Every finding on record at Highland Park Rehabilitation & Care Center

Based on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to ensure the facility was kept free from cockroaches, beetles, and other insects.Findings include: I. Professional referenceAccording to the Centers for Disease Control's (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities (revised July 2019), retrieved on 8/10/26 from https://www.cdc.gov/infection-control/media/pdfs/Guideline-Environmental-H.pdf,From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on: eliminating food sources, indoor habitats, and other conditions that attract pests; excluding pests from entering the indoor environments; and applying pesticides as needed. Sealing windows helps to minimize insect intrusion. When windows need to be opened for ventilation, ensuring that screens are in good repair and closing doors to the outside can help with pest control. A pest-control specialist with appropriate credentials can provide a regular insect-control program that is tailored to the needs of the facility and uses approved chemicals and/or physical methods. II. Facility policy and procedureThe Pest Control Program policy, revised 1/8/26, was received from the administrator in training on 8/7/26 at 4:46 p.m. It read in pertinent part, Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. Facility will utilize a variety of methods in controlling certain seasonal pests, such as flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations.III. Facility observations and resident interviewsResident #80 was interviewed on 8/5/26 at 8:07 a.m. Resident #80 said she had seen bugs in her room before. She said she had seen large black beetles and many brown cockroaches. She said she used to call staff into her room to kill them, but she did it herself now. She said the most bugs she had ever killed in one night was four large black beetles. During the interview, a brown cockroach was observed dead in the middle of her room. Resident #80 pointed out another dead black beetle in the corner of her room. On 8/5/26 at 9:17 a.m., during a housekeeping observation of room [ROOM NUMBER], housekeeper (HK) #2 was sweeping the floor under bed A. HK #2 swept up approximately 10 ants that were still alive. On 8/5/26 at 2:00 p.m. during the group interview, one resident who did not wish to be identified said he would see large cockroaches and would call the staff into his room to kill them and throw them into the toilet. On 8/5/26 at 11:23 a.m., during a walk-through of the shower rooms, a wasp was observed in the 600 unit's shower room. On 8/6/26 at 12:03 p.m., during a walk-through with the administrator in training and the maintenance director, two wasps were seen in the 600 unit's shower room (one dead and one alive). IV. Record reviewReview of the facility's pest control receipts revealed that a new pest control company started on 6/30/26.V. Staff interviewsHK #2 was interviewed on 8/5/26 at 9:39 a.m. HK #2 said she had seen ants, beetles and cockroaches in the building. She said she saw the ants as she was cleaning room [ROOM NUMBER]. She said she saw cockroaches in the employee bathroom two weekends ago. She said she would tell the maintenance director right away when she saw bugs. She said she had not seen beetles or cockroaches in residents' rooms recently. She said she saw a pest control employee earlier in the week. Certified nurse aide (CNA) #6 and CNA #7 were interviewed together on 8/5/26 at 11:31 a.m. CNA #6 and CNA #7 said they saw the occasional spider in the shower room and residents' rooms. CNA #9 was interviewed on 8/5/26 at 12:24 p.m. CNA #9 said he had not seen any insects in residents' rooms. He said he had seen cockroaches in the employee breakroom. The maintenance director was interviewed on 8/6/26 at 2:25 p.m. The maintenance director said he had recently switched pest control companies because he was not seeing results with the other company. He said when an issue came up between visits with the pest control company, the facility used Home Defense (a pet safe, and safe to use indoor insect killer). He said he used it in room [ROOM NUMBER] with the ants after HK #2 told him about the ants when she was cleaning the room (during the survey). He said he let the pest control company know about the ants right away. He said that there was still an ongoing problem with pests in the facility, even with the improved results with the new pest control company.

Based on observations and interviews, the facility failed to have adequate outside ventilation by means of a window or mechanical ventilation in three out of five units.Specifically, the facility failed to:-Ensure the ventilation fan for the 500 unit shower room was operational; and,-Ensure the bathroom ventilation fans for rooms #303, #306, #326, #323 and #602 were operational.Findings include:I. Professional referenceAccording to the U.S. Department of Energy's Office of Energy Efficiency and Renewable Energy, April 2021, retrieved on 8/10/26 from https://docs.nrel.gov/docs/fy21osti/79150.pdf,Proper ventilation helps reduce the concentration of bioaerosols (bioaerosols consist of aerosols originated biologically such as metabolites, toxins, or fragments of microorganisms), which can be particularly important in nursing homes due to the presence of vulnerable adults. Good ventilation can improve the health and wellbeing of the residents by reducing infection risks and preventing respiratory issues. By ensuring proper ventilation, nursing homes can significantly enhance the safety and quality of life for their residents.According to the Centers for Disease Control's (CDC) Ventilation in Healthcare Settings (1/22/26), retrieved on 8/10/26 fromchrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cdc.gov/project-firstline/media/pdfs/ventilation-508.pdf, In healthcare settings, ventilation is important because it helps remove things from the air that we don't want to breathe in - like small virus particles. Good ventilation improves air quality and reduces the risk of germs spreading.II. Facility policy and procedureThe Safe and Homelike Environment policy and procedure, revised 1/8/26, was provided by the administrator in training on 8/7/26 at 4:46 p.m. It read in pertinent part, Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. The facility will have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two.III. Resident interviewResident #80 was interviewed on 8/3/26 at 2:22 p.m. Resident #80 said the ventilation fan in her bathroom did not work. She said she had told maintenance about it at some point, but the facility had not fixed the issue. IV. ObservationsOn 8/6/26 at approximately 3:21 p.m. observations of five resident bathrooms and the 500 unit shower room revealed the following:-In rooms #303, #306, #326, #323 and #602, the residents' personal bathroom ventilation systems revealed there was no airflow present. -In the 500 shower room, the ventilation system revealed there was no airflow present. V. Staff interviewThe maintenance director was interviewed on 8/6/26 at 5:10 p.m. The maintenance director said he was unaware that the ventilation systems were not operational in the bathrooms in rooms #303, #306, #326, #323 and #602 or in the 500 unit shower room. He said it was important for the ventilation to work because it helped keep the smells down and kept the air moving. He said anyone could notify the maintenance department if something was not working.

Based on interviews and record review, the facility failed to ensure one (#52) of three residents reviewed for abuse out of 51 sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #52 from physical abuse by Resident #62.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, revised January 2026, was provided by the administrator in training on 8/3/26 at 12:59 p.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility will have written procedures to assist staff in identifying the different types of abuse: mental/verbal abuse, sexual abuse, physical abuse and the deprivation by an individual of goods and services. This includes staff-to-resident abuse and certain resident-to-resident altercations. Possible indicators of abuse include but are not limited to: resident-to-resident, staff or family report of abuse, verbal abuse of a resident overheard, and physical abuse of a resident observed.II. Physical abuse of Resident #52 by Resident #62 on 7/9/26 A. Facility investigationThe facility investigation of the incident involving Resident #52 and Resident #62 was provided by the director of nursing (DON) on 8/4/26 at 9:10 a.m. The investigation documented that on 7/9/26 at approximately 6:00 p.m., Resident #52 reported that he and his roommate, Resident #62, engaged in a physical altercation in self-defense. Resident #52 said he was using the sink in their room when the incident happened. An investigation was immediately started. Resident #52 and #62 were assessed, and Resident #52 was noted to have sustained a skin abrasion below the right eye crease.The immediate intervention was to assign Resident #52 to a different room on another unit.Licensed practical nurse (LPN) #3 documented in her statement that Resident #52 was using the room sink when his roommate said something he did not understand. LPN #3 documented that Resident #52 alleged he got into an argument with his roommate and acted in self-defense and engaged in physical contact and got scratched in the process.A 7/10/26 statement from social services director (SSD) #2 documented a follow-up psychosocial visit with Resident #52. The resident was resting in his bed with no presence of anxiety or change to his baseline.Registered nurse (RN) #4 documented that she was called to assess Resident #52 and Resident #62 following a physical altercation involving the two residents. An assessment of the residents was completed and a small abrasion was noted below the right eye of Resident #52. Resident #62 had no injuries noted.B. Resident #52 (victim)1. Resident statusResident #52, age greater than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included unspecified dementia, psychotic disturbance, mood disturbances, and anxiety.The 7/7/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. He required maximum assistance with toileting, supervision with eating and was dependent on staff assistance for personal hygiene. The assessment indicated the resident did not exhibit physical or behavioral symptoms towards others.2. Resident #52's representative interviewResident #52's representative was interviewed on 8/3/26 at 1:55 p.m. Resident #52's representative said she remembered the incident of aggression towards Resident #52 with his roommate, Resident #62 (on 7/9/26). She said she was informed of the incident by LPN #3, who reported that Resident #52 sustained a small abrasion to his right lower eye. The resident's representative said she was informed that Resident #52 was using the sink to brush his teeth and his roommate came up to him and told him that he was a stranger in his room and started an altercation with Resident #52, which resulted in a red abrasion on Resident #52's lower right eye. The representative said staff assessed Resident #52 and moved him to a different unit after the incident.3. Record reviewResident #52's behavior care plan, initiated 1/28/26, documented Resident #52 had behavior problems related to unspecified dementia, psychotic disturbances, mood disturbances, anxiety, and cognitive communication deficit. Resident #52's target behaviors included depression, agitation, confusion, and yelling. Pertinent interventions, initiated 1/28/26, included anticipating and meeting Resident #52's needs, administering medications as ordered, and monitoring and documenting for side effects and effectiveness. Additional pertinent interventions, initiated 7/9/26, included monitoring the resident for changes in mood and behavior and reporting changes to the provider.A late entry nursing progress note, dated 7/10/26, documented that on 7/9/26, Resident #52 reported he engaged in physical contact in self-defense with his roommate, Resident #62, while using the sink. Upon evaluation, a skin abrasion was noted to the resident's right eye crease, which was cleansed with normal saline. RN #4 completed a physical assessment, and no further injuries were observed. Resident #52 was immediately separated from his roommate and relocated to a room on a different unit. The police were notified, and 15-minute checks were initiated for both residents. A 7/10/26 interdisciplinary team (IDT) risk management follow-up note documented that Resident #52 reported he engaged in a verbal and physical altercation with his roommate, Resident #62. RN #4 completed an assessment during which Resident #52 denied pain, discomfort, fear, or anxiety. An assessment revealed the resident had a superficial scratch mark measuring approximately 1 centimeter (cm) to the right eye crease area, with no bleeding or swelling noted. The root cause was identified as impaired memory secondary to impaired cognition related to dementia, and Resident #52 reported that he was approached by Resident #62 and acted in self-defense. Resident #52's skin below the right eye was cleansed and treated, with ongoing monitoring of the area planned until fully healed. As part of the new interventions, Resident #52 was separated and reassigned to a different room, and Resident #62 was placed on 15-minute safety checks with monitoring for mood and behavior changes every shift for 72 hours, to be reported to the physician as needed. The on-call physician/provider was notified.C. Resident #62 (assailant)1. Resident statusResident #62, age greater than 65, was admitted on [DATE]. According to the July 2026 CPO, diagnoses included vascular dementia with other behavioral disturbance, homicidal ideation, and alcohol use.The 7/21/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of five out of 15. He required moderate assistance with activities of daily living (ADL's), set-up assistance with toileting and eating, and uses a wheelchair for mobility.The assessment indicated the resident did not have behaviors toward others.2. Record reviewResident #62's behavior care plan, initiated 8/11/25, documented the resident had dementia with a history of homicidal behaviors and triggers for outbursts. Pertinent interventions, initiated 8/11/25, included calling the resident's family and friends, listening to music, watching television, anticipating and meeting needs, administering medication as ordered, monitoring and documenting for side effects, assisting the resident to develop more appropriate methods of coping and interacting and encouraging the resident to express his feelings appropriately.A 7/6/26 long-term care (LTC) medical director's visit note revealed that the resident's medical history was notable for vascular dementia and hypertension. The medical director's note revealed the resident was previously hospitalized after exhibiting psychosis or progressing dementia, including making threats toward his daughter, which led to an M1 hold (a legal process that allows a person to be held involuntarily for emergency psychiatric evaluation) and an initial blood alcohol level of 0.063 with a negative urine drug screen. Following medication adjustments, clearance from suicidal/homicidal ideation, and the expiration of the M1 hold, Resident #62 was discharged to the facility for continued medical management along with physical, occupational, and speech therapies.A 7/9/26 nursing progress note documented that Resident #62 reported he engaged in physical contact in self-defense with his roommate. The resident said he did not know who his roommate was or why the roommate was using the sink, leading him to try to defend himself. The resident's roommate (Resident #52) was immediately removed from the resident's room and relocated to a different floor. RN #4 completed a physical assessment and documented that the resident's vital signs were within normal limits and he had no apparent injuries. The police were called and notified of the incident. The resident was placed on 15-minute safety checks and monitored closely for any behavioral changes.III. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 8/6/26 at 2:55 p.m. CNA #5 said right after dinner on the day of the incident between Resident #52 and Resident #62 (on 7/9/26), he assisted Resident #52 at the sink in his room to brush his teeth. CNA #5 said shortly after setting up Resident #52 by the room sink, the resident came out into the hallway in his wheelchair yelling that Resident #62 had attacked him. CNA #5 said he immediately assisted Resident #52 to a safer area near the nurses' station to ensure his immediate safety and informed Resident #52's nurse right away. Upon observing Resident #52, CNA #5 said he observed a red mark below the resident's lower right eye, which was not observed before the incident. CNA #5 said there was no further contact between Resident #52 and Resident #62 after the incident, and Resident #52 was reassigned to a new room on a different unit.LPN #3 was interviewed on 8/6/26 at 3:35 p.m. LPN #3 said she remembered the alleged resident-to-resident altercation between Resident #52 and Resident #62 when they were roommates (on 7/9/26). LPN #3 said Resident #62 said he did not remember that he had a roommate and wanted Resident #52 to leave his room. She said he reported that he acted in self-defense. LPN #3 said Resident #52 sustained a red abrasion on his lower right eye. LPN #3 said RN #4 was called to assess both residents. LPN #3 said that, as a result of the altercation, Resident #52 was reassigned to a different unit to prevent further contact between the two residents.The director of nursing (DON) was interviewed on 8/6/26 at 4:00 p.m. The DON said the alleged physical aggression incident between Resident #52 and Resident #62 on 7/9/26 was unsubstantiated due to insufficient evidence. The DON said a small red abrasion was observed below Resident #52's lower right eye. The DON said she was informed of the incident and approved the reassignment of Resident #52 to a different unit. The DON said both Resident #52 and Resident #62 were assessed, and an investigation was initiated immediately. She said the allegations of abuse were unsubstantiated because there were no witnesses to the incident and there was insufficient evidence, as both residents claimed they acted in self-defense.

Based on observations and interviews, the facility failed to provide a comfortable and homelike environment for residents on two of five units. Specifically, the facility failed to:-Maintain comfortable temperature levels in residents' rooms; -Ensure residents' bathrooms were in good repair; -Ensure residents were not exposed to foul odors in common hallways; and,-Ensure residents were served meals in reusable cups, bowls and plates in the secure unit.Findings include: I. Facility policy and procedure The Safe and Homelike Environment policy and procedure, revised 1/8/26, was provided by the administrator in training on 8/7/26 at 4:46 p.m. It read in pertinent part, The facility will maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 degrees Fahrenheit (F) and 81 degrees F. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to the housekeeping department. Minimize the use of institutional signage in areas visible to residents and the public. Eliminate the use of meal trays during dining service, unless otherwise requested by the resident.The Resident Environmental Quality policy and procedure, revised 1/8/26, was provided by the administrator in training on 8/7/26 at 4:46 p.m. It read in pertinent part, Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. The facility must provide each resident with toilet facilities containing a lavatory or toilet in or near the resident's room. Resident rooms and activity areas should be of a comfortable temperature for the resident, not the staff. Resident behavior should be observed to determine the appropriate temperature levels. Preventive maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue. II. Failed to maintain comfortable temperatures in residents' roomsA. Professional referenceAccording to the National Institute on Aging's, Hot Weather Safety for Older Adults, September 2022, retrieved on 8/13/26 from https://www.nia.nih.gov/health/safety/hot-weather-safety-older-adults, Too much heat is not safe for anyone. It is even riskier if you are older or have health problems. It is important to be cautious and get relief quickly when you are overheated. Otherwise, you might start to feel sick or risk a heat-related illness that could cause serious health issues. Hotter days can cause difficulty in the body's ability to regulate its temperature. This can be challenging for older adults who typically do not adjust as well as others to sudden temperature changes. Additionally, older adults are more likely to have chronic medical conditions that affect the body's response to temperature, and to take prescription medicines that alter the body's ability to control temperature or sweat. Being overheated for too long or being exposed without protection to the sun can cause many health problems. Heat-related illnesses include the following: Heat syncope a sudden dizziness. Heat cramps: a painful tightening or spasms of muscles in your stomach, arms, or legs. Heat edema, a swelling in your ankles and feet when you get hot. Heat rash, a skin irritation from heavy sweating. Heat exhaustion, a warning that your body can no longer keep itself cool. Heat stroke, a medical emergency in which the body's temperature rises above 104 degrees F.B. Resident interviews and observations Resident #57's representative was interviewed on 8/3/26 at 1:12 p.m. The representative said Resident #57 had resided in the facility for a couple of weeks and the facility was always hot. The representative said the heat had gradually worsened. He said he talked to several nurses about the concern. He said the facility had provided a fan but it did not help lower the temperature in the resident's room. He said in the last week or two, the facility provided an ice portable air conditioning unit for the resident. He said it made the temperature better, but it was still miserable. He said the heat made it difficult to close the resident's door because the room would get hotter with the door closed. He said he eventually took Resident #57 outside when he visited because it was too hot to visit inside the building. He said the best way to describe how hot the room was is that it was suffocating. He said to imagine how it felt when a person first sat in a car that had been sitting in the sun. Resident #57's representative said the resident was very miserable because of the heat and he had to remind the resident to eat and to drink water. He said Resident #57 had cancer, and the heat increased his hot flashes. Resident #42 was interviewed on 8/3/26 at 4:18 p.m. Resident #42 was lying in his bed located in the 200 unit with a T-shirt on and a bed sheet covering his lower extremities up to his hips. He said it had been hot in his room for a while. He said about two weeks ago, nursing staff decided to turn on the central air and it blew hot air into the hallways and into his room. He said it was ridiculous that he and the other residents had to experience hot temperatures all day and all night. Resident #42 said the facility's administration staff all had swamp coolers in their offices and residents did not have swamp coolers. He said having a floor fan made it hard for him to sleep at night because of the noise. He said had a face fan that he used and in the last couple of days, the facility had given him a floor fan. He said he talked to the previous social services director (SSD) and she agreed the building was hot. He said he did not talk to the administrators because he had not seen them in the last couple of weeks. Resident #42 said he knew how to file a grievance, but he was concerned if the facility put money into keeping the building cool that they would have to cut costs in another area. -During the interview, Resident #42's room temperature was observed to be 87 degrees F. Resident #10 was interviewed on 8/3/26 at 4:40 p.m. Resident #10 was lying in his bed located in the 200 unit with a T-shirt on and his disposable briefs exposed. He did not have blankets covering his body. He had an oscillating fan across from his bed turned on. He said the heat in July 2026 and August 2026 was horrible. He said it was a nightmare trying to sleep during the heat. He said it kept him up all night because he bought himself an oscillating fan and after three to four hours of the fan being on, it started to vibrate. He said there was no air conditioning that flowed into the residents' rooms. Resident #10 said he had talked to the nursing staff and they did not provide any solutions to the temperature concern. C. Additional observations During several observations in the facility during the survey, the following temperatures were observed: -On 8/3/26 at 4:18 p.m. room [ROOM NUMBER] was observed to be 87 degrees F;-On 8/4/26 at 8:00 a.m., room [ROOM NUMBER] was observed to be 80 degrees F; -On 8/6/26 at 3:08 p.m. room [ROOM NUMBER] was observed to be 82 degrees F; and,-On 8/6/26 at 3:38 p.m. room [ROOM NUMBER] was observed to be 89 degrees F. D. Record reviewAccording to the National Weather Service Temperature website, retrieved on 8/13/26 from , https://www.weather.gov/wrh/Climate?wfo=bou, the external high temperatures recorded in the facility's zip code during from 8/3/26 to 8/6/26 were as follows: -On 8/3/26, the high temperature was 102 degrees F;-On 8/5/26, the high temperature was 84 degrees F; and,-On 8/6/26, the high temperature was 96 degrees F.Grievances regarding temperature concerns were requested and provided by the administrator in training on 8/6/26 at 12:50 p.m. A grievance form submitted by Resident #102 revealed the grievance form was completed by the social services assistant on 4/22/26. The grievance revealed that Resident #102 was concerned because the temperature in his room on 4/21/26 was 82 degrees F at 5:30 p.m., and 84 degrees F at 9:00 p.m. The resident stated his carbon monoxide monitor recorded temperatures. He stated he was heat intolerant due to his diagnosis of multiple sclerosis. The facility's immediate response was that maintenance turned the boilers off on 4/22/26. The follow-up action was that maintenance took a follow-up temperature of the resident's room, which read 72 degrees F, and maintenance would offer the resident a fan. A second grievance form submitted by Resident #102 revealed the grievance form was completed on 5/4/26 and was completed by social services. It revealed Resident #102 reported the heat in his room over the last few days has been between 80 degrees F and 82 degrees F. He said due to his multiple sclerosis, he had heat intolerance. The facility's immediate response was maintenance went to the resident's room and the temperature was 72 degrees F. Maintenance said they would ask the resident if he wanted a better fan. The follow-up action was maintenance spoke with the resident and Resident #102 said the room felt better after the air conditioning was turned on. A third grievance form, dated 7/23/26, revealed the grievance form was completed on 7/23/26 and was completed by Resident #24's representative. The grievance form indicated it was super hot in the secure unit. The facility's immediate response was that the secure unit had four portable air conditioners. Staff were filling the air conditioning units with ice and water. Maintenance installed a window air conditioner on top of the portable air conditioners. E. Staff interviews The maintenance director, the regional clinical resource and the administrator in training were interviewed on 8/6/26 at 11:11 a.m. The maintenance director said he was responsible for the building maintenance. He said he had two full time staff in his department. He said he was notified about work that needed to be done through work orders submitted on an electronic system. He said anyone who had access to the electronic medical record (EMR) system had access to the maintenance reporting system He said if anyone told him about a maintenance concern verbally, he completed the requests right away and he did not document the verbal requests. The maintenance director said he was responsible for monitoring the temperatures in the building. He said once a week, he took the temperature of the building. He said an acceptable range of temperatures was between 71 degrees F and 81 degrees F. He said if he took the temperature and it was outside of the parameters, he offered the residents a fan or increased the air conditioning. The maintenance director said the air conditioning was run through the hallways and there was not air conditioning in the residents' rooms. He said if residents complained to him that it was too hot, he provided them with a fan and if it was too cold, he would turn the heat up through the central heating system or offer more blankets. The maintenance director said the facility had extra fans for residents who said their rooms were too hot. The maintenance director said he did not know some residents bought their own fans and he said he did not know the temperature in some of the residents' rooms were too hot this week. The maintenance director, the regional clinical resource and the administrator in training said they needed to do retraining of nursing staff to ensure they knew where extra fans were stored so if residents complained about the temperature, they could offer fans to the residents. III. Failed to ensure bathrooms were in good repairA. Resident interviews and observationsResident #75 was interviewed on 8/3/26 at 10:51 a.m. Resident #75 said there was a large hole in the tile near her bed. She said her roommate had a larger hole the facility did not fix correctly. -During the interview, a hole that was approximately four inches to six inches long and approximately 0.5 inch to one inch wide, was observed near Resident #75's bed. There was a visible downward sloping area near her bed and the tile was a different color than Resident #75's roommate's tile. Resident #80 was interviewed on 8/3/26 at 2:22 p.m. Resident #80 said the concrete in her bathroom has been exposed since around 5/30/26 when there was an emergency with the plumbing. She said nursing staff took her roommate to use the shower room for toileting because the floor in their shared bathroom was not cleanable. -During the interview, the resident's bathroom was observed to have a large part of the concrete surrounding the toilet exposed. B. Additional observationsOn 8/3/26 at 12:57 p.m., the visitor and staff bathroom in the secure unit had a sign on the door indicating the bathroom was out of order. The bathroom was observed to have the concrete surrounding the toilet exposed. C. Staff interviews Certified nurse aide (CNA) #10 and CNA #11 were interviewed together on 8/5/26 at 11:15 a.m. CNA #11 said the Do not use sign was on the visitor/staff bathroom door in the secure unit because the bathroom did not work CNA #10 and CNA #11 said it had been a couple of months since the bathroom had not worked. CNA #10 and CNA #11 said anytime staff had a work request for maintenance, they told maintenance verbally. CNA #10 and CNA #11 said they had not asked maintenance about the bathroom on the secure unit not working because they assumed maintenance knew about the bathroom since there was an out of order sign on the door. The maintenance director, the regional clinical resource and the administrator in training were interviewed together on 8/6/26 at 11:11 a.m. The maintenance director said he did not know the concrete surrounding the toilets was exposed for Resident #75's bathroom. He said he had a plumber come out on Memorial Day weekend 2026 to fix a leak with the toilet in Resident #80's bathroom. He said he did not know the plumber did not leave the bathroom in working order. The maintenance director said he would work on ensuring the bathrooms for Resident #75 and Resident #80 were fixed so the residents could use them. The maintenance director said the visitor and staff bathroom in the secure unit was supposed to be fixed, but Resident #75's bathroom had leaked around the same time so the plumber fixed the resident's bathroom first. The regional clinical resource and the administrator in training agreed it was important to ensure the bathrooms were in working order for the resident's use. IV. Failed to ensure residents were not exposed to foul odors in common hallwaysA. ObservationsOn 8/3/26 at 11:24 a.m. the entrance of the secure unit, near room [ROOM NUMBER] and room [ROOM NUMBER] had a urine odor. On 8/3/26 at 11:29 a.m. the entrance to the dining room of the secure unit had a smell of urine. On 8/4/26 at 11:08 a.m. the entrance of the secure unit, near room [ROOM NUMBER] and room [ROOM NUMBER] had a urine odor. B. Staff interviews The maintenance director, the regional clinical resource and the administrator in training were interviewed together on 8/6/26 at 11:11 a.m. The maintenance director said the residents' rooms and hallways on the secure unit were cleaned daily. He said when he received complaints about odors, he had housekeeping staff do a deep clean for residents' rooms. He said he was not aware that there were odors at the entrance of the secure unit. The maintenance director, the regional clinical resource and the administrator in training said they could increase the frequency of emptying the trash (which contained soiled residents' briefs) from the soiled utility closet. The maintenance director, the regional clinical resource and the administrator in training said the soiled utility closet was near room [ROOM NUMBER] and room [ROOM NUMBER], which could have been the cause of the odor in the secure unit. V. Failure to ensure residents were served meals in reusable cups, bowls and plates in the secure unitA. ObservationsDuring a continuous observation of the secure unit on 8/3/26, beginning at 11:24 a.m. and ending at 12:32 p.m., all residents' drinks, such as juice, were served in white paper cups and all residents' desserts were served in plastic souffle cups. During a continuous observation of the secure unit on 8/4/26, beginning at 11:08 a.m. and ending at 12:57 p.m., all residents' drinks, such as juice were served in white paper cups and all residents' desserts were served in plastic souffle cups. B. Staff interviews CNA #10 and CNA #11 were interviewed together on 8/5/26 at 11:15 a.m. CNA #10 and CNA #11 said they did not know why paper cups and plastic souffle cups were being used in the secure unit. CNA #10 and CNA #11 said the secure unit had been provided with paper cups and plastic dessert cups for at least a year by the kitchen. CNA #10 said she thought it was a management decision to provide paper cups and plastic souffle cups only in the secure unit. The dietary manager (DM) was interviewed on 8/5/26 at 1:30 p.m. The DM said paper cups and plastic souffle cups were served in the secure unit as a safety precaution. The DM said residents in the secure unit could have behaviors and could use the cups and dessert plates as a weapon and throw them at other residents. The DM said she knew regular plates and silverware were provided to the residents in the secure unit and could not explain why regular cups and dessert plates and bowls could not be provided to the secure unit. The DM said she served the residents' desserts in plastic souffle cups because the desserts were transported from the kitchen to the secure unit and it was easy to cover the desserts with the plastic cap. The DM said she realized that residents who had room trays were served desserts on small plates or bowls that were covered with plastic wrap. She said she could do the same for the secure unit. The director of nursing (DON), the regional clinical resource and the administrator in training were interviewed together on 8/6/26 at 5:00 p.m. The DON, the regional clinical resource and the administrator in training said they did not know that paper cups and plastic souffle cups were being used to serve residents in the secure unit. DON, the regional clinical resource and the administrator in training said they would work towards ensuring residents in the secure unit were provided with regular dessert plates, cups and bowls when being served their meals.

Based on record review and interviews, the facility failed to ensure supervision and monitor assistive devices to prevent accidents for one (#1) of three residents reviewed for accidents out of 20 sample residents. Resident #1 was admitted to the facility for skilled nursing care on 6/13/25 .The resident's care plan directed staff to utilize a mechanical lift for transfers. On 6/18/25, Resident #1 was noted to have pain to her left upper extremity and bilateral lower extremities after being lowered to the floor with the use of a mechanical lift by certified nurse aide (CNA) #1. After the resident's fall, CNA #1 and CNA #6 proceeded to assist Resident #1 into her wheelchair using the mechanical lift, prior to the resident being assessed by a registered nurse (RN) (see staff interviews below). Resident #1 was transported to the hospital on 6/18/25 where it was revealed that the resident had sustained fractures to her upper left arm (humerus) and both legs (tibia). The facility investigation after the incident revealed CNA #1 attempted to transfer Resident #1 using the mechanical lift and did not have additional staff members present to assist withthe transfer. Specifically, the facility failed to:-Ensure staff transferred Resident #1 appropriately with a mechanical lift which resulted in a fall with major injury for the residents; and,-Ensure staff did not move Resident #1 after a fall prior to being assessed by a RN.Findings include:I. Facility policy and procedureThe Safe Resident Handling/Transfers policy, revised 6/18/25, was provided by the nursing home administrator (NHA) on 7/28/25 at 12:11 p.m. It read in pertinent part, All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. Two staff members must be utilized when transferring residents with a mechanical lift. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. The staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file.II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included end stage renal (kidney) disease requiring dialysis, COPD (chronic obstructive pulmonary disease, a lung disease), diabetes, respiratory failure, heart failure, left below the knee and right above the knee amputations.The 6/18/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #1 required set up assistance with eating and was dependent on staff for toileting, showering, dressing and transfers, including lying to sitting and bed to chair.B. Incident investigationThe facility investigation for Resident #1's fall incident on 6/18/25 was provided by the NHA on 6/30/25 at approximately 3:00 p.m.The investigation documented that on 6/18/25 at 3:45 a.m. Resident #1 sustained a fall while being transferred from her bed to go to dialysis. It documented Resident #1 was sent to the hospital for her pain and the hospital found Resident #1's injuries included a fracture of the left arm and both legs.The investigation documented Resident #1 was interviewed on 6/18/25 via telephone and stated that CNA #1 gave her a bed bath and got her dressed for dialysis. The investigation documented CNA #1 attempted to transfer the resident from the bed to her wheelchair with a mechanical lift when Resident #1 slipped and landed on the floor. It documented the nurse (RN #s) assessed Resident #1 and got her back to bed. It documented the resident had pain in her knees and requested to be transferred to the hospital.The investigation included a statement documented by RN #3 on 6/18/25. It documented CNA #1 said Resident #1 was assisted down (to the floor) during the mechanical lift transfer. It documented RN #3 arrived to the resident's room and found Resident #1 sitting in a wheelchair and the resident complained of pain to her upper left extremity. The statement documented Resident #1 said that she fell on her arm. It documented Resident #1 later complained of pain to her bilateral lower extremities and the physician ordered pain medication and x-rays.The investigation included a statement documented by CNA #1 on 6/18/25. It documented CNA #1 transferred the resident using a mechanical lift sling the resident had requested, the sling broke, and CNA #1 attempted to stop her from falling and the resident had left arm pain after the incident.-The statement revealed CNA #1 transferred the resident using the mechanical lift without other staff members present.The investigation included a phone interview with CNA #6 documented on 6/18/25. It documented CNA #1 had been instructed to call for assistance with transferring the resident when Resident #1's hygiene care was completed. It documented CNA #1 called CNA #6 to assist with the resident's transfer and when CNA #6 arrived to the room, Resident #1 was on the floor. It documented CNA #1 told CNA #6 that she attempted transferring the resident by herself and the resident fell. It documented that CNA #6 proceeded to assist CNA #1 in transferring the resident from the floor into her wheelchair using the mechanical lift. The investigation documented seven interviews with residents at the facility and revealed no concerns with transfer assistance.The investigation documented the facility determined that CNA #1 did not follow the facility's policy and did not wait for a second CNA to arrive prior to transferring the resident using the mechanical lift.C. Record reviewThe activities of daily living (ADL) care plan, initiated 6/17/25, revealed Resident #1 was dependent on staff for bathing/showering, dressing and bed mobility. The fall care plan, initiated 6/17/25, revealed Resident #1 was at high risk for falls related to amputations, renal disease, COPD and respiratory failure.A nursing progress note, dated 6/18/25 at 6:03 a.m., documented Resident #1's change of condition due to fall. It documented Resident #1's pain at her left upper extremity and bilateral lower extremities post staff-assisted fall. It documented the nurse's recommendation for stat (immediate) x-rays and transfer to the hospital.A nursing progress note, dated 6/18/25 at 7:51 a.m., documented Resident #1 was lowered to the floor by staff when the strap from the mechanical lift sling loosened. It documented that upon initial assessment, the resident complained of left upper extremity pain and the resident later complained of bilateral lower extremity pain. It documented the resident would not allow range of motion to the extremities and was intolerant of a transfer back to the bed. It documented the resident did not want to wait for completion of x-rays at the facility and was sent to the hospital. It documented the physician and the resident's representative were notified of the transfer to the hospital.Resident #1's hospital history and physical record, dated 6/18/25 at 9:38 a.m., documented Resident #1 had admission diagnoses of non-displaced fracture of the surgical neck of left humerus, displaced fracture of her right tibia and fracture of the upper end of her left tibia.An interdisciplinary team (IDT) progress note, dated 6/20/25 at 12:55 p.m., documented Resident #1's fall was caused by an improper transfer. It documented Resident #1 was transferred to the hospital and noted to have fractures. D. Staff educationThe facility provided documentation of staff education completed after the incident which included the following:A document titled Utilizing Kardex (staff directive tool) and Report Sheets Inservice, dated 6/18/25. The document included 27 CNA signatures. The document emphasized the importance of using the Kardex and report sheets as a quick reference to aid in resident safety, including prevention of falls due to improper transfers.A document titled Employee Competency Checklist, Sit to Stand Mechanical Lift, which included individual competency checklists for 25 staff members, dated from 6/19/25 to 6/26/25. The competency checklist included each employee's demonstrations of the mechanical lift transfer skill.A document titled Hoyer (mechanical lift), Sit to Stand Safe Transfer Techniques, documented as an in-service provided by the director of rehabilitation (DOR) and the director of nursing (DON) on 6/18/25 at 11:30 a.m. The document included 43 staff signatures and included the facility's policy for transferring residents.-However, there was no documentation provided to indicate the facility had identified other residents at potential risk or looked at other residents' mechanical lift slings in the facility to determine if all slings were in proper working order, despite documentation and CNA #1's statement that Resident #1's sling broke during the transfer, causing her to fall to the floor (see record review above and staff interviews above related to the sling).-There was no documentation provided to indicate how the facility was monitoring staff to ensure staff were transferring residents using a mechanical lift with two person assistance following the incident with Resident #1.III. Resident #8's interviewResident #8, another resident in the facility, was interviewed on 6/30/25 at 1:25 p.m. Resident #8 said she required a mechanical lift for transfers until a few months ago. She said most of the time, only one CNA would transfer her using the mechanical lift. She said there were only a few CNAs who insisted upon having a second CNA present when using the mechanical lift.IV. Staff interviewsThe hospital physician was interviewed on 6/30/25 at 10:45 a.m. The hospital physician said Resident #1 told her that a CNA attempted to transfer her with only one person assistance from the bed to the wheelchair and the resident sustained a fall with fractures. The hospital physician said the resident had been hospitalized a week earlier and nursing staff had told the hospital physician that Resident #1 required assistance of two people for transfers. The hospital physician said she was concerned the facility did not provide proper staff education for Resident #1's transfers. RN #2 was interviewed on 6/30/25 at 1:00 p.m. RN #2 said she had completed mechanical lift training at another facility. RN #2 said she was asked by the facility to sign a document which confirmed she knew how to use the mechanical lift. RN #2 said at least two staff members were required to use a mechanical lift. CNA #2 was interviewed on 6/30/25 at 2:45 p.m. CNA #2 verbalized the process for using a mechanical lift. CNA #2 said the facility emphasized to all staff the need to use two people for transfers and provided recent education to staff about these transfers.CNA #3 was interviewed on 6/30/25 at 2:50 p.m. CNA #3 verbalized the process for using a mechanical lift. CNA #3 said at least two to three people were required to use a mechanical lift.CNA #4 was interviewed on 6/30/25 at 2:55 p.m. CNA #4 said the restorative CNA taught him how to use the mechanical lift. CNA #4 said the facility reviewed the lift process again a week ago. CNA #4 said two people were required for use of a mechanical lift.Licensed practical nurse (LPN) #1 was interviewed on 7/21/25 at 12:25 p.m. LPN #1 said he had not had to transfer residents with the mechanical lift, as the CNAs typically did those transfers. He said two people were always required when using the mechanical lift.CNA #5 was interviewed on 7/21/25 at 12:40 p.m. CNA #5 said two CNAs were required for mechanical lift transfers and she had always used at least two people for those transfers. CNA #5 said staff were provided mechanical lift training upon hire and received refresher training a month ago.The DON was interviewed on 7/22/25 at 1:25 p.m. The DON said CNA #1 transferred Resident #1 without additional assistance and there should always be at least two staff members present for a mechanical lift transfer. The DON said RN #3 initially had provided a statement that Resident #1 had been moved prior to assessment but then later told the DON the resident was assessed prior to being moved to the wheelchair. The DON said she asked RN #3 to correct her statement, but said the RN never corrected the written statement.-However, RN #3 and CNA #6 confirmed in interviews that Resident #1 was moved to the wheelchair prior to the RN assessment (see interviews below).The DON said CNA #1 should have gotten the assistance of a second person to assist with using the mechanical lift. She said CNA #1 should not have transferred Resident #1 by herself. The DON said it was the facility's policy for resident safety to use at least two staff members for mechanical lift transfers at all times.RN #3 was interviewed on 7/23/25 at 10:56 a.m. RN #3 said she was Resident #1's nurse the night the resident fell from the mechanical lift. RN #3 said she instructed CNA #1 to call RN #3 when the resident was ready to be transferred. She said CNA #1 was getting Resident #1 ready for dialysis. She said CNA #1 was not the assigned CNA, but was getting the resident ready because Resident #1 did not want the male CNA (CNA #6) doing personal care, so the male CNA was sent to another unit while CNA #1 got Resident #1 ready. RN #3 said CNA #1 did not call her to assist with transferring the resident and instead, attempted to transfer Resident #1 without additional assistance. RN #3 said CNA #1 came to her and told her that she had lowered Resident #1 to the floor. RN #3 said CNA #1 said she utilized the resident's sling and it broke.RN #3 said when she arrived to Resident #1's room, she expected to find the resident on the floor, but the resident was sitting in the wheelchair with a sling for the mechanical lift underneath her. She said CNA #6 was also present in the room. RN #3 said Resident #1 told her she had fallen on her left arm. She said the resident would not allow her to perform a range of motion assessment on her extremities to assess for injuries. RN #3 said she contacted the physician and the physician ordered x-rays. RN #3 said Resident #1 later began to say her legs were also hurting and she would not allow her legs to be touched. RN #3 said Resident #1 told her that she wanted to go to the hospital and did not want to wait for x-rays. RN #3 said she notified the physician and transferred the resident to the hospital.RN #3 said CNA #6 told her Resident #1 was on the floor when he entered the room. She said CNA #6 told her he was under the impression that RN #3 had assessed the resident, so he helped CNA #1 transfer Resident #1 to the wheelchair. RN #3 said she had not yet assessed the resident and the CNAs should not have moved the resident prior to her assessment. RN #3 said the DON was aware that the CNAs had moved the resident before she assessed the resident. RN #3 said Resident #1 was in a lot of pain and yelling out after the injury, and RN #3 gave the resident medication for her pain. RN #3 said there were CNAs at the facility who had transferred residents with the mechanical lift using only one person's assistance. She said another CNA had recently received disciplinary action for transferring a resident without additional assistance. CNA #6 was interviewed on 7/24/25 at 10:48 a.m. CNA #6 said he had been assigned to Resident #1, however, the resident did not want male CNAs for personal care so a female CNA (CNA #1) from another unit temporarily traded the assignment with him to prepare Resident #1 for dialysis. CNA #6 said he was walking in a hallway when CNA #1 called out to him and asked for assistance. CNA #6 said he followed CNA #1 to Resident #1's room and when he walked in the room, Resident #1 was lying on her back on the floor, and moaning. CNA #6 said it was obvious that Resident #1 was hurt. CNA #6 said CNA #1 did not tell him how the resident fell. CNA #6 said he did not know if CNA #1 had told the nurse about the fall. CNA #6 said he was asked to help lift Resident #1 into the wheelchair and he and CNA #1 did this together using the mechanical lift. CNA #6 said the facility had a skills lab once per year to practice using the mechanical lift. He said there should always be two people present to transfer a resident using a mechanical lift. CNA #6 said he thought CNA #1 transferred Resident #1 without additional assistance.

Based on record review and interviews, the facility failed to ensure notification to the resident representative of a significant change in the resident's physical, mental or psychosocial status for one (#11) of three residents reviewed for change of condition out of 20 sample residents.Specifically, the facility failed to notify Resident #11's representative of the resident's deteriorating wounds in a timely manner.Findings include:I. Facility policy and procedureThe Notification of Change policy, revised January 2025, was provided by the nursing home administrator (NHA) on 7/28/25 at 12:11 p.m. The policy read in pertinent part, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family members or legal representative when there is a change requiring such notification. Circumstances requiring notification include significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include life threatening conditions or clinical complications.II. Resident #11A. Resident statusResident #11, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included cellulitis of the right lower limb, pleural effusion (a buildup of fluid in the tissue that lines the lungs), immunodeficiency (immune system unable to defend the body from foreign or abnormal cells), cirrhosis of liver (chronic liver damage), chronic venous hypertension with ulcer and inflammation of both lower extremities (high pressure within leg veins which causes fragile skin prone to opening).The 6/26/25 minimum data set (MDS) assessment revealed Resident #11 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required set up assistance with eating and repositioning and substantial assistance with dressing, transferring to the shower, toileting and personal hygiene.B. Resident representative interviewResident #11's representative was interviewed on 7/21/25 at 2:00 p,m. The representative said the facility did not contact her for most of Resident #11's condition changes and she often found things out later. The representative said she was not notified of any changes with the resident during the previous two weeks prior to Resident #11's hospitalization on 7/12/25. She said she last met with the facility on 6/20/25, at which time she understood Resident #11 required a few more weeks of physical therapy and then he would potentially be discharged to home with assistance. The representative said she was notified on 7/12/25, the date of Resident #11's transfer to the hospital, that his vital signs and level of consciousness had changed and he was lethargic. The representative said she was surprised to learn from the hospital physician that Resident #11's wounds had worsened and he had an infection because nothing was communicated to her from the facility about his wounds worsening. C. Record ReviewThe impaired skin integrity care plan, initiated 6/1/25, revealed Resident #11 had skin ulcers on both legs, including the right achilles (heel) and required wound care and measurements of the wounds width, length, depth, type of tissue and exudate and any other notable changes or observations.The wound care physician (WCP) note, documented on 7/9/25 at 9:42 p.m., revealed the following changes of Resident #11's wounds:On 7/9/25, Resident #11's right achilles wound measured 13.6 centimeters (cm) width by 6.4 cm length by 0.3 cm depth. This was an increase from 7/2/25, when it measured 6.2 cm by 6.3 cm by 0.3 cm. The WCP documented the wound had worsened.On 7/9/25, Resident #11's right lateral foot wound measured 10.0 cm by 5.6 cm by 0.1 cm. This was an increase from 7/2/25, when it measured 6.6 cm by 4.0 cm by 0 cm. The WCP documented the wound had worsened.The WCP documented the care plan was discussed with Resident #11 and the nursing staff. It documented an ultrasound on 7/3/25 revealed mild to moderate peripheral artery disease (PAD) was suspected in the resident's legs with occlusion of the right dorsalis pedis (a blockage in the artery on top of the foot). A nursing progress note, dated 7/9/25 at 7:43 p.m., documented the PCP (primary care physician) and the WCP reviewed Resident #11's ultrasound result and recommended a vascular consult. The note documented a message had been left at an office for this consult.An interdisciplinary team (IDT) note, written by the director of nursing (DON) on 7/11/25 at 9:45 a.m., documented the worsening of Resident #11's wounds and Resident #11 had been noncompliant with lab draws and incontinence care.A PCP progress note, dated 7/11/25 at 5:32 p.m., documented Resident #11's wound worsening was unavoidable due to poor oral intake, the resident's refusals for supplementation and his immunocompromised status. A nursing progress note, dated 7/12 at 2:40 p.m., documented Resident #11's change of condition. It documented Resident #11 was confused and his blood pressure was 82/49 millimeters of mercury (mmHg), his heart rate was 115 beats per minute (bpm) and his oxygen saturation (level of oxygen in the blood) was 86% (percent) with an oxygen mask in place. It documented that the resident's representative was notified of the resident's transfer to the hospital.-The notes documented Resident #11's wounds worsening on 7/9/25, the resident's ultrasound results and the recommended specialist referral, however, there was no documentation to indicate the resident's representative was notified until Resident #11's transfer to the hospital on 7/12/25 for a change of condition.III. Staff interviewsThe DON was interviewed on 7/22/25 at 1:20 p.m. The DON said Resident #11's representative should have been notified about the worsening condition of Resident #11's wounds on 7/9/25, when it was documented by the WCP. The DON said Resident #11's wounds were worsening because of his refusals of interventions, especially related to his nutrition.The WCP was interviewed on 7/23/25 at 4:45 p.m. The WCP said he told Resident #11 on 7/9/25 that his wounds were not getting better and there were more aggressive treatments that could be done. The WCP said the resident was a candidate for amputation. The WCP said Resident #11 had not decided if he was going to do more aggressive treatment. The WCP said the representative should have been notified on 7/9/25 when the wounds had worsened.Registered nurse (RN) #1 was interviewed on 7/24/25 at 1:15 p.m. RN #1 said he was provided information by the night nurse in the shift-to-shift report on 7/11/25 that Resident #11's wounds had been worsening. RN #1 said the PCP said on 7/11/25 that Resident #11 had reached the point to consider hospice. RN #1 said he did not know if the resident's representative had been notified of the deterioration of Resident #11's wounds.

Based on record review and interviews, the facility failed to ensure one (#6) of seven residents reviewed for abuse out of 20 sample residents were free from abuse.Specifically, the facility failed to protect Resident #6 from abuse by Resident #9.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, reviewed January 2025, was provided by the nursing home administrator (NHA) on 6/30/25 at 12:00 p.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility will have written procedures to assist staff in identifying the different types of abuse: mental/verbal abuse, sexual abuse, physical abuse and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident-to resident altercations. Possible indicators of abuse include but are not limited to: resident-to-resident, staff or family report of abuse, verbal abuse of a resident overheard, and physical abuse of a resident observed.II. Physical abuse of Resident #6 by Resident #9 on 6/9/25A. Facility investigationThe facility investigation of the incident involving Resident #6 and Resident #9 was provided by the NHA on 7/23/25 at 9:54 a.m. The investigation documented that on 6/9/25 at 2:30 p.m. it was reported Resident #9 approached Resident #6 and Resident #6's representative and called Resident #6 an explicit word. Resident #9 then proceeded to make contact with Resident #6's arm.The immediate intervention was to take Resident #9 to the dining room by therapy staff and Resident #6 was assessed with no noted changes.Licensed practical nurse (LPN) #2 documented in her statement that Resident #6 and his representative were sitting in the hallway. Resident #9 approached them and Resident #9 called Resident #6 an explicit word and proceeded to hit Resident #6 in the arm. The investigation documented Resident #6's representative was interviewed by the facility over the phone and the representative said she was sitting with Resident #6 when Resident #9 approached her and asked her if she knew what an (explicit word) was. Resident #6's representative said Resident #9 pointed at Resident #6 and made a nudge contact with his arm and said this guy is the biggest (explicit word) here. Therapy staff came and redirected Resident #9.A 6/9/25 statement from the director of nursing (DON) documented that at approximately 2:45 p.m. a nurse notified the DON that Resident #9 went to Resident #6 and called him an explicit word and hit him on his right arm. Resident #9 was immediately redirected by staff.B. Resident #9 (assailant)1. Resident statusResident #9, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included severe vascular dementia with behavior disturbance, type 2 diabetes mellitus, post traumatic stress disorder (PTSD) and major depressive disorder.The 6/24/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of seven out of 15. He needed substantial assistance with bathing, supervision with transfers and set up assistance for other activities of daily living (ADL). The assessment did not document the resident had physical or verbal behaviors toward others.2. Record reviewResident #9's dementia care plan, revised 7/23/25 documented the resident had a history of anger outbursts, delusional thinking, PTSD and wandering related to a diagnosis of dementia with psychotic behaviors. On 4/6/25 Resident #9 had a behavior outburst during coffee social and threw coffee on another resident. On 6/9/25 Resident #9 was observed engaging in physical contact and using inappropriate language toward another resident.Pertinent interventions, revised 6/14/25 included one-to-one activity tailored to the resident's preferences, anticipating and meeting the resident's needs, intervene as necessary to protect the rights and safety of others, approaching the resident and speaking in a calm manner, removing the resident from the situation and taking him to an alternate location as needed.A 6/9/25 nursing note documented that at approximately 2:30 p.m., the nurse was approached by an occupational therapist (OT). According to the OT, a resident-to-resident physical contact occurred in the hallway. The nurse immediately went to investigate. Staff quickly separated Resident #9 from Resident #6. Resident #6's representative, who was visiting, stated that Resident #9 went up to them, called Resident #6 an explicit word, then hit Resident #6 on his right arm. No bruise, redness or abrasion was observed on the resident's right arm and the resident's skin remained intact. Resident #6 and his representative also stated that Resident #6 did not hit Resident #9. The NHA and the physician were notified.A 6/9/25 alert note documented the facility contacted the local police department to report a resident-to-resident physical altercation. A 6/10/25 social services note documented Resident #9 displayed increased episodes of unprovoked verbal and physical aggression towards peers. He had been in his third reportable incident since February 2025. C. Resident #6 (victim)1. Resident statusResident #6, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included collapsed vertebrae, type 2 diabetes mellitus, dementia, depression and dependence on a wheelchair.The 6/23/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of seven out of 15. He needed moderate assistance with ADLs and set up assistance at meals.2. Resident's representative interviewResident #6's representative was interviewed on 7/22/25 at 3:10 p.m. The representative said Resident #6 told her that Resident #9 hated him and he did not know why. She said she and Resident #6 were sitting in wheelchairs by the dining room talking (on 6/9/25). She said Resident #9 watched them for awhile, then he came up to Resident #6, called Resident #6 was an explicit word and then he reached out and punched Resident #6 on the right arm. The representative said staff members were walking by and the nurse had been watching. She said the nurse asked what happened and she told the nurse. She said the nurse asked Resident #6 if he was okay and he said he was but it hurt. She said Resident #6 had no mark on him and no pain later, just pain in the moment it happened. She said the staff separated Resident #9 from Resident #6 and assisted him down the hall. The representative said staff checked Resident #6 and the NHA from the nursing home called her about the incident. 3. Record reviewResident #6's behavior care plan, initiated 4/22/25, documented the resident had depression and a history of suicidal behavior. Pertinent interventions, initiated 4/22/25, included to monitor/document/report to the physician as needed if the resident was at risk for harming others, increased anger, feeling threatened by others or thoughts of harming someone. A 6/9/25 nursing progress note documented that after getting a shift change report from the dayshift nurse at 2:30 p.m, a nurse was approached by the OT to report a resident-to-resident physical contact in the hallway. The nurse quickly went to investigate. Staff took Resident #9 to his room. Resident #6's representative was visiting and they were sitting facing each other in the hallway. Resident #6 and his representative said Resident #9 came up to them and called Resident #6 an explicit word and then proceeded to hit Resident #6 on the right arm. No bruise, abrasion or redness was observed on Resident #6's upper extremity and his skin remained intact.III. Staff interviewsThe OT was interviewed on 7/28/25 at approximately 1:00 p.m. The OT said she was in the secure unit on 6/9/25 and heard a mumbling but was not paying attention to the residents. The OT said she was not able to see Resident #9's hand or hear a slap, but saw his arm swing at Resident #6. She said she heard Resident #6's representative tell Resident #9 to not do that. The OT said she notified the nurse of what she observed. She said she reported it because she wanted to make sure the nurses had her eye on the residents because sometimes tensions could get high. She said she would report suspected abuse regardless of a resident's cognition.LPN #2 was interviewed on 7/28/25 at 2:10 p.m. LPN #2 said usually when she started her shift, she separated Resident #9 from other residents and gave him something to drink and eat and he would calm down. LPN #2 said Resident #9 did not like noise so she tried to remove him from the noise and the rest of the residents if they were talking loudly. LPN #2 said she would take Resident #9 to the television room for privacy because he would reach out and think that people were trying to hit him if they were making a movement. LPN #2 said moving Resident #9 helped him deescalate. LPN #2 said she watched Resident #9 more than others because he was reactive and had a difficult time understanding that the other residents' behaviors were not directed at him. LPN #2 said if there was a hit or physical contact between residents, she would report the abuse. She said the OT came to her (on 6/9/25) and reported Resident #9 might have hit someone and the OT said she heard screaming. LPN #2 said Resident #6 told her that Resident #9 hit him. LPN #2 said she checked Resident #6 after the reported incident and he did not have any marks on his skin. She said she notified the family and told the director of nursing (DON). LPN #2 said the NHA told her to file a police report, which she did.

Based on observations, record review and interviews, the facility failed to provide each resident with a nourishing, palatable and well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences. Specifically, the facility failed to ensure weekly menus were balanced and included a variety of menu items. Findings include: I. Resident interviews Resident #4 was interviewed on 5/21/25 at 11:18 a.m. Resident #4 said she wished the menu had better variety and the menu options changed more frequently. Resident #4 said lately the menu was too repetitive and there was too much chicken and pork on the menu. Resident #8 was interviewed on 5/21/25 at 3:55 p.m. Resident #8 said the menus were too repetitive. Resident #8 said the vegetable options on the menu were too repetitive. Resident #8 said there were too many vegetable blends and mixed vegetables on the menu. Resident #15 was interviewed on 5/21/25 at 4:10 p.m. Resident #15 said at times the menu was too repetitive. II. Weekly menu Four weeks of menus were provided by the nursing home administrator (NHA) on 5/22/25 at 2:42 p.m. A review of the four week menu (served during the survey) revealed repeated menu items. Vegetables, vegetable blends, chicken, pork, potatoes and rice were items repeated on the weekly menu. The menu reviewed for the week of 4/28/25 to 5/4/25 revealed the following: -On 4/29/25 the dinner vegetable was mixed vegetables; -On 4/30/25 the lunch vegetable was vegetables; -On 5/1/25 the lunch vegetable was mixed vegetables; -On 5/3/25 the lunch vegetable was seasoned vegetables; and, -On 5/4/25 the lunch vegetable was mixed vegetables. The menu reviewed for the week of 5/5/25 to 5/10/25 revealed the following: -On 5/5/25 lunch was chicken fajitas and red rice; -On 5/6/25 the lunch vegetable was seasoned vegetables; -On 5/6/25 the dinner vegetable was vegetables; -On 5/7/25 the lunch was sweet and sour chicken, steamed rice and vegetables; -On 5/8/25 the lunch was a barbecue chicken breast and vegetables; -On 5/9/25 the lunch vegetable was mixed vegetables; -On 5/9/25 the dinner entree was a chicken sandwich; -On 5/10/25 the dinner vegetable was vegetables; and, -On 5/11/25 the lunch vegetable was seasoned vegetables. The menu reviewed for the week of 5/12/25 to 5/18/25 revealed the following: -On 5/13/25 the lunch vegetable was vegetables; -On 5/13/25 the dinner vegetable was mixed vegetables; -On 5/14/25 the lunch vegetable was vegetables; -On 5/15/25 the lunch vegetable was mixed vegetables; -On 5/15/25 the dinner vegetable was vegetables; and, -On 5/16/25 the lunch vegetable was seasoned vegetables. The menu reviewed for the week of 5/19/25 to 5/25/25 revealed the following: -On 5/19/25 the dinner was a crispy chicken wrap; -On 5/20/25 the lunch was a creamy chicken breast, pasta (penne) and seasoned vegetables; -On 5/20/25 the dinner was pasta (egg noodles) and seasoned vegetables; -On 5/21/25 the lunch was pineapple barbecue chicken thigh; -On 5/22/25 the lunch was slow roast pork loin and seasoned vegetables; -On 5/22/25 the dinner was chicken fajitas; -On 5/23/25 the lunch vegetable was mixed vegetables; -On 5/24/25 the lunch was roast pork loin with scalloped potatoes; -On 5/24/25 the dinner was grilled chicken with gravy creamy mashed potatoes and vegetables; -On 5/25/25 the lunch was baked ham with baked sweet potato and seasoned vegetables; and, -On 5/25/25 the dinner was slow roast pork loin, roasted potatoes and vegetables. III. Staff interviews The dietary manager (DM) was interviewed on 5/22/25 at 10:30 a.m. The DM said she could change the menu at the facility and she could choose which options to place on the weekly menu. The DM said the areas she needed to work on at the facility when she arrived four months ago was menu choices and food quality. The DM said the residents used to receive one kind of mixed vegetable blend every day and the residents wanted more variety of vegetables. The DM said specific vegetables she ordered would not be delivered. She said if she ordered five kinds of vegetables during the week the vegetables would not be delivered and she would go to purchase vegetables at the store. The DM said when the menu said' vegetables' the cooks received verbal instruction on which vegetable to make. The DM residents have said to her,' oh pork again what can I have instead?' The DM said residents could order a variety of items such as chicken breasts, chicken tenders and a beef patty. The DM said these items were not listed on the alternate menu. The nursing home administrator (NHA) was interviewed on 5/22/25 at 10:30 a.m. The NHA said facility employees brought residents menus so residents could choose what they wanted at meal time. The NHA said he did not know how the residents knew what vegetable was being served each day when the menu offered ' vegetables.'

Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for two (#2 and #3) of eight residents out of 15 sample residents. Specifically, the facility failed to complete a thorough investigation after an allegation of physical abuse towards Resident #3 by Resident #2. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, revised January 2025, was provided by the nursing home administrator (NHA) on 5/21/25 at 11:30 a.m. The policy read in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation and misappropriation of property or resident property. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include identifying staff responsible for the investigation, exercising caution in handling evidence that could be used in a criminal investigation, investigating different types of alleged violations, identifying and interviewing all involved persons including that alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations, focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred, the extent and the cause, and providing complete and thorough documentation of the investigation. II. Incident of physical abuse of Resident #3 by Resident #2 A. Facility investigation The 3/10/25 facility investigation was provided by the director of nursing (DON) on 5/22/25 at 12:00 p.m. The incident report revealed Resident #2 had combative behaviors during care toward staff on 4/6/25. When Resident #2 was in the dining room, he was offered snacks by activities assistant (AA) #1 at approximately 10:30 a.m. Resident #2 started to throw items off the table and splashed his cup of coffee across the table where other residents were sitting nearby. Resident #2 was immediately removed from the dining room and was redirected to his room with a certified nurse aide (CNA). He was placed on one to-one supervision with a CNA in his room where he was easily redirectable and exhibited no such behaviors afterwards. -Review of the facility's investigation did not identify the coffee was thrown towards Resident #3, however, licensed practical nurse (LPN) #1 said Resident #2 threw the coffee at Resident #3 (see interview below). The investigation documented Resident #2 was interviewed on 4/7/25 and did not recall the incident from the day prior. He was in a pleasant mood and away from other residents in the common area. The investigation documented Resident #3 was interviewed on 4/7/25 and appeared to have no recall of an incident occurring the day prior. The investigation documented five additional residents on the secured unit were interviewed by the DON on 4/7/25 with no additional information. The investigation documented five additional staff interviews (LPN #2, LPN #3, LPN #4, CNA #2 and CNA #3) were completed on 4/7/25 by the DON with no additional information. -LPN #2, LPN #3, LPN #4, CNA #2 and CNA #3 typically worked on the secured unit, but were not present during the 4/6/25 altercation. The investigation documented AA #1, who witnessed the incident, was interviewed on 4/7/25 by the DON. AA #1 said she was in the dining room during the coffee social in the secured unit when Resident #2 was being disruptive and attempting to throw items off the table. Resident #2 threw his coffee towards an area where other residents were sitting. AA #1 said the assistant director of nursing (ADON) was notified. AA #1 said another CNA took Resident #2 out of the dining room area and redirected him back to his room. B. Resident #3 (victim) 1. Resident status Resident #3, age 66, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included dementia, alcohol abuse and history of falling. The 4/7/25 minimum data set (MDS) assessment documented Resident #3 had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out 15. He required supervision with activities of daily living (ADLs). The MDS assessment indicated Resident #3 did not exhibit verbal, physical or other behavioral symptoms directed towards others. 2. Record review The 4/7/25 alert note documented Resident #3 was being monitored after a resident-to-resident altercation. Resident #3 was alert to self and his needs were anticipated by staff. It documented Resident #3 was compliant with care, showed no signs or symptoms of pain or discomfort and there were no behaviors reported. C. Resident #2 (assailant) 1. Resident status Resident #2, age 76, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included vascular dementia and type two diabetes. The 5/9/25 MDS assessment documented Resident #2 had moderate cognitive impairments with a BIMS score of eight out 15. He required supervision for ADLs. The MDS assessment indicated Resident #2 did not exhibit verbal, physical or other behavioral symptoms directed towards others. 2. Record review The 4/6/25 behavior charting note revealed Resident #2 was reported to have combative behavior towards staff members. When Resident #2 was in the dining room, he was disruptive and was seen throwing his cup of coffee where other residents were sitting. Resident #2 was immediately removed from the dining room away from other residents. III. Staff interviews The pulmonary program coordinator was interviewed on 5/22/25 at 11:22 a.m. The pulmonary program coordinator said he was working in the secured unit on 4/6/25. The pulmonary program coordinator said he witnessed an incident between Resident #2 and Resident #3 on 4/6/25. The pulmonary program coordinator said Resident #2 had a cup of coffee and Resident #2 threw his cup of coffee in the area of Resident #3, who was seated at a different table. The pulmonary program coordinator said he wrote a statement about the incident between Resident #2 and Resident #3 on 4/6/25 and gave the statement to the DON. -However, review of the facility's investigation did not include documentation that the pulmonary program coordinator provided a statement (see facility investigation above). The pulmonary program coordinator said LPN #1 assessed Resident #3 after the incident on 4/6/25. The pulmonary program coordinator said the ADON was called and the ADON came to the secured unit to assess the resident. LPN #1 was interviewed on 5/22/25 at 12:41 p.m. LPN #1 said she was working on the secured unit on 4/6/25. She said there was an activity going on in the unit around 10:30 a.m. She said AA #1 was handing out coffee to the residents in the dining room area. She said Resident #2 was sitting across the table from Resident #3. She said Resident #2 looked at Resident #3 and threw his cup of coffee at him unprompted. She said she immediately notified the ADON who was in the building in another unit. She said she separated Resident #2 and Resident #3. She said she took Resident #3 to his room to complete a skin assessment. She said the ADON assisted her in the skin assessment. She said there were no skin alterations but she put damp towels on Resident #3's skin in case there was burning. She said she communicated the allegations of abuse to the ADON because he was the manager there and she was a mandatory reporter. LPN #1 said the ADON called the DON and then handed the phone to LPN #1. LPN #1 said she told the DON what happened and said the DON instructed her to fill out the first page of the risk management note which included a summary of what happened, the resident's description of what happened, and immediate action that was taken, which included the skin assessment she completed. She said she asked the DON if there was anything more she needed to do and the DON said she would take care of it. She said the DON said she would fill out the rest of the risk management note and notify the police. She said about an hour later, she sent a text message to the ADON verifying that the DON would take care of notifying the police and filling out the rest of the risk management note. She said the DON told her not to write a nursing progress note about the incident. She said nobody attempted to reach out to her regarding the situation. She said when she came back to work the following Sunday (4/13/25), the risk management note was no longer in the medical charts and there was no note under either resident's progress notes about the incident. -Review of the facility's investigation did not include documentation that LPN #1, who witnessed the resident-to-resident altercation, was interviewed during the investigation process (see facility investigation above). The ADON, the DON and the NHA were interviewed together on 5/22/25 at 1:00 p.m. The ADON said he was working on 4/6/25 and staff in the secured unit called him. The ADON said he went to the secure unit after Resident #2 threw his coffee. The ADON said he was notified there was an incident because he was a manager and was told it was a behavior issue. The ADON said he assigned a restorative aide to provide one-to-one supervision after the incident. The ADON said when he arrived in the secured unit, Resident #2 was not having any behavior issues. The DON said she was not working on 4/6/25 when Resident #2 threw his coffee. The DON said the ADON called her to inform her Resident #2 was having behaviors. The DON said the ADON told her the resident was throwing coffee. The DON said she instructed the ADON to remove the resident from the activity that was occurring. The DON said she came into the facility on Monday (4/7/25) to do the investigation. The DON said Resident #2 had splashed his coffee across the room. The DON said none of her interviews revealed that Resident #2 threw his coffee at Resident #3. The DON said she called LPN #1 about the incident but LPN #1 did not call her back. The DON said LPN #1 only worked on Sundays at the facility. The DON said she did not attempt to interview LPN #1 again. The DON said she did not have a statement provided by the pulmonary program coordinator. The DON and the NHA were interviewed together on 5/22/25 at 2:52 p.m. The DON said she wanted to investigate to see if there was any harm involved from the behavior Resident #2 exhibited. She said when Resident #2's behavior occurred on 4/6/25, it was one of her first weeks as the DON. The DON said since the behavior Resident #2 had was not new behavior, she decided to interview other residents and ask if they were in distress or remembered the incident. The DON said she provided verbal education with the nursing staff on 4/7/25 regarding behavior charting and how to document it. The NHA said he was the abuse coordinator and he found out about the incident between Resident #2 and Resident #3 on 4/7/25. The NHA said the facility did not complete a thorough investigation to determine if Resident #2 throwing his coffee was a behavior or an abuse incident. He said the facility should have completed staff interviews with all staff in the secured unit during the time this occurred. He said he thought since there were a lot of behaviors that occurred on the memory care unit, it was not communicated to the DON as abuse but rather as a behavior.

Based on observations, record review and interviews, the facility failed to ensure three (#19, #54 and #25) of four residents who required respiratory care received care consistent with professional standards of practice out of 34 sample residents. Specifically, the facility failed to: -Follow physician's orders to maintain, clean, sanitize and store Resident #19's continuous positive airway pressure (CPAP) mask and machine and Resident #54's bilevel positive airway pressure (BiPAP) mask and machine; and, -Rinse and store cup and mouthpiece for Resident #25's nebulizer (a small machine that turns liquid medication into a mist that can be inhaled to treat lung conditions.) Findings include I. Facility policy and procedure The CPAP/BiPAP Cleaning policy, revised 6/1/24, was provided by the director of nursing (DON) on 12/5/24 at 1:36 p.m. The policy revealed in pertinent part It is the policy of the facility to clean CPAP/BiPAP equipment with current Center for Disease Control (CDC) guidelines and manufacturer's recommendations in order to prevent the occurrence or spread of infection. Respiratory therapy equipment can become colonized with infectious organisms and serve as a source of respiratory infections. Clean the mask frame daily after use with CPAP cleaning wipes or soap and water. Dry well. Cover with a plastic bag or completely enclosed in machine storage when not in use. Wash headgear/straps and tubing in warm, soapy water and air dry weekly. The Nebulizer Therapy policy, revised 6/1/24, was provided by the DON on 12/5/24 at 1:36 p.m. The policy revealed in pertinent part, Clean after each use. Wash hands before handling the equipment. Disassemble the parts after each treatment. Rinse the nebulizer cup and mouth piece with sterile or distilled water. Shake off excess water. Air dry on an absorbent towel. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag. II. Resident #19 A. Resident status Resident #19, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, mild vascular dementia (caused by strokes), obstructive sleep apnea, obesity and nicotine dependence. The 11/6/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. She required maximum assistance with bathing and moderate assistance with upper and lower body dressing, putting on/off footwear and tub transfers. The assessment indicated the resident received oxygen and a non-invasive mechanical ventilator. -The assessment did not indicate if the non-invasive mechanical ventilator was a CPAP or a BiPAP. B. Observations On 12/2/24 at 2:46 p.m. Resident #19's CPAP mask was sitting on the resident's dresser behind the CPAP machine. On 12/3/24 at 9:07 a.m. Resident #19's CPAP mask was sitting on top of the dresser behind the CPAP machine. On 12/3/24 at 2:44 p.m. Resident #19's CPAP mask was sitting on top of the dresser behind the CPAP machine. On 12/4/24 at 11:25 a.m. Resident #19's CPAP mask was lying on the floor under the head of the bed. The CPAP mask was attached to the tubing and the tubing was attached to the machine. On 12/4/24 at 3:43 p.m. the resident's CPAP mask was lying on the floor under the head of the bed. The CPAP mask was attached to the tubing and the tubing was attached to the machine. On 12/5/24 at 9:19 a.m. Resident #19's CPAP mask was on the resident's bedside table attached to the tubing. The CPAP machine was behind the bedside table on the dresser. -During all of the above observations, Resident #19's CPAP mask was not covered by a plastic bag or enclosed in a storage case, which was identified by the facility as the process for CPAP/BiPAP storage (see facility policy above). C. Resident interview Resident #19 was interviewed on 12/5/24 at 3:04 p.m. She said the CPAP machine should be cleaned weekly and the mask daily, but the facility staff never cleaned them. She said when she was not using her CPAP mask, the staff stored it on top of her dresser. D. Record review Review of Resident #19's December 2024 CPO revealed the following physician's order: CPAP machine daily care: remove mask from head gear. Clean the mask with soapy water or with CPAP wipe. Clean the humidifier chamber with warm soapy water. Rinse the humidifier chamber using sterile or distilled water one time a day for CPAP maintenance, ordered 12/2/24. The altered respiratory status care plan, revised 7/30/24, revealed Resident #19 had difficulty breathing related to chronic obstructive pulmonary disease and obstructive sleep apnea. The interventions included assisting the resident with placement of the CPAP nightly at bed time and as needed with naps, and cleansing the CPAP water chamber and machine as instructed in the physician's orders. III. Resident #54 A. Resident status Resident #54, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included chronic respiratory failure with hypoxia (not enough oxygen), dependence on supplemental oxygen, morbid obesity and obstructive sleep apnea. The 10/24/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. She required maximum assistance with toileting hygiene, bathing, upper body dressing, personal hygiene, sitting to lying, lying to sitting, sitting to standing, chair to bed transfers and toilet transfers. She was dependent on staff for lower body dressing, putting on/off footwear and rolling left to right. The assessment indicated the resident received oxygen. -The assessment did not indicate the resident used a CPAP or a BiPAP. B. Observations On 12/2/24 at 9:19 a.m. Resident #54's BiPAP mask was on the resident's night stand on top of the BiPAP machine. The BiPAP mask was attached to the tubing and placed on top of the night stand laying across the BiPAP machine. On 12/3/24 at 9:05 a.m. Resident #54's BiPAP mask was lying on the floor under the head of the bed. The BiPAP mask was attached to the tubing. On 12/4/24 at 11:23 a.m. Resident #54's BiPAP mask was on the resident's night stand on top of the BiPAP machine. The BiPAP mask and the tubing were bunched up on top of the BiPAP machine on the night stand. On 12/5/24 at 9:18 a.m. Resident #54's BiPAP mask was on the resident's night stand on top of the BiPAP machine. The BiPAP mask and the tubing were bunched up on top of the BiPAP machine on the night stand. -During all of the above observations, Resident #54's BiPAP mask was not covered by a plastic bag or enclosed in a storage case, which was identified by the facility as the process for CPAP/BiPAP storage (see facility policy above). C. Resident interview Resident #54 was interviewed on 12/5/24 at 2:45 p.m. Resident #54 said her BiPAP mask and machine had not been cleaned since she was admitted to the facility (1/31/24). She said the mask should be cleaned daily. She said she asked the facility staff to provide an instruction book for the BiPAP so she could properly care for the machine. She said the mask and tubing were stored over her machine on the night stand next to the bed. D. Record review Review of Resident #54's December 2024 CPO revealed the following physician's orders: Assist the resident with placement of BiPAP via nose mask nightly at bed time and as needed for naps, ordered 2/8/24. CPAP machine daily care: remove mask from head gear. Clean the mask with soapy water or with CPAP wipe. Clean the humidifier chamber with warm soapy water. Rinse the humidifier chamber using sterile or distilled water one time a day for CPAP maintenance, ordered 8/1/24. -The physician's order indicated Resident #54 had a CPAP, however, the resident had a BiPAP machine. The BIPAP care plan, revised 2/8/24, revealed Resident #54 required the BiPAP for effective symptom management of obstructive sleep apnea and chronic hypoxemic respiratory failure. Interventions included assisting the resident with the mask placement to ensure an appropriate seal. -The care plan failed to include cleaning and storage of the BiPAP. IV. Resident # 25 A. Resident status Resident #25, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the December 2024 CPO, diagnoses included chronic obstructive pulmonary disease, dependence on supplemental oxygen and vascular dementia. The 10/10/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. She required maximum assistance with lower body dressing and putting on/off footwear. She required moderate assistance with upper body dressing, toileting hygiene and personal hygiene. The assessment indicated the resident received oxygen. B. Observations On 12/2/24 at 9:53 a.m. Resident #25's nebulizer was sitting on top of the night stand with what appeared to be drops of medication still in it. The nebulizer cup and mouthpiece had not been rinsed and stored appropriately after the resident received her nebulizer treatment. On 12/3/24 at 9:03 a.m. Resident #25's nebulizer was sitting on top of the night stand with what appeared to be drops of medication still in it. The nebulizer cup and mouthpiece had not been rinsed and stored appropriately after the resident received her nebulizer treatment. C. Resident interview Resident #25 was interviewed on 12/5/24 at 9:26 a.m. She said she received the nebulizer treatment three times a day. She said when the treatment was completed, staff sometimes put the nebulizer cup and mouthpiece in a bag, but she said usually the nurse just placed it on her night stand. She said she had never seen the nurses rinse it out after use. D. Record review Review of Resident #25's December 2024 CPO revealed the following physician's orders: Albuterol sulfate nebulization solution 2.5 milligrams (mg)/3 ml (milliliters). Inhale orally via nebulizer three times a day related to chronic obstructive pulmonary disease, ordered 6/13/24. Nebulizer mask cleaning: Place in warm, soapy water and soak/agitate for five minutes. Rinse with warm water and allow it to air dry between uses. Store it in a clean bag, ordered 6/13/24. The altered respiratory status care plan, revised 11/27/24 revealed Resident #25 had difficulty breathing related to chronic obstructive pulmonary disease and other long term drug therapy. The interventions included administering medication as ordered and monitoring for changes in orientation, increased restlessness, anxiety and air hunger (breathlessness). V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 12/5/24 at 9:21 a.m. CNA #1 said the facility had a respiratory therapist (RT) who was responsible for changing the oxygen tubing and the nurse was responsible for cleaning and storing the nebulizer, the CPAP and the BiPAP equipment. Licensed practical nurse (LPN) #2 was interviewed on 12/5/24 at 10:32 a.m. LPN #2 said the nurse was responsible for cleaning and storing the nebulizer, CPAP and BiPAP after each use. She said the nebulizer cup should be rinsed with water after each treatment and changed every three days and stored in a bag. She said medication should not be left in the nebulizer cup. She said the CPAP and BiPAP mask should be cleaned with soap and water and stored in a bag between uses to prevent infections. She said the mask should not be stored on the floor. The infection preventionist (IP) and the DON were interviewed together on 12/5/24 at 12:02 p.m. The IP said she had just started in the position a month prior to the survey (November 2024). The DON said with each and every nebulizer treatment, there was a physician's order for the cleaning and storing of the equipment. She said the nurses should be following the physician's orders. She said every resident using a CPAP/BiPAP had a physician's order in place for the cleaning and storage of the equipment. She said the mask should be cleaned after every use and stored in a bag to prevent any aspiration of foreign particles into the lungs and infections. She said the mask should not be stored on the floor.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of four units. Specifically, the facility failed to: -Ensure housekeepers followed appropriate infection control processes when cleaning resident rooms; and, -Ensure high touch areas in resident rooms were disinfected. Findings include: I. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 11/12/24 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 11/12/24 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. II. Facility policy and procedure The Routine Cleaning and Disinfection policy and procedure, undated, was received from the director of nursing (DON) on 12/5/24 at 1:36 p.m. It revealed in pertinent part It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge. Cleaning considerations include, but are not limited to, the following: -Dry cleaning procedures will be conducted before wet procedures; -Clean from areas that are visibly clean and least likely to be contaminated to areas usually visibly dirty; -Clean from top to bottom (bring dirt from high levels down to floor levels); and, -Clean from back to front areas. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to toilet flush handles, bed rails, tray tables, call buttons, TV (television) remotes, telephones, toilet seats, monitor control panels, touch screens and cables, resident chairs, IV poles, blood pressure cuffs, sinks and faucets, light switches and door knobs and levers. III. Observations On 12/3/24 at 8:45 a.m. housekeeper (HSK) #1 was cleaning resident room [ROOM NUMBER], a double occupancy room. HSK #1 put on gloves collected Oxivir (disinfectant spray) from her cleaning cart and sprayed the sink and counter top. HSK #1 then entered the shared resident bathroom and sprayed the toilet riser, the toilet seat and the grab bars. She returned to her cart, collected [NAME] Bay toilet cleaner and put it on the floor around the toilet pedestal. -HSK#1 failed to sanitize her hands prior to putting on gloves and beginning to clean the resident room. HSK #1 did not put toilet bowl cleaner into the toilet bowl. HSK #1 returned to the cleaning cart, collected the Oxivir disinfectant spray again and sprayed the resident's dresser handles, bedside table and night stand on side B of the room. -HSK #1 failed to disinfect the resident's call light. HSK #1 returned to her cart, collected a bucket with a toilet scrub brush and proceeded to place the bucket on the bedside table of the resident on side B of the room, returned to her cart and changed her gloves. -HSK #1 placed the dirty toilet bowl bucket on the resident bed side table and failed to perform hand hygiene between glove changes. HSK #1 returned to the toilet brush bucket, entered the bathroom and dunked the toilet brush into the toilet bowl water. HSK #1 proceeded to scrub the toilet bowl. After scrubbing the toilet bowl, HSK #1 scrubbed the toilet rim and then the toilet seat with the scrub brush. HSK #1 dunked the toilet bowl brush into the toilet a second time and scrubbed the seat of the toilet riser. -HSK #1 failed to use disinfectant to clean the toilet. -HSK #1 failed to clean the toilet from the cleanest area to the dirtiest area. HSK #1 returned to her cleaning cart, collected a wet mop pad from the bucket on her cleaning cart, then mopped the bathroom. -HSK #1 failed to change her gloves after cleaning the toilet and prior to putting her soiled gloves into the mop bucket to collect the mop pad. HSK #1 collected a second mop pad and placed it on the floor on side B of the room. She collected trash from both residents' trashcans and removed it from the room. -After dumping the trash, HSK #1 changed her gloves but failed to perform hand hygiene. HSK #1 sprayed Oxivir disinfectant spray on the resident's TV and trash can on side B, wiping them with a dry rag. HSK #1 proceeded to side A of the room and sprayed disinfectant spray on the resident's dresser, bedside table and trash can and dried the items with the same rag she had used on side B of the room. -HSK #1 failed to use separate rags to clean the two sides of the room. HSK #1 returned to side B of the room, mopped the floor and retrieved a new mop pad from the bucket on her cleaning cart and mopped the floor on side A to the door. -HSK #1 failed to clean/disinfect high touch areas in the room such as the call lights, door knobs and TV remotes. HSK #1 failed to perform hand hygiene when changing gloves. HSK #1 mopped both sides of the room with mop pads from the bucket she contaminated when reaching in with soiled gloves from cleaning the toilet. At 9:44 a.m. HSK #1 completed cleaning room [ROOM NUMBER], removed her gloves and placed a wet floor sign in the entry way of the room. At 9:49 a.m. HSK #1 moved her cart to begin cleaning room [ROOM NUMBER]. HSK #1 put on new gloves and entered room [ROOM NUMBER], a double occupancy room. -HSK #1 failed to perform hand hygiene after removing gloves and between cleaning the residents' rooms. HSK #1 collected Oxivir disinfectant spray from her cleaning cart, entered room [ROOM NUMBER] and sprayed the sink and counter top. After spraying the sink, HSK #1 entered the bathroom, moved a pile of briefs, wipes and multiple bottles of barrier creams from on top of the toilet. HSK #1 dropped a tube of barrier cream into the toilet. HSK #1 reached into the toilet with her gloved hands, retrieved the tube of barrier cream, sprayed it with Oxivir disinfectant spray and placed the tube into the sink. -HSK #1 failed to dispose of the tube of barrier cream after it fell into the toilet. After retrieving the tube of barrier cream from the toilet bowl, HSK #1 sprayed Oxivir disinfectant spray on the resident's bedside table on side A. She then sprayed the resident's bedside table on side B of the room and returned to the bathroom. -HSK #1 failed to change her gloves and perform hand hygiene after reaching into the toilet bowl to retrieve the barrier cream. HSK #1 collected trash from the bathroom, removed her gloves and carried the trash bag across the hall to the soiled utility room. HSK #1 then put on new gloves and returned to the room. -HSK #1 did not perform hand hygiene before putting on the new pair of gloves. After returning to the room, HSK #1 went back and forth between side A and side B side of the room, spraying Oxivir disinfectant spray and wiping surfaces on both sides of the room with the same cloth. -HSK #1 failed to clean all of one side of the room before moving to the other side of the double occupancy room and used the same cloth to wipe the disinfectant spray on both sides of the room. HSK #1 returned to her cart, collected [NAME] Bay toilet cleaner and put it on the floor around the pedestal of the toilet. -HSK #1 failed to apply toilet bowl cleaner to the toilet bowl. HSK #1 returned to her cleaning cart, changed her gloves, collected a dry rag and returned to the sink. HSK #1 wiped the skin bowl, then the rim and then the counter top with the same rag. -HSK #1 failed to perform hand hygiene between glove changes. -HSK #1 failed to clean the sink from the cleanest area to the dirtiest area. HSK #1 collected the toilet bowl brush from her cart and scrubbed the toilet bowl. She proceeded to spray Oxivir disinfectant spray on the toilet handles, the toilet rim, the toilet tank lid and the outside of the toilet to the floor. She returned to her cleaning cart, collected a new dry rag and wiped the toilet from top to bottom. -HSK #1 failed to change her gloves and perform hand hygiene after scrubbing the toilet. HSK #1 returned to her cleaning cart to collect a new dry cloth and a mop pad from the mop bucket with her soiled gloves. She placed the mop pad in the bathroom then went to side B of the room and sprayed Oxivir disinfectant spray on the TV, dresser handles, head/footboards of the bed and the resident's personal picture frames. -HSK #1 sprayed side B of the room with the same soiled gloves she cleaned the toilet with. After cleaning side B of the room, HSK#1 changed her gloves and sprayed side A of the room with Oxivir disinfectant spray. -HSK #1 failed to perform hand hygiene in between glove changes. -HSK #1 failed to clean the high touch areas in room [ROOM NUMBER] such as call lights, light switches, bathroom door handles and TV remotes. IV. Staff interviews HSK #1 was interviewed on 12/3/24 at 10:31 a.m. HSK #1 said she needed to change her gloves after cleaning the bathroom or before moving to a different area in the residents' rooms to prevent contamination. HSK #1 said she needed to sanitize her hands when she exited a room and when she finished cleaning it. HSK #1 said she did not need to change her gloves or perform hand hygiene when she was cleaning the same room. HSK #1 said high touch areas in the residents' rooms were call lights, light switches, handles, grab bars and bedside tables. HSK #1 said she did not clean those items daily unless they looked soiled. HSK #1 said the Oxivir disinfectant she sprayed on the toilet was enough to clean the toilet bowl with and that another cleaner was not necessary to effectively clean the toilet bowl. HSK #1 said she should clean one side of the room, then the other side and then the bathroom last to prevent the spread of infection. HSK #1 said she did not realize she was going back and forth between side A and side B of the room. HSK #1 said she was unaware she did not change her gloves or perform hand hygiene after cleaning the toilet and before she started cleaning the living space of the residents' rooms. HSK #1 said the way she cleaned room [ROOM NUMBER] and room [ROOM NUMBER] was not effective for preventing infections. HSK #1 said she felt the barrier cream tube was clean enough because she sprayed Oxivir disinfectant on it after it fell into the toilet. The housekeeping and laundry manager (HLM) was interviewed on 12/5/24 at 9:57 a.m. The HLM said she trained all housekeepers on hire on the chemicals to be used for what and their dwell times. The HLM said housekeepers were taught to clean from the cleanest areas to the dirtiest areas in residents' rooms. The HLM said housekeepers should clean residents' rooms in the following order: side B, then side A and the bathroom last to prevent the spread of infection. The HLM said the toilet scrub brush should only be used on the inside of the toilet bowl to prevent infection, as the bowl was considered dirtier than other areas of the toilet. The HLM said housekeepers should change their gloves when moving from side B to side A in residents' rooms and after cleaning the bathroom. The HLM said housekeepers should perform hand hygiene when changing gloves and on completion of cleaning a room, prior to starting cleaning a new room, in order to prevent the spread of infection. The HLM said high touch surface areas in residents' rooms were call lights, bed controls, light switches, bedside tables and door handles. The HLM said high touch areas should be cleaned daily to prevent the spread of infection. The HLM said she did daily audits of her housekeeping staff and watched them clean a room. She said she would do on the spot education if she observed something not being cleaned appropriately. The HLM said she did not have any documentation of her audits or documentation of the on the spot education she had provided to her housekeeping staff. The HLM said she would provide immediate education to HSK #1. The infection preventionist (IP) was interviewed on 12/5/24 at 11:15 a.m. The IP said she worked with the housekeeping department frequently to ensure they were following all precautions. The IP said she liked to know what cleaners or disinfectants were being used to ensure the housekeeping staff were using them correctly. The IP said high touch areas in residents' rooms were call lights, door knobs, hand rails, TV remote controls, phones, toilet handles, bedside tables and light switches. The IP said high touch areas should be cleaned daily with Oxivir disinfectant spray to help prevent the spread of infection. The IP said housekeepers should follow room appropriate cleaning procedures and clean from top to bottom and from cleanest areas to dirtiest areas. The IP said all staff should perform hand hygiene between glove changes. The IP said the housekeepers should change gloves after cleaning the toilet and when they changed the chemicals they were using to clean. The IP said housekeepers should perform hand hygiene after cleaning a resident's room and prior to starting cleaning another resident's room in order to prevent the spread of infection.

Based on observations, record review and interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors. Specifically, the facility failed to post the total number of actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift. Findings include: I. Failure to have staffing hours posted Observations in the facility on 12/2/24 at 8:00 a.m. revealed there were no staff postings including hours worked posted in the facility Observations in the facility on 12/3/24 at 12:40 p.m. revealed there were no staff postings including hours worked posted in the facility. Observations in the facility on 12/4/24 at 4:40 p.m. revealed there were no staff posting including hours worked posted in the facility. II. Staff interviews The regional clinical coordinator (RCC) was interviewed on 12/4/24 at 4:43 p.m The RCC said the facility did not have the staffing posted. The director of nursing (DON) was interviewed on 12/4/24 at 4:45 p.m The DON said she had not seen daily staffing with hours posted in the facility since she had started working there about six months ago. The nursing home administrator (NHA) was interviewed on 12/4/24 at 4:46 p.m The DON said he had not seen daily postings with the amount of hours worked posted in the facility. The NHA said he was unsure whose responsibility it was to ensure the daily hours worked were posted.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure: -Hair restraints were worn by staff in the main kitchen while preparing, handling, cooking and serving food for the residents: and, -Ensure fluorescent ceiling lights above areas where food was prepared, cooked, and served were covered by light shades. Findings include: I. Professional reference According to the Colorado Retail Food Establishment Rules and Regulations (2024)) retrieved from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view on 4/18/24, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair,that are designed and worn to effectively to keep their hair from contacting exposed food; clean equipment, utensils, and linens. Lights bulbs shall be shielded, coated, or otherwise shatter-resistant, in areas where there is exposed food; clean equipment, utensils, and linens. II. Facility policy and procedure The Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions policy, revised January 2024, was provided by the regional corporate consultant (RCC) #2 on 4/17/24 at 1:54 p.m. It read in pertinent part, Staff always wear proper clothing, and foot wear, uniforms, and hair restraints on. III. Hair nets A. Observations On 4/16/24 at 9:45 a.m. the dietary manager (DSM), dietary cook (DC) #1 and DC #3 were not wearing hair restraints in the kitchen while handling, preparing, or serving food. On 4/16/24 at 12:00 p.m. the nursing home administrator (NHA), the environmental service director (ESD), and RCC #1 were standing at the entry door to the kitchen. The NHA, ESD, and RCC #1 said they could not go into the kitchen because there were no hair nets available to wear. On 4/16/24 at 12:05 p.m. the DSM, DC #1, DC #2 and DC #4 were not wearing hair restraints as they prepared, cooked and served food for the residents. B. Staff interviews The DSM was interviewed on 4/16/24 at approximately 9:45 a.m. The DSM said he did not know where the box of hair nets was for staff to utilize when entering the kitchen. He said he ordered the hair nets but he could not remember when he placed the order. He said the box of hair nets might not have been delivered or was stolen. The DSM said he was not aware the kitchen staff did not have hair nets on when handling food or that the staff did not have hair restraints to use. He said he did not purchase additional hair restraints from the store when he realized the box he had ordered was missing. He said staff should know to wear hair nets when they were in the kitchen. He said he did not know if hair nets could be reworn since there were no new hair nets available to be used. He said he did not know how long it had been since the kitchen staff had hair restraints to use while preparing and cooking food. The DSM said he did not wear a hair restraint because his hair was short. He said he did not know he needed to wear a hair net when he was the cook. He said if staff did not properly wear hair restraints the resident's food could potentially become contaminated. He said he knew there was a regulation the staff were to wear hair restraints when they handled the food in the kitchen. RCC #1 was interviewed on 4/16/24 at 12:00 p.m. RCC #1 said she would go to the supply store and get hair nets immediately. She said the supply store was close to the facility. She said the DSM should have gone to get a box of hair restraints when the kitchen ran out of the supply. At 12:15 p.m. RCC #1 returned with a supply of hair restraints for the kitchen staff. DC#1 and DC #3 were interviewed together on 4/16/24 at 12:05 p.m. DC #1 and DC #3 said they knew they should be wearing hair restraints when they were in the kitchen handling, preparing and serving food. They said there were no hair nets available to wear so they did not wear one. They said they did not remember when there were hair nets available to wear in the kitchen. DC #4 was interviewed on 4/16/24 at 12:10 p.m. DC #4 said she did not have a hair restraint on because there were no hair nets available for her to use. She said she knew she should have worn a hair net while preparing food. DC #3 was interviewed again on 4/17/24 at 11:45 a.m. DC #3 said he had a hair net on today. He said the kitchen staff were provided education on wearing hair nets while in the kitchen on 4/16/24. IV. Kitchen lights A. Observations On 4/16/24 at approximately 9:40 a.m. three of four light fixtures which held fluorescent lights on the ceiling were observed in the main kitchen. Each light fixture held two long light bulbs (each bulb was four feet in length), which totaled six fluorescent lights. The three light fixtures above food preparation areas did not have protective light shades over them (see ESD interviews below). B. Staff interviews The DSM was interviewed on 4/16/24 at 9:45 a.m. The DSM said he did not know why there were no shades over the lights in the kitchen where the food was prepared, cooked and served. He said it was not his job to make sure there were covers over the lights. He said he could not remember if he told the ESD to order covers for the lights. He said if a light were to break, the glass could go in the resident's food as well as onto the dietary staff. He said light covers were for safety and should be installed in the kitchen. RCC #2 was interviewed on 4/17/24 at 9:30 a.m. RCC #2 said the light bulbs in the kitchen above the food stations were fluorescent bulbs. She said yesterday afternoon (4/16/24) the fluorescent bulbs were replaced with LED lights and shades for the lights were ordered. The ESD was interviewed on 4/17/24 at 2:30 p.m. He said yesterday he replaced the fluorescent light bulbs in the kitchen where the food was prepared with LED lights. He said he ordered more LED (light-emitting diode) lights as well as shades for the light fixtures. He said he knew certain types of light bulbs could break and then the resident's food would be contaminated. He said he knew it was a regulation to have shades on the lights but the lights were without shades.

Based on observations, record review and interviews, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure hallway ceiling light fixtures on hallways 200 and 500, and Resident #4's room were free from bugs. Findings include: I. Professional reference According to the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, updated July 2019, pp. 94-95, retrieved on 4/22/24 from https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (able to transmit infectious diseases). Arthropods recovered from health-care facilities have been shown to carry a wide variety of pathogenic microorganisms. From a public health and hygiene perspective, arthropod and vertebrate pests should be eradicated from all indoor environments, including health-care facilities. Modern approaches to institutional pest management usually focus on: eliminating food sources, indoor habitats, and other conditions that attract pests; excluding pests from the indoor environments and applying pesticides as needed. A pest-control specialist with appropriate credentials can provide a regular insect-control program that is tailored to the needs of the facility and uses approved chemicals and/or physical methods. Industrial hygienists can provide information on possible adverse reactions of patients and staff to pesticides and suggest alternative methods for pest control, as needed. II. Facility policy and procedure The Pest Control policy revised May 2008, was provided by the regional corporate consultant (RCC) #3 on 4/17/24 at 10:19 a.m. It revealed in pertinent part, Our facility shall maintain an effective pest control program. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Maintenance services assist, when appropriate and necessary, in providing pest control services. III. Observations On 4/16/24 at 9:45 a.m. the following was observed: -On the 200 hallway, two of five hallway ceiling light fixtures had bugs visible inside the protective light covers (see interviews below). -On the 500 hallway, four of nine hallway ceiling light fixtures had bugs visible inside the protective light covers. On 4/16/24 at 1:00 p.m. on the 500 hallway, Resident #4's window ledge had approximately 20 dead bugs on it. The window track inside his closed window sill had approximately 20 alive and dead bugs. IV. Staff and resident interviews The environmental service director (ESD) was interviewed on 4/16/24 at 9:45 a.m. The ESD took off the covers over the light fixtures on the 200 hallway. He said the bugs were maybe flying ants and mosquitos but he was not sure exactly what type of bugs were in the light covers. He said it was difficult to count the exact amount of bugs but maybe there were 60-100 small bugs in the light fixture covers. He said he was never told there were bugs in the light fixtures. He said he had not noticed the bugs in the lights. He said bugs in the light fixtures were not his job to handle. The nursing home administrator (NHA) was interviewed on 4/16/24 at 9:50 a.m. The NHA said it was the job of the floor technician (FT) to keep the light fixtures cleaned. The FT was interviewed on 4/16/24 at 10:00 a.m. The FT said part of his job was to clean the ceiling light fixtures. He said he noticed bugs in the ceiling light covers on the 200 and 500 hallway. He said he told the assistant environmental service director (AESD) about the problem last Wednesday. (see AESD interview below) The NHA was interviewed again on 4/16/24 at 10:03 a.m. The NHA said the bug problem in Resident #4's room was brought to her attention in the morning meeting today on 4/16/24 around 9:15 a.m. She said she did not know why the ESD did not know about the bug problems on the 200 and 500 hallway. She said the ESD had worked in the position for about one year and he could not know everything there was to know about his job in that amount of time. The AESD was interviewed on 4/16/24 at 12:30 p.m over the phone. He said the FT had told him about the bugs in the light covers the week before. The AESD said he told the ESD about the problem with the bugs in the lights. He said a few weeks prior to telling the ESD about the bugs in the lights, a company came to the facility to spray for bugs. He said the environmental company met with him and the ESD. He said the company said they were going to order bug traps for the facility and that was the last he heard about the traps. He said he did not know what happened with the order for bug traps but no traps ever came in to handle the ongoing bug problem. Resident #3 was interviewed on 4/16/24 at 12:15 p.m. Resident #3 said she was the resident council president and she tried to speak for the residents in the facility as needed. She said she lived on the 500 hallway and there was an ongoing bug problem in the ceiling lights. She said she had told facility staff many times about the bugs but the problem was never fixed. Certified nurse aide (CNA) #1 was interviewed on 4/16/24 at 12:50 p.m. She said she observed bugs in the ceiling lights on several occasions. She said Resident #4 had concerns about the bugs yesterday (4/15/24) in his care conference meeting. She said the bugs were on his window ledge today (4/16/24). Resident #4 was interviewed on 4/16/24 at 1:00 p.m. Resident #4 said his room had an ongoing bug problem. He said he told the staff about the bugs at his care conference yesterday (4/15/24). He said the social services staff said it would be addressed but it had not gotten any better. He said he thought the bugs on his window sill and ledge were flying ants. He said he kept a fly swatter by his bed in case any bugs landed on him. He said he told the assistant social worker (SSA) and two of his relatives who were at the care conference about the bugs. He said the SSA and his family members saw all of the bugs in his room during the care conference. Resident #4's family member was interviewed on 4/16/24 at 1:05 p.m. She said she was not at the care conference yesterday. She said she saw all of the bugs in his room today (4/16/24). She said she hoped the facility would fix the problem. RCC #1 was interviewed on 4/16/24 at 1:30 p.m. She said housekeeping went into Resident #4's room within the last half hour and cleaned his window area from the bugs but did not get them all. She said all of the bugs would be removed immediately. The social service director (SSD) and the NHA were interviewed together on 4/16/24 at 2:36 p.m. The SSD said the SSA did not tell her about the bug problem. She said this morning (4/16/24)she went through the papers (stacked on the SSA's desk) and found a grievance form about the bug problem in Resident #4's room. She said she brought the grievance form to the morning meeting today at approximately 9:15 a.m. She said she discussed it with the facility management team. She said she did not know why the bug problem for Resident #4 was not handled as soon as it was brought to the attention of the SSA. She said she did not know why the problem had not been resolved yet as it had been discussed in the morning meeting The NHA said nothing had been done to fix the bug problem yet because the problem was just brought to her attention today (4/16/24) around 9:30 a.m She said she did not know why the resident still had bugs in his room four hours after it was brought to the facility managements attention. The SSA was interviewed on 4/16/24 at 2:57 p.m. over the phone. She said she attended the care conference with Resident #4 on 4/15/24. She said the conference took place in Resident #4's room. She said two of his family members were in attendance. She said Resident #4 complained about the flying ants and he showed everyone the bugs. She said Resident #4 kept a fly swatter by his bed so that he could kill the bugs. She said she told the SSD about the situation shortly after the care conference on 4/16/24. She said the SSD told her to write down on a white piece of paper what had happened in the care conference and the bug problem would get handled the following morning on 4/16/24. She said she did her job to report the situation about the bugs before she went home on 4/15/24. RCC #1 was interviewed on 4/16/24 at 3:05 p.m. RCC #1 said she immediately implemented education to all facility staff that if they saw any bugs at any time it was to be reported to the NHA immediately. RCC #1 said she had a team of staff members immediately walk around the building both inside and outside to investigate the building for any pest control needs. She said she told the team of staff members to look for any areas where bugs could come in, holes or gaps in the walls or windows. The ESD was interviewed on 4/16/24 at 3:45 p.m. The ESD said he and the AESD had a meeting with a bug extermination company about a month ago. He said the company said they were going to order bug traps for the facility. He said the company did not order the bug traps for the facility. He said he did not know why the bug traps were not ordered. He said he did not follow up with the situation to investigate when the bug traps would arrive at the facility. The NHA was interviewed again on 4/17/24 at 1:44 p.m. The NHA said she requested the company that owned the facility to provide her with a new bug extermination company that she could rely on. She said the company who owned the facility agreed to her request and that by tomorrow (4/18/24) they would hire a new company for her. She said the bug problem would get resolved immediately.

Based on observations, resident and staff interviews the facility failed to provide a comfortable and homelike environment for the residents of the facility for three out of four units. Specifically the facility failed to ensure: -Residents were provided with washcloths and hand towels; and -Room walls, furniture were properly maintained. Findings include: I. Lack of walls and furniture properly maintained A. Observations 7/9/23 at 10:30 a.m. -room [ROOM NUMBER] the window blinds were bent both forward and backward and were not effective in keeping light out of the room when closed. -room [ROOM NUMBER] the wall behind the resident ' s headboard had deep scratches and gouges approximately 12 inches long by one inch wide from the bed being lifted and lowered. -room [ROOM NUMBER] the bathroom door got stuck and was difficult to open. -room [ROOM NUMBER] the top two dresser drawers were missing. 7/11/23 at 12:15 p.m. -room [ROOM NUMBER] the dresser drawers were not aligned and falling out. 7/12/23 at approximately 10:00 a.m. -room [ROOM NUMBER] the towel bar was broken near the sink. -room [ROOM NUMBER] had scuffs on the wall near the bed. -room [ROOM NUMBER] had a plastic bag covering a hole in the ceiling. -room [ROOM NUMBER] the heat register was unattached from the wall. -room [ROOM NUMBER] the dresser in the room was missing two drawers out of four. -room [ROOM NUMBER] the dresser drawers were not aligned and falling out. -room [ROOM NUMBER] the dresser drawers were not aligned and falling out. -room [ROOM NUMBER] the dresser drawers were not aligned and falling out. -room [ROOM NUMBER] the decorative shelf hanging on the wall was not attached securely. -room [ROOM NUMBER] the towel bar was broken which was near the sink. B. Interviews The regional maintenance director (RMTD) was interviewed on 7/13/23 at 11:37 a.m. The above detailed observations were reviewed. The RMTD said any work requests should be completed on the TELS computer system or on the 24 hour report. He said the facility had one maintenance director. He said he would conduct an audit of the areas which needed to be repaired. The clinical nurse consultant was interviewed on 7/13/23 at approximately 12:00 p.m. She said the building was going to order some new dressers to replace the broken ones. II. Lack of washcloths and hand towels in resident rooms A. Observations 7/10/23 at 1:58 p.m. -room [ROOM NUMBER] had no towels. 7/11/23 at 1:47 p.m. room [ROOM NUMBER] still had no towels. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had one bar that only had one wash cloth on it and it was a shared room. room [ROOM NUMBER] had one wash cloth on the bar and it was a shared room. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had one bar with one hand towel for a shared room. room [ROOM NUMBER] had no towels. 7/12/23 at 10:00 a.m. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -Room#527 had no towels. 7/12/23 at 11:36 a.m. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. 7/12/23 at 10:00 a.m. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER]had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -Room#527 had no towels. B. Resident interviews The resident group interview was conducted on 7/11/23 at 1:00 p.m. The group consisted of four residents (#14, #19, #25 and #28) who were interviewable based on assessment and facility. The residents said the following in regards to not having towels in the rooms: -Towels were not delivered to rooms unless they asked for them. -The facility runs out of towels, so they have purchased their own towels. Resident #67 was interviewed on 7/12/23 at approximately 10:15 a.m. The resident said she did not have towels at her sink. She said she used paper towels to wash her face and to dry her hands. She said she would like to have linen towels. C. Interviews The assistant director of nurses (ADON) was interviewed on 7/12/23 at 2:00 p.m. The ADON confirmed select rooms randomly selected from the above observation revealed there were no towels in the rooms. She said there were towels available in the linen closets. She said there were plenty of towels and residents could request towels. She said the night shift certified nurse aides should pass towels to the resident rooms.

Based on observations, record review and interviews, the facility failed to provide necessary services consistent with professional standards of practice in accordance with a resident's inability to carry out activities of daily living (ADLs) for three (#68, #47 and #20) out of seven residents reviewed for ADLs of 43 sample residents. Specifically, the facility failed to provide supervision, encouragement, cueing and assistance during meals to Resident #68, Resident #47 and Resident #20. Findings include: I. Resident #68 A. Resident status Resident #68, age 78, was admitted on [DATE]. According to July 2023 computerized physician's orders (CPO), diagnoses included dementia, chronic kidney disease, depression and nutritional deficiency. The 4/25/23 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired and unable to complete a brief interview for a mental status (BIMS). She required extensive assistance of one person with one-person assistance with bed mobility, personal hygiene, dressing and toilet use. She required oversight, encouragement and cueing with eating. B. Observations On 7/9/23 at 11:57 a.m. Resident #68 was observed walking around the dining room. Lunch was served at 12:04 p.m. Staff did not direct her to her food nor did they set a plate down for her. The resident continued to walk through the hallways until 12:35 p.m. The resident continued to walk through the hallway. On 7/11/23 at 11:12 a.m. Resident #68 was observed walking around wandering through the hallway holding her tummy and crying. One unknown staff member walked by her but did not stop to check on the resident. At 12:01p.m. Resident #68 was observed walking around the dining room. The resident sat down before the meal was served where she cried and put her hands on her face. The resident got up and continued to walk through the dining room and hallway. Lunch was served at 12:04 p.m. Staff never directed her to her food nor did they set a plate down for her. She was not offered food by 12:20 p.m. C. Record review The nutritional care plan, reviewed on 2/6/23, documented the resident was at risk for nutritional deficiencies. The documented interventions were to monitor and report signs of dysphagia (swallowing difficulty), choking, coughing, drooling, holding food in their mouth, refusing to eat and appearing concerned during meals. The activities of daily living (ADL) care plan, reviewed on 9/6/22, documented the resident's interventions including the resident was independent with eating set up as needed. -However, according to the MDS assessment, she required oversight, encouragement and cueing with meals. D. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 7/13/23 at 9:10 a.m. CNA #4 said the resident ate finger foods. CNA #4 said the resident did not like staff to physically help her eat. CNA #4 said the staff helped her sit down and encouraged her to eat. CNA #4 said they would leave her food so she could come and get her food and walk with it since she has difficulty sitting down. Licensed practical nurse (LPN) #3 was interviewed on 7/13/23 at 10:35 a.m. LPN #3 said Resident #68 ate finger foods. LPN#3 said they should leave the residents food out on a table and encourage her to eat. LPN #3 said the resident was at nutritional risk. The director of nursing (DON) was interviewed on 7/13/23 at 2:32 p.m. The DON said Resident #68 wandered a lot and had difficulty sitting down during lunch. The DON said staff should put out her food and encourage the resident to eat. The DON said the resident often threw her food away. The DON said the staff gave her a Boost throughout the day. II. Resident #47 A. Resident status Resident #47, [AGE] years old, was admitted on [DATE]. According to July 2023 CPO, diagnoses included major dementia, psychotic disturbance, anxiety and chronic kidney disease. The 4/5/23 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of two out of 15. She required extensive assistance of two people with bed mobility, transfers and toileting. She required extensive assistance from one person with personal hygiene, dressing and eating. B. Observations On 7/9/23 at 11:38 a.m. the resident was in the dining room eating lunch. She had one eight ounce cups filled half way full of liquid. The cup was far away from her and she was unable to reach it and no staff offered to help her with eating or drinking. On 7/10/23 at 11:45 a.m. until 12:30 p.m. the resident was in the dining room. There was not a drink in front of her and the staff did not offer to help her or offer her a drink. C. Record review The activity of daily living care plan, revision on 1/27/23, documented the resident had activity of daily living decline. The resident may need assistance with eating at times. D. Staff interview CNA #4 was interviewed on 7/13/23 at 9:18 a.m. CNA #4 said Resident #47 required assistance while eating and drinking. CNA #4 said the staff should help her at meal times. III. Resident #20 A. Resident status Resident #20, [AGE] years old, was admitted on [DATE]. According to July 2023 CPO, diagnoses included major depressive disorder, legal blindness, acute kidney failure and dementia. The 6/8/23 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of five out of 15. She required extensive assistance of one person with bed mobility, transfers, personal hygiene, dressing and supervision with walking. The resident needed supervision which included oversight, encouragement and cueing with setup of one-person assistance with eating. B. Observations On 7/9/23 at 11:50 a.m. until 12:38 p.m. the resident was in the dining room. The resident had a drink but it was too far for her to reach. The resident was barely able to put food to her mouth and no staff offered to help her. On 7/11/23 at 11:04 a.m. until 12:57 p.m. the resident was in the dining room and the water was out of reach from the resident. Staff did not assist her at the meal. C. Staff interviews CNA #4 was interviewed on 7/13/23 at 9:18 a.m. CNA #4 said Resident #20 was blind but could eat and drink on her own. CNA #4 said the staff help the residents if they see that they need assistance. CNA #4 said the staff should put the residents' drinks and meals close enough for the resident to reach. The nursing home administrator (NHA) was interviewed on 7/13/23 at 9:54 a.m. The NHA said staff should assist residents with eating and drinking if needed.

Based on interviews, observations and record review the facility failed to ensure that each resident received food that was palatable, attractive and an appetizing temperature. Specifically, the facility failed to: -Ensure food was palatable and attractive when delivered to residents; and, -Ensure food was served at a safe and appetizing temperature. Findings include: I. Facility policy and procedure The Meal Preparation policy and procedure, revised 2021, was delivered by the nursing home administrator (NHA) on 7/12/23 at 11:15 a.m. It read in pertinent part: each resident receives and the facility provides food prepared by methods that conserve nutritive value, flavor, and appearance; food that is palatable, attractive, and at the proper temperature. Food is served at palatable temperatures, above 125 degrees for hot food and below 50 degrees for cold food. II. Resident interviews Resident #28 was interviewed on 7/9/23 at 10:52 a.m. The resident said the eggs were often over cooked. Resident #15 was interviewed on 7/9/23 at 10:55 a.m. The resident said his daughter brought in his dinners and he kept them in the refrigerator because he did not like the food at the facility. Resident #14 was interviewed on 7/9/23 at 11:11 a.m. The resident said the dining room had been closed for reconstruction since 5/23/23. She said she had been eating in her room since. She said the food was served cold. She said her breakfast meal was served cold, as she did not receive her meal timely. Resident #88 was interviewed 7/9/23 at 11:30 a.m. The resident said the food was served cold, there was a lack of seasoning and flavor to the food. He said the meat was tough and difficult to cut with a knife. He said they provide the menu for choices but then he did not receive what he had requested. He said he complained about the food but did not receive any answer to the cold food. Resident #61 was interviewed on 7/10/23 at 9:28 a.m. The resident said he ate in his room and the food was served cold. He said it had no flavor and it was straight out of the can. He said he was not eating his eggs as they were cold. Resident #27 was interviewed on 7/10/23 at 9:45 a.m. The resident said she loved cauliflower and broccoli but it was mushy and served cold. She said she had to put salt and pepper on it to get flavor. She said in general the food was not good and was served cold. Resident #9 was interviewed on 7/10/23 at 10:10 a.m. The resident said the food was served cold, the meat was tough and there was a lack of seasoning. She said she did not like the food. Resident #91 was interviewed on 7/10/23 at 11:22 a.m. The resident said her meals were served cold. She said oftentimes the staff did not send condiments. She said the hamburger she received the other day was burnt and served with no condiments. Resident #13 was interviewed on 7/11/23 at 9:41 a.m. The resident said she had milk and cookies last night for dinner. She said she did not want what the facility served. Resident #4 was interviewed on 7/11/23 at 9:52 a.m. The resident said the facility served small portion sizes. She said she could have had more food. III. Resident council interview The resident council was interviewed on 7/11/23 at 1:10 p.m. four residents (#28, #25, #19 and #14) attended and participated in a resident council meeting. The majority of the residents said the food was delivered cold and had no flavor. Resident #28 said they had noodles that were so cold the resident could not melt her soft butter on it. Resident #25 said food was delivered cold when it was supposed to be hot. The resident said they kept the salads under the light so the lettuce was limp and warm. Resident #19 and Resident #14 said the food did not taste good and the items that were to be hot were served cold. IV. Test tray A test tray of the breakfast meal was performed on 7/13/23. The tray left the kitchen at 8:13 a.m. and was delivered to the unit and was served after the last resident was served at 8:49 a.m. The meal test tray for palatability was tried by four surveyors: -The scrambled eggs were 88 degrees F (farenheit); the eggs were cold, bland and had no palatable taste. They did not have a palatable texture. -The biscuit was 87 degrees F; the biscuit was cold, bland and did not have a palatable taste. The biscuit was covered with white gravy that had soaked into the bottom which made it soggy and slimy. -The sausage links were 86 degrees F and were cold and bland. The sausage tasted undercooked. -The oatmeal was 122 degrees F and was slimy, cold and tasteless. No condiment such as sugar was offered. V. Observations During continuous kitchen observation on 7/12/23 from 7:04 a.m. to 8:13 a.m. the delivery carts were not big enough for all the trays going out to units. Some carts had trays on top and the dietary director (DD) had to carry some items by hand to the units. On 7/12/23 at 8:53 a.m. Resident #11 was sitting in the doorway of her room. She motioned to the assistant director of nursing (ADON) in an upset manner that she had not received her meal. The ADON told the resident that it was coming. The resident left to go smoke a cigarette. At 9:00 a.m., the resident returned and her meal was on her bed. The resident uncovered the meal and found scrambled eggs and sausage. The resident gave permission to have the temperature of the food taken. The eggs were 84 degrees F and the sausage was 92 degrees F. The resident said the eggs were cold. Certified nurse aide (CNA) #2 walked into the room and was asked by the resident to heat the food up. VI. Record review A complaint form dated 4/9/23 at 6:30 p.m. documented the food is not good, two pieces of turkey lunch meat on bread is not dinner. The food is the same everyday. Eggs - biscuit and bread lunch meat is dry and old. Salads are dry and has some slime on it. Coffee needs creamer of choice, old potato chips - stale, same choice daily! Food committee meeting minutes dated 6/2/23 at 3:00 p.m. recorded the meals were not being served on regular plates but on paper plates and it was cold. Food committee meeting minutes dated 6/9/23 at 3:00 p.m. recorded the meals were not being served on regular plates. Food committee meeting minutes dated 7/11/23 at 10:30 a.m. recorded residents suggested training for the chefs on how to cook eggs, pancakes, chicken quesadillas and low sodium soups. VII. Staff interviews Dietary aide (DA) #1 was interviewed on 7/12/23 at 9:08 a.m She said she was setting aside the broken plate warmers. She said the facility did not have enough warming bases for every plate. DA #1 said the dietary director (DD) had ordered the warming bases but they did not have them yet so they did not have enough. She said there were 106-108 residents at the facility and they did not have enough. The DD was interviewed on 7/13/23 at 9:40 a.m. The DD said she had received a test tray that morning and did not get condiments with it that were requested. The DD said the facility had used paper plates and did not have condiments with meals. The DD said the facility had to use plastic silverware and there was not enough regular silverware for every resident tray. The DD said the plate heater had been unplugged on 7/12/23 and the plates were cold. The DD said the evening cook had been a cook for two weeks, he had been a dietary aide prior to obtaining the position and his only experience was cooking at home. 20287

Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption. Specifically, the facility failed to have a thermometer and monitor temperatures for Resident #28, #15, #9, #38, #37 and #19's personal refrigerators. Findings include: I. Facility policy and procedure The Food from Outside Sources policy, dated 5/3/23, was delivered by the nursing home administrator (NHA) on 7/10/23 at 2:01 p.m. It read in pertinent part, to allow access to foods not provided by the facility and to assure foods are safe to prevent foodborne illness and to add quality to residents' life. If food is not consumed upon arrival, it may be stored in a suitable container and labeled with date, residents name and item description if needed. Resident's food stored under refrigeration shall have name, date, and expiration date of the label. Perishable food is discarded within three days from any resident refrigerator sources unless the food item is safe until a printed expiration date. II. Observation Personal resident refrigerators for Resident #28, #15, #9, #38, #37 and #19 were observed on 7/12/23. None of the personal refrigerators had thermometers to monitor the temperatures. Resident #28 was interviewed on 7/12/23 at 10:05 a.m. The resident said the refrigerator did not have a thermometer and the resident did not know who monitored the temperature. At 10:23 a.m. a refreshment refrigerator was observed with resident food stored in it. The temperature log was incomplete with missing temperatures. The refrigerator had an opened undated bottle of apple juice, creamer and other items that were not provided by the dietary department. III. Staff interviews The regional registered dietitian (RRD) was interviewed on 7/12/23 at 9:51 a.m. The RRD said the personal refrigerators should have a thermometer to monitor the temperatures and daily temperature logs.

Based upon an observation and interviews, the facility failed to provide a safe and sanitary environment consistent with professional standards of practice to help prevent the development and transmission of communicable disease and infections. Specifically, the facility failed to: -Ensure standard hand hygiene precautions and donning and doffing gloves were followed by staff involved in direct resident incontinent care and contact; -Clean high touch items, call button and door knobs, in resident rooms; and, -Follow the recommended surface disinfectant time for cleaning solution. Findings include: I. Lack of proper hand washing A. Facility policy and procedure The Handwashing/Hand Hygiene policy, revised August 2009, was provided by the nursing home administrator on 7/12/23 at 11:30 am. It read in pertinent part, The facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is the last step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Single use disposable gloves should be used before aseptic procedures and when anticipating contact with blood or body fluids. B. Observation On 7/11/23 at 12:47 p.m. certified nurse aide (CNA) #2 entered Reisdent #66's room and did not perform hand hygiene prior to resident contact. The CNA donned gloves and moved to the resident's bedside. The CNA proceeded to turn the resident to the right side.The resident was incontinent of both stool and urine. The CNA obtained wipes from the resident's bathroom. The CNA opened the wipes and provided peri-care.The CNA obtained the barrier cream from atop the resident's dresser drawers and removed the barrier cream cap. The CNA applied the barrier cream to the resident's peri-area, replaced the barrier cream cap and placed a new undergarment on the resident without changing his gloves during the entire process. The CNA did not perform hand hygiene before leaving the resident's room. C. Interviews CNA #2 was interviewed on 7/11/23 at 12:59 pm. CNA #2 said he washed his hands before entering the resident's room. CNA #2 said he did not realize he did not change his gloves after performing incontinent care. CNA #2 said his gloves did not appear soiled and believed the wipes sanitized his gloves. The director of nurses (DON) was interviewed on 7/11/23 at 3:40 p.m. The DON said the CNAs had been educated on proper handwashing. He said they educated staff on infection control, hand washing and personal protective equipment (PPE) on hire and annually. The DON said the CNA should have removed gloves after contact with bodily fluids, including stool and urine. The DON said the CNA should have changed gloves after performing peri-care and applying barrier cream. The DON said he would provide education to the CNA. 47024 II. Housekeeping failures A. Professional reference The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 7/21/23 read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs Proceed From Cleaner To Dirtier Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: -During terminal cleaning, clean low-touch surfaces before high-touch surfaces. -Clean patient areas (patient zones) before patient toilets. -Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone. -Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Manufacturer recommendations The disinfectant in the facility was identified as: Spic and Span with a five minute dHwell time. C. Observation and interview During continuous observation on 7/13/23 between 11:37 a.m. and 12:03 p.m. housekeeper (HSK) #1 failed to spray the door knobs and call buttons in the room. The HSK sprayed the bedside tables, night stands, refrigerator, television stand, bedside fan and dressers and immediately wiped them off without waiting for the five minute surface disinfectant time. HSK #1 said the cleaning spray had a three to five second surface disinfectant time. During continuous observation of a deep clean of a room from 1:09 p.m. to 1:39 p.m. it was HSK #2 and HSK #3 failed to follow the manufacturer's recommended five minute surface disinfectant time while cleaning. The housekeeping director (HD) joined at 1:11 p.m. HSK #3 cleaned the metal bed frame with a surface disinfectant time of two minutes. The HD cleaned the bedside commode with a surface disinfectant time of one minute. The HD failed to apply cleaning spray directly to the call button, she sprayed a cloth to wipe the button. She failed to clean the pull cord to the overhead light. The HD cleaned the recliner and pillow allowing a two minute surface disinfectant time. HSK #3 said the cleaning spray had a 20 minute surface disinfectant time. The HD was interviewed on 7/13/23 at 1:42 p.m. She said the cleaning spray that was currently in use had a five minute surface disinfectant time and housekeeping staff were trained on the cleaning process and surface disinfectant times when they started. She said tops of furniture were the high touch areas and should be cleaned first. She said call buttons and door knobs were high touch areas and should be disinfected to prevent infections.

Based on observations, record review, and resident and staff interviews, the facility failed to provide one (#91) of two residents reviewed for dignity, out of 43 sample residents, care in a dignified, respectful and individualized manner. Specifically, on 7/11/23, Resident #91 said she did not receive her dinner meal, and the cook disagreed and refused to prepare a meal for her. Resident #91 said this made her feel unimportant and that she did not matter. Findings include: I. Facility policy and Procedure The Dignity policy, last revised in February 2021 was received on 7/12/23 from the nursing home administrator. The policy read in pertinent part, Each resident should be cared for in a manner that promotes and enhances his or her sense of wellbeing, level of satisfaction with life, and feelings of self-worth and self-esteem. II. Resident #91 Resident #91, age 69, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included a history of falling, diabetes mellitus, kidney failure, and neuropathy. The 4/12/23 minimum data set (MDS) assessment coded the resident with no cognitive impairments with a score of 15 out of 15 for the brief interview for mental status. The resident required supervision or oversight for activities of daily living. III. Resident interview Resident #91 was interviewed on 7/11/23 at 3:59 p.m. The resident said she was upset because she did not get a dinner meal last night. She said the dinner carts were not delivered until 6:55 p.m. to the floor. She said she waited for her meal, however, it did not arrive. She said at 7:30 p.m., she inquired about her meal. The certified nurse aide (CNA) told her she did not get a meal. The receptionist, who was in the nearby area, went to the kitchen. The resident said she followed the receptionist and there was no one in the kitchen. After the fourth call out to the kitchen, the dietary aide came in, followed by the cook, and said she and the cook were on break. The cook told the resident that she had received a meal. The resident told the cook no, she had not received it. The cook stated he would get her a meal. At 8:30 p.m., about an hour later, the resident said she went back to the dining room area. At that time, the cook said the kitchen was closed; the dishes had been washed. The resident said she never received her meal and went to bed hungry. She said she woke up hungry, too. She said the whole situation made her cry, and she was angry. She said she felt unimportant and that she did not matter. IV. Staff interview The receptionist was interviewed on 7/11/23 at 4:49 p.m. The receptionist said she was present when Resident #91 came out to the circle common area, visibly upset, and stating she had not received a dinner meal. The receptionist said she spoke with the resident's assigned certified nurse aide (CNA) who confirmed the resident had not received a meal tray. The CNA offered the resident a snack until the kitchen could prepare a meal. The receptionist said she went into the kitchen and hollered for the cook, but there was no response. She said on the fourth call-out, the kitchen staff answered back that they were on break. She said the cook told the resident that she had received soup, but the resident denied it. The cook then said he would get the resident something to eat. The receptionist said she then left the kitchen area as she thought the issue was resolved. The receptionist said she felt bad for the resident who was so upset and was crying, both when she met the resident in the common area and while talking with the cook She said the resident told her this morning that she never received her meal and at 8:30 p.m., she went back to the kitchen and she was told that the dishes needed to be done and the kitchen was closed. The receptionist said she would not have left the resident if she had known the situation was not resolved. V. Record review The concern form dated 7/10/23 documented that the resident was very upset that she did not receive dinner, the CNA had confirmed that was correct (the resident had not received dinner) and no one was in the kitchen when she and the receptionist went to the kitchen. The resident spoke to the cook to notify him about the situation and said he was going to help the resident get a meal. However, see above; she never received one. The follow-up action dated 7/12/23 documented, discussed with staff being in the kitchen, honoring request. VI. Additional interviews The regional registered dietitian (RRD) was interviewed on 7/13/23 at 9:00 a.m. The RRD said the dietary manager had instituted some changes in meal service. She said the meals were being served to the residents in their rooms because the kitchen was being remodeled. She said the kitchen staff was available to get a resident a meal if it was missed. She also spoke with the new dietary manager in regard to the events that occurred on 7/11/23.

Based on record review and interviews, the facility failed to maintain the highest practical well being for one (#4) of seven sample residents. Specifically the facility failed to follow or clarify physician's order [REDACTED]. Subsequently the resident had to have both of his eyes surgically removed. I. Facility Policy On 3/25/15 at 3:35 p.m., the policy entitled " Medication Compounding " was received and reviewed. The policy read: " The (name of the contracting pharmacy) does not compound medications, this is done per a contracted pharmacy Allow 5 business days for compounded medication Attention Nurses!!! If you have a new order for medication and it needs to be compounded, notify the provider and obtain order for a T.O. to read as follows: Start ______________ (name of medication) when arrives from pharmacy OR Check with provider to see if an alternative medication can be ordered, or if another medication can be used until compounded medication arrives from pharmacy. " There was no evidence the facility contacted the ophthalmologist to see if an alternative medication could have been ordered, or if another medication could have been used until compounded medication arrived from the pharmacy (see record review below). A. Resident Status Sample resident #4, [AGE] years old, was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] indicated the resident scored a ten in the Brief Interview for Mental Status (BIMS) indicating the resident had moderate impairment in the daily decision making skills. The MDS revealed the resident did not wear glasses, although his vision was defined as moderately impaired, meaning he had limited vision, not able to see newspaper headlines but could indentify objects. The MDS indicated the resident had no behaviors, was occasionally incontinent of bladder, always continent of bowel. The resident needed extensive assistance of a staff member for bed mobility, transferring, and with toilet use. He used a walker or wheelchair for mobility. The MDS dated [DATE] (before the resident was admitted to the hospital in 1/15), revealed the resident scored 15 on his BIMS which indicated intact cognition, had moderately impaired vision, no behaviors, was always continent of bowel and bladder, and needed limited assistance of a staff member with bed mobility, transferring and extensive assistance of a staff member with toileting and personal hygiene. B. Family Interview On 3/23/15 at 10:43 a.m. a family member of the resident was interviewed. The family member stated the facility failed to follow and give the physician ordered medications including the eye antibiotics. The resident continued with eye problems until both eyes had to be removed because of the infection. The family member stated that one time a facility nurse called her in October (2014) sometime to apologize that she had not given the eye drops ordered for the resident ' s [MEDICAL CONDITION]. The family member went on to say that after the removal of the eyes, the resident was returned to the facility because s/he had expected the resident to stay in the hospital for a while, giving her time to find a new facility. S/he went on to say that even after the surgery of his removal of the eyes due to infection, the resident returned to his surgeon one week later with another infection ([MEDICAL CONDITION] of the eye sockets and face.) The family member stated the first night after surgery, the resident had scratched under his dressing with his bare hands because of itching. The nurse on duty had informed the family member that his bloody sheets had to be removed and there was blood all over the bed, even on a blue comforter the family member had purchased for the resident. The family member stated the blue comforter mysteriously disappeared after that day. The family member stated the resident often complained of itching in the surgery site and even the facility physician ordered [MEDICATION NAME] for the itching. S/he stated the facility tried to cancel the one week follow up appointment, but s/he insisted the resident keep it because the family member was waiting at the surgeon ' s office. When he returned to the surgeon with red puffy eye lids and a red swollen face, the surgeon was more upset that the facility had not sent the resident to the emergency room after the resident had removed the dressings the first day post-op (after surgery). C. Care Plan The care plan initiated on 4/6/13 and updated on 1/8/15, indicated the resident was at risk for changes with vision and increased risk of falls due to moderately impaired vision related to the [DIAGNOSES REDACTED]. The care plan read the resident appears to identify, follow objects, faces, looks at staff when being spoken to and is able to self navigate in his electric scooter. The goals included the resident will move around the room, eat and meet dressing and toileting needs with assistance from staff as needed, requested thru the next review, to have concerns, changes with vision identified, treated promptly thru the next review, and will have no injury related to the impaired vision thru the next review. Some of the interventions included: --Staff to notify the physician, the family as needed with changes or concerns noted with his vision, --Nursing to monitor and observe signs and symptoms with vision to include complaints of pain, dizziness and administer eye drops as per the physician's order [REDACTED]. --vision exams as ordered, and --adequate lighting and keep needed items within reach. The resident was care planned on 12/26/14 regarding the resident expressing some sadness and frustration over ongoing eye problems with diminished eyesight that causes him to rely more on staff for assistance. D. Record Review On 5/29/14, a physician ' s telephone order (TO) was written to follow-up with (named hospital) to see when the resident ' s next eye appointment was scheduled and may change a.m. artificial tears and [MEDICATION NAME] drops to 6 a.m. administration as resident wishes. On 6/6/14, the resident had an eye appointment at the eye specialty eye clinic and the physician orders [REDACTED]. The physician at the eye clinic documented the resident had severe eye dryness in both eyes and that his eyes were not completely closing with blink or at the right time. The physician documented to continue Dorzolomide 2% two times a day both eyes, [MEDICATION NAME] Z at bedtime both eyes, Artificial Tears four times a day both eyes and Gel at bedtime both eyes. According to the current 6/14 physician's order [REDACTED]. -Artificial Tear Solution one drop both eyes three to four times a day (5/14/14) (no [DIAGNOSES REDACTED]. -[MEDICATION NAME] Severe 0.3% Instill into both eyes at bedtime (4/14/14)(no [DIAGNOSES REDACTED]. -[MEDICATION NAME] Z Solution 0.004% Instill one drop into both eyes every day at bedtime (12/23/12) for [MEDICAL CONDITION], -DorZolam/Tim 2%/0.5% ([MEDICATION NAME]) one drop right eye twice a day (8/12/13) for [MEDICAL CONDITION], and - [MEDICATION NAME] 0.2%, Instill two drops into both eyes twice a day (8/12/13) for [MEDICAL CONDITION]. On 6/20/14, the resident saw the eye lid specialist (at the eye specialty clinic) and the specialist documented the resident as having [DIAGNOSES REDACTED] (drooping of the upper eyelid), FES (Floppy Eyelid Syndrome), lagaphthalmus (inability to close eyelids completely), [MEDICAL CONDITION] (complicated disease in which damage to the optic nerve leads to progressive, irreversible vision loss), and ulcerative blepharitis ( severe condition that may be characterized by matted, hard crusts around the eyelashes, which, when removed, leave small sores that may bleed or ooze). New medications were ordered and included: - [MEDICATION NAME] Gel twice a day both eyes for three weeks then every day both eyes times three weeks, and -[MEDICATION NAME] drops twice a day both eyes for three weeks and then every day both eyes times three weeks. " Wait three to five minutes between each drop. " The resident was to follow-up with the ophthalmologist in two weeks. There was evidence that the resident returned for follow-up in two weeks as ordered. On 6/23/14 the resident was seen by the facility ' s optometrist. The optometrist documented the resident had an increased [MEDICAL CONDITION] response both eyes. The optometrist documented [MEDICATION NAME] was not in the formulary and the resident had not been receiving the medication as ordered. The optometrist ordered Pred Forte 1% one drop both eyes four times a day for two weeks than twice a day and monitor one month. For the ulcerative blepharitis to continue the current [MEDICATION NAME] one drop both eyes twice a day and monitor for one month. The progress note included to continue [MEDICATION NAME] Z one drop both eyes at bedtime, [MEDICATION NAME] one drop right eye twice a day and [MEDICATION NAME] 0.2% one drop both eyes twice a day. On 7/30/14 the resident ' s primary physician documented the resident was being followed by an ophthalmologist for [MEDICAL CONDITION], iritis (inflammation affecting the iris of the eye) and ulcerative blepharitis. The physician documented the resident denied eye pain but continued to complain of poor vision. The optometrist documented the resident should be monitored for a month with the new medications and the eye inflammation. The resident ' s medical record indicated the resident was not able to be seen for a follow up appointment on 8/6/14 due to: " The resident was not able to be seen for the following reason -time constraints. " On 8/20/14, the resident was seen at the eye specialty clinic and the Pred Forte was discontinued. The [MEDICATION NAME] gel both eyes twice a day was again ordered (originally ordered on [DATE] and discontinued on 6/23/15 due to the unavailability). The [MEDICATION NAME], and the [MEDICATION NAME] eye medications were to be continued. The clinic recommend continued use of the [MEDICATION NAME] 1% both eyes twice a day (based on record above the resident had not received the medication since 7/10/14).The resident was to return in a month. On 9/25/14, the resident was seen at the hospital eye clinic and was diagnosed as having Blepharitis both eyes, pre-septal [MEDICAL CONDITION] (a common infection of the eyelid and periorbital soft tissues that is characterized by acute eyelid [DIAGNOSES REDACTED] and [MEDICAL CONDITION]) in the right eye and [MEDICAL CONDITION]. The physician orders [REDACTED].¼ inch ribbon twice a day both eyes to upper and lower lids for two weeks and warm compresses daily to both eyes. The resident was to follow-up in seven to ten days. The telephone order written on 9/25/14 and clarified on 9/25/14 documented [MEDICATION NAME] ointment ¼ inch ribbon twice a day both eyes to upper and lower lids for two weeks On 9/28/14 a12:33 p.m., a nurse documented the resident ' s eyes had some drainage, but no redness. On 10/1 /14 at 12:46 a.m., a nurse documented the resident was antibiotics for bilateral eye infection and the " R (right) eye remains swollen and reddish. " On 10/9/14 at 10:38 a.m., a nurse documented the resident was noted to " have swelling and [MEDICAL CONDITION] to the rt (right) eye, sclera reddened, resident complains of pain, redness noted to surrounding skin " and the primary physician was notified. On 10/9/14, a physician order [REDACTED]. If no improvement by 12 noon on 10/10/14, then the physician was to be called and the resident was to be sent to the emergency room department. On 10/10/14, the resident returned to the eye specialty clinic, and was diagnosed with [REDACTED]. A handwritten note on the consultation form read the resident had, " increased eyelid swelling 10/9/14 and was started on Keflex and [MEDICATION NAME] eye drops. The note also read the resident had increased pain in his eyes. The Keflex and the [MEDICATION NAME] eye drops were discontinued. The [MEDICATION NAME] gel and the [MEDICATION NAME] ointments were discontinued. (Hot) warm compresses six times a day for two weeks were ordered in addition to [MEDICATION NAME] ointment 1/2 inch to both upper and lower eyelids twice a day for two weeks then every day for one week. All pressure lowering drops were to be continued as was the [MEDICATION NAME] for the ordered 10 days and the resident was to follow-up in two weeks. On 10/10/14, a telephone order from the physician assistant documented to use [MEDICATION NAME] Solution drops instead of the [MEDICATION NAME] ointment. The order was to administer one drop to the right eye twice a day for one week and then daily for a week for the [DIAGNOSES REDACTED]. On 10/11/14, a telephone order from the physician assistant documented to discontinue the [MEDICATION NAME] and start [MEDICATION NAME] 1% one drop to right eye twice a day for a week and then daily for a week. On 10/14/14, the primary care physician visited the resident for eye swelling. The physician documented, " staff reported increased right eye swelling, [DIAGNOSES REDACTED], pain on 10/10, patient started on antibiotics, he was seen the next day by ophthalmologist, progress note from appointment reviewed. Today staff reports decrease in eye [MEDICAL CONDITION] and redness, resident still c/o right eye [MEDICAL CONDITION], discomfort and unable to open the eye, he needs to use his finger to lift upper eyelid. He denies fever, chills. " The physician also documented the resident was on [MEDICATION NAME] ointment to upper and lower lids twice a day for a week and was on warm compresses 6 times a day for two weeks. (However, see below, according to the 10/14 MAR, the [MEDICATION NAME] eye drops or [MEDICATION NAME] ointment were never started) On 10/15/14, a physician ' s clarification order was written to discontinue the [MEDICATION NAME]. [MEDICATION NAME] ointment to both upper and lower eye lids twice a day for a week was ordered. (See order written on 10/11/14 to discontinue the [MEDICATION NAME] and start [MEDICATION NAME] eye drops.) On 10/15/14, a physician telephone order was written to discontinue the [MEDICATION NAME] ointment due to insurance. On 10/18/14 the resident continues to have swelling in his right eye and complained of pain in his right eye documented by a nurse at 2:57 p.m. On 10/23/14, the resident went back to the hospital eye clinic and all previous eye drops were discontinued. New orders included [MEDICATION NAME] eye drops, one drop twice a day both eyes; [MEDICATION NAME] eye drops, two drops to both eyes twice daily; [MEDICATION NAME] eye drops, one drop to both eyes at bedtime, and [MEDICATION NAME] 0.6% ophthalmic suspension and to instill one drop into both eyes three times a day. On 11/6/14 the NP saw the resident and documented " will have to call eye MD to find out the date of f/u (follow-up). " The NP again visited the resident on 11/27/14 and documented the resident has " ongoing eye issues that he is being followed by 2 eye specialist for. Was seen last month, will have to call office to see when next f/u is. He continues to require (require) asst (assistance) from staff for safe mobility, eating. . . . " There was no evidence the resident saw the ophthalmologist at the eye specialty clinic during the month of November. On 12/3/14 from approximately 8:30 a.m. to 10:30 a.m., the resident saw the eyelid specialist and an ophthalmologist at the eye specialty clinic. The notes from the clinic dated 12/3/14 documented the resident had ulcerative blepharitis and central corneal ulcer. The notes indicated the resident had " lid margin ulceration (infectious), lid laxity, with overriding margins, conjunctive ulceration with purulent discharge, and K peripheral ulceration with infiltrate. It was documented the " pt cannot see, discharge OU (both eyes) for 1 mo (month), no pain, but had pain in the past, pt takes Tylenol. " Oral [MEDICATION NAME], and fortified vanco and fortified [MEDICATION NAME] eye drops were ordered. The resident was to return in two weeks. A physician order [REDACTED]. On 12/4/14 the nurses ' electronic progress notes (at various times 1:57 a.m., 1:59 a.m., 4:25 a.m., and 5:48 a.m.), read the eye drop antibiotics had not arrived from the pharmacy yet. On 12/4/14 at 4:49 a.m., a nurse documented the resident was on monitoring for antibiotic therapy/eye infection and the " bilateral sclera remains red with discharge/sticky matter. " The nurse documented that both eyes were cleaned and the right eye was more swollen than the left eye. On 12/4/14 at 11:30 a.m., a registered nurse (RN) documented, Bilateral eyes reddened and swollen and painful to touch. " On 12/4/14 (no time) the primary care physician wrote an order that read, " May hold Vanco/[MEDICATION NAME] eye drops until available by pharmacy. " There was no evidence the ordering ophthalmologist was contacted to inform him the antibiotic eye drops were not available and/or what could be substituted until the ordered medications were available. On 12/5/14 at 4:51 a.m., a nurse documented the resident had moderate drainage noted to both eyes. There was no description of the type of drainage. On 12/5/14 at 12:10 a.m., a nurse documented the resident ' s eyes " remain reddened with drainage and painful to touch. " There was no description of the type or amount of drainage. On 12/6/14 at 4:06 a.m., a RN documented the resident had minimal drainage to both eyes. There was no description of the type of drainage. On 12/7/14 at 3 a.m. and on 12/8/14 at 9:40 a.m., two RNs documented the resident still had discharge from both eyes. The amount and description of the discharge were not documented. On 12/11/14 at 3:07 a.m., a RN documented, " Sticky matter and discharge from eyes continues. Decreased swelling noted. Denies pain. Will continue to monitor. 12/18/14 (noted at 10 a.m.), " May hold [MEDICATION NAME] and [MEDICATION NAME] eye drops until available. " On 12/17/14, the resident returned to the eye specialty clinic and saw the ophthalmologist. .The notes documented, " ...overall improved of lids. Continue medication as directed ... " The notes indicated to finish the oral [MEDICATION NAME], to continue the fortified vanco eye drops and the fortified [MEDICATION NAME] eye drops and to follow-up in two weeks. A " Report of Consultation " form (the form was the communication sheet between the facility and the eye clinic) had handwritten instructions by the ophthalmologist which read, " Continue medication fortified [MEDICATION NAME] q 3 h 1OU (every three hours, one drop both eyes), fortified [MEDICATION NAME] q3h 1OU, -alternate the two drops, continue with warm compresses TID (three times a day) x OU, continue lid scrubs/wash with saline TID x OU. " On 12/17/14 a physicians order was written to continue the [MEDICATION NAME] and [MEDICATION NAME] eye drops every three hours to both eyes for one week, to continue the bilateral lid washes with normal saline three times a day, to continue warm compresses to both eyes three times a day, and to follow-up on 1/7/14 at 9:20 a.m. There was no evidence the facility clarified the 12/17 ophthalmologist ' s order that read to " alternate the two drops. " The resident did not return to the eye specialty eye clinic on 1/7/15 as ordered; however, was seen on 1/12/15, five days after the recommended appointment and almost four weeks between appointments. On 1/12/15 the communication form was handwritten from the eye clinic to the facility, " Patient is to be referred to (name of hospital) for possible in hospital treatment ASAP. " Also documented on this form was the primary care physician had been notified. Notes from the eye specialist clinic indicated an ophthalmologist had been consulted during the visit and [MEDICATION NAME] 500 mg every day orally times two weeks, fortified [MEDICATION NAME] and fortified [MEDICATION NAME] eye drops were ordered to be given every hour, and the resident needed to be referred to the hospital for further assessment. On 1/12/15 at 5 p.m. a physicians order read to give [MEDICATION NAME] 500 mg one tablet orally daily for two weeks, fortified [MEDICATION NAME] 50/ml drops, one drop every hour both eyes times three weeks, fortified [MEDICATION NAME] 14 mg/ml, one drop every hour both eyes for three weeks. Refer to (name of hospital) for further evaluation of eyes and lids (in hospital treatment) for ulcerative blepharitis. Handwritten on the side of the order sheet was that two 250 mg of [MEDICATION NAME] had been taken from the E Kit. In addition, the primary care physician gave a verbal order on 1/13/15 at 7 p.m. that read, " May send resident to (name of hospital) ER in AM for further eval and tx (treatment) of lids and eye. On 1/14/15 (no time), the medical director gave a telephone order to clarify the order written by the primary care physician on 1/13/15 to refer the resident to the hospital for consideration of " in hospital treatment " . On 1/15/15 at 12:52 a.m., a Licensed Practical Nurse (LPN) documented when she was administering the first of the fortified eye drops, the resident thought the drops would be every two hours so he could get some sleep. The LPN documented, " Nurse will then be giving the eye drops every 2 hrs (hours). " On 1/15/15 the NP associated with the resident ' s primary care physician visited the resident for " eye issues " and documented, " Earlier this wk (week) res(ident) had orders to go to ER at (name of hospital) for possible in patient tx ' ment of ongoing eye infections. ER transfer did not go through and res doing in-house po [MEDICATION NAME] x 14d, fortified [MEDICATION NAME] and Vanco gtts (drops) x 3 wks and pharmacy will deliver when these arrive. Appears to be tolerating everything now. Will need to find out f/u appt time with (name of hospital) specialists ... " According to the consultation/communication form, the resident was referred back to the eye specialty clinic on 1/15, three days after the eye specialty clinic had sent a communication form to the facility (on 1/12/15) recommending "Patient is to be referred to (name of hospital) for possible in hospital treatment ASAP " (see above). On 1/15/15 the consultation form (communication sheet) documented the findings as, " Severe corneal ulceration and endophthalmitis both eyes. No light perception both eyes with perforation. Very poor prognosis, unlikely to salvage eyes and may need eviscerations. " Notes from the ophthalmologist dated 1/15/15, included these documentations: " corneal ulcer " , " First time - endophthalmitis " , " anatomy of eye is grossly abnormal with bilateral perforations " , " Purulent discharge " , " at appointment alone. " Orders included, start the fortified [MEDICATION NAME] drops and the fortified [MEDICATION NAME] eye drops every hour, [MEDICATION NAME] 400 mg. daily, and to return tomorrow for a B scan (an ultrasound of the eye used for diagnosing [MEDICAL CONDITION] of the posterior segment of the eyeball). The resident returned to the hospital clinic on 1/16/15 for the B scan. E. Medication Administration Record [REDACTED] Review of the 6/14 MAR indicated [REDACTED]. This was replaced by the 6/23/14 ordered Pre Forte1% which according to the MAR indicated [REDACTED]. This was a delay in the ordered treatment of [REDACTED]. Review of the 7/14 MAR indicated [REDACTED]. The medication was also not documented as given on 7/20/14 by the absence of any initials in the dated square. The MAR indicated [REDACTED]. In addition, the medication was to be given twice a day for three weeks and then once a day for three weeks. There was no evidence on the MAR indicated [REDACTED]. Pred Forte 1% was not documented as given by absence of initials in the dated squares on 7/11/14 at the scheduled a.m. and the midday administration time. Cross reference F281 (Professional Standards) Review of the 8/14 MAR indicated [REDACTED]. According to the back of the MAR, the [MEDICATION NAME] eye drops for [MEDICAL CONDITION] were not given twice a day on 8/16/14 because they were " unavailable from the pharmacy. " [MEDICATION NAME] 1% twice a day both eyes for blepharitis was restarted on 8/22, over a month after it had been stopped on 7/11/14 (without an order or clarification). Review of the 9/14 MAR indicated [REDACTED]. On the back of the MAR indicated [REDACTED]. " Documentation on the MAR indicated [REDACTED]. In addition, [MEDICATION NAME] was not given evidence by circled initials in the dated square for the a.m. dose on 9/25/14. The daily warm compresses were not started until two days later on 9/27/14 and then documented as completed twice a day instead of the ordered daily on 9/27, 9/28, 9/29 and on 9/30/14. [MEDICATION NAME] ophthalmic gel was documented as given daily in the p.m. instead of as ordered on [DATE] as to be given twice a day. Documentation showed evidence that it was given daily for five days (on 9/26, on 9/27, on 9/28, on 9/29, and on 9/30/14. Review of the 10/14 MAR indicated [REDACTED]. The [MEDICATION NAME] ointment ordered on [DATE] was not started due to insurance and Azasit 1% eye drops ordered on [DATE] was not started until the evening of 10/13/14. Review of the MAR indicated [REDACTED]. Review of the 11/14 MAR indicated [REDACTED]. In addition, a transcription error was discovered on 11/6/14 in regards to [MEDICATION NAME] Z eye solution 0.004%. It was documented as instill one drop into both eyes twice daily and given twice daily for five days (11/1 through 11/5). The 10/23/14 order read [MEDICATION NAME] Z eye solution 0.004% one drop at bedtime. Review of the 12/14 MAR indicated [REDACTED]. Despite the 12/3 physician order [REDACTED]. Evidenced by the absence of initials in the dated squares, the warm compresses to both eyes were not completed as ordered three times a day on 12/17, 12/23, 12/25, and on 12/29, all at 9 p.m. The bilateral lids wash with normal saline three times a day were not completed as ordered on the evening shift at 9 p.m. on 12/17, 12/23, 12/25, and on 12/29/14.Review of the 1/15 MAR indicated [REDACTED]. There was no evidence the facility contacted the eye specialist clinic for other medications to be substituted for the eye drops that were not available or for information on where these medications could be obtained till available by their pharmacy. Again, a telephone order was written on 1/13/15 by the primary care physician to hold the [MEDICATION NAME] and [MEDICATION NAME] eye drops until available from the pharmacy. Documentation of initials in the dated squares revealed the ordered fortified vanco and the [MEDICATION NAME] hourly eye drops were not given until midnight on 1/15/15 and then given every two hours from midnight until 6 a.m. (see LPN interview above). Documentation of initials in the dated squares revealed the fortified [MEDICATION NAME] and the fortified [MEDICATION NAME] eye drops were administered every hour from 7 a.m. until noon on 1/15/15 when the resident left for the hospital eye clinic, three days after the 1/12 order of referring the resident for in hospital treatment ASAP. The eye drops were resumed on 1/15 at 4 p.m. and given hourly as ordered until 10 p.m. when the nurse documented the resident refused the eye drops. Documentation by initials in the dated squares revealed the ordered hourly eye drops were given at midnight on 1/16, at 2 a.m., at 4 a.m., at 6 a.m., at 7 a.m., until the resident returned to the hospital at 8 a.m. Documentation of the code in the dated squares by the same LPN on duty the night of 1/15 (see documentation above) for 1/15 at 11 p.m., on 1/16 at 1 p.m., at 3 p.m., and at 5 p.m. was that the resident was sleeping. F. Post hospitalization Documentation On 1/16/15 at approximately 7:30 p.m. per nurse ' s note the resident returned to the facility. The nurse documented the resident had bilateral eye evisceration and dressings on both eyes. " New order received is being looked at by manager on duty. " Hospital discharge orders included Tylenol #3, 1-2 tablets by mouth every six hours as needed for pain,[MEDICATION NAME] mg one tablet two times a day and [MEDICATION NAME] ophthalmic ointment ([MEDICATION NAME]), place 0.25 inch strip over incision/in eye four times a day. Handwritten beside the order for the [MEDICATION NAME] was, " Start in a week when dressing. " Handwritten beside the order [MEDICATION NAME] " ASAP. " Handwritten on the discharge Instructions was the resident was to return for a follow-up appointment on 1/21/15 at 9:20 a.m. Included in the discharge instructions was to wash hands with soap and water before touching the incision or changing bandaged. On 1/16/15 at 11.50 p.m. a nurse documented the discharge medications were verified with the on call physician for the primary care physician. On 1/17/15 at 2:53 p.m., a LPN documented, " When the resident was assessed first thing this morning he was found with his bandages pulled up and dried blood on his face. The resident said he was rubbing his eyes. Some slight bleeding was noted from his eyes. It was explained to the resident that he is supposed to leave the bandages in place until the nurse changes them. It was also explained that rubbing under the dsg. (dressing) could cause infection. The resident was encourage to call the nurse if he had excessive itching or pain in his eyes and not to rub under the bandages. The daughter was in today and gave the resident a haircut. " On 1/17/15 (Saturday) at 3:17 p.m., a LPN documented, " The RN supervisor spoke with the on-call Dr. about the resident ' s orders The Dr. wants all eye medications held until 1/23/15. " There was no evidence the ophthalmologist was notified of the resident removing the dressings, of the bleeding from the eyes sockets, and the itching of the eyes sockets. On 1/17/15 (no time), a telephone order was received fro

Based on observations, record review, resident interview, and staff interviews, the facility failed to ensure that one (#72) of 30 sample residents maintained acceptable parameters of nutritional status. Specifically, -The facility failed to conduct and complete an initial nutritional assessment of resident #72 and then failed to timely complete a comprehensive re-assessment based on resident #72's current health status, preferences and needs to prevent additional weight loss and to help return to an ideal body weight after weight loss was identified in March 2014. -The facility failed to identify resident #72's food preferences, such as a dislike of the food served at breakfast, resulting in a delay in developing an eating plan designed to help resident #72 meet her caloric needs. Cross reference F364-Food Palatability Professional Reference: The risks of unintended weight loss are chronicled in the Mayo clinic article "Rational Approach to Patients with Unintentional Weight Loss." In pertinent part, the article available at: <http://medchiefs.bsd.uchicago.edu/documents/MayoClin.Proc.2001Bouras.pdf> states, " Clinically important weight loss can be defined as the loss of 10 lb (4.5 kg) or more than 5% of the usual body weight over a period of 6 to 12 months, especially when progressive. Weight loss greater than 10% is considered to represent protein-energy malnutrition, which is associated with impaired physiologic function such as impaired cell mediated and humoral immunity." The article also stated, "As a cumulative effect, low body weight and weight loss are powerful predictors of morbidity (e.g., wound healing, infectious complications, pressure sores, performance status), response to medical therapy, and mortality." Resident #72, age [AGE] years, was admitted to the facility on [DATE]. According to the Computerized physician's orders [REDACTED].#72's [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set ((MDS) dated [DATE] revealed: -Resident was cognitively intact with a Brief Interview Mental Status score of 15/15. -The resident did not demonstrate [MEDICAL CONDITIONS], rejection of care or wandering during the MDS observation period. -Resident required extensive assistance with bed mobility, transfers, walking in room, dressing, toilet use and personal hygiene. -Resident required supervision with eating and locomotion on and off the unit. -Resident had a height of 67 inches and weight of 112 pounds. -Resident did not have dental problems. -Resident was not on a physician directed weight loss program. -Resident was marked as having had a significant weight loss since the last review. Record Review: a. Weights: On 6/24/14 a review of resident #72's weights was completed. The weight review revealed: 1/3/14 - 131 2/3/14 - 135 3/3/14 - 112 (This weight represents a 19 pound weight loss in two months and a 14.5% weight decrease since admission. Further, this weight represents a 23 pound weight loss (17% of weight) in one month. 4/19/14 - 112 5/5/14 -115 5/24/14 - 108 5/25/14 - 111 This weight represents a 20 pound weight loss (15.2% loss of body weight) in less than six months since admission. This weight also represents a 25 pound weight loss in less than three months and an 18.5% weight loss in less than three months. 5/31/14 - 111 6/7/14 - 111 On 6/25/14 the clinical record was reviewed for the facility identification and response to resident #72's severe, unplanned weight loss. The review revealed: b. Physician and physician extender notes: -Physician and physician extender notes dated 1/3/14, 1/15/14, 1/22/14, and 2/13/14 all describe resident #72 was well developed, well nourished and without [MEDICAL CONDITION]. -The physician extender note dated 2/17/14 stated that resident #72 appeared alert, thin and unwell with no [MEDICAL CONDITION] to the lower extremities. Resident #72 was noted to have a moist cough, increased oxygen needs, and an elevated white blood cell count. A telephone order dated 2/17/14 showed resident #72 was started on [MEDICATION NAME] 500 mg tab for seven days. The resident was also started on a [MEDICATION NAME] ([MEDICATION NAME] 250 mg) for 14 days on 2/17/14. -Physician and physician extender notes dated 3/7/14 and 4/1/14 describe resident #72 as alert, thin and pleasant. No [MEDICAL CONDITION] was noted. These notes did not address resident #72's severe weight loss. -Physician extender notes on 5/5/14 stated, "Today on exam, we discussed her weight loss of about 20 pounds since February. She states that this is due to her [DIAGNOSES REDACTED] infection and the fact that she does not like the food. She states that she ate McDonald's for her birthday meal and she ate the whole meal." Resident #72 agreed to try Ensure as a supplement to help address the unplanned weight loss. Resident #72 was described as "thin." The note also showed that resident #72 no longer required [MEDICATION NAME] as her A1C was stable at 6.1 when the [MEDICATION NAME] was discontinued. -Physician extender notes on 6/2/14 stated, "She (resident #72) continues to lose weight and reports that she does not like food at the facility; last month she agreed to drink Ensure (not MedPass) for supplementation but has been refusing, eats 25-75% of meals." Resident #72 was described as alert, thin and pleasant. The note continued, "She states that she just doesn't like the food at the facility. Denies other constitutional complaints. Refuses MedPass and ensure. Weight loss is concerning and not expected given resident's age." The note went on to request a "chest CT without contrast" to rule out malignancy. c. Labs and Diagnostics -A 6/13/14 Chest CT found no malignancy in the lungs. -A 3/16/14 [MEDICAL CONDITION] stimulating hormone test showed that resident #72 was within normal limits with a result of 1.88 uiu/ml. (reference range 0.34-5.60 uiu/ml) -A 3/9/14 stool culture showed that resident #72 was positive for [DIAGNOSES REDACTED] toxin. -1/5/14 [MEDICATION NAME] level was 3.7 with a reference range of 3.5 to 5.7. -Labs assessing resident #72 [MEDICATION NAME] and/or pre-[MEDICATION NAME] levels after the significant unplanned weight loss were not located in the clinical record. d. Nutrition Notes/Assessments/Interventions -The initial nutrition assessment dated [DATE] showed that resident #72 was admitted with a weight of 131.4 pounds. The initial assessment was not completed as evidenced by blank for sections on usual body weight, current body weight, current body mass index (BMI), usual BMI. The 1/2/14 Food Preferences form showed that resident #72 consumed 3 meals daily, liked most foods, and had a good appetite with no chewing problems. The form did not identify any favorite foods that resident #72 liked to eat. The form showed that resident #72 denied recent weight gain or weight loss. -A 3/4/14 nutrition note documented that resident #72 had experienced a 17.03% unplanned weight loss in 30 days. The weight loss was attributed to a respiratory infection and poor oral intake. The facility's former registered dietician (RD) recommended adding a nutritional supplement of sugar free MedPass 120 ml three times daily between meals. The former RD did not reassess caloric, protein or fluid needs in light of the weight loss. -A 3/10/14 nutrition note from the facility's former RD stated that resident #72 was refusing the sugar free MedPass. The resident was noted to be receiving intravenous fluids. No new interventions to increase oral intake or calorie intake were documented. No reassessment of caloric, protein or fluid needs was present. -A 4/3/14 nutrition re-assessment completed by a different RD no longer employed by the facility showed that resident had significant weight loss. The RD did not document the resident's usual body weight, current or usual BMI, or new caloric needs in light of the weight loss. The RD noted that resident #72 refused the nutritional supplement; however there was no new approach to increase the oral intake for resident #72 identified in the assessment. -A 6/5/14 nutrition note by third former RD showed that resident #72 had severe unplanned weight loss. The notes stated that resident #72 had a current BMI of 17.4, which was underweight. The note showed that resident #72 did not like nutritional supplements. Resident #72 was encouraged to drink milk with meals. Resident #72 was also to receive a peanut butter and jelly sandwich as a bedtime snack. Resident #72 was not re-assessed for calorie needs, usual body weight or ideal body weight. Resident #72 was not assessed for favorite foods. The note did not identify that resident #72 regularly refused the breakfast meals offered by the facility. e. Meal Intakes -The January 2014 meal intake documentation had 24 instances of blank meal intakes. Resident #72 refused meals on four instances. Resident #72 ate 75-100% of most evening meals. -The February 2014 meal intake documentation had 15 instances of blank meal intakes. Resident #72 refused meals on ten instances. Resident #72 ate 25-50% of most evening meals. -The March 2014 meal intake documentation had 24 instances of blank meal intakes. Resident #72 refused meals on two instances. Resident #72 ate 25-50% of most evening meals. - The April 2014 meal intake documentation had zero instances of blank meal intakes. Resident #72 refused meals on six instances. Resident #72 ate 50-100% of most evening meals. Resident #72 refused or did not receive any evening snacks during the month. -The May 2014 meal intake documentation had one instance of blank meal intake documentation. Resident #72 had five instances of meal refusals. -A review of meal intakes from 6/1/14 through 6/27/14 showed that resident #72 consumed less than 50% of her meals 32 times including four meal refusals. f. Nurse's note -A review of available nurse's notes from 12/31/13 through 6/25/14 revealed one nurse's note on 6/3/14 indicating resident #72 experienced a significant weight loss. g. Medication Administration Record [REDACTED] -March 2014 MAR indicated [REDACTED]. Resident #72 refused the sugar free MedPass on all but five occasions. -April 2014 MAR indicated [REDACTED]. -The May 2014 MAR indicated [REDACTED]. The Ensure was discontinued on 5/14/14 due to resident refusals. h. Care Plan -A care plan dated 6/23/14 stated resident #72 had a nutritional problem related to significant weight loss with decreased appetite and underweight status. -The goal was that resident #72 will maintain adequate nutritional status as evidenced by maintaining or gaining weight to healthy BMI status as clinical possible, no signs or symptoms of malnutrition, and consuming at least 50% of meals daily through review date. -Approaches included provide diet as ordered; monitor intake and record each meal; provide alternates as needed; encourage good intakes for weight gain. Observations: On 6/25/14 at 10:02 a.m., resident #72 was observed in her room. She was wearing shorts and a tee shirt. She was very thin in appearance. On 6/27/14 at 8:57 a.m., resident #72 was weighed on the standing scale by Certified Nurse Aide (CNA) #2. The scale showed a weight of 109.4 pounds. Resident #72 observed the weight and then stated, "I keep losing weight because the food here is so lousy. I cannot eat it." The weight of 109 pounds represents an additional two pounds of weight loss from the most recent weight (see above). The weight of 109 pounds represents an unplanned weight loss of 26 pounds and 19.25% in less than six months. Resident Interview: On 6/23/14 at 2:34 p.m., resident #72 stated the food was not served at the proper temperature. Resident #72 stated that she consumed most meals in her room and that the food was "rarely hot." Additionally, resident #72 stated the food at the facility did not taste good. Resident #72 stated that there used to be a cook at the facility that made tasty meals, but that the new cook did not properly prepare food. On 6/25/14 at 10:02 a.m., an interview with resident #72 revealed: -Resident did not eat breakfast provided by the facility, except once a week on biscuit and gravy day. -Resident acknowledged she had weight loss during her stay at the facility. According to resident #72 she was not trying to lose weight and was not being assisted by the physician to lose weight. -Resident attributed her unplanned weight loss to an illness earlier in the year and the poor quality of food served by the facility. -Resident stated that before she had the weight loss, she usually weighed around 130 pounds. -Resident stated she did not like her current weight because she felt it was too low. -Resident stated she had tried to drink the nutritional supplement Ensure, but did not care for it and asked to stop receiving it. -Resident denied that the facility had tried alternate nutritional supplement approaches like a high calorie nutritional juice, a high calorie nutritional cookie, or a fortified food diet that added extra calories regular menu items in order to help her maintain and gain weight. -Resident stated she feared she has continued to lose weight and requested that she be weighed to see how much weight she had lost. On 6/26/14 at 3:50 p.m., resident #72 stated she did not eat breakfast and had consumed very little lunch that day because the lunch was "terrible." On 6/27/14 at 7:40 a.m., resident #72 stated she did not order breakfast for the morning. Resident #72 reminded that she only eats breakfast on biscuit and gravy day because she does not like any other breakfast items furnished by the facility. On 6/27/14 at approximately 2:15 p.m., resident #72 was interviewed about the lunch meal. Resident #72 stated she did not like the lunch meatloaf, potato and lima bean offering. Resident #72 re-stated the food at the facility was not edible. (See F364 for further resident interviews for food palatibility) Staff Interviews: On 6/27/14 at 8:31 a.m., Certified Nurse Aide (CNA) #1 was interviewed about resident #72's eating habits. CNA #1 stated that resident #72 usually refused to take a breakfast tray on most days. According to CNA #1, resident #72 had refused the breakfast tray on that morning. On 6/27/14 - 2:27 p.m., an interview was conducted with the Consulting Registered Dietician (CRD) and the facility Registered Dietician (RD). The interview revealed: -The CRD stated resident #72 had experienced a significant, unplanned weight loss which was due to poor intake and illness in February and March. -The RD and CRD acknowledged the facility had not conducted a comprehensive re-assessment of resident #72, in light of the weight loss. -The CRD stated she did not see evidence that the facility had offered alternate approaches like nutritional juices, high calorie cookies or fortified foods to help resident #72 increase her calorie intake. -The CRD acknowledged resident #72 was offered the same approach of nutritional supplement (i.e., MedPass and Ensure) when the weight loss was identified. -The CRD and RD denied knowledge that resident #72 refused room breakfast room trays on most mornings. -The CRD and RD acknowledged that the initial assessment of resident #72 was absent basic information like BMI and usual and ideal body weight. -The CRD and RD felt that 120 pounds would be low end of the ideal body weight range for resident #72 and that resident #72 had fallen below the ideal body weight range. -The CRD acknowledged that the food preferences form did not capture resident #72's favorite foods and did not reflect resident #72's refusal of breakfast meals via the room tray cart. -The CRD acknowledged that identifying resident eating habits, favorite foods and food dislikes was important to developing a resident-centered nutrition plan to meet nutrition needs. -The CRD stated that resident #72 may have slipped through the cracks due to turn over in the dietary manager and registered dietician positions in the facility in recent months. -The RD stated she would immediately contact resident #72 for an assessment to identify eating habits, opportunity for increased oral intakes and assessment of nutritional status and need. Facility Follow-up: On 6/30/14 the facility provided an updated nutrition assessment that was completed on 6/27/14. Resident #72 had a usual body weight in the 130s and an ideal body weight between 121 and 149 pounds. The assessment noted that resident #72 seldom ate breakfast and enjoyed consuming "junk" food. Consultation with the RD identified that resident #72 liked strawberry yogurt. Strawberry yogurt would be offered between meals as a snack to help increase calorie intake. Resident #72 agreed to switch to whole milk to increase her calorie intake. Resident #72 was to be offered a peanut butter and jelly sandwich as a bedtime snack. A nutrition note dated 6/29/14 showed that resident #72 was interested in regaining weight toback into the 120 to 125 weight range.

Based on observation, record review and interviews, the facility failed to ensure four of 53 sample residents (#58, #19, #50, #30) received the care and services necessary to attain and/or maintain their highest practicable level of physical well-being. Specifically: -The facility failed to ensure one dependent resident (#58) was positioned and assisted at meals in a manner to prevent respiratory complications (aspiration). The facility's failure to ensure this resident was positioned and assisted at meals in a manner to prevent respiratory complications created a situation of immediate jeopardy for serious harm. -The facility also failed to ensure resident #19 was properly positioned at meals and failed to ensure the skin of residents #50 and #30 was assessed for bruising and skin redness in a timely manner. The findings include: I. IMMEDIATE JEOPARDY A. IMPOSITION OF IMMEDIATE JEOPARDY Observations during the dinner meal, on 6/13/12, starting at 5:20 p.m., revealed resident #58, who had a [DIAGNOSES REDACTED]. The resident was coughing, gurgling, and sneezing while being fed peanut butter-thick puree by a certified nurse aide (CNA). The CNA was not looking at the resident, not monitoring her swallowing, not offering fluids between bites of puree, and not checking to see if the resident's mouth was clear before feeding the resident another spoonful of food. Observations of the resident's mouth revealed that some of the puree had not cleared and remained in her mouth. Following this observation, the resident was taken back to her room at 5:35 p.m., left alone in the room in the Geri-chair her head hyper-extended, compacted puree on the roof of her mouth and more puree on her gums and tongue. On 6/13/12 at 6:19 p.m., the Nursing Home Administrator (NHA), and the Director of Nursing (DON) were notified by the Colorado Department of Public Health and Environment (CDPHE) that leaving resident #58 alone in her room with her head hyper-extended and with food in her mouth created a situation of immediate jeopardy for serious harm. B. FACILITY ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY On 6/13/12 at 7:35 p.m., the nursing home administrator (NHA) submitted a plan of correction to remove immediate jeopardy to CDPHE. Five areas of concern were identified. A revised plan was submitted at 8:50 p.m. The plan read: - Resident #58 was immediately assessed by nursing staff to identify any potential immediate outcome or concerns related to a potential change in status after the meal. - Resident #58 was to be screened by ST (speech therapy) and PT (physical therapy) in the morning prior to initiation of next meal. - Notification of family and physician. - The other resident identified as at risk, resident #19, would be screened by ST/PT at the morning breakfast meal. - Nursing staff was provided with education regarding specific feeding techniques for the identified residents and the importance of positioning and puree consistency. They were also educated on oral care for resident #58. The dietary manager was to educate on the importance of accurate puree consistency. Training (was) to continue on an on-going basis. - Husband would be provided with training prior to assisting the resident to eat again. - Resident #58 reassessed for change in condition and would be monitored for 72 hours. Documentation of the in-services was provided. C. REMOVAL OF IMMEDIATE JEOPARDY On 6/13/12 at 9:00 p.m., the NHA was notified that the facility's plan of correction had been accepted and immediate jeopardy had been removed. However, deficient practice remained at an E level (potential for more than minimal harm at a pattern) II. FAILURE TO ENSURE DEPENDENT RESIDENTS WERE POSITIONED AND ASSISTED AT MEALS IN A MANNER TO PREVENT RESPIRATORY COMPLICATIONS 1. Resident #58 Resident #58, age 62, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of [MEDICAL CONDITION], dementia with behavioral disturbances, constipation, [MEDICAL CONDITION], neurotic disorder, abnormal involuntary movements, generalized pain, agitation, [MEDICAL CONDITIONS] reflux, abnormal posture, hypertension (HTN), urinary incontinence, persistent vegetative state, and long-term oxygen therapy. a. Resident Status The 3/29/12 significant change in status Minimum Data Set (MDS) documented that the resident was totally dependent with bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. Under the Swallowing/Nutritional Status section it was documented that the resident did not have problems with swallowing. However, review of the most recent therapy notes and screening (5/11 and 6/11) revealed the facility was aware the resident had swallowing difficulties due to positioning. Specifically: - Occupational Therapy (OT) had seen the resident the previous year on 5/24/11 through 6/22/11, for sitting balance and posture. The initial evaluation from 5/24/11, documented that the resident was at risk for aspiration due to positioning in the Geri-chair. Comments included repositioning to improve trunk alignment and neck support. The 6/8/11 discharge summary documented that the resident had been fitted with positioning device to assist her posture in maintaining proper positioning. The nursing staff was instructed on correct positioning to reduce risk of aspiration. The comments read, "Pt. positioning has decreased her risk of swallowing difficulties. RCS (resident care specialist) and nursing staff (have) been educated in proper positioning and demonstrated knowledge of correcting improper positioning." - Physical Therapy and Speech Therapy (PT and ST) screened the resident 5/5/11 (Interdisciplinary Therapy Screen) while the resident was in the dining room. Comments read that the resident was "poorly positioned" in her Geri-chair which could lead to "swallowing difficulties." Per the screen, even though no changes were noted, OT/PT evaluation for positioning might be warranted. The ST screen documented that the resident did not have any change with food texture or swallowing but the resident was at risk for aspiration due to positioning. - ST 10/11/10 - 10/18/10 notes documented that one of the goals of therapy was to have the staff use safe swallowing strategies with the resident when assisting her to eat. The resident had dysphagia. The safe swallowing techniques included: 1.) Give small bites and sips. 2.) Don't feed more until the patient empties her mouth. 3.) Alternate food/fluids to clear mouth and help digestion. 4.) Always have pt. sitting up during meals and for 30 minutes afterward. Note: ST trained (resident's) husband 10/11/10 at evening meal. - PT evaluation 4/4/10 of the resident's positioning in her chair indicated staff were educated on proper positioning of the resident in her Geri-chair and the resident's use of lateral support bolsters "placed behind (resident's) neck to keep head midline & slightly forward flexed to decrease p[DIAGNOSES REDACTED] ..." Care plan review revealed a plan for ADLs (revised 5/26/12) and nutrition (11/17/11). - The ADL plan identified the resident was at risk for complications due to persistent vegetative state; staff was to perform all ADLs and was to observe the resident for safety when family assisted with feeding. - The nutrition plan identified the potential for altered nutrition status; the diet noted was regular puree with honey think liquids (revised 6/15/12). b. Observations and Interviews 6/13/12 (1) Lunch On 6/13/12 at 11:25 a.m., resident #58 was observed being wheeled into the dining room in a Geri-chair. She was leaning back at approximately 100 degrees with her neck propped up by gray bolsters positioned around her head. - At 11:30 a.m., the resident's family member came in, wiped her month, and started feeding her. The resident remained positioned as above, leaning back approximately 100 degrees. - At 11:32 a.m., a staff member pulled up a chair but did not attempt to reposition the resident, assist the family member, or observe the resident "for safety" as care planned. - At 11:33 a.m., another staff member sat down to assist the resident next to resident #58. She did not attempt to reposition the resident, assist the family member, or observe the resident "for safety" as care planned. - At 11:35 a.m., the family member pushed the resident's head up to about midline in order to give her a sip of water. Multiple times during the observation the resident was observed to sneeze after being given food. - At 11:54 a.m., the family member removed the resident from the dining room. No staff was observed to interact with the resident or her family member as they left the dining room. On 6/13/12 at 3:16 p.m., the CNA who had assisted resident #58's tablemate during lunch was interviewed. She said she had been employed at the facility 3 years and 7 months. - She stated resident #58 was always positioned as above because when she was sitting straight up, she was not comfortable. The CNA said staff was to assist the resident except when family was present. - She was not aware of any precautions or specifications for her assistance with eating. When she was coughing, the CNA stated she attempts to straighten her and give her something to eat. She said she had been educated on how to assist the resident to eat by a therapist, but did not remember how long ago that had been. - She said the resident usually ate well (100%), but not today (25%). - She was not sure if the husband had been given any training on how to assist the resident to eat. She said she had been observing the resident while she was feeding the other resident to ensure that she was not choking or had any other issues. She said had encouraged the family member to give her drinks but the resident had not wanted any. (2) Dinner On 6/13/12 at 5:20 p.m., resident #58 was observed in the dining room in her Geri-chair. The resident's head was observed to be more hyper-extended than at lunch, as the gray bolsters which had been observed positioned around her head were not in place. The base of the resident's head was resting on the upper part of her back. The resident was heard gurgling loudly. - A CNA began to feed the resident with her neck hyper-extended approximately 110 degrees. The CNA was not looking at the resident, not monitoring her swallowing, not offering fluids between bites of puree, and not checking to see if the resident's mouth was clear before feeding the resident another spoonful of food. - The resident was receiving a puree diet with thin liquids. The resident was observed coughing, gurgling, and sneezing throughout the meal. When she was being given food, it was observed to be spilling out of both sides of her mouth. The resident's puree was very thick; it appeared to be the consistency of peanut butter as the food was sticking to the roof of the resident's mouth and tongue. The CNA was not observed alternating food with liquids. The resident was observed to cough more with her fluids than her solids. - At 5:25 p.m., the CNA stepped away while the resident was gurgling. At 5:27 p.m., the CNA returned but did not address the resident; rather, he started feeding another resident. - At 5:29 p.m., the CNA asked another CNA to take the resident back to her room as she was "sleepy." A surveyor request was made at this time to observe the resident's oral cavity. The resident was observed to have food stuck to the roof of her mouth and food around the base of her tongue, as well as her gums and tongue. The resident was observed to make a swallowing motion and the CNA was asked a second time to stop while her oral cavity was observed. The food had not cleared and remained in her mouth. - At 5:35 p.m., the CNA then rolled the resident back to her room, leaving her in her Geri-chair with her neck hyper-extended. He clipped her call light on, although the resident, in a persistent vegetative state, was unable to operate it and left the resident unattended in her room. - At 5:37 p.m., the lead nurse on the unit was summoned to the resident's room by the surveyor. The nurse was asked to do a head to toe assessment of the resident. She looked the resident up and down, but did not do any hands-on physical exam of the resident. When told the resident had food in her mouth, the nurse donned a pair of gloves and removed the compacted food at the top of the resident's mouth with her gloved finger. Upon completion of a second sweep of the resident's mouth, the nurse removed more food from the resident's gums and tongue. She then gave the resident a drink of water and the resident began coughing. c. Facility Failures (1) See observations above. The facility failed to ensure resident #58 was properly positioned and monitored for safety on 6/13/12. On 6/13/12 at 5:40 p.m., the lead nurse was interviewed. She reported that there were approximately two centimeters (cm) of food caked to the roof of the resident's mouth (2.54 cm is equivalent to an inch). She said the resident had pocketed food around her tongue and gums. The nurse said it was her expectation that staff ensure that the resident's mouth was clear of all food prior to her leaving the dining room and prior to her being left unattended. She said referrals to therapy were made, "... like when they are choking, like she just did on thin liquids, or when we think they may need a change in the texture and consistency." (2) See care plans above. Notwithstanding PT, OT, and ST's documentation regarding the resident's need for proper positioning and safe swallowing techniques, care plan review on 6/13/12 at 1:00 p.m. revealed no care plan instructing staff how to properly position the resident in her Geri-chair. Moreover, there was no plan regarding strategies for safe swallowing set out by ST. (3) Menu review revealed that the resident's dinner menu on 6/13/12, received on 6/13/12 at 4:45 p.m., from the registered dietician was cheddar egg bake, parmesan tomatoes, muffin and chilled pears. The puree was observed to be too thick. Observations revealed it was not the consistency of pudding or mashed potatoes; it was peanut butter thick - sticky and dry. (4) Family interview revealed no education on assisting resident #58. Specifically, the resident's family member was interviewed on 6/13/12 at 3:24 p.m. following lunch observations. He stated he usually visited and assisted at lunch on Monday, Wednesday and Friday, but sometimes he visited Tuesday and Thursday. He said he had not been provided with any education on how to assist the resident to eat. He said the resident's appetite was different today as she usually had a good appetite. He stated that it was normal for her to lean back and he had not noticed that she had any choking or coughing. He said when she sat up straighter, she would slide down. He said he had started feeding her when she had lost the ability to feed herself. He thought she had been on a puree diet for three years. d. Staff Interviews On 6/13/12 at approximately 7:00 p.m., the Speech Language Pathologist (SLP) stated that she had attempted to assess the resident that evening and the resident was fast asleep. - Regarding the resident's positioning at meals, the SLP stated that the resident needed to be as close to an upright position as possible. An ideal position would be at 90 degrees; if they could not position her correctly, then her head would be in extension. The resident should have some positioning device to have her neck forward. - The SLP stated she would consider it unsafe to feed a resident in extension position. She said she would be doing staff education, of signs and symptoms of choking, educate staff on proper and appropriate positioning for feeding and hyperextension. - The SLP stated that proper feeding techniques were: Don't feed residents when they are not alert; make sure the resident can complete a swallow; best practice is to alternate solids and then liquids. The SLP said she would instruct staff to do an oral check and finger sweep and keep the resident upright for 30-45 minutes (after the meal) due to delayed swallow and, even after being up, she would recommend that they leave the head of bed in a raised position. - The SLP said she would advise nursing to watch for elevated temperatures and change in voice quality, maybe get a chest x-ray, invite the family member and educate them as well. She stated she would let nursing know that they can down grade the resident's diet temporarily at any time. The SLP said that if she observed that the resident was unable or having difficulty swallowing the puree, she would add a teaspoon of liquid to it and make it less thick. On 6/13/12 at 7:18 p.m., the lead nurse stated that the gray head bolsters observed around the resident's head at lunch but not at dinner had been removed by therapy that afternoon. She said the missing bolsters had been brought to her attention by the CNAs; no one seemed to know why they had been removed. On 6/13/12 at 7:45 p.m., the registered dietician (RD) was interviewed and reported that she felt that the puree at dinner was a little thick and she had attempted to thin it prior to meal service. On 6/21/12 at 8:42 a.m., a CNA who had assisted the resident that morning was interviewed. The CNA stated that she had worked with the resident on and off in the past few months. She stated that when she had fed her in the past, if the resident did not have the small blue pillow (which tilted her head up to midline), she would tilt her head up straight with her hand in order to feed her. She was not sure if the family member had been given education regarding keeping her neck up. She had watched the family member tilt her head up during the times she had been at the table and she had never noticed a problem. In the past 6 months, when she was assisting the resident, the resident had never coughed or gurgled when she was feeding her as she would make sure her neck was in the correct position and she sat her up straight. She said she had observed that staff tries to position the resident correctly during the meal. On 6/21/12 at 8:49 a.m., the director of nursing (DON) was interviewed. - The DON stated she does rounds in the dining room and she had seen resident #58 being assisted to eat in the dining room multiple times. Each time she had seen her; the resident had her head up at midline and was sitting up in her Geri-chair. The DON also said she had assisted the resident to eat in the past and she had not noticed any positioning issues or aspiration concerns. If she had concerns, she would have stopped feeding her and would have had ST evaluate immediately. - The DON said she had never observed the resident in the dining room reclined back with her neck hyper-extended and if she had, she would have intervened immediately. Regarding the bolsters being gone on 6/13/12 at dinner, she stated that Restorative had ordered new equipment for positioning and they were trying it out; that was the reason the bolsters were gone. The Restorative CNA had been educated about not taking anything off of a wheelchair without talking to someone first about the change. On 6/21/12 at 2:11 p.m., the lead nurse was interviewed again. She stated that she was not assigned to the main dining room during meals; she was assigned to be in the secure unit dining room. Regarding the resident's positioning she knew that Restorative had been working with the resident regarding her positioning prior to the survey start date (6/13/12). She said the resident's positioning had been stable; she had not received any complaints from staff of the resident coughing or gurgling during meals. On 6/21/12 at 2:42 p.m., the Restorative CNA stated she had started working with the resident to try to make her chair more comfortable. She was not working with her on positioning. She said the reason the gray bolsters had been taken off of the resident's chair on 6/13/12 was to trial it on another resident's wheelchair. There was a miscommunication between the staff, as once it was trialed, the bolster was to be placed back on resident #58's chair. They had not wanted to take it off permanently. e. Facility Follow-up (1) A 6/13/12 acute care plan read: "I had a coughing episode after taking fluids. I had pocketed food in my mouth from dinner." The goal was that the resident would not have signs/symptoms of aspiration in the next 14 days. The approaches were: - STAT C (chest) X-Ray - ST screen & eval & TX (treatment) - VS Q (vital signs every) shift x 72 hours & resp assessment (2) A 6/13/12, 7:30 p.m., Physician Telephone Order documented, "STAT chest x-ray related to coughing after fluids. Speech therapy eval & tx. (3) A 6/14/12 Physical Therapy Evaluation documented: - Short-term goal - the resident would have aligned posture in her wheelchair during meals as evidenced by neutral pelvic, trunk, and neck positioning via adaptive equipment properly placed. - Long-term goal - all caregivers for the resident trained in proper use of the positioning of the adaptive equipment for her optimum posture while sitting in her Geri-chair. - Assessment - documented that the resident was dependent for all care including feeding. She was observed sitting improperly in the dining room for safe feeding. She would require adaptive equipment to support her head/neck, which was to be determined. The resident was at risk for aspiration, pneumonia, contracture(s), and increased tone limiting her functional movement. (4) A 6/14/12 ST Evaluation read: - Short-term goal - The resident to improve laryngeal elevation and excursion with puree consistencies via optimal positioning to facilitate safe swallow on 5 of 10 trials with and moderate verbal cues in order to efficiently consume least restrictive diet. - Long-term goal - increased the success rate with the trials to 8/10. The resident to improve labial coordination via passive oral motor exercises to mild impairment with and moderate tactile cues and minimal verbal cues in order to increase oral containment and facilitate [MEDICATION NAME] control and propulsion. - Recommendation - ST related to poor positioning and corresponding swallowing difficulty. The reason for the referral was due to a new onset of decreased safety during oral intake, coughing/choking during oral intake, decreased ability to use compensatory strategies and increased need for assistance from others placing her at risk for further decline in function, aspiration, pneumonia and increased dependency on caregivers. Her prior level of functioning (PLOF) was the ability to tolerate pureed & thin liquids via feeding assistance with no overt s/s (signs/symptoms) of aspiration. The diet texture analysis for puree follows: Oral Phase = Intact Pharyngeal Phase = Impaired Laryngeal Elevation/Excursion = Decreased Swallow Initiation Time = 2 seconds Airway Protection = Moderately Impaired Respiratory/Swallow Coordination = Intact [MEDICAL CONDITION] Phase = Intact The diet texture for regular liquids follows: Oral Phase = Intact Pharyngeal Phase = Impaired [MEDICAL CONDITION] Phase = Intact The diet texture for nectar thick liquids follows: Oral Phase = Intact Pharyngeal Phase = Impaired Laryngeal Elevation/Excursion = Decreased Swallow Initiation Time = 2 seconds Airway Protection = Moderately Impaired [MEDICAL CONDITION] Phase = Intact The diet texture for honey thick liquids follows: Oral Phase = Intact Pharyngeal Phase = Impaired Laryngeal Elevation/Excursion = Decreased Swallow Initiation Time = 3 seconds Airway Protection = Moderately Impaired [MEDICAL CONDITION] Phase = Intact During the meal assistance the resident was seated at 90 degrees with precautions applied - small bites & sips, liquids by spoon, multiple swallows, supervised feeding, among others. The resident showed moderate oral & severe pharyngeal dysphagia with aspiration of thin liquids via cup (trace cough), nectar via cup & pureed residual (both significant silent from residual). NPO (nothing by mouth) recommended due to decreased airway protection from residual, poor positioning for po (intake by mouth), and decreased swallow ability over time due to possible fatigue. The resident allowed passive interventions in terms of positioning to facilitate optimal positioning for feeding and swallowing. The recommendations were for the resident to be NPO but upon discussions with the MD and the husband, the determination was made to have her on puree with honey thick liquids. ST would continue to work with the resident to educate staff regarding safe feeding strategies to facilitate safe swallowing as well as to participate with educating spouse to help him make decisions pertaining to her long-term nutrition and hydration needs. (5) A Modified [MEDICATION NAME] Swallow Study (MBSS) completed on 6/14/12 documented: The resident was nonverbal during the study and was edentulous. Per the study, the resident had moderate oral and severe pharyngeal dysphagia with aspiration of thin cup (trace/cough), nectar cup and pureed residual (both significant silent from residual). The impression was that the resident should be NPO (no food by mouth) due to decreased airway protection from residual, poor positioning during food intake and decreased swallow ability over time due to possible fatigue. (6) The 6/15/12, 9:00 a.m., physician progress notes [REDACTED]. The physician wrote that he had met at the bedside with her husband and had reviewed her diagnoses, orders, and prognosis. The husband understood that she had Alzheimer's with an inevitable decline and the best solution would be comfort care. The plan was that the resident would not have a [DEVICE] ([MEDICAL CONDITION]) placed and no hospitalization s. She was to be nourished via pureed food and honey thick liquids. The doctor and the husband accepted the risk of aspiration. The husband wanted the resident to be evaluated by hospice. (7) The in-service conducted by PT and ST was about positioning for resident #58 during meals. The content of the in-service was: "Equipment that should remain in her Geri-chair: 2 grey lateral support orthoses (LSO's lumbar-sacral orthosis), 1 grey head/back support cushion. For meals, (the resident's) Geri-chair should be in the upright position. Her head should be up - NOT tilted back at all. If she pushes her neck back, place a small pillow or rolled towel between her head and the grey pillow to keep her head forward. Ensure pt (patient) is in as close to upright position as possible. Head needs to be in midline, preferably in slightly forward bent position. - Present small bites & sips via teaspoon. - Give patient enough time to complete swallow (patient takes extra time to swallow). - If any of the pureed items seem dry or tough notify dietary supervisor/add 1-2 tsps. of liquid to moisten the item so it is easier to swallow. - Notify charge nurse if any symptoms of aspiration such as coughing, excessive throat clearing, runny nose, watery eyes, etc are noted. - Provide oral care post meal to ensure no residue in mouth. - Supervise resident while she stays upright for 30 minutes post meal. (8) On 6/16/12 there was an addition to the Treatment Administration Record which documented, "Provide oral hygiene following every meal." It had been signed off as completed every shift since it had been started. (9) The 6/18/12 aspiration care plan documented, "At risk for aspiration related to (r/t) dysphagia. Husband very involved and agrees to training so (he) can continue to feed wife. Husband aware of aspiration risk but his preference is to continue with oral nutrition - puree diet with honey thick liquids. Dietary consult form has been signed by husband and MD. Resident is currently on hospice care." The approaches included: - Resident to be positioned in an upright position at 90 degrees or as close as possible for all meals. - Positioning in chair with head & back insert AND side LSO at all times in chair. - Neck pillow to keep head at neutral position - for meals only. - Provide diet of puree texture and honey thick liquids alternating bits of food and liquid. - Monitor resident for swallowing during dining. Provide time between bite to allow for complete swallowing. - Provide oral care following all meals. - (Resident) to remain in upright position for at least 30 mins. following meals. (10) The ST was interviewed on 6/18/12 at 4:45 p.m. - The ST stated that she had spoken with the family member on Saturday (6/16/12) about the resident. During lunch time, she provided education to him about her positioning and how to feed her. He was in agreement and he signed off on that. He did not comment on her positioning. She said the physician had a conversation with the husband on Friday about the resident's NPO status. She was keeping herself available should he need clarification. - The ST said she had seen the resident in passing in the past, and did not recall seeing the resident in extension. She felt that the resident being extended would have prompted her to look at her for ST in the past. She said the resident had never been brought to her attention previously. - The ST said that for now, the resident's positioning was being monitored during meals and education was being provided to caregivers about positioning and feeding assistance. The CNAs had reported that they felt comfortable with the new strategies and the resident was on hospice. The ST was also going to educate hospice on feeding strategies and positioning. - The ST said the resident was still aspirating with honey thick liquids and puree when she was educating the husband. She talked to him about what to do when she started coughing. She had not noticed aspiration on 6/18/12, but they were aware of the silent aspiration. 2. Resident #19 Resident #19, age 81, was admitted to the facility on 3/8/07. According to the June 2012 computerized physician orders, the resident had the following diagnosis; anxiety, [MEDICAL CONDITION], dementia, depression, hypertension, pain, paranoia, parkinsonism and [MEDICAL CONDITION]. a. Resident Status According to the most recent MDS, dated [DATE], the resident was coded as having short- and long-term memory impairment. She sometimes was understood by others and rarely had the ability to understand others. The resident required total assistance for all activities of daily living (ADLs). b. Observations On 6/13/12 at 11:15 a.m., the resident was observed being taken to a table in the dining room. She was seated in her wheelchair. Her eyes were closed and her head rested on her chest toward the right side. - At 11:35 a.m., the resident's lunch was served to her. Her head position was not readjusted and remained on her chest to the right side. An aide arrived to assist her at 11:40 a.m. Her diet order, according to the diet slip was pureed, but the puree was thick, not pudding or mashed potato-like consistency. - The resident's eyes remained closed while the aide began assisting her to eat. The staff member fed her spoonfuls of food. At 11:50 a.m., the aide said, "... I think you're done" and removed her plate. On 6/13/12 at 5:35 p.m., the resident was observed with her eyes closed during her dinner meal. The resident was observed lunging her head forward toward the spoon to get her food and drinks. She acted startled when the staff put the cup or spoon to her mouth. Observations revealed the resident had food in her mouth when the CNA gave her another bite and the food was observed spilling out the sides of her mouth. The resident required both tactile and verbal cues with feeding, and was often slumped to her right side with her head and chin down. On 6/13/12 at 6:13 p.m., resident #19 was observed sleeping in her Geri-chair with her head and body tilted to the right. Her oral cavity was clear. She was observed to have red material down the sides of her chin and tongue. On 6/14/12 at 7:30 a.m., resident #19 was observed sleeping at the dining room table in her Geri-chair with her right hand fisted and propping her head up. The resident was leaning to the right and had her head down and her legs flexed up. At 7:35 a.m., a