Every finding on record at Life Care Center of Collegedale

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure expired food items were discarded for 3 residents (Resident #20, Resident #70 and Resident #28) of 11 residents' personal refrigerators observed, failed to maintain safe food storage in the dietary department and failed to maintain sanitary kitchen equipment which had the potential to effect 111 of 111 residents.The findings include: Review of the facility's policy titled, Resident Refrigerators, revealed .The facility will .Store, prepare, distribute and serve food in accordance with professional standards for food service safety .Facility staff will check individual food items weekly for expiration dates and discard outdated food promptly from the residents' personal refrigerator .Food will be labeled and dated, appropriately to monitor food safety .All food items should be consumed or discarded after three (3) days .Food items in unmarked or unlabeled containers should be labeled with contents, and the date the food item was stored .Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Morbid Obesity, and Obstructive Sleep Apnea.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an observation on 8/3/2026 at 1:14 PM, in Resident #20's room revealed a personal refrigerator which contained 1 carton of milk with an expiration date of 7/31/2026, 1 bottle of salad dressing with an expiration date of 7/1/2026, 1 bottle of salad dressing with an expiration date of 3/31/2026, and 1 bottle of lemon juice with an expiration date of 5/15/2026. During an observation and interview on 8/3/2026 at 1:30 PM, in Resident #20's room with Licensed Practical Nurse (LPN) C revealed 1 carton of milk with an expiration date of 7/31/2026, 1 bottle of salad dressing with an expiration date of 7/1/2026, 1 bottle of salad dressing with an expiration date of 3/31/2026, and 1 bottle of lemon juice with an expiration date of 5/15/2026. LPN C stated she did not know who was responsible for cleaning the resident personal refrigerators and disposing of expired items. LPN C confirmed the milk, salad dressings, and lemon juice were expired and available for resident use.Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Atrial Fibrillation, and Hypertension. Review of a quarterly MDS assessment dated [DATE], revealed Resident #70 did not have a BIMS assessment completed because the resident was rarely or never understood. During an observation on 8/3/2026 at 1:34 PM, in Resident #70's room revealed a personal refrigerator which contained two 11.5 fluid ounce protein vanilla shakes with a best by date of 4/14/2026 and one uncovered, undated, and unlabeled styrofoam bowel of strawberry ice cream. During an observation and interview on 8/3/2026 at 1:38 PM, in Resident #70's room with Certified Nursing Assistant (CNA) G revealed a personal refrigerator which contained two 11.5 fluid ounce protein vanilla shakes with a best by date of 4/14/2026 and one uncovered, undated, and unlabeled Styrofoam bowel of strawberry ice cream. CNA G confirmed the two vanilla shakes had expired, the ice cream was not stored properly, and the items were available for resident use.Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including Anxiety, Hypertension, and Insomnia.Review of an annual MDS assessment dated [DATE], revealed Resident #28 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment.During an observation on 8/3/2026 at 1:34 PM, in Resident #28's room revealed a personal refrigerator which contained 2 nutritional supplement shakes with an expiration date of 5/2026. During an observation and interview on 8/3/2026 at 4:10 PM, in Resident #28's room revealed a personal refrigerator which contained 2 nutritional supplement shakes with an expiration date of 5/2026. Registered Nurse (RN) I confirmed the 2 nutritional supplement shakes were expired and available for resident use. During an interview on 8/5/2026 at 4:35 PM, the Director of Nursing confirmed food items in the residents' refrigerators were to be checked and expired food items were to be discarded. During an observation of the dietary department dry storage area on 8/3/2026 between 11:00 AM and 11:30 AM with the Dietary Manager revealed the following:1. One 14-ounce bag of chicken gravy mix with 3/4 of the bag used with no open date. 2. Two 1-gallon ranch dressing containers, opened, with no open date and no use by date.3. One 46 fluid ounce thickened orange juice labeled with a use by date of 1/28/2026.4. One 46 fluid ounce thickened orange juice labeled with a use by date of 6/22/2026.5. Two 46 fluid ounce thickened orange juice labeled with a use by date of 6/28/2026.6. One opened 46 fluid ounce thickened lemon-flavored water with no open date and available for resident use. 7. One opened 46 fluid ounce thickened fruit Punch with no open date and available for resident use.8. One 46 fluid ounce Grape Juice with a use by date of 6/28/2026, with no open date and available for resident use.During an interview on 8/3/2026 at 11:15 AM, the Dietary Manager (DM) confirmed the food items observed were expired, had been stored improperly and was available for resident use.During an observation and interview on 8/3/2026 at 11:22 AM, with the DM revealed the mixer had dried, light brown food debris located on the back of the motor base. The microwave had dried, dark brown food debris located on the turntable and the back and top of the cooking chamber. The toaster had loose brown food debris in the bread slots and crumb tray. During an interview on 8/3/2026 at 11:28 AM, the DM confirmed the kitchen equipment was not maintained in a clean and sanitary condition.

Based on facility policy review, medical record review, observation, and interviews the facility failed to follow Enhanced Barrier Precautions (EBP) for 1 resident (Resident #14) and the facility failed to post signage related to Enhanced Barrier Precautions for 1 resident (Resident #108) of 34 resident's reviewed for Enhanced Barrier Precautions. The findings include: Review of the facility policy titled, Enhanced Barrier Precautions, dated 6/5/2026, revealed .The facility should use Enhanced Barrier Precautions (EBP) .for residents that meet the following criteria, during high-contact resident care activities .wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized . Indwelling medical device examples include central lines, urinary catheter, feeding tubes .The facility may choose to post signage on the door or wall outside of the resident room indicating the resident is on Enhanced Barrier Precautions .Examples of high-contact care activities include .Providing hygiene .Changing briefs or assisting with toileting .Device care or use: central line, urinary catheter Personal protective equipment (PPE) for enhanced barrier precautions is .necessary when performing high-contact care activities . Review of the medical record revealed Resident #108 was admitted to the facility on [DATE] with diagnoses including Aftercare Following Joint Replacement Surgery, Bacteremia, and Methicillin Resistant Staphylococcus Aureus. Review of a Physician's order for Resident #108 dated 7/29/2026, revealed .Observe PICC [Peripherally Inserted Central Catheter] [an intravenous access used to deliver medications or fluids] line insertion site every shift for s/s [signs and symptoms] of infection . Review of a Physician's order for Resident #108 dated 7/29/2026, revealed .Vancomycin HCL [Hydrochloride] [a medication used to treat infections] Intravenous Solution 500 MG [Milligram]/100 ML [Milliliter] .Use 500mg Intravenously one time a day . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #108 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident had the following active diagnosis including After care Following Joint Replacement, Multidrug Resistant Organism, and Bacteremia. Continued review revealed the resident received antibiotics during the 7 day look back period. During an observation and interview on 8/3/2026 at 3:59 PM, revealed Resident #108 had a PICC line to the right upper extremity. Resident #108 stated he received IV antibiotics once a day every day due to a knee infection. During an observation on 8/3/2026 at 4:03 PM, revealed there was no signage for EBP outside of Resident #108's door. During an observation on 8/4/2026 at 7:48 AM, revealed there was no signage for EBP outside of Resident #108's door. During an interview on 8/4/2026 at 8:25 AM, the Infection Preventionist (IP) confirmed Resident #108 had a PICC line to the right upper extremity and there was no signage in place to indicate Resident #108 was on EBP. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Acute Kidney Failure, Diabetes, and Retention of Urine. Review of a quarterly MDS assessment dated [DATE], revealed Resident #14 had modified independence for cognitive skills for daily decision making and had an indwelling urinary catheter. Review of a Physician's Order for Resident #14 dated 5/5/2026, revealed .Enhanced Barrier Precautions .Indwelling Catheter . During an observation and interview on 8/4/2026 at 10:03 AM, in Resident #14's room with the Assistant Director of Nursing Services (ADNS) revealed Certified Nursing Assistant (CNA) A entered the room, emptied Resident #14's catheter, and failed to wear a gown. The ADNS confirmed Resident #14 was on EBP, an EBP sign was posted on the outside of the resident's entrance door identifying the resident was on EPB and confirmed CNA A failed to wear a gown when she emptied Resident #14's catheter and did not follow the EBP recommendations. During an interview on 8/4/2026 at 10:15 AM, CNA A confirmed she did not wear a gown when she emptied Resident #14's catheter. During an interview on 8/5/2026 at 9:20 AM, the Director of Nursing stated CNA A failed to follow the facilities infection control policy when the CNA failed to wear a gown when she emptied Resident #14's catheter.

Based on medical record review, observation, and interview, the facility failed to maintain and store a Continuous Positive Airway Pressure (CPAP) mask (mask used on machine that involves the administration of air through the nose to keep airway open during sleep) in a clean and sanitary condition for 1 resident (Resident #50) of 3 residents reviewed for CPAP equipment storage.The findings include: Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction affecting Right Dominant Side, Obstructive Sleep Apnea, Muscle Weakness, and Abnormalities of Gait. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #50 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. During an observation on 8/3/2026 at 4:34 PM and 8/4/2026 at 9:35 AM, in Resident #50's room revealed a CPAP mask lying on the nightstand and was not stored in a clean and sanitary condition. During an observation and interview on 8/4/2026 at 2:40 PM, in Resident #50's room with the Infection Preventionist (IP) revealed a CPAP mask lying on the nightstand and confirmed the CPAP mask had not been stored in a clean and sanitary condition. During an observation and interview on 8/5/2026 at 9:04 AM, in Resident #50's room with the Director of Nursing (DON) revealed a CPAP mask lying on the nightstand and confirmed the CPAP mask had not been stored in a clean and sanitary condition and was available for resident use.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to prevent hazards for 1 resident (Resident #50) of 23 residents reviewed.The findings include: Review of the facility policy titled, Facility Safety, dated 4/1/2026, revealed .The facility must ensure .resident environment remains .free of accident hazards .The facility must provide .a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible .safely .and does not pose a risk . Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction affecting Right Dominant Side, Obstructive Sleep Apnea, Muscle Weakness, and Abnormalities of Gait. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #50 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. During an observation on 8/4/2026 at 10:38 AM, in Resident #50's room revealed a 10.1 fluid ounce bottle of nail polish remover, a 1-pound container of bleach wipes, 1- 8.1 ounce can of air freshener, 1- 8.8 ounce can of air freshener, and a 32 fluid ounce plastic container of window cleaner on a shelf. During an observation and interview on 8/4/2026 at 10:55 AM, in Resident #50's room with Licensed Practical Nurse (LPN) D revealed a 10.1 fluid ounce bottle of nail polish remover, a 1-pound container of bleach wipes, 1- 8.1 ounce can of air freshener, 1- 8.8 ounce can of air freshener, and a 32 fluid ounce plastic container of window cleaner on a shelf. LPN D removed the items from the room and stated she would have to check with management to see if the items were permitted to be in Resident #50's room. During multiple observations on the hallway where Resident #50 resided from 8/3/2026 - 8/4/2026, revealed no residents wandering in the hallway or other resident rooms. During an interview on 8/4/2026 at 11:05 AM, the Regional [NAME] President confirmed the items observed on the shelf in Resident #50's room could pose an accident risk to the resident and should not have been the resident's room.

Based on facility policy review, medical record review, observation, and interview, the facility failed to implement care plan interventions for 2 residents (Resident #77 and Resident #2) out of 24 residents reviewed for care plans.The findings include: Review of the facility policy titled, Comprehensive Care Plans and Revisions, dated 8/29/2025, revealed .The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan .The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care .When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery, this can include .additional interventions on existing problems . Review of the facility policy titled, Fall Management, dated 9/25/2025, revealed .The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls . Review of the medical record revealed Resident #77 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Fracture of Left Hip, Muscle Weakness, and History of Falling. Review of the comprehensive care plan for Resident #77 dated 7/3/2026, revealed the resident was at risk for falls, with an intervention to include bolsters bilaterally (both sides) while in bed. Review of a 5 Day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #77 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident required substantial to maximal assistance for transfers, toileting, dressing and bathing. Review of a Risk Management Incident Review Form report dated 7/23/2026, revealed Resident #77 had an unwitnessed fall in her bedroom. The fall intervention was for bilateral bolsters to be added to the resident's bed. Review of a progress note dated 7/23/2026, revealed the IDT (Interdisciplinary Team) reviewed an unwitnessed fall on 7/23/2026 at 1:45 AM. Resident #77 was found on floor in bedroom, sent to emergency room (ER) for evaluation and treatment and a new intervention was added to the care plan for bilateral bolsters to be added to the resident's bed to help define bed parameters. During an observation on 8/5/2026 at 11:25 AM, revealed Resident #77 was in bed and the bilateral bolsters were not in place. During an observation and interview on 8/5/2026 at 11:31 AM, the Staff Development Coordinator confirmed the bilateral bolsters were not in place for Resident #77. During an interview on 8/5/2026 at 11:33 AM, the Director of Nursing confirmed the bilateral bolsters were not in place, and the care plan had not been followed. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Anxiety, Muscle Weakness, and Protein-Calorie Malnutrition. Review of an admission MDS assessment dated [DATE], revealed Resident #2 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact.set-up or clean-up assistance with eating and oral hygiene .mechanically altered diet .obvious broken natural teeth .Yes, Obvious or likely cavity or broken natural teeth .No, Mouth or facial pain, discomfort or difficulty with chewing . Review of a comprehensive care plan for Resident #2 dated 3/30/2026, revealed .At risk for weight fluctuation . The resident's dental status had not been addressed in Resident #2's care plan. Review of a physician's order for Resident #2 dated 3/31/2026, revealed .Regular diet, Easy to Chew texture, Thin consistency .Admit to Hospice .effective 4/3/26 [4/3/2026] . During an observation and interview on 8/4/2026 at 2:50 PM, Resident #2's bottom teeth were black in color, broken, and worn down to the gumline. During an interview on 8/4/2026 at 3:00 PM, CNA F stated, [Resident #2] has no problems chewing and consuming meals .[Resident #2] is able to do self oral care . During an interview on 8/5/2026 at 12:12 PM, the MDS Nurse confirmed the Comprehensive Care Plan had not been developed for Resident #2 and did not accurately reflect the resident's oral/dental status.

Based on facility policy review, medical record reviews, and interviews the facility failed to notify the Long-Term Care (LTC) Ombudsman of emergency discharges for 2 residents (Resident #8 and Resident #119) of 4 residents reviewed for discharge. Review of the facility policy titled, Notice of Transfers and Discharges, revised 6/19/2026, revealed .copies of notices for emergency transfers must also be sent to the ombudsman .such as in a list of residents on a monthly basis . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including History of Falling, Hypertension, and Crohn's Disease. Review of a nurse progress note dated 6/1/2026, revealed Resident #8 was transferred to the hospital. Further review revealed the resident readmitted to the facility on [DATE]. Review of a discharge return anticipated Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 discharged to an acute general hospital. Review of the medical record revealed Resident #119 was admitted to the facility on [DATE] with diagnoses including History of Falling, Hypertension, and Toxic Encephalopathy. Review of a nurse progress note dated 6/15/2026, revealed Resident #119 was transferred to the emergency room while at a physician's office appointment. Further review revealed the resident readmitted to the facility on [DATE]. Review of a discharge return anticipated MDS assessment dated [DATE], revealed Resident #119 discharged to an acute general hospital. Review of a nurse progress note dated 7/15/2026, revealed Resident #119 was transferred to the emergency room. Further review revealed the resident readmitted to the facility on [DATE]. Review of a discharge return anticipated MDS assessment dated [DATE], revealed Resident #119 discharged to an acute general hospital. During an interview on 8/5/2026 at 8:02 AM, the Social Services Director stated she had not notified the ombudsman when any residents were discharged to the hospital or emergency room and confirmed she had not notified the ombudsman when Resident #8 and Resident #119 were transferred to the hospital. During an interview on 8/5/2026 at 3:37 PM, the Director of Nursing confirmed the ombudsman had not been notified of any resident emergency discharges and stated it was her expectation for the ombudsman to be notified.

Based on facility policy review, facility document review, medical record review, and interviews the facility failed to protect 1 resident (Resident #4) from Misappropriation of 32 residents reviewed for abuse. Review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 4/1/2026, revealed .It is the policy of this facility to identify abuse, neglect, and exploitation of residents and misappropriation of resident property .The resident has the right to be free from .misappropriation of resident property .Misappropriation of resident property .is defined as the deliberate .use of a resident's property or money without the resident's consent .Resident's property includes .Unauthorized .purchases on a resident's credit card . The findings include: Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Cerebral Infarction affecting the Right Dominant Side and Congestive Heart Failure. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of a police report dated 5/1/2026, revealed .On 4/11/2026 .employee [Certified Nursing Assistant] (CNA) [H] .stated he stole the credit card to buy items for his child .[Resident #4] decided not to press charges for Theft . Review of a facility document titled Witness Interview/Statement Form, dated 4/11/2026, revealed .I [CNA H] took [Resident #4's] debit card about 2 weeks using it to provide for my family. I did talk to [Resident #4] and confessed to my wrong doing and she [Resident #4] understood . During an interview on 8/3/2026 at 2:25 PM, Resident #4 stated CNA H had stolen her debit card and charged over $800. Resident #4 stated the facility had replaced her money and she did not press charges against CNA H. During an interview on 8/4/2026 at 3:30 PM, the Regional [NAME] President confirmed CNA H had taken Resident #14's debit card, charged approximately 800 dollars, and was terminated from the facility. During a telephone interview on 8/4/2026 at 8:58 PM, CNA H confirmed he had taken Resident #14's debit card without her knowledge and made several purchases for his family which totaled over $800. During an interview on 8/5/2026 at 7:58 AM, the Staff Development Coordinator (SDC) stated she worked on 4/11/2026 when CNA H reported he had taken Resident #14's debit card without her knowledge and made multiple purchases.

Based on facility policy review, observation, and interview, the facility failed to maintain a clean, homelike environment for 5 residents (Resident #8, Resident #20, Resident #39, Resident #92, and Resident #96) of 15 residents reviewed for homelike environment.The findings include: Review of the facility policy titled, Housekeeping Services, revised 7/21/2026, revealed .Clean and disinfect low-touch surfaces on a routine basis and as needed .include walls, curtains, and blinds .Privacy curtains should be laundered between residents . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including History of Falling, Hypertension, and Crohn's Disease. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, and Obstructive Sleep Apnea. Review of a quarterly MDS assessment dated [DATE], revealed Resident #20 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, and Generalized Muscle Weakness. Review of a quarterly MDS assessment dated [DATE], revealed Resident #39 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the medical record revealed Resident #92 was admitted on [DATE] with diagnoses including Major Depressive Disorder and Multiple Sclerosis. Review of a quarterly MDS assessment dated [DATE], revealed Resident #92 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the medical record revealed Resident #96 was admitted on [DATE] with diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Generalized Muscle Weakness, and Hypertension. Review of a quarterly MDS assessment dated [DATE], revealed Resident #96 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. During an observation on 8/3/2026 at 12:08 PM and on 8/4/2026 at 10:07 AM, in Resident 96's room revealed the privacy curtain had multiple areas of an unknown brown substance. During an observation on 8/3/2026 at 12:15 PM and on 8/4/2026 at 10:10 AM, in Resident #20 and Resident #39's room revealed the privacy curtains had multiple areas of an unknown brown substance. During an observation on 8/3/2026 at 12:40 PM and on 8/4/2026 at 10:17 AM, in Resident #8 and Resident #92's room revealed the privacy curtains had multiple areas of an unknown brown substance. During an interview on 8/5/2026 at 3:07 PM, the Environmental Services Director stated he had not washed the privacy curtains since last year and did not wash the privacy curtains when a resident was discharged and another resident was admitted to the same room. During an interview on 8/5/2026 at 3:13 PM, the Director of Nursing stated it was her expectation the privacy curtains in the residents' rooms to be washed when visibly soiled and when a resident discharged from the facility and another resident was admitted to the same room.

Based on facility policy review, medical record review, and interview, the facility failed to obtain consent for psychotropic medication use for 2 residents (Resident #15 and Resident #109) of 5 residents reviewed for psychotropic medication use. The findings included: Review of the facility's policy titled, Psychotropic Medication Informed Consent Policy, dated 2/17/2026, revealed .The facility will obtain consent or refusal to the use of Psychotropic Medications .This documentation will reflect the intended or actual benefit is understood by the resident and, if appropriate, his/ her family and/ or representative(s) and is sufficient to justify the potential risk(s) or adverse consequences associated with the selected medication, dose, and duration . Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Delusional Disorders, Anxiety, Insomnia, Dementia, Delirium, and Visual Hallucinations. Review of a Physician's order for Resident #15 dated 5/11/2026, revealed .Mirtazapine [a medication used to treat Depression] Give 1 tablet by mouth at bedtime .Start Date 5/11/2026 . Review of a Medication Administration Record (MAR) for Resident #15 dated 7/1/2026 through 8/4/2026, revealed Mirtazapine 15mg was administered daily. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 was severely impaired for daily decision making. Further review revealed the resident had the following active diagnoses Non-Alzheimer's Dementia, Anxiety, Psychotic Disorder, Insomnia, Delirium, and Visual Hallucinations. Continued review revealed the resident received an antidepressant during the 7 day look back period. Review of the medical record for Resident #15, revealed a consent for the use of mirtazapine 15mg had not been obtained. Review of the medical record revealed Resident #109 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Diabetes Mellitus, Dementia, and Osteoarthritis. Review of a Physician's order for Resident #109 dated 5/1/2026, revealed .Mirtazapine .Give 1 tablet by mouth at bedtime for depression and poor appetite .Start Date 5/1/2026 . Review of a MAR for Resident #109 dated 7/1/2026 through 8/4/2026, revealed Mirtazapine 7.5 mg was administered daily. Review of a quarterly MDS assessment dated [DATE], revealed Resident #109 scored a 3 on the Brief Interview for Mental status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident had an active diagnosis of Non-Alzheimer's Dementia. Continued review revealed the resident was receiving Antianxiety and Antidepressant medications. Review of the medical record for Resident #109, revealed a consent for the use of Mirtazapine had not been obtained. During an interview on 8/5/2026 at 3:50 PM, the Assistant Director of Nursing Services (ADNS) confirmed a psychotropic medication consent had not been obtained for Resident #15 and Resident #109 prior to the initiation and administration of the Mirtazapine. During an interview on 8/5/2026 at 4:28 PM, the DON (Director of Nursing) confirmed it was the facility's expectation to have psychotropic medication consents obtained prior to the administration of any psychotropic medications.

Based on facility policy review, observation, and interview, the facility failed to provide dignity during mealtime for 1 resident (Resident #3) of 8 residents reviewed during meals. The findings include: Review of the facility's policy titled, Dignity, dated 5/6/2019, revealed .The resident has a right to be treated with respect and dignity .promoting resident independence and dignity while dining, such as avoiding .staff standing over residents while assisting them to eat . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction Affecting Left Non-Dominant Side, Dementia, and Generalized Anxiety Disorder. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 0 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment and was dependent with eating. During an observation during lunch on 8/5/2026 at 12:26 PM, revealed Resident #3 lying in bed, while Unit Coordinator E was observed standing over the resident assisting with the lunch meal. During an observation and interview on 8/5/2026 at 12:28 PM, Licensed Practical Nurse (LPN) C observed Unit Coordinator E standing and assisting Resident #3 with the lunch meal. LPN C confirmed when staff provide assistance to the residents with meals, the staff should be seated and at eye level with the resident. During an interview on 8/5/2026 at 4:33 PM, the Director of Nursing stated it was her expectation for staff to be seated beside a resident when assisting the resident with meals to promote dignity.

Based on facility policy review, review of manufacturer guidelines, medical record review, observation, and interview, the facility failed to store insulin pens appropriately on 1 medication cart of 3 medication carts observed for medication storage.The findings include: Review of the facility's policy titled, Storage and Expiration Dating of Medications and Biologicals, dated 6/30/25, revealed .Once any medication .is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications .Facility staff should record the date opened on the primary medication container .when the medication has a shortened expiration date once opened . Review of manufacturer guidelines, dated 2023, revealed .Storage of Product .Upon opening, all pens should be dated .Storage Conditions for Insulin Aspart [medication used to treat diabetes] .Opened .Room Temperature .28 days .Storage conditions for .Lantus (Glargine) [medication used to treat diabetes] .Opened .Room Temperature .28 days . During an observation of medication cart (South Back #2 Cart) on 8/4/2026 at 7:45 AM, revealed 1 opened Glargine Insulin 100 UNIT/Milliliter (ML) Flexpen, stored at room temperature and 2 opened Insulin Lispro 100 UNIT/ML pens, stored at room temperature. The insulin pens had not been dated when opened. During an interview on 8/4/2026 at 7:50 AM, RN (Registered Nurse) B confirmed the Insulin Glargine and Insulin Lispro were opened, stored at room temperature, and undated.

Based on facility policy review, Resident Assessment Instrument (RAI) Manual 3.0 review, medical record review, and interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 1 resident (Resident #1) of 3 residents reviewed for MDS assessments. The findings include: Review of the facility's policy titled, Certification of Accuracy of the MDS, reviewed 9/05/2024, revealed .the assessment must accurately reflect the resident status . Review of the RAI Manual 3.0 dated 10/2024, revealed .Section M .Skin Conditions . Document the risk, presence, appearance, and change of pressure ulcers as well as other skin ulcers, wounds or lesions . Medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnosis including Dementia, Delusional Disorders, Malignant Neoplasm of Skin, Diabetes Mellitus with Chronic Kidney Disease, Stage 5 Chronic Kidney Disease, Peripheral Vascular Disease, and Dependence on Renal Dialysis. Review of the Nursing Progress Notes for Resident #1 dated 12/10/2024, revealed .[name of resident son] notified of right heel pressure wound, tx [treatment plan] and interventions in place . Review of the Nursing Progress Notes for Resident #1 dated 1/4/2025, revealed .Nurse Aide notified this nurse that resident has an open wound to his left heel which she found when bathing him this morning . Review of an Annual MDS assessment for Resident #1 dated 1/28/2025, revealed the right and left heel wounds were not documented in Section M for skin conditions of the MDS. During an interview on 2/13/2025 at 11:48 AM, the Director of Nursing (DON) confirmed the Annual MDS assessment for Resident #1 dated 1/28/2025 was not an accurate assessment and did not note the wounds on Resident #1.

Based on facility policy review, observations, and interview the facility failed to maintain a sanitary kitchen which had a potential to effect 114 of 116 residents of the facility. The findings include: Review of the facility policy titled, Sanitation and Maintenance, revised 11/4/2022, showed .Director of Food and Nutrition Services is responsible for ensuring that the department is maintained according to the standards of sanitation and in compliance with federal, state and local requirements . All dishes, pots and pans must be air dried after sanitizing and should not be stored wet to prevent wet nesting. During an observation of the kitchen on 3/28/2023 at 11:09 AM, showed the following cooking pans were stacked and stored wet: -6 full size pans, -4 1/3 size pans -8 1/6 size pans. During an interview on 3/28/2023 at 11:09 AM, the Certified Dietary Manager (CDM) confirmed the washed pans had been stacked and stored wet in a unsanitary manner in the facility kitchen.

Based on facility policy review, record review, observation and interview, the facility failed to obtain the most recent Hospice plan of care for 1 resident (Resident #319) of 3 residents reviewed for Hospice services. The findings include: Review of the facility's policy titled, Hospice Coordination of Care, reviewed 8/18/2022, showed, .Each LTC [long term care] facility .designate a member of .interdisciplinary team .to coordinate care to the resident .Obtaining the following .from the hospice .most recent hospice plan of care .Each LTC facility providing hospice care .must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #319 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Alzheimer's Disease and Congestive Heart Failure. Review of physician's orders showed Resident #319 was admitted to Hospice care on 3/18/2023. Review of a care plan dated 3/22/2023 showed the resident had dehydration or potential fluid deficit related to a decline in health and resident was placed on hospice. Record review on 3/27/2023 at 4:27 PM, showed a hospice tab was available for Hospice staff to record interactions with the resident on Resident 319's chart. The record did not have documentation of hospice or a Hospice care plan in Resident #319's chart. During an interview on 3/28/2023 at 3:42 PM, the Assistant Director of Nursing (ADON) confirmed there was no hospice documentatoin or hospice care plan in Resident #319's medical record. The ADON stated hospice communication was to be documented between the Hospice provider and the facility, and she a copy of the hospice care plan for facility staff to reference in the resident's medical record to provide care needs.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medical information was not visible for 2 residents (#56 and #84) of 38 residents reviewed for dignity. The findings include: Review of the facility's policy titled, Safeguarding Posted PHI, revised on 4/15/2022, showed .Protected health information (PHI) is not posted or displayed in a public location .A resident or his/her personal representative may make a request to have PHI posted in the room. It is acceptable to accommodate this request; the request should be documented in the medical record .PHI intended for viewing by staff involved in resident care is not displayed by any means that might be viewed by visitors or staff who would normally not have access to the protected information . Review of the facility's policy titled, Resident Rights, reviewed on 10/6/2022, showed .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life .The resident has a right to personal privacy and confidentiality of his or her personal and medical records .The resident has a right to secure and confidential personal and medical records . Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Persistent Vegetative State, Contracture to Right and Left Wrist, Other Lack of Coordination, Chronic Pain, Osteoarthritis, Anxiety Disorder, Anoxic Brain Damage, Gastrostomy, Seizures, and Muscle Weakness. Review of Resident #56's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #56 had severely impaired cognitive skills for daily decision making. Review of Resident #56's Comprehensive Care Plan showed no documentation that Resident #56 or Resident #56's family had requested for the sign to be posted in the resident's room. During observations on 3/27/2023 at 12:42 PM, 3/27/2023 at 3:26 PM, and 3/28/2023 at 8:54 AM, a sign was posted on the wall across from Resident #56's bed which read, .[Resident #56's room number and bed location] .Has a cushion that needs to be put into chair when up in Chair on (Monday), (Wednesday), (Friday) + [and] (Saturday) .Thanks . The sign was visible to anyone who entered the room. During an interview on 3/28/2023 at 2:48 PM, the Director of Nursing (DON) stated it was the expectation of the facility that resident care needs were communicated to staff on the Care Plan or Kardex. The DON stated signage which contained resident care information was not to be posted in resident rooms unless requested by the resident or family and approved by the Interdisciplinary Team. Signage approved to be posted was to be documented on the Care Plan. The DON stated signage posted in resident rooms that contained information about the resident's care was a dignity concern. During an observation and interview on 3/28/2023 at 2:53 PM with the DON, in Resident #56's room showed a sign posted on the wall across from Resident #56's bed that read, .[Resident #56's room number and bed location] .Has a cushion that needs to be put into chair when up in Chair on (Mon, Wed, Fri + Sat .Thanks) . The DON confirmed the signage was visible to anyone who entered the room. Resident #56's roommate had a visitor in the room at the time of the observation. During a telephone interview on 3/28/2023 at 3:47 PM, Resident #56's responsible party stated she had not requested any signage to be posted in Resident #56's room. Resident #56's responsible party stated someone from the facility .called today . and asked for permission to post the sign. Resident #84 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Nontraumatic Subarachnoid Hemorrhage From Basilar Artery, Osteoarthritis, Dementia, Contracture of Muscle of Left Thigh Muscle, Left Ankle and Foot, Left Lower Leg, Left Hand, Left Forearm, and Left Upper Arm. Review of Resident #84's significant change MDS assessment dated [DATE], showed Resident #84 scored a 5 on the Brief Interview for Mental Status (BIMS), indicating the resident was severely cognitively impaired. Review of Resident #84s Comprehensive Care Plan showed no documentation that Resident #84 or Resident #84's family had requested for the sign to be posted in the resident's room. During observations on 3/27/2023 at 12:30 PM and 3/28/2023 at 8:58 AM, a sign was posted on the mirror across from Resident #84's bed which read, .Splint to be worn 6-8 (hours) a day .Carrot splint when splint removed + at Night .Thanks .Rehab . The sign was visible to anyone who entered the resident's room. During an interview on 3/27/2023 at 12:30 PM, Resident #84 stated she did not request for the sign to be posted. During an observation and interview on 3/28/2023 at 2:55 PM, in Resident #84's room, there was a sign posted on the mirror across from Resident #84's bed that read, .Splint to be worn 6-8 hrs a day .Carrot splint when splint removed + at Night .Thanks .Rehab . The DON confirmed the sign was visible to anyone who entered the resident's room. During a telephone interview on 3/28/2023 at 3:52 PM, Resident #84's emergency contact stated she did not request any signage be posted in the Resident #84's room. Resident #84's emergency contact stated .they called me today . and asked if it was ok for the sign to be posted. During an interview on 3/28/2023 at 4:09 PM, the DON confirmed after surveyor inquiry the facility had contacted Resident #56 and #84's families today (3/28/2023) for permission for the signs to be posted.

Based on observation and interview, the facility failed to post daily staffing for 1 of 3 days reviewed for residents in the facility. The findings include: An observation on 3/27/2023 at 10:10 AM, showed the daily staffing sheet, displayed in the facility lobby, was dated 3/24/2023. During an interview on 3/27/2023 at 10:20 AM, the Assistant Director of Nursing confirmed the daily staffing sheet was dated 3/24/2023 and did not reflect the staffing on 3/27/2023. During an interview on 3/28/2023 at 8:49 AM, the Director of Nursing (DON) stated the facility census and staffing was to be printed and posted daily.

Based on facility policy review, review of Quality Assurance Performance Improvement (QAPI) documents, medical record review, and interview, the facility's QAPI committee failed to monitor facility identified ongoing concerns with obtaining accurate weights and nutritional supplements for residents with significant weight loss for 3 residents (Resident #1, Resident #2, and Resident #5) of 6 residents reviewed for nutrition. The findings include: Review of a facility policy Performance Improvement Projects (PIPs) dated 12/28/2020, showed .the facility will conduct Performance Improvement Projects .designed with a systemic approach to improve care and services in areas that are identified as an opportunity for improvement. These PIPs will address systemic changes, increase efficacies and associate improvement across all departments to have a positive impact on the quality of life and care of the residents .these Performance Improvement Projects will assist the facility in assessing and determining the effectiveness of the Quality Assurance Performance Improvement Activities . Review of a Quality Assurance/Performance Improvement Plan (PIP) Weight Monitoring dated 4/8/2020, revealed a PIP had been developed after it was identified that the facility had an opportunity for improvement with weight monitoring .to identify all active residents with a significant weight loss or weight gain . The facility PIP included the Registered Dietician (RD) would complete Nutrition Assessment Recommendations and give to the Director of Nursing (DON) to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a complaint survey conducted from 3/22/2021-3/29/2021, deficient practice was identified for the facility's failure to provide an ordered/recommended nutritional supplement for 3 residents (Resident #1, Resident #2, and Resident #5) with significant weight loss, failure to obtain daily weights for Resident #1 and weekly weights for Resident #2, and failure to revise the care plan to address significant weight loss for 3 residents (Resident #1, Resident #2, and Resident #5). During a telephone interview with the DON on 3/29/2021 at 1:10 PM, he confirmed he is part of the QAPI Committee and a weight monitoring action plan was presented to QAPI last year, with the components followed up on and discussed during their monthly meetings.Weights is an issue we do continue to discuss .during QAPI .discuss how plan is progressing .PIP on weights continues .we lost our restorative program .in October .nurses on the units should be checking them [weights] .do not see [anyone] specifically assigned to see those process were completed .a component is missing . The DON confirmed the facility QAPI committee identified an opportunity for improvement related to weight monitoring on 4/8/2020 but failed to implement ongoing monitoring to ensure residents at risk or with actual weight loss obtained accurate weights as ordered and received the recommended/ordered nutritional supplement. Refer to F-657 and F-692

Based on review of facility policy, medical record review, and interview, the facility failed to revise the care plan for 1 resident (Resident #1) with a newly developed pressure ulcer, and failed to revise the care plan for 3 residents (Resident #1, Resident #2, and Resident #5) with significant weight loss of 6 residents reviewed. The findings include: Review of a facility policy Resident at Risk Meeting (RAR) Revised 1/22/2019, showed .This facility conducts a weekly resident at risk meeting to review the residents who have been identified with nutritional and/or hydration problems/concerns or who have an identified risk factor that may lead to nutritional/hydration issues .The care plan is updated during the meeting. Interventions should be specific and individualized and dated . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident was severely cognitively impaired and required extensive assistance with 2 or more staff members for activities of daily living (ADLs). Resident #1 required supervision and tray set up for eating. Review of Resident #1's Weights and Vitals Summary dated 11/17/2020-1/16/2021, showed from 11/23/2020-12/24/2020, Resident #1 lost 43.8 pounds (lbs) and had a 22.2% weight loss in 30 days. Review of Resident #1's Wound Observation Tool dated 1/6/2020, showed the resident acquired a stage 2 pressure ulcer to his left outer ankle. Resident #1's comprehensive care plan dated 11/17/2020, showed Resident #1 was at risk for weight fluctuations due to his health status and had a pressure wound to his .buttock . There was no revision for the significant weight loss occurring 11/23/2020-12/24/2020, updated nutritional approaches were not documented, and there were no updates for the newly developed stage 2 left ankle pressure ulcer on 1/6/2021. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's comprehensive MDS assessment dated [DATE], showed the resident had a Brief Interview for Mental Status Score of 11, indicating moderate cognitive impairment. Resident #2 required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and required set up assistance with eating. Review of Resident #2's Weight and Vitals Summary dated 12/28/2020-3/4/2021, showed between 1/13/2021 and 2/19/2021, Resident #2 lost 33 lbs. and had 22.9% weight loss. Review of Resident #2's comprehensive care plan dated 12/29/2020 and revised 1/5/2021 showed the resident had a nutrition problem or potential nutritional problem and there was no revision for significant weight loss occurring 1/28/2021-2/3/2021, and no updates for nutritional approaches to address weight loss. Medical record review showed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Weight and Vitals Summary dated 12/10/2020-3/22/2021, showed on 12/30/2020, the resident weighed 132.4 and on 1/5/2021, the resident weighed 127.1, a 7.2% weight loss in 1 week. Review of Resident #5's comprehensive care plan dated 12/21/2020, showed the resident had a nutritional problem or potential nutritional problem related to stroke, [CONDITION(S)] (partial paralysis), dysphagia (difficulty in swallowing), diuretic use, and a mechanically altered diet. There was no revision for the significant weight loss that occurred between 12/30/2020 and 1/5/2021, and no updates for nutritional approaches to address weight loss. During an interview with the Director of Nursing (DON) on 3/28/2021 at 1:10 PM, the DON stated it would be his expectation care plans would be updated with significant changes and the facility did not revise Resident #1, Resident #2, and Resident #5's care plan to reflect the significant weight loss and new nutrition interventions, and did not revise Resident #1's care plan to reflect a newly developed Stage 2 pressure injury.

Based on review of facility policy, medical record review, observations and interviews, the facility failed to order a nutritional supplement recommended by the Registered Dietician (RD) for 2 residents (Resident #1 and Resident #5); failed to follow a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #2) of 6 residents reviewed for nutrition. The findings include: Review of a facility policy Resident at Risk Meeting (RAR) Revised 1/22/2019 showed .This facility conducts a weekly resident at risk meeting to review the residents who have been identified with nutritional and/or hydration problems/concerns or who have an identified risk factor that may lead to nutritional/hydration issues .The review list includes but is not limited to the following: New admissions for a minimum of one week .Residents with significant weight change- 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. Residents with unplanned gradual weight loss (insidious weight loss) such as: 6% in 180 days, 15% in 270 days, 20% in 365 days. Residents with declining intake that has decline for 3 consecutive days from usual intake and residents with intake of 25% or less . Review of a facility policy Nutrition/History Assessment and the Resident Assessment Instrument (RAI) dated 10/4/2019 showed .Each resident receives a comprehensive nutrition assessment to determine nutritional needs on admission, annually and when the resident becomes at risk for compromised nutritional status .The resident's nutritional status is updated as it changes, but no less than quarterly .A systematic approach will be used to optimize a resident's nutritional status. The process includes identifying and assessing each resident's nutritional status and risk factors, evaluating/analyzing the assessment information, developing and consistently implementing pertinent approaches and monitoring the effectiveness of interventions and revising them as necessary . Review of a facility policy Weights and Heights reviewed 5/5/2020, showed .All residents are weighed within 24 hours of admission and weekly for 4 weeks and as needed thereafter or more as determined by the RAR (Resident at Risk) committee and/or physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident was severely cognitively impaired and required extensive assistance with 2 or more staff members for activities of daily living (ADLs). Resident #1 required supervision and tray set up for eating. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Daily weight r/t [related to] HF [heart failure] . Review of Resident #1's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Weights and Vitals Summary dated 11/17/2020-1/16/2021, showed from 11/23/2020-12/24/2020, Resident #1 lost 43.8 pounds (lbs) and had a 22.2% weight loss in 30 days. Review of Resident #1's Interdisciplinary Team (IDT) Progress Notes dated 12/16/2020 and 12/29/2020, showed the meeting notes indicated the resident was on .Med Pass [nutritional supplement] 2.0 90 mL [milliliters] BID [twice a day] . Review of Resident #1's EMAR dated 12/1/2020-12/31/2020 showed no documentation the 2.0 Med Pass 90 ml was administered twice a day. Medical record review showed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's comprehensive MDS assessment dated [DATE] showed the resident had a Brief Interview for Mental Status Score of 11, indicating moderate cognitive impairment. Resident #2 required extensive assistance with bed mobility, transfer, dressing, toilet use personal hygiene, and required set up assistance with eating. Review of Resident #2's Weight and Vitals Summary dated 12/28/2020-3/4/2021, showed no recorded weekly weight for the following weeks: 1/3-1/9/2021, 1/17-1/23/2021, 2/10-2/16/2021, and 3/7-3/13/2021. Continued review showed between 1/13/2021 and 2/19/2021, Resident #2 lost 33 lbs. and had 22.9% weight loss. Review of Resident #2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #2] because of chronic problems including hypertension and [CONDITION(S)] .current weight 111 [pounds] on February 9 admission weight 134 [pounds] on December 28 .Discussed with dietary possible supplements I plan to start med Pass [Med Pass] today 2 calorie med Pass 60 ml twice daily and reevaluate . Review of Resident #2's Order Summary Report dated 12/28/2020 - 3/17/2021 showed .2 -calorie med pass 60 mL twice daily . Review of Resident #2's EMAR dated 2/1/2021-2/28/2021, showed no documentation the 2 calorie Med Pass was administered twice daily. Review of Resident #2's IDT Notes dated 2/4/2021-3/16/2021 showed the resident was followed in the at-risk meeting and was to have weekly weights. Medical record review showed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's admission MDS assessment dated [DATE] showed the resident was moderately cognitively impaired and required extensive assistance of 1 staff member for ADLs, including eating. Review of Resident #5's Weight and Vitals Summary dated 12/10/2020-3/15/2021, showed on 12/30/2020, the resident weighed 132.4 lbs and on 1/5/2021 the resident weighed 127.1 lbs, a 7.2% weight loss in 1 week. Review of an RD Progress Note dated 1/22/2021, showed she was consulted for Resident #5's 7.2% weight loss. Continued review showed a recommendation was made for .med pass 2.0-60mL BID r/t decreased PO [oral] intake .to assist in meeting ENN [expected nutritional needs] . Review of the Order Summary Report for Resident #5 dated 12/10/2020-3/22/2021, showed there was no order for Med Pass 2.0. Review of Resident #5's EMAR dated 12/2020-2/28/2021 showed Med Pass 2.0 was not administered. During a telephone interview with the Medical Director (MD) on 3/25/2021 at 1:15 PM, he confirmed he did not disagree with the supplement recommendations made by the IDT Team and Registered Dietician for Resident #1, Resident #2, or Resident #5 .apparently we need to have a process in place that someone is recommending something . During a telephone interview with the RD on 3/26/2021 at 12:53 PM, she confirmed .[nursing] recommendations are given to the DON [Director of Nursing] and dietary recommendations are given to the CDM [Certified Dietary Manager] at the end of my visit. I keep a copy and give the copy to the DON for nursing recommendations and the CDM for dietary recommendations .Yes I made a recommendation for med pass 90mL BID [for Resident #1] .I made a mistake .I wrote it in my notes but it was not included on the recommendation [sheet] . During an interview with the DON on 3/28/2021 at 1:10 PM, the DON stated the IDT Team can make recommendations for oral nutritional supplements. Resident #1 was discussed during IDT meetings but the DON did not recall seeing a Med Pass recommendation. The DON was unsure why the recommendation for Med Pass made for Resident #5 by the RD was not ordered. The DON confirmed Resident #2's order for Med Pass on 2/18/2021 was written by the physician, and when the nurse confirmed the order, the supplement was not marked correctly and did not transfer to the EMAR. The DON confirmed Resident #2 did not receive 2.0 Med Pass 60 ml twice daily as ordered from 2/18/2021 - 2/26/2021.

Based on facility policy review, observation, and interview, the facility failed to dispose of expired medications and supplies in 2 medication storage rooms (South Wing and West Wing) of 3 medication storage rooms observed. The findings include: Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biological, Syringes and Needles, revised 4/5/2019, showed .Facility should destroy or return all .outdated/expired .medications .Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis . During an observation of the South wing medication storage room and interview with Licensed Practical Nurse (LPN) #1 on 2/20/2020 at 9:42 AM, showed 7 wound culture swabs with an expiration date of 12/27/2019, 98 urine chemistry test strips (used to test the urine for possible infection) with an expiration date of 12/31/2019, and 5 unopened 5 milliliter vials of influenza vaccine with an expiration date of 5/31/2019. LPN #1 confirmed the above items were expired and were available for resident use. Observation of the West wing medication storage room and interview with LPN #2 on 2/20/2020 at 10:14 AM showed 4 [MEDICAL CONDITION] flanges (device used to hold a [MEDICAL CONDITION] bag) with an expiration date of 12/2018, 100 [MEDICATION NAME] plastic cannulas (needle free device used with intravenous injections) with an expiration date of 12/2019, and 42 [MEDICATION NAME] syringes with an expiration date of 4/2019. LPN #2 confirmed all above items were expired and were available for resident use. During an interview on 2/20/2020 at 10:27 AM the Director of Nursing stated it is his expectation for the medication storage rooms to be checked routinely and for all expired items to be discarded immediately.

Based on medical record review, observation, review of the facility investigation, review of facility policy, and interview, the facility failed to provide supervision and the correct dining environment for one Resident (#10) of sixteen Residents reviewed. The facility's failure to ensure Resident #10 was placed in the correct dining environment with supervision resulted in the Resident choking and aspirating food, requiring emergency rescue measures, transfer to the hospital emergency room , and admission to the Critical Care Unit on [DATE], and death on [DATE]. The facility's failure placed Resident #10 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a Resident). The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room on [DATE], at 2:15 p.m. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment, with a score of three out of fifteen. A score of three revealed the Resident's cognition was severely impaired. Medical record review of the Physician's Recapitulation Orders dated [DATE] - 30, 2012, revealed orders for a mechanical soft diet and liquids in a two-handled cup. Observation of the Resident on [DATE], at approximately 1:05 p.m., in the West Day Room, revealed a meal tray was on a table directly in front of the Resident and the Resident was eating, independently and unsupervised. Continued observation at approximately 1:20 p.m., revealed the Resident was non-responsive to verbal stimuli, the body was limp, face was pale, and the lips were blue. The Resident's chest was still and then the mouth opened and closed, with a silent gasp. During the gasp a large amount of food could be seen in the Resident's mouth. Immediate observation of the West Day Room, the two West Hallways adjacent to the West Day Room, and the West Nursing Station directly across from the West Day Room revealed no staff were present and/or supervising the Resident while eating. A visitor came out into the West Hallway from a Resident's room (located between the West Day Room and the Sun Room Bistro). The surveyor informed the individual a nurse was needed immediately. As the visitor ran up the West Hallway to get a nurse, Licensed Practical Nurse (LPN) #1 came out into the West Hallway from a Resident's room (located between rooms 319 and 323). The visitor informed LPN #1 assistance was needed in the West Day Room. LPN #1 ran to the West Day Room; the Resident was not breathing and food was spilling from the Resident's mouth. LPN #1 did a finger-sweep and removed more food from the Resident's mouth and initiated the Heimlich Maneuver (abdominal thrusts applied as an emergency response to clear an obstructed airway of a person that is choking); as LPN #1 applied abdominal thrusts, food was expelled from the Resident's mouth. LPN #2 arrived and began to assist LPN #1. With several additional abdominal thrusts, the Resident took some irregular breaths; but the breathing was not ongoing or spontaneous. LPN #1 and #2 transported the Resident to the Resident's room. The Director of Nursing began applying abdominal thrusts, and was relieved by Registered Nurse (RN) #1, who applied several abdominal thrusts. LPN #1 suctioned the Resident's mouth and obtained a small amount of food particles. Oxygen was applied to the Resident at four liters per minute using a nasal cannula; the Resident's breathing was irregular and labored. 911 had been called during the onset of the emergency; the Emergency Medical Services (EMS), arrived within minutes, assumed control of the situation, and transported the Resident to the hospital emergency room (ER). Review of a facility investigation dated [DATE], with "lunch" in parenthesis, revealed, "...Summary of Investigative Facts: Resident found by State Surveyor choking in West Wing Day Room. Recommendations/Actions Taken: Resident given Heimlich Maneuver, 911 called, transport to hospital..." Review of a written statement dated [DATE], by the Assistant Activities Director, revealed, "I rolled (Resident) down to the "Day Room" on West Wing and gave (Resident) a lunch tray." Review of a written statement dated [DATE], by LPN #1, revealed, "...I was coming out of a Resident room...told me someone needed me toward the day room, the lady that I knew to be from the State, said I was needed...(Resident) was at table and appeared to be choked, had food coming out of mouth, appeared not to be breathing. Started Heimlich, got food out of mouth, pt (Patient) took breath, done Heimlich several more times, got food out...took some breaths...took Resident to room...suctioned Resident, got small amount of food out..." Review of a written statement dated [DATE], at 3:50 p.m., by LPN #2, revealed, "...I was in the office on West Wing charting when I overheard someone repeatedly calling a resident's name. I came out of the office and saw LPN #1 trying to get the Resident to wake up. I immediately ran over and assisted...Resident was pale...tongue sticking out...unresponsive..." Review of a written statement dated [DATE], at approximately 1:21 p.m., by the Assistant Director of Nursing (ADON), revealed, "...I quickly ran down hallway to (Resident's) room...DON (Director of Nursing) was performing the Heimlich Maneuver. (Resident) was not breathing, pale, and blue around the lips, radial pulse felt and it was steady...LPN #1 began suctioning (Resident)...placed oxygen at four liters...continued Heimlich...began breathing spontaneously, unable to obtain oxygen saturation (the amount of oxygen bound to hemoglobin in the blood, with the normal range being ,[DATE]%) (percent), fingers would not read on either hand. (Resident) began to moan, but no verbal speech...EMS arrived and took over..." Review of the Diet Tray Card, dated [DATE], revealed the Resident's required dining location was "2nd (second) Dining (supervised dining area)." Review of the facility policy "Hydration and Nutrition" dated as revised [DATE], revealed, "...Policy: Nursing staff are assigned to each unit dining room at mealtime to provide supervision of residents while eating...Procedure:...4. An ongoing assessment of ability to consume and assimilate food and fluid by resident is conducted by nursing personnel. Assessment includes:...c. Ability of resident to feed self. d. Ability to chew, drink, and swallow..." Medical record review of a Resident Transfer Record, dated [DATE], (no time) revealed, "...Transferred From: (Nursing Home)...Reason for Transfer: Aspirated on lunch - unresponsive..." Medical record review of the Emergency Department (ED) admission orders ...ICU (Intensive Care Unit)...Diagnosis: [REDACTED]. Medical record review of a Pulmonary/CCU (Critical Care Unit) Progress Note, dated [DATE], at 3:30 p.m., revealed, "...began choking on lunch today, semi-responsive upon EMS arrival, intubated in the field. Continued review on [DATE], at 8:20 a.m., revealed, "...Pt s/p (status [REDACTED]. Medical record review of a Triage Report, dated [DATE], at 4:17 p.m., revealed, "...Complaint: Choking/Aspiration...Triage Notes: Pt choking during lunch, semi-responsive upon EMS arrival, intubated in the field...History of Present Illness:...pt choked during lunch...MD (Medical Doctor) Physical Exam: Pt is intubated...peas are currently being removed...Diagnosis: [REDACTED]. Medical record review of a History - Physical Examination, dated [DATE], at 4:29 p.m., revealed, "...brought to the emergency room ...intubated...resides at (Nursing Home) and apparently aspirated mostly on peas...the patient was brought to the emergency room and remains intubated on the ventilator and apparently there was quite a bit of food matter that was suctioned through the endotracheal tube...Assessment and recommendations:...aspirated while eating and was intubated for respiratory distress..." Medical record review of portable Chest Radiology Reports revealed the following: [DATE]; "...Volume loss right upper lobe, question some endobronchial plugging versus early Pneumonia..." [DATE]: "...Clearing right upper lobe infiltrate..." [DATE]; "...status [REDACTED]. [DATE]; Minimal interstitial infiltrate, primarily in the right upper lobe, superimposed on chronic disease..." Medical record review of a Pulmonary/CCU Progress Note, dated [DATE], at 8:20 a.m., revealed, "...Pt s/p episode of aspiration..." Continued review on [DATE], at 8:21 a.m., revealed, "...Pt s/p aspiration with food...resulting in respiratory failure...may have had some level of anoxic injury during episode of aspiration...consider hospice or palliative care." Continued review on [DATE] at 1:30 p.m., revealed a Hospice consult, "...patient will be admitted ...upon transfer out of CCU to the Hospice Unit..." Medical record review of a Death Record Form dated [DATE], and telephone interview with the Hospital's Release of Information Coordinator on [DATE], at 12:30 p.m., revealed the Resident expired on [DATE], at 8:01 a.m. and a Discharge Summary had not been dictated yet. Interview with the Administrator on [DATE], at 1:40 p.m., in an empty Resident room across from the North Nursing Station, confirmed the Resident was assigned to eat all meals in the second dining, located in the Bistro Sun Room. Continued interview confirmed the resident required supervision during all meals. Interview with LPN #2 on [DATE], at 1:50 p.m., at the West Nursing Station, confirmed, "...Residents are not to be eating in the (West) Day Room because there's no supervision there...(LPN #2) was in an office behind the West Nursing Station...(LPN #2) confirmed...was not watching the Resident eat...I don't know if I could have seen (Resident)...from where I was sitting..." Continued interview confirmed the Resident did require supervision while eating. Interview with LPN #3 on [DATE], at 2:00 p.m., at the North Nursing Station confirmed, "...(Resident) is a second diner in the Bistro Sun Room...requires assistance or to be fed at meals...requires supervision during meals..." Interview with the DON on [DATE], beginning at 2:20 p.m., in the Administrator's Office, and continued in the DON's Office, confirmed, "Resident's are not supposed to eat in the West Wing Day Room due to the lack of supervision. (Resident) eats in the second dining Bistro Sun Room." Interview with RN #2 on [DATE], at 2:40 p.m., in the Conference Room confirmed (Resident) was assigned to the second dining in the Bistro Sun Room for meals. Continued interview confirmed (Resident) had cognitive deficits, required supervision during meals, and was not to be placed in the West Day Room unsupervised for meals. Interview with the Assistant Activities Director on [DATE], at 3:00 p.m., in the Conference Room confirmed the Assistant Activities Director placed the Resident in the West Day Room for lunch, put the lunch tray on the table in front of the Resident to eat, and left. Continued interview confirmed the Assistant Activities Director did not check to make sure staff was in the West Day Room to supervise the Resident's meal, and did not recall any staff present in the West Day Room to supervise the meal. Interview with Speech Language Pathologist (SLP) #1, on [DATE], at 3:45 p.m., by telephone, confirmed Residents assigned to eat in second dining in the Bistro Sun Room required assistance and supervision to eat safely and efficiently. Interview with SLP #2, on [DATE], at 4:05 p.m., in the Conference Room confirmed, "...It is not acceptable to place a Resident assigned to second dining that required supervision in an unsupervised area for meals; it is not safe." Interview with CNA #1, on [DATE], at 6:00 p.m., on the North Hall near the North Nursing Station confirmed the Resident is to be taken to the second dining in the Bistro Sun Room, and stated, "(Resident #10) is not able to eat by (Resident's) self." Interview with LPN #4, on [DATE], at 6:07 p.m., at the North Nursing Station confirmed the Resident eats second dining in the Bistro Sun Room, and stated, "(Resident) does require supervision during meals for safety and a decline in cognition." A second interview with the Assistant Activities Director, in the presence of the DON, on [DATE], at 11:50 a.m., in the Conference Room confirmed, "...I put (Resident) in the West Day Room for lunch...I went to the second dining in the Bistro Sun Room and got the (Resident's) lunch tray from the tray cart, took it to the West Day Room and placed it in front of (Resident) and left...I knew (Resident) was assigned to and ate in second dining in the Bistro Sun Room...and the tray ticket says "second dining"...I don't know why I put (Resident) there...I don't have a clue why I did it." Interview with CNA #2 and #3, on [DATE], at 12:00 p.m., in the Bistro Sun Room, confirmed (Resident) was assigned to eat all meals in the second dining in the Bistro Sun Room. Interview with the DON on [DATE], at 12:10 p.m., in the Bistro Sun Room confirmed, "(Resident) is assigned to the second dining in the Bistro Sun Room because of poor cognition, which does not enable her to make safe decisions." Continued interview with the DON confirmed the facility failed to provide supervision for safety in the correct dining environment for the Resident. In summary, the facility failed to ensure Resident #10 was placed in the Bistro Sun Room for second dining with supervision during lunch on [DATE], resulting in the Resident choking and aspirating food substances, requiring emergency rescue measures, transfer to the hospital emergency room , admission to the Critical Care Unit, and death on [DATE]. The Immediate Jeopardy was effective from [DATE], through [DATE], and was removed [DATE]. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on [DATE]. The surveyor verified the allegation of compliance by: 1. Reviewing the corrective action implemented for the Assistant Activities Director. 2. Reviewing the facility's plan for ensuring Residents are supervised and in the correct dining room. Reviewing the facility's plan for auditing the dining environments to ensure staff is following the plan. Reviewing the facility's in-service records to ensure facility staff have been educated regarding changes to and implementation of the facility's policies "Dining Assignment Best Practice," and "Resident Dining Changes." 3. Conducting interviews with facility staff, to include eight of thirteen nurses, three of nine environmental services, one of two maintenance, two of four activities, one of two social services, nine of twenty-one CNA's, on staff to determine the level of comprehension gained through in-service education conducted regarding changes to and implementation of the facility's policies "Dining Assignment Best Practice," and "Resident Dining Changes" for transporting residents to the correct dining room; supervision of dining and non-dining areas during meals; ensuring correct dining placement upon admission, re-admission, and change of condition. 4. Observation of the dining and non-dining areas during meals to ensure staff supervision and correct dining room placement of the Residents. Non-compliance continues at a "D" level for monitoring corrective actions. The facility is required to submit a plan of correction.