R386 was admitted with diagnoses that included but not limited to right femoral fracture, status post right hip open reduction internal fixation (ORIF), fall, and compression fracture of the lumbar vertebra. Review of R386's physician orders dated 1/29/2025 revealed, an order for enoxaparin 40 mg (milligram)/0.4 ml (milliliter) subcutaneously, to be administered daily. Review of R386's Electronic Medication Administration Record (eMAR) revealed that the medication was documented as administered daily, except on 2/16/2025. It was signed by Licensed Practical Nurse (LPN) AA with the comment See nurse note; however, no corresponding nurse's note was documented. Interview on 3/27/2025 at 2:45 pm with the Director of Nursing (DON) revealed, she contacted LPN AA, who stated she was unable to locate the enoxaparin at the time and had forgotten to document the reason it was not administered. LPN AA also reported that she had informed the incoming nurse on the next shift that the medication had not been given. The following day, the medication was located, and the resident received the next dose prior to discharge. As a result, one dose was missed during the resident's stay. The DON further stated that she expects staff to document a reason whenever a medication was not administered. In an interview with Pharmacist EE from [Name] Pharmacy on 3/26/2025 at 3:20 pm she stated that, upon reviewing the records, enoxaparin was dispensed three times during the resident's stay, each as a one-week supply-on 1/29/2025, 2/7/2025, and 2/14/2025. She confirmed that the facility could not have been out of stock of that medication. Pharmacist EE also provided the surveyor with a faxed confirmation showing that the medication was sent and delivered to the facility. The surveyor reviewed the delivery sheet, which confirmed that the medication was last delivered on 2/14/2025. In an interview with Pharmacist EE from Eldercare Pharmacy on 3/27/2025 at 4:05 pm, the surveyor asked her about the possible consequences if a resident missed a dose of enoxaparin. Pharmacist EE explained that enoxaparin was typically prescribed to prevent blood clots, and while it was difficult to say with certainty whether a single missed dose would directly result in a clot, the risk cannot be ruled out. She emphasized that the medication must be administered daily to maintain its effectiveness, as inconsistent dosing could compromise the resident's protection against thromboembolic events. 52213 2. Review of the medical records for R17 revealed diagnoses that included, but not limited to, prostate cancer with metastasis, heart failure, Gastro-Esophageal Reflux Disease (GERD) hyperlipidemia, Benign Prostatic Hypertrophy (BPH), vitamin D deficiency and cognitive communication deficit. Review of R17's Physicians Orders revealed an order dated 2/18/2025 for lisinopril (an Angiotensin Converting Enzyme (ACE) inhibitor medication used to treat high blood pressure), one tablet by mouth one time a day. Hold if systolic blood pressure less than (<) 110, diastolic blood pressure greater than (>) 65. Review of the R17's eMAR revealed, on 3/4/2025 Blood Pressure(B/P) was 107/46, on 3/8/2025 B/P was 95/42, on 3/10/2025 B/P was 115/48, and on 3/18/2025 B/P was 90/48 however, lisinopril was documented as administered on these dates. During observation of medication administration on 3/25/2025 at 8:36 am with Certified Medication Assistant (CMA) BB revealed, R17's lisinopril was held by CMA BB because his blood pressure was outside of parameters, as the diastolic blood pressure was greater than 65. R17's blood pressure reading was 137/76. CMA BB was questioned about her decision and if the parameter was appropriate. The CMA BB then administered the medication, stating the appropriate use of the drug and admitting that the parameter was incorrect. She brought it to the attention of her supervisor the Resident Care Coordinator (RCC). The RCC also agreed that the order for the parameters had been entered incorrectly. In an interview on 3/25/2025 at 9:00 am, the RCC stated all nurses were able to transcribe physician orders. She verified that R17's orders related to the parameters for lisinopril was not transcribed accurately and should specify, hold for a diastolic blood pressure less than (<) 65.

Based on observations, staff interviews, and record review, the facility failed to cover clean laundry when transporting to prevent the spread of infection on one of five halls. These failures had the potential to increase the risk of infection transmission. Findings include: Observation on 3/25/2025 at 9:51 am revealed an unattended, uncovered clean clothes rack in the hallway. Further observation revealed two staff members transporting the hanging clothes from the cart to the resident rooms. An interview on 3/25/2025 at 9:52 am with the Environmental Supervisor (ES) revealed, that they have never covered the hanging clean laundry in the hallways, and that they use a sheet to cover the hanging clothes when transporting outside from the laundry room to the main building, as the laundry room was in a separate building from the main building. The ES further stated that their standard practice was not to cover the clean hanging laundry when in the hallways. An interview on 3/26/2025 at 1:20 pm with Laundry Aide (LA) DD revealed she has worked at the facility for four years. LA DD stated they cover the clothes with a sheet on top when transporting the clean hanging laundry from the laundry building to the facility and then remove the sheet when going from room to room. An interview on 3/27/2025 at 11:57 am with the Administrator revealed that the ES oversees the laundry operations. The Administrator stated that she expects clean laundry carts to be covered when transporting from building to building and in the hallways. The Administrator further stated that they have a clean hanging laundry rack which should also be covered when transported from building to building and in the hallways. The Administrator further confirmed that covering clean linen during transportation was the facility's standard of practice.

Based on resident and staff interviews, record review, and review of the facility's policy titled, Notice of Transfer or Discharge from Center, the facility failed to ensure five of five Residents (R) (R11, R16, R64, R74 and R79) reviewed for facility initiated emergent hospital transfers were provided with written transfer notice that contained all required information. This failure has the potential to affect the residents and/or the Resident Representatives (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility's policy titled, Notice of Transfer or Discharge from Center, reviewed 12/30/2022, showed: Intent It is the intent of this center to provide notification of a transfer or discharge in writing. Guideline A completed Notice of Transfer or Discharge form will be provided to the patient or legal representative. This notice: -Will be completed in a language and manner they can understand .Is required for all discharges except for death in the facility. 1. Review of R11's undated Face Sheet, provided by the facility revealed the R11 was admitted to the facility on [DATE] with diagnoses that included kidney stones. Review of R11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/2023 revealed a Brief Interview for Mental Status (BIMS) score of 11 out 15 which indicated the resident was cognitively intact. During an interview on 11/13/2023 at 2:28 pm, R11 stated, I've been to the hospital several times, last April I was non-responsive; last time I went [to the hospital] was two months ago for kidney stone surgery. Review of R11's MDS showed discharge to hospital assessments with ARDs of 3/23/2023, 6/21/2203, 7/20/2023, and 9/25/2023. Review of R11's Nurse's Notes, Progress Notes, Data Collection, and Scanned Docs [Documents] tabs located in the resident's Electronic Medical Record (EMR) showed no evidence R11 and/or her RR received a written notice of transfer/discharge. Review of the Notice of Transfer or discharge date d 3/23/2023, 6/21/2203, 7/20/2023, and 9/25/2023 revealed a section at the bottom of the form: Check to indicate appropriate copy (for emergency transfer to hospital, resident's copy is attached to transfer papers): Resident's Copy-Resident Representative's Copy- Chart Copy None of the four forms had any of the check boxes marked. During an interview on 11/16/2023 at 3:08 pm, R11 was shown the written transfer notice form and asked if she had received one for each transfer. R11 reviewed the form and stated, No, I've never seen that form before. 2. Review of R64's Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R64's Nurse Note located in the resident's EMR under the Nurse's Notes tab revealed R64 was transferred to the hospital on 1/8/2023 due to an unwitnessed fall. 3. Review of R16's Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R16's Nurse Note located in the resident's EMR under the Nurse's Notes tab revealed R16 was transferred to the hospital on 8/28/2023 due to an unwitnessed fall, and on 8/31/2023 due to becoming unresponsive later in the day after experiencing delusions and hallucinations throughout the day. During an interview on 11/15/2023 at 12:25 pm, the Health Information Manager (HIM) stated residents were not given written information during a resident's transfer to the hospital, the resident's representative was notified via telephone; however, no written information was given to a resident and/or their representative prior to, upon, or post transfer. 4. Review of R74's undated Face Sheet, provided by the facility showed the resident was admitted to the facility on [DATE] with diagnoses that included hydronephrosis with renal and ureteral calculous, urinary tract infection, chronic kidney disease, hypertensive heart failure, and diverticulosis. Review of R74's Nurse's Notes located in the resident's EMR under the Nurse's Notes tab showed: 7/28/2023. 17:46 [5:46] pm at 10 am Residents B/P 88/44, per staff has had weight gain since admission on the 25th, dizzy, . PT [Physical Therapy] states placed resident back into bed because of weakness. Notified NP [Nurse Practitioner] sent to ER [emergency room ] to evaluate and treat. Family notified.8/15/2023. 12:46 pm Resident nephrostomy tubes were not draining and had blood in the tubing this am [morning]. Flush attempted by RN [Registered Nurse], flush was unsuccessful. Resident sent to [hospital name] via transport. Resident was alert and oriented upon leaving facility vital signs were within normal limits. RP [RR name], and NP [Nurse Practitioner name] both notified. 8/17/2023. 18:01 [6:01 pm] 08:00 [8:00 am] Therapy aide came to unit 3 for nurse to check on resident, stated resident was having respiratory difficulty O2 sat [oxygen saturation] 72-74 with O2 at 2lpm [liters per minute], resident lethargic. SOB [short of breath]. call D.O.N. send to ER report called to [hospital name] .EMS called for transport. resident transported to [hospital name] 09:00 [9:00 am]. resident admitted to hospital DX [diagnosis]: severe UTI [urinary tract infection]. Review of R74's Notice of Transfer or discharge date d 7/28/2023, 8/15/2023, and 8/17/2023, provided by the facility showed at the bottom of the form Check to indicate appropriate copy (for emergency transfer to hospital, resident's copy is attached to transfer papers): Resident's Copy - Resident Representative's Copy - Chart Copy. For all three forms, nothing had been Checked/Marked to indicate R74 and/or his RR received copies of any of the three forms. During an interview on 11/16/2023 at 2:10 pm, the Director of Nursing (DON) reviewed the forms and stated, Have transfer notices for all and nurses' notes, but none of the boxes are checked [at the bottom] so no, the resident and representative didn't get a copy. 5. Review of R79's undated Face Sheet, provided by the facility showed R79 was admitted to the facility on [DATE] with diagnoses that included femur fracture, urinary tract infection, dementia, shoulder fracture, chronic kidney disease, and hypertensive heart disease. Review of R79's written Notice of Transfer or Discharge, dated 8/4/2023 provided by the facility revealed Check to indicate appropriate copy (for emergency transfer to hospital, resident's copy is attached to transfer papers): Resident's Copy - Resident Representative's Copy - Chart Copy. There were no Checks/Marks to indicate R79 and/or his RR received a copy of the form. Review of R79's Nurse's Notes and Progress Notes tabs revealed no documented evidence why R79 was sent to the hospital on 8/4/2023. During an interview on 11/15/2023 at 9:11 am regarding the provision of the transfer/discharge notice to the resident & RR, the DON stated, .The notice is scanned in the chart, goes to financial, and it goes in the record. We don't give it to the family, and no, the resident doesn't get a copy either. 46592

Based on staff and resident interviews, record review, and review of the facility's policy titled, Bed Hold During Hospital Stays and Therapeutic Leaves, the facility failed to ensure the resident and/or the Resident Representative (RR) was provided with the notice of the facility's notice of bed-hold policy for five of five Residents (R) (R11, R16, R64, R74, and R79) reviewed for hospital transfers. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include: Review of the facility policy titled Bed Hold During Hospital Stays and Therapeutic Leaves, reviewed 12/30/2022, showed: Intent It is the intent of this nursing center to offer all residents and/or his/her designee the choice of either paying the appropriate amount to hold the bed when the resident goes to the hospital or on therapeutic leave or releasing the bed and being readmitted to their previous room if available or to the first available bed. A letter must be mailed to the resident and/or responsible party within twenty-four (24) hours of the resident's admission to the hospital or the start of the resident's therapeutic leave. The decision regarding holding the bed or releasing the bed must be submitted in writing to the Administrator and/or his/her designee .The Financial Controller, or Administrator's designee, will attempt to telephone the resident and/or the responsible party to explain the process and make arrangements to obtain a signed decision regarding the holding of the bed and payment of bed hold. The date and time of the telephone call will be documented. Upon notification that a resident has been transferred to the hospital or is going on therapeutic leave, the Financial Controller, or the Administrator's designee, will prepare a bed hold letter to be sent to the resident and/or his/her designee. The letter to be used is in the Business Office Forms Manual and is to be retyped on facility letterhead. This letter will specify the rules regarding absence. This letter will indicate the date that private bed hold begins. This letter will specify the amount to be paid per day on private bed hold. This letter will provide a space for signature of the resident and/or his/her designee indicating the desire to pay private bed hold or a space to decline to do so. The letter will advise of the resident's right to return to the facility to their previous room if available or to the first available bed if the resident declines to hold the bed provided that the resident requires the services provided by the Facility and the Facility is able to meet the clinical needs of the resident. The letter must be mailed to the resident and/or responsible party within twenty-four (24) hours of transfer. 1. Review of the R11's undated Face Sheet, provided by the facility showed R11 was admitted to the facility on [DATE]. During an interview on 11/13/2023 at 2:28 pm, R11 stated, I've been to the hospital several times, last April I was non-responsive; last time I went [to the hospital] was two months ago for kidney stone surgery. Review of R11's MDS showed discharge to hospital assessments with ARDs of 3/23/2023, 6/21/2203, 7/20/2023, and 9/25/2023. Review of R11's) Nurse's Notes, Progress Notes, Data Collection, and Scanned Docs [Documents] tabs located in the resident's EMR showed no documented evidence the resident and/or the RR received a written bed-hold policy prior to or upon discharge to the hospital. Review of R11's written Notice of Transfer or Discharge provided by the facility and contained the information regarding the written bed hold notices for the four transfers showed a section at the bottom of the form: Check to indicate appropriate copy (for emergency transfer to hospital, resident's copy is attached to transfer papers): Resident's Copy Resident Representative's - Copy -Chart Copy None of the four forms had any of the boxes Checked/Marked to indicate the resident was provided with the facility's bed-hold policy prior to or upon transfer to the hospital. 2. Review of R64's Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R64's Nurse Note located in the resident's EMR under the Nurse's Notes tab revealed R64 was transferred to the hospital on 1/8/2023 due to an unwitnessed fall. 3. Review of R16's Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R16's Nurse Note located in the resident's EMR under the Nurse's Notes tab revealed R16 was transferred to the hospital on 8/28/2023 due to an unwitnessed fall, and on 8/31/2023 due to becoming unresponsive later in the day after experiencing delusions and hallucinations throughout the day. During an interview on 11/15/2023 at 12:25 pm, the Health Information Manager (HIM) stated residents and/or their representatives were not given written information regarding the facility's bed hold policy prior to or upon transfer to the hospital. 4. Review of R74's undated Face Sheet, provided by the facility showed the resident was admitted to the facility on [DATE]. Review of R74's Nurse's Notes, located in the resident's EMR under the Nurse's Notes tab showed the resident was transferred to the hospital on 7/28/2023, 8/15/2023, and 8/17/2023. The notes revealed no documented evidence that the resident and/or representative received bed-hold notice information prior to each transfer. Review of R74's three Notice of Transfer or Discharge forms dated 7/28/2023, 8/15/2023, and 8/17/2023 revealed each form contained information regarding the written bed hold notices. Continued review of the forms revealed Check to indicate appropriate copy (for emergency transfer to hospital, resident's copy is attached to transfer papers): Resident's Copy - Resident Representative's Copy - Chart Copy. None of the three forms had any of the check boxes Checked/Marked to indicate the resident was provided with the facility's bed-hold policy prior to or upon transfer to the hospital. 5. Review of R79's undated Face Sheet provided by the facility showed R79 was admitted to the facility on [DATE]. Review of R79's written Notice of Transfer or Discharge, form dated 8/4/2023, provided by the facility revealed the form included information regarding the written bed hold notice policy. Continued review of the form revealed Check to indicate appropriate copy (for emergency transfer to hospital, resident's copy is attached to transfer papers): Resident's Copy - Resident Representative's Copy - Chart Copy. The form did not have any of the boxes Checked/Marked to indicate the resident was provided the facility's bed-hold policy prior to or upon transfer to the hospital. During an interview on 11/15/2023 at 9:11 am, the Director of Nursing (DON) stated, .The notice is scanned in the chart, goes to financial, and it goes in the record. We don't give it to the family, and no, the resident doesn't get a copy either. The DON confirmed the facility's Notice of Transfer or Discharge form contained the bed hold policy; however, residents and/or the RR were not provided the forms prior transferring to the hospital. 46592

Based on observations, interviews, and record review, the facility failed to ensure meaningful activities were offered for three of five Residents (R) (R3, R65, and R68) reviewed for dependent activities. This failure created the potential for the residents to experience a decreased quality of life. Findings include: 1. Review of R3's undated Face Sheet, provided by the facility, indicated R3 was with diagnoses which included dementia. Review of R3's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/27/2023, revealed a Brief Interview of Mental Status (BIMS), score of three out of 15, which indicated the resident was severely cognitively impaired. Continued review of the MDS revealed R3 was assessed for the following activity preferences as very important to her: having books, newspapers, and magazines to read, to listen to music, to be around animals, such as pets, to keep up with the news, to do things with groups of people, to do her favorite activities, to go outside to get fresh air when the weather is good, and to participate in religious services or practices. Review of R3's Care Plan initially dated 6/7/2019 and updated on 11/15/2023 during survey was provided by the facility revealed, Needs assistance to participate in activities due to hearing related to planned activity development as evidence by SNF (skilled nursing facility) residency. Interventions included: If patient needs hearing aids, ensure they are present and working. Hearing aids were not working at one time and had to be fixed. Place patient near the activity leader/speaker or in the line of sight of the activity leader. Place her close to the speaker if we are using the microphone. (Revision added on 11/15/2023): We usually sit right outside her room during hallway activities so she can see what we are doing even if she doesn't come out into the hall for the activity. Repeat instructions as needed to enhance communication and hearing. Check with her to make sure she is understanding what we are asking and watch her to see if she is able to hear what it is we are saying. Review of R3's Attendance Record for one (1) to1 Visits and Specialized Small Groups dated 9/2023, provided by the Activity Director (AD), revealed on 9/14/2023 the resident participated in an activity listed as Family Visit. There was no other documented evidence the resident participated or was offered to participate in any other activities for the month. Review of R3's Attendance Record for 1 to 1 Visits and Specialized Small Groups dated 10/2023, provided by the AD, revealed there was no documented evidence the resident participated or was offered to participate in any activities for the month. Review of R3's Attendance Record for 1 to 1 Visits and Specialized Small Groups, dated 11/2023, AD revealed on 11/2/2023 the resident participated in an activity listed as Family Visit. There was no other documented evidence that the resident participated or was offered to participate in any other activities for the month. During observations conducted throughout the survey on 11/13/2023, 11/14/2023, and 11/16/2023, R3 was observed in bed, and not participating in any meaningful activities that were important to her. 2. Review of R65's undated Face Sheet provided by the facility, indicated R65 was admitted to the facility on [DATE] with diagnoses which included dementia. Review of R65's admission MDS with an ARD of 10/11/2023, revealed the facility assessed the resident to have a BIMS score of seven out of 15 which indicated R65 was severely cognitively impaired. Continued review of the MDS revealed the following activity preferences were very important to the resident: to be around animals, such as pets, to keep up with the news, to do my favorite activities, to go outside to get fresh air when the weather is good, and to participate in religious services or practices. It is somewhat important to listen to music I like, and not very important to have books, newspapers, and magazines to read, and it is important, but can't do or no choice to do things with groups of people. Review of R65's Care Plan dated 10/17/2023, provided by the facility, documented Expresses past and/or present activity interests (strength) related to decreased mobility as evidenced by patient expresses interest in activities. Interventions included: Past and/or resent interest in games including playing some games when he was younger. Past and/or present interest in music including listening to country music. Past and/or present interest outdoor activities including going hunting and fishing. He loved to go hunting and it didn't matter what he went hunting for as long as he got to go. And he loved working out in the yard. Past and/or present interest in pets/animals including having three (3) cats at home. Past and/or present interest in socializing with others including spending time with his family mostly. He says he used to be more social than he is now. Past and/or present interest in spiritual/religious including attending church services often when he lived in Kansas. Past and/or present interest in sports including going hunting and fishing. He is also a football fan who enjoys watching all levels of football both college and pro. UGA (University of Georgia) is his favorite team. Past and/or present interest in (television)TV/Internet including watching ABC, CBS, [NAME], ESPN (channel listings), and the Weather Channel. He likes to watch sports, especially football and UGA football. Provide a schedule of events to post in his/her room. Review of R65's Attendance Record for 1 to 1 visits and Specialized Groups dated 10/2023, documented the resident participated in the following activities: 10/5-admitted , 10/9-family visit, 10/10-family visit, 10/11-family visit, 10/13- family visit, 10/16-family visit, 10/19-barbershop and family visit, 10/20-family visit, 10/23-family visit, 10/26-family visit, and 10/31-family visit. There was no documented evidence the resident participated in or offered to participate in any facility provided activities. Review of R65's Attendance Record for 1 to 1 visits and Specialized Groups dated 11/2023, documented the resident participated in the following activities: 11/02-family visit, 11/9, family visit, and 11/14-family visit. There was no documented evidence the resident participated in or was offered to participate in any facility provided activities. During observations conducted during the survey on 11/13/2023, 11/14/2023, and 11/16/2023, R65 was observed lying in bed, and not participating in any meaningful preferred activities. 3. Review of R68's undated Face Sheet provided by the facility, indicated R68 was admitted with diagnoses which included dementia. Review of R68's significant change in status MDS with an ARD of 9/25/2023, located in the resident's EMR under the MDS tab, revealed the Staff Assessment of Cognitive Skills indicated the resident's cognition was severely impaired-never/rarely made decisions. The resident was not assessed for preferences in activities. Review of R68's Care Plan dated 10/11/2023, documented Expresses past and/or present activity interests (strengths) related to planned activity development as evidenced by SNF (Skilled Nursing Facility) Residency. Interventions included: Past and/or present interest in arts/crafts including cooking for all. She loved cooking for her family, Past and/or present interest in music including listening to gospel music, Past and/or present interest in outdoor activities including gardening and doing yard work, Past and/or present interest in socializing with others including spending time with her family, Past and/or present in spiritual/religious including attending church services and listening to gospel music, her faith is very important to her, Past and/or present interest in TV/Internet including watching the news, lifetime channel and mystery/crime shows, provide a schedule of events to post in his/her room, provide assist to/from activities of interest as needed, assist with transportation to/from activity settings, and place patient near activity leader. Review of R68's Attendance Record for 1 to 1 visits and Specialized Groups dated 9/2023, documented the resident participated in the following activities: 9/4-family visit, 9/7-hospital, 9/18-returned from hospital, and 9/19- family visit. There was no documented evidence that the resident participated in or was offered to participate in any facility provided activities. Review of R68's Attendance Record for 1 to 1 visits and Specialized Groups dated 10/2023, documented the resident participated in the following activities: 10/11-hospital, 10/16-returned from hospital, and 10/18-family visit. There was no other documented evidence the resident participated in or was offered to participate in any facility provided activities. Review of R68's Attendance Record for 1 to 1 visits and Specialized Groups dated 11/2023, documented the resident participated in the following activities: 11/1-family visit. There was no documented evidence the resident participated or was offered to participate in any facility provided activities. During observations conducted during the survey on 11/13/2023, 11/14/2023, 11/15/2023, and 11/16/2023, R68 was observed sitting in the hallway in a Geri-chair, staring at the wall and lying in bed. The resident was not observed participating in any activities. During an interview on 11/13/2023 at 3:42 pm, Family Member (FM)1 stated R68 was supposed to be out of bed. FM1 also stated R68 liked to watch television shows such as westerns and enjoyed listening to music. During an interview on 11/16/2023 at 8:36 am, the Activity Director (AD), was questioned concerning R3, R65, and R68's lack of documented evidence that the residents participated or were offered to participate in facility provided activities? The AD stated she was trying to get R3 back into activities, R65 had not shown any interest in getting out of the room. The AD stated as far as R68 attending group activities, when there was too much going on around her, we had to take her back to the hallway or to her room. The AD was asked what the activity department was doing for residents who needed one-to-one activities? The AD stated it was just her in the activity department, so she tried to keep her eyes and ears open to see if the residents needed anything. The AD further stated she tried to do activities with the residents as needed; however, there was no set schedule for dependent residents. During the interview, the AD confirmed the observations made by the surveyor of the three residents not participating in any activities. During an interview on 11/16/2023 at 9:46 am, the Administrator stated it was her expectation that activities were provided for all residents. The Administrator stated it was also her expectation for the AD to go around with the activities cart and try to do activities that interest the dependent residents.

Based on staff interview and record review, the facility failed to ensure four of four Certified Nurse Aides (CNA) (CNA 1, CNA3, CNA4 and CNA5) and one of one Licensed Practical Nurses (LPN) (LPN 4) reviewed had received behavioral health training to care for residents diagnosed with mental health illnesses. This failure had the potential for direct care staff to lack current knowledge to work with the unique challenges mental health illnesses present. Findings include: Review of the Facility Assessment, reviewed 9/8/2023, revealed under the category I. Resident Profiles showed the facility accepted Psychiatric/Mood Disorders of Psychosis (Hallucinations, Delusions, etc.) Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Anxiety Disorder Unspecified, Schizophrenia, Schizoaffective, Post Traumatic Stress Disorder, Behaviors not listed else where [sic], Pasarr Level II Review of five random direct care employee files with Human Resources (HR) on 11/16/2023 at 4:00 pm revealed four CNAs and one LPN did not have any behavioral health training on the facility provided list of education courses and/or in-service sign in sheet. The staff roster showed CNA1 was hired on 2/16/2015 and the list of courses taken in 2023 did not include anything related to behavioral health training. The staff roster showed CNA3 was hired on 10/1/2014 and the list of courses taken in 2023 did not include anything related to behavioral health training. The staff roster showed CNA4 was hired on 7/26/2023 and the list of courses taken since hire did not include anything related to behavioral health training. The staff roster showed CNA5 was hired on 7/26/2021 and the list of courses taken in 2023 did not include anything related to behavioral health training. The staff roster showed LPN4 was hired on 10/1/2014 and the list of courses taken in 2023 did not include anything related to behavioral health training. During an interview on 11/16/2023 at 4:00 pm, while reviewing the employee files with HR, HR stated They are starting the behavioral health training in December [2023]. When asked to clarify if that was an annual training or the first time it was being completed, HR clarified it was the first time it was being done. During an interview on 11/16/2023 at 5:10 pm, the Administrator stated they [the facility] did not find a policy about behavioral health training.

Based on staff interviews, record reviews, and review of the facility's policy titled, Abuse Prohibition, the facility failed to report an allegation of abuse reported immediately, but no later than two (2) hours after the allegations of abuse for one of five Residents (R) (R 17) reviewed for alleged abuse. This failure had the potential for allegations of abuse to not be identified and reported as required. Findings include: Review of the facility's policy titled Abuse Prohibition dated 12/30/2022, revealed It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse, or misappropriation of patient property .Mandated Reporters: .Employees of a public or private agency engaged in professional health related services to elder persons or disable adults. The policy failed to include timeframes for the required reporting and failed to include who and what agencies allegations of abuse should be reported to. Review of R17's discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/20/2023, located in R17's Electronic Medical Records (EMR) under the MDS tab revealed R17's Staff Assessment of Mental Status indicated R17's cognitive skills for daily decision making were moderately impaired (decisions poor, cues/supervision required). Review of R17's Patient Transfer Record-Inter Agency Referral revealed she was transferred to the hospital on 2/20/2023 with primary diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. Review of the R17's Nurses Notes, dated 2/21/2023 completed by Licensed Practical Nurse (LPN) 2, included in the Facility Reportable Incident (FRI) provided by the facility, documented Family of R17, called the facility stated he had some news to share with the person in charge. He stated he was calling to give us a heads-up that when [R17] went to her wound care appointment, she told them she had been abused. Wound Care sent resident [R17] to the ER [emergency room ] for breathing difficulty, where she continued to state she had been abused at the facility. He wanted to make sure we knew the family had nothing to do with the report and they had tried to tell the hospital that this was a behavior for her and that she was delusional or dreaming. During a telephone interview on 11/15/2023 at 9:26 am, the emergency room (ER) Patient Affairs Coordinator (PAC) 2 revealed, R17 complained of being abused at the facility while at the ER. PAC 2 revealed the resident could not recall any dates or names related to the alleged abuse. The PAC 2 stated the allegation was reported to the police and the State Survey Agency. During an interview on 11/15/2023 at 10:05 am, LPN2 stated she informed the Resident Care Coordinator (RCC) and the Director of Nursing (DON) regarding Family of R17's phone call and was told to document the conversation in a nursing note. When questioned if the family said the abuse was related to another resident or staff member, LPN2 stated the son did not say, and she did not ask if it was a resident or a staff member. LNP2 also stated R17 was care planned for embellishing stories. During an interview on 11/15/2023 at 10:30 am, the RCC was asked what she done after LPN2 reported the alleged abuse to her? The RCC stated it was discussed in the management group. When asked who was part of the management group, the RCC stated it was herself. The DON was present during the interview and stated honestly I can't remember. I don't recall if we reported the allegation. Because [we] assumed the hospital reported it [the allegation]. [I] don't remember doing anything. Generally, we report everything, [I] guess since it [the allegation] was reported at the hospital, and they did the investigation we left it at that. During an interview on 11/15/2023 at 10:40 am, the Director of Nursing (DON) stated she remembered R17 going to an appointment and then being sent to the hospital for respiratory issues. The DON also stated she did not recall what the facility did about it (the allegation of abuse). A further interview revealed the DON spoke to the Administrator during the morning meeting about the allegation of abuse. The DON further stated the allegation was not reported to the State Survey Agency and she could not recall if she spoke to resident, about the allegation. The DON also stated she did not talk to the resident's family about the allegation. When questioned if the allegation should have been reported to the State Survey Agency and other required agencies, the DON responded, technically the facility should have reported it. During an interview on 11/15/2023 at 10:50 am, the Administrator stated she did not recall the incident of the alleged abuse. When questioned what her expectation was related to reporting the Family of R17 allegation of abuse, the Administrator stated, once we heard from the family, we should have spoken to the resident who was at the hospital, and we should have reported it [the allegation of abuse].

Based on staff interviews, record reviews, and review of the facility's policy titled, Abuse Prohibition, the facility failed to conduct a thorough investigation following an allegation of abuse for one of five Residents (R) (R17) reviewed for alleged abuse. This failure not to conduct a thorough abuse investigation had the potential to result in other residents not being identified as potential victims of abuse. Findings include: Review of the facility's policy titled, Abuse Prohibition, dated 12/30/2022, revealed, It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse .We believe that each patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse . The procedures herein establish standards of practice for protection of patients and for identification and prevention of abuse . Once an injury or event is identified as suspicious and may constitute abuse, the center will follow the investigation procedures . The facility's policy did not include a process for completing an investigation. Review of R17's discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/20/2023, located in R17's EMR under the MDS tab revealed R17's Staff Assessment of Mental Status indicated R17's cognitive skills for daily decision making were moderately impaired (decisions poor, cues/supervision required). Review of R17's Patient Transfer Record-Inter Agency Referral revealed she was transferred to the hospital on 2/20/2023 with primary diagnoses of chronic obstructive pulmonary disease (COPD) exacerbation. Review of the R17's Nurses Notes, dated 2/21/2023 completed by Licensed Practical Nurse (LPN) 2, included in the Facility Reportable Incident (FRI) provided by the facility, documented Family of R17, called the facility stated he had some news to share with the person in charge. He stated he was calling to give us a heads-up that when [R17] went to her wound care appointment, she told them she had been abused. Wound Care sent resident [R17] to the ER [emergency room ] for breathing difficulty, where she continued to state she had been abused at the facility. He wanted to make sure we knew the family had nothing to do with the report and they had tried to tell the hospital that this was a behavior for her and that she was delusional or dreaming. During an interview on 11/15/2023 at 10:05 am, LPN2 stated she informed the Resident Care Coordinator (RCC) and the Director of Nursing (DON) regarding Family of R17's phone call and was told to document the conversation in a nursing note. During an interview on 11/15/2023 at 10:40 am, the DON stated the facility should have conducted an abuse investigation. During an interview on 11/15/2023 at 10:50 am, the Administrator stated she did not recall the incident of alleged abuse. The Administrator stated it was her expectation after the facility learned of the allegation of abuse from the Family of R17, the facility should have investigated the allegation of abuse.

Based on record review and interviews, the facility failed to ensure that two residents (R#12 and R#260) were provided showers according to their preferences. The sample size was 20 residents. Findings include: Per the Director of Nursing (DON) the facility did not have a policy related to resident bathing/showering. 1. Review of the clinical record for R#12 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated moderate cognitive impairment. Section F revealed that making decisions related to bathing was very important to resident. Review of the shower schedule for R#12, who resides in room [ROOM NUMBER]W, revealed she was scheduled to receive showers on Tuesday and Friday during the day shift. Review of the facility shower sheets with Licensed Practical Nurse (LPN) BB on 11/12/22 at 7:45 a.m., revealed there were no shower sheets completed for R#12 to indicate showers were completed for September 2022, October 2022, and November 1 through November 12, 2022. Interview on 11/11/22 at 9:32 a.m. with R#12, stated she was supposed to get a bath twice per week, but only received a bath on Tuesdays. She stated she would like to bathe twice a week. During further interview, she stated she did not know why she did not receive her baths as scheduled. During an interview on 11/12/22 at 7:40 a.m. with R#12, stated staff did not offer her a bed bath, or shower yesterday. Additionally, she said she did not receive a shower this week. 2. Review of the clinical record for R#260 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as eight, which indicated moderate cognitive impairment. Section F revealed that making decisions related to bathing were very important to resident. Review of the shower schedule for R#260, who resides in room [ROOM NUMBER]D, revealed she was scheduled to receive showers on Tuesday and Friday during the day shift. Review of the shower sheets with LPN BB on 11/12/22 at 7:45 a.m., revealed no shower sheet was completed for R#260 to indicate showers were completed for November 1 through November 12, 2022. Interview on 11/11/22 at 9:32 a.m. with R#260, stated she had been in the facility for three weeks. She stated she had only received one bed bath and had not had her hair washed or showered since her arrival. She stated the facility explained she would receive regular bathing and did not know why she had not received any baths or showers. Interview on 11/12/22 at 7:40 a.m. with R#260, she stated staff did not offer her a bed bath, or shower yesterday. She said she would like to have a shower and wash her hair. She again explained that she had not showered or washed her hair since admission to the facility. Interview on 11/12/22 at 7:45 a.m. with the Licensed Practical Nurse (LPN) BB, stated the Certified Nursing Assistants (CNA) provided the baths and showers for the residents, two times per week. She stated the CNAs completed a bath sheet for each resident when bathed. She added that if a resident refused a bath, the bath sheet still had to be filled out, and the word refused is written on the sheet. She said the nurse was supposed to be informed if a resident refused their bath or shower. During further interview, she stated that the CNAs placed the completed forms in a box outside of her office door, and she filed them. When asked why there are no bath sheets completed for R#12 and R#260, LPN BB explained that she assumed both residents received their showers. She said it was her expectation for the CNAs to offer the residents a bath or shower on their scheduled days, and it was her expectation for the shower sheets to be completed for each resident. Interview on 11/12/22 at 7:56 a.m. with the DON, she stated it was the responsibility of LPN BB to monitor the bathing forms to ensure that residents received a bath or shower. She stated if a resident refused a shower, a bath sheet would still be filled out and documented as refused. She stated she expected the CNAs and nurses to offer a bath or shower to each resident on their scheduled bath/shower days. Interview on 11/13/22 at 10:17 a.m. with CNA CC, she stated that residents receive a bath or shower two days per week. She explained that each resident had a bath form filled out, which indicated whether they received or refused their bath/shower. She stated the CNAs gave the completed forms to LPN BB after completion. LPN BB had a box on the wall outside her office to place the forms if she was not in her office to receive them.

Based on record review, staff interviews, and review of the policy titled Patient's Plan of Care, the facility failed to develop a person-centered care plan for one resident (R) (R#261) for refusal of care and medications. The sample size was 20 residents. Findings include: Review of the policy titled Patient's Plan of Care, reviewed 12/4/21, revealed each patient will have a person-centered comprehensive plan of care developed and implemented to meet patient's medical, physical, mental, and psychosocial needs. A continued review revealed if a patient chooses to decline certain services or treatments that staff believe to be indicated to assist the patient in reaching his or her highest practicable level of well-being or safety, the comprehensive care plan would identify the care or service being declined, the risk the declination poses to the patient, and efforts by the interdisciplinary team to educate the patient and the representative, and attempts to find alternative means to address the identified risk/need. Review of the History and Physical (H&P) for R#261, dated 11/22/21, revealed under Review of Systems: psychiatric refusal of care and medications. Review of updated care plan dated 9/2/22, did not have evidence that R#261 had a care plan problem to include refusal of care and medications. Review of the Nursing Notes dated 3/27/22 at 11:58 a.m. revealed that R#261 refused to take her scheduled medications. Resident stated she would wait for her son to arrive before taking any medications. Staff educated resident on the importance of medication compliance, and resident verbalized understanding. Review of the Nursing Notes dated 8/23/22 at 11:21 p.m. revealed that R#261 was confused, spat out her medications, and refused water. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/12/22 at 11:00 a.m. with the Minimum Data Set (MDS) Coordinator, stated she develops the comprehensive care plan for each resident based on information from family interviews, the clinical history and physical (H&P), hospital documentation, resident interviews, and the admission assessment. She stated that the staff did not notify her of R#261's refusal of medications. She stated she reviews the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/12/22 at 12:35 p.m. with the Licensed Practical Nurse (LPN) AA, stated if a resident refuses care or medications, she would document the refusal on the MAR. LPN AA stated she would fill out a communication form for the physician and Nurse Practitioner (NP) to ensure they were aware of the resident's refusal. She stated the only person that could create a care plan for a care area was the MDS Coordinator. She stated she was unaware how the MDS Coordinator was made aware of a care area issue for a resident.

Based on observations, interviews, and policy review, the facility failed to properly seal, label, and date food items in the refrigerator and in dry storage area; failed to maintain sanitary conditions in the kitchen related to condensation and dripping water, dirty floors, and dirty work surfaces; and failed to prepare and serve food in sanitary manner. The census was 62 and the sample size was 20. Food items were found not sealed, labeled, and dated in the refrigerator; condensation from vents in the ceiling of the kitchen dripped onto pots and pans as they were air-drying after having been washed; water was leaking from a filtration cartridge connected to the dish machine into a pan of standing water on the floor; floors under movable appliances and storage shelves were dirty; and multiple work surfaces in the kitchen were tacky to touch. Additionally, dietary personnel preparing plates of food for the noon meal service on 8/23/22 did not change gloves after touching non-food surfaces and before handling ready-to-eat foods, nor did dietary personnel wash hands with soap and water when gloves were changed. Findings include: Review of the policy titled Food Preparation and Distribution, reviewed 12/4/21, revealed it is the intent of the center to prepare and distribute food in a manner that minimizes the risk of food-borne illness and promotes safe food handling. Further review revealed good hand washing techniques should be practiced; gloves should be worn between tasks; and work surfaces and equipment should be cleaned and sanitized as needed. 1. During initial tour of the kitchen on 8/23/22 at 9:35 a.m. revealed in the dry goods storeroom, a clear plastic scoop resting in ground meal in a bulk storage bin and a plastic coffee mug was in an open, unsealed box of bread crumb mix. Observation on 8/23/22 at 9:41 a.m. revealed inside of the reach-in freezer labeled Zone 11 found pieces of cardboard stuck to the bottom of the freezer in front of a box of regular cut French Toast. The outer doors of this freezer unit were streaked with dried liquid and the handles were soiled. The gasket on the upper right-hand corner of the freezer door did not provide an effective seal, resulting in ice build-up on the inside corner of the freezer. Observation on 8/23/22 at 9:45 a.m., revealed inside the walk-in refrigerator, an open, unsealed package of sliced turkey, loosely covered with plastic wrap, and an open, unsealed gallon-sized plastic storage bag containing sliced cheese. The package of turkey was not labeled or dated, and the labeling on the bag of cheese was illegible. 2. Observation on 8/23/22 at 9:56 a.m., revealed water leaking from a water filtration cartridge connected to the dish machine. The water was being collected in a pan on the floor behind a shelving unit on which clean dishes were stacked. Observation on 8/23/22 at 10:00 a.m. revealed the tops of worktables and the doors of the reach-in freezer units were tacky to the touch, the floors under movable appliances (e.g., reach-in freezer units), racks, shelves, and food preparation tables, were unclean with significant debris from food and dirt built-up along corners and edges. Observation on 8/23/22 at 11:55 a.m. revealed drops of water fell on the surveyor when standing near the fruit and vegetable sink in the kitchen. Further observation found a ceiling vent and an adjacent overhead light fixture with water collecting in the lens of the light fixture and dripping from the ceiling vent onto the floor and the edge of the stainless-steel food preparation table next to the fruit and vegetable sink. Observation on 8/23/22 at 12:20 p.m. revealed a ceiling vent actively dripping water on the pots and pans on the drying table next to the three-compartment sink, where pots and pans were left to air-dry after being washed and sanitized. Also, the ceiling vent over the juice dispenser was dripping condensation on the beverage dispenser and the floor. 3. Observation on 8/23/22 at 12:40 p.m. the main meal being served was hamburger on bun, whole sweet potato, slices of fried green tomatoes, and apple pie. The alternate meal was fried chicken patty on bun and French fries. The regular and altered consistencies of the hamburger, sweet potatoes, and fried green tomatoes were being held on the steam table. The chicken patties and French fries were being held in a hotbox, along with pre-portioned servings of apple pie, behind the steam table. Continued observation on 8/23/22 at 12:42 p.m., revealed Cook D wore disposable gloves to handle the plates, serving utensils, tray tickets, hamburger rolls, sweet potatoes, and the fried green tomatoes. she grasped the plate with her gloved hands, opened a hamburger bun, used tongs to place a hamburger patty on the bun, and used her gloved hands to place the top of the bun on the hamburger patty. She then used tongs to select a sweet potato, used the same tongs - and later a butter knife - to slice open the top of the sweet potato from end to end, used tongs to place the sweet potato on the plate, and then used her gloved hands to push the sides of the sweet potato inward to open the potato. She then used a serving utensil to place slices of fried green tomatoes on the plate, put the completed plate on the shelf above the sneeze guard of the steam table. Observation on 8/23/22 at 12:46 p.m., Dietary Aide (DA) E retrieved the prepared plate and placed an insulated base (not an insulated dome lid, which was available for use) on top of the plate and put the covered plate with a serving of apple pie on a tray, which was set up on the tray cart. Observation on 8/23/22 at 12:50 p.m. revealed Cook D used her gloved hands to slide the remaining tray tickets down the shelf of the sneeze guard and began to assemble additional meal plates. This process was repeated for all regular texture meals for residents receiving whole hamburger patties. On one occasion, Cook D picked up a hamburger bun, carried it in her hand over to the pan of ground hamburger, scooped a portion of the ground meat onto the bun, assembled the sandwich, and carried the sandwich back over to the plate. Observation on 8/23/22 at 12:57 p.m. for residents receiving chopped hamburger, Cook D, on three occasions, used her gloved hand to hold a hamburger patty while chopping it with tongs. She then used the tongs to place the chopped patty on the bun, assembled the sandwich with her gloved hands, and proceeded with handling the sweet potatoes as described above. She did not change gloves after handling the hamburger patties. Observation on 8/23/22 at 1:05 p.m. for residents receiving the alternate entree (fried chicken patty on bun), Cook D obtained a hamburger bun with her gloved hands, carried the bun over to the hotbox in one gloved hand, opened the hotbox with the other gloved hand, used tongs to obtain a chicken patty and placed it on the bun, assembled the sandwich, and carried the sandwich back to the tray line to put it on the plate. For residents who requested sandwiches instead of hamburgers or chicken patties, Cook D unwrapped the pre-made plastic-wrapped sandwiches and handled them with her gloved hands to place them on the plate. Cook D was observed to change gloves at 12:54 p.m., when she stopped to retrieve a scoop that had fallen into a pan of pureed food. After retrieving the scoop, she removed her gloves, and applied a new pair of gloves without washing or sanitizing her hands. Cook D was observed to change gloves again at 1:02 p.m., when she accidentally dropped a sweet potato on the serving line. After cleaning up the serving line, she removed her gloves, briefly washed her hands at the nearby hand sink for approximately 20 seconds and put on a new pair of gloves. Observation on 8/23/22 at 1:15 p.m. DA F would leave the tray line to transport the tray cart to the nursing unit. Upon returning to the tray line, DA F used alcohol-based hand sanitizer on her hands instead of washing them with soap and water. The above observations were brought to the attention of the Administrator, the Director of Nursing (DON), and Registered Nurse (RN) C on the afternoon of 8/23/22. RN C acknowledged that alcohol-based hand sanitizer may not be used as a substitute for washing hands with soap and water in the food service setting.

Based on observation, interview and policy review, the facility failed to ensure medications were dated appropriately when opened to determine the discard date, in three of four medication carts; also failed to maintain correct narcotic count in one of four medication carts observed. Findings include: Review of the undated facility policy titled Pharmacy Services-Medication Administration-General revealed Procedural Guidelines 7. Medications dispensed for multi-use, e.g. blister/punch cards, large volume liquids, multi-dose vials, shall be labeled by the nurse as to the date of first use or first administration. Procedural Guidelines 18. During routine medication administration of medications, the medication cart is kept in the doorway of the patient's room, with open drawers inward and all other sides closed. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to patients and others passing by. Procedural Guidelines Observation on 9/24/19 at 12:00 p.m. with Licensed Practical Nurse (LPN) AA revealed on the 400 Hall medication cart one opened multi use vial of insulin with sticker that indicated to discard after 28 days. There was not a date indicating on vial or box of when the insulin vial was first used. Observation on 9/24/19 at 12:00 p.m. with Licensed Practical Nurse (LPN) AA revealed on the 400 Hall medication cart narcotic count of [MEDICATION NAME] was incorrect, revealing 17 pills in Kardex, with count sheet revealing 16 pills. An interview on 9/24/19 at 12:05 p.m. with LPN AA revealed that she knows that insulin's are supposed to be dated when they are opened. LPN AA futher revealed that she would not know when to discare the insulin, because it did not have an opened date. She further stated that when there are discrepancies with the narcotic count, she notifies the Director of Nursing (DON). Observation on 9/24/19 at 12:11 p.m. with LPN BB revealed on the 300 Hall medication cart, one insulin pen with pharmacy sticker indicating to discard after 28 days. There was no date marked on the pen to indicate the date in which the insulin was first used. There was one bottle of [MEDICATION NAME] eye drops, with pharmacy sticker that indicated to discard after 30 days of opening although there was no indication to show when the [MEDICATION NAME] eye drops were first used. An interview on 9/24/19 at 12:11 p.m. with LPN BB revealed that she knows that insulin should be dated when they are opened. She further revealed that without a date when the insulin is opened she would not know when it should be removed. Observation on 9/24/19 at 12:31 pm with LPN CC revealed on the 200 Hall medication cart, one bottle of [MEDICATION NAME] eye drops and one bottle of Lantaprost without open date on the bottle. An interview on 9/24/19 at 12:31 p.m. with LPN CC revealed that she does not give the two eye drops to the residents as they are ordered at bedtime, so she is not sure of when they were opened. She further stated that if the medications were not labeled with an open date, then she would discard them and order new ones from the pharmacy. An interview on 9/24/19 at 4:06 p.m. with Pharmacist DD, revealed that the pharmacy places discard stickers on the insulin's and certain eye drops, as a reminder for the staff that the medications should be discarded within the time frame indicated by the sticker. During further interview the Pharmacist stated that if the medications are not dated as to when they were first used, the staff should discard and re-order the medication, to ensure the potency of the medications. An interview on 9/24/19 at 4:36 p.m. with Director of Nursing (DON) stated it is her expectation that the nurses label the insulin and eye drops when opened and that they sign out narcotics at the time they are administered.

Based on observations, record reviews, review of facility policies and staff interviews, the facility failed to investigate 12 out of 82 grievances received. Findings include: A review of the facility policy titled Skilled Inpatient Services Grievance/Concern Guidelines for Patients with an updated for release date of (MONTH) 2019, copyrighted 2004-2018 GHSGa, revealed the center shall appoint a Grievance Officer who is responsible for overseeing the grievance process, receiving and tracking grievances, leading any investigations, and issuing written grievance decisions to the patient. If, at anytime during an active investigation, there is evidence that abuse may have occurred, this will immediately be reported to the administrator. The Social/Patient Services Director should be responsible for tracking all complaints. Once the concern is referred to the responsible discipline, the discipline is responsible for conducting a thorough investigation. A review of the facility polity titled Grievances Abuse Prohibition with an updated for release date of (MONTH) (YEAR); copyrighted 2004-2017, revealed it is the intent of the center to actively preserve each patient's right to be free from mistreatment, neglect, abuse or misappropriation of patient property. The center will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of patient property is more likely to occur. A review of the facility Concerns Log for grievances received from 5/7/2018 through 7/16/2019, revealed the facility received 82 grievances, during that time, related to nursing care, courtesy and respect, missing/lost items, and/or other. Of the 82 incidents reviewed, 12 of the incidents were not investigated. A review of the facility policy titled Skilled Inpatient Services Reporting and Investigating Abuse with an updated for release date of (MONTH) 2019, copyrighted 2004-2018 GHSGa, revealed once a complaint is identified involving alleged mistreatment, neglect, or abuse .the incident will be immediately reported (within 2 hours). A review of facility grievance reports revealed the following 12 reports were not investigated: 5/23/2019, two grievances on 5/8/2019, 4/29/2019, 4/4/2019, 4/2/2019, 4/1/2019, 3/14/2019, 3/1/2019, 2/26/2019, two grievances on 2/19/2019. An interview with the facility Administrator, Social Worker, and Regional Nurse, on 7/24/19 at 9:06 a.m., the Administrator reported, when she came to the facility in (MONTH) 2019, she realized the grievance process at the facility needed some improvement. She began an improvement process and realized a lot of people did not have access to the software program used for entering and tracking grievances. She reported there were many open reports to review and that she decided to begin with the (MONTH) 2019 open reports. Continued interview with the facility Administrator, Social Worker, and Regional Nurse, on 7/24/19 at 9:15 a.m., the Social Worker reported the process for grievances has been the same since the three years she has been in the role as social worker and the facility has used the same grievance software program. She reported it was realized, recently, the Director of Nursing, the Activity Director, and the Admissions Coordinator needed access to the grievance software program, and they needed to get the automatic alerts to let them know there was a grievance to review and investigate. She reported the software program indicates if the report is 'satisfied' or 'not satisfied' to indicate an open or closed status. She reported they counted 20 open grievances that no action was taken on and they did not go back, instead they went to speak with the interviewable residents and asked if they had any outstanding grievances. She reported if there is no action on a report, the system will not close the grievance. An interview with the facility Regional Vice-President, Administrator, Director of Nursing, and Regional Nurse, on 7/25/19 at 9:45 a.m., the Regional Vice-President reported the grievance process in the facility was broken. They confirmed there were 12 open reports that had not been investigated.

Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (Form CMS- ) to 2 residents (R) (R #39 and R #66) who remained in the facility from a sample of three (3) residents reviewed who were discharged from Medicare Part A services in the last 6 months. Findings include: 1. Record review revealed that R #39 was discharged from Medicare Part A services on 7/8/19 and remained in the facility. However, the only notice that was provided to the resident was the Notice of Medicare Non-Coverage (NOMNC) (Form CMS- ). There was no evidence the facility issued an SNFABN (Form CMS- ) to R#39 or her responsible party, which would provide the opportunity to continue with skilled services, at her cost, if Medicare did not reimburse. 2. Record review revealed that R #66 was discharged from Medicare Part A services on 7/16/19 and remained in the facility. However, the only notice provided to the resident was the Notice of Medicare Non-Coverage (NOMNC) (Form CMS- ). There was no evidence that the facility had issued the SNFABN (Form CMS- ) to R#66 or his responsible party, which would provide the opportunity to continue with skilled services, at his cost, if Medicare did not reimburse. During and interview on 7/25/19 at 8:45 a.m., the Financial Controller (FC) AA confirmed that R#66 and R#39 had not been issued the SNFABN (Form CMS- ) although both had remained in the facility. She further stated she needed more training in this area. She stated she only gave them the generic CMS 3 form. A follow up interview on 7/25/19 at 12:12 p.m., with FC AA revealed that she was unable to locate the Beneficiary Protection Notice policy for the facility.

Based on record review, staff, family, Nurse Practitioner and Medical Director interview and review of facility policy, the facility failed to notify one Responsible Party of a [DIAGNOSES REDACTED].#3). The facility failed to notify a Physician of a medication that was not available for administration for three days for one resident,(R#3). The sample was five residents. Findings include: 1. Review of the clinical record for R#2 revealed a notice to the Nurse Practitioner dated 6/19/18 at 7:00 p.m. indicating the family had noticed a strong urine odor and requesting a urinalysis with culture and sensitivity. The urinalysis was collected as ordered on [DATE] and reported on 6/21/18. The results of the culture and sensitivity were reported to the facility on [DATE] and indicated R#2 had a urinary tract infection that was sensitive to [MEDICATION NAME]. Review of the Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED] The clinical record was searched for documentation related to notification of the Responsible Party (RP) of the urinary tract infection and the order for antibiotic administration and no documentation of notification could be found. An interview was conducted with the Director of Nurses (DON) on 7/23/18 at 9:05 a.m. and she was aware the urinalysis result and antibiotic order had not been reported to the family of R#2 and was unable to educate the nurse who had received the antibiotic order because she is no longer employed by the facility. The DON confirmed there was not one specific policy indicating the nursing staff are to notify the RP of any changes, but the staff all know to do this. During an interview conducted with two family members of R#2 on 7/23/18 at 4:20 pm and the Responsible Party for R#2 on 7/24/18 at 1:40 p.m., they revealed the facility had not notified them of the urinalysis results and the order for antibiotics that followed until they had asked one of the Resident Care Coordinators (RCC) and by then R#2 had completed the antibiotic therapy. An interview with the RCC II on 7/25/18 at 4:55 p.m. revealed she was aware of the antibiotic (ABX) order for the resident's UTI not being communicated to the family in a timely manner, The ABX was ordered 6/23/18 and started on that date, and she thinks the residents family was notified on 6/25/18 or 6/26/18, but there is no documentation to indicate they were notified at all. The RCC revealed there had been an education given to all nurses a few months ago regarding notification of families of any changes with the residents and documentation of the notifications, but the family was not notified. The nurse was working her last day of her notice and cannot be reached. 2. Review of the clinical record for R#3 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Continued review revealed a hospital Physician's Progress Note dated prior to the resident's initial admission to the facility, 4/12/18 indicating R#3 had been admitted to the hospital multiple times for elevated sodium levels. Continued review of the clinical record indicated a consulting Nephrologist closely managed her care, in conjunction with the facility Medical Director and Nurse Practitioners. The Nephrologist ordered Basic Metabolic Panels (BMP) to monitor her sodium and other electrolyte levels periodically. Review of a seven (7) page consultation note written by the Nephrologist revealed continued concern regarding R#3 requiring [MEDICATION NAME], a steroid medication used to treat [MEDICAL CONDITION] in conjunction with [MEDICATION NAME]. The Nephrologist explained in the consultation that [MEDICATION NAME] elevates sodium levels but R#3 requires the medication for [MEDICAL CONDITION], and increasing fluid intake to control elevated sodium levels has not been effective due to the residents dementia, resulting in erratic fluid intake. A physician's orders [REDACTED]. Additionally the Nephrologist ordered the facility to encourage 2200 milliliters (mls) of fluids every day, and to decrease the [MEDICATION NAME] to one half tablet daily. Review of the lab reports for R#3 revealed the BMP's were drawn by the laboratory, and the results were communicated to the Nephrologist on 5/24/18, and 6/7/18. The BMP results on 6/7/18 indicated a sodium level of 144, which is within the normal range of 136 to 145. On 6/21/18 the BMP was collected by the lab as ordered, and the results returned the same day, with an elevated sodium level of 155. The clinical record did not include any indication of this result being faxed or called to the Nephrologist. A note on the lab report indicated the results had been called to the facility Nurse Practitioner, who ordered fluids be encouraged. This order had been given four (4) weeks previously by the Nephrologist, and the sodium level had become elevated despite this continued order, as well as decreasing the [MEDICATION NAME] dosage by half. The clinical record was searched for any indication the elevated sodium level had been communicated to the Nephrologist who ordered the BMP and could not be found, until 7/9/18. During an interview with Resident Care Coordinator (RCC) II on 7/24/18 at 4:10 p.m. she revealed a Complete Metabolic Panel (CMP) was ordered on [DATE] by the Nurse Practitioner because R#3 had an appointment with the Nephrologist on 7/11/18 and needed to bring updated results. The CMP was drawn on 7/10/18 and the sodium result was 175, which was critically elevated. The Nurse Practitioner was advised of the results, and ordered intravenous fluids, and to repeat the CMP on 7/11/18 and to notify the Nephrologist. The Nephrologist was notified of the critical sodium level collected on 7/10/18, and the resident was transferred to the hospital on [DATE]. Attempts were made by the surveyor to communicate with the Nephrologist on 7/25/18 at 3:15 p.m. and 4:30 p.m. and on 7/26/18 at 12:05 p.m. and 1:00 p.m. and two (2) call back messages were received on 7/25/18 and 7/26/18 and were unable to be answered due to poor reception. The last call to the Nephrologist was not answered. The office staff revealed they were not authorized to speak to the surveyor. R#3 returned from the hospital on [DATE]. Review of the transfer orders from the hospital indicated R#3 was to continue receiving [MEDICATION NAME] 5 mg, two tablets by mouth at bedtime (hs). The transfer order was approved by the Medical Director, who managed the care of R#3. Review of the Medication Administration Record [REDACTED]. An interview with LPN EE on 7/24/18 at 6:35 p.m. revealed she had worked for the facility for three weeks and had administered medications with another nurse on day shift then on night shift for two and a half weeks for orientation and had not encountered any missing medications. LPN EE confirmed this had not been discussed in orientation. When she had discovered the [MEDICATION NAME] for R#3 was missing on 7/19/18 she had thought it would be delivered later that night and did notify the Physician or Pharmacy or the oncoming shift. When she discovered it was still missing on 7/20/18 she looked for it in the medications that were left over from R#3's previous admission, found it and administered the [MEDICATION NAME] as ordered. LPN EE acknowledged she still did not notify the Pharmacy they needed to deliver the [MEDICATION NAME]. During an interview conducted on 7/24/18 at 7:07 p.m. LPN JJ revealed he had worked 7/21/18 and 7/22/18 and had not administered R#3 [MEDICATION NAME] 5 mg two tablets by mouth on those nights because it was not in the drawer. LPN JJ indicated he ordered the [MEDICATION NAME] on 7/21/18 and gave the other medications. LPN JJ confirmed he did not notify the Physician of not having the medication to administer on 7/21/18 and 7/22/18. LPN JJ revealed he was aware that [MEDICATION NAME] should not be skipped or stopped suddenly. Review of facility policy titled Medication Unavailable for Administration, reviewed and updated (MONTH) (YEAR) indicated if at any time a medication is not available for a specific time of administration, the nurse shall notify the prescriber that the medication is not available. During an interview with the Medical Director conducted on 7/25/18 at 12:10 p.m. the Physician indicated he was not notified R#3 had missed three doses of [MEDICATION NAME] when she returned from the hospital. He would expect to be notified if any resident with daily administrations of [MEDICATION NAME] missed 3 administrations in six days. The Medical Director confirmed he would probably have ordered a higher dose for a day or two if he had been informed. The Medical Director further revealed he expects the nursing staff to notify families when the residents have new medication orders, medication changes and any change in condition such as urinary tract infections. The Medical Director revealed he expects the nursing staff to notify the Physician who orders lab work of the results. Revealed he had discussed the care of R#3 with the Nephrologist recently and the Nephrologist is very involved with her care and would not have ordered lab work if he had not wanted to be made aware of the results. An interview on 7/25/18 at 5:05 p.m. with the Administrator, revealed she expects the nursing staff to notify the physician who orders laboratory testing of the results as soon as the results are received. The Administrator confirmed she expects the Nursing staff to notify families of their residents being started on antibiotic therapy and the reason for the order, as soon as the order is received. She further revealed that nursing staff is expected to notify the Physician whenever a resident misses a medication. The Administrator revealed that education of the new nurses should have included this information.

Based on record review, staff, Pharmacy Director and Medical Director interview, and review of facility policy, the facility failed to provide a medication, as ordered by the prescriber to meet the needs of one resident (R) (R#3). The sample size was five residents. Findings include: Review of facility policy titled Medication Unavailable for Administration Reviewed and updated (MONTH) (YEAR), revealed if a medication is not found in the appropriate place at the time of administration, the administering nurse shall call the provider pharmacy and inquire about the last dispensing date. The provider pharmacy may assist in obtaining the medication from a back up pharmacy, if available. The provider pharmacy may send the medication via a STAT delivery, if needed prior to the regularly scheduled delivery. Review of the clinical record for R#3, revealed on return from a hospital admission from 7/11/18 through 7/18/18, a Transferring Physician order [REDACTED]. The facility attending Physician approved the orders, and the [MEDICATION NAME] was to be continued. Review of the Medication Administration Record [REDACTED]. Review of the Pharmacy Delivery Sheet, dated 7/19/18 revealed no [MEDICATION NAME] was delivered for R#3. A resupply order was transmitted electronically on 7/22/18, indicating the [MEDICATION NAME] had been ordered by the Physician on 7/18/18. A note handwritten on the resupply order by a pharmacist indicated that unchanged medications were not delivered on return from the hospital 7/18/18. An interview with LPN EE on 7/24/18 at 6:35 p.m. revealed she had worked here for three weeks and had passed medications with another nurse on day shift then on night shift for two and a half weeks and did not have any medication that was ordered that was not available. LPN EE indicated this was not covered in orientation. She confirmed she noted the medication was ordered for R#3 on 7/19/18 and expected it to be brought that night or the next day. When the [MEDICATION NAME] was not found on 7/20/18, she had found the medication in the resident's previous admission medications and administered it. LPN EE confirmed she had not called the pharmacy or the Physician regarding the missing medication and was not aware that medications can be delivered from the pharmacy at any time they are needed. An interview with the DON revealed on 7/24/18 at 6:40 p.m. that medications are very seldom not available for administration and this may not have been covered in orientation of LPN EE who has only been employed here for three weeks. During an interview on 7/24/18 at 7:07 pm, LPN JJ revealed he had worked 7/21/18 and 7/22/18, and had not administered R#3 [MEDICATION NAME] 5 mg po on 7/21/18 or 7/22/18 at 9:00 pm, because it was not in the drawer. LPN JJ ordered the medication on 7/21/18, and gave the other medications. LPN JJ acknowledged he was aware that [MEDICATION NAME] administrations should not be omitted or stopped suddenly. LPN JJ confirmed he was aware that emergency deliveries from the pharmacy are available by calling the pharmacist on call, and revealed he thought the emergency deliveries were just for narcotics and antibiotics. During an interview conducted on 7/25/18 at 9:05 a.m. with the Director of Pharmacy, the Director revealed the pharmacy received notification of R#3's hospitalization on [DATE] and due to the new electronic medication administration system the discharge was not stopped on 7/18/18 when she returned to the facility. The new medications had been provided, but the medication continued from her previous admission was not delivered until 7/23/18. The Director of Pharmacy revealed the facility had all the medications for R#3 except the [MEDICATION NAME] and had pulled from what was left from her previous admission but it was not enough. There is a pharmacist on call twenty four hours a day, but the pharmacist had not been notified that the medication was needed, and a nurse had completed a resupply order on Sunday 7/22/18 and resupply orders are not reviewed until Mondays. The Director of Pharmacy confirmed there was no [MEDICATION NAME] in the Emergency Box. During an interview conducted on 7/25/18 at 5:05 p.m. the Administrator revealed she expects the nursing staff to obtain missing medications from the pharmacy day or night and on weekends and holidays. The Administrator acknowledged she expects the pharmacy to review orders for medications and deliver medications whenever they are needed. The Administrator confirmed the education of newly employed nurses should include this information.

Based on record review, staff interview, Registered Dietician interview, interview with the Medical Director, and review of facility policy, the facility failed to ensure an admission nutritional assessment was provided in a timely manner for one resident (R) (R#3), determined to be at nutritional risk related to diagnoses, from a sample of five residents. Findings include: Review of facility policy titled Nutrition Screening, Assessment and Monitoring, Reviewed and updated for release (MONTH) (YEAR), revealed the Registered Dietician (RD) will complete a nutritional assessment after admission, annually, and as determined by the patient's needs and plan of care. Review of the clinical record for R#3 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the hospital record for R#3 revealed a Physicians Progress Note dated 4/12/18 that indicated R#3 had been hospitalized multiple times for [MEDICAL CONDITION]. Continued review of the clinical record revealed there was no Registered Dietician Admission Assessment, or any ongoing nutritional assessments. The Registered Dietician Assessments were requested from the Director of Nurses (DON) on 7/24/18 at 7:25 p.m. An interview conducted with the Medical Director on 7/25/18 at 12:10 p.m. revealed he expected all residents to have Registered Dietician admission assessments when they are admitted . The Medical Director confirmed he would consider a resident with a [DIAGNOSES REDACTED]. During an interview with the Regional Registered Dietician, conducted on 4/25/18 at 4:08 p.m., the dietician revealed she did not think it was necessarily a priority for a resident who has a [DIAGNOSES REDACTED]. The dietician indicated that an evaluation by the Dietary Manager was sufficient. The Regional Registered Dietician revealed that there is no specific time frame for newly admitted residents to be assessed for nutritional needs and these admission assessments can be completed any time during the first three months after admission. The facility RD had provided an admission assessment today by review of R#3's electronic clinical record. An interview on 7/25/18 at 4:17 p.m. with the Director of Nursing (DON) revealed that the DON is responsible for making a list of new admissions for the RD to see and the DON was sure she made this list and included R#3 when she was admitted in (MONTH) (YEAR). The DON confirmed there had been no RD admission assessment for R#3 until the surveyor had requested it on 7/24/18. The DON confirmed an RD had been in the facility on 4/25/18, 4/26/18, 5/30/18, 5/31/18, 6/1/18, and 6/25/18. During an interview on 7/25/18 at 5:05 p.m. the Administrator revealed she expects the RD to assess the nutritional needs of any newly admitted resident within two or three days of admission.

Based on record review and interview, the facility failed to develop a care plan for one of 40 sampled residents identified with left upper extremity contracture, Resident (R) R#40. Findings include: Review of R#40's clinical record revealed a [DIAGNOSES REDACTED]. R#40's most recent Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 2/19/18, documented R#40 as being cognitively intact and requiring extensive assistance of one to two staff persons for bed mobility, transfers, dressing and toileting. R#40 was further coded as having Functional Limitation in Range of Motion affecting one side of the body. A review of Section O, Special Procedures, did not code R#40 as receiving therapy, restorative nursing or wearing any splints. On 5/2/18 at approximately 9:00 a.m. R#40 was observed seated in her wheelchair beside her bed. A positioning tray was observed to be installed on the left arm of the wheelchair and R#40 had her left arm positioned on the positioning tray. R#40 was further observed to have paralysis of her left arm, the left hand was closed in a tight fist. R#40 was asked if she could open her hand, she stated that she could not. R#40 was asked if she had any type of splint that she used on that hand and R#40 stated that she used to have one that she wore but she had no idea what had happened to it. On 5/3/18 at 8:47 a.m., R#40 was observed seated in her wheelchair inside of her room, beside her bed. The positioning tray was observed to be in place and her left arm resting on the positioning tray. R#40 was not observed to be wearing any type of splint device to the left hand. LPN AA was invited into the room at 8:55 a.m. and R#40 gave permission to have the nurse open her hand to assess her palm. Licensed Practical Nurse (LPN) AA assisted the resident with opening her left hand. LPN AA was able to open R#40's hand with some difficulty, the resident did not complain of any pain, LPN AA explained that the fingers were permanently contracted and closed into a fist. The skin on the palm of R#40's hand and the underside of the fingers were observed to be clean, dry and without any skin breakdown. When asked if R#40 wore any type of splint device to prevent further contractures LPN AA stated that she didn't. LPN AA was made aware that R#40 had stated that she had worn a splint in the past but now she couldn't find it, R#40 stated that the splint was lost when she moved rooms. LPN AA stated that she had not seen a splint and that therapy had been working with her. When asked how the staff were assessing R#40's left hand and keeping it clean and free from skin breakdown, LPN AA stated that the staff looked at the resident's hand all the time and the aides made sure that the inside of the hand stayed clean and dry. A review of R#40's comprehensive care plan dated 2/24/15 with a revision date of 3/5/18 did not reveal any documentation regarding R#40's left hand contracture or the care necessary to maintain current level of function or to prevent skin breakdown at the contracture site. On 5/3/18 at 9:45 a.m. an interview was conducted with LPN BB, the MDS Coordinator, revealed that the MDS coordinators were responsible for completing the initial residents' comprehensive care plans at the time of admission. When asked the purpose of the care plan, LPN BB stated that it was a written communication for everyone to know how to care for the patient, it provided the process/ guide to take care of the resident. LPN BB further stated that it was the facility's goal that the care plan to be an up to date reflection of the needs of the resident. At this time LPN BB reviewed R#40's comprehensive care plan specifically for documentation regarding the left-hand contracture and any interventions in place to prevent further range of motion decline or skin breakdown of the left palm. LPN BB stated that she knew that there was nothing in the care plan about the hand. I included positioning (of the body) and turning the resident while in bed but nothing about the hand. When asked if the hand should be care planned, LPN BB stated that it should have been. A policy was requested that addressed care planning. On 5/3/18 at 2:44 p.m. the Administrator and Corporate nurse were made aware that there was no care plan for R#40's left hand contracture. The Corporate nurse stated that this was something that should have been care planned and that neither the Corporate nurse or the Administrator understood why it was not. A review of the facility policy titled Patient's Plan of Care dated (MONTH) (YEAR) revealed, in part, the following documentation: Intent. It is the intent of this center to develop and maintain an individualized plan of care for each patient. 2. The care plan is developed from the patient assessment (MDS) and in coordination with the attending physician's regimen of care. All professional personnel involved in the care of the patient review the care plan as necessary, but at least quarterly. 3. The care plan is available for use by all personnel providing care/services to/for the patient. It includes, but is not limited to: F. Prevent declines in the patients (sic) functional status and/or functional levels; and G. Enhance the optimal functioning of the patient by focusing on a rehabilitative program.