Every finding on record at Holland Lake Rehabilitation and Wellness Center

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 5 of 7 residents (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for care plans. 1. The facility failed to ensure the staff implemented the comprehensive care plan goals and interventions for Resident #1. 2. The facility failed to ensure the comprehensive care plan for Resident #2, Resident #3, Resident #4 and Resident #5 described the resident's goals for admission and desired outcomes. 3. The facility failed to ensure the comprehensive care plans for Resident #2, Resident #3, Resident #4 and Resident #5 described the resident's preference and potential for future discharge. 4. The facility failed to ensure the comprehensive care plans for Resident #2, Resident #3, Resident #4 and Resident #5 documented a desire to return to the community was assessed. These failures could place residents at risk of inadequate care and services resulting in physical harm or psychosocial harm.Findings include: Record review of Resident #1's face sheet, reviewed on 4/11/2026, revealed an [AGE] year-old male with an admission date of 01/07/2026. Resident #1 had diagnoses which included: type 2 diabetes (body does not use insulin and sugar builds up in the blood), fracture of lower end of right femur (break in lower thigh bone above knee), hypertension (high blood pressure), disorder of kidney and ureter (blockage where kidney and ureter meet and may cause kidney to swell and eventually stop working), leukemia (cancer of blood-forming tissues, including bone marrow and lymphatic system), atrial fibrillation (irregular and often very rapid heart rhythm), muscle wasting and atrophy (reduction in muscle thinning and mass). Record review of Resident #1's comprehensive care plan, dated 1/29/2026, revealed Resident #1 had potential for signs and symptoms and complications related to hypertension. The comprehensive care plan intervention for this focus was to give anti-hypertensive meds as ordered. Observe for side effects such as orthostatic hypotension, and increased heart rate. Record review of Resident #1's Physician Orders, dated 01/26/2026, revealed AmLODIPine Besylate tablet 10 MG to give 1 tablet by mouth one time a day for HTN. Hold for SBP less than 110. The Physician Orders further revealed Metoprolol Tartrate Oral Tablet 100MG to give 1 tablet by mouth two times a day for HTN. Hold for HR less than 55 and/or SBP less than 100. Record review of Resident #1's MAR, reviewed on 4/12/2026, revealed on 4/07/2026, Resident #1's blood pressure reading was 109/52 and HR of 53. RN administered AmLODIPine Besylate and Motoprolol despite the hold parameters in the physician orders for both medications. In an interview on 4/12/2026 at 11:34 a.m. with RN, she revealed she did provide the HTN medications to Resident #1 on 4/7/2026, because she utilized her nursing judgement instead of following the physician orders. RN stated Resident #1's blood pressure was borderline, and he was about to get up for therapy. She stated to get this resident up was a workout for him and therapy would also get his blood pressure and HR up. The RN stated her fear was his blood pressure would skyrocket during therapy. The RN stated she should have contacted the doctor before administering the medication. She also stated Resident #1's blood pressure and heart rate were good and back up later per documentation, so nothing bad happened to Resident #1. Record review of Resident #2's face sheet, reviewed on 4/11/2026, revealed a [AGE] year-old female with an admission date of 12/06/2025. Resident #2 had diagnoses which included: metabolic encephalopathy (brain dysfunction due to an underlying condition), hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side (partial weakness and motor impairment on one side often due to brain damage), cerebral infarction (stroke caused by blockage in an artery supplying blood to the brain resulting in tissue death due to lack of oxygen), narcolepsy without cataplexy (sudden and temporary muscle weakness usually triggered by strong emotions), depression (persistent sadness interfering with daily life). Record review of Resident #2's comprehensive care plan record, dated 2/12/2026, revealed no evidence of documented discharge plans or discharge assessments. In an attempted interview on 4/10/2026 at 3:45 p.m. with Resident #2, she did not answer questions and was uninterviewable. Record review of Resident #3's face sheet, reviewed on 4/11/2026, revealed a [AGE] year-old female with an admission date of 01/16/2026. Resident #3 had diagnoses which included: type 2 diabetes (body does not use insulin and sugar builds up in the blood), spinal stenosis (space inside backbone too small), bipolar disorder (extreme mood swings), emphysema resulting from a procedure (air gets into tissues under the skin). Record review of Resident #3's comprehensive care plan record, dated 3/16/2026, revealed no evidence of documented discharge plans or discharge assessments. In an interview on 4/10/26 at 6:15 p.m. with Resident #3, she stated staff make sure she is taken care of. Resident #3 stated she finally realized she cannot live on my own. Record review of Resident #4's face sheet, reviewed on 4/11/2026, revealed a [AGE] year-old female with an admission date of 03/01/2023. Resident #4 had diagnoses which included: atrial fibrillation (irregular and often very rapid heart rhythm), unspecified dementia (loss of memory, language problem-solving and other thinking abilities affecting daily life), depression (persistent sadness interfering with daily life), atherosclerotic heart disease of native coronary artery (hardening of artery from gradual plaque buildup), cognitive communication deficit (problem with communication due to a disruption in cognitive processes). Record review of Resident #4's comprehensive care plan record, dated 04/09/2026, revealed no evidence of documented discharge plans or discharge assessment. In an interview on 4/10/2026 at 1:06 p.m. with Resident #4, she revealed she was cared for by staff and had no concerns. She stated she was not sure if she would stay at the facility but had no plans to leave currently. Record review of Resident #5's face sheet, reviewed on 4/11/2026, revealed a [AGE] year-old male with an admission date of 01/28/2025. Resident #5 had diagnoses which included: major depressive disorder (persistent low mood and loss of interest in activities), type 2 diabetes (body does not use insulin and sugar builds up in the blood), nontraumatic subdural hemorrhage (type of bleeding in the head when blood collects under outer layer of tissue closest to the skull between brain and skull), acquired absence of right and left foot, hemiplegia and hemiparesis following cerebral infarction (weakness on one of the body due to lack of blood flow to the brain). Record review of Resident #5's comprehensive care plan record, dated 03/11/2026, revealed no evidence of documented discharge plans or discharge assessments. In an interview on 4/10/2026 at 4:10 p.m. with Resident #5, he stated staff took care of his needs and he had no concerns. In an interview on 04/12/2026 at 11:13 a.m. with the ADON, she stated the SW, DON, activities, dietary, and therapy all met to set up the care plan and goals of if the resident would go home or if they would set up more skilled days or not. The ADON stated she believed they all had a part in documenting discharge plans for the residents. She stated a negative effect of the discharge plan not documented on the care plan could be the residents not being followed up with properly. In an interview on 4/12/2026 at 12:12 p.m. with the DON, she stated the SW was responsible for documenting discharge planning in the care plan. In an interview on 4/12/2026 at 12:38 p.m. with the SW, she stated she was the person responsible for documenting discharge planning in the care plan. The SW stated she was aware discharge information was supposed to be in the care plan. She stated she felt it was in the care plan under psychosocial well-being due to long-term care placement. The SW stated she did not document if the resident planned to stay at the facility, but it was documented elsewhere. The SW further stated if it was not in the care plan, she had not gotten to it yet. In an interview on 4/12/2026 at 2:11 p.m. with the ADM, she stated she did not feel there were any negative effects from the discharge planning not being in the care plan because staff always looked at discharge planning and addressed it. Record review of the Comprehensive Care Planning policy, dated December 2016, reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will: a.c. Describe services That would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; d.f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desired.

Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 7 resident's (Resident #1) reviewed for pharmaceutical services. The facility failed to ensure staff followed physician orders in administering Resident #1's medication. This failure could place residents at risk of physical harm and inadequate care and services.Findings include: Record review of Resident #1's face sheet, dated 4/11/2026, revealed an [AGE] year-old male with an admission date of 01/07/2026. Resident #1 had diagnoses which included: type 2 diabetes (body does not use insulin and sugar builds up in the blood), fracture of lower end of right femur (break in lower thigh above knee), hypertension (high blood pressure), disorder of kidney and ureter (blockage where kidney and ureter meet and may cause kidney to swell and eventually stop working), leukemia (cancer of blood-forming tissues, including bone marrow and lymphatic system), atrial fibrillation (irregular and often very rapid heart rhythm), muscle wasting and atrophy (reduction in muscle thinning and mass). Record review of Resident #1's Physician Orders, dated 1/26/2026, revealed AmLODIPine Besylate tablet 10 MG to give 1 tablet by mouth one time a day for HTN. Hold for SBP less than 110. The Physician Orders further revealed Metoprolol Tartrate Oral Tablet 100MG to give 1 tablet by mouth two times a day for HTN. Hold for HR less than 55 and/or SBP less than 100. Record review of Resident #1's MAR, reviewed on 4/12/2026, revealed on 4/07/2026, Resident #1's blood pressure was 109/52 and HR was 53. RN administered AmLODIPine Besylate and Metoprolol despite hold parameters in the physician orders for both medications. In an interview on 4/10/2026 at 7:08 p.m. with Resident #1, he stated he believed he got his medications correctly and experienced no issues with his medications. Resident #1 stated the only concern he had was he got cold. In an interview on 4/12/2026 at 11:34 a.m. with RN, she revealed she was trained in medication administration. The RN stated she did provide the HTN medications to Resident #1 on 4/7/2026, because she utilized her nursing judgement instead of following the physician orders. The RN stated Resident #1's blood pressure was borderline, and he was about to get up for therapy. She stated to get this resident up was a workout for him and therapy would also get his blood pressure and HR up. The RN stated her fear was his blood pressure would skyrocket during therapy. The RN stated she should have contacted the doctor before administering the medication. In an interview on 4/11/2026 at 1:38 p.m. with LVN, she stated too much blood pressure medication could make a person dizzy or non-responsive and not enough could also make them dizzy as it depended on the patient. In an interview on 4/12/2026 at 11:13 a.m. with the ADON, she stated all nurses were trained in medication administration. The ADON stated she was not aware the RN provided HTN medications outside of physician order parameters to Resident #1. She stated this could cause dizziness and hypotension episodes such as not being able to stand up, faint, or have a fall. The ADON stated other negative effects could be that the patient may not feel good and it could make them feel cold. In an interview on 4/12/2026 at 12:12 p.m. with the DON, she stated she was not aware the RN provided medications outside of parameters for Resident #1. The DON stated parameters were there for a reason and the nurses were not to make that judgment call and the RN should have contacted the doctor and documented the conversation. The DON stated the negative effect could have been Resident #1's blood pressure could have dropped. The DON did not provide further effects on blood pressure dropping. In an interview on 4/12/2026 at 2:11 p.m. with the ADM, she stated she could not say if there would be a negative effect of the RN providing the medication to Resident #1 and not following parameters because that was a medical question. The ADM stated they would educate staff to make sure they follow parameters in the future. Record review of Administering Medications policy, dated December 2012, revealed Medications shall be administered in a safe and timely manner, and as prescribed.3. Medications must be administered in accordance with the orders, including any required time frames.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food service. The facility failed to ensure that the dietary staff performed proper hand hygiene when entering the kitchen area and between tasks. The facility failed to ensure that kitchen equipment and nutrition service areas (nourishment rooms) were maintained in clean and in sanitary conditions. The facility failed to properly label open food items in the kitchen and nutrition areas. These failures placed residents at risk for foodborne illness and infection.Findings included: In an observation and interview on 1-6-2026 at 9:00 AM during the initial tour of the kitchen, it was revealed that several pieces of equipment were dirty. The steam table had a large amount of a white dry substance on the lower shelf. The steam table temperature control knobs and areas around the knobs had dried food substances on them. The oven had a brown dry substance on the exterior shelf area below both doors and food buildup on the inside of the doors. The front of the fryer had grease buildup present. The ceiling tiles were dirty and discolored. There was rust on the metal crossbars that held the ceiling tiles in place. There were 2 partial loaves of bread on a prep table that had no labels of date received, opened or date to discard. DM placed date on bread loaf bags at this time and stated they usually do not label bread as the bread cart in the storage room has dates it was received, and they do not date the bread once it has been opened. She also stated that bread is to be used within 5 days of package being opened. In an observation on 1-6-2026 at 11:05 AM Cook-A was observed using drinking cups to scoop ice from a round silver kitchen bowl with bare hands. She used each individual cup as a scoop and placed cups on tray and filled them with tea or juice for the lunch meal. After ice and drinks were placed in the cups, she placed a lid on each cup with bare hands. In an observation on 1-6-2026 at 12:15 PM DA-C entered the kitchen from a non-food service area and failed to wash her hands. She was observed exiting a break room/storage area located within the kitchen with her cellphone in hand and placed it in the right leg pocket of her pants. She proceeded to come in contact with resident trays without performing any hand hygiene. This was observed a total of 3 times during the meal prep and lunch service. In an observation on 1-6-2026 at 12:20 PM staff member DA-B came into contact with uncooked food with bare hands. She had previously prepared buttered bread with cheese between two slices for grilled cheese sandwiches and placed them on parchment paper in a kitchen tray. These were also covered with parchment paper and placed near the stovetop. During lunch service she removed the sandwich from the tray without gloves and placed into a pan to cook the sandwich. She moved from the stovetop area to the microwave area to prepare tomato soup and returned to the stovetop to complete cooking of the sandwich. She did not wash her hands between tasks. She placed gloves on after returning to the stovetop, without washing her hands prior to applying gloves before starting the next sandwich. In an interview on 1-7-2026 at 1:40 PM with staff member DA-C, she was unable to verbalize facility policy regarding handwashing. During interview she reported to be new to this job and still learning her responsibilities. She also stated that an in-service was completed yesterday with DM about handwashing. She reported that not washing her hands prior to contact with food or equipment can cause the residents to become sick. She verbalized being educated to wash her hands when entering the kitchen area, when her hands are dirty, before putting on gloves and when she changes areas or tasks within the kitchen. In an interview on 1-7-2026 at 2:15 PM with DM, she stated her expectations of handwashing to be completed when entering the kitchen, after using the bathroom while still in the bathroom and to wash them again in the handwashing sink of the kitchen area, when changing stations in the kitchen and when changing gloves. She stated she expects dietary employees to use gloves when preparing food and drink items. She expects all staff and outside delivery people to use proper handwashing techniques and wear hair covering. Her expectation of kitchen equipment being cleaned depends on the specific piece of equipment. She expects the fryer be cleaned weekly, the oven should be cleaned when it is dirty, and the steam table to be cleaned as needed but at a minimum of once or twice a week. She stated that there has been a leak on the steam table causing the white dry substance on the lower shelf. She stated that maintenance department has responsibility for cleaning/replacing the ceiling tiles and it was her understanding that her boss had sent a maintenance request for those to be repaired/replaced in November or December. DM stated she has no access to the maintenance requests made by her boss and she has no access to the system to personally make requests for repair. DM stated she provided in-services with dietary staff as needed or with changes in policies. All new employees must complete facility related required training prior to training in the kitchen. Once an employee starts working in the kitchen they have 3 days of training. The first day the new employee only observes. The second day, new employee assists with tasks. The third day they are expected to do the job while being watched to ensure they complete tasks properly. DM also stated that the facility has 2 nutrition rooms located at each nurses' station. Dietary department has responsibility for stocking and maintaining snacks in those rooms. She stated that the dietary department was not responsible for cleaning or any items placed in the nutrition rooms that belong to residents or staff members. In an observation on 1-7-2026 at 2:50 PM, the nutrition room located behind the nurses' station of the 100 hall revealed the sink was full of towels. There was a sign posted indicating the sink is out of order and the paper towel holder on the wall to the left of the sink also had a sign stating the sink was out of order until further notice. The nutrition room refrigerator was at 24 degrees. The freezer had no thermometer. The refrigerator had items (pudding and yogurt) that were open with no label of when to discard. Inside of the refrigerator items were found that were partially used and had several cups of pudding that were empty with cellophane covering dated 1-6-2026 and 1-7-2026. There was a temperature log on the door of the freezer indicating daily temperature checks had been completed for the month of January. In an observation on 1-7-2026 at 3:00 PM of the nutrition room located behind the nurses' station of the 200 hall reveled a sign on the sink indicating it was out of order. There was a cup with a dark brown liquid noted sitting next to the coffee pot, it was covered with another cup of same size turned upside down on top of it. There was no label on this item describing contents or date it was prepared or should be discarded. The countertops were dirty with areas of a brown dried substance. The edge of the countertop to the right of the sink was peeling. The cabinets were in poor repair. The refrigerator had a sign on the door stating Refrigerator is for resident use only. All staff are required to use the breakroom fridge. Any and all food unlabeled and staff food found in this fridge will be thrown away daily. This refrigerator had many unlabeled items including a Styrofoam food tray marked Club sandwich 210. And a clear bowl with a blue lid also only marked with 210. There was no thermometer in the refrigerator. The freezer was at 0 degrees and all items in the freezer were solid. The freezer had many items without labels indicating who the items belong to or when they were to be discarded. There was a temperature log on the door of the freezer indicating daily temperature checks had been completed for the month of January. In an interview with facility ADMN on 1-8-2026 at 5:20 PM she stated her expectation of handwashing for dietary staff would be before entering the kitchen or after returning from a break, after using the restroom, and after touching anything contaminated. A negative outcome of not washing hands properly could result in residents becoming sick. She also stated she expects the equipment in the kitchen to be in clean, useable condition per [Company] policies. ADMN stated the nutrition rooms are cleaned by the housekeeping staff on a schedule and additionally as needed. She stated that there will be a remodel of the nutrition rooms soon. She was unable to state when remodel will occur but stated the plumbers came today and the cabinet contractors are coming soon. She stated she was aware of the non-working sinks in the nutrition rooms, and they will be repaired with the remodel. She stated that the food items in the nutrition refrigerators belong to the residents and employees are only allowed to use the refrigerator in the employee breakrooms. Record review of an undated document titled Food Receiving Policy and Procedure. Policy statement reads: This policy establishes guidelines for the safe handling of all food items during transport, delivery, and storage, with a focus on maintaining strict time and temperature controls to ensure food safety. Policy states [in part]; 5. Labeling and dating: All food items must be clearly labeled and dated using either the manufacturer's food packaging information or manual staff entries, to ensure traceability and freshness. Record review of an undated document titled Equipment Maintenance Policy and Procedure revealed: Policy statement: Our commitment is to ensure that all food service equipment remains clean, sanitary and fully operations always. Policy states [in part]; 1. Regular cleaning and maintenance of all equipment will be conducted in strict adherence to the manufactures guidelines and training materials. 3. All equipment that cones into contact with food will undergo through cleaning and sanitization after each use. 5. Requests for maintenance or repair of equipment will be promptly forwarded to the administrator and/or Maintenance Director by the Dietary Services Director, as necessary. 7. Monthly submission of service repairs and preventative maintenance reports will be ensured. Record review of document dated June 1, 2024, titled Equipment and Facility Maintenance Responsibility Policy, revealed: Policy statement [Company] Services is committed to maintaining a safe, functional and compliant physical environment for residents, staff and visitors. All equipment and facility maintenance activities are the responsibility of the Maintenance Department. Record review of an undated document titled [Company] Dietary Manager Job Routine Checklist-Daily revealed: daily tasks include Daily inventory Check, Attend Morning Meeting, Meal service Check Prior to each Service (cooks fill in when manager is offsite) Hold AM Shift Huddle, Resident Visits, Clinical Duties, Administrative Duties, Hold PM Shift Huddle. Record review of an undated document titled [Company] Dietary Manager Job Routine Checklist-Weekly reads in part: Monday: empty, degrease, clean, sanitize, refill deep fryer (if applicable). Tuesday: AM cook, clean left oven stove top, back splash and warming tray. PM cook, clean right oven, drip pans, wall behind oven equipment. Thursday: AM cook clean pot and pan racks, storage shelves under steam table. Friday PM cook: Delime steam table. Record review of an undated document titled [Company] Dietary Manager Job Routine Checklist-Monthly reads in part: Equipment Maintenance: Assign deep cleans and side work for the upcoming month. Record review of facility infection control log over the last few months did not indicate any gastrointestinal illnesses related to failures found in the kitchen or nutrition rooms.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for two (Resident #1 and, Resident #2) of three residents reviewed for infection control in that:-LVN A failed to perform hand hygiene and changed her gloves at the appropriate times while providing urostomy care for Resident #1.-CNA B failed to perform hand hygiene and change his gloves at the appropriate times while providing incontinence care for Resident #2.These deficient practices could place residents at risk for infection due to improper care practices.Findings included: Review of Resident #1's face sheet, dated 10/16/25, revealed a 90- year- old male admitted to the facility on [DATE] with diagnoses of urinary tract infection, neuromuscular dysfunction of bladder (occurs when an injury or disease disrupts the electrical signals between the nervous system and bladder function), muscle weakness and Alzheimer's disease (a degenerative brain disorder that leads to a progressive and irreversible decline in memory and cognitive abilities). Review of Resident #1's MDS assessment, dated 09/01/25, revealed Resident #1 required total dependence with most ADLs and one-person assistance with transfer. Resident #1 had a urostomy (a device that redirects the ureter (transport tube) to the abdomen to bypass the bladder after bladder or urinary tract problems). Review of Resident #1 's care plan, dated 09/18/25, revealed Resident #1 had urostomy due to diagnosis of bladder obstruction. The Its goal was to show no signs and symptoms of urinary infection through review date of 09/28/25. Observation of urostomy care on Resident #1 on 10/15/25 at 1:30 p.m. revealed LVN A washed her hands and put on gloves before the start of care. She prepared a clean field on a bedside table. LVN A removed Resident #1's brief. She emptied the urine from the pouch and removed the whole pouching system. The drained urine was clear yellow without sediments. She cleansed the stoma (a surgically created opening in the skin). There was no swelling, irritation or redness noted on the stoma area. LVN A's gloves were visibly soiled. She did not change gloves, washed her hands, or performed hand hygiene. She retrieved a new pouching system with the same soiled gloves. She prepped the skin area before inserting a new pouch system. LVN A used the same soiled gloves throughout the urostomy care. She removed her gloves and washed her hands. LVN A picked up the trash before exiting Resident #1's room. During In an interview on 10/15/25 at 1:46 p.m., LVN A said she was employed by the facility since February 2025 and received infection control training about 3 months ago. LVN A stated she should have washed her hands and performed hand hygiene before picking up the new and clean pouching system for the urostomy. LVN A said she was nervous., She said that was the reason she failed to follow a good infection control practice. She noted Resident #1 could get an infection and become sick. Review of Resident #2's face sheet, dated 10/16/25, revealed the resident was an 81- year- old female admitted to the facility on [DATE] with diagnoses of retention of urine, neuromuscular dysfunction of the bladder ((occurs when an injury or disease disrupts the electrical signals between the nervous system and bladder function), presence of urogenital implants (a medical device used to treat various conditions of urinary incontinence), constipation, muscle weakness, and dementia ( a general term for a decline in cognitive functions that interferes with daily activities). Review of Resident #2's quarterly MDS assessment, dated 09/09/25, revealed Resident #2 required moderate assistance with most ADLs and one person assistance. Resident #1 was always continent of bowel and bladder. Review of Resident #2's care plan, dated 10/14/23, revealed a diagnosis of neuromuscular dysfunction of bladder with history of retention. During an observation of incontinence care for Resident #2] on 10/16/25 at 12:45 a.m., CNA B did not wash his hands but put on gloves before the start of care. He removed Resident #2's fecal matter soiled brief. CNA B wiped the resident from front to back. He made five strokes of cleaning with the same soiled wipes. CNA A did not change his gloves and continued to clean Resident #2. CNA B's gloves were visibly soiled with fecal matter. He did not wash his hands, change gloves, or perform hand hygiene before putting on Resident #2's clean brief, and placing it underneath the resident, and fastened.it. CNA B retrieved the trash and walked out of Resident #2's room without washing his hands. During In an interview on 10/16/2052 at 12:58a.m, CNA B stated he was employed by the facility for about two 2 years. CNA B stated he could not remember the last time he received infection control training. He noted that night shift employees don't receive much training on infection control. CNA B stated cross contamination meant mixing clean with dirty. He stated he should have washed his hands and changed gloves at the appropriate times while providing care. He stated Resident #2 could get an infection as a result of for not using good infection control practices. During an interview on 10/16/25 at 1:34 p.m. the DON stated being aware of some of the concerns raised about infection control practice. She stated she and ADON C were responsible for infection control in the facility. The DON stated employees received training on hire and annually. She noted that she conducts spot checks and training with return demonstration periodically. The DON explained aides were expected to follow standard precautions including washing hands and changing gloves while providing care. The facility's Handwashing/Hand Hygiene policy, revised August 2015, revealed the following:Policy Statement:This facility considers hand hygiene the primary means to prevent the spread of infections.Policy Interpretation and Implementation1) All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2) All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.3) Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies.4) E-containing soaps will not be used.5) Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and/or other written materials provided at the time of admission and/or posted throughout the facility. 6) Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations:a. When hands are visibly soiled; andb. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile.

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 3 of 6 resident (Residents #11, #13, #14) reviewed for respiratory care. 1. The facility failed to ensure Resident #11, #13, #14's nebulizer/Mask and tubing were kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. Findings include: Record review of Resident #11's face sheet, dated 3/26/25, reflected an [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #11 had diagnoses which included, cerebral infarction (stroke), diverticular disease of intestine (abnormal pouches form in the bowl wall), dementia (cognitive decline), encephalopathy (disease of the brain), asthma (inflammatory disease in the lungs). Record review of Resident #11's MDS quarterly assessment dated [DATE], reflected a BIMS score of 3 which indicated severe cognitive impairment. Section O of the MDS reflected: respiratory therapy. Record review of Resident #11's Physician Orders, revealed, 3 ML INHALE ORALLY EVERY 4 HOURS AS NEEDED FOR SHORTNESS OF BREATH OR WHEEZING VIA NEBULIZER. Record review of Resident #11's MAR date 3/26/25 revealed the last breathing treatment was 3/26/25 at 10:50am. Record review of Resident #11's quarterly Care Plan, dated 2/2/25, revealed Resident #11 had a diagnosis of asthma and to give nebulizer treatments and oxygen therapy as ordered. In an observation on 3/26/25 at 12:55pm, revealed Resident's #11 was lying in bed, and sleeping. Observed the nebulizer/mask and tubing sitting on the bedside table with the tubing touching the floor, and the nebulizer and tubing not bagged. Record review of Resident #13's face sheet, dated 3/26/25, reflected a [AGE] year-old female, who was admitted to facility 9/2/23, with diagnoses which include, Fracture of right femur (thigh bone), atrial fibrillation (abnormal heart rhythm), Chronic Obstructive Pulmonary Disease (damage to lungs). Record review of Resident #13's MDS quarterly assessment dated [DATE] reflected a BIMS score of 13 which indicated the resident was cognitively intact. Record review of Resident #13's Physician Orders, revealed, Ipratropium-Albuterol 0.5-2.5 (3) MG/3ML Solution, 1 vial inhale orally every 4 hours as needed for SHORTNESS OF BREATH. Record review of Resident #13's quarterly Care Plan, dated 3/15/25, revealed Resident #13 was diagnosed with Chronic Obstructive Pulmonary Disease and medications were to be administered as ordered. In an observation on 3/26/25 at 1:03pm, revealed Resident's #13 in her room sitting in wheelchair visiting with family. Observed the nebulizer mouthpiece hanging on a hook on the wall behind a recliner and not bagged. The resident stated that staff hung the nebulizer mouthpiece on the hook to keep it off the floor. The resident could not recall the last breathing treatment, stating it was sometime yesterday 3/25/25. Record review of Resident #14's face sheet, dated 3/26/25, reflected an [AGE] year-old male, admitted to the facility 4/29/22, readmit 2/27/25, with diagnoses which include, nontraumatic subarachnoid hemorrhage (type of stroke), Heart failure, edema (fluid retention), atrial fibrillation (abnormal heart rhythm). Record review of Resident #14's MDS re-admit assessment dated [DATE], reflects a BIMS score of 1, which indicated severe cognitive impairment. Record review of Resident #14's Physician Orders, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML 1 VIAL INHALE ORALLY EVERY 6 HOURS AS NEEDED FOR SHORTNESS OF BREATH. Record review of Resident #11's MAR, revealed the last Breathing treatment was 3/26/25 at 8:00 am. In an observation on 3/26/25 at 1:15pm, revealed Resident #14 was lying in bed sleeping. The nebulizer/mask and tubing observed sitting on the bedside table not bagged. Interview on 3/26/25 at 3:20pm, the DON stated that her expectation was that staff were to bag nebulizer masks and tubing in a plastic bag after use. The DON stated that placing a nebulizer mask and tubing in bag could prevent equipment from getting dirty and damaged and helped with infection control. Review of Facility policy: Departmental (Respiratory Therapy) Nursing Prevention of Infection, Med-Pass date 2001 (Revised April 2007) revealed: Steps in procedure: Infection Control Considerations related to Medication Nebulizer/Continuous Aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses.

Based on observations, and interview and record review the facility failed to ensure that drugs and biologicals were secured and stored in locked compartments, and permit only authorized personnel to have access to the keys for 1 of 2 treatment and medication carts (Hall 200 treatment cart ) observed for medication storage, The treatment cart on hall 200 was left unlocked in the hallway by room # 216. This failure placed the residents at risk for medications being misappropriated or for potential harm and adverse reactions from access to medications not prescribed for them. The findings included: In an observation and interview on hall 200 on 12/31/24 at 9:16 AM a treatment cart was left unlocked in the hallway beside room [ROOM NUMBER]. There were no staff members or residents in view of the cart. The State Surveyor walked down the hallway and around a corner . The Administrator was observed sitting at a table doing paperwork at a table located in a sitting area. The cart was not in view by the administrator. The surveyor informed the administrator of the unlocked treatment cart on the 200 hall. The administrator stated it should be locked, and she would take care of it. The administrator then escorted the surveyor to the conference room and left . In an observation on hall 200 and interview at 9:20 AM on 12/31/24, the cart was still unlocked and parked beside the wall next to the door of room [ROOM NUMBER] with the drawers facing the hallway . There were no staff or residents in the hallway at that time. The DON came down the hallway and locked the cart . She stated, I locked the cart and started to walk away. The surveyor asked her to come back and open the cart. She turned around to come back, and as she started back toward the cart the Wound Care Nurse and the Wound Care Physician came out of a resident room. In an interview and observation on 12/31/24 at 9:23 AM the Wound Care Nurse stated the DON had told her she left the cart unlocked. She stated she was not sure how long she was in the room to do wound care. She stated the cart should be locked and never left unattended in order to prevent residents from getting a medication that was not meant for them. She stated there were all sorts of adverse outcomes that could occur, but she really couldn not think at the moment. She then stated Well, they could get into something that was not meant for them. She opened the cart at the surveyor's request. There were several tubes of topical prescription and non- prescription creams which included antifungal creams, prescription antibiotic cream, nonsteroidal anti-inflammatory gels, and different dressing supplies and topical medication used for wound care. There was also a pair of scissors in a drawer beneath that drawer. In an interview with the DON at 9:45 AM on 12/31/24 She stated her expectation was that the medication and treatment cart should be kept locked at all times. She stated she had talked to the treatment nurse, and she would do an Inservice with staff on the importance of keeping the carts locked. She stated not locking medication and treatments could lead to a resident getting a medication that was not intended for them and having an adverse reaction. The security of the treatment cart was not specifically addressed in the policy provided. Record review of the facility policy Security of Medication Cart, dated revised April 2024, revealed the following [in part]: The medication cart shall be secured during medication passes. 1. The nurse must secure the cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart and doors and drawers should be facing the resident's room. 3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway with the doors facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not in use it must be locked and parked at the nurse's station. Or inside the medication room.

Based on observation, interview and record review, the facility failed to ensure residents have the right to formulate an advance directive for 1 of 24 residents (Resident #279) reviewed for advanced directives. The facility failed to maintain medical records on each resident that are complete, and accurately documented for Resident #279. This failure could affect residents by not having their preferences honored concerning advanced directives . Findings included: Record review on [DATE] of Resident #297's electronic face sheet revealed an [AGE] year-old female, admitted on [DATE] with a DNR status and a diagnosis of, unspecified fracture of right femur, and heart disease. Resident #297's Record Review on [DATE] of Resident #297's MDS Section C Cognitive Status, indicated the residents BIMS was 13 (cognitively intact). Record review on [DATE] of Resident #297's physician's orders dated [DATE] revealed there was an order for DNR. Resident #297's CP (Care Plan) dated [DATE] revealed she had a MPA (Medical Power of Attorney) on file with a Full Code status. Record review on [DATE] of Resident #297's electronic health record from [DATE] through [DATE] revealed there was no evidence of the following: *Advanced Directive for Out of Hospital Do Not Resuscitate Order (OOH-DNR) form; *Progress notes related to the DNR status; *Preadmission Advanced Directive Information form; *Advanced Directive for Out of Hospital Do Not Resuscitate Order (OOH-DNR) verbal assessment. During an interview and Record Review on [DATE] at 10:30 AM the DON stated Resident #297's code status was DNR and had documentation of the Physician order in the electronic chart. The DON stated there was a book at the nurse's station that revealed if residents had a DNR code status DNR, indicated by a RED paper, and Full code status, indicated by a green paper. She stated the SW may have the signed consent on her desk if she was a new admission. The DON reviewed Resident #297's CP and stated the resident was a Full Code status, she must have placed the DNR order on the wrong resident and would go take it out of PCC (electronic charting) immediately. During an interview on [DATE] at 10:48 AM the SW stated Resident #297 was a Full Code and did not have a DNR status or a consent form for her. She stated Resident #297's CP also revealed a Full Code status. The SW stated she did not know what the floor nurses looked at during a code, whether it be the book at the nurse's station or the electronic charting. Record Review of the DNR book dated [DATE] revealed Resident #297 had a green paper that indicated a full code status. During an interview on [DATE] at 11:05 AM, LVN A stated when a resident had a code she looks at the electronic charting for that resident. She revealed in PCC where she would have looked for the resident code status (DNR/Full code) under resident name. LVNA stated, if the resident was sent to the ER, the code status would then have looked at the code status book. She stated if there was a DNR status for that resident there would have also been an order, which would verify a consent that the status would be correct. LVN A stated there would be a negative impact to resident with time lost to being resuscitated. During an interview on [DATE] at 1:15 PM the DON stated she was at home and misunderstood her SW when she called to place the code status order and was a mistake on her part. The DON stated the negative impact for resident would have been, residents have not gotten the correct medical treatment such as CPR if a Full code. She stated it was a typo on her (DON) part, as she misunderstood the SW's text message to place an order for DNR status for Resident #297. The DON stated her expectations was for the resident to fill out the paperwork on admission as well as not relying on texts. She stated the nurse placing the order for the DNR status would be present to verify the consent form. Record review of the facility's undated DNR policy on [DATE] revealed there was no evidence that addressed entering the wrong code status on a Resident.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: 1. The lids to the bulk storage containers were soiled with food particles. 2. Opened gravy mix and breaded chicken patties were not stored in sealed bags. 3. The vent-a-hood was soiled with grease and the interior surface of the deep fryer unit was soiled with fried food crumbs. 4. Sanitized cooking utensils and pans were stored on hooks suspended in the air from a frame located near the ceiling air duct vents and the sanitized surfaces were not protected from contaminants in the air. 5. Knives were stored on a magnetic strip rack and in a metal box holder mounted on a wall with the sanitized knife blades exposed to the air and potential contaminants. 6. The service delivery door to the outside of the building was not kept securely closed. The facility's failure placed residents at risk for foodborne illness and a decline in health status. The findings included: Observation on 8/28/23 at 8:35 AM, during the initial tour of the facility kitchen, revealed the following: 1 - the dry food storage area had plastic bulk storage bins containing granulated sugar and flour; the lids to the bins were lightly soiled with sugar crystals, food crumbs, and flour dust; 2 - the dry food storage area had wire rack shelf units; a shelf held an open paper package of gravy mix that had been rolled closed and wrapped with plastic cellophane wrap that was not labeled and dated; the CDM removed the wrapped package from the shelf; 3 - the freezer unit contained an open cardboard box with breaded chicken patties that were in a bag that was open to the air and not securely closed; the CDM removed the box from the freezer and handed it to the Dietary Supervisor and told her to throw it away; 4 - the vent-a-hood located above the oven unit and grill was soiled with grease; 5 - the deep fryer unit was covered with a rectangular metal sheet pan; the interior surface of the deep fryer had dried fried food crumbs and was filled with dark colored cooking oil; 6 - cooking utensils and pans were hanging from hooks on a metal frame above the food preparation counter, with the sanitized food surfaces of the utensils and pans exposed to potential contaminants in the air; ceiling air duct vents were located near the metal frame; 7 - a magnetic knife rack was mounted to a wall with knife blades stuck to it; 8 - a knife holder box, with knives stored blade end down inside the box, was mounted on the wall next to the magnetic knife rack. During an observation and interview on 8/30/23 beginning at 1:27 PM, the service delivery door to the outside of the building was observed located near the Dietary Supervisor's office. The door was self-closing and self-locking and also had a deadbolt lock. The deadbolt lock had been turned, preventing the door from closing completely and leaving a small gap of space between the door and the door frame, which could allow the entrance of pests. The CDM stated she thought the staff had taken the trash out to the dumpster and had turned the deadbolt to prevent the door from locking so they could get back into the kitchen without using a key. In an interview on 8/31/23 at 3:59 PM, the CDM stated she would provide a policy for storing sanitized pans and food preparation utensils. Review of the facility's policy and procedure for Manual Warewashing, dated as revised September 2017, provided by the CDM, revealed it did not include the storage of sanitized pans and food preparation utensils. A policy and procedure for the storage of sanitized pans and utensils used for food preparation was not provided before the completion of the survey and exit from the facility on 8/31/23. The Food and Drug Administration Food Code 2022 specified [in part]: Chapter 3 Food 3-202.15 Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. Chapter 4 Equipment, Utensils, and Linens 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.

Based on observation, interview, and record review, the facility failed to ensure a resident who entered the facility without limited range of motion did not experience a reduction in range of motion; residents with limited range of motion received appropriate treatment and services to increase range of motion or prevent further decrease in range of motion; and residents received appropriate services, equipment, and assistance to maintain or improve mobility for 3 of 15 residents (Residents #34, #45, and #63) who were reviewed for care and assistive devices to maintain mobility and avoid further contractures. 1. Resident #35 had contracted fingers in both hands and did not use assistive devices to prevent further contractures. 2. Resident #45 had contractures in both legs and did not use positioning devices to avoid pressure applied between her knees and protect her feet and ankles while seated in a wheelchair. 3. Resident #63 had contractures in the small finger and ring finger of his left hand and did not use an assistive device to prevent further contractures. The facility's failure placed residents at risk for developing avoidable and worsening contractures, decreased functional mobility and range of motion in extremities, and decreased feelings of well-being and quality of life. The findings included: 1. Resident #35 Review of Resident #35's Admission Record, dated 8/31/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of metabolic encephalopathy (brain dysfunction caused by problems with body metabolism). Additional diagnoses included: anxiety disorder; constipation; hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function); major depressive disorder, recurrent; pseudobulbar affect (nervous system disorder that causes inappropriate involuntary laughing and crying); vascular dementia, unspecified (cognitive impairment caused by lack of blood flow to the brain); atherosclerotic heart disease (hardened arteries due to plaque build-up); dysphagia (swallowing problem); essential (primary) hypertension (high blood pressure); gastro-esophageal reflux disease (liquid content of the stomach refluxes into the esophagus); heart failure, unspecified; muscle wasting and atrophy; generalized muscle weakness; Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves); Type 2 diabetes mellitus (high blood sugar - adult onset). Review of Resident #35's Contracture Potential Assessment - Full Assessment, dated 5/04/23, revealed a score of 11 indicating the resident was at risk for contractures. The assessment documented the resident's state of health was poor/declining; he was confused; he had limited mobility in upper and lower extremities; he was chairfast; and had a diagnosis of Parkinson's disease. Review of Resident #35's Quarterly Contracture Potential Assessment, dated 8/05/23, revealed a score of 12 indicating the resident was at risk for contractures. The assessment documented the resident's state of health was poor/declining; he was confused; he had limited mobility in upper and lower extremities; he was chairfast; and had a diagnosis of Parkinson's disease. Observation on 8/28/23 at 11:16 AM revealed Resident #35 was lying on his back in bed on a foam mattress with the room call light in reach of his right hand. The resident was observed to have contractures in the fingers of both, with his hands closed in fists. Resident #35 was able to demonstrate use of his right thumb to activate the call light button. The resident was not using hand splints or soft hand rolls. In an interview on 8/31/23 at 3:01 PM, the LVN Treatment Nurse stated she did weekly skin assessments on Wednesdays. She stated she saw Resident #35 for maceration (redness and excoriation) on his buttocks. She stated the resident's fingers had been a little swollen this week. She stated he could open his fingers, but it depended what mood he was in. During an observation and interview on 8/31/23 beginning 3:16 PM, accompanied by the LVN Treatment Nurse, revealed Resident #35 was resting on his back in bed with the room light off. The resident's hands were closed in fists. The LVN donned gloves and asked Resident #35 if he could open his left hand fingers. The resident moved his left thumb and index finger and was unable to open his other left hand fingers. Resident #35 was able to open right hand thumb and was unable to open his remaining right hand fingers. Resident #35 stated his hands and fingers hurt a little. The LVN noted a red area on the inner crease of the right thumb. 2. Resident #45 Review of Resident #45's Admission Record, dated 8/31/23, revealed a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted [DATE] with a primary diagnosis of post-laminectomy syndrome (failed back syndrome - a condition characterized by chronic pain following back surgeries). Additional diagnoses included: spinal stenosis, cervical region (abnormal narrowing of the spinal canal that puts pressure on the spinal cord and causes pain, numbness or weakness in the arms or legs); muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); generalized muscle weakness; chronic pain; unspecified dementia (impaired cognition); major depressive disorder, recurrent; insomnia; anxiety disorder; hyperlipidemia; essential (primary) hypertension (high blood pressure); hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function); acute embolism and thrombosis of unspecified deep veins of right lower extremity (blood clot in right leg); gastro-esophageal reflux disease (liquid content of the stomach refluxes into the esophagus); chronic kidney disease, stage 3 unspecified (moderate loss of kidney function). Review of Resident #45's Admission Contracture Potential Assessment, 1/06/23, revealed a score of 4 (not at risk for contractures); and assessed the resident as being alert, well nourished, having a general state of health of fair, full mobility in upper and lower extremities, and needs help with cane/walker. Review of Resident #45's Quarterly Contracture Potential Assessment, dated 8/05/23, revealed a score of 13 (at risk for contractures); and assessed the resident as being alert, thin, having a general state of health of fair, very limited mobility in upper and lower extremities; chairfast; and the documented comment: Limited mobility due to spinal stenosis. Review of Resident #45's Physician Progress Note, dated 7/05/23, revealed documentation of a physical examination and review of systems. The physician documented a note for review of the resident's Musculoskeletal system - contractures: flexion contractures bilateral lower extremities and left upper extremity. Observation on 8/28/23 at 4:12 PM revealed Resident #45 was seated in a wheelchair. The resident appeared to have contractures in legs and had a small pillow between her knees. During an interview and observation on 8/29/23 beginning at 1:44 PM, Resident #45 stated she could move her right leg and stated she could not move her left leg. She stated she could move left arm but could not lift it. Resident #45 stated she thought she may have had a stroke during the past. Resident #45 was seated in a wheelchair with her feet in an awkward position on the foot pedals. The resident's knees appeared contracted and touching, and her feet were at an angle toward the outer sides of the foot pedals, with the outer sides of her feet and ankles against the extension bars connected to the foot pedals. No protective padding or positioning pillows were observed between her knees or between her outer feet and wheelchair foot pedal extension bars. In an interview on 8/31/23 at 5:34 PM, the LVN MDS Coordinator stated Resident #45 had walked a little during her first stay, from 12/12/22 to 1/02/23. She stated Resident #45 had been discharged home and after a few days decided she needed help and was readmitted on [DATE]. The LVN stated Resident #45 had back surgery during April 2023 and she did not walk any more. She stated the resident's feet were on foot pedals when she was in the wheelchair. 3. Resident #63 Review of Resident #63's Admission Record, dated 8/31/23, revealed an [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction, unspecified (a type of stroke caused by impaired blood flow to the brain). Additional diagnoses included: transient cerebral ischemic attack, unspecified (mini-stroke); unspecified atrial fibrillation (irregular heart beat); depression; essential (primary) hypertension (high blood pressure); gastro-esophageal reflux (liquid content of the stomach refluxes into the esophagus); muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); hemiplegia and hemiparesis following cerebral infarction affecting the dominant right side (left sided weakness); chronic obstructive pulmonary disease (a type of progressive lung disease with shortness of breath and cough); schizoaffective disorder, depressive type (a mental disorder with psychotic symptoms and abnormal thought processes, and an unstable mood - schizophrenia with bipolar disorder or depression); dysphagia (difficulty swallowing), polyneuropathy (damage or disease affecting peripheral nerves in areas on both sides of the body, featuring weakness, numbness, and burning pain); and abnormal weight loss. Review of Resident #63's Admission Contracture Potential Assessment, dated 9/10/22, revealed a score of 8 (not at risk for contractures), and he was alert, well nourished, his general state of health was fair, he had full mobility of upper and lower extremities, he was chairfast, and had a history of stroke. Review Resident #63's Contracture Potential Assessment - Full Assessment, dated 2/09/23, revealed a score of 14 (at risk for contractures), and he was confused, thin, his general state of health was poor/declining, he had full mobility of upper extremities and limited mobility of lower extremities, was bedfast, and had a history of stroke. Review Resident #63's Quarterly Contracture Potential Assessment, dated 6/07/23, revealed a score of 15 (at risk for contractures), and he was confused, thin, his general state of health was poor/declining, he had limited mobility of the upper and lower extremities, was bedfast, and had a history of stroke. Review of Resident #63's comprehensive care plan, dated as initiated 9/17/22, revealed it addressed ADL self-care deficit related to fatigue and impaired balance. The care plan had not been revised to address the limited range of motion and contractures in his left hand fingers. During an interview and observation on 8/29/23 beginning at 3:26 PM, Resident #63 stated he could not raise his left arm. The resident's left hand small finger and ring finger were contracted. Resident #63 stated his left hand fingers hurt. He stated he had not had a hand splint or hand roll to place in his left hand. Resident #63 stated he had a little ball to hold in his hand and he did not know what happened to it. In an interview on 8/30/23 at 2:59 PM, the Hospice RN stated she was at the facility to evaluate Resident #63 for services per his family's request for a change in hospice agencies. The RN stated she had noticed the resident's left hand fingers were contracted, swollen, and very tender. She stated Resident #63 had severe arthritis and he yelled out when she barely touched his finger. The RN stated he would benefit from soft hand rolls. She stated ultimately the facility was responsible for the care of the resident. In an interview on 8/30/23 at 3:23 PM, Resident #63's family members stated they had come to meet with the nurse from Hospice. The family stated Resident #63 had a stroke and he could not use his left side. The family stated Resident #63 had received therapy and they did not recall the resident having a hand splint or hand roll for his left hand. The family stated Resident #63's left hand did not have contractures when he was admitted to the facility about a year ago in September 2022. They stated his fingers had gradually contracted over the course of the past 8 months or so. They family stated they brought small balls for the resident to have in his hands and they did not know what happened to them. Resident #63 attempted to open his left hand fingers and he could not open or move the small finger and ring finger. In an interview on 8/31/23 at 3:09 PM, the LVN Treatment Nurse stated she did not know anything about Resident #63's hands. She stated she knew his hands shook and he had tremors. During an observation and interview on 8/31/23 beginning at 3:31 PM, accompanied by the LVN Treatment Nurse, revealed Resident #63 was resting in bed. His family members were seated in chairs in the room and were visiting with him. Resident #63 was unable to open his left hand small finger and ring finger. The resident's family stated the resident's left hand had been getting progressively worse since he had his stroke. The family did not recall seeing Resident #63 use a hand roll. The LVN stated a contraction device for Resident #63's hand could be ordered by the therapy department. In an interview on 8/31/23 at 5:26 PM, the LVN MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated she followed the guidelines of the RAI Manual. She stated Section G0400 of the RAI Manual defined upper extremity as shoulder, elbow, wrist, and hand. The LVN stated if the limitation in Resident #63's hand did not interfere with his abilities to perform ADLs or eating, she could not code a limitation in range of motion. She stated Resident #63 ate with his right hand. Review of the facility's policy and procedure for Resident Mobility and Range of Motion, dated as revised July 2017, revealed the following [in part]: Policy Statement 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Resident with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Policy Interpretation and Implementation 1. As part of the resident's comprehensive assessment, the nurse will identify the resident's: a. Current range of motion of his or her joints; b. Current mobility status (per current MDS assessment tool), including his or her ability to: (1) Move to and from the lying position; (2) Turn and move side-to-side in bed; (3) Change body positions; (4) Transfer to and from bed or chair; and (5) Walk. c. Limitations in movement or mobility; d. Opportunities for improvement; and e. Previous treatment and services for mobility. 2. As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including: a. Pain; b. Skin integrity; c. Muscle wasting and atrophy; d. Gait and balance issues that may lead to falls or fractures; e. Contractures; or f. Other complications that could cause or contribute to immobility, impaired ROM or injury from falls . 3. During the resident's assessment, the nurse will identify the underlying factors that contribute to his or her range of motion or mobility problems, if any, including: a. Immobilization (bedfast, chair or wheelchair usage); b. Neurological conditions (e.g., cerebral palsy, cerebral vascular accident, etc.); c. Conditions in which movement may lead to pain; and/or d. Conditions that limit or immobilize movement of limbs or digits (e.g., splints). 4. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. 6. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts .

Based on observation, interview, and record review, the facility failed to ensure residents received adequate care to maintain the highest practical physical and psychosocial well-being for 5 of 26 residents (Residents #7, #21, #33, #63, and #68) reviewed for ADL care, in that: 1. The facility failed to ensure Resident #7's right hand fingernails were trimmed and filed. 2. The facility failed to ensure Resident #21's fingernails on both hands were cleaned and her toenails on both feet were filed or trimmed. 3. The facility failed to ensure Resident #33 had his fingernails on both hands trimmed and filed. 4. The facility failed to ensure Resident #63's left hand fingernails were trimmed and filed. 5. The facility failed to ensure Resident #68 had her toenails on both feet cut and filed. This failure placed residents at risk for experiencing a decreased quality of life and an increased risk for infection and injury. The findings included: 1. Resident #7 Review of Resident #7's Admission Record, dated 8/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE] her diagnoses included: hypertension (high blood pressure); muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); dysphagia (difficulty swallowing), congestive heart failure (failure of the heart to adequately pump blood to the body) and mitral valve insufficiency( failure of the mitral valve to close which causes a back flow of blood to into heart). Review of Resident #7's Annual MDS Assessment, dated 8/10/23, revealed she was independent with personal hygiene. During an observation and interview on 8/29/23 at 10:26 AM, Resident #7 was sitting up in her bed. She was noted to have contractures to the 3rd and 4th fingers of her right hand and her fingernails were 1/4 inch long. The resident stated she would like to have her fingernails cut, but she could not do it herself. She stated she had asked someone to do it, but she could not recall who she asked. In an interview with the ADON on 8/30/21 at 11:00 AM she stated it was the responsibility of the CNAs to keep resident's fingernails clean, cut and filed. She stated the charge nurses were responsible to monitor to see that the residents' nails were clean and cut. She stated the nurses were responsible to keep the Diabetics Nails cut. She stated nail care did not necessarily mean the nails were cut, just that they were clean. She stated toenails were not cut by the aides or the nurses. She stated the podiatrist cut residents toenails. Interview with CNA G revealed that CNAs should do nail care when they bathed the residents unless they were diabetic, and then they were cut by the LVN. 2. Resident #21 Review of Resident #21's Admission Record, dated 8/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE] her diagnoses included: Diabetes; congestive heart failure (failure of the heart to adequately pump blood to the body); pruritus (an uncomfortable, irritating sensation that creates an urge to scratch that can involve any part of the body); muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues) and schizoaffective disorder (a mental disorder with cycles of improvement that may include the symptoms of delusions, hallucinations, depressed episodes, and periods of manic energy). Review of Resident #21's Quarterly MDS Assessment, with an ARD of 8/12/23, revealed she required extensive assistance of one person physically assisting for personal hygiene. In an interview and observation on 8/28/23 beginning at 11:30 AM Resident #21 was in her room. She had a visible scabbed rash that she stated covered her entire body. She stated she had seen a dermatologist and had another appointment on 8//29/23. Her toenails were unkempt and approximately 1/4 inch in length. She stated she would like them to cut. She stated she did not remember when they were last cut. Her fingernails were dirty. She stated she scratched constantly until the rash bleeds, and nobody ever offered to wash her hands before she eats. She stated she feels like the aides get irritated because she gets her nails and sheets dirty, but she can help herself. A deep brown substance was noted underneath her fingernails. Spots of old dried blood was noted on resident #7's sheets. In an interview with the ADON on 8/28/23 at 1:00 pm she stated Resident #7 scratched her skin constantly. She stated that she had been seen by a dermatologist and had another appointment was scheduled the following day. She stated Resident #21 should have nail care every shift because she constantly scratches the rash until it bleeds. She stated the nurses were responsible for cutting the nails of a diabetic resident, but an aide could clean the nails. She stated it was the LVN's responsibility to monitor to see that the resident's nails were clean. In an observation on 8/30/23 at 10:00 AM an unidentified CNA who stated she was in training was observed in Resident #21's room with a bath basin containing water cleaning and filing resident #21's nails. In an interview with the DON on 8/30/23 at 1:30 PM she stated it would be impossible to do nailcare on Resident #21 every time she got her nails dirty because she constantly scratched and made herself bleed. She stated she would purchase gloves to see if this kept the resident from making herself bleed. 3. Resident #33 Review of Resident #33's Admission Record, dated 8/31/23, revealed a [AGE] year-old male admitted to the facility on [DATE] his diagnoses included muscle weakness, intellectual disability; full incontinence of feces; difficulty in walking; unspecified urinary incontinence. Review of Resident #33's Quarterly MDS Assessment, with an ARD of 8/10/23, revealed he required extensive assistance of one person physically assisting for personal hygiene. Observation on 8/28/23 at 10:38 AM revealed Resident #33 was up in his wheelchair and was returning from therapy. He was transferred to his bed with extensive assistance by a therapist. The resident's nails were chipped, with sharp edges. In an interview with the ADON on 8/30/21 at 11:00 AM she stated it was the responsibility of the CNAs to keep resident's fingernails clean, cut and filed. She observed Resident #33's nails and agreed they needed to be trimmed and filed. She stated he could injure himself with his jagged chipped nails She stated the charge nurses were responsible to monitor to see that the residents' nails were clean and cut. 4. Resident #63 Review of Resident #63's Admission Record, dated 8/31/23, revealed an [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction, unspecified (a type of stroke caused by impaired blood flow to the brain). Additional diagnoses included: transient cerebral ischemic attack, unspecified (mini-stroke); unspecified atrial fibrillation (irregular heart beat); depression; essential (primary) hypertension (high blood pressure); gastro-esophageal reflux disease (chronic digestive disease where the liquid content of the stomach refluxes into the esophagus); muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); hemiplegia and hemiparesis following cerebral infarction affecting the dominant right side (right sided weakness); chronic obstructive pulmonary disease (a type of progressive lung disease with shortness of breath and cough); schizoaffective disorder, depressive type (a mental disorder with psychotic symptoms and abnormal thought processes, and an unstable mood - schizophrenia with bipolar disorder or depression); dysphagia (difficulty swallowing), polyneuropathy (damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain); and abnormal weight loss. Review of Resident #63's Quarterly MDS Assessment, with an ARD of 8/10/23, revealed he required extensive assistance with two persons physically assisting for personal hygiene. During an observation and interview on 8/28/23 at 10:25 AM, Resident #63 was resting on his back in bed on an air mattress with a pillow under his knees. The resident stated he did not get out of bed except for showers. During and observation and interview on 8/29/23 at 3:26 PM, Resident #63 was not able to raise his left arm and his left-hand fingers were contracted. Resident #63 stated his left-hand fingers hurt. In an interview on 8/30/23 at 2:59 PM, the Hospice RN stated she had noticed Resident #63's left hand fingers were contracted, swollen, and very tender. She stated the resident had severe arthritis and he yelled out when she barely touched his finger. The Hospice RN stated Resident #63's fingernails were long, and her aides could cut and file his nails. She stated ultimately the facility was responsible for the care of the resident. During an interview and observation on 8/30/23 at 3:23 PM, Resident #63's family members were seated in chairs in the resident's room. The family stated they had come to meet with the Hospice nurse. The family stated Resident #63 had a stroke and he could not use his left side. The family stated the resident's left hand did not have contractures when he was admitted to the facility about a year ago in September 2022. They stated his fingers had gradually contracted over the course of the past 8 months or so. Resident #63 attempted to open his left-hand fingers and he could not open or move the small finger (digit 5) and the ring finger (digit 4). His left-hand fingernails appeared to extend an approximate 1/4 inch over the tip of his fingers, and his fingers were contracted toward the palm of his left hand. 5. Resident #68 Review of Resident #68's Admission Record, dated 8/31/23, revealed an [AGE] year-old male admitted to the facility on [DATE] her diagnoses included: muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues). morbid obesity (weight 80 to 100 lbs. over ideal body weight); high blood pressure; age related cognitive decline; generalized weakness. Review of Resident #68's Quarterly MDS Assessment, with an ARD of 8/12/23, revealed she was independent with personal hygiene with supervision only. She had a BIMS score of 13 (cognitively intact). In an interview and observation on 08/28/23 at 10:09 AM resident #68's left foot was uncovered on her bed. Her toenails on her left foot were 1/4 inch in length. She stated she would like to have them cut or filed and had asked to see the podiatrist. She stated she was able to cut them herself before she came to facility, but now she needed someone else to do it because she could not do it herself. She stated she had asked a nurse for someone to cut them, but nobody had. She did not remember who she asked, but it was when she was in a room on the other side of the building. She stated the social worker stated she would put on a list to see the podiatrist. In an interview with the social worker on 8/31/23 at 2:00 PM the social worker revealed she had placed Resident #68 on the list for the podiatrist. She stated she did not normally place any resident on the list to be seen by the podiatrist until she was sure that the resident was going to be a long-term resident. She stated when it was determined a resident was going to be long- term and remain in the facility she talked with the resident to see if they needed referrals to see a podiatrist, optometrist, dentist, etc. She stated she normally does then when she does this when she completes her section of the MDS assessment. Review of the document titled: Care of Fingernails/Toenails provided by the Administrator on 8/31/23 revealed the following [in part]: Purpose The purpose of this procedure is to clean the nail bed, to keep nails trimmed and to prevent infections. General guidelines: 1. Nail care includes daily cleaning and regular trimming. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the health status for 4 of 26 residents (Residents #7, #35, #45, and #63) whose MDS assessments were reviewed, in that: 1. Resident #7 had contractures in two fingers of her right hand. Her MDS documented no limitations in ROM. 2. Resident #35 had contractures in the fingers of both hands. His MDS assessments documented no limitations in range of motion in his upper extremities. 3. Resident #45 had contractures in both of her legs. Her MDS assessments documented no limitations in range of motion in her lower extremities. 4. Resident #63 had contractures in two fingers of his left hand. His MDS assessments documented no limitations in range of motion in his upper extremities. This failure placed residents at risk for not receiving care and services to meet their physical needs and promote feelings of well-being and quality of life. The findings included: 1. Resident #7 Review of Resident #7's Admission Record, dated 8/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE] diagnoses included: hypertension (high blood pressure); muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); dysphagia (difficulty swallowing), congestive heart failure (failure of the heart to adequately pump blood to the body) and mitral valve insufficiency( failure of the mitral valve to close which causes a back flow of blood to into heart). Review of Resident #7's Annual MDS Assessment, dated 6/10/23, revealed she was independent with personal hygiene and ADL's, and she had no limitations in ROM to her upper extremities and hands. Her BIMS score was 7 (moderate cognitive impairment) During an observation and interview on 8/29/23 at 10:26 AM, Resident #7 sitting up in her bed. She was noted to have contractures to the 3rd and 4th fingers of her right hand. Her fingernails were approximately 1/4 inch long. She stated she would like them trimmed and filled, but she was unable to do it herself due to her arthritis in her hands. In an interview on 8/31/23 at 10:40 AM, the LVN MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated she followed the guidelines of the RAI Manual. When questioned by the surveyor why she did not code the contractures to Resident #7's fingers as a limitation in ROM in her upper extremities, she stated Section G0400 of the RAI Manual defined upper extremity as the shoulder, elbow, wrist, and hand. The MDS nurse she talked to her company MDS consultant, and she stated if the limitation did not affect the resident's ability to feed himself, it could not be coded on the MDS. She stated Resident #7's functional status was not impaired. 2. Resident #35 Review of Resident #35's Admission Record, dated 8/31/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of metabolic encephalopathy (brain dysfunction caused by problems with body metabolism). Additional diagnoses included: anxiety disorder; constipation; hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function); major depressive disorder, recurrent; pseudobulbar affect (nervous system disorder that causes inappropriate involuntary laughing and crying); vascular dementia, unspecified (cognitive impairment caused by lack of blood flow to the brain); atherosclerotic heart disease (hardened arteries due to plaque build-up); dysphagia (swallowing problem); essential (primary) hypertension (high blood pressure); gastro-esophageal reflux disease (liquid content of the stomach refluxes into the esophagus); heart failure, unspecified; muscle wasting and atrophy; generalized muscle weakness; Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves); Type 2 diabetes mellitus (high blood sugar - adult onset). Review of Resident #35's Contracture Potential Assessment - Full Assessment, dated 5/04/23, revealed a score of 11 indicating the resident was at risk for contractures. The assessment documented the resident's state of health was poor/declining; he was confused; he had limited mobility in upper and lower extremities; he was chairfast; and had a diagnosis of Parkinson's disease. Review of Resident #35's Quarterly Contracture Potential Assessment, dated 8/05/23, revealed a score of 12 indicating the resident was at risk for contractures. The assessment documented the resident's state of health was poor/declining; he was confused; he had limited mobility in upper and lower extremities; he was chairfast; and had a diagnosis of Parkinson's disease. Review of Resident #35's Admission MDS Assessment, dated 3/30/23, revealed a BIMS score of 00 out of 15 (severe cognitive impairment); he required extensive to total assistance with ADLs with 1 to 2 persons assisting, including extensive assistance with eating with one person assisting; did not walk; had no functional limitation in ROM in upper extremities or lower extremities; and used a wheelchair for mobility. Review of Resident #35's Significant Change in Status MDS Assessment, dated 4/27/23, revealed a BIMS score of 00 out of 15 (severe cognitive impairment); he required extensive to total assistance with ADLs with 1 to 2 persons assisting, including extensive assistance with eating with one person assisting; did not walk; had no functional limitation in ROM in upper extremities or lower extremities; and used a wheelchair for mobility. The assessment documented the resident was receiving hospice care services. Review of Resident #35's Quarterly MDS Assessment, dated 7/27/23, he required extensive to total assistance with ADLs with 1 to 2 persons assisting, including extensive assistance with eating with one person assisting; did not walk; had no functional limitation in ROM in upper extremities or lower extremities; and used a wheelchair for mobility. Observation on 8/28/23 at 11:16 AM revealed Resident #5 was lying on his back in bed on a foam mattress with the room call light in reach of his right hand. The resident was observed to have contractures in the fingers of both, with his hands closed in fists. Resident #35 was able to demonstrate use of his right thumb to activate the call light button. The resident was not using hand splints or soft hand rolls. In an interview on 8/31/23 at 5:40 PM, the LVN MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated she followed the guidelines of the RAI Manual. She stated Section G0400 of the RAI Manual defined upper extremity as the shoulder, elbow, wrist, and hand. The LVN stated if the limitation did not affect the resident's ability to feed himself, it could not be coded on the MDS. She stated Resident #35 could eat finger foods. 3. Resident #45 Review of Resident #45's Admission Record, dated 8/31/23, revealed a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted [DATE] with a primary diagnosis of post-laminectomy syndrome (failed back syndrome - a condition characterized by chronic pain following back surgeries). Additional diagnoses included: spinal stenosis, cervical region (abnormal narrowing of the spinal canal that puts pressure on the spinal cord and causes pain, numbness or weakness in the arms or legs); muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); generalized muscle weakness; chronic pain; unspecified dementia (impaired cognition); major depressive disorder, recurrent; insomnia; anxiety disorder; hyperlipidemia; essential (primary) hypertension (high blood pressure); hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function); acute embolism and thrombosis of unspecified deep veins of right lower extremity (blood clot in right leg); gastro-esophageal reflux disease (liquid content of the stomach refluxes into the esophagus); chronic kidney disease, stage 3 unspecified (moderate loss of kidney function). Review of Resident #45's Admission Contracture Potential Assessment, 1/06/23, revealed a score of 4 (not at risk for contractures); and assessed the resident as being alert, well nourished, having a general state of health of fair, full mobility in upper and lower extremities, and needs help with cane/walker. Review of Resident #45's Quarterly Contracture Potential Assessment, dated 8/05/23, revealed a score of 13 (at risk for contractures); and assessed the resident as being alert, thin, having a general state of health of fair, very limited mobility in upper and lower extremities; chairfast; and the documented comment: Limited mobility due to spinal stenosis. Review of Resident #45's Physician Progress Note, dated 7/05/23, revealed documentation of a physical examination and review of systems. The physician documented a note for review of the resident's Musculoskeletal system and documented contractures: flexion contractures bilateral lower extremities and left upper extremity. Review of Resident #45's Initial Admission MDS Assessment, dated 12/18/22, revealed the resident required extensive assistance with 1 person assisting for transfers and bed mobility, required supervision with 1 person assisting while walking in-room, there were no functional limitations in range of motion in upper extremities or lower extremities, and mobility devices used were a walker and a wheelchair. Review of Resident #45's Admission MDS Assessment, dated 1/10/23, revealed the resident required extensive assistance with 1 person assisting for transfers and extensive assistance with 2 persons assisting for bed mobility, there were no functional limitations in range of motion in upper extremities or lower extremities, and a wheelchair was used for mobility. Review of Resident #45's Quarterly MDS Assessment, dated 3/28/23, and Significant Change in Status MDS Assessment, dated 5/01/23, revealed there were no functional limitations in range of motion in upper extremities or lower extremities, and a wheelchair was used for mobility. Review of Resident #45's Quarterly MDS Assessment, dated 8/01/23, revealed the resident required extensive assistance with 2 persons assisting for transfers and bed mobility, there were no functional limitations in range of motion in upper extremities or lower extremities, and a wheelchair was used for mobility. Observation on 8/28/23 at 4:12 PM revealed Resident #45 was seated in a wheelchair. The resident appeared to have contractures in legs and had a small pillow between her knees. In an interview on 8/31/23 at 5:34 PM, the LVN MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated she followed the guidelines of the RAI Manual. The LVN stated Section G0400 of the RAI Manual defined lower extremities as the hip, knee, ankle, and foot. The LVN stated if the limitation in Resident 45's knees did not limit her functional ability, she could not code a limitation in range of motion. She stated Resident #45 had walked a little during her first stay, from 12/12/22 to 1/02/23. She stated Resident #45 had been discharged home and after a few days decided she needed help and was readmitted on [DATE]. The LVN stated Resident #45 had back surgery during April 2023 and she did not walk any more. She stated the resident's feet were on foot pedals when she was in the wheelchair. 4. Resident #63 Review of Resident #63's Admission Record, dated 8/31/23, revealed an [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction, unspecified (a type of stroke caused by impaired blood flow to the brain). Additional diagnoses included: transient cerebral ischemic attack, unspecified (mini-stroke); unspecified atrial fibrillation (irregular heart beat); depression; essential (primary) hypertension (high blood pressure); gastro-esophageal reflux (liquid content of the stomach refluxes into the esophagus); muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); hemiplegia and hemiparesis following cerebral infarction affecting the dominant right side (left sided weakness); chronic obstructive pulmonary disease (a type of progressive lung disease with shortness of breath and cough); schizoaffective disorder, depressive type (a mental disorder with psychotic symptoms and abnormal thought processes, and an unstable mood - schizophrenia with bipolar disorder or depression); dysphagia (difficulty swallowing), polyneuropathy (damage or disease affecting peripheral nerves in areas on both sides of the body, featuring weakness, numbness, and burning pain); and abnormal weight loss. Review of Resident #63's Admission Contracture Potential Assessment, dated 9/10/22, revealed a score of 8 (not at risk for contractures), and he was alert, well nourished, his general state of health was fair, he had full mobility of upper and lower extremities, he was chairfast, and had a history of stroke. Review Resident #63's Contracture Potential Assessment - Full Assessment, dated 2/09/23, revealed a score of 14 (at risk for contractures), and he was confused, thin, his general state of health was poor/declining, he had full mobility of upper extremities and limited mobility of lower extremities, was bedfast, and had a history of stroke. Review Resident #63's Quarterly Contracture Potential Assessment, dated 6/07/23, revealed a score of 15 (at risk for contractures), and he was confused, thin, his general state of health was poor/declining, he had limited mobility of the upper and lower extremities, was bedfast, and had a history of stroke. Review of Resident #63's Admission MDS Assessment, dated 9/16/22, revealed a BIMS score of 14 out of 15 (cognitively intact), and he required extensive assistance with ADLs with 2 persons assisting for transfers, bed mobility, dressing, personal hygiene, and toileting. He was independent with eating with set up help. He was assessed as having functional limitation in range of motion with impairment on one side in upper and lower extremities and used a wheelchair for mobility. Review of Resident #63's Quarterly MDS Assessment, dated 12/17/22, revealed a BIMS score of 11 out of 15 (moderate cognitive impairment) and he was assessed as having functional limitation in range of motion with impairment on one side in upper and lower extremities and used a wheelchair for mobility. Review of Resident #63's Significant Change in Status MDS Assessment, dated 2/07/23, revealed a BIMS score of 00 out of 15 (severe cognitive impairment), and he was assessed as having no functional limitation in range of motion with no impairment on either side in upper and lower extremities and used a wheelchair for mobility. Review of Resident #63's Quarterly MDS Assessments, dated 5/10/23 and 8/01/23, revealed a BIMS score of 00 out of 15 (severe cognitive impairment), and he required extensive assistance with ADLs with 2 persons assisting for transfers, bed mobility, dressing, personal hygiene, and toileting. He was independent with eating with set up help. He was assessed as having no functional limitation in range of motion with no impairment on either side in upper and lower extremities and used a wheelchair for mobility. Review of Resident #63's comprehensive care plan, dated as initiated 9/17/22, revealed it addressed ADL self-care deficit related to fatigue and impaired balance. The care plan had not been revised to address the limited range of motion and contractures in his left-hand fingers. During an interview and observation on 8/29/23 at 3:26 PM, Resident #63 stated he could not raise his left arm. The resident's left hand small finger and ring finger were contracted. Resident #63 stated his left-hand fingers hurt. He stated he had not had a hand splint or hand roll to place in his left hand. Resident #63 stated he had a little ball to hold in his hand and he did not know what happened to it. In an interview on 8/31/23 at 5:26 PM, the LVN MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated she followed the guidelines of the RAI Manual. She stated Section G0400 of the RAI Manual defined upper extremity as shoulder, elbow, wrist, and hand. The LVN stated if the limitation in Resident #63's hand did not interfere with his abilities to perform ADLs or eating, she could not code a limitation in range of motion. She stated Resident #63 ate with his right hand. Review of the facility's policy and procedure for Resident Mobility and Range of Motion, dated as revised July 2017, revealed the following [in part]: Policy Statement 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Resident with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Policy Interpretation and Implementation 1. As part of the resident's comprehensive assessment, the nurse will identify the resident's: a. Current range of motion of his or her joints. b. Current mobility status (per current MDS assessment tool), including his or her ability to: (1) Move to and from the lying position; (2) Turn and move side-to-side in bed; (3) Change body positions; (4) Transfer to and from bed or chair; and (5) Walk. c. Limitations in movement or mobility; d. Opportunities for improvement; and e. Previous treatment and services for mobility. 2. As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including: a. Pain; b. Skin integrity; c. Muscle wasting and atrophy; d. Gait and balance issues that may lead to falls or fractures; e. Contractures; or f. Other complications that could cause or contribute to immobility, impaired ROM or injury from falls . 3. During the resident's assessment, the nurse will identify the underlying factors that contribute to his or her range of motion or mobility problems, if any, including: a. Immobilization (bedfast, chair or wheelchair usage); b. Neurological conditions (e.g., cerebral palsy, cerebral vascular accident, etc.); c. Conditions in which movement may lead to pain; and/or d. Conditions that limit or immobilize movement of limbs or digits (e.g., splints). 4. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. 6. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of two residents (Resident #1) reviewed for infection control practices, in that: CNA A failed to perform proper hand before resident contact and after glove changes while providing incontinence care to Resident #10. This failure could place residents at risk for the spread of infection. The findings included: Review of Resident #10's face sheet dated 8/31/23, revealed an [AGE] year-old male admitted to the facility on [DATE] whose diagnoses included: high blood pressure, kidney disease, and malnutrition. Review of Resident #1's Significant Change MDS assessment dated [DATE] revealed Resident #10 required total dependence of ADL's and she was incontinent of both bowel and bladder. Observation of incontinence care performed by CNA A and CNA B for Resident #10 on 8/29/23 at 10:30 revealed CNA A did not perform hand hygiene after entering Resident 10 s room and prior to donning gloves to begin incontinent care. CNA A removed Resident #1's brief that was soiled with urine and feces. CNA A wiped the resident from front to back. CNA A did not perform hand hygiene after changing gloves and before positioning Resident #10 on her left side and cleaning her buttocks. He changed gloves and performed hand hygiene before placing a new brief on Resident # 10. He removed his gloves and performed hand hygiene before leaving the room. In an interview on 08/29/23 at 10:45 a.m. with CNA A, he revealed he should have washed his hands before starting care and performed hand hygiene between each glove change during care. CNA A stated he had infection control training. He said the resident could acquire an infection when he did not follow good infection control practices including washing hands before commencing care. He stated he was nervous and there were several knocks on the resident's door during incontinent care which cause him to become distracted. 29/23 During an interview with the DON on 8/29/23 at 1:00 PM., she revealed she was aware of some of the concerns raised about infection control. She stated she expected the aides to follow the facility protocols during care, one of which was to ensure hand hygiene when entering the residents' room before beginning care, between glove changes and when completing care and leaving the room. and change of gloves as needed. She stated the LVN's were responsible for monitoring the aides on a shift-to-shift basis. And the ADON's performed proficiency exams on the aides when they began employment and annually. She stated she intended to start inservicing her staff immediately. Review of the facility's infection control policy titled Hand washing/Hand Hygiene, dated August 2015, reflected the following [in part]: The facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub or alternatively soap and water Before and after coming on duty, Before and after direct contact with residents and after removing gloves

Based on interview and record review, the facility failed to ensure resident care plans were updated timely after completion of comprehensive assessments for 1 of 6 (Resident #38) reviewed for care plan timing and revision, in that: Resident #38's comprehensive care plan was not updated within seven days after completion of his comprehensive MDS Assessment on 6/28/2023. The facility's failure placed residents at risk of not having their needs met due to lack of direction related to care area triggers. The findings included: Record review of Resident #38 revealed a [AGE] year-old male with the following diagnosis: chronic kidney disease, Type 2 Diabetes Mellitus, Major Depressive Disorder, Vascular Dementia, Anxiety Disorders, Hypertension (high blood pressure) and constipation. Record review of Resident #38's MDS Nursing Home Comprehensive (NC) Item Set started June 14, 2023 and completed June 28, 2023 (date RN Assessment Coordinator signed assessment as complete) revealed CAA triggers for the following: 02. Cognitive Loss/Dementia 06/14/2023 04. Communication 06/14/2023 05. ADL Functional/Rehabilitation Potential 06/14/2023 06. Urinary Incontinence and Indwelling Catheter 06/14/2023 11. Falls 06/14/2023 12. Nutritional Status 06/14/2023 16 Pressure Ulcer 06/14/2023 17 Psychotropic Drug Use 06/14/2023 Record review of Resident #38's care plan revealed the following: - Cognitive Loss/Dementia, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - Communication, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - ADL/Functional/Rehabilitation Potential, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - Urinary Incontinence and Indwelling Catheter, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - Falls, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - Nutritional Status, no care plan for this issue found. - Pressure Ulcer, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - Psychotropic Drug Use, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/17/2019. In an interview on 08/29/2023 at 2:30 PM, the DON said that care plans should be updated no later than seven days after a comprehensive MDS assessment has been completed. The DON did not know why this one was not done and offered no resident outcomes. The facility supplied three policies related to care plans and comprehensive assessments, none of which indicated the number of days after a comprehensive assessment that a care plan should be completed or updated.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (Resident #1) of two residents reviewed for care plan. The care plan for Resident #1 did not identify the need for a back brace ordered by the doctor. The failure could place residents in the facility at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #1's Face Sheet revealed a [AGE] year-old male with an admitted [DATE], with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on 10/19/2022 at www.healthline.com revealed Spinal stenosis happened when the space inside the backbone was too small and without [CONDITION(S)] claudication meant not affecting the nervous system with leg pain, heaviness, and/or weakness in walking. [CONDITION(S)] meant your blood had too many lipids (or fats) such as cholesterol and triglycerides. Type II Diabetes Mellitus was an impairment in the way the body regulated and used sugar as fuel which occurred over a long period of time and [CONDITION(S)] happened when the body had too little insulin. Record review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], revealed a BIMS of 06 out of 15, indicating severe cognitive impact. The document revealed under the section for health conditions and staff assessment for pain to be conducted as not needed. Record review of Resident #1's document, Active Hospital Encounter, dated 9/14/2022 revealed the details of Resident #1's surgical procedure of L3 - S1 decompression with instrumented fusion on 9/14/2022. Record review on 10/13/2022 at https://mayfieldclinic.com revealed L3 - S1 decompression with instrumented fusion surgery would open the spinal cord and fuse the spine to stabilize sections of vertebra with instruments that consist of a combination of bone graft, screws, and rods to connect two separate vertebrae together into one new piece of bone. Record review of Resident #1's Facility Transfer Orders, dated 9/19/2022, revealed Resident #1 was ordered an LSO spinal brace to be delivered to the hospital prior to discharge, to be sent with Resident #1 upon discharge from the hospital. The orders were documented as, Spinal Brace - Continuous, Routine, to apply sitting on side of bed, and to wear OOB (out of bed). Record review of Resident #1's initial nursing facility physician's visit, completed by Physician A, dated 9/19/2022, revealed Resident #1 had the surgical procedure of L3 - S1 decompression with instrumented fusion on 9/14/2022. Record review of Resident #1's 48-hour Care Plan Conference Summary, dated 9/21/2022 revealed Resident #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation concerning the need to wear a back brace following spinal surgery. Record review of Resident #1's Care Plan, dated 9/25/2022, documented Resident #1 had chronic back pain due to spinal stenosis and the goal was to avoid interruption in normal activities due to pain. Review of the care plan made no reference that Resident #1 had a back brace to be worn per doctor's orders because of back surgery on 9/14/2022. During an interview on 10/12/2022 at 10:01am, Resident #1 said he came to the nursing facility after he had back surgery. He said his back hurt because something was wrong with his spine. Resident #1 said he had surgery and was at the nursing home to receive physical therapy and speech therapy and he was going home with his wife afterwards. Resident #1 said he wore his brace most of the time but said he did not enjoy wearing it. During the interview, Resident #1 was observed sitting in his wheelchair and wearing his back brace. During an interview on 10/13/2022 at 12:50pm, CNA A said she was familiar with Resident #1's care and how to assist him when putting on his back brace. CNA A said she was instructed by the physical therapy department when they came down to his room and physically demonstrated how to put on the back brace properly on Resident #1. CNA A said she was not sure if the care plan documented that Resident #1 had to wear a back brace. During an interview on 10/13/2022 at 1:01pm, RN A said when Resident #1 was admitted , she waited until physical therapy came down to his room, evaluated him, and showed Resident #1 and herself how to properly use the back brace prior to assisting him with any movement. RN A said she verbally told the nurse who came on duty on the next shift how to apply the back brace. RN A said Resident #1 had to wear the back brace when OOB (out of bed). RN A said the information about Resident #1's back brace would be in the eMAR and the electronic chart. RN A said if a new staff came on duty, she verbally in-serviced the staff on the information of when Resident #1 must wear the brace. RN A said she was not sure if the information was in Resident #1's Care Plan. RN A said the staff relied on verbal communication to relay information to the on-coming staff at shift change. RN A said the information about Resident #1's back brace was in the electronic data system record for Resident #1. During an interview on 10/13/2022 at 2:23pm, the DON said the order on the back brace for Resident #1 was put into the eMAR electronic system which would direct staff to wait on physical therapy prior to Resident #1 ambulating upon admission. The DON said she considered the Care Plan for Resident #1 to be his entire chart and not just the paper care plan. The DON said information for Resident #1 was in different places including the eMAR, electronic data system, and the care profile which was accessible through the electronic data system. The DON said staff knew to look for the information in the electronic records. The DON said staff did not have time to read through the entire care plan prior to working their shift. The DON said the staff relied on verbal communication when relaying information during shift change. The DON said she was responsible for developing the care plan for Resident #1. The DON said the care plan not containing information about Resident #1's need for a back brace was an error and she forgot to put the information into the plan. The DON said the information not being in the Care Plan would not be an issue because the information was in different locations of the electronic chart. The DON said the staff are in-serviced to look for the information in other places than the Care Plan. The DON said she was responsible for completing Resident #1's 48-hour care plan conference and comprehensive care plan. During an interview on 10/13/2022 at 4:06pm, the Administrator said the Interdisciplinary Team would be responsible to ensure information concerning Resident #1's need for a back brace based on doctor orders at admission was included into the Care Plan. The Administrator said the information about Resident #1's back brace would come from nursing and physical therapy and said the documentation was there, but just did not carry over into the Care Plan. The Administrator said she agreed the information was not in the Care Plan and said she knew the regulation required Resident #1's Care Plan to contain accurate medical information based on physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Care Planning - Baseline and Interdisciplinary Team Policy, dated 12/2016, revealed the Interdisciplinary Team was responsible for the development of the individualized comprehensive care plan and the plan would be based on review of the resident's comprehensive assessment and would include input from physician orders. The Interdisciplinary Team included by was not limited to, the resident's Attending Physician, the Registered Nurse who was responsible for the resident, the Dietary Manager/Dietician, the Social Services Worker responsible for the resident, the Activity Director/Coordinator, Therapist (speech, occupational, recreational, etc. as applicable), the Director of Nursing, the Charge Nurse responsible for the resident, Nursing Assistants responsible for the resident, others appropriate or necessary to meet the needs of the resident, the resident, the resident's family and/or the resident's legal representative/guardian or surrogate.

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen. The facility failed to ensure a kitchen staff changed their gloves and washed their hands after putting hand within the trash can. This failure could place residents at increased risk of exposure to food-borne illnesses. Findings included: During meal service observation 06/28/2022 at 4:30 PM, Dietary Aide was observed moving a large garbage can out of his path by placing his fingers within the inside of a garbage can used near the stove. This staff failed to change gloves or wash hands prior to walking over to a reach in refrigerator moving three pitchers consisting of water, orange juice and cranberry juice. This staff removed a case of milk cartons and placed ten milk cartons in a pan with ice, and placing the pitchers and milk carton on a cart and took to the residents on the facility halls and dining room. During an interview with Dietary Aide on 06/29/2022 at 1:40 PM, he said he was confused about when to change gloves and wash hands and did not realize he needed to change gloves or wash hands after touching the inside of the garbage can. (Dietary Aide had not completed his Safe Serve Certification training at this time) During an interview with the Dietary Manager on 06/29/2022 at 1:45 PM, she said the Dietary Aide had only been working there for about a week and undergoing training on the Safe Serve Certification and they were required to complete it within 30 days. She said he was supposed to complete it on Monday 6/27/2022 and not sure he has completed it yet. The Dietary manager said he should have removed his gloves and washed his hands before providing food service to the residents. Review of the kitchen policy and procedures dated 2020 titled, Proper Hand Hygiene: Dining Services Employees. Handwashing with soap and water is required in a Dining Services Setting in the following situations: - After handling dirty dishes or trash

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 7 residents reviewed for palatable food. (Residents #2, #3, #12,#15, #28, #32 and #33 residents in a Residence Council Meeting) This failure could place residents at risk of diminished nutrition and quality of life Findings included: During the resident council meeting on 06/28/2022 at 11:00 AM, residents attending (residents #2, #3, 12,15, 28, 32 and 33) stated that frequently, the food taste is terrible, cold, and always late. Resident #3 stated they have complained on several occasions and it would improve for a while then return to the food late cold and taste terrible. Review of Monthly Grievance Log for January, February, March. April, and May revealed complaints regarding food taste, cold and late. 1 January 30 resident complained regarding she was unhappy with breakfast - facility response showed Dietary Manager note of the complaint. 2. February 7 and 8 four residents complained about the quality of the food service - facility response - They have new contract dietary service. 3. March 17 established food committee with 6 residents complaining to the dietary manager regarding taste, cold, and late service and not alternatives- facility response: Dietary Manager met with residents to discuss concerns and work with the food committee. 4. March 19 resident complained regarding food service - facility response will talk to the dietary manager 5. April 28 Resident Council expressed concerns with dietary department with staffing in department - facility response - Dietary manager to attend next resident council meeting to work on resolving issues and work on staffing. 6. May 12 Food Committee express concerns to the Dietary Manager regarding taste, cold and late service - Facility response - follow up with Resident group and happy with progress made. 7. May 17, May 20 Concerns expressed regarding dietary services and unhappy with substitutes - facility response - happy with response if there no excuses moving forward. During a Confidential Group Interview on 6/28/22 at 11:00 p.m., the residents stated the food was cold and gross. One resident stated, there wasn't enough food to feed a baby. The residents stated there were no snacks. They stated if they asked for the substitute, they were not going to get it and sandwiches had no condiments. When asked if they could pick one thing, they wanted surveyor to work on, they unanimously stated the food which is terrible always late and frequently cold. Observation of a test tray evaluation on 06/28/2022 at 1:00 PM, revealed the test tray consisted of 1 cup of collard greens, 1 corn bread square, a bowl of beans and bacon, and a fruit cup Three surveyors evaluated the test tray. The collard greens Luke-warm corn bread, Luke-warm, beans Luke-warm residents complain about food being cold taste during meal service. Interview on 06/28/2022 at 1:00 PM, revealed the Admissions Manager (Administrator unavailable) stated corn bread Luke-warm collard greens Luke-warm beans warm. Flavor was good. During an interview on 06/28/2022 at 4:45 PM, the Dietary Manager said that the previous Dietary Manager was let go and they have been working with the Resident Council and the Food Committee, but have not had a chance to get together since she was terminated. She said we had been short-handed, and the food time is posted at 12:00 Noon and as I understand , we must deliver the first tray by 12:00 Noon and the first tray is delivered by that time. Sometimes the hall trays do not get delivered till after 12:00 Noon and the dining room is delivered after all the hall trays are delivered. She also said water should not be added to puree food. Observation of staff during diner food service on 06/28/2022 at 4:30 PM reveals 1 Cook 1 Dietary Aide 1 Dietary Manager Staff to provide meals for 63 residents who eat in the facility's only dining room. Observation of food delivered to the dining room 06/27/22 - 12:50 PM 06/28/22 - 1:00 PM 06/29/2022 request dietary policy and procedure and food times revealed Lunch meals time begin at 12:00 Noon. No dietary policy and procedure regarding delivery was provided.

Based on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups for Resident Council Meetings reviewed for grievances consisting 7 residents who regularly attend the meetings and complain about the temperature, taste, and lateness of the food. The facility failed to comply with grievances voiced by residents #12, #32,#46, #3, #20, #15 and #33 in the resident council meeting held in January 2022, February 2022, March 2022, April 2022, and May 2022 consisting of residents , These failures could place residents at risk unresolved grievances, a decreased sense of self-worth, and a decline in quality of life. Findings Included: Review of Grievances followed up by the Resident Council meetings reveal the following: Review of Monthly Grievance Log for January, February, March. April, and May 2022 revealed the following dietary complaints: 1. On January 30, 2022 a resident complained that she was unhappy with breakfast - facility response: showed Dietary Manager note of the complaint. 2. February 7 and 8 2022 four residents complained about the quality of the food service - facility response: They have new contract dietary service. 3. March 17, 2022established food committee with 6 residents complaining to the dietary manager regarding taste, cold, and late service and not alternatives- facility response: Dietary Manager met with residents to discuss concerns and work with the food committee. 4. March 19, 2022 resident complained regarding food service - facility response will talk to the dietary manager 5. April 28, 2022 Resident Council expressed concerns with dietary department with staffing in department - facility response - Dietary manager to attend next resident council meeting to work on resolving issues and work on staffing. 6. May 12, 2022 Food Committee express concerns to the Dietary Manager regarding taste, cold and late service - Facility response - follow up with Resident group and happy with progress made. 7. May 17, 2022 May 20 Concerns expressed regarding dietary services and unhappy with substitutes - facility response - happy with response if there no excuses moving forward. During a Confidential Group Interview on 6/28/22 at 11:00 p.m., residents (#12, 32,46,3,20,15 and33 ) stated the food was cold and gross. One resident stated, there wasn't enough food to feed a baby. The residents stated there were no snacks. They stated if they asked for the substitute, they were not going to get it and sandwiches had no condiments. When asked if they could pick one thing, they wanted surveyor to work on, they unanimously stated the food, which was terrible always late and frequently cold. During an interview on 06/28/2022 at 4:45 PM, Dietary Manager said that the previous dietary manager was let go (Present DM was not specific when she was let go) and they had been working with the Resident Council and the Food Committee, but had not had a chance to get together since she was terminated. She said they had been short-handed, and the food time is posted at 12:00 Noon and she said they must deliver the first tray by 12:00 Noon and the first tray was delivered by that time. Sometimes the hall trays do not get delivered until after 12:00 Noon and the dining room was delivered after all the hall trays are delivered. During an interview with Administrator on 06/30/2022 at 3:00 PM, she said food was the major topic and they tried to work with the residents. The kitchen was contracted out and they have made it known about the issues and were trying to resolve them.

Based on observation, interview and record review, the facility failed to ensure that residents of the facility ( Resident #'s 212, 56,and the North Eas [NAME] had the right to a safe, clean, comfortable, and homelike environment. The facility failed to ensure : A. The floor was clean and free of soiled areas in Resident #212's room. B. The bedside table, infusion pole, and floor were cleaned and free of spills and debris in Resident #56's room C. Residents' equipment (Hoyer lift, wheel chairs, walkers and other pieces of heavy equipment) were stored in a way to ensure cleanliness, order, and resident/visitor safety. These failures could affect the residents, by placing them at risk for unsafe, unclean, and uncomfortable environment, low self-esteem, and a diminished quality of life. Findings included: An observation on 06/27/22 at 12:06 PM, and 6/29/22 at 3:37 PM revealed the floor of Resident # 212 was soiled with feces. The resident refused an interview. An observation of Resident # 56's room revealed a bedside table and an infusion pole sitting in the resident's room, had built up dust/grime and spilled tube feeding formula on the metal frames. There were multiple syringe caps littering the carpet of the room. The carpet in the room was soiled with stains. The resident was not interviewable due to cognitive impairment and [CONDITION(S)]. In interviews during the Resident council meeting on the 6/28/22 at 11:15 AM Resident #' s 12, 32, 28, 3, 20, 15, 2, and 33 complained about the housekeeping staff only pulling trash from the public bathrooms and living room areas of the facility, and never vacuuming or mopping the floors of the resident rooms. They concurred that the bathrooms sinks are never cleaned, and they had cleaned the sinks themselves. They stated they found this disgusting and stated it happened on a regular basis. An interview with the Housekeeping Supervisor on 06/29/22 4:30 PM, revealed the floors in the resident's rooms were to be mopped daily. She also stated she mopped Resident #212's floor on 6/28/22 and must have missed seeing the feces that was left on the floor. She stated she was responsible for monitoring to ensure the resident's rooms were cleaned and another housekeeper(who not available for an interview) should have mopped the room on 06/29/22. An interview on 06/29/22 at 3:46 with a facility nursing staff member that wished to remain anonymous, revealed the staff member felt Resident #56's room was always dirty. She stated the room was horrible and housekeeping did not keep the resident's room clean. She stated it was housekeeping's responsibility to clean the resident's bedside tables and Infusion poles. In an interview on 06/29/22 at 4:30 PM, the DON witnessed the condition of resident #'s 212 and #56's rooms. She stated the nurses were responsible for cleaning up anything that they spill, or for picking up any equipment or trash that they drop in a resident's room. She stated she was not aware that resident #'s 212 and 56 rooms needed cleaning. In an observation on 06/029/2022 at 03: 51 PM, of the North East hall revealed the area in front of the therapy room, at the end of the hall, had several walkers hanging from the walls on brackets. There were several walkers on each bracket. There were also several wheelchairs, a Hoyer lift, a weight chair, and various other pieces of unused resident equipment in the open hallway in direct view and access of residents and visitors. In an interview on 01/10/2019 at 12:00 PM, the Administrator stated she was aware of the equipment stored at the end of the Northeast Hallway in front of the therapy room. She stated she could see that it did not contribute to a safe and home-like environment now that she had been made aware of it. She stated it has just been there so long; I didn't notice it being there. She stated she would move the equipment immediately. In a record review, the facility's policy, titled Quality of life - Home Like Environment dated revised October 2009 revealed in part: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. There characteristics include cleanliness and order, comfortable noise levels.

Based on observation, interview, and record review, the facility failed to post the actual hours worked by the licensed and unlicensed nursing staff directly responsible for direct resident care per shift on a daily basis. The daily nursing staffing information was posted but did not include the total numbers of actual hours worked for RNs, LVNs, CNAs, and RNAs. The facility's failure could place residents at risk of not knowing the daily nurse staffing data. The findings included: Observation on 06/27/22 to 06/30/22 revealed the daily nursing staffing hours form was posted on the wall outside the Director of Nurses (DON) office on the main hallway entrance. Review of the Facility's staffing form titled [NAME] Care Centers dated 6/27/22 at 10:00 AM and posted outside of the DON's office revealed the following Scheduled Hours 6 AM - 2 PM, RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 6 AM - 2 PM Hours Worked. RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Scheduled Hours RN - 8 Hrs. LVN - 24 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Hours Worked. RN - 8 Hrs. LVN - 24 Hrs. CNA - 45 Hrs. Scheduled Hours 10 PM - 6 AM, RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. 10 PM - 6 AM Hours Worked. RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. Resident Census: 65 Review of the Facility's staffing form titled [NAME] Care Centers dated 6/28/22 at 11:00 AM and posted outside of the DON's office revealed the following Scheduled Hours 6 AM - 2 PM, RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 6 AM - 2 PM Hours Worked. RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Scheduled Hours RN - 8 Hrs. LVN - 24 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Hours Worked. RN - 8 Hrs. LVN - 24 Hrs. CNA - 45 Hrs. Scheduled Hours 10 PM - 6 AM, RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. 10 PM - 6 AM Hours Worked. RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. Resident Census: 65 Review of the Facility's staffing form titled [NAME] Care Centers dated 6/29/22 at 10:30 AM and posted outside of the DON's office revealed the following Scheduled Hours 6 AM - 2 PM, RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 6 AM - 2 PM Hours Worked. RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Scheduled Hours RN - 8 Hrs. LVN - 24 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Hours Worked. RN - 8 Hrs. LVN - 24 Hrs. CNA - 45 Hrs. Scheduled Hours 10 PM - 6 AM, RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. 10 PM - 6 AM Hours Worked. RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. Resident Census: 65 Observation on 6/29/22 at 10: 40 AM revealed the daily nursing staff posted hours and resident census had not been modified to reflect the actual staff present on each shift nor a change in the resident census from 6/27/22 - 6/29/22. In an interview on 6/29/22 at 1:50 PM, the DON stated she completed the daily staffing sheets every morning for all three shifts, morning 6 AM - 2 PM, evening 2 PM - 10 PM, and night 10 PM - 6 AM. According to the scheduled staff, not the actual staff and posts it outside her door. She further stated she was not aware the staffing sheets were supposed to be completed at the beginning of each shift and reflect the actual number of staff on the floor. And could negatively affect resident care and give anyone inquiring about the number of staff present inaccurate information. In an interview on 6/29/22 at 2:00 PM, the Administrator stated, the DON was responsible for posting the daily nursing staffing hours. And the posting of the actual staff present is a new one on me. The administrator further stated, not having the actual hours posted could negatively affect resident care and give anyone inquiring about the number of staff present inaccurate information. Review of the facility policy titled Posting Direct Care Daily Staffing Numbers, revised July 2016, showed: Policy Interpretation and Implementation 1. Within two (2) hours of the beginning of each shift .will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format . 3 .The information recorded on the form shall include: a. The name of the facility. b. The date for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift schedule operated by the facility. e. The shift for which the information is posted. f. Type (RN [registered Nurse], LPN [Licensed Practical Nurse], LVN [Licensed Vocational Nurse], or CNA [Certified Nursing Assistant]) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non-licensed nursing staff working for the posted shift

Based on observation, interview, and record review the facility failed to ensure the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of two residents reviewed (Resident #1) for infection control practices. CNA C and CNA D failed to perform hand hygiene and change their gloves while providing incontinence care for Resident #1. This failure place residents at risk for the spread of infection. Findings include: Record review of Resident #1's face sheet, dated 05/19/22, revealed the resident was an 89- year- old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Material Data Set (MDS) assessment, dated 04/20/22, revealed Resident #1 required extensive assistance with most activity of daily living (ADLs) and two-person assist. Resident #1 was always incontinent of bowel and bladder. Record review of Resident #1's care plan, dated 12/18/21, revealed the resident was care planned for being incontinent of bladder but none noted for bowel. Observation of incontinence care for Resident #1 on 05/19/22 at 2:20 p.m. revealed CNA C and CNA D washed their hands before the start of care. Both CNAs donned gloves. CAN C put on doubled gloves. CNA C and CNA D transferred Resident #1 from chair to the resident's bed with Hoyer lift before commencing care. Neither CNA C nor CNA D changed their gloves after the transfer. CNA C, with the same gloves on, removed the resident's soiled brief. She wiped from front to back making 6 strokes of clean with the same on four different occasions. Resident #1's brief was soiled with urine and fecal matter. Both CNAs repositioned Resident #1 and CNA C continued to clean the resident. She doffed one of her doubled gloves. CNA C wiped Resident #1's back side. CNA C did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #1's clean brief. She placed the clean brief on the resident and fastened it. CNA D assisted CNA C to provide care to Resident #1. CNA D wore the same gloves for transferring the resident, repositioning the resident, and to fasten the clean brief to the resident. CNA C and CNA D doffed their gloves and washed their hands before exiting the room. In an interview on 05/19/22 at 2:44 p.m. with CNA C, she stated she had been employed at the facility for about 1 week and received infection control training during orientation. CNA C stated cross contamination meant mixing clean with dirty. CNA C stated she should have washed her hands and changed gloves at the appropriate times while providing care. She stated Resident #1 could get an infection for not using good infection control practice. Interview with CNA D on 05/19/22 at 2:50 p.m. revealed she had been employed at the facility for about three weeks and received infection control training during orientation. She stated cross contamination was transferring germs from one place to another. CNA D stated she should have changed her gloves and washed her hands after transferring Resident #1 before fastening his clean brief. During an interview with the DON 05/19/22 at 3:33 p.m., she stated she was aware of some of the concerns raised about infection control. She stated the aides were expected to follow standard protocols to include appropriate hand hygiene (hand washing and changing gloves) when providing incontinent care. Record review of the facility handwashing and hand hygiene policy, revised August 2015, reflected, The facility considers hand hygiene the primary means to prevent the spread of infections . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies . 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; and b. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. 7) Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a) Before and after coming on duty b) Before and after contact with residents . c) After contact with a resident's intact skin d) After removing gloves

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #16) of 18 residents reviewed for accidents. CNA B failed to transfer Resident #16 with the assistance of another staff person or the use of a gait belt, which resulted in the resident sustaining fractures of the right leg. This failure could place residents at risk for accidents and injuries. Findings included: Review of Resident #16's MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. She was cognitively intact with a BIMS (brief interview mental status) of 15. Resident #16 required extensive assistance of two staff people with transfers. For surface-to-surface (transfer between bed and chair or wheelchair), the resident was not steady and was only able to stabilize with staff assistance. Review of Resident #16's care plan initiated 10/09/17 revealed she was at risk for falls related to gait/balance problems. Interventions included the assistance of two staff for all transfers. Review of a Provider Investigation Report, signed and dated by the Administrator on 12/31/18, revealed CNA B failed to follow plan of care on 12/23/28, which resulted in a fall with injury. The resident had a history of [REDACTED]. The post investigation provider action included all nursing staff was in-serviced on two person transfers, use of gait belt when appropriate and how to access their Resident Plan of Care in their electronic chart. In addition, CNA B was written up pending the investigation. Review of Resident #16's incident report dated 12/23/18 revealed the following: .CNA was giving shower to resident, after shower, attempted to transfer from shower chair to motorized scooter. Resident holding bar for support, legs began to buckle, assisted to knees. Right foot was outward resident transferred to hospital via stretcher Review of Resident #16's hospital records dated 12/23/18 revealed she had a right tibia and fibula fracture s/p (status [REDACTED]. Observation and interview on 04/30/19 at 10:18 AM revealed Resident #16 was sitting in a manual wheelchair with a boot to her right leg. When asked about her right leg, Resident #16 revealed an aide assisted her back into her motorized scooter after a shower. As she was getting into it, the chair moved back because it was not turned off causing her to fall on the floor. She stated she was immediately in pain and was sent to the hospital right away. The resident stated the aide had transferred her alone and had not used a gait belt. Attempts to contact CNA B were unsuccessful as her phone was not receiving incoming calls. Review of the Provider Investigation Report dated 12/31/18 and signed by the Administrator revealed the following: CNA B was assisting Resident #16 in the shower room. She was helping her transfer from shower chair to her power chair when the resident's leg gave out and resident went down onto the floor. She was experiencing significant pain in her right leg. MD(medical doctor) was notified and order received to transfer resident to hospital via ambulance. Resident was found to have fractures in RLE (right lower extremities). The resident was care planned as a two person transfer due to instability in her RLE. The employee failed to follow the plan of care. A written statement by CNA B, dated on 12/22/18 (even though the incident occurred on 12/23/18) revealed the following: I was showering Resident #16, finished her shower, transferring the resident. She was holding on to the bar for support. She went down on her knees. I called for help, I pulled the call light, another CNA and nurse came in to help. We transferred her into shower chair Review of CNA B's Gait Belt Transfer Skill Assessment date 11/25/18 and signed off by LVN C revealed CNA B was clinically proficient in applying the gait belt appropriately and safely transferring and supporting a resident appropriately. Interview with LVN C on 05/01/19 at 2:40 PM revealed CNA B told her the day of the incident, 12/23/18, she had taken Resident #16 into the shower and as she was transferring her back into her motorized chair, the resident's foot did not turn and just snapped. LVN C stated the emergency call light was pulled and when she went in the shower room, the resident was on the floor, in pain, and she was starting to get a hematoma to one side of her right leg. LVN C could not recall if a gait belt had been used. The resident was transported to the hospital. LVN C also stated Resident #16 sometimes required the assistance of one staff to transfer because she was able to bear weight and shift herself during the transfer but they normally had two people assisting. She said they were short-handed the day of the incident and did not have another person. After the incident all staff were in-serviced on how to appropriately transfer a resident with two staff members. Interview with RN D on 05/01/19 at 3:05 PM revealed she was working the day of the incident, 12/23/18, and she was called in to assist Resident #16 after she fell . The resident was on the floor in the shower room and she was in pain and was sent to the hospital soon after. RN D also stated Resident #16 required 2 staff to transfer her during the time she had worked with her. Interview with LVN [NAME] on 05/02/19 at 9:42 AM revealed Resident #16 required a two person transfer with a gait belt for safety during her shift. Interview with CNA F on 05/02/19 at 9:57 AM revealed Resident #16 required 2 staff to transfer her with a gait belt before her fall and fracture. Interview on 05/03/19 at 11:45 AM with CNA G revealed she was working the day Resident #16 fell on [DATE], and she stated she had not been asked to help assist the resident in or out of the shower. CNA G further stated everyone, including CNA B, knew Resident #16 required 2 staff for transfer. Interview on 05/02/19 at 2:31 PM with the DON revealed CNA B told her, during her investigation, Resident #16 had been transferred into the shower chair with two staff members and she transferred the resident alone after the shower because the resident told her she could hold on to the grab bar and stand up and assist. The DON further revealed Resident #16 required the assistance of 2 staff to transfer for a long time because she had been diagnosed with [REDACTED]. She also stated staff could check the resident care plan for changes or she would hold direct inservices with staff about the changes. Interview with Resident #16 on 05/03/19 at 11:20 AM revealed she never told CNA B she could be transferred with one staff member after her shower when she fell . Review of the inservice dated 12/23/18 and signed by the Administrator and RN D revealed the following: The following areas of instructions were covered: 1. Transfers of residents always have two CNAs for resisdent that are two person transfers - or for any residents that are weak, unsteady, or combative. Always use gait belts. 2. How to access care plans in P[NAME] (point of care).