Every finding on record at Integrity HC of Cobden

Based on interview, observation and record review the facility failed to provide food in a texture as directed by the physician for 6 (R1, R8, R11, R28, R32, and R46) of 11 residents reviewed for diet texture in a sample of 34. Findings include:1. The facility document titled, Diet Spreadsheet documents day 16 lunch; dental soft (Mech (mechanical) soft): ground rosemary pork with gravy #8 dip with gravy, soft chopped au Gratin potatoes 4 ounce spoodle, soft chopped zucchini and tomatoes, frosted cake 3 inch by 2 1/2 inch, soft dinner roll/margarine teaspoon, and beverage 8 ounces. On 09/15/25 during the lunch meal from approximately 12:05-12:25 PM, R1 and R8 received the mechanical soft pork, the mechanical soft pork had the appearance of pulled meat with the pieces being over an inch long but pulled apart. The facility recipe for, ground rosemary pork with gravy documents 6. Place prepared pork loin in a washed and sanitized food processor. Pulse/grind to the size and texture of finely ground beef. On 09/15/25 at approximately 1:00 PM, V5 (Dietary Manager) stated, they knew they were not going to have enough pork for lunch so they made beef also to switch to when they ran out of pork.On 09/15/25 during the lunch meal from approximately 12:05-12:25 PM, R11, R28 and R46 received the mechanical soft beef, the mechanical soft beef had the appearance of pulled meat with the pieces being over an inch long but pulled apart. 2. The facility document titled, Diet Spreadsheet documents day 17 lunch, dental soft (Mech (mechanical) soft): ground roast beef with gravy #8 dip with gravy, brown gravy 2 ounce ladle, soft roasted carrots, potatoes, and onions two 4 ounce spoodle, pudding parfait #8 dip/#30 dip topping and beverage 8 ounces.On 09/16/25 during the lunch meal from approximately 12:05-12:15 PM, R1, R8, R11, R28 and R46 received the mechanical soft beef, the mechanical soft beef had the appearance of pulled meat with the pieces being over an inch long but pulled apart. The facility recipe for, ground roast beef with gravy documents 5. Place needed portions of cooked meat into a clean and sanitized food processor. Pulse/grind until meat is the size and texture of finely ground beef. 3. The facility document titled, Diet Spreadsheet documents day 19 lunch; dental soft (Mech (mechanical) soft): ground ham steak with gravy #8 dip, garlic mashed potatoes #8 dip, soft chopped buttered carrots 4 ounce spoodle, soft chopped fruit crumble #8 dip, and beverage 8 ounces. On 09/18/25 during the lunch meal from approximately 12:00- 12:10PM, PM R8, R11, R28 and R46 received carrots slices and peach fruit crumble with lunch, carrots the mechanical soft carrots were carrot slices, with some of the slices being an inch and some being an inch and a half long. The peaches in the mechanical soft fruit crumble were over an inch to approximately two inches long. The facility recipe for, soft chopped buttered carrots documents 4. Chop carrots into bite-size pieces. The facility recipe for, soft chopped fruit crumble documents 1. Chop fruit into bite-sized pieces, if needed. On 09/18/25 at 3:22 PM, V5 (Dietary Manager) stated, her and her staff need to review the recipes for the mechanical soft texture. V5 stated, she thought if the food was soft, that it was acceptable. V5 stated the carrots were over a half an inch in size. The meat probably was not mechanically altered enough. Her staff tends to be a little shy on the meat in the food processor because they feel it balls up. V5 stated, she will make sure they chop the vegetables from now on and they will use diced fruit. R46's admission record documents an admission date of 06/12/25 with diagnoses including: cerebral infarction, encephalopathy, muscle weakness, unspecified intellectual disabilities, major depressive disorder, vitamin D deficiency, anxiety disorder. R46's medication review report documents a dietary order of general diet, mechanical soft texture, thin liquids consistency, chopped meat, add gravy as needed, avoid thick sticky foods with an order date of 06/12/25 and an order status of active. R46's care plan documents a focus area of: R46 receives a regular mechanical soft diet with thin liquids, chopped meat and add gravy as needed, and avoid thick sticky foods. Encourage R46 to not talk while eating dated 06/24/25 with an intervention listed as: staff will serve diet as ordered per physician. R11's admission record documents an admission date of 01/21/16 with diagnoses including: Alzheimer's disease, chronic lymphocytic leukemia of B-cell type not having achieved remission, non-Hodgkin lymphoma, paranoid schizophrenia, major depressive disorder, splenomegaly, vitamin D deficiency, and anxiety disorder. R11's medication review report documents a dietary order of regular diet, mechanical soft texture, thin liquids consistency, ground meat, with extra sauces and gravies, with no bread, no pasta and all food to be served in bowls, and double portions all meals with an order date of 09/10/24 and an order status of active. R11's care plan documents R11 receives a mechanical soft diet with double portions of all meals with ground meats with extra sauces and gravies, no bread or pasta dated 04/04/23 with an intervention listed as staff will serve diet as ordered per physician.R28's admission record documents an admission date of 02/06/18 with diagnoses including: major depressive disorder, schizoaffective disorder, venous insufficiency, atherosclerotic heart disease, adjustment disorder with mixed disturbance of emotions and conduct, and other dietary vitamin B12 deficiency anemia. R28's medication review report documents a dietary order of low concentrated sweets diet with mechanical soft texture, thin liquids consistency, no added salt, can have regular hamburger (not mechanical soft), seconds only fruit and veggies with an order date of 07/22/24 with an order status of active. R28's care plan documents a focus area of R28 receives a mechanical soft, no added soft, low concentrated sweets diet with seconds only on fruits and vegetables and is able to have a regular hamburger that is not mechanical soft dated 04/09/2020 with an intervention listed of: staff will serve diet as ordered per physician. R8's admission record documents an admission date of 05/31/23 with diagnoses including dementia, type 2 diabetes mellitus, diaphragmatic hernia, anxiety disorder, edema, allergic rhinitis, and depression. R8's medication review report documents a dietary order of low concentrated sweets diet with mechanical soft texture, thin liquids with an order dated of 07/17/25 with an order status of active. R8's care plan documents R8 receives a mechanical soft low concentrated sweets diet, R8 has her own teeth and has no chewing or swallowing problems dated 04/14/25 with an intervention of: staff will serve diet as ordered per physician. 5.R1's admission record documents and admission date of 11/11/24 with diagnoses including: emphysema, chronic obstructive pulmonary disease, endocarditis, cerebral infarction, vitamin B12 deficiency anemia, hypothyroidism, panic disorder, major depressive disorder, anxiety disorder, atherosclerotic heart disease, pericardial effusion, chronic atrial fibrillation, and shortness of breath.R1's medication review report documents a dietary order of no added salt diet with mechanical soft texture, thin liquids consistency, chocolate pudding and gelatin with every meal with an order date of 11/21/24 with an order status of active. R1's care plan documents R1 receives a regular mechanical soft no added salt diet, give pudding and gelatin at all meals. R1 has no natural teeth, no chewing or swallowing problems dated 11/20/24 with an intervention listed as staff will serve diet as ordered per physician. 4. R32's admission record documents an admission date of 07/23/19 with diagnoses including: dementia, schizophrenia, major depressive disorder, anxiety disorder, essential hypertension, conversion disorder with seizures or convulsions, and scoliosis. R32's medication review report documents a dietary order of regular diet with a pureed texture, nectar thick liquids consistency, hand feed as needed, give super cereal at breakfast, provide bowls for the patient at meals to reduce spillage and improve self-feeding abilities with an order date of 07/22/24 with an order status of active. R32's care plan documents R32 receives a regular puree diet with nectar thick liquids with super cereal at breakfast. R32 has no chewing or swallowing problems noted with current consistency, resident has no natural teeth or dentures with a diagnosis of schizophrenia, seizure disorder, anxiety, hypertension, depression with a date initiated of 04/24/23 with an intervention listed of staff will serve diet as ordered per physician. The facility document titled, Diet spreadsheet day, documents pureed lunch; pureed rosemary pork #8 scoop, pureed au gratin potatoes #8 dip, pureed zucchini and tomatoes #16 scoop, pureed frosted cake #10 dip, pureed dinner roll/margarine #20 scoop, and beverage 8 ounce.On 09/15/25 at 12:32 PM, R32 received tapioca pudding with visible seeds in it with whipped topping on top. The pudding had visible tapioca pearls in the pudding. On 09/15/25 at 12:35 PM, V5 (Dietary Manager) stated, they lost power last night and they did not have time to make an extra cake so the pureed diet residents received pudding, either tapioca or chocolate. On 09/15/25 at 3:22 PM, V5 stated, residents on a puree diet should not receive tapioca pudding unless the pudding is pureed.

Based on observation, interview, and record review the facility failed to follow enhanced barrier precautions for 1 of 5 residents (R67) reviewed for infection control in a sample of 34 Findings include:R67's admission Record dated 09/18/25 documents an admission date of 09/02/25 with diagnoses in part of chronic obstructive pulmonary disease, unspecified protein-calorie malnutrition, and dysphagia.R67's MDS (Minimum Data Set) dated 09/08/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 14 which indicates cognitively intact. Section GG documents eating as partial/moderate assistance.R67's Care Plan documents a Focus area of R67 requires tube feeding when he eats 50% or less of his meals. He is at risk for complications. R67 has protein calorie malnutrition and dysphagia. R67's order summary report dated 09/18/25 documents, flush G-Tube (Gastrostomy tube) with 60 cc (cubic centimeters) H20 (water) every shift. Verify placement via external tube length. 32cm (centimeters) every shift with an order date of 09/17/25 no end date. R67's order summary report dated 09/18/25 documents, Initiate EBP (Enhanced Barrier Precautions) with an order date of 09/02/25 order status documents discontinued. R67's order summary report date 09/18/25 documents Initiate EBP precautions with an order date of 09/17/25. R67's progress note date 09/10/25 at 5:54PM by V2 (Director of Nursing/DON) documents Resident is now off of EBP precautions. On 09/15/25 at 10:16AM observed R67's door. No EBP signage noted to door. Observed no PPE (Personal Protective Equipment) outside of doorway along with no bins inside of R67's room. On 09/16/25 at 11:00AM observed R67 door which had no signage located on outside of doorway. Observed no PPE outside of doorway. Observed no isolation bins in R67's room. On 09/17/25 at 10:35AM observed R67's door which had no signage located on door, no PPE noted outside of doorway, and no bins noted inside of R67's room. On 09/17/25 at 1:00PM observed V8 (Certified Nurse Assistant/CNA) and another staff member taking R67 to the restroom not donning any gown or PPE prior to providing care. On 09/17/25 at 1:44PM observed R67 door no signage noted to door, no PPE noted outside of room. On 09/17/25 at 1:44PM observed V9 (Licensed Practical Nurse) performing flush to R67's G-tube. V9 had a new gradual which she placed 60cc of water in container. V9 then donned a gown, gloves, and mask. V9 then measured R67's G-tube which measured 36cm with end and 32 cm without the end. V9 stated that placement was correct. V9 then opened G-tube end and flushed with 60cc of water. V9 then closed the cap and removed PPE and placed in trash bag. On 09/17/25 2:00PM, V2 (DON) stated that he did write on 09/10/25 that R67 was off EBP. V2 stated R67 had a surgical wound to his hip from a recent hip surgery and they were doing a dressing change to the hip and having the wound care doctor see R67 for the surgical wound. V2 said the surgical wound healed and so he took R67 off EBP. V2 stated he didn't know for sure if R67 should be on EBP for the G-tube since R67 had only been getting the flushes and hasn't required any feedings. V2 said he did question if R67 should still be on EBP since he had the G-tube. V2 stated that he could see now were R67 still needed to be on EBP. V2 stated that he was going to put R67 back on EBP right away. V2 stated that the nurses usually always wear a gown and gloves when they flush R67 G-tube. On 09/17/25 at 2:43PM, V8 (CNA) stated that R67 was on enhanced barrier precautions, but that he was taken off it now. V8 couldn't remember when R67 was taken off of the EBP. V8 stated when she has been providing care to R67 she has not been donning a gown since he has come off the EBP. V8 stated that she knew when R67 came off EBP because they removed the signage from his door. V8 said when a resident is on EBP that they have a sign on the outside of their door along with a bin outside of the door with PPE and isolation bins inside of their rooms for trash. On 09/18/25 at 10:00AM observed R67's room which had a EBP signage on the outside of the door along with a bin on the outside of the room with PPE of gloves and gowns The facility policy titled Isolation-Categories of Transmission -Based Precautions with a reviewed and updated date of 2023 documents under Enhanced Barrier Precaution 1. In addition to Standard Precautions, implement Enhanced barrier Precautions for all residents with any of the following. A. Infection or colonization with a MDRO (Multidrug-Resistant Organism) when Contact Precautions do not apply. B. wounds and /or indwelling medical devices (e.g central line, urinary catheter, feeding tubes, tracheostomy/ventilator) regardless of MDRO colonization status. 7. Signs- the facility will implement a system to alert staff and visitors to the type of precautions the resident requires. 8. Because enhanced barrier precautions do not impose the same activity and room placement restrictions as contact precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed then at higher risk.According to https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html. Enhanced Barrier Precautions: Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs356. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing.

Based on observation and interview the facility failed to dispose of refuse properly and securely. This failure has the potential to affect all 61 residents residing in the facility. Findings include: On 10/16/23 at 4:30 PM and 10/17/23 at 4:30 PM there was trash on the ground around the dumpster and approximately five feet from the dumpster, including cups, food bowls, paper, plastic utensils, and napkins. On 10/18/23 at 4:30 PM there was bags of trash piled in the dumpster to where the lids could no longer close and there was a bag of trash on the ground behind the dumpster. There was trash on the ground around the dumpster to approximately eight feet from the dumpster, including cups, food bowls, paper, plastic utensils, and napkins. On 10/19/23 at 12:50 PM V13 (housekeeping) stated, sometimes the dumpster will get full where the lids will not shut, but not that often anymore. They are currently using all disposable ware so that makes it worse. On 10/19/23 at 1:03 PM V14 (Dietary) stated, sometimes the dumpster will get full where the lids don't shut but not that often. She believes trash gets on the ground due to the trash truck. On 10/19/23 at 1:17 PM V15 (Environmental Services) stated, the dumpster does get too full where the lids don't shut sometimes, especially with all the disposable ware now. V15 said he believes all the trash has ended up on the ground because staff will sling the bags into the dumpster and sometimes it spills. V15 said sometimes the trash ends up on the ground due to the trash truck picking it up and some of the stuff will go flying. On 10/19/23 at 3:20 PM V1 (Administrator) stated, they now have three times a week pick up instead of two, they have educated staff on making sure there was no trash on the ground and it gets picked up, there are a few times the lids wouldn't shut due the added disposable ware. Also, the neighbors will go through the dumpster and leave the lids open. The document from the trash service company dated 10/19/23 documents three times a week pick up for the facility. The Resident Census and Condition of Residents form (CMS 672) dated 10/19/23 documents that there are 61 residents residing in the facility.

Based on interview, observation and record review the facility failed to provide the mechanical soft diet texture as directed by the recipe for 8 of 15 residents (R1, R55, R31, R5, R58, R60, R39, R22) reviewed for dining in a sample of 67. Findings include: The Facility document titled, Diet Spreadsheet dated week 4, Day 23 documents: Dental Soft (Mech Soft) - Ground Italian Herbed Pork Loin with gravy, Cornbread stuffing with gravy, Brussel sprouts (d/s), and frosted cake. On 09/19/22 at 11:30 AM throughout lunch V6 (dietary aide) served Italian Herbed pork that was pulled apart pieces. The muscle fibers were pulling apart easily however, they were approximately 2 inches long. The meat was not mechanically altered. The Brussel Sprouts were not cut up for the mechanical soft diet. On 09/19/22 between 11:30 AM and 1:00 PM R1, R55, R31, R5, R58, R60, R39 and R22 were observed with and eating the mechanical soft textured diet for lunch that consisted of Ground Italian Herbed Pork Loin with gravy, Cornbread stuffing with gravy, Brussel sprouts (d/s), and frosted cake. On 09/21/22 at 2:20 PM, V13 (Speech Language Pathologist) stated, mechanical soft meat should be pieces of meat that are a few millimeters long in length. The meat should go through mechanical alteration. Any larger vegetables such as Brussel sprouts should also be cut up. The recipe card should list the procedure for the mechanical soft diet preparation. On 09/19/22 at 12:45 PM, V11 (Registered Dietician) stated, the facility should utilize the recipe card for the directions for the mechanically altered diet. On 09/19/22 at 12:40 PM, V5 (Dietary Manager) stated, the Ground Italian Herbed Pork Loin with gravy is the recipe for the mechanical soft diet Italian Herbed pork. The Brussel Sprouts (d/s) - dental soft is the recipe used for the mechanical soft diet Brussel Sprouts. The Ground Italian Herbed Pork Loin w/Gvy (Gravy) Day 23 lunch recipe documents: 5. Place needed number of servings into a clean and sanitized food processor and grind to the size and texture of fine hamburger. The Brussel Sprouts (d/s) Day 23 lunch recipe documents: 4. Chop brussel sprouts into bite-size pieces. Transfer to greased steam table pans. The undated document by the American Dietetic Association titled, National Dysphagia Level 2: Mechanically Altered Nutrition Therapy (provided by V13 (Speech Language Pathologist)) documents: Description: This level consists of foods that are moist, soft-textured, and easily formed into a bolus. Meats are ground or are minced no larger than one-quarter-inch pieces; they are still moist, with some cohesion. 1. R1's Physician order sheet dated 09/01/22 documents: Regular diet, mechanical soft texture with a start date of 06/20/22 and no end date documented. R1's Physician order sheet dated 09/01/22 documents: Speech Therapy Clarification: Diet change from pureed solids to mechanical soft solids. All food must be cut up/set up via staff. Use aspiration precautions: reduced bolus size for all PO (by mouth). Patient requires direct supervision for all PO (by mouth). R1's Minimum Data Set (MDS) section K dated 09/15/22 documents : Mechanically altered diet require change in texture of food or liquids with the yes checked. 2. R55's Physician order sheet dated 09/01/22 documents: Regular diet, mechanical soft texture with a start date of 03/25/22 and no end date documented. R55's Minimum Data Set (MDS) section K dated 08/25/22 documents : Mechanically altered diet require change in texture of food or liquids with the yes checked. 3. R31's Physician order sheet dated 09/01/22 documents: General diet, mechanical soft texture with a start date of 08/24/22 and no end date documented. R31's Physician order sheet dated 09/01/22 documents: Speech Therapy diet clarification: Diet change from regular solids, thin liquids to mechanical soft solids, honey thick liquids. Patient requires intermitted supervision from staff. Continued all other diet orders, with an ordered date of 08/22/2022. 4. R5's Physician order sheet dated 09/01/22 documents: General diet, mechanical soft texture with a start date of 11/15/21 and no end date documented. R5's Minimum Data Set (MDS) section K dated 07/01/22 documents : Mechanically altered diet require change in texture of food or liquids with the yes checked. 5. 58's Physician order sheet dated 09/01/22 documents: Low Concentrated Sweets diet, mechanical soft texture with a start date of 10/12/21 and no end date documented. R58's Minimum Data Set (MDS) section K dated 08/26/22 documents : Mechanically altered diet require change in texture of food or liquids with the yes checked. 6. R60's Physician order sheet dated 09/01/22 documents: Regular diet, mechanical soft texture with a start date of 03/21/22 and no end date documented. R60's Minimum Data Set (MDS) section K dated 08/29/22 documents : Mechanically altered diet require change in texture of food or liquids with the yes checked. 7. R39's Physician order sheet dated 09/01/22 documents: Regular diet, mechanical soft texture with a start date of 06/20/22 and no end date documented. R39's Minimum Data Set (MDS) section K dated 07/29/22 documents : Mechanically altered diet require change in texture of food or liquids with the yes checked. 8. R22's Physician order sheet dated 09/01/22 documents: Regular diet, mechanical soft texture with a start date of 10/26/21 and no end date documented. R22's Minimum Data Set (MDS) section K dated 07/07/22 documents : Mechanically altered diet require change in texture of food or liquids with the yes checked.

Based on observation, interview, and record review, the facility failed to ensure housekeeping and maintenance services were able to maintain a sanitary, orderly, and comfortable environment for 6 (R2, R4, R6, R9, R10, R11) out of 6 residents reviewed for environment in a sample of 12. This has the potential to affect all 65 residents in the facility. On 08/11/22 at 9:10 AM, upon entrance into the facility there was a carpeted floor interior throughout covering both resident dining rooms, lounging area, and three resident hallways. There was no carpet observed in resident rooms or community bathrooms. On 08/11/22 at 9:35 AM, R4's room has a long electric baseboard heater on the outer wall with cracked and peeling paint along the bottom part of the wall and around the heater. The window casing on this same wall appears intact with no evidence of cracks, however there are unpatched screw size holes on the window frame where it appears a screw used to be, open to the outside elements. On 08/11/22 at 9:42 AM, R12's room has damage on the wall below the window with the paint bubbling from possible moisture damage. R12's room also had three cracked floor tiles and a broken window frame with some sharp metal edges exposed. On 08/12/22 at 8:16 AM, V13 (Maintenance Director) stated R4's room is first on his list and stated the drywall is on back order. V13 stated the water damage appears to be coming up from the floor and the window seems to be in relatively good condition but agreed water could come in from the window because they are old and worn out. V13 believes the water is seeping in from the ground or could possibly be leaking down the interior wall but cannot know for sure until he gets in there. V13 stated he did not want to knock a hole in R4's wall before he had all his supplies to be able to fix it correctly. V13 stated half the battle was getting the orders filled from the out of state company they use. On 08/11/22 at 10:08 AM, R10 and R11's shared bathroom had a very strong urine odor. The toilet had a black ring around the base and appeared off-center. On 08/12/22 at 10:07 AM, V19 (Housekeeper) stated he believed that toilet needed a new wax seal. V19 stated you can bleach mop the floor but until it was properly sealed the odor would not go away. On 08/11/22 at 10:10 AM, R6's bathroom cabinet on the toilet side had moisture damage missing the entire veneer layer with raw wood at the bottom splintered/curling out into sharp edges along the floor. The seal/glue around the base of the toilet was black and there was a strong urine odor. On 08/12/22 at 8:15 AM, this surveyor and V13 observed R6's bathroom together. V13 stated he is aware, and this was on his list to fix, he just had not gotten to it yet. On 08/11/22 at 10:30 AM, the hall communal restroom's toilet is slightly loose and not fully secured to the floor. There is a sign that says leaking on the wall above the open door to the hot water shut off valve. On 08/11/22 at 11:16 AM, V12 (Housekeeping) stated there are specific residents who have a urine odor. Some are incontinent, some pour their urine on the floor. V12 confirmed R2 likes to pee in whatever is handy then pour it between the wall and his bed. V12 stated staff try to check his room throughout the day. V12 confirmed there are two windows in the facility that leak when they have a heavy rain where R4 and R9 reside. She stated staff put towels around the window and on the floor to try and keep water from going across the floor into the hall. She stated all staff know about it and watch for leaking. She was not sure if this was on the list for maintenance or not. She stated housekeeping does not have a shampoo machine, but a commercial cleaning company has come in and shampooed the carpet. She stated they have constant spills and accidents, and they do the best they can to keep the carpet maintained. On 08/11/22 at 11:15 AM, V4 (Licensed Practical Nurse/LPN) stated R2 urinates on the walls and under the bed and gets mad if the staff clean it up. V4 stated the damage to R2's walls and floor is not from moisture coming in through the window but is from R2 urinating. On 08/11/22 at 2:45 PM, R2 was sitting in his wheelchair in his room, oxygen in place via nasal cannula, and he was watching TV. R2 was disheveled in appearance but had no complaints. The bottom of the wall behind his bed had damage along the trim work, appearing to be moisture related. There were three cups on the nightstand with straws and some liquid left in them. A couple of flies were buzzing around the straws. On 08/11/22 at 2:50 PM, R9 was in the corner of his room seated in his wheelchair, with what appeared to be a large puddle of urine in the middle of his room, a portable bathroom chair was in the far corner of the room on top of a waterproof pad. The only other piece of furniture in his room was his bed against the entrance wall. R9's window had visible screw holes in the frame which was open to the outside elements. On 08/12/22 at 8:20 AM, when asked about R9's window, V13 stated he was told R9's window blew in and shattered earlier this year before he started working here. The window in R9's room was observed place but had screw size holes in the frame. This surveyor pointed out that it appeared water could potentially come through these screw holes in a heavy rain and V13 acknowledged this. On 08/12/22 at 8:16 AM, V13 and this surveyor did a walk-through of the facility. There was a cluster of small black spots visible in the Red Hall bathroom. This surveyor and V13 observed the hot water heater/closet in the Blue Hall community bathroom. It appeared as though there had been a previous leak in the closet, as the floor was in poor condition with rotting wood observed from moisture damage. There was a huge rust stain down the front of the water heater and several areas that appeared to have a clear glue-like substance on it. On 8/12/22 at 8:16AM, during the above observations, V13 stated his first day in the facility was 06/22/22. V13 stated he has a drop box for his work orders. V13 said that usually, residents will tell staff and staff will fill out the orders and drop them off. V13 stated staff will do odd jobs as well, like try and fix a clogged sink. V13 stated he prioritizes his work orders with fixing things that jeopardize resident safety first, then resident requests, then staff. V13 stated he has completed a lot, but still has numerous work orders to complete. As far as the cluster of small black spots (in the Red Hall bathroom), V13 said he believed those were mildew due to the moisture in the bathrooms. V13 stated he had treated these areas with (brand name) primer to seal and cover the mildew areas but must have missed the area observed in the Red Hall bathroom. Regarding the water heater/closet in the Blue Hall community bathroom, V13 stated this was the first time he had seen the water closet but added that he was told the previous maintenance man changed the heating elements, so it was not actively leaking. V13 stated the clear substance on the water heater was sealant. V13 stated the leak was coming from a pipe in that bathroom wall and there was an opening in the ceramic tile wall to gain access to the shut off valve, which staff use to turn hot water on/off as residents take showers. V13 stated it was ok for the valve to be on for an hour or so, but staff are supposed to shut it off after that. Staff have forgotten to turn it off in the past and it caused a major leak with water seeping from the bathroom under the floor to the hall saturating the carpet. V13 confirmed it would be a major job to take out the wall and repair the water pipe, then do the finish work. V13 acknowledged the entire water heater closet had moisture damage, rotting wood, sealant in various locations on the hot water heater from leaks, a huge rust stain down the front of the water heater, and the floor underneath the water heater looking unstable due to the condition of the wood and floor. V13 was unsure if they would need to hire the work out, but he still did not have the items he needed to do that job and it would be at least a 2-week project for him alone. He stated he could replace the pipe, but again would have to knock the wall out to do that and would be unable to repair the wall without the needed supplies. On 08/11/22 at 10:35 AM, V10 (Certified Nursing Assistant/CNA) stated she has worked here 4 years. V10 confirmed staff vacuum and spot clean the carpet. V10 stated staff have work order sheets for maintenance and turn them in to V13. On 08/12/22 at 9:15 AM, V15 (Housekeeping) stated V13 is new and is doing the best he can do by himself. V15 stated the way the facility looks now is the way it has looked for a very long time. V15 relayed the following, They are replacing curtains right now. I don't know if V1 (Administrator) is aware of all these issues. She is busy in her office and not out checking on things like the previous administrator. I can't tell the difference between black mold or mildew, but I have attempted to scrape and clean those areas myself. R10 and R11 share a bathroom that is awful. R4's room does flood through the bottom of the window on a hard rain. We put towels in window and on floor to keep the water draining down. R9's window fell in earlier this year from a hard wind, and it floods, too. On 08/11/22 at 9:48 AM, V1 (Administrator) stated they have had a new maintenance man since the end of June 2022, and he has a heavy backlog of work that he is addressing job by job. V1 stated she was not aware of any resident windows that rain poured in or of a resident window that broke and shattered on the floor. V1 stated they do have a commercial carpet cleaning company come in to sanitize and clean 1-2 times a year, otherwise staff vacuum, and spot clean the carpet. During this survey on 08/11/22 and 08/12/22, the facility carpet was in very poor condition with too numerous to count stains and discoloration from staff reported food spills, resident incontinence accidents, and moisture damage. There was not an area on the carpet that did not appear dirty, soiled, or have stains. On 08/11/22 at 11:16 AM, V12 (Housekeeping) confirmed the facility does not have a carpet shampooer and is only able to spot clean and vacuum which she reports they do daily. V12 stated that although housekeeping does not have a shampoo machine, a commercial cleaning company has come in and shampooed the carpet. On 08/12/22 at 10:07 AM, V19 (Housekeeping) was vacuuming Red Hall and also confirmed the facility does not have a carpet shampooer. The facility Resident List Report dated 08/11/22 documents 65 residents currently reside in this facility.

Based on observation, interview and record review the facility failed to keep food contact surfaces clean and serve food in a sanitary manner. This failure has the potential to affect all 59 residents in the facility. On (MONTH) 17, 2019 at 10:00 AM on initial tour of the kitchen the following items were observed: 1. Behind the countertop slicer crumbs and food debris were found behind the blade. The slicer was covered with a bag, indicating that it was ready for the next use. V3 (Dietary Manager) stated that she would have it dismantled and cleaned, that it had been used yesterday and those staff members are unable to get it taken apart. 2. The bucket of sanitizing solution used to wipe surfaces had over 200 parts per million sanitizer present when staff tested the water with the test strip. V3 had V5 (Dishwasher) emptied the bucket of bleach solution, and used the sanitizer to make a new cleaning solution and retested the level of sanitizer. 3. During the lunch preparation, V4 (Cook) scraped the french fries into the steam pan using an oven mitt. The Resident Census and Condition of Residents dated 9/17/19, reports 59 residents live in the facility

Based on observation, interview and record review, the facility failed to ensure staff use appropriate transmission based precautions while performing blood glucose monitoring for 2 of 2 residents (R15, R 10)observed during blood glucose monitoring in the sample of 35. The findings include: 1. On 9/18/19 at 4:15 PM V6, Licensed Practical Nurse (LPN) was observed performing blood glucose monitoring. V6 carried a plastic caddy like basket which held blood glucose monitoring equipment into R15's room and set it on R15's bed. V6 wiped the blood glucose monitor with an alcohol wipe, put on gloves and obtained a blood sample using a lancet device. After completing the test V6 wiped the monitor with an alcohol wipe, laid the monitor on R15's bed without a barrier underneath and sanitized her hands. V6 then placed the blood glucose monitor back into the plastic basket, picked up the basket and carried it into R10's room, setting the basket on R10's bed, without a barrier in place. V6 obtained the same monitor from the basket and again performed a blood glucose test, wiped the machine with an alcohol wipe and placed the monitor back into the basket. The basket was then carried back to the medication room. A facility Glucometer Cleaning/Disinfection Policy dated (MONTH) (YEAR) states the procedure for cleaning and disinfection of a blood glucose meter is by use of a 1:10 bleach and water dilution or an approved sanitizing and disinfection wipe. V7, Regional Nurse Consultant verified on 9-19-19 at 3:00 PM that the use of alcohol wipes is not an approved method or facility procedure for cleaning and disinfection of blood glucose monitors.

Based on interview and record review, the facility failed to notify the resident representatives in writing of hospital transfers for 5 of 5 residents (R39, R42, R44, R45, and R51) reviewed for hospitalization s in a sample of 14. 1. R39's clinical Admission Record - Resident Information sheet documents V7 (guardian) as the responsible party for R39. On 08/21/18, a nurse's note documents R39 was sent to the local hospital emergency roiagnom on [DATE] for evaluation due to respiratory difficulty. On 08/21/18 at 10:38 PM a nurse's note documents R39 was admitted to the hospital with [REDACTED]. R39's Hospital Discharge Documentation Summary documents an admission date of [DATE] and discharge date of [DATE]. This same Summary documents R39's discharge [DIAGNOSES REDACTED]. There is no documentation of the guardian/resident family representative being notified in writing found in R39's clinical record. 2. R42's clinical Admission Record - Resident Information sheet documents lists V8 (POA - Power of Attorney) as the responsible party for R42. On 02/23/18, a nurse's note documents R42 was sent to the local hospital emergency roiagnom on [DATE] for evaluation and admitted on [DATE] with a chief complaint of cough and shortness of breath. R42's Hospital Discharge Documentation Summary documents an admission date of [DATE] and discharge date of [DATE]. On 08/02/18, a nurse's note documents R42 was sent to the local hospital emergency room for evaluation due to respiratory issues and bilateral lower extremity [MEDICAL CONDITION]. R42's Hospital Discharge Documentation Summary documents an admission date of [DATE] and discharge date of [DATE] with [DIAGNOSES REDACTED]. There is no documentation of the guardian/resident family representative being notified in writing found in R42's clinical record. 3. R44's clinical Admission Record - Resident Information sheet documents R44 as being his own responsible party. On 04/07/18, a nurse's note documents R44 was sent to the local hospital emergency roiagnom on [DATE] for evaluation of lower extremity redness and [MEDICAL CONDITION]. On 04/08/18 at 12:30 AM a nurse's note documents R44 was admitted to the hospital for [MEDICAL CONDITION]. R44's Hospital Discharge Documentation Summary documents an admission date of [DATE] and discharge date of [DATE]. This same Summary documents R44's discharge [DIAGNOSES REDACTED]. On 08/03/18, a nurse's note documents R44 was sent to the local hospital emergency roiagnom on [DATE] for evaluation of lips swelling and hives on the arms. R44's Hospital Discharge Documentation Summary documents an admission date of [DATE] and discharge date of [DATE]. This same Summary documents R44's discharge [DIAGNOSES REDACTED]. There is no documentation of resident being notified in writing found in R44's clinical record. On 10/18/18 at 1:00 PM V1 (Administrator), V2 (Director of Nursing - DON), and V3 (Regional Director of Nursing - RDON) stated nothing in writing is provided to the resident representative and/or the resident, when a resident is transferred to the hospital. 4. Record review of R51's Nurses Notes found that on 8/20/18 at 11:15 AM R51 had complaints of chest pain, congestion and elevated temperature with orders from the physician for transfer to the emergency room for evaluation. The nurse's note further stated that R51 was admitted to the hospital with [REDACTED]. There is no documentation that the facility notified the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand, as is required. This was verified with V3, Regional Director of Nurses on 10/18/18 2:49 PM 5. A Review of a Patient Transfer Form and Nurse's Notes noted R45 was transferred to the hospital on 6-3-18 with complaints of chest pain, congestion and elevated temperature, with orders from the physician for transfer to the emergency room for evaluation. R45 was admitted to the hospital with [REDACTED]. Nurse Progress Notes and a Patient Transfer Form document R45 was again transferred to the hospital on [DATE] with complaints of a stomach ache and diarrhea with decreased appetite. R45 was admitted with a [DIAGNOSES REDACTED]. There is no documentation that the facility notified the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand as is required. This was verified with V3, Regional Director of Nurses on 10/18/18 2:49 PM

Based on observation and interview the facility failed to provide an environment free of flies and gnats for 3 (R32, R44, R30 and R45) of 14 residents reviewed in the sample. 1. On 10/16/18 at 11:58 AM an observation was made of R32 eating her lunch in her room. At this time a live gnat was observed in R32's food. R32 swatted at the gnat and when asked if gnats had been a recent problem, R32 stated Yeah, that's not the first time that has happened. 2. 10/16/18 at 12:00 PM, an observation was made of R45's lunch tray which was sitting in the room. R45 stated he had just finished eating. There was some food remaining on the plate and a live gnat was observed in the food. When asked if there had been any problem with pests such as flies and gnats, R45 stated that there has sometimes been flies in his room. 3. On 10/16/18 at 11:00 AM R44 was observed to have a fly and gnats landing on and crawling inside the open ended dry dressing wrapped around his right foot. R44 stated this bothered him, but didn't know what could be done about it. 4. On 10/16/18 at 01:29 PM during an interview 2 flies were noted on R30's bed pillow and bed while resident is in bed trying to eat lunch. Styrofoam cups and napkins located on R30's bed. On 10/19/18 at 12:30 pm, V3 (Regional Director of Nursing) states It is just that time of year. What can you do about it?

Based on record review and interview, the facility failed to assure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, for 3 of 14 (R42, R44, and R45) residents reviewed for accuracy of resident assessments in the sample of 14. 1. R45's (MONTH) (YEAR) Physician order [REDACTED]. Nurse progress notes dated 6/3/18 document R45 with complaints of a temperature, coughing and pain in his chest. R45 was transferred on 6/3/18 to the hospital emergency room for evaluation and the faclity was notified by the hospital that R45 was admitted with a [DIAGNOSES REDACTED]. A hospital Discharge Summary dated 6-7-18 includes a [DIAGNOSES REDACTED]. Section I of R45's Minimum Data Set (MDS) 5 day Medicare assessment dated [DATE], as well as Section I of the 14 day Medicare assessment dated [DATE] do not identify R45 as having a UTI [DIAGNOSES REDACTED]. This was verified on 10/18/18 at 2:30 PM with V10, MDS and Care Plan Coordinator. 2. R42's (MONTH) (YEAR) physician's orders [REDACTED]. 3. R44's (MONTH) (YEAR) physician's orders [REDACTED]. On 10/18/18 at 2:00 PM when asked to provide the order for R42 and R44's anticoagulant medication, V2, DON (Director of Nursing), and V3, RDON (Regional Director of Nursing), referred to their (MONTH) (YEAR) POS and stated, It's [MEDICATION NAME], which is [MEDICATION NAME].

Based on observation, record review and interview, the facility failed to address problem areas of recurrent Urinary Tract Infections and anti-coagulant medication use for 2 of 14 residents (R4 and R45) reviewed for care plans in the sample of 14. The findings are: 1. R45's (MONTH) (YEAR) Physician order [REDACTED]. A physician progress notes [REDACTED]. Nurses Notes document that R45 was in the hospital from 4-20-18 and returned on 4-23-18 with a [DIAGNOSES REDACTED]. Nurse progress notes dated 6/3/18 document R45 with complaints of a temperature, coughing and pain in his chest. R45 was transferred to the hospital emergency room for evaluation and the facility was notified by the hospital that R45 was admitted with a [DIAGNOSES REDACTED]. A hospital Discharge Summary dated 6-7-18 includes a [DIAGNOSES REDACTED]. On 10/16/18 at 3:30 PM an observation was made of R45's catheter bag and tubing hooked above bladder level on the arm of R45's chair. An observation on 10/18/18 at 11:45 AM noted that R45's catheter bag and tubing were laying on the floor next to R45's chair. V3 stated on 10/18/18 at 2:12 PM that R45 refuses to allow staff to provide cath care and R45 empties his own catheter bag. R45's current Care Plan identifies a problem area of R45 being at risk of Urinary Tract infections (UTI's) due to having an indwelling urinary catheter but fails to address the fact that R45 has a recent history of re-occurring UTI's. Interventions address monitoring for signs and symptoms related to a UTI but do not address interventions for prevention of UTI's. 2. R4's annual Minimum Data Sets (MDS) dated (MONTH) 6, (YEAR) lists R4 as being unable to be interviewed for the Brief Interview for Mental Status (BIMS) and the staff have scored R4 cognitive status as moderately impaired indicating R4's decisions are poor and cues / supervison is required. The physician's orders [REDACTED]. According to the Care Plan provided on (MONTH) 18, (YEAR), R4 has a [DIAGNOSES REDACTED]. According to this same care plan no focus areas, goals, interventions, side effects to observe for or to report regarding increased bleeding related to R4 receiving an anticoagulant are not listed on the plan of care including the Medication Administration Record, [REDACTED].

Based on interview and record review, the facility failed to ensure that a resident was free from unnecessary medication used for treatment of [REDACTED]. The Findings Include: R46's current Physician order [REDACTED]. A Note to Attending Physician/Prescriber from the Pharmacist with a print date of 1/22/18, states the resident has been receiving [MEDICATION NAME] 2.5mg daily since 5/27/17 and a dose reduction/discontinuation attempt is necessary at this time. The same document then states that if the therapy is to continue at the current dosing, please provide rationale describing a dose reduction as clinically contraindicated at this time. V11 (Psychiatrist) checked the box that declined the recommendation. Under Physician/Prescriber Response V11 wrote in patient stable at this time. With no further explanation as to why the medication should not be reduced or what behaviors were occurring with R46. V3 (Regional Director of Nursing) stated on 10/19/18 at 11:42 AM that there is no behavior tracking for R46 for the use of [MEDICATION NAME]. V13 (Social Services) stated on 10/19/18 at 12:30 PM, that R46's behaviors that should be tracked for [MEDICATION NAME] are that she becomes combative at times. V13 stated at this time as well, that behavioral tracking should have been in place for this resident.

Based on observation, record review and interview the facility failed to give the correct medication and at the correct time as prescribed. There were 26 opportunities with 2 errors resulting in a 7.69 % Medication error rate. The errors involved 2 resident (R18, R27) in a sample of 7 residents reviewed for medication pass. The findings include: 1. R18's Physician order [REDACTED]. R18's Medication Administration Record [REDACTED]. On (MONTH) 18, (YEAR) at 8:20 AM V5, Registered Nurse (RN) placed Tamsulosoin 0.4 mg capsule into a cup and provided it to R18 at the dining room table while he was eating breakfast. 2. R27's PO for (MONTH) (YEAR) lists [MEDICATION NAME] tab 300 mg Take 1 Tablet by mouth every evening. R27's MAR indicated [REDACTED]. On (MONTH) 18, (YEAR) at 8:20 AM V5 placed [MEDICATION NAME] 150 mg into a medication cup and gave it to R27 in which R27 placed the medication in his mouth and swallowed it. During an interview on (MONTH) 19, (YEAR) at 11:52 AM V5 states she thought the Tamsulosin could have been given prior to meals. After reviewing the physician order [REDACTED].

Based on interview and record review the facility failed to provide physician prescribed labwork for 1 (R18) of 14 residents reviewed for physician orders [REDACTED]. The findings include: The Physician order [REDACTED]. Lipid every 6 months and lists a [DIAGNOSES REDACTED]. R18's medical record did not contain laboratory results for Lipids for R18. On 10/17/18 at 12:41 PM V2, Director of Nursing (DON) said the lipid lab work ordered for R18 has not been completed since June, (YEAR). V4, R18's attending physician has been notified and we are going to draw it, the refusals R18 has had, according to the nursing notes has been regarding the CBC (Complete Blood Count) and not the Lipid.

Based on observation, interview and record review the facility failed to keep food contact surfaces clean and sanitary. This failure has the potential to affect all 53 residents in the facility. On (MONTH) 16, (YEAR) at 9:30 AM on initial tour of the kitchen the following items were observed: 1. A scoop was found in the bulk rice container with the handle touching the food item. 2. Behind the countertop slicer crumbs and food debris were found behind the blade. The slicer was covered with a bag, indicating that it was ready for the next use. 3. The bucket of sanitizing solution used to wipe surfaces had zero sanitizer present when staff tested the water with the test strip. 4. A grate on the back of the stove top was found to have a build up of grease and food debris, and was sticky to touch. V13 (Food Service Director) stated on 10/17/18 at 11:45 AM, that the back of the stove needs to be dismantled in order to properly clean the grate. V13 agrees that it is in need of a good cleaning. The Resident Census and Condition of Residents dated 10/16/18, reports 53 residents live in the facility.

Based on interview and record review, the facility failed to follow current CDC (Centers for Disease Control) guidelines and the facility's policy for the administration of pneumonia vaccines for 4 of 5 residents (R1, R3, R5, R8) reviewed for pneumonia vaccines in the sample of 14. The findings include: 1. R5 is an [AGE] year old resident with [DIAGNOSES REDACTED]. The facility Pneumococcal Immunization Informed Consent form signed on12-14-16 notes that the Pneumococcal vaccination was declined due to R5 having received previously at the local veteran hospital. This consent form does not indicate which of the pneumonia vaccines the consent is for. The facility policy titled Pneumococcal Vaccine with a revision date of March 2004 states that prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, provided the vaccination within 30 days of admission. It further states that pneumococcal vaccination assessments will be conducted within 5 working days of the resident's admission if not conducted prior to admission. An addendum to this policy, titled Pneumonia 23 Vaccine/Prevnar 13 QAPI with no date, states that for each resident, a review will be made of past Pneumonia Vaccines and the age of the resident at the time of the vaccine. This information is then used to determine the type of pneumonia vaccine the resident will be offered. The facility Pneumococcal Vaccine Log does not include documentation describing which type of Pneumonia vaccine was given or refused. 2. R3's Admission Face Sheet documents R3's date of birth as 7/5/1949, indicating that R3 is now [AGE] years old. According to the facility's Pneumonia Log, R3 refused the pnuemonia vaccine on 8/3/2015. There is no evidence in R3's medical record regarding which pneumoccal vaccine R3 was offered or for which vaccine R3 recieved education. Current CDC guidelines found at www.cdc.pneumococcal/vaccination.html state that for an adult 65 and older who has not previously received pneumococcal vaccines, or those with unknown vaccination history, 1 dose of Prevnar 13 should be administered and 1 dose of PPSV23 should be given at least 1 year later. 3. According to the pneumonia immunization log R1 received a pneumonia vaccine on April 15, 2009, when she was [AGE] years old. The pneumococcal immunization informed consent form provided by the facility for R1 does not contain any information regarding 13-valent pneumococcal conjugate vaccine (PCV13, Prevnar 13) being offered to R1. 4. According to the facility's Pneumoccal Vaccine Log, R8 declined the vaccine on 3/22/17. The Authorization and Release for Pneumococcal Vaccine which R8 signed on 3/22/17 and documents R8' refusal does not indicate which vaccine was offered, and does not include any information regarding PCV 13. On 9/22/2017 at 12:40 pm, E2, Director of Nursing, stated that it is the facility's practice to follow CDC guidelines for the administration of vaccines. On 9/21/2017 at 11: 30 am, E4, Social Services Designee, stated that it is her responsibility to prepare consent forms for vaccines and stated further that she was not aware until yesterday that PCV 13 should have been offered to the residents.

Based on observation, interview, and record review the facility failed to ensure water is accessible to 1of 4 residents (R9) reviewed for hydration in the sample of 14. Findings include: R9's physician's orders [REDACTED]. R9's MDS ( Minimum Data Set) dated 7/12/2017 indicates that R9 requires supervision and set-up only for eating. On 9/21/2017 between 10:15 am and 11:20 am, a container of water was on R9's over-the-bed table and was noted to be placed at the head of the bed and approximately 2 feet away from the bedside. On 9/20/2017 at 2:00 pm, Z3, (family member) stated that he visits almost everyday and that sometimes when he comes in, R9's water is on the table, but the table is placed where R9 can't reach it. When asked by surveyor if R9 can drink without assistance, Z3 stated, that he saw her drink on her own yesterday. Z3 added somedays it is easier for her than others. On 9/21/2017 at 10:05 am, E6, Certified Nurse's Aid, stated that R9 is able to drink without assistance at times, but only if fluid is placed close to her. On 9/22/2017, at 9:00 am, R9 was holding a container with water and drinking without assistance.

Based on record review and interview the facility failed to attempt gradual dose reductions associated with the use of anti-psychotic medications for 1 of 4 residents (R7) reviewed for anti-psychotic use in the sample of 14. The Findings Include: R7's September 2017 Physician order [REDACTED]. E3 (Task Manager) provided a form on 9/19/17 at 10:30 AM from the pharmacy that was addressed to R7's medical doctor recommending a dose reduction for [MEDICATION NAME]. The form had the disagree box checked with the word verbally written next to the disagree box dated 9-6-17. The reason given for not reducing the medication was, MD disagree, resident on minimum effective dose. No signature or date is on the form. E3 stated that she is the one who contacted the psychiatrist in regards to the dose reduction over the phone and it was declined based on the above mentioned reason. E3 also confirmed that no previous dose reductions for R7's [MEDICATION NAME] had been attempted since it was initiated on 9/1/2016. E3 went on to state that all residents on an anti-psychotic medications are monitored by the psychiatrist not the medical doctor. E4 (Social Services Designee) stated on 9/22/17 at 9:30 AM, that R7 has not been seen by the psychiatrist since starting the anti-psychotic medication. E4 went on to say that R7 has not been seen by the psychiatrist since the medication was prescribed in September 2016. R7 was just approved by the corporate office on 7/20/17 to obtain services by the psychiatrist due to a conflict in insurance billing. R7 refused to see the doctor over tele-medicine on 7/27/17, and the psychiatrist canceled the appointment on 8/17/17. Z1 (R7's physician) stated on 9/21/17 at 10:00 AM over a phone interview that he leaves gradual dose reductions to the psychiatrist to manage.

Based on observation, interview, and record review, the facility failed to re-distribute resident clothing to appropriate resident rooms. This has the potential to affect all residents living in the facility. Findings include: The Resident Census and Conditions of Residents Report dated 9/20/2017 indicates there are 56 residents currently living in the facility. On 9/21/2017 at 1:00 pm, R12 stated her clothes were not returned and that she has to go find them in other residents' rooms, and she has also found other people's clothes in her closet. On 9/22/2017 at 12:00 pm, R8 stated, Today I found someone else's clothes in my closet. On 9/21 /2017, at 12:00 pm, Z2, ( resident family member) stated that Z2 has found other resident's clothing in Z2's spouse's closet and has seen other residents wearing Z2's spouse's clothing a time or two. On 9/21/2017 at 12:00 pm, E6, Certified Nurse's Aid, stated that E6 has seen residents wearing clothing that E6 knows belongs to another resident. On 9/22/2017, E5, Laundry Staff, stated that occssionally this does happen, but not very often. E5 went on to say that an inventory list of clothing is completed when a resident is admitted to the facility and when families bring in new clothing it is added to this list. E5 added that if she discovers clothing that isn't lableled she will sometimes consider the size and give it to a resident who may be in need. E5 stated that they get a lot of clothing that is donated. On 9/21/2019 at 2:10 pm, 4 clothing items were noted in R9's closet which were labeled with the name, other than her own. Resident Council Meeting Minutes for 8/16/2017 documents residents' concern with laundry as being clothes in wrong closets. Resident Council Memorandum with the same date includes the following response to resident concerns: Administrator will place updated census in laundry room and re-educate laundry staff.

Based on observation, interview and record review, the facility failed to provide comfortable sound levels throughout the facility. This has the potential to affect all 56 residents of the facility. The findings include: The Resident Census and Conditions of Residents Report dated 9-20-2017 notes a facility census of 56 residents. 1. R2 stated on 9-21-17 at 10:00 am that the door alarm on Red Wing (for the exit door just outside of R2's room) is very loud and sounds several times a night waking him and his room mate up. R2 stated it takes too long for staff to shut it off because not everyone has the key that must be used to shut it off. R2 stated that it is very annoying anytime it goes off because it's so loud. 2. On 9-22-2017 at 9:28 am the exit door alarm at the end of White Hall started sounding as a result of a wandering resident R16 opening it. The alarm, which was siren like, was very loud, high pitched and piercing. It sounded for several seconds and then shut off without staff being present to shut it off. E7, Activity Director, came down the hall to the door after the alarm had shut off. E7 stated that she was trying the key to make sure that it was the right one for the alarm. When asked why it had shut off, E7 stated that it will automatically stop sounding after about half a minute or so if not manually shut off with the key and that it cannot be shut off at the Nurse Station. A few minutes later at 9:33 am, the same wandering resident was observed to open the door again. The alarm was timed and sounded for 90 seconds before shutting off on its own. The surveyors that were in one of the last rooms on White Hall near the exit door, had difficulty hearing each other during the time the alarm was sounding. 3. On September 19, 2017 at 1:15 PM during a resident group meeting, R2 stated and R1 agreed we want employees to have keys to those door alarms at night especially. It's disrespectful to have the alarms going off all the time. 4. On 9/21/2017 at 3:45 pm, E1, Administrator, stated that the Maintenance Supervisor, Assisiant Administrator, Nurses all have a key to turn off these alarms. E1 added, We try to have a key for the Hall Monitor on each shift as well.