Every finding on record at Highlands of Bella Vista Health & Rehab, LLC

Based on facility policy, record reviews, interviews, and facility document review, it was determined that the facility failed to ensure an allegation of abuse was immediately reported to the administrator for two (Resident #3 and Resident #7) of three residents reviewed for an allegation of abuse. The findings include: Resident #3 Review of Resident #3's admission Record revealed the facility admitted Resident #3 with diagnoses which included major depressive disorder, generalized anxiety disorder, chronic pain syndrome, blindness in one eye, difficulty swallowing and difficulties in communication stemming from cognitive impairments. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/06/2025 indicated Resident #3 had a Staff Assessment for Mental Status (SAMS) score of 3 which indicated a short- and long-term memory problem with decision making skills that were severely impaired. The MDS also indicated Resident #3 did not usually exhibit behavior problems and could roll side to side independently but was dependent on staff for hygiene. Review of Resident #3's Order Summary Report revealed Resident #3 was comfort care only, was transferred via mechanical lift, and had orders for scheduled and as needed pain medication. Review of a Care Plan Report revealed Resident #3 lacked the capacity to understand and make decisions related to progressive dementia. Resident #3 had a self-care deficit related to progressive functional decline associated to a diagnosis of amyotrophic lateral sclerosis [ALS] which was a progressive disease that caused degeneration of the nerves. The Care Plan Report also revealed Resident #3 was dependent on staff for daily care and had combative behavior during care at times, such as grabbing, slapping and attempting to scratch or pinch staff. Review of an OLTC Incident and Accident Report (I&A)form dated 02/06/2025 revealed, CNA reported that on 02/02/2025 she was helping [CNA #2] lay [Resident #3] down in bed and [CNA #2] was rough with [Resident #3] when she rolled [Resident #3] and when tucking under the [name brand](lift) pad. [Resident #3] was being aggressive, and [CNA #2] took [Resident #3's] hand and pushed it back [at the resident] and told [Resident #3 that the resident] could not hit [CNA #2] because hitting a healthcare worker is a felony. Under Findings and Actions Taken, the I &A revealed, Body audit completed on [Resident #3], a small red area found on [the resident's] hand.It is undetermined if the red mark is from abuse or is self-inflicted from gripping [the resident's] own hands together. Resident #7 Review of Resident #7's admission Record revealed Resident #7 had diagnoses which included Alzheimer's disease, dementia, fatigue, abnormal side-to-side curvature of the spine, and back pain. Review of a quarterly MDS with an ARD of 09/18/2025 revealed Resident #7 had a SAMS score of 3 and their cognitive skill for decision making was severely impaired. The MDS also indicated Resident #7 was dependent on staff for all aspects of care. Review of a Care Plan Report revealed Resident #7 lacked the capacity to understand and make decisions regarding their care due to Alzheimer's disease. The Care Plan Report also indicated Resident #7 had a self-care deficit related to Alzheimer's disease, dementia and chronic pain; was totally dependent on one to two staff to turn and reposition while in bed and for daily hygiene needs. Additionally, the Care Plan Report revealed Resident #7 had limited physical mobility related to weakness, impaired cognition and communication deficits secondary to dementia and that Resident #7 exhibited resistive and physically aggressive behaviors during personal care. Review of an OLTC Incident and Accident Report (I&A) form dated 02/06/2025 revealed, CNA today 02/03/25 reported working with [CNA #2] yesterday and when they took care of [Resident #7], CNA reports [CNA #2] was rough with [Resident #7]. CNA reports [CNA #2] hit [Resident #7] on the arm and then held [Resident #7's] arm down to finish care. CNA also reported [CNA #2] told [Resident #7] that he was a piece of [expletive] and smelled like [expletive]. Review of an Office of Long-Term Care Witness Statement Form revealed that on 02/03/2025 at 1:30 PM, Certified Nursing Assistant (CNA) #1 reported that while working on 02/02/2025 with CNA #2, CNA #2 was aggressive with Resident #3. Resident #3 was showing signs of frustration, attempting to hit CNA #2. CNA #1 reported that CNA #2 took [the resident's] hand and pushed it back toward Resident #3. Later in the shift, around 4:00 PM, CNA #1 and CNA #2 provided care for Resident #7 who became combative, tried to hit when CNA #2 hit Resident #7 on their arm, and remarked [residents name] you're a piece of [excrement profanity]. CNA #1 reported CNA #2 also remarked toward Resident #7 that the resident smelt like [excrement profanity] because [Resident #7] had peed all over themselves. CNA #1 continued that CNA #2 held [Resident #7's] arm down after [CNA #2] hit them. A document titled Employee Memorandum dated 02/03/25 and signed by the Administrator and CNA #1, indicated CNA #1 was suspended due to failure to report abuse of a resident until the next day of business. CNA #1 reported to the lead CNA on the hall at 1:40 PM, and the alleged incident occurred on 02/02/25. Review of an Acknowledgment Form-Abuse Investigation and Reporting Policy revealed CNA #1's signature with a date of 12/03/2024. The Policy indicated that by their signature, the employee acknowledged their receipt and understanding of the policy, had received training related to the facilities Abuse Investigating and Reporting Policy. This acknowledgement indicated the employee would immediately report any suspected maltreatment. Review of an electronic training program completion report for CNA #1 revealed Neglect, Abuse and Theft training was completed on 12/03/2024. During an interview on 11/25/2025 at 9:38 AM, CNA #1 reported that while providing care for Resident #3 and Resident #7 on 02/03/2025, CNA #2 was rough with the residents and made the statement Resident #7 smells like [excrement profanity] while in the residents' room. CNA #1 reported that while providing care in the room with Resident #3, CNA #2 was a little rough with the resident. CNA #2 was not gentle with Resident #3, and the resident tried to hit her, that was when CNA #2 told Resident #3 that it was a felony to hit a health care worker. CNA #1 reported later on the same shift, CNA #2 hit Resident #7. CNA #1 indicated the reason the abuse was not reported immediately to the Administrator, or the supervisor was that she was nervous. CNA #1 reported that it was weighing on her conscious and had to report it the next day. She came in early for her shift to report the incident [the incident was reported at 1:40 PM the next day]. CNA #1 reported their suspension was due to failure to report an allegation of abuse immediately, and that she understood, any allegation should be reported immediately to the supervisor or the Administrator. During an interview on 11/25/2025 at 9:45 AM, the Administrator indicated CNA #1 had been suspended due to failure to report an allegation of abuse immediately. During an interview on 11/26/2025 at 8:45 AM, the Director of Nursing (DON) indicated that abuse training was conducted on hire, during orientation, and throughout the year. The reporting of abuse was expected to occur immediately to the Administrator or the supervisor. The DON reported they would consider rough handling or hitting any resident or calling them a name as abuse that should have been reported immediately to the Administrator. If this incident with Resident #3 had been reported immediately, the incident with Resident #7 would not have occurred. CNA #2 would have already been removed from the facility pending investigation. During an interview on 11/26/2025 at 10:30 AM, the Administrator reported the alleged abuse incident with Resident #3 and Resident #7 was reported at 1:40 PM on 02/03/2025 when the incident allegedly occurred on 02/02/2025. CNA #1 was placed on suspension due to failure to follow facility policy of reporting suspected allegations of abuse immediately. The Administrator reported CNA #1 was retrained prior to being allowed to return to providing care. The Administrator reported abuse training was usually completed on hire, quarterly and with incidents. CNA #2 was suspended pending investigation for Resident #3 and Resident #7. The Administrator reported that during their interview with CNA #2, that CNA #2 remarked she may or may not have said to a co-worker, that Resident #7 smelled like [excrement profanity]. The Administrator indicated CNA #2 was terminated due to this statement, but the physical abuse was not founded. The Administrator reported that if CNA #1 had reported the first allegation of suspected abuse with Resident #3, then the alleged abuse incident with Resident #7 would not have occurred, as CNA #2 would have already been suspended. Review of an Employee Memorandum signed by the Administrator, dated 02/06/2025 revealed CNA #2 was suspended on 02/03/25 for an allegation of abuse and terminated on 02/06/25 for a founded allegation of abuse. Review of a policy, without a review date, titled, Abuse Investigation and Reporting, revealed the facility would endeavor to protect its residents from maltreatment. The facility recognized the residents' rights to be free from physical, verbal and mental abuse. The section titled, Staff Training and Competency indicated that new employees would be given a copy of the facilities abuse policy, at which time the employees were expected to sign acknowledging they had read and understood the information provided. Under the section titled, Immediate reporting the policy revealed all facility staff must immediately report all incidents of alleged, witnessed or suspected resident mistreatment including abuse. The Administrator or their designee will immediately initiate an investigation of all alleged incidents. Any employee who fails to immediately report an allegation of abuse would be subject to disciplinary action. Additionally in the section titled, Protecting Residents the policy revealed to protect the resident(s) involved with the incident, the employee may be reassigned, shadowed or suspended immediately pending the completion and determination of the investigation. The facility terminated CNA #2 on 02/06/2025 per an employee memorandum. The facility suspended pending investigation CNA #1 per an employee memorandum. CNA #1 was retrained before returning to work. These actions were performed before the survey team entered the facility, resulting in this finding being cited at past non-compliance.

Based on observation, interviews, and facility menu and policy review, the facility failed to ensure the planned, written recipe was followed for residents who received meals from 1 of 1 kitchen. Specifically, the recipe was not followed for scrambled eggs, oatmeal, and creamy wheat cereal in accordance with the written recipe. Findings include: A review of a facility policy titled, Food Preparation, dated 05/15/2020, indicated the purpose was to conserve nutritive value, provide palatable flavor, attractive appearance and appropriate temperature of food received by residents. The procedure revealed the cook was responsible for food preparation in accordance with the menu and recipes. A review of the menu used to prepare breakfast on 11/20/2024 included egg of choice and cereal of choice. A review of the Egg 1 oz (ounce) recipe dated 02/22/2024, instructed Prepare according to package directions. A review of the Oatmeal recipe dated 10/01/2023, instructed to prepare according to package directions, omitting salt. A review of the Creamy Wheat recipe dated 10/01/2023, instructed to stir dry cereal into boiling water using wire whip until cereal begins to thicken. During an observation on 11/20/2024 at 5:45 AM, the Dietary [NAME] (Cook #1) stated breakfast was being prepared for 64 residents. [NAME] #1 turned on stove, placed two pots containing water on stove to heat, filled steam table with water, placed various sized pans into four slotted areas on steam table, and covered with four large covers. [NAME] #1 obtained two flats of raw eggs in shells, and two clear plastic bags of liquid eggs, from refrigerator, oatmeal and wheat cereal the dry storage area. Two bags of liquid eggs were placed in large pot of boiling water on top of stove, and a large fry pain was placed over the top to form a lid. No instructions were on or attached to bags. Two flats of raw eggs in shells were placed on top of the griddle on the stove. During an observation on 11/20/2024 at 6:01 AM, [NAME] #1 opened a sealed jug of margarine, unscrewed lid, pierced barrier seal with thumb and removed seal. [NAME] #1 removed lid from pans on steam table, used cooking spray on three pans, differing in size, poured an unmeasured amount of margarine, into 3 of the silver pans, added hot water to one of the pans containing margarine, and stirred in the dry wheat cereal. Cook #1 opened a box of quick oats, added the oats to a second pan containing margarine, added boiling water to the oatmeal, and vigorously stirred with a whisk to combine ingredients. [NAME] #1 placed a portion of wheat cereal into a small pan and stated 4-5 residents received enhanced cereal which was the wheat cereal with a powder added. [NAME] #1 stated the cereals would be cooked on the table while other food was being prepared. During an observation on 11/20/2024 at 6:44 AM, [NAME] #1 cut open the two bags of eggs and poured the cooked eggs into the third pan containing margarine and added an unmeasured amount of water. [NAME] #1 stated the margarine was added to provide a butter flavor to the food and was not part of the recipe. During an interview on 11/20/2024 at 12:20 PM, the Dietary Director (DD) stated [NAME] #1 was unable to read and has been told not to add things to recipes and should have followed the recipes. The DD stated the recipes for oatmeal, wheat cereal, and eggs did not call for margarine or butter, and did not know why water was added to the eggs after they were cooked. The DD stated enhanced wheat cereal was made by adding a multi mix that contained a combination of powdered milk and powdered protein.

Based on observations, interviews, and facility policy review, the facility failed to maintain overall kitchen sanitation, failed to ensure food was prepared under sanitary conditions, and failed to ensure hand hygiene was performed by dietary staff, in 1 of 1 kitchen. Findings include: A review of a facility policy titled, Food Preparation, dated 05/15/2020, indicated the purpose was to conserve nutritive value, provide palatable flavor, attractive appearance and appropriate temperature of food received by residents. The procedure revealed bare hands should not come in contact any foods, ready to eat or otherwise. A review of a facility policy titled, Cleaning & Sanitation, dated 09/20/2020, indicated the purpose was to ensure a clean, sanitary, and safe environment according to state and federal regulations. The procedure included the Dietary Director (DD) would develop, implement, and monitor cleaning of the kitchen and equipment. A review of the Monthly Cleaning Log for November 2024 revealed the table legs on kitchen worktables were to be cleaned during Week 3. No completion date or initials were documented. Week 4 indicated that the pipes, walls, and floor behind equipment were to be cleaned. No completion date or initials were documented. A review of the Weekly Cleaning Log for the week of 11/10/2024 through 11/16/2024 had missing entries for items that included, walls, steam table #1, table surfaces, tray line, floors, stove top and grill. A review of the Weekly Cleaning Log for the week of 11/17/2024 to 11/23/2024 had missing entries for items that included, deep fryer, floors, steam table, tray line, stovetop and grill. A review of the dietary in-service topic Kitchen Cleaning, dated 11/20/2024 revealed the summary of the in service included cleaning schedules, keeping kitchen clean is to ensure a sanitary and safe environment, and had 5 participant signatures. A review of the dietary in-service topic Hand Washing, dated 11/20/2024 revealed the summary of the in service included staff were to wash hands after touching body parts, going from dirty to clean, handling dirty utensils or equipment, during food preparation, or engaging in any activity that will contaminate hands, and had 5 participant signatures. During an observation on 11/20/2024 at 5:43 AM, a silver-colored griddle portion of stovetop had yellow orange debris from center to back of the griddle. The top edge of the silver-colored cooktop had an irregular brown/tan pour pattern of debris. The oven door had dark discoloration in splotchy, running pattern. The ledge above the door opening had gritty, brown and black buildup the width of the oven door. The fryer door had discoloration in a splotchy and running pattern. The front of a fryer, the fryer door, and leg of the standalone oven had a circular white, tan, and yellow debris. The floor in front of the fryer and around the leg of the standalone oven, had blotchy black and gray debris in various thickness. The top of the fryer contained an uncovered dark colored liquid, identified by the Dietary Director (DD) as oil, and light tan/yellow gritty debris, two fryer baskets above the oil with yellow debris. A flat pan with foil inside the rim covering the bottom of the pan, had a puddle of yellow fluid with yellow gritty debris, two silver utensils covered with wet layer and yellow gritty debris were laying on the pan above the yellow puddle of fluid. A preparation table, to the right of a refrigerator holding beverages, left of a kitchen entry door, had black and white debris on the lower shelf that contained condiments, salad dressing, honey, and syrup. The floor under and behind the preparation table, near the kitchen door, had dark gray and black debris, and the baseboard had a layer of black debris along the top edge. The front and legs of a food serving cabinet, a lower shelf and legs of a serving table, and the floor had white, black, and gray debris. During an observation on 11/20/2024 at 5:45 AM, Dietary [NAME] (Cook #1) stated breakfast was being prepared for 64 residents. Two loaves of bread, one white and one wheat, were placed on a blue meal tray, located on a preparation counter next to the toaster. The tray contained a half loaf of bread in a sealed storage bag. At 5:46 AM, a blue trashcan with an attached black lid and two black wheels, contained a gray trash bag, had white debris in a splatter and running pattern on the front and sides, and brown debris splattered and running pattern on the front and sides, was positioned next to the stove, touching the side of the stove with the handle overlapping the top of the stove. During an observation on 11/20/2024 at 6:01 AM, [NAME] #1 opened a sealed jug of margarine, unscrewed lid, pierced barrier seal with thumb and removed seal. [NAME] #1 removed lid from pans on steam table, used cooking spray on three pans, differing in size, poured an unmeasured amount of margarine into 3 of the silver pans. During a concurrent observation and interview on 11/20/2024 at 6:18 AM, [NAME] #1 completed puree sausage preparation, removed blender parts and rinsed in sink and wiped hands on shirt. No hand hygiene was performed. [NAME] #1 went to the stand-alone oven, put on oven mitts and removed a shelf, placed two pans containing mechanical soft and puree sausage, covered with foil, in the oven. [NAME] #1 stated they were nervous and moved to the sink and washed their hands. During an observation on 11/20/2024 at 6:27 AM, [NAME] #1 obtained food temperatures from the steam table, put glasses on, picked up an ink pen from the table next to binders, documented temperatures, removed and hooked glasses on top of shirt. No hand hygiene was performed, moved toward stove, wiped left hand on lower portion of shirt near hip. During a concurrent observation and interview on 11/20/2024 at 6:37 AM, Dietary Aide (DA) #2 placed 6 slices of bread into an automatic conveyor toaster, 6 slices of toast removed and stacked on a blue tray. DA #2 used a large, handled butcher type knife to cut the toast diagonally, placed toast cut side down to the back of the tray. DA #2 was asked if the tray was clean prior to placing the toast on the tray to cut it. DA #2 stated the bread was on the tray upon arrival and placed there by [NAME] #1, and believed the tray was clean at that time. DA #2 was asked if the tray was cleaned before placing toast on it. DA #2 did not respond, picked up the tray, threw the toast into the trash can, placed the tray to the dish washing area, and obtained a new tray. During an interview on 11/20/2024 at 6:39 AM, the (DD) was asked what the debris on top of the griddle was and stated it was a reaction of something that was set on top of the griddle but could not identify what was set on the griddle to cause the debris. The DD stated the trash can could be within 2 inches of the stove according to guidance. The DD cleaned the top of the griddle. The DD stated the evening dietary staff should have cleaned the kitchen before leaving. The DD stated deep cleaning was done weekly and monthly. The DD stated the kitchen did not look like it was cleaned in the last month. During an observation on 11/20/2024 at 6:03 AM, the floor and red connection line, on the serving side of the steam table, was covered in thick black and gray debris. The right side of the steam table had dried brown debris in a running pattern, and the floor between the steam table and preparation table had a layer of dark debris. There were white bowls, and two flats of raw eggs on the griddle, and the trash can handle was overlapping the top of griddle. During an interview on 11/20/2024 at 12:20 PM, the DD stated it was okay to have a trash can within 2 inches of the stove if not touching the stove and did not believe it was an infection control issue, moved the trash can from overlapping the griddle. The DD was asked to provide information about distance from stove. The DD stated [NAME] #1 should have performed hand hygiene after touching glasses, clothing or moving from one station to another. DD stated an in-service was completed earlier for cleaning and hand washing. After the in-service, DD stated she observed [NAME] #1 wiping their hand on the apron and had to bring attention to that and remind [NAME] #1 to do hand hygiene. The Administrator walked through the kitchen area and observed the debris on the wall and ceiling above the beverage refrigerator, debris on shelves, floor, baseboard, stove, fryer, and location of the trashcan, and stated the large trashcan would be replaced with a smaller one and the kitchen would be cleaned to correct concerns. On 11/20/2024 at 12:30 PM, the DD stated the guidance for a trash can being 2 inches from the stove, and the trash can was moved due to infection control concerns.

Based on observation, record review, and interview, the facility failed to ensure physician orders were followed to prevent significant medication errors which could result in complications for 1 (Resident #10) of 1 sampled resident. These failed practices resulted in an immediate jeopardy, as defined at 42 CFR S488.301. The survey team provided the State Operations Manual Appendix Q Immediate Jeopardy template to the which Director of Nursing (DON) on 11/9/23 at 1:14 p.m. An Immediate Jeopardy removal was submitted and accepted, on 11/9/23 at 3:06 p.m. The findings are: Resident #10 had a diagnosis of type 2 diabetes mellitus and dementia. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/1/2023 documented the resident scored 11 on the Brief Interview for Mental Status (BIMS) and received insulin injection 7 times. Review of the lab results report dated 9/7/2023 for Resident #10, .hemoglobin A1c documented .10.5 high . A physician order with a start date of 9/28/2023 documented, .metformin hydrochloride oral tablet 1000 mg (milligrams) by mouth two times a day . A physician order with a start date of 11/8/2023 documented, .insulin glargine subcutaneous solution 100 unit/ml (milliliter) inject 24 unit subcutaneously one time a day . A physician order with a start date of 11/7/2023 documented, .NovoLog injection solution 100 unit/ml inject as per sliding scale: if 0 - 60 = 0 give oj (orange juice) and notify provider; 61 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 600 = 10 if > 400 give 8 u and notify provider . before meals and at bedtime . A review of the medication administration record dated August 1 through August 31, 2023; documented no blood sugar results and no insulin glargine was administered on August 2 or August 12 at 6:30 a.m. A review of the medication administration record dated September 1 through September 30, 2023; documented no blood sugar results and no insulin glargine was administered on September 24 at 6:30 a.m. A review of the medication administration record dated September 1 through September 30, 2023; documented no blood sugar results and no NovoLog insulin 100/mg/ml was administered on September 28th or 30th at 9:00 p.m. A review of the medication administration record dated November 1 through November 30, 2023 documented on November 7th at 12:00 p.m. a blood glucose reading of 438 with 10 units of NovoLog insulin was documented administered; at 5:00 p.m. a blood glucose reading of 360 with 10 units of Novolog insulin was documented administered; on November 8th at 8:00 a.m. a blood glucose reading of 358 with 10 units of Novolog insulin was documented administered; at 12:00 p.m. a blood glucose reading of 366 with 10 units of Novolog insulin was documented administered; at 5:00 p.m. a blood glucose reading of 433 with 10 units of Novolog insulin was documented as administered to Resident #10. On 11/8/2023 at 4:25 p.m. Licensed Practical Nurse (LPN) #3 administered metformin hcl (hydrochloric acid) 500 mg 1 tablet from a pharmacy bottle in the medication cart. The bottle documented metformin hcl 500 mg tablet. LPN #3 administered 10 units of NovoLog insulin 100 mg/ml into Resident #10 lower left quadrant after a blood glucose reading of 433. On 11/9/2023 at 9:01 a.m. LPN #2 was asked why Resident #10 was on insulin and metformin. LPN #2 revealed Resident #10 was a very brittle diabetic. LPN #2 was asked how Resident #10 metformin hcl tablets were dispensed and where did they come from? LPN #2 revealed the facility pharmacy did not accept resident's insurance, so the nurse's call in the refills and the family picks them up and brings them to the facility. LPN #2 verified Resident #10 was administered 1 metformin 500 mg tablet once a day at 8:00 a.m. and it comes from the bottle on the cart. LPN #2 clarified Resident #10 ' s metformin orders to read: metformin 1000 mg 1 tablet two times a day. LPN #2 clarified insulin glargine 24 units once a day; and clarified NovoLog flex pen insulin per sliding scale .with a blood glucose reading of over 400 - give 8 units and notify the physician. LPN #2 was asked to verify the blood glucose readings and insulin administration for August 2nd and the 12th at 6:30 a.m.; September 24th at 6:30 a.m. and September 28th and 30th at 9:00 p.m. LPN #2 revealed there was no blood glucose and no insulin documented given. LPN #2 revealed residents should be given insulin and metformin as ordered to maintain a constant blood sugar level. On 11/9/23 at 9:26 a.m. during an interview, the Director of Nursing (DON) revealed Resident #10 was on insulin and metformin due to type 2 diabetes and that the family supplied the medications. The DON verified the NovoLog insulin order for sliding scale; verified the order for insulin glargine at 6:30 a.m.; and verified the order for metformin hcl 1000 mg 1 tablet twice a day. The DON was asked to verify the blood glucose readings and insulin administration for August 2nd and the 12th at 6:30 a.m.; September 24th at 6:30 a.m. and September 28th and 30th at 9:00 p.m. The DON revealed there was no blood glucose and no insulin documented given. The DON revealed Resident #10 should receive insulin and metformin as ordered because obviously Resident #10 blood sugar is not controlled with insulin alone. The DON was asked, why should physician orders be followed and what are your expectations from the staff regarding following physician orders, insulin administration, and administration of oral diabetic medications? The DON replied, It's the physician's scope of practice to give orders and our scope of practice to follow those orders. My expectation is that the staff follow the orders as written and if there is a question, they should contact the physician for clarification. The DON was asked, how do you ensure licensed staff are administering medications per the physician orders and in accordance with current accepted professional standards of practice? The DON replied, By doing medication pass audits. The DON revealed that after two weeks the secure messages drop from the system and if it's not documented the in-progress notes, then we don't have documentation for physician notifications. A facility policy titled, Medication, General Administration of, provided by the Director of Nursing (DON) on 11/9/23 at 10:55 AM documented, .Medications must be charted immediately following the administration by the person administering the drugs. The date, time administered, dosage, etc., must be entered in the medical record and signed by the person entering the data . The Plan of Removal for Immediate jeopardy received on 11/09/23 at 2:56 PM from the Administrator included the following: Resident was assessed blood glucose was obtained, provider was notified of Metformin 500mg given BID (twice a day) instead of the ordered amount of Metformin 1000mg po BlD, order was received to draw Hgb A1C. Provider also clarified the sliding scale order for resident and the Metformin order was corrected in the Electronic Health Record to administer Metformin 500mg 2 tabs po BID to 1000m9, by the Charge Nurse and ADON (Assistant Director of Nurisng). Resident was noted to have no negative side effects at this time. All residents that receive accu-checks (blood glucose monitoring) had an accu-check completed and the provider was notified of any accu-check below 60 or above 400. Treatment was provided as ordered by the charge nurse. All residents who receive Metformin orders were verified that the physician orders and the dose on hand was accurate by the ADON. All residents with orders for sliding scale insulin and all scheduled does of insulin were double checked for accuracy with no negative findings noted by the ADON. Potential to be affected: The deficient practice has the potential to affect 12 residents that receive accu- checks, 4 residents that receive Metformin, 11 residents that receive insulin. All verified per physician orders by the ADON. Systemic Change: ln-service began immediately with Licensed staff by the DON/ADON on: Five Rights of Medication Administration and Proper documentation of physician notification and ensuring sliding scale orders are entered accurately into the Electronic Health Record and followed completely. Monitoring: All physician orders will be checked for accuracy and completeness and documentation of physician notification if indicated. Monday -Friday by the DON/Designee.

Based on observation, record review, and interview, the facility failed to ensure that meals were prepared and served according to the planned written menu for 1 (#24) of 2 residents with a physician's order for a pureed diet for one of two meals observed according to a list provided by the Director of Nursing on 11/9/23 at 2:33 PM. The findings are: On 11/06/23 at 12:07 PM, lunch trays for resident's receiving a pureed diet were observed and contained a container of apple juice, a container of snack pack pudding, pureed goulash, pureed bread and a salt and pepper packet. The resident's diet card was also on the tray and read: Puree, *Regular Diet, Apple Juice, Fortified Soup. On 11/06/23 at 12:48 PM the Dietary Manager provided a copy of the menu for the pureed, regular diet. The menu called for goulash, seasoned squash, dinner roll, margarine spread, pound cake/chilled peaches. On 11/09/23 at approximately 2:00 PM, the dietary manager was asked to review the contents of resident's meal from 11/06/23. The Dietary manager (DM) stated, There is no vegetable. Upon further examination DM identified that there was no fortified soup. DM was unable to determine the reason for the absence of the vegetable or fortified soup. DM was then asked why the resident was served a prepackaged pudding instead of a pureed cake and peaches. DM stated, I don't understand why the dessert isn't there. It seems like I can remember there being 2 pureed desserts and I worked the tray line that day. Concerning the fortified soup, the DM speculated that it had simply not been prepared. DM was asked why it was important to follow the planned menu. She stated, So they will get all of their nutrients. When asked why it was important for a dietary intervention to be provided the DM stated, Because they need the calories because they are losing weight.

Based on observation, interview, and record review, the facility failed to ensure ensure expired liquid nutrition was removed and placed into an area for destruction to prevent potential administration to residents; and failed to ensure residents medications were labeled with name to prevent potential administration to other residents; and failed to ensure a insulin was dated with an open date to ensure medications were stable / compatible for use as observed by surveyor on 2 Halls (Hall 100 and 200) of 3 Halls (100, 200, and 300) that were observed on 11/7/23. The findings are: On 11/07/23 at 2:35 p.m.,100 hall medication cart was assessed with Licensed Practical Nurse (LPN) #3 present. 1- Novolog Pen 100 unit/ml (milliliter) with no open date with a fill date of 10/3/23 for Resident #10. 1- foil package containing 1 vial of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution 05. mg/3 mg (milligram) per 3 ml found in the medication cart with no name. Licensed Practical Nurse (LPN) #3 was asked how long is the Novolog Pen good for once it has been opened? LPN #3 stated, 28 days, they are all supposed to be dated when opened. LPN #3 was asked why should the insulin pen be dated when opened? LPN d#3 revealed that all insulins are supposed to be dated when opened to make sure they don't go bad, we need an open date on all our stuff. LPN #3 was asked who the Ipratropium Bromide and Albuterol Sulfate Inhalation Solution belong to. LPN #3 stated, I really don't know. On 11/7/23 at 2:53 p.m., the 200-hall medication cart was assessed with LPN #1. 3. There was an 8-ounce carton of calorie liquid nutrition with an expiration date of November 1, 2023. LPN #1 stated, Resident # 61 uses the calorie liquid nutrition. LPN #1 was asked, was the date on the 3 cartons of calorie liquid nutrition on the medication cart expired? LPN #1 stated, yes. LPN #1 was asked, why should expired calorie liquid nutrition not be left on the medication cart? LPN #1 stated, after the date on the cartons, we can't ensure the safety of the product. On 11/09/23 3:11 PM, the Director of Nursing (DON) was asked why are insulin pens dated when opened and how long are they good for after opening? The DON revealed that insulin pens were good for 28 days after opening so we don't go pass the 28 days. The DON was asked what guidelines licensed staff follow regarding how long insulin pens are good for after opening. The DON stated, It ' s a policy we just adopted for all insulins. The DON was asked, who ensures expired medications/liquid nutrition are removed from the medication carts? The DON replied, Nurses, pharmacists and nurse managers. The DON was asked, why should expired cartons of calorie liquid nutrition be removed from the medication cart and not available for resident use? The DON replied, It could make them sick. The DON was asked, why should individual packages of updraft treatments be labeled with the resident's information? The DON replied, because people are prescribed medications for a reason and residents don't need to take another residents medication because they may be allergic to it. A package insert titled, Novolog, obtained on 11/9/23 from website .https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/020986s082lbl.pdf documented Store the Pen you are currently using out of the refrigerator below 86 F (30 C) for up to 28 days A facility policy titled, Medication Storage in the Facility, provided by the Director of Nursing (DON) on 11/9/23 at 1:15 P.M. documented, .medication and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. Outdated, contaminated, or deteriorated medications .are immediately removed from inventory .When the original seal of a manufacturer's container or vial is initially broken the container or vial with be dated. No expired medication will be administered to a resident .

Based on observation, record review and interview, the facility failed to ensure the medication error rate was less than 5%. Physician orders were not followed for 2 residents (Resident #10 and #62) of 5 residents observed during the medication passes resulting in medication errors. The medication error rate was 9.09 % based on administration of 33 medications opportunities with 3 errors observed. The findings are: Resident #10 had a diagnosis of type 2 diabetes mellitus and dementia. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/1/2023 documented the resident scored 11 on the Brief Interview for Mental Status (BIMS) and received insulin injection 7 times. A physician order with a start date of 9/28/2023 documented, .metformin hydrochloride oral tablet 1000 mg (milligrams) 1 tablet by mouth two times a day . A physician order with a start date of 11/7/2023 documented, .NovoLog injection solution 100 unit/ml inject as per sliding scale: if 0 - 60 = 0 give oj (orange juice) and notify provider; 61 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 600 = 10 if > 400 give 8 u and notify provider . before meals and at bedtime . On 11/8/2023 at 4:25 p.m. Licensed Practical Nurse (LPN) #3 administered metformin hcl (hydrochloric acid) 500 mg 1 tablet from a pharmacy bottle in the medication cart. The bottle documented metformin hcl 500 mg tablet. LPN #3 administered 10 units of NovoLog insulin 100 mg/ml into R#10 lower left quadrant after a blood glucose reading of 433. On 11/9/2023 at 9:01 a.m. LPN #2 was asked why Resident #10 was on insulin and metformin. LPN #2 revealed Resident #10 was a very brittle diabetic. LPN #2 verbally verified Resident #10 was administered 1 metformin 500 mg tablet once a day at 8:00 a.m. by LPN #2. LPN #2 clarified Resident #10 metformin orders to read: metformin 1000 mg 1 tablet two times a day. LPN #2 verbally clarified NovoLog flex pen insulin per sliding scale .with a blood glucose reading of over 400 - give 8 units and notify the physician. On 11/9/23 at 9:26 a.m. during an interview, the Director of Nursing (DON) revealed Resident #10 was on insulin and metformin due to being diabetic. The DON verbally verified the NovoLog insulin order for sliding scale; and verbally verified the order for metformin hcl 1000 mg 1 tablet twice a day. The DON revealed Resident #10 should receive insulin and metformin as ordered because obviously Resident #10 blood sugar is not controlled with insulin alone. Resident #62 had a diagnosis of disorders of bone density and structure. A physician order with a start date 9/30/23 documented . cholecalciferol oral tablet 125 mcg (micrograms) (5000 unit) give 1 tablet by mouth one time a day . On 11/08/23 09:15 AM LPN #2 administered 1 cholecalciferol 25 mcg tablet by mouth to R #62. On 11/08/23 10:48 AM, LPN #2 was asked to see the bottle of Vitamin D3 that was given to Resident #62. LPN #2 was asked if this was the correct dose to be given. LPN #2 looked at another bottle of Vitamin D3-5 and stated, this is the Vitamin D that was supposed to be given, it's 125 mcg to equal 5000 units. LPN #2 stated, It's the wrong medication I gave. LPN #2 was asked, why should the residents receive medications as ordered? LPN #2 stated, Because that's how they are ordered. On 11/9/23 09:26 PM, the DON was asked, why should physician orders be followed and what are your expectations from the staff regarding following physician orders, insulin administration, and administration of oral diabetic medications? The DON replied, It's the physician's scope of practice to give orders and our scope of practice to follow those orders. My expectation is that the staff follow the orders as written and if there is a question, they should contact the physician for clarification. The DON was asked, how do you ensure licensed staff are administering medications per the physician orders and in accordance with current accepted professional standards of practice? The DON replied, By doing medication pass audits.

Based on record review and interview, the facility failed to ensure discharge instructions were provided for a Peripherally Inserted Central Catheter (PICC) and the resident/caregiver received complete discharge planning goals to include needs and caregiver instruction for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents. The findings are: 1. Resident #1 was admitted to the facility on [DATE] with a diagnosis of encounter for surgical aftercare following surgery on the digestive system. a. Physicians order dated 7/12/23 noted Resident #1 would discharge home on 7/15/23 with home health to follow up with skilled nursing care to include physical therapy, occupational therapy, and home health aide. b. The Nursing Discharge Instructions form dated 07/15/23 documented Resident #3 was discharged home with home health to provide therapy services, (Name) agency was to provide caregiver assistance and medical equipment (Hoyer Lift and Hospital Bed) arrangements were made. The form did not contain documentation that the PICC line was reviewed or identified with the care giver. c. On 07/26/23 at 10:05 AM, the Surveyor asked the Director of Nursing (DON) if the facility had reviewed the PICC line care with the care giver on discharge for Resident #1. She stated they had not. It had been missed.

Based on record review and interview, the facility failed to ensure Physician Orders were obtained for dressing changes and care for a Peripherally Inserted Central Catheter (PICC) for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents. The findings are: 1. Resident #1 was admitted to the facility on [DATE] with a diagnosis of encounter for surgical aftercare following surgery on the digestive system. a. The June 2023 Medication Administration Record (MAR) reflected Resident #1 was to receive a 10 milliliter normal saline flush intravenously (IV) one time a day to flush the PICC line before and after every IV infusion for 14 days with an order date of 06/26/23. There was no documentation the flush was administered on 06/28/23 for the day shift. There was no PICC line care documented on the June 2023 MAR or Treatment Administration Record (TAR). b. The July 2023 MAR reflected Resident #1 received flushes July 1st through 10th. No saline flushes were documented for July 11th through July15th. No PICC line care was documented on the July 2023 MAR or TAR. c. On 07/26/23 at 11:21 AM, the Surveyor asked the DON if she had documentation of a dressing treatment/change on Resident #1's PICC line. She stated, No. There was no order for a dressing change.

Based on observation, record review, and interview the facility failed to assure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to safely meet the residents' needs, promoted each resident's assessments and individual plans of care, and considered the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #2) sample mix residents who had unwitnessed falls in the last 30 days. 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of ,d+[DATE] documented the resident scored 7 (,d+[DATE] indicated severe cognitive impairment on a Brief Interview for Mental Status (BIMS), required total dependence of two people for transfers and extensive assist of two people for bed mobility. The MDS did not document the resident used side rails. a.The Care Plan initiated [DATE] documented, . The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) impaired cognition and aggressive behaviors (verbally) during care provision secondary to progressive Dementia and [CONDITION(S)]. Date Initiated: [DATE] .TRANSFER: The resident is totally dependent on 2 staff for transferring .TRANSFER: The resident requires Mechanical Hoyer Lift with 2 staff assistance for transfers as per protocol . BED MOBILITY: The resident requires extensive assistance by 2 staff to turn and reposition in bed every 2 hours and as necessary .SIDE RAILS: half rails up as per Dr.'s (doctors) order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition every 2 hours w/routine care rounds and as necessary to avoid injury. Date Initiated: [DATE] . The resident is High risk for falls r/t impaired mobility, cognition, behavioral disturbances, incontinence, high risk medications. Date Initiated: [DATE] .The resident will not sustain serious injury through the review date. Date Initiated: [DATE] . Anticipate and meet the resident's needs . Follow facility fall protocol. Date Initiated: [DATE] . b.The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . DO NOT TRANSPORT TO HOSPITAL Phone Active [DATE] . c. On [DATE] at 1:22 PM, The Administrator provided a document titled, .Nsg (nursing) Side Rail assessment dated [DATE] documented, . c. Increased Independence Side Rails will increase independence in the following areas: .Turning side to side . Holding self to one of bed . 3. Sense of security . Prevent rolling out of bed, alleviate fear of falling from bed, establish boundaries of the bed . The Nsg Admit/Readmit/Quarterly assessment dated [DATE] documented, . page 29, 45. Side Rails . Why is the use of side rails being considered .7. Medically necessary to perform bed mobility and/or transfers .b. Physical contributing factors to side rail use .8. Incontinence or frequency of bladder 9. Incontinent of bowel . c. Medications the resident is taking that require increase safety measures 1. Diuretics . 3. Antidepressants .7. Antihypertensives .d. Side rails will increase independency in the following areas . Turning side to side 2. Moving up and down in the bed .M1. History of falling 46A. Yes . Morse Fall Score G. 75 . 46H. Total score from questions A through H. A total score of 10 or higher indicate resident is AT RISK for falling . 45 or higher. High Risk . Focus . Goal: The resident will be free of minor injury through review date, Goal: The resident will not sustain serious injury through the review date. Intervention: Anticipate and meet the resident's needs. Be sure the resident's call light is withing in reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance . d. On [DATE] the Director of Nursing (DON), provided a copy of an un-witnessed fall Investigation and Accident (I and A) that documented dated [DATE], . This nurse was called to resident's room regarding a fall. Upon entering room noticed resident was lying on the floor. The Surveyor asked resident what had happened, and she stated that she was trying to reach for her remote and then fell . Assessment was done and noted no visible injuries. Resident stated slight pain to her right knee, no at the time. Resident was transferred on to bed using sheet transfer x4 assist- informed aides to ensure items are within residents always reach. Side rails in place to set bed boundaries for resident. Immediate Action Taken: Resident was transferred on to bed using sheet transfer x [times] 4 . The un-witnessed fall I and A that documented dated [DATE], . This nurse was 100 Hall nurse's station when resident walking the hall stated that somebody was on the floor. Upon entering residents room noticed resident was lying on the floor next to her bed, belly side down on top of the legs of her bedside table. Side rail was in low position. The Surveyor asked the resident what happened, and she stated she didn't know. Called for assistance from other nurses. Resident was rolled over her to the back and head to toes assessment was performed. Large knot to L (left) side of forehead was noted with small abrasion. Skin tear to R (right) upper thigh and RFA (right forearm). Bruising noted to top of L shoulder and both upper thighs. Skin tears were cleansed, pat dried, and dressing applied. Resident is alert and verbally responsive. ROM (range of motion) is WNL (Within Normal Limits). Assisted resident back to bed using sheet transfer x 3 assist. Informed the assistants to ensure both bed rails are up at all times when resident is in bed . e. The nurses progress notes documented, . [DATE] 15:01 . Resident currently resting in bed. Noted to s/s (signs and symptoms) of pain or discomfort at the time. Resident states that she feels a bit better but does not recall what happened. L (left) eye cannot be opened due to swelling from fall. Dressings are clean dry and intact. Call light and fluids within reach. Neuros in place. Will continue plan of care .[DATE] 01:01 . Hot Rack Charting: Resident S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Light purple discoloration to left shoulder and both upper thighs. Dressing CD and I to right thigh. VS with heart rate elevated at 93 regulars. B/P ,d+[DATE] No sx distress. No grimacing when providing care every two hours and PRN [ as needed]. Neuro checks preformed all within normal range. Encourage fluids and fluids taken Offered snack Ate 100 % [percent] of yogurt. ROM within normal limits. Bed in lowest position. Call light and fluids within reach . [DATE] 06:47: Administrator, DON, Hall managers and coroner aware. Coroner coming to building. All parties aware .[DATE] 08:00 . Note Text: Resident deceased at 0617, Coroner notified at 0620, PA, DON and Admin notified at 0625. Coroner arrived at 0730, gave 5 pages of note, face sheet and med list. He requested the incident from Sunday, gave him a copy. Family was here when she passed. Funeral home notified at 0800, Order to release body to funeral home . f. On [DATE] at 12:55 PM, The Surveyor asked Licensed Practical Nurse (LPN) #1, Were you working on Resident #1's hall the day of her fall on [DATE]? She said, I was one of the nurses that that assisted her back to bed. The Surveyor asked, Were her side rails up when you picked her up from the ground? She said, No. The Surveyor asked, Do you know how long she laid on the floor before she was found? She said, No. Were her side rails supposed to be up? She said, Yes g. On [DATE] at 12:55 PM, The Surveyor asked LPN #2, were you working on Resident #1's hall the day of her fall on [DATE]? He said, It was around lunch time on 100 Hall. A staff member said, there is a lady on the floor. I went to the room. She was laying on top of the over bed table. She had a skin tear to her right forearm, right upper thigh, large hematoma to her left side of her forehead, bruises to left shoulder and top of thighs. Her pupils were reacting, and she was in a confused state. She always is. The Surveyor asked, how long had the side rails been down and how long had she been in the floor? He said, I don't know. h. On [DATE] at 1:00 PM, The Surveyor asked the DON; do you have a side rail policy? She said, No. i. On [DATE] at 1:10 PM, The Surveyor asked Certified Nursing Assistant (CNA) #1, Were you working on Resident #1's hall the day of her fall on [DATE]? She said, I was not on that hall. The Surveyor asked, Do you work weekends? She said, I will pick up some extra shifts when I can. j. On [DATE] at 1:15 PM, The Surveyor asked CNA #2, Were you working on Resident #1's hall the day of her fall on [DATE]? She said, I was not on that hall. The Surveyor asked, Do you work weekends? She said, I will pick up some extra shifts when I can, I work a lot of extra shifts. k. On [DATE] at 1:21 PM, The Surveyor asked CNA #3, Were you working on Resident #1's hall the day of her fall on [DATE]? She said, I didn't work that day. I was supposed to, and I switched a day with someone else. She didn't show up and now I know I was supposed to get that in writing. The Surveyor asked, Do you work weekends? She said, I will pick up some extra shifts when I can, we have a lot of weekends. I sometimes work a Saturday or a Sunday. l. On [DATE] at 9.43 AM, The Administrator provided a copy of August, September, and October Resident Council Reports that documented, . New Concerns . Resident did not get shower .staff reported resident refused . Resident did not receive fresh water . shower schedule is inconsistent . staff don't answer call lights . staff sleeping . The Grievance Log for August, September, and October documented, . No showers . oral care .water pitcher not filled .medication timeliness . no bedrail .food tray not set up . m. On [DATE] at 10:05 AM, The Surveyor held a group meeting with 5 residents who reside in the facility. The Surveyor asked the group, Do you feel like you have enough staff to meet your needs? They said, the weekends are the worst. Sometimes there is one assistant per hall if that. We are not getting our showers and some of the CNAs are not nice. The Surveyor asked, Does the staff assist residents who need assistance with meals? They said, Yes, most of the time. n. On [DATE] at 11:20 AM, The Surveyor asked the DON Can you tell me about Resident #1's fall in July? She said, The nurse found the resident lying on her right side. She fell out of the bed reaching for her remote. Four staff used a sheet to pick resident up out of the floor. The Surveyor asked, What was your intervention for the fall? She said, to use ,d+[DATE] side rails to set bed boundaries for resident. The Surveyor asked, Were they to be up at all times? She said, No, they would put them down at her mealtimes. They would push the overbed table for meals over the resident. The Surveyor asked, Can you tell me about the fall on [DATE]th? She said, The same thing, basically except this time when she fell , she was stomach side down. The Surveyor asked, Why were her side rails down? She said, I'm assuming they were down to get her ready for lunch because it was 11:30 AM. The Surveyor asked, Do you know how long the side rails were down? She said, No. The Surveyor asked, Do you know how long she laid on the floor? She said, No. The Surveyor asked, When staff would let the side rails down, were they told to monitor the resident to prevent falls? She said, Yes, normally they would let the side rails down, set her up for lunch with overbed table over her to get ready for the tray. The Surveyor asked, had she eaten when the fall happened? She said, No. The Surveyor asked, What was your intervention for this fall? She said, Side rails to be up while in bed. o. On [DATE] at 12:50 PM, The Surveyor asked the Administrator; Can you tell me about Resident #1's fall in July? He said, I was not here and was briefly informed about her fall when I started. The Surveyor asked, Can you tell me about her fall in October? He said, She fell out of bed and landed on the floor and bedside table. She came out with numerous bruising and skin tears from the fall. The Surveyor asked, Did she hit her head when she fell ? He said, Yes, she had a hematoma. The Surveyor asked, Were her side rails supposed to have been up? He said, Yes. The Surveyor asked, Were they to be up all times? He said, As tolerated. The Surveyor asked, Can you tell me why you didn't investigate an un-witnessed fall? He said, We did an I and A, we did our daily stand-up meeting. It was discussed for bed rails to be up at all times. The Surveyor asked, Did you document any of these discussions? He said, No. The Surveyor asked, Do you know how long she was lying on the floor? He said, No. The Surveyor asked, Do you know how long the side rails were down prior to the fall? He said, No.

Based on observation, record review and interview, the facility failed to ensure foods stored the freezer, refrigerator, and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination; and failed to ensure 1 of 2 ice machines was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 65 residents who receive meals from the kitchen (total census: 65), as documented on a list provided by Dietary Supervisor. The findings are: 1. On [DATE] at 10:13 AM, The following observations were made in the storage room: a. There were six, 5-pound (lb.) containers of baking powder stored on a shelf in the storage. The containers had a use by date of [DATE]. b. There were two, 32 oz [ounce] bags of Hershey's stored on a shelf in the storage room. The bag had a use by date of ,d+[DATE]. c. An opened box of Sysco iodized salt was stored on shelf below the steam table. The box was not covered. d. An opened box of baking soda was stored in an opened zip lock bag that was on a shelf below the steam table. Both the bag and the box were not covered or sealed. e. An opened box of Cream of Wheat was stored below the steam table. The box was not covered. 2. On [DATE] at 10:32 AM, The following observations were made in the walk-in refrigerator: a. An opened box of white eggs was stored on a shelf in the walk-in refrigerator. The box was not covered. b. An opened box of sausage was stored on a shelf in the walk-in refrigerator. The box was not covered or sealed. c. An opened box of bacon was stored on a shelf in the walk-in refrigerator. The box was not covered or sealed. 3. On [DATE] at 10:36 AM, The following observations were made in the walk-in freezer: a. An opened box of pizza was stored on a shelf in the freezer. The box was not covered or sealed. b. An opened box of biscuit was stored on a shelf in the walk-in freezer. The box was not covered. c. An opened box of box of garlic bread was stored on a shelf in the walk-in freezer. The box was not covered or sealed. d. An opened box of dinner rolls was stored on a shelf in the walk-in freezer. The box was not covered or sealed. 4. On [DATE] at 10:39 AM, the following observations were made in the refrigerator in the nourishment on 200 Hall: a. A container of cantaloupe was stored on a shelf in the refrigerator located in the nourishment room on 200 Hall. The cantaloupe was discolored. The Surveyor asked the Dietary Supervisor to describe the appearance of the cantaloupe. She stated, They have mold on them. b. A box of Fat Boy ice cream was on a shelf in the freezer. There was no name or date when it was delivered c. Two bottles of Virgil's Root Beer were stored on a shelf in the refrigerator. There was no name or date when it was received. 5. On [DATE] at 11:03 AM, Dietary Employee #1 used a teaspoon to place 2 spoonfuls of beef base in a cup. Dietary Employee turned on the two-compartment sink faucet and obtained water from the sink. After obtaining water from the sink, he turned off the faucet with his bare hand. Then, picked up the clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the resident on a puree diet for lunch meal. 6. On [DATE] at 11:28 AM, Dietary Employee #1 touched his mask and without washing his hands, he picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the resident on a pureed diet for lunch. When he was ready to place food into a blender to puree, he immediately was stopped and the Surveyor asked him, what should you have done after touching dirty objects and before handling clean equipment. He stated, Washed my hands and rewash the equipment. 7. On [DATE] at 11:40 AM, Dietary Employee #1 took out a bag of shredded lettuce from the walk-in refrigerator and placed it on the counter. He opened the bag and without washing his hands, he removed a glove from the glove box and placed it on his right hand, which contaminated the glove. He then used the contaminated gloved hand to press shredded lettuce down into a pan to be served to the residents for lunch. 8. The facility's policy on hand washing provided by the Administrator at 2:33 PM documented under procedure Dry hands thoroughly with paper towels and then turn off faucets with a clean dry paper towel.

Based on observation, record review, and interview, the facility failed to ensure that an unattended medication cart was secured, and the resident Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #19) sampled resident. This failed practice had the potential to affect all 65 residents in the facility as documented by the Resident Census and Conditions of Residents, which was provided by the Administrator on 8/10/22 at 9:21 AM. The findings are: 1. Resident #19 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/30/22 documented a Brief Interview of Mental Status (BIMS) of 10 (7-12 indicates moderate cognitive impairment) cognitive status. a. Resident #19 care plan last reviewed on 3/2/22 documented, .Focus: The resident has impaired cognitive function, memory deficits, impaired decision-making ability secondary to progressive dementia . b. Resident #19 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Resident #19 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . d. On 08/08/22 at 10:42 AM, Resident #19 was sitting up in chair in room with feet up in w/c (wheelchair). Right foot with sock on and resident states that she has a sore foot. States it started out as a small sore and now is a big wound. No bootie on foot. Resident in discomfort. Two pills noted to pill cup on bedside table. Resident does not know what they are but states she was supposed to take them this morning. Resident precedes to take the medications before surveyor can alert staff. One pill is a small round yellow pill the other is a larger round pinkish orange pill. Resident with noted bruises to bilateral hands. Resident does not know how she got them. States Maybe from my watch. She is unsure if she is on blood thinner. 2. On 08/09/22 at 08:07 AM, the medication cart on the 100 hall was unlocked med cart with keys hanging out of the lock and the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no nurse present. (Photo) 3. On 08/09/22 at 8:09 AM, Licensed Practical Nurse (LPN) #1 exited a resident room where the door had been closed. She stated, Oh that's not good. The Surveyor asked, Is this your cart? She answered, Yes. The Surveyor asked, can you tell me what is wrong? She answered, The keys are hanging out and the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ? She answered, Someone could swipe them. The Surveyor asked, what could happen if the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ? She answered, Someone could read it and they aren't supposed to. 4. On 08/10/22 at 10:15 AM, The Surveyor asked LPN #2, how should the medication cart be secured when not in use? She answered, Locked. Nurse keeps the keys. Cart turned toward the wall. The Surveyor asked, how should the MAR be secured when not in use? She answered, Locked and off screen. She was asked, what could happen if the cart is not secured and if the keys are in the lock when the cart is unattended? She answered, A resident could get the meds out and someone could get harmed. She was asked, what could happen if the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ? She answered, It's a breach of privacy. 5. On 08/10/22 at 10:35 AM, the Surveyor asked Director of Nursing (DON), how should the medication cart be secured when not in use? She answered, Locked. Keys in the nurse's pocket. The Surveyor asked, how should the MAR be secured when not in use? She answered, Hidden screen or closed. The Surveyor asked, what could happen if the cart is not secured and if the keys are in the lock when the cart is unattended? She answered, Anyone could get in it. The Surveyor asked, what could happen if the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ? She answered, It's a breach of privacy. 6. A Policy titled, Medication Storage in the Facility which was provided by the Administrator on 8/10/22 at 10:44 AM documented, . Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .

F867 483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies. Based on observation, record review and interview the facility failed to use the Quality Assessment and Assurance to develop and implement appropriate plans of action to correct identified quality deficiencies. This failed practice had the potential to affect all 63 residents as documented on the Census and Condition provided by the Administrator on 10/17/22 at 12:57 p.m. The findings are: 1. On 10/19/22 at 9:31 a.m., the Surveyor asked the Administrator, did the facility identified the survey issues on 8/11/22 to QA&A? The Administrator replied, I think so, let me look for them. 2. On 10/19/22 at 9:48 a.m. a review of the Grievance Log for September 2022 documented a Grievance from a non-sampled resident 0n 9/15/22 regarding showers. A review of the Grievance Log for October 2022 documented two grievances from two non-sampled residents on 10/11/22 regarding showers. 3. On 10/19/22 at 10:30 a.m. a review of the Grievance forms all documented not getting showers on Saturdays, 2-3 weeks since last shower, and not receiving showers consistently. 4. On 10/19/22 at 11:30 a.m. the Administrator stated, I don't believe we QA'd the survey issues, but I will keep looking for them. The Surveyor asked the Administrator, in light of the grievance's made after your date of alleged compliance, should it have been addressed with the Quality Assessment and Assurance team? The Administrator replied, yes.

F867 483.75(g) Quality assessment and assurance. S483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies. Based on observation, record review and interview the facility failed to use the Quality Assessment and Assurance to develop and implement appropriate plans of action to correct identified quality deficiencies. This failed practice had the potential to affect all 63 residents as documented on the Census and Condition provided by the Administrator on 10/17/22 at 12:57 p.m. The findings are: 1. On 10/19/22 at 9:31 a.m., the Surveyor asked the Administrator, did the facility identified the survey issues on 8/11/22 to QA&A? The Administrator replied, I think so, let me look for them. 2. On 10/19/22 at 9:48 a.m. a review of the Grievance Log for September 2022 documented a Grievance from a non-sampled resident 0n 9/15/22 regarding showers. A review of the Grievance Log for October 2022 documented two grievances from two non-sampled residents on 10/11/22 regarding showers. 3. On 10/19/22 at 10:30 a.m. a review of the Grievance forms all documented not getting showers on Saturdays, 2-3 weeks since last shower, and not receiving showers consistently. 4. On 10/19/22 at 11:30 a.m. the Administrator stated, I don't believe we QA'd the survey issues, but I will keep looking for them. The Surveyor asked the Administrator, in light of the grievance's made after your date of alleged compliance, should it have been addressed with the Quality Assessment and Assurance team? The Administrator replied, yes.

Based on observation, record review and interview, the facility failed to ensure an oxygen nasal cannula tubing was stored in accordance with professional standards of practice when not in use for 2 (Resident #10, 33) of 5 (Resident #26, 40, 33, 28, 10) sampled residents who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident #10 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 5/7/22 documented a score of 01 (00 - 07 indicates severe impairment) on the Brief Interview for Mental Status (BIMS). She received oxygen while a resident. a. On 08/08/22 at 11:13 AM, Resident #10 was in her wheelchair (w/c) in the Activity Room. A portable oxygen cylinder was on the back of her wheelchair. The oxygen tubing was not connected to the cylinder. The end of the tubing that connects to the cylinder was hanging down, touching the back of the resident's wheelchair. The tubing was dated 08/8/22. b. On 08/09/22 at 11:52 AM, Resident #10 was in the dining room sitting in the wheelchair using portable oxygen cylinder at 2 liters. The tubing was connected to the portable cylinder and dated 8/8/22. c. On 08/10/22 at 01:39 PM, the Surveyor asked the MDS Coordinator, what is a care plan? She answered, What guides the staff with care provision based on the resident preferences and their disease process. The Surveyor asked, Does Resident #10 have a care plan for oxygen? She answered, No, but she will in a few minutes. The Surveyor asked, should she have a care plan for oxygen? Yes. d. On 08/10/22 at 02:00 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1, if Oxygen is not in use, how should tubing be stored? She answered, In a plastic Ziplock bag. The Surveyor asked, what could happen if tubing is not stored correctly? She answered, It could drop on the floor. The Surveyor asked, If there is a chance that tubing is contaminated, what should you do with the tubing? She answered, Replace it. e. On 08/10/22 at 02:15 PM, the Surveyor asked CNA #1, if Oxygen is not in use, how should tubing be stored? She answered, The nurses usually do this, but I think in a plastic Ziplock bag. The Surveyor asked, what could happen if tubing is not stored correctly? She answered, It could get broken, damaged, or not work right. The Surveyor asked, if there is a chance that tubing is contaminated, what should you do with the tubing? She answered, Dispose and get new. f. On 08/10/22 at 03:30 PM, the Director of Nursing (DON) was asked, if oxygen is not in use, how should the tubing be stored? She answered, In a bag. She was asked, what could happen if the tubing is not stored in a bag? She answered, It could become soiled or be a tripping hazard. She was asked, if there is a chance the tubing is soiled, what should you do with the tubing? She answered, throw away and get new. 2. Resident #33 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/11/22 documented a Brief Interview of Mental Status (BIMS) of 11 (7-12 indicates moderate cognitive impairment) cognitive status. The MDS also documented, .While a Resident .Oxygen .Yes . a. Resident #33 care plan that was last reviewed on 3/25/22 documented, .Focus: The resident has [CONDITION(S)] ([CONDITION(S)]) and chronic [CONDITION(S)] r/t (related to) history of asthma, positive smoking history- not currently smoking .Interventions: OXYGEN SETTINGS: O2 (oxygen) via (by) NC (nasal cannula) @ 5L (liters) continuously as tolerated, may remove for ADLs (activities of daily living) as needed/desired. Humidified while on concentrator. No humidification w/ [with] portable tanks. b. Resident #33 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .every shift for to maintain sats [saturation] > 90% related to CHRONIC [CONDITION(S)], UNSPECIFIED WHETHER WITH [CONDITION(S)] OR HYPERCAPNIA (J96.10) . c. On 08/08/22 at 11:39 AM, Resident #33 was sitting up in recliner in room O2 on at 4 liters via nasal cannula (NC). Resident states it should be at 4 or 5. Tubing on oxygen tank on w/c is laying in seat of w/c not bagged. Resident has no complaints of care. d. On 08/09/22 at 09:19 AM, Resident was up in room walking behind w/c with O2 on via NC and resident turns it on to 3L herself. Tubing for concentrator is laying over bed with no bag. Concentrator is set to 4L. e. On 08/10/22 at 02:25 PM, Resident is up in w/c sitting in activity room with O2 on via NC at 3L. The Surveyor asked LPN #3, to observe resident's oxygen and asked LPN #3, What is R #33 oxygen set at? He said, It's at 3 liters. The Surveyor asked, Do you know what the order is for? He said, I believe she came in on a high flow of 5 liters. He proceeded to check the computer and then said, Yes, it is 5 liters continuous. LPN #3 then went to resident and increased the flow rate to 5 liters. He then stated to surveyor, I believe she turns it to 3 liters herself. The Surveyor asked, What could the complications be if the oxygen is not set at the correct rate? He said, Her O2 sat is not going to be what it should be.

Based on record review and interview, the facility failed to review and revise the resident care plan to meet the residents' needs to reflect the use of oxygen for 1 (Resident #10) of 5 (Resident #26, 40, 33, 28, 10) sampled residents who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Resident #10 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an Assessment Reference Date of 5/7/22 documented a score of 01 (00 - 07 indicates severe impairment) on the Brief Interview for Mental Status (BIMS). She received oxygen while a resident. a. On 08/08/22 at 11:13 AM, Resident #10 was in her wheelchair in the Activity Room. A portable oxygen cylinder was on the back of her wheelchair. The oxygen tubing was not connected to the cylinder. b. On 08/08/22 at 12:35 PM, Resident #10 was in the dining room. The oxygen tubing was not connected to portable cylinder. c. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ (at) 1-4 LPM (liters per minute) via (by way of) n/c (nasal cannula) prn (as needed for] SOB (shortness of breath) . d. Resident #10's Care Plan did not document the use of oxygen. e. Section 4.7 of the RAI (Resident Assessment Instrument) Manual documented, . The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving . 2. Resident #16 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 5/16/22 documented a score of 12 (8 - 12 indicates moderate impairment) on the BIMS. She received Anticoagulant Medications 7 days during the lookback period. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)]. b. Resident #16's Care Plan did not document the use of Anticoagulant Medication. c. On 08/10/22 at 01:39 PM, the Surveyor asked the MDS Coordinator, what is a care plan? She answered, What guides the staff with care provision based on the resident preferences and their disease process? The Surveyor asked, Does Resident #10 have a care plan for oxygen? She answered, No, but she will in a few minutes. The Surveyor asked, should she have a care plan for oxygen? Yes. Does Resident #16 have a care plan for anticoagulant? MDS Coordinator stated, No. The Surveyor asked, should she have a care plan for anticoagulant? The MDS Coordinator stated, Yes.

Based on record review and interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) within 14 days of determining a decline in Activities of Daily Living (ADLs) for 2 (Resident #10, 20) sampled residents. This failed practice had the potential to affect 65 residents in the facility as documented on the Resident Census and Conditions of Residents which was provided by the Administrator on 8/10/22 at 9:21 AM. The findings are: 1. Resident #10 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an Assessment Reference Date (ARD) of 5/7/22 documented a score of 01 (00 - 07 indicates severe impairment) on the Brief Interview for Mental Status (BIMS). a. The Quarterly MDS with an ARD of 2/4/22 documented Resident #10 required extensive assistance from one staff member for bed mobility, transfers, and toilet use. She required limited assistance from one staff member for eating. b. There was no Significant Change in Status MDS completed in May 2022. 2. Resident #20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 5/23/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a BIMS. a. On 08/08/22 at 11:00 AM, R#20 was interviewed while sitting on her bed in her room. R#20 stated she was not getting therapy for my legs and I need it, so my legs do not get any worse since her fall. b. On 08/10/22 at 02:00 PM, during electronic record review to locate restorative or therapy notes for the last 120 days, the Surveyor found decline in Activities of Daily Living (ADLs) from Quarterly MDS 2/20/22 to Quarterly MDS 5/23/22 in all ADLs from Extensive Assistance (3)/One-person physical assist (2) to Extensive Assistance (3)/Two-person physical assist (3) in all areas except eating and locomotion on & off unit. Surveyor found no Significant Change MDS in electronic records. 3. Page 47 of the Resident Assessment Instrument (RAI) manual documented, . An SCSA (Significant Change in Status Assessment) is appropriate if there are . two or more areas of decline or two or more areas of improvement . a. The RAI Manual pages 2-7 which was provided by the MDS Coordinator documented, . Guidelines for Determining Significant Change in Resident Status . Decline in two or more of the following Overall deterioration of resident's condition; resident receives more support (e.g., in ADLs .) . 4. On 08/10/22 at 01:34 PM, the Surveyor asked the MDS Coordinator, what is a Significant Change in Status MDS? She answered, A change in 3 or more ADLs either improvement or decline that will not resolve in 14 days, admit to hospice or discontinue hospice. The Surveyor asked to review Resident #1's Quarterly MDS from 2/4/22 and 5/7/22. The Surveyor asked, should there have been a Significant Change MDS done? She answered, Hers is not a decline in self-performance. It's a decline in staff support. I don't think that will trigger a significant change. And the system didn't prompt me to do one. Let me find out if I should have done one. a. On 08/10/22 at 01:55 PM, The MDS Coordinator stated I talked to my consultant, and she said the amount of staff support does not trigger a significant change. One episode in the lookback period will change how I code it. The Surveyor asked her to provide the page from the RAI manual to support the Consultant's statement.

Based on interview and record review, facility failed to ensure residents' preferences were accommodated and had the right to choose their schedule and make choices regarding when they bathe and not develop a schedule for bathing without the input of the residents. This failed practice had the potential to effect 45 resident's dependent or requiring assistance for showers/baths per list provided by Administrator 8/10/22. The findings are: 1. On 08/08/22 during initial rounds of facility, Resident # 41 stated there are not enough staff to get showers during the day. R # 41 stated she has not had a shower in 2 weeks because she refused one Thursday when they tried to give her a shower at 9 PM and she was tired. R # 41 stated, they should not bring in any more people if they cannot take care of who they already have. R # 41 stated I know I get impatient, but I should not have to wait until 9 PM or 2 weeks to get a shower. They tell me I cannot ask for a shower when it is not my shower day. a. On 08/10/22 at 03:12 PM, R # 41, was lying in bed on left side was asked, What is your schedule for showers She said, Monday and Thursday. She was then asked, When would you like to have your showers? She said, Monday and Thursday is fine but during the day instead of the evening. She was then asked, Do you prefer showers or baths? She said, Showers is fine. 2. On 08/09/22 from 02:31 PM to 04:12 PM, the Surveyor interviewed Resident Council members due to concerns voiced during initial rounds by residents about not receiving showers and shower grievances and resident council notes. a. Resident # 19 was asked about showers/baths and stated, The nurses are trying but there is not enough of them. My showers do not always happen. I also do not like that they tell me when I must have a shower. Some days I am not dirty but other days I am and then it is not my day they tell me. b. Resident # 21 was asked about showers/baths and stated, My catheter leaks and my penis drips and I need a shower at least 2xs [times] a week. I don't get them sometimes and I have to use all my energy and wash with a rag in the bathroom myself and then I am drained the rest of the day. It wears me to a frazzle. They say these are the golden years, but they are not when you have to rely on others to help you be clean and they don't come. I wanted a shower, and it was not my shower day, so I was told they would try to fit me in but never came back. We have told them repeatedly at the resident council meetings about the shower issues everyone is having but nothing changes. They even told a man he cannot have a bath and has to have a shower because he is incontinent. That is odd because a lot of elderly are incontinent. I'm sure they have chemicals to clean the tub or is it just a hassle to them. c. Resident # 22 was asked about showers/baths and stated, It is important to me to get a shower each day. They won't let me get one each day and sometimes I don't get them on my shower days either. They also come when I am at an activity or playing a game with [husband] and they say I have to go then, or I won't get one. That's not right. d. Resident # 33 was asked about showers/baths and stated, I am scheduled for Wednesdays, and Saturdays and it is a joke trying to get a shower on Saturdays. There are never enough nurses here. I want my shower in the mornings to start my day clean but then the nurse comes when I am doing something or late in the evening and says if I don't go, I will not get one. They often come late in the evening, and I am ready for bed not a shower. e. Resident # 38 was asked about showers/baths and stated, I want a whirlpool bath, but they say I have to take a shower because I am incontinent. They tell me I will contaminate the whirlpool and they cannot clean it. I don't know why they can't clean it like a public pool that kids go to the bathroom in. I really prefer baths. f. Resident # 44 was asked about showers/baths and stated, It's rare that we get a shower twice a week. It is not really their fault because they do not have enough nurses. I have a catheter that goes down under my chair and I know it's a hassle to give me a shower, but I don't want to smell. 3. On 08/10/22 at 01:27 PM, Surveyor interviewed Licensed Practical Nurse (LPN)#3 regarding showers/baths. How often do residents receive showers/baths? The LPN stated Obviously it should be at least twice a week, but sometimes that gets neglected due to staffing issues. Unfortunately, showers get lost or put off until their next shower day. Do residents receive showers/baths on a specific schedule? The LPN stated, Yes, the system tells the Assistants which days to give which residents a shower or bath. Can residents receive showers/baths on other days and at other times? Of course, if we have enough staff. When we only have one aide on a hall, then the bath is no longer a priority. Unfortunately, that happens more than we like. Are there times of day that showers/baths should be given? The LPN stated, I see my assistants try to give them late morning and then after lunch. If you lived at the facility, would you be ok with staff coming to give your shower at 9 PM once you are in bed? Once I am in bed, I don't want to get up and take a shower. 4. On 08/10/22 at 01:41 PM, Surveyor interviewed Certified Nursing Assistant (CNA)#2 regarding showers/baths. How often do residents receive showers/baths? The CNA stated, Two times a week. Do residents receive showers/baths on a specific schedule? The CNA stated, Yes ma'am Can residents receive showers/baths on other days and at other times? The CNA stated, Yes ma'am. I just did 2 today that were not on the schedule. Do staffing shortages affect being able to receive showers/baths? The CNA stated, I think all kinds of things get in the way and effect residents not receiving showers when they want. I don't think it is necessarily staffing because department heads can help if we need. Surveyor asked, So, department heads give showers when staffing or other things get in the way? CNA stated, If need be, I can get a department head to help me. They do not necessarily give showers but can help me transfer a resident so I can give a shower. Are there times of day that showers/baths should be given? The CNA stated, Depending on the hours I am here. If I am here 7 to 3 then I give them then. If I am here 3 to 11, I give them then. I have 'til then to get them done. If you lived at the facility, would you be ok with staff coming to give your shower at 9 PM once you are in bed? The CNA stated, If it was me, yeah, because I am a night owl. If a resident was awake at night and wanted a shower then and I was working, I would give it then. 5. On 08/10/22 at 03:17 PM, Surveyor interviewed Administrator regarding showers/baths. How often do residents receive showers/baths? The Administrator stated, They are encouraged and offered a minimum of 2 times a week. Do residents receive showers/baths on a specific schedule? The Administrator stated, Yes, the system prints the list for staff of which residents are to receive their shower or bath each day. Can residents receive showers/baths on other days and at other times? The Administrator stated, Yes Can residents receive more than two baths/showers a week? Yes Have staff reported that showers are affected by staffing issues and other things that get in the way and do not happen because they are a low priority? No, I haven't Are there times of day that showers/baths should be given? The Administrator stated, Usually, 1st and 2nd shifts between 6:30 AM and 11 PM, but hopefully not that late at night. If you lived at the facility, would you be ok with staff coming to give your shower at 9 PM once you are in bed? The Administrator stated, I probably would not be. Were you aware that not receiving showers/baths and staff not listening to when residents want showers/baths has been brought up in resident council meetings for at least the past 3 months and some grievances? The Administrator stated, I was not aware until I gave you the copies of the notes. 6. On 08/08/22 at 11:57 AM, Grievances and Resident Council reports for last 3 months received from the Administrator. Surveyor reviewed the documentation. a. July grievance log documented, .07/20/22 R#44 Concern: not receiving regular showers .07/8/22 R#18 Concern: No bath/shower June grievance log documented, .06/6/22 R#44 Concern: showers . May grievance log documented, .05/26/22 R#11 Concern: Bath . b. July Resident Council report documented, .07/19/22 .residents would like time frame as to when they will receive a shower .[R#38] would like a whirlpool bath instead of a shower .Residents knew when their shower days were .07/20/22 [R#38] unable to accommodate whirlpool request - resident has become severely incontinent, so due to possible contamination of whirlpool - he has been receiving regular showers .[R#21] made aware of scheduled shower days and shift .(DON) . June Resident Council report documented, .06/14/22 .[R#19] wants to know in advance when she will get a shower. [R#22] reported she wants this too .05/18/22 Residents made aware of shower shift and days .Director of Nursing (DON) . May resident council report documented, .05/17/22 .residents report that they don't consistently receive their shower .05/18/22 Showers addressed [residents] repeatedly refuse showers without adequate notice . (DON) . 7. On 08/11/22 at 10:27 AM, Administrator came into conference room and stated facility does not have a shower policy and they follow the federal guidelines.

Based on record review and interview, the facility failed to ensure each resident in a nursing facility was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 (R #19) of 26 (R #7, 22, 29, 258, 26, 46, 56, 31, 50, 38, 8, 24, 40, 19, 42, 55, 20, 49, 41, 52, 15, 209, 28, 16, 45, 23 and 42) sample selected residents according to a list provided by the Administrator on 8/11/22 at 9:05 am. The findings are: 1. Resident #19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/27/21 documented a Brief Interview of Mental Status (BIMS) of 10 (7-12 indicates moderate cognitive impairment) cognitive status. The MDS also documented, Is the resident currently considered by the state level II PASRR (Pre-Admission Screening and Resident Review) process to have serious mental illness and/or intellectual disability or a related condition? No . a. R #19 care plan last reviewed on 3/2/22 documented, .Focus: The resident had impaired cognitive function, memory deficits, impaired decision-making ability secondary to progressive dementia . b. R #19 did not have any documented PASARR on file. c. On 8/10/22 at 1:23 PM, the Surveyor asked the Administrator, Were you able to locate R#19's PASARR? He said, Her PASARR was done before the facility was bought by the current company and we are looking through boxed records to locate it.

F657 S483.21(b) Comprehensive Care Plans S483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Based on observation, record review and interview the facility failed to revise a care plan for oxygen for 1 (Resident #209). This failed practice had the potential to affect 32 residents with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident #209 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/27/22 documented a Staff Assessment for Mental Status (SAMS) as short-term memory problem, long-term memory problem, and oxygen. The care plan was not revised to reflect oxygen. 2. On 10/17/22 at 11:50 a.m. R#209 was observed in bed with eyes closed oxygen concentrator running at 2 liters via nasal cannula. 3. On 10/17/22 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .may have oxygen at 1-4 lpm (liters per minute) via nasal canula prn (as needed) for shortness of breath .