Every finding on record at Lafayette Nursing and Rehabilitation Center

Based on observation, interview, and record review the facility failed to provide appropriate milliliter per hour of auto flushes via feeding tube for 1 (Resident #8) of 2 reviewed for enteral feedings.Findings include: During an observation on 4/8/2026 at 1:30 PM with Staff C, Licensed Practical Nurse (LPN), confirmed Resident #8's automatic water flushes were running at 50 ml [milliliters] per hour. During an interview on 4/8/2026 at 1:38 PM, Staff C, LPN, stated, [Resident #8's name] auto flushes should be running at 60 ml per hour. The night shift nurse is the one to hang the feedings. I will need to go back and adjust the flushes. During an observation on 4/8/2026 at 1:43 PM with Staff D, Unit Manager LPN confirmed Resident #8's auto water flushes were running at 50 ml per hour. Review of Resident #8's physician's order dated 2/16/2026 read, Osmolite 1.5 give @ 65 ml/hr [at 65 milliliters per hour] and flush rate of 60 ml/hr via g-tube [gastric] x [times] 20 hrs, one time a day for Nutrition up x 20 hours /down x 4 hours and remove per schedule and remove per schedule. Review of Resident #8's Nutritional Risk Screen and assessment dated [DATE], read, 9. Nutrition Summary: Recommend increase flushes to 60 ml/hr while infusing. Review of Resident #8's progress note dated 3/31/2026, read, EN [enteral nutrition] osmolite 1.5 @ 65ml/hr x 20 hours (1950 kcal [kilocalorie], 81g pro [protein], 993 ml h20 [water]), flush 60 ml water x 20 hours (1200ml h20). During an interview on 4/8/2026 at 3:53 PM, the Registered Dietitian stated, [Resident #8's name] flushes were increased to 60 ml. That would be nursing's function to make sure the flushes are running at the correct ordered rate. During interview an 4/9/2026 at 8:42 AM, the [NAME] President of Operations stated, Nurses are expected to check the flush rate when they are given medications or hanging a new feed. They are to double check rate is correct. Review of the facility policy and procedure titled, Nutrition and Care for Feeding Tubes with a last review date 12/30/2025, read, Policy: It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to extent possible. Policy Explanation and Compliance Guidelines: e. Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders.

Based on interview and record review the facility failed to encode and transmit the resident discharge assessment for 1 (Resident #1) of 6 residents reviewed for minimum data set [MDS] completion. Findings include:Review of Resident #1's physicians order dated 3/19/2026 read, [Resident #1's name] will discharge to [Facility's Name] in [Town's and State Name] on 3/19/26.Review of Resident #1's Discharge summary dated [DATE] read, Transferring to [Name of Facility]. Mode of Transportation: Transportation provided by facility. Date: 3/19/2026. Time: 11:00.Review of Resident #1's progress note dated 3/20/2026 read, [Resident #1's name] discharged to [Name of Facility] 3/19/2026 in [Town's and State's Name]. [Resident #1's name] is to follow up with PCP [primary care provider] at [Facility's name].Review of Resident #1's Minimum Data Set did not document a discharge assessment. During an interview on 4/8/2026 at 3:20 PM, Staff E, Minimum Date Set Coordinator, Registered Nurse, stated, I verified with my regional and I am missing the discharge assessment which is due 14 days after the resident is discharged and is considered late. Normally I combine the different assessments. I did not do the discharge assessment.Review of the facility policy and procedure titled MDS 3.0 Completion with a last review date of 12/30/2025 read, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: f. Discharge Assessment- completed using the discharge date as the ARD [Assessment Reference Date]. Must be completed with 14 days of the discharge date /ARD.

Based on observation, interview and record review the facility failed to follow infection control standards for 1 (Resident #8) of 3 residents reviewed for enhance barrier precautions, failed to perform hand hygiene for 1 (Resident #6) of 2 residents reviewed for enteral nutrition, and failed to provide weekly changes for nebulizer equipment for 1 (Resident #48) of 3 residents reviewed for respiratory services. Findings include: 1) During an observation on 04/08/2026 at 1:30 PM, Staff C, Licensed Practical Nurse (LPN) prepared medication for Resident #8. Staff C entered Resident #8's room and performed hand hygiene. Staff donned gloves but did not don a gown. Staff C checked Resident #8's gastric tube placement and administered Resident #8's medication enterally. During an interview on 4/8/2026 at 1:38 PM, Staff C, LPN, stated, [Resident #8's name] is on enhanced barrier precautions, I should have donned a gown. Review of Resident #8's physician's orders dated 1/8/2026, read, Enhanced Barrier Precautions for high contact residents care activities. Indication: Indwelling medical device every shift for Precautions. During an interview on 4/8/2026 at 3:05 PM, the Infection Preventionist stated, Staff need to wear gloves and gown when the resident is on enhanced barrier precautions and follow the guidelines. During an interview on 4/9/2026 at 8:41 AM, the [NAME] President of Operations stated, Staff are to wear gloves and gown when providing care to residents on enhanced barrier precautions. Review of the facility policy and procedure titled, Enhanced Barrier Precautions Policy, with a last review date 12/30/2025 read, Policy: It is the policy of this facility to implement enhanced barrier precautions for prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 4. High-contact resident care activities include: g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. 2) During an observation on 4/08/2026 at 3:00 PM, Staff B, RN, prior to flushing the G-tube in anticipation of resuming her enteral feeding, the RN donned gloves and a gown. While pulling a gown out of the holder, a gown fell on the floor. The RN picked the gown up off of the floor and returned the gown to the holder. She did not remove her gloves or perform hand hygiene after picking up the gown. She later pulled the gown out of the holder and set it on the resident's bed and instructed the CNA to utilize the gown [and gloves] while assisting Resident #6 with her shower. During an interview on 4/08/2026 at 3:00 PM, Staff B, RN, confirmed that she had picked up a gown off of the floor, set it on the resident's bed, and instructed the CNA to use the gown while providing care to Resident #6. The gown should not have been returned to the holder or used; it should have been discarded. Staff B, RN, also confirmed she did not remove her Personal Protective Equipment (PPE), perform hand hygiene, or don clean PPE after she picked up the gown off of the floor. During an interview on 4/08/2026 at 3:15 PM, the IP (Infection Preventionist) stated that if a nurse was anticipating the need to provide care to a resident with a feeding tube, the nurse should wear a gown and gloves. If a nurse picked up something from the floor [an isolation gown], it should not be returned to the rack, placed on the resident's bed, or used by anyone. The nurse should remove the PPE (personal protective equipment), perform hand hygiene, and don clean gloves and a clean gown before providing care to the resident. Review of Resident #6's admission record revealed she was admitted on [DATE] with medical diagnoses that included cerebral infarction, dysphagia, and gastrostomy status. Review of Resident #6's physician's order dated 1/28/2026, read, Enhanced Barrier Precautions for high contact resident care activities. Indication: indwelling medical device every shift for Precautions. Review of the policy and procedure titled, Hand Hygiene, last reviewed on 12/30/2025 read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy explanation and compliance guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6. Additional considerations: a) The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand Hygiene Table - Condition: After handling contaminated objects; Before performing resident care procedures. 3) During an observation on 4/06/2026, Resident #48's nebulizer was on her bedside table. The mask and tubing were in a zippered plastic bag dated 3/25/2026. (photographic evidence obtained) During an interview on 4/06/2026 at 2:00 PM, Resident #48 stated that she routinely received nebulizer treatments. During an observation on 4/08/2026 at 12:10 PM, there was a nebulizer on the bedside table for Resident #48. The nebulizer mask and tubing were in a zippered plastic bag with 3/25/26. (photographic evidence obtained) During an interview on 4/08/2026 at 12:00 Staff A, LPN, Unit Manager, stated that the process for oxygen/nebulizer accessories and supplies, such as masks and tubing, was that they were changed every Wednesday, put into a Ziploc bag, and the resident's name, room number and the date were written on the bag. During an interview on 4/08/2026 at 12:30 PM the VP (Vice President) of Operations stated that the expectation was for the oxygen/nebulizer tubing and related respiratory accessories or supplies, were changed every Wednesday and placed in a plastic bag. The bag was labeled, either through writing on the bag or using a sticker, with the resident's name, and the date. Review of Resident #48's admission record revealed she was admitted on [DATE] with medical diagnoses that included chronic obstructive pulmonary disease, asthma, and uncomplicated personal history of other malignant neoplasm of bronchus and lung. Review of Resident #48's physician orders dated 3/30/2026 read, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3)mg (milligrams)/3 ml (milliliters) (Ipratropium-Albuterol): 1 vial inhale orally two times a day for COPD (chronic obstructive pulmonary disease). Review of the policy and procedure titled, Oxygen Administration, with the last review date 12/30/2025 read, Policy: Oxygen it is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy explanation and compliance guidelines: 5. Staff shall utilize standard precautions when administering oxygen or when in contact with oxygen equipment other infection control measures include: d. If applicable, change nebulizer tubing and delivery devices weekly or as needed if they become soiled or contaminated.

Based on observation, interview, record review the facility failed to document accurately skin assessments for 1 (Resident #56) of 3 residents reviewed for skin conditions.Findings include:During an observation on 4/06/2026 at 10:23 AM, Resident #56 was sitting up in bed. Resident #56's right forearm had a small 2x2 white dressing. The dressing had no date. During an interview on 4/06/2026 at 10:23 AM, Resident #56 stated, On Saturday I bumped myself and got a skin tear. The nurse insisted on putting a dressing on it. Normally, if I was home I would just put Neosporin and that's all. They change the dressing every day. During an observation on 4/7/2026 at 12:10 PM, Resident #56 was sitting up in bed. There was a dressing on his right forearm dated 4/6/2026.Review of Resident #56's physician's orders documented no orders for a skin tear on right arm.Review of Resident #56's progress notes did not document any incident regarding right arm skin tear or provider documentation.Review of Resident #56's medical records did not document a skin assessment for the right arm skin tear.During an interview on 4/7/2026 at 12:13 PM, Staff C, License Practical Nurse (LPN), stated, I am not aware of anything on his right arm. I worked with him last week and he did not have anything on his right arm.During an observation on 4/7/2026 at 12:18 PM, the Staff D, LPN, Unit Manager entered Resident #56's room and asked the resident what had happened to his arm. Resident #56 stated that on Saturday he bumped his arm with the walker and got a skin tear.During an interview on 4/7/2026 at 12:18 PM, Staff D, LPN, Unit Manager, stated Usually for something like that [skin tear], we would need orders in place.During an interview on 4/8/2026 at 10:05 AM, the [NAME] President of Operations stated, The nurse should put a note in the system just so we do not have to wonder and know where the skin tear came from.During an interview on 4/9/2026 at 10:02 AM, Medical Doctor #1 stated, The nurse called me over the weekend in regards to the [Resident #56's name] skin tear. Orders were to cover it if bleeding.Review of the facility policy and procedure titled, Documentation in Medical Record, with a last review date 12/30/2025 read, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.Review of the facility policy and procedure titled, Skin Integrity-Skin Tears, with a last review date 12/30/2025 read, Policy: It is the policy of this facility to provide treatment and care to maintain skin integrity. This policy pertains to the prevention and management of skin tears. Policy Explanation and Compliance Guidelines: a. Licensed nurses will conduct a skin assessment in accordance with facility policy.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's active diagnoses for 1 (Resident #20) of 6 residents reviewed for weight and nutrition, by failing to code a thyroid disorder in Section I, resulting in inaccurate clinical data used for care planning, quality measures, and reimbursement. Findings include:Review of Resident #20's active medical diagnosis include thyrotoxicosis, also known as hyperthyroidism.Review of Resident #20's physician's order dated 1/25/2025 read, Methimazole tablet 10 milligrams (MG), give one tablet by mouth one time a day for hyperthyroidism.Review of Resident #20's Annual MDS dated [DATE] section I, subsection I3400 Thyroid disorder was coded as No.During an interview on 4/8/2026 at 1:16 PM, the Regional MDS Nurse stated, I reviewed the MDS concerns and identified that the resident was coded incorrectly in section I for not being documented for having the active diagnosis of thyroid disease.

Based on observation, interview and record review, the facility failed to provide care and services to ensure acceptable parameters of nutritional status for 2 (Resident #31 and Resident #61) of 6 residents reviewed for nutritional concerns.Findings include: 1.) Review of Resident #61's clinical record under Vital Signs documented the following weights: 4/1/2026: 122.3 lbs (pounds); 3/25/2026: 122.7 lbs; 3/22/2026: 124.9 lbs; 3/11/2026: 127.3 lbs; 3/8/2026: 133.9 lbs; 3/7/2026: 134.3 lbs; 3/6/2026: 133.2 lbs; 3/5/2026: 133.9 lbs. On 3/05/2026, Resident #61 weighed 133.9 lbs and on 4/01/2026, Resident #61 weighed 122.3 lbs which calculated to a -8.66% Loss. Review of Resident #61's Nutritional Risk Screen assessment dated [DATE] read, 80YOF ([AGE] year-old female) admitted with dx (diagnosis) of fx (fracture), CVA (Cerebrovascular Accident), dysphagia [difficulty with swallowing], T2DM (Type 2 Diabetes Mellitus), hypothyroidism, HTN (Hypertension). Allergy: food dye. Ht (height) 64in, wt (weight) 122.7#, BMI (Body Mass Index) 21.1. Wt trending down since admitted , triggers for -8.4% (-11.2#(pounds)) in 2 weeks. Wt loss possibly r/t (related to) poor PO (by mouth) intake. WNL (within normal limits) BMI. Diet is regular, pureed texture, honey thick consistency. PO intake 0-25%, varies. Independent with meals. Supplement: magic cup QD (every day). Skin intact. Recommendation start fortified food w/meals (with meals) r/t poor PO intake. Monitor and evaluate PRN (as needed). Review of Resident #61's Progress Notes revealed a Dietary note dated 3/13/2026 that read, Ht 64in, wt 127.3#, BMI 21.8. Triggers for wt loss of -5.2% (-7#) in 4 days. Res (resident) in need of additional kcal (kilocalorie, the standard unit used in medicine and nutrition to measure food energy) r/t wt loss and poor PO intake. Recommendation magic cup (a fortified, high-calorie, and high-protein nutritional frozen dessert) daily for additional nutrition support. Monitor and evaluate PRN. Review of Resident #61's Progress Notes from 3/05/2026 through 4/07/2026 revealed there were no notes regarding communication with her physician regarding her weight loss or the recommendations from the RD. Review of Resident #61's Physician Orders revealed an order dated 3/05/2026 that read, Regular diet - Pureed texture, Honey Thick Liquids consistency, for Diet. Review of Resident #61's Physician Orders revealed an order dated 3/13/2026 that read, Magic Cup one time a day for Risk for malnutrition. Review of Resident #61's Care Plan documented a focus for compromised nutrition and hydration status secondary to: variable/poor PO intake, dx of fx, CVA, dysphagia, T2DM, hypothyroidism, HTN, Allergy: food dye with a goal the resident will not have significant weight changes through next review; The resident will maintain weight within ideal body weight range through next review; The resident will maintain adequate nutritional status through review date. Interventions included - Monitor/record/report to MD (medical doctor) PRN s/sx (signs and symptoms) of malnutrition; Refer to RD (Registered Dietitian) to evaluate and make diet change recommendations as needed/PRN. Review of Resident #61's meal tray tickets for 4/08/2026 documented her diet as Pureed, Honey Thick Liquid, with an allergy of Food Dye. During an interview on 4/08/2026 at 12:00 PM, Staff A, LPN, Unit Manager stated that the process for monitoring weight loss for the residents was to let the physician know when there was a 5-pound loss. The physician would decide whether to consult the dietitian or start appetite stimulants such as Remeron or Megace. They would contact the dietitian, and the dietitian would do her thing. During an interview on 4/08/2026 at 1:20 PM. the CDM (Certified Dietary Manager) stated that [Resident #61's Name] was not receiving fortified foods. The process was when the dietitian saw a resident, she would email the nurses any recommendations and the nurses would put in the diet orders or modifications. During an interview on 4/08/2026 at 3:30 PM, the RD stated that she made a recommendation for [Resident #61's Name] to have fortified foods because she continued to lose weight. The RD confirmed that [Resident #61's Name] diet order was not changed to add fortified foods; it would show up under the diet [order]. During an interview on 4/08/2026 at 4:43 PM, Staff A, LPN, Unit Manager stated that she had not received any recent emails regarding RD recommendations. She had not received any emails directly from the RD, the DON would forward the RD recommendations to her. No emails had been sent to her today regarding RD recommendations. During an interview on 4/08/2026 at 5:06 PM, the CDM stated that if [Resident #61's Name] were on fortified foods it would show on her meal ticket. He confirmed that not everything they served could be considered fortified. Since [Resident #61's Name] was on a pureed diet, they would add the fortification to whatever food she was having for that meal. Review of the policy and procedure titled Nutritional Management, with the last review date 12/30/2025, read, Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Compliance Guidelines: 1. A systematic approach is used to optimize each resident's nutritional status: c. Developing and consistently implementing pertinent approaches. 3. Evaluation/analysis: a. The assessment shall clarify the resident's current nutritional status and individual risk factors for altered nutrition/hydration. 5. Monitoring/revision: a. Monitoring of the residence condition and care plan interventions will occur on an ongoing basis. Examples of monitoring include: i. Interviewing the resident and/or resident representative to determine if their personal goals and preferences are being met. Ii. Directly observing the resident. d. The physician will be notified of: ii. Lack of improvement toward goals. 2.) Review of Resident #31's weight on 02/25/2026, the resident weighed 138 pounds. On 03/22/2026, the resident weighed 128.6 pounds which is a -6.81% Loss. Review of Resident #31's dietary note dated 3/27/2026 read, Ht [height] 64in [inches], wt [weight] 128.6# (pounds), BMI 22.1. Triggers for sig [significant] wt loss of -6.8% (-9.4#) in 30 days. Wt continue to trend down, wt loss r/t [related to] variable PO [by mouth] intake. Diet: Regular, mechanical soft with chopped meats texture, thin consistency. PO intake varies 0-100%, some meal refusals. Supplement: med pass 90ml [milliliters] QD [every day], house nutritional supplement 120ml BID [twice a day]. Res [Resident] in need of continued supplement r/t wt loss. Recommendation increase medpass 90ml BID, weekly wt x [times] 4. Monitor and evaluate PRN [as needed]. Review of Resident #31's physician's order dated 3/13/2026 read, Med Pass one time a day for risk of malnutrition r/t poor PO intake offer 90ml. During an interview on 4/8/2026 at 8:38 AM, Staff C, Licensed Practical Nurse, stated, [Resident #31's name] med pass is once a day. [Resident #31's name] will refuse at times but when you circle back and attempt again, he will drink them. During an interview on 4/8/2026 at 3:30 PM with the Registered Dietitian stated, All recommendations are to be given to the Director of Nursing. At the beginning I would put in my orders into the system and the facility said not to do that and to send an email. This week we had a problem about sending the recommendations to the Director of Nursing because she was not in the facility. This was told to me today in the morning. I am not too familiar with [Resident #31's name] but I addressed his weight loss on 3/27/2026 and 3/13/2026. He [Resident #31] is not eating so great. On 3/13/2026 I added med pass once a day, the increased to twice a day. The same thing happened with this resident, the email did not go to through to the right person and I had to resend a copy today. The med pass was not increased to twice a day. Normally the Director of Nursing does not reply when I send her the emails. During an interview on 4/8/2026 at 4:21 PM, the [NAME] President of Operations stated, The Director of Nursing has been out for about two weeks for a scheduled surgery. We added [Staff A ,Unit Manager, Licensed Practical Nurse's name] to receive the recommendations via email from the Registered Dietitian. I was not aware the Registered Dietitian had made recommendations on 3/27 [3/27/2026]. The process is to send an email with recommendations not just put them in a note. During an interview on 4/8/2026 at 4:41 PM, Staff A , Unit Manager, Licensed Practical Nurse, stated, I was not aware of [Resident #31's name] dietary recommendation. The Director of nursing did not talk to me about how the recommendations would be taken care off when she was out. Normally, she [Director of Nursing] will forward me all the recommendations, and I have not received any new recommendations.

Based on observation, interview, and record review, the facility failed to ensure staff sanitized resident-care equipment between resident use to prevent the possible development and transmission of communicable diseases and infections. Findings include: During an observation on 10/22/2024 at 8:03 AM, Staff A, Licensed Practical Nurse (LPN), obtained blood pressure for Resident #261 and returned to the medication cart and placed the blood pressure cuff on top of the medication cart without sanitizing the blood pressure cuff. At 8:04 AM, Staff A proceeded to Resident #23's room and obtained blood pressure reading from right arm and administered the medications returning to the medication cart to prepare medication for Resident #55. Staff A did not sanitize the blood pressure cuff. During an interview on 10/22/2024 at 8:30 AM, Staff A, LPN, stated, They are cloth. How are we going to clean them? I didn't wipe it off and I should have wiped it down with a sanitizer cloth after each resident use. During an observation on 10/22/2024 at 10:35 AM, Staff B, Registered Nurse (RN), obtained oxygen saturation with finger probe for Resident #31. The portable oxygen finger probe monitor was placed back into the medication cart. Staff B did not sanitize the probe. During an interview on 10/22/2024 at 10:50 AM, Staff B, RN, stated, I forgot the probe has to be cleaned before and after resident use. During an interview on 10/22/2024 at 10:59 AM, the Registered Nurse Consultant stated, Durable medical equipment needs to be cleaned between each resident use. The blood pressure cuff and machine should be cleaned between each resident use. The finger oxygen monitor must be cleaned between each resident use. During an interview on 10/22/2024 at 12:18 PM, the Director of Nursing stated, Any re-useable equipment must be cleaned with purple wipes [sanitary wipes] and then the dwell time should be followed per the container. Blood pressure cuffs and oxygen finger probes must be cleaned before and after each resident use with sanitizer. Review of the facility policy and procedure titled Cleaning and Disinfection of Resident-Care Equipment dated 1/4/2024 and last reviewed on 12/29/2023 showed it read, Policy: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Centers for Disease Control and Prevention] recommendations in order to break the chain of infection . Policy Explanation and Compliance Guidelines: 1. Resident-care equipment is categorized based on the degree of risk for infection involved in the use of the equipment . c. Non-critical items come in contact with intact skin, but not mucous membranes. These items require cleaning followed by low/intermediate-level disinfection (i.e., use of EPA [Environmental Protection Agency]-registered disinfectants) following manufacturers' instructions . 3. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include . b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use.

Based on observation, interview, and record review, the facility failed to ensure residents received food at a safe and appetizing temperature. Findings include: During an observation of the tray line for breakfast meal service on 10/23/2024 at 7:40 AM, after one hall's trays were prepared, sausage patty temperature was at 130 degrees Fahrenheit on the steamtable and 4-ounce strawberry yogurt was at 47.8 degrees Fahrenheit. During an interview on 10/23/2024 at 7:40 AM, the Dietary Manager confirmed the temperatures recorded and stated that the temperature for the sausage should have been above 135 degrees and the temperature of the yogurt should have been below 41 degrees. Review of the facility policy and procedure titled Food Holding and Service dated 10/1/2018 and last reviewed on 12/31/2023 showed it read, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be held and served according to the state and US Food Codes and HACCP [Hazard Analysis Critical Control Point] guidelines. Procedure: 1. Serve all hot foods at a temperature of 135 F [Fahrenheit] or greater and all cold food at 41F or less. Adjust the temperature to account for the time the food will be held prior to service on the steam table and on the tray carts.

Based on observation, interview, and record review, the facility failed to ensure residents received oxygen as prescribed by physician for 3 of 8 residents reviewed for oxygen therapy, Residents #5, #31, and #44. Findings include: 1) During an observation on 10/21/2024 at 9:59 AM, Resident #31 was receiving oxygen via nasal cannula at 5 L/M [liters per minute]. During an observation on 10/21/2024 at 1:58 PM, Resident #31 was receiving oxygen via nasal cannula at 5 liters per minute. During an observation on 10/22/2024 at 7:40 AM, Resident #31 was receiving oxygen via nasal cannula at 5 liters per minute. Review of Resident #31's physician order dated 4/10/2023 read, Oxygen PRN [as needed]- O2 [oxygen] at 2 L/M via nasal cannula as needed for O2 sats [saturation] < [less than] 90%. Review of Resident #31's care plan dated 3/14/20244 read, Focus: [Resident #31's name] has COPD [Chronic Obstructive Pulmonary Disease] . Interventions/Tasks . Give oxygen therapy as ordered by the physician. During an interview on 10/22/2024 at 11:20 AM, Resident #31 stated, My oxygen is supposed to be set at 2 liters. I don't know what it is. I cannot and do not adjust it myself. During an observation on 10/22/2024 at 12:18 PM with Staff B, Registered Nurse (RN), she confirmed that oxygen was delivered to Resident #31 at 5 liters per minute, and stated, The oxygen should be set and delivered per physician orders at 2 liters via nasal cannula. 50695 2) During an observation on 10/21/2024 at 10:30 AM, Resident #5 was lying in bed, receiving oxygen via nasal cannula at 2 L/M (Photographic evidence obtained). During an interview on 10/21/2024 at 10:30 AM, Resident #5 stated, I wear oxygen all the time. During an observation on 10/22/2024 at 8:39 AM, Resident #5 was lying in bed, receiving oxygen via nasal canula at 2 L/M. Review of Resident #5's physician order dated 8/1/2024 showed it read, O2 @ [at] 4 lpm [liter per minute] via N/C [nasal cannula] to keep O2 Sat above 90% as tolerated every shift for COPD/CHF [Congestive Heart Failure]. Review of Resident #5's care plan dated 9/29/2023 showed it read, Focus: [Resident #5's name] has COPD . Interventions . Administer oxygen as ordered. During an interview on 10/22/2024 at 12:20 PM, Staff A, Licensed Practical Nurse (LPN), stated the resident should be at 4 liters per minute. During an interview on 10/22/2024 at 1:05 PM, the Director of Nursing (DON) stated, The expectation is that we follow orders for oxygen, even if it is prn. 50123 3) During an observation on 10/21/2024 at 9:45 AM, Resident #44 was lying in bed, receiving oxygen via nasal cannula at 3 L/M. During an observation on 10/22/2024 at 9:00 AM, Resident #44 was lying in bed, receiving oxygen via nasal cannula at 3 L/M. During an interview on 10/22/2024 at 9:00 AM, Resident #44 stated, I only wear it when I'm laying down. I don't usually have problems otherwise. Review of Resident #44's physician orders showed an order dated 3/25/2023 for administration of oxygen at 2 L/M via nasal cannula as needed to keep oxygen saturation above 92%. During an interview on 10/23/2024 at 10:55 AM, Staff C, Certified Nursing Assistant (CNA), stated, He [Resident #44] lets us know when he needs it and then I let the nurse know. I can't make sure it's on the correct setting, so I have the nurses do it. During an interview on 10/22/2024 at 2:00 PM, Staff B, Licensed Practical Nurse (LPN), stated, I would document if his [Resident #44's] sats were down under 92%. I would hook him up. During an interview on 10/22/2024 at 12:10 PM, the Director of Nursing (DON) stated, It is my expectation that they follow doctor's order to a tee. Only nurses should be adjusting the oxygen settings in accordance with physician orders. Review of the facility policy and procedure titled Oxygen Administration last reviewed on 12/29/2023, showed it read, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences . Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. Review of the facility policy and procedure titled Physician Medication/Treatment Orders last reviewed on 12/29/2023, showed it read, Policy: This facility shall use uniform guidelines for the ordering of medications and treatments by practitioners. Policy Explanation and Compliance Guidelines: 1. Medications/Treatment should be administered only upon the signed order of a person lawfully authorized to prescribe . 3. Elements of the Medication/Treatment Order . d. Dosage-strength of medication is included.

Based on observation, record review, and interview, the facility failed to ensure residents received intravenous therapy (IV) in accordance with professional standards of practice for 1 of 1 resident, who was receiving intravenous medications, Resident #55. Findings include: Review of Resident #55's admission record showed the resident was most recently admitted on [DATE] with the diagnoses to include encounter for surgical aftercare following surgery on the nervous system, disruption of internal operation (surgical) wound, and infection and inflammatory reaction due to internal fixation device. Review of Resident #55's physician order dated 10/21/2024 read, Cefepime HCl Injection Solution Reconstituted 1 GM [gram], Use 1 gram intravenously one time a day for Toxic Metabolic Encephalopathy until 10/24/2024 23:59 [11:59 PM]. Review of Resident #55's care plan dated 9/20/2024 read, [Resident #55's name] is on IV medications r/t [related to] toxic metabolic encephalopathy . Interventions . Administer medications as ordered. During an observation on 10/22/2024 at 8:24 AM, Staff A, Licensed Practical Nurse (LPN), was preparing Peripherally Inserted Central Catheter (PICC) in Resident #55's upper right arm for administration of Cefepime 1 gram in 100 milliliters (ml) Normal Saline. Staff A, LPN, sanitized and flushed the PICC line with 10 ml of normal saline and initiated antibiotic infusion via pump. Staff A did not check the patency of the line by aspiration for blood return to determine patency prior to flushing or administering the medication. During an interview on 10/22/2024 at 8:30 AM, Staff A, LPN, stated, We do not have to aspirate prior to flushing or providing intravenous medication. We just have to flush with saline first. During an interview on 10/22/2024 at 12:18 PM, the Director of Nursing stated, The PICC line must be checked for patency by aspiration of blood prior to flushing with normal saline and before administering medication via the line. That's our policy and process. Review of the facility policy and procedure titled Administration of IV Fluids and Medications, Setting Up a Primary Infusion (Hydration or Medication) dated 12/29/2023 read, Purpose: To correctly and aseptically set up the primary IV bag and tubing . Procedure . 7. Attach flush syringe, aspirate for a blood return to determine patency and then flush resident's IV catheter with appropriate flush solution as ordered. Review of the facility policy and procedure titled Intravenous Therapy dated 12/29/2023 read, Procedures. Continuous Infusion . 10. Confirm patency of vascular device (peripheral IV or CVAD) as per flush protocols . Intermittent Medication Infusion . 13. Attach 10 mL syringe normal saline and confirm patency of vascular access device as per protocol.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 1 of 5 residents reviewed for unnecessary medications, Resident #38. Findings include: Review of Resident #38's Medicare Admission 5-day MDS dated [DATE] showed the resident was receiving anticoagulant medication under Section N- Medications. Review of Resident #38's physician orders revealed no current or previous orders for anticoagulant medication. During an interview on 10/24/2024 at 8:15 AM regarding Resident #38's MDS dated [DATE], the MDS Coordinator stated, I reviewed it and it is inaccurate. During an interview on 10/24/2024 at 8:30 AM regarding MDS accuracy, the Administrator stated, I expect them to be accurate. Review of the facility policy and procedure titled Conducting an Accurate Resident Assessment revised on 1/4/2024 showed it read, Policy Explanation and Compliance Guidelines . 3. The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status.

Based on observation, interview, and record review, the facility failed to ensure nurse staffing information was posted on a daily basis. Findings include: During an observation on 10/21/2024 at 9:15 AM, Daily Nursing Staffing Form was posted in the main entry hall of the facility. The form read, Saturday. Today's Date: 10/19/2024. During an interview on 10/24/2024 at 9:10 AM, the Administrator stated, I would like the staffing sheet posted by 11:00 AM. Mondays can take a little longer because they are balancing 3 days of staffing. Review of the facility policy and procedure titled Nurse Staffing Posting Information last reviewed on 12/29/2023, showed it read, Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information . 2. The facility will post the Nurse Staffing Sheet daily each morning.

Based on observation, interview, and record review, the facility failed to ensure foods were stored in a sanitary manner in the kitchen and in 1 of 2 nourishment rooms, Nourishment room [ROOM NUMBER] (100 Hall). Findings include: During an observation on 7/10/2023 at 9:20 AM, there were an unlabeled unidentifiable food item in a plastic bag and an undated pizza crust, lying open on the second shelf of the walk-in freezer. During an interview on 7/10/2023 at 9:20 AM, the Certified Dietary Manager (CDM) acknowledged there was no label or date on the plastic bag and/or the frozen pizza crust. During an observation on 7/10/2023 at 9:30 AM, there was 1/2 case of single serve bowls of cheerios with an expiration date of February 2023 on the bottom shelf of the storage room. During an interview on 7/10/2023 at 9:33 AM, the CDM acknowledged the expiration date of the 1/2 case of single serve bowls of cheerios. During an observation on 7/10/2023 at 9:40 AM, there were 10 single serve bowls of cereal stored in the upper cabinet of Nourishment room [ROOM NUMBER] on 100 Hall, with an expiration date of February 2023. There were three zip lock bags of unlabeled/undated snacks sitting on the counter in a basket. The resident's name was observed on the bags, but there was no date label on the bags. During an interview on 7/10/2023 at 9:40 AM, the CDM acknowledged the expiration date of the single serve bowls of cereal and stated that he did not know when the zip lock bagged items were brought into the facility, and they should have dates on them. Review of the facility policy and procedure titled Food Receiving and Storage revised in July 2014 read, Policy Interpretation and Implementation . 7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated. Review of the facility policy and procedure titled Use and Storage of Food Brought in by Family or Visitors read, read, Policy Explanation and Compliance Guidelines . 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. b. The prepared food must be consumed by the resident within 3 days. c. If not consumed within 3 days, food will be thrown away by facility staff.

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to professional standards of practice for 2 residents, Resident #31 and Resident #3. Findings include: During an observation on 7/10/2023 at 9:43 AM, Resident #31 was lying in her bed. There were 3 halves of medication tablets in a medication cup on the bedside table in front of Resident #31. During an observation on 7/10/2023 at 9:44 AM, Staff A, Licensed Practical Nurse (LPN), was standing outside of Resident #31's room, facing the room. Resident #31's room door was ajar. Staff A was intermittently glancing in the direction of Resident #31's room and at her computer screen. Resident #31's room door was not fully open and Staff A did not constantly maintain visual supervision of Resident #31. During an interview on 7/10/2023 at 9:44 AM, Staff A stated, I park right here and keep an eye on her. Review of Resident #31's medical records did not show the resident had been assessed as able to safely self-administer medications. During an observation on 7/10/2023 at 12:20 PM, Resident #3 was seated at a dining table in the main dining room. Staff A approached Resident #3 and put a medication cup that contained one large tablet in front of Resident #3. Staff A then turned her back to Resident #3 and walked away from Resident #3 towards the kitchen area. Review of Resident #3's medical records did not show the resident had been assessed as able to safely self-administer medications. During an interview on 7/12/2023 at 9:41 AM, the Director of Nursing stated she would expect the nurse to watch the resident take medications and not leave the medications at bedside. She added she would expect the nurse to keep their eyes on the resident at all times when administering medications to the resident. During an interview on 7/12/2023 at 12:27 PM, the Director of Nursing confirmed Resident #3 and Resident #31 had not been assessed for self-administration of medications. Review of the facility policy and procedures titled Medication Administration, last reviewed on 12/21/2022, read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . Policy Explanation and Compliance Guidelines . 15. Observe resident consumption of medication.

Based on observation, record review, and interview, the facility failed to ensure resident records were accurate for 1 of 2 residents reviewed for nutrition, Resident #152. Findings include: During an observation on 7/10/2023 at 12:10 PM, Resident #152 was eating in her room. Resident #152's meal tray contained noodles mixed with beef, mixed veggies, fries, frosted cake. No ice cream was observed with Resident #152's meal. Review of Resident #152's lunch meal ticket dated 7/10/2023 read, Buttered Noodles, California Vegetables, Tater Tots, Jello-Red, Water. Instructions: Vegetarian only send meat on request. During an observation on 7/11/2023 at 12:12 PM through 12:53 PM, Staff B, Certified Nursing Assistant (CNA), brought Resident #152's lunch meal tray that contained a fruit cup and cottage cheese. Resident #152 told Staff B that she would go into the kitchen to get the other items missing. Staff B returned with a plate of scallop potatoes, green beans, and dinner roll. No ice cream was delivered with the tray or during lunch time. Staff B removed the lunch tray from Resident #152's room at 12:53 PM. Resident #152 had consumed approximately 50% of the meal. During an observation on 7/12/2023 at 12:00 PM, Resident #152 was sitting on the side of her bed. Her meal tray was in front of her, containing mixed vegetables, potatoes, and a brownie. There was no ice cream on the tray. During an interview on 7/12/2023 at 12:00 PM, Resident #152 stated, They have never brought me ice cream during lunch time. I would love some ice cream. Review of Resident #152's lunch tray ticket for 7/12/2023, which was dated 7/11/2023, read, Food Likes: Chocolate ice cream, No Meat. Instructions: Vegetarian only send meat on request. Review of Resident #152's physician order dated 7/7/2023, read, Ice cream two times a day for dietary supplement. Review of Resident #152's Medication Administration Record (MAR) for July 2023 revealed staff initials on 7/10/2023 at 12:00 PM, 7/11/2023 at 12:00 PM and 7/12/2023 at 12:00 PM that documented ice cream was received by Resident #152. During an interview on 7/12/2023 on 1:06 PM, the Director of Nursing stated, The nurses should observe the resident before documenting in the MAR that the resident received the ice cream. Review of the facility policy and procedures titled Documentation in Medical Records last reviewed on 12/21/2022, read, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines . 3. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. i. False information shall not be documented.

Based on observation, interview, and record review, the facility failed to ensure residents received dietary supplement at mealtimes for 1 of 2 residents reviewed for nutrition, Resident #152. Findings include: Review of Resident #152's Weights and Vitals Summary showed the resident weighed 132.6 pounds on 7/3/2023, and 130.7 pounds on 7/11/2023, which was a -1.43% loss. During an interview on 7/10/2023 at 9:32 AM, Resident #152 stated, The food is bland. I do not enjoy it, always the same thing. I am vegetarian and they always give me oatmeal and grits. During an observation on 7/10/2023 at 12:10 PM, Resident #152 was eating in her room. Resident #152's meal tray contained noodles mixed with beef, mixed veggies, fries, frosted cake. No ice cream was observed with Resident #152's meal. During an interview on 7/10/2023 at 12:15 PM, Resident #152 stated, I will not eat this. I do not eat beef. Review of Resident #152's lunch meal ticket dated 7/10/2023 read, Buttered Noodles, California Vegetables, Tater Tots, Jello-Red, Water. Instructions: Vegetarian only send meat on request. During an observation on 7/11/2023 at 12:12 PM through 12:53 PM, Staff B, Certified Nursing Assistant (CNA), brought Resident #152's lunch meal tray that contained a fruit cup and cottage cheese. Resident #152 told Staff B that she would go into the kitchen to get the other items missing. Staff B returned with a plate of scallop potatoes, green beans, and dinner roll. No ice cream was delivered with the tray or during lunch time. Staff B removed the lunch tray from Resident #152's room at 12:53 PM. Resident #152 had consumed approximately 50% of the meal. During an observation on 7/12/2023 at 12:00 PM, Resident #152 was sitting on the side of her bed. Her meal tray was in front of her, containing mixed vegetables, potatoes, and a brownie. There was no ice cream on the tray. During an interview on 7/12/2023 at 12:00 PM, Resident #152 stated, My daughters will bring me lunch today. The food is terrible. They have never brought me ice cream during lunch time. I would love some ice cream. Review of Resident #152's lunch tray ticket for 7/12/2023, which was dated 7/11/2023, read, Food Likes: Chocolate ice cream, No Meat. Instructions: Vegetarian only send meat on request. Review of Resident #152's admission record showed the resident was admitted on [DATE] with diagnoses that included anxiety, displaced intertrochanteric fracture of left femur, anemia, vitamin D deficiency, and gastro-esophageal reflux disease without esophagitis. Review of Resident #152's physician order dated 7/7/2023, read, Ice cream two times a day for dietary supplement. Review of Resident #152's progress note dated 7/7/2023, read, RD [Registered Dietician] completed Rounds 7/4, PCP [Primary Care Physician] reviewed recommendations, New orders noted for Ice Cream with lunch and dinner for dietary supplement. Res. [Resident] also states her preference is vegetarian diet, diet updated in chart, Will con't [continue] to offer snacks and meals of choice daily. During an interview on 7/12/2023 at 12:38 PM, Certified Dietary Manager (CDM) stated, Monday [7/10/2023] was my first day of work. Normally supplements will come out with the meal tray. Any resident with supplements is included in the list dietary makes. I will check to see if [Resident #152's name] is on this list. During an interview on 7/12/2023 at 12:45 PM, the Registered Dietician stated, I haven't been in the facility this week. The resident was open to the idea of ice cream. During an interview on 7/12/2023 at 12:56 PM, Staff B, CNA, stated, [Resident #152's name] did not get ice cream for the past few days. We normally do not know if the resident has to get ice cream unless it is written on the meal ticket, or the resident asks for it. The nurses have not come to ask me if the resident has had ice cream during her lunch. During an interview on 7/12/2023 on 1:06 PM, the Director of Nursing stated, The supplement should come out on the meal tray. The staff are expected to follow physician orders. During an interview on 7/12/2023 at 3:03 PM, the Registered Dietician stated, The ice cream was for additional calories that were more a precautionary measure for [Resident #152's name]. I do not think it would have an effect in her weight. I spoke to CDM and he spoke to [Resident #152's name] in regards to additional protein we will be providing. I spoke to him in regards to the protein intake and I feel she was getting adequate protein. Review of the policy and procedures titled Nutritional and Dietary Supplements, last reviewed on 12/21/2022, read, Policy: It is the policy of this facility that nutritional and dietary supplements will be used to complement a resident's dietary needs in order to maintain adequate nutritional status and resident's highest practical level of well being . Policy Explanation and Compliance Guidelines . 8. Nutritional supplements are to be provided to residents within 45 minutes of either a resident's request or less depending on the facility's scheduled time for meals. 9. Supplements may be provided by dietician recommendation as allowed by physician standing order.

Based on observation, interview, and record review the facility failed to ensure that all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional standards, included expirations dates when applicable and ensured that no expired medication were available for use in 2 out of 3 medication carts observed. Findings: An observation on [DATE] at 9:48 AM of Hallway 100's medication cart revealed the following: [MEDICATION(S)] 1% 20 ML (Milliliter) multi dose vial showed no documentation of the date opened, [MEDICATION(S)] R Insulin opened on [DATE] and expired on [DATE], [MEDICATION(S)] Flex Pen showed no documentation of the date opened, another [MEDICATION(S)] 1% 20 ML multi dose vial showed documentation that it was opened [DATE], [MEDICATION(S)] ear drops showed no documentation of the date opened, and [MEDICATION(S)]-Polym eye drops showed no documentation of the date opened. Review of the narcotic drawer revealed one medication card of [MEDICATION(S)] 50 MG (Milligram) with (60) tablets with a remaining that expired ,d+[DATE] and one medication card of [MEDICATION(S)] 50 MG with a remaining count of 29 tablets that expired [DATE]. During an interview on [DATE] beginning at 10:07 AM, Staff A Licensed Practical Nurse (LPN) stated, I do not know why the Insulins are in the drawer with no opened or expired dates. I do not know why the [MEDICATION(S)] is opened without the date that the [MEDICATION(S)] was opened or why the one [MEDICATION(S)] was opened for more than 30 days. Insulin and [MEDICATION(S)] is only good for 30 days after opening. Insulin, eye drops, and the multi dose vials are all supposed to be dated. I am not sure why the ear drops, and the eye drops do not show the date they were opened. I don't know why the [MEDICATION(S)] in the narcotics drawer is expired. An observation on [DATE] at 10:15 AM of Hallway 200's medication cart revealed the following: [MEDICATION(S)] 1% multi dose vial 20 ML showed no documentation of open date, [MEDICATION(S)] N Insulin showed an opened date of [DATE] with expiration date of [DATE], and [MEDICATION(S)] Insulin showed no documentation of the date opened. During an interview on [DATE] at 10:30 AM Staff B, LPN stated, I don't know why the [MEDICATION(S)] is opened with no date opened on the box or the vial. The [MEDICATION(S)] pen does not have a date opened. The [MEDICATION(S)] N Insulin is past the expiration date. Insulin and multi dose vials should show the date opened. During an interview on [DATE] at 8:20 AM the Director of Nursing (DON) stated, On each nursing medication cart there is a sheet [titled Expiration Date and Expiration Dating of Common Pharmaceuticals] to show the nursing staff when things like Insulin, eye drops, and ear drops expire. Multi dose vials of medications are only good for 30 days after opening. The nursing staff are supposed to check for expiration dates. Review of the document titled Expiration Date reads, Brand: [MEDICATION(S)] N, Vial Exp (expires): 28, Brand: [MEDICATION(S)] R, Vial Exp: 28, Brand: [MEDICATION(S)], Vial Exp: 28, Brand: [MEDICATION(S)], Pen Exp: 42. Review of the document titled Expiration Dating of Common Pharmaceuticals reads Product: Insulin vials unrefrigerated: Expiration Guideline: 28 days either opened or unopened; or per manufacturer guidelines and Multi dose injectable vials with preservatives: Expiration Guideline: 28 days from date opened. Review of the facility policy titled Storage of Medications with a revised date of [DATE] and last reviewed on [DATE] read Policy Statement. The facility policy shall store all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation #4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed upon discovery.

Based on observation, interview, and facility policy review, the facility failed to ensure food was stored in accordance with professional standards for food service safety which has the potential to affect the total population of 39 residents. Findings: During a tour of the facility's kitchen and cold food storage areas conducted with the facility's Certified Dietary Manager on 10/11/20 beginning at 10:32 AM, it showed an open bag of grits located on a prep cart in the kitchen that was not labeled with the open date. On wired shelves in the walk-in cooler an open plastic wrapped cut onion, a bag of shredded cheddar cheese, and a bag of lettuce were not labeled with the open dates. In the reach in cooler there was plastic wrapped sliced cheese on a shelf that was not labeled with the open date. (photographic evidence obtained) During an interview on 10/11/20 at 2:00 PM, the facility's Certified Dietary Manager verified the opened grits bag on the prep cart and the opened food items in the coolers were not labeled. The Certified Dietary Manager stated they should be reclosed, labeled when opened, and then placed in storage in a cooler or freezer. Record review of the facility's policy titled, Food Receiving and Storage, revised in July 2014, read: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated.

Based on observation, interview, and record review the facility failed to ensure the implementation of the plan of care for 1 of 2 sampled residents, Resident #13 for contracture management specific to the application of splints/devices; and Resident #16 for activities of daily living (ADL) specific to personal hygiene for 1 of 2 residents Resident #16 sampled for ADL care in a total sample of 18 residents. Findings: 1. Review of the facility medical record for Resident #13 revealed the resident was admitted with the following Diagnosis: [REDACTED]. Review of the physician's orders [REDACTED]. During an observation on 10/11/20 at 10:57 AM of Resident #13 it showed the resident is in bed watching television. Both hands were observed to have severe contractures. The Resident has jagged and long fingernails which are embedding into the palm of her hand. On the bedside dresser there were two carrot cone splints. During an interview with Resident #13 on 10/11/2020 at 10:59 AM, she said she has been here over a year. The Resident stated, The cones are supposed to be put on every morning for a few hours and then on all night long. During an interview with Resident #13 on 10/12/2020 at 9:17 AM, she stated, the staff did not apply my hand cones yesterday or last night. During an observation on 10/12/20 at 9:17 AM showed two carrot cones on top of Resident #13's bedside dresser. During an interview with Resident #13 on 10/12/2020 at 2:20 PM, she said, I would like to have my hand carrots on me. I cannot put them on by myself. I have not refused it in the past if they offered it to me, but they have not offered to apply them. During an observation on 10/13/2020 at 8:02 AM of Resident #13 it showed the resident is in bed awake and alert. The two carrot cone splints are on her bedside dresser. During an interview on 10/13/2020 at 8:02 AM with Resident #13 when asked if staff applied the hand splints the resident said the splints were not applied yesterday or last night. Resident # 13 stated, They wrote a sign yesterday on my table to apply carrot cones daily. There was a note observed on 10/13/2020 at 8:05 AM, the handwritten note is taped on the bedside table and reads: apply carrot cone daily. During an interview with Staff E, on 10/13/2020 at 8:36 AM, she said she is the permanent Certified Nursing Assistant (CNA) for Resident #13. Staff E said she used to apply the carrot cones for 30 minutes to one hour. Staff E said she was off the last three days. During an interview with Staff I, Certified Occupational Therapy Assistant (COTA) on 10/13/2020 at 11:06 AM, he stated, (Resident #13's name) was picked up for skilled Occupational Therapy (OT) services on 9/30/2020. I have not applied the carrot splints to be honest with you since 9/30/2020. I am supposed to apply them daily. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment with a start date of care on 9/30/2020 reads: Goal # 4: Patient will tolerate overnight wear of bilateral carrot splints in order to decrease contracture and pain and increase functional dexterity during daytime hours. Review of the care plan revealed and reads: Resident with alteration in musculoskeletal status related to contracted to bilateral hands revised on 9/9/2020. Interventions include: Keep skin clean and dry in creases. Provide hand roll/hand carrot in right hand if she will allow as tolerated to prevent further tightness. Review of the Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/20/2020 under section G0400 revealed Resident #13 has functional limitation in range of motion, impairment of both sides of upper extremities. Section C0500 of the MDS, Resident #13 was scored 15 on the Brief Interview for Mental Status (BIMS) (no cognitive impairment). 2. Review of Resident #16's facility medical record revealed Resident #16 was admitted with the following Diagnoses: [REDACTED]. An observation on 10/11/20 at 11:58 AM showed Resident #16 was in bed, awake, with left hand fingernails jagged and unclean with a black colored sediment underneath each fingernail. An observation on 10/12/2020 at 9:41 AM showed Resident #16 is up in her wheelchair, alert. Resident #16's left hand fingernails remained unclean with a black colored substance underneath her fingernails. An observation on 10/13/2020 at 9:02 AM showed Resident #16 is in the activity room and her left-hand fingernails remained unclean with a black colored substance under her fingernails. An observation on 10/13/2020 at 2:40 PM revealed Resident #16 is in bed and awake. Her left-hand fingernails remained unclean with a black colored substance under her fingernails. During an interview on 10/13/2020 at 2:41 PM with Staff G, CNA she verified the resident's nails needed to be cleaned. During an interview on 10/13/2020 at 2:42 PM with Staff J, CNA she said she has been assigned to Resident #16 for the past two days. Staff J said, I gave her a bed bath today. When asked if she failed provided nail care to Resident #16, Staff J, CNA replied, There is a team that does nail care. Review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/20/2020 under Section C0500 revealed Resident #16 was scored 3 for Brief Interview for Mental Status (BIMS) (severely impaired cognition). Under Section G for activities of daily living, Resident #16 was coded as 3/2 for extensive assistance with one person assist for personal hygiene including washing face and hands. Review of the care plan revealed Resident #16 was care planned for activities of daily living (ADL) deficit related to fatigue, impaired balance, limited mobility, and confusion at times. Interventions include: Encourage resident to participate to the fullest extent possible with each interaction. Personal hygiene/oral care- the resident requires staff participation with personal hygiene and oral care. Review of the facility's policy titled, Quality of Life - Dignity Policy and Procedure revised in August 2009, revealed: Page 1 of 2 of the policy reads: Policy Statement: Each Resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation reads: 3. Resident shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). Resident will be provided activity of daily living (ADL) and hygiene care by staff according to their individual needs and preferences.

Based on observation, interview, and record review the facility failed to ensure Activities of Daily Living (ADL) care was provided for 1 of 2 sampled residents who are unable to carry out the Activities of Daily Living necessary to maintain grooming and personal hygiene, Resident #16, in a total sample of 18 residents. Findings: Review of Resident #16's facility medical record revealed Resident #16 was admitted with the following Diagnoses: [REDACTED]. An observation on 10/11/20 at 11:58 AM showed Resident #16 was in bed, awake, with left hand fingernails jagged and unclean with a black colored sediment underneath each fingernail. An observation on 10/12/2020 at 9:41 AM showed Resident #16 is up in her wheelchair, alert. Resident #16's left hand fingernails remained unclean with a black colored substance underneath her fingernails. An observation on 10/13/2020 at 9:02 AM showed Resident #16 is in the activity room and her left-hand fingernails remained unclean with a black colored substance under her fingernails. An observation on 10/13/2020 at 2:40 PM revealed Resident #16 is in bed and awake. Her left-hand fingernails remained unclean with a black colored substance under her fingernails. During an interview on 10/13/2020 at 2:41 PM with Staff G, CNA she verified the resident's nails needed to be cleaned. During an interview on 10/13/2020 at 2:42 PM with Staff J, CNA she said she has been assigned to Resident #16 for the past two days. Staff J said, I gave her a bed bath today. When asked if she failed provided nail care to Resident #16, Staff J, CNA replied, There is a team that does nail care. Review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/20/2020 under Section C0500 revealed Resident #16 was scored 3 for Brief Interview for Mental Status (BIMS) (severely impaired cognition). Under Section G for activities of daily living, Resident #16 was coded as 3/2 for extensive assistance with one person assist for personal hygiene including washing face and hands. Review of the care plan revealed Resident #16 was care planned for activities of daily living (ADL) deficit related to fatigue, impaired balance, limited mobility, and confusion at times. Interventions include: Encourage resident to participate to the fullest extent possible with each interaction. Personal hygiene/oral care- the resident requires staff participation with personal hygiene and oral care. Review of the facility's policy titled, Quality of Life - Dignity Policy and Procedure revised in August 2009, revealed: Page 1 of 2 of the policy reads: Policy Statement: Each Resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation reads: 3. Resident shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). Resident will be provided activity of daily living (ADL) and hygiene care by staff according to their individual needs and preferences.