Every finding on record at Life Care Center of Hendersonville

Based on record review and staff interviews, the facility failed to ensure Registered Nurse (RN) coverage was provided for at least 8 consecutive hours per day for 5 of 6 days reviewed (Dates 02/01/25, 02/02/25, 02/09/25, 03/01/25, and 03/02/25). Findings included:Review of the daily nurse staffing sheets and associated time clock reports for the period 01/01/25 through 03/31/25 revealed the facility did not have the required RN coverage on the following dates: 02/01/25, 02/02/25, 02/09/25, 03/01/25, and 03/02/25.During an interview on 08/27/25 at 1:52 PM, the Central Supply Manager revealed she handled the Skilled Nursing staff schedules in January 2025 through March 2025. She stated there were times when no RN was scheduled daily from 8 to 12 hours, although she could not recall specific dates. The Central Supply Manager stated that when there was no RN scheduled for at least 8 consecutive hours, she notified the Former Administrator, and the Former Administrator handled the situation from that point.A telephone interview with the Former Administrator on 08/27/25 at 2:49 PM revealed she was employed at the facility in January 2025 through mid-to-late March 2025 and was aware that there were times when an RN was not scheduled for 8 consecutive hours on weekends. She stated she had a Minimum Data Set (MDS) Nurse who was an RN, work one weekend, and the Treatment Nurse, who was also an RN, work the opposite weekend to ensure there was RN coverage for 8 consecutive hours. The Administrator stated after she implemented having the MDS Nurse and Treatment Nurse working on alternating weekends she was not aware of any issues with not having an RN scheduled for 8 hours a day. She stated she could not recall the date when she implemented placing the 2 RNs on alternating weekends. During an interview with the Regional Director of Clinical Operations on 08/27/25 at 3:54 PM she acknowledged the facility did not have documentation of the required RN coverage on 02/01/25, 02/02/25, 02/09/25, 03/01/25, and 03/02/25. She stated she thought having the MDS Nurse and Treatment Nurse alternate weekends addressed the lack of RN coverage on weekends but there may have been times when there were call-outs or staff worked in a sister facility. The Regional Director of Clinical Operations stated with the change in nursing administration in May 2025 nurse staffing had improved and the facility had sufficient RN staff to ensure required RN coverage was met consistently.

Based on observations, record review, and staff interviews the facility failed to discard expired milk in 1 of 1 walk-in cooler; label and date a food item in 1 of 1 walk-in freezer; label and date open food items and store food off the floor in 1 of 1 dry storage room; maintain a clean and sanitary ice machine for 1 of 2 ice machines; and maintain a clean and sanitary refrigerator in 1 of 2 nourishment rooms (500/600 hall nourishment refrigerator). Findings included:1. An initial observation of the walk-in cooler on 08/24/25 at 9:22 AM revealed a 3/4 full box of 8-ounce cartons of 2% milk with a use-by date of 08/21/25. An interview with the Dietary Manager on 08/27/25 at 9:16 AM revealed the milk should have been used or discarded on or before the use-by date. He stated all dietary staff were responsible for checking for and removing expired food and beverage items. An interview with the Administrator on 08/27/25 at 4:25 PM revealed she expected all food and beverages to be used or discarded on or before the use-by date. 2. An observation of the walk-in freezer on 08/24/25 at 9:28 AM revealed an unlabeled and undated bag of boneless chicken breasts sitting on a shelf. An interview with the Dietary Manager on 08/27/25 at 9:16 AM revealed he expected all food items to be labeled and dated. An interview with the Administrator on 08/27/25 at 4:25 PM revealed she expected all food items to be labeled and dated. 3. An observation of the dry storage room on 08/24/25 at 9:32 AM revealed the following:a. an open and undated bag of powdered sugar sitting on a shelfb. an open and undated bag of graham crackers sitting on a shelfc. three boxes of nutritional supplement stored on the floorAn interview with the Dietary Manager on 08/27/25 at 9:16 AM revealed all opened food items should be labeled and dated by the staff member opening the items and no stock should be stored on the floor. An interview with the Administrator on 08/27/25 at 4:25 PM revealed she expected all open food items to be labeled and dated, and no stock should be stored on the floor. 4. An observation of the ice machine in the dining room on 08/24/25 at 9:40 AM revealed a build-up of gray debris on the left vent. An interview with [NAME] #1 on 08/26/25 at 11:52 AM revealed maintenance was supposed to clean the ice machine. An interview with the Maintenance Director on 08/27/25 at 8:34 AM revealed a contract company de-limed and de-scaled the ice machine quarterly and he was responsible for ensuring the outside of the ice machine was clean. He stated he cleaned the ice machine if dietary staff made him aware of any areas that were visibly dirty, and he had not been informed of any concerns with the ice machine. An interview with the Administrator on 08/27/25 at 4:25 PM revealed she expected the ice machine to be clean and free of debris. 5. An observation of the 500/600 hall nourishment room refrigerator on 08/24/25 at 11:17 AM revealed a large area of a dried white substance with cardboard stuck in the center on the middle shelf of the refrigerator. An interview with the Dietary Manager on 08/27/25 at 9:16 AM revealed he expected dietary staff to clean nourishment room refrigerators when they noticed they were dirty. An interview with the Administrator on 08/27/25 at 4:25 PM revealed she expected the nourishment room refrigerators to be checked daily for cleanliness.

Based on observations, record review, and interviews with the Registered Dietitian (RD) and staff, the facility failed to follow the physician's diet order to provide double portions (Resident #10) and nutritional supplements (Resident #54) for 2 of 4 residents reviewed for nutrition (Resident #10 and Resident #54). Findings included:1. Resident #10 was admitted to the facility 04/28/25 with diagnoses including diabetes and malnutrition. Review of Resident #10's physician orders revealed an order dated 05/09/25 for a mechanical soft diet (a texture modified diet which restricts foods that are difficult to chew or swallow) and double portions. Resident #10's nutrition care plan initiated 05/16/25 revealed he had a nutritional problem related in part to malnutrition and diabetes. Interventions included having the Registered Dietitian (RD) evaluate and make diet changes as needed and providing and serving Resident #10's diet as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was severely cognitively impaired and received a mechanically altered diet. The MDS assessment further indicated he had a weight loss of 5% or more in the last month or weight loss of 10% or more in the last 6 months. An observation of Resident #10's lunch meal ticket on 08/24/25 at 11:59 AM revealed he was to receive a mechanically altered diet with double portions. An observation of Resident #10's meal tray at the same date and time revealed he received a large serving of mashed potatoes and cooked carrots and one small scoop of beef on his plate. An interview with Nurse Aide #1 on 08/24/25 at 11:59 AM revealed she set-up Resident #10's meal tray and did not notice he did not receive a double portion of beef. An observation of Resident #10's lunch meal with [NAME] #1 on 08/24/25 at 12:00 PM revealed he did not receive a double portion of beef on his meal tray. She stated double portions were considered to be 2 servings of a food item. [NAME] #1 stated she was working as a dietary aide on 08/24/25 and was responsible for checking meal trays for accuracy and she overlooked providing Resident #10 with a double portion of meat. An interview with the Dietary Manager on 08/27/25 at 9:16 AM revealed he expected residents to receive double portions as ordered. A telephone interview with the Registered Dietitian (RD) on 08/27/25 at 10:39 AM revealed she made a recommendation for Resident #10 to receive double portions as an intervention for weight loss. She stated she expected residents to receive double portions as ordered. An interview with the Administrator on 08/27/25 at 4:25 PM revealed she expected residents to receive double portions as ordered. 2. Resident #54 was admitted to the facility 11/18/16 with a diagnosis of stroke. Resident #54's nutrition care plan last revised 04/10/25 revealed she was at risk for weight fluctuation related to her current health status and interventions included providing assistance with meals as needed and providing supplements as ordered. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was severely cognitively impaired and did not have weight loss. Review of Resident #54's physician orders revealed an order dated 08/13/25 for a frozen nutritional supplement two times a day to promote weight stability.An observation of Resident #54's lunch meal ticket on 08/24/25 at 12:33 PM revealed she was to receive a 4-ounce frozen nutritional treat. An observation of Resident #54's meal tray at the same date and time revealed the frozen nutritional treat was not provided with her lunch meal. An interview with [NAME] #1 on 08/24/25 at 12:43 PM revealed the kitchen was out of frozen nutritional treats and she was unsure how long the facility had been out of the supplement. An additional observation of Resident #54's lunch meal ticket on 08/25/25 at 12:33 PM revealed she was to receive a 4-ounce frozen nutritional treat. An observation of Resident #54's meal tray at the same date and time revealed the frozen nutritional treat was not provided with her lunch meal. An interview with the Dietary Manager on 08/27/25 at 9:16 AM revealed dietary staff usually notified him if the facility ran out of nutritional supplements and he followed-up with the resident's nurse, but he had been out of town on 08/24/25 and 08/25/25. He stated in his absence, dietary staff should have notified the resident's assigned nurse that the frozen nutritional treat was unavailable. A follow-up interview with [NAME] #1 on 08/27/25 at 10:35 AM revealed she would usually notify the Dietary Manager when the facility was out of frozen nutritional treats, but he was unavailable and she did not notify Resident #54's nurse that the supplement was unavailable. A telephone interview with the Registered Dietitian (RD) on 08/27/25 at 10:39 AM revealed she expected residents to receive nutritional supplements as ordered. She stated if the facility ran out of ordered supplements, dietary staff should notify nursing staff so orders for an appropriate substitute could be obtained. An interview with the Administrator on 08/27/25 at 4:25 PM revealed she expected residents to receive nutritional supplements as ordered and if they were unavailable, then nursing staff should have been notified so an appropriate substitute could be ordered.

Based on observations, record review and staff interviews, the facility failed to follow their infection control policy and procedure to implement Enhanced Barrier Precautions (EBP) for a resident with a diabetic foot ulcer (Resident #10) and failed to wear a protective gown during tracheostomy care (a surgical opening in the neck), and a dressing change for an endoscopic gastrostomy (feeding tube) for a resident on EBP (Resident #3). Additionally, the facility failed to follow their hand hygiene policy and procedure to remove gloves and perform hand hygiene when a soiled dressing was changed from around a feeding tube (Resident #3). The deficient practice occurred for 1 of 3 staff members observed for infection control practices (Treatment Nurse). The findings included: The facility’s EBP policy last revised on 4/22/25 revealed EBP was used as an additional MDRO (multidrug-resistant organism) mitigation strategy for any resident who met the criteria during high-contact resident care activities. Examples that met criteria for the use of EBP included chronic wounds and listed diabetic foot ulcers as a chronic wound. The policy’s definition of high-contact resident care activities that required glove and gown use included wound care of any skin opening that required a dressing. The policy included the facility had discretion in using EBP for residents who do not have a chronic wound. The policy indicated EBP should not be used for residents who are infected or colonized with an MDRO for which contact precautions were recommended in Appendix A of the Center for Disease Control and Prevention (CDC) guideline for isolation precautions. The CDC Appendix A guideline for a pressure ulcer with a minor or limited infection and if a dressing covered and contained drainage was to use standard precautions. 1. An observation of Resident #10’s wound care for a diabetic foot ulcer performed by the Treatment Nurse was conducted on 8/25/25 at 1:58 PM. There was no dressing in place at the time of the observation, and the wound did not have visible drainage. The Treatment Nurse used an alcohol-based hand sanitizer and put on a pair of gloves prior to care. The Treatment Nurse wiped the ulcer with gauze moistened with normal saline, applied a petroleum infused dressing, and covered the ulcer with a protective dressing. The Treatment Nurse did not wear a protective gown during Resident #10’s wound care for the diabetic ulcer on the right foot. During an interview on 8/25/25 at 3:44 PM, the Treatment Nurse revealed the old dressing was removed prior to the observation for assessment by the Wound Care Nurse Practitioner. The Treatment Nurse was asked if EBP were used for Resident #10 during care for the diabetic foot ulcer. The Treatment Nurse stated it was her understanding if the wound was 3 months old EBP were used and if not, she did not wear a protective gown during wound care for Resident #10’s diabetic foot ulcer. An interview was conducted with Director of Nursing (DON) in the presence of the Infection Preventionist on 8/27/25 at 8:30 AM and at 9:18 AM. It was explained the Treatment Nurse did not wear a protective gown while she provided wound care for Resident #10’s diabetic foot ulcer because EBP were not implemented. The DON confirmed EBP were not implemented for Resident #10 and only used for wounds that were present for 3 months or longer. The DON stated in the policy the facility had the discretion to use EBP for any resident who did not have a chronic wound. The DON stated she did not consider Resident #10’s diabetic ulcer as a chronic wound since it had not been present for 3 months. The DON stated the facility’s EBP policy included the CDC Appendix A and based on the guidance for pressure ulcers she had determined standard precautions should be used for Resident #10. During an interview on 8/27/25 at 3:56 PM, it was explained to the Administrator, EBP were not implemented for Resident #10 who had a diabetic foot ulcer, and during wound care the Treatment Nurse did not wear a protective gown when the wound was cleaned, and a new dressing applied. The Administrator stated based on the facility’s EBP policy the examples of chronic wounds included diabetic foot ulcers and should be implemented for Resident #10 and followed during wound care. 2. Review of the facility’s Enhanced Barrier policy last revised 04/22/25 read in part as follows: “Policy: The facility should use Enhanced Barrier Precautions (EBP) as an additional MDRO [multidrug-resistant organisms] mitigation [prevention] strategy for residents that meet the following criteria, during high contact resident care activities; EBP are indicated for residents with any of the following: Indwelling medical device examples includ[ing] feeding tubes and tracheostomies (a surgical opening in the neck that allows breathing). EBP should be used for any residents who meet the above criteria. Enhanced Barrier Precautions (EBP)-refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Examples of high-contact resident care activities requiring gown and glove use include device care or use: feeding tube [and] tracheostomy/ventilator.” An observation of Resident #3’s door on 08/25/25 at 2:45 PM revealed signage indicating Resident #3 was on EBP and a shelf was hanging on the door containing gowns and gloves. A continuous observation of the Treatment Nurse on 08/25/25 from 2:47 PM through 2:58 PM revealed she entered Resident #3’s room, performed hand hygiene with alcohol-based hand rub (abhr), donned (put on) gloves, opened the tracheostomy care kit and added normal saline (salt water), removed the inner cannula (tube) and discarded it in the trash, removed her gloves and performed hand hygiene with abhr, donned sterile gloves, inserted a new inner cannula into Resident #3’s tracheostomy, removed the soiled gauze from the tracheostomy, removed her gloves, performed hand hygiene with abhr, donned clean gloves, cleaned around the tracheostomy with normal saline moistened gauze, removed her gloves, performed hand hygiene with abhr, donned clean gloves, applied a clean gauze to the tracheostomy, removed her gloves, and performed hand hygiene with abhr. The Treatment Nurse did not don a gown while providing tracheostomy care. An additional continuous observation of the Treatment Nurse on 08/25/25 at 2:59 PM through 3:02 PM revealed she performed hand hygiene with abhr, donned clean gloves, entered Resident #3’s room, removed the soiled gauze from Resident #3’s feeding tube, cleaned around the feeding tube with normal saline moistened gauze, dried the area around the feeding tube with gauze, applied clean gauze around the feeding tube, removed her gloves, performed hand hygiene with abhr, and exited Resident #3’s room. The Treatment Nurse did not don a gown while providing feeding tube care. An interview with the Treatment Nurse on 08/25/25 at 3:04 PM revealed she should have donned a gown when providing tracheostomy care and feeding tube care and she did not because it was an oversight. An interview with the Director of Nursing (DON) on 08/25/25 at 3:18 PM revealed she expected nursing staff to follow EBP when providing as indicated. An interview with the Administrator on 08/27/25 at 4:25 PM revealed she expected staff to follow EBP when providing care as indicated. 3. Review of the facility’s hand hygiene policy last reviewed 07/07/25 read in part as follows: “Policy: The facility has adopted CDC [Centers for Disease Control] Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings for indications for hand hygiene that are generally consistent with the WHO [World Health Organization] 5 moments for hand hygiene. Definitions: Alcohol-based hand rub (ABHR) refers to a 60-95 percent ethanol [alcohol] or isopropyl alcohol-containing preparation base designed for application to the hands to reduce the number of viable micro-organisms. Hand hygiene refers to a general term that applies to hand washing, antiseptic handwash, and alcohol-based hand rub. Procedure: Associates perform hand hygiene (even if gloves are used) in the following situations: a. before and after contact with the resident; b. after contact with body fluids; c. after removing personal protective equipment (gloves, gown, eye protection, facemask) Introduction: An alcohol-based hand rub is appropriate for decontaminating the hands when moving from a contaminated body site to a clean body site during patient care and after contact with bodily fluids. 5 Moments for Hand Hygiene 1. before touching a patient 2. before a clean procedure 3. after body fluid exposure risk 4. after touching a patient 5. after touching patient surroundings.” A continuous observation of the Treatment Nurse on 08/25/25 at 2:59 PM through 3:02 PM revealed she performed hand hygiene with abhr, donned clean gloves, entered Resident #3’s room, removed the soiled gauze containing a small amount of white drainage from Resident #3’s feeding tube, cleaned around the feeding tube with normal saline moistened gauze, dried the area around the feeding tube with gauze, applied clean gauze around the feeding tube, removed her gloves, performed hand hygiene with abhr, and exited Resident #3’s room. The Treatment Nurse did not remove her gloves and perform hand hygiene after removing the soiled gauze and before cleaning around the feeding tube. An interview with the Treatment Nurse on 08/25/25 at 3:04 PM revealed she would not remove her gloves and perform hand hygiene after removing soiled gauze and before cleaning around the feeding tube unless her gloves were visibly soiled. An interview with the Director of Nursing (DON) on 08/25/25 at 3:18 PM revealed she expected nursing staff to remove their gloves and perform hand hygiene after removing soiled gauze around a feeding tube. An interview with the Administrator on 08/27/25 at 4:25 PM revealed she expected staff to remove their gloves and perform hand hygiene when moving from a dirty task to a clean task.

Based on record review and staff interviews, the facility failed to ensure daily nurse staffing sheets accurately reflected the nursing staff who worked for 4 of 6 days reviewed (02/01/25, 02/02/25, 02/09/25, and 03/02/25).Findings included:Review of the facility's daily nurse staffing sheet revealed underneath the facility's name was a space to specify the date along with columns to specify the resident census, number of staff and hours worked for Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) for each 12-hour shift, 7:00 AM to 7:00 PM (day shift) and 7:00 PM to 7:00 AM (night shift). a. The daily nurse staffing sheet dated 02/01/25 revealed on day shift there was 1 RN and 3 LPNs. The nursing staff time clock report for 02/01/25 revealed there were 3 LPNs and no RN.b. The daily nurse staffing sheet dated 02/02/25 revealed on day shift there was 1 RN and 3 LPNs. The nursing staff time clock report for 02/02/25 revealed there were 3 LPNs and no RN. c. The daily nurse staffing sheet dated 02/09/25 revealed on day shift there was 1 RN and 3 LPNs. The nursing staff time clock report for 02/02/25 revealed there were 3 LPNs and no RN. d. The daily nurse staffing sheet dated 03/02/25 revealed on day shift there was no RN and 3 LPNs. The nursing staff time clock report for 03/02/25 revealed there was an RN for 3 hours and 3 LPNs. An interview with the Assistant Director of Nursing (ADON) on 08/27/25 at 12:56 PM revealed since beginning employment in May 2025 she was responsible for completing daily nurse staffing sheets. She stated on weekends the nursing supervisor was responsible for updating the daily nurse staffing sheets to reflect call-outs and/or schedule changes. The weekend nursing supervisor was unavailable for interview during the survey. An interview with the Central Supply Manager on 08/27/25 at 1:52 PM revealed in February 2025 and March 2025 she was responsible for completing the daily nurse staffing sheets. She stated on Fridays she would complete and give the receptionist the daily nurse staffing sheets for Saturday, Sunday, and Monday and the receptionist would fill in the census and post the staffing each weekend day. She stated it was the responsibility of the nursing staff working the weekend to update the daily staffing sheets to reflect information such as call-outs and/or schedule changes. An interview with the Administrator on 08/27/25 at 4:18 PM revealed the ADON was responsible for posting and updating daily nurse staffing sheets throughout the week and the weekend nursing supervisor was responsible for posting and updating the sheets on weekends. She stated she expected the daily nurse staffing sheets to be updated as needed to reflect the correct number and hours of nursing staff that worked each shift.

Based on staff and Physician Assistant (PA) interviews and record review, the facility failed to notify the Physician or Physician Assistant (PA) about a newly identified pressure ulcer for 1 of 4 residents reviewed (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with diagnosis that included dementia and protein-calorie malnutrition. Resident #3 was discharged from the facility on 10/31/24. Review of a wound observation tool for Resident #3's sacrum dated 10/24/24 revealed that this was a facility acquired stage 2 pressure ulcer which was first identified on 10/18/24. The Wound observation tool was completed by Nurse #1. A phone interview with Nurse #1 on 11/22/24 at 8:39 AM revealed that she was aware of a new wound for Resident #3 on the sacrum on 10/18/24. She further revealed that she did not document the occurrence or the treatment of the wound, nor did she inform the PA about the wound. She stated that she knew she should have told the PA and obtained an order for treatment. An interview with the PA on 11/22/24 at 11:31 AM revealed that if a skin issue that could result in a pressure ulcer was discovered the Nurse could start treatment but she would like to be notified as soon as possible. An interview with the Director of Nursing (DON) on 11/22/24 at 3:05 PM revealed that she recalled Resident #3. Nurse #1 told the DON that she did not notify the Physician or PA and get treatment orders. The DON stated that she was unsure why Nurse #1 did not complete the protocol that was in place for addressing new wounds. She stated that her expectation was that when a nurse discovered a new wound that they contact the Physician or PA and get a treatment order to start wound care. An interview with the Administrator on11/22/24 at 3:28 PM revealed that her expectation was that when a nurse discovered a new wound that she contacts the Physician or PA and obtains orders for treatment and documents that appropriately.

Based on record review, and staff and Physician Assistant (PA) interviews, the facility failed to complete weekly skin assessments and comprehensive assessments including measurements of newly identified pressure ulcer and failed to obtain treatment orders which resulted in no treatment being completed for five days for 1 of 4 residents reviewed for pressure ulcers (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with diagnosis that included dementia and protein-calorie malnutrition. Resident #3 was discharged from the facility on 10/31/24. Review of the admission skin assessment dated [DATE] for Resident #3 revealed that there were no skin issues. Review of the admission minimum data set (MDS) dated [DATE] revealed that Resident #3 was severely cognitively impaired. Resident #3 was at risk for pressure ulcers. Resident #3 had no skin issues or injuries and had a pressure-reducing device on her bed. Review of the care plan dated 10/16/24 revealed that Resident #3 was at risk of developing a pressure ulcer due to a decrease in mobility. Goals included Resident #3, will be without the development of pressure areas through next review. Interventions included assist as needed to reposition/shift weight to relieve pressure. Clean and dry skin after each incontinent episode. Complete Braden scale risk assessment monthly and as needed. Encourage use of side rails to assist turning in bed. Float heels when in bed as needed/ordered. Minimize pressure over boney prominences. Notify nurses immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. Pressure reducing mattress. Weekly skin checks. No weekly skin assessments were documented as completed during Resident #3's stay at the facility. Review of a wound observation tool for Resident #3's sacrum dated 10/24/24 revealed this was a facility acquired stage 2 pressure ulcer which was first identified on 10/18/24. The wound observation tool was completed by Nurse #1. There was no documentation present on 10/18/24 to indicate the initial discovery of this pressure ulcer. A physician's order dated 10/24/24 read, cleanse sacral wound with normal saline. Pat dry, apply calcium alginate (a material that absorbs excess moisture and promotes healing of wounds) inside wound border only, not touching edges. Cover wound with bordered foam gauze everyday. Turn resident every two hours every day shift for wound care. The order was discontinued on 10/31/24. Review of the treatment administration record (TAR) for the month of October 2024 revealed the treatment to Resident #3's sacrum was completed as ordered from 10/24/24 through 10/31/24. A phone interview with Nurse #1 on 11/22/24 at 8:39 AM revealed that she was aware of a new wound for Resident #3 on the sacrum on 10/18/24. She stated that she cleansed the wound with normal saline and applied a foam border dressing but did not stage the wound. She further revealed that she did not document the occurrence or the treatment of the wound. She stated that she knew she should have told the PA and obtained an order for treatment. An interview with the PA on 11/22/24 at 11:31 AM revealed that if a skin issue could result in a pressure ulcer was discovered the Nurse could start treatment. She stated that treatment orders being placed would have been nice but with Resident #3's poor nutrition and refusal to offload she felt this delay in treatment had not impacted the outcome of Resident #3's pressure ulcer. An interview with the Director of Nursing (DON) on 11/22/24 at 3:05 PM revealed that she recalled Resident #3. She spoke with Nurse #1 who discovered Resident #3's sacral wound, and Nurse #1 told the DON that she discovered the wound on 10/18/24 and cleaned the wound with normal saline and applied a foam border dressing. The DON stated that she was unsure why Nurse #1 did not complete the protocol that was in place for addressing new wounds. She stated that her expectation was that when a nurse discovered a new wound that they would contact the Physician or PA and get a treatment order to start wound care. An interview with the Administrator on11/22/24 at 3:28 PM revealed that her expectation was that when a nurse discovered a new wound that she contact the Physician or PA and obtained orders for treatment and documented that appropriately.

Based on observation, staff interviews and record reviews, the facility failed to remove an opened eye medication from the medication cart as specified by manufacturer's guidelines and failed to discard expired antiseptic wound care solutions from another medication cart in accordance with the manufacturer's expiration date for 2 of 5 medication carts observed during medication storage checks (200 halls and 600 halls). The findings included: a. The manufacturer's package inserts for Latanoprost eye drops revealed an unopened bottle should be stored under refrigeration between the temperature of 36 to 46 Fahrenheit (F) and protected from light. Once it was opened, Latanoprost could be stored at room temperature up to 77 F for up to six weeks. A medication storage audit was conducted on 08/22/24 at 10:10 AM for 200 halls medication cart in the presence of Nurse #1. One opened bottle of Latanoprost 0.005% eye drops was found in the medication cart under room temperature and ready to be used. The handwriting on the label indicated it was opened on 04/28/24. An interview was conducted with Nurse #1 on 08/22/24 at 10:11 AM. She acknowledged that the bottle of Latanoprost eye drops was opened and stored in the medication cart since 04/28/24. She stated that she saw the eye drops when she checked the medication cart in the morning. She did not discard it as she thought it could be stored in the medication cart under room temperature until the manufacturer's expiration date in June 2026. b. During a medication storage audit conducted on 08/22/24 at 11:09 AM for 600 halls medication cart in the presence of Nurse #2, an opened bottle containing approximate 90 milliliters (ml) of Povidone Iodine 10 % solution expired on 10/31/23 was found in the medication cart and ready to be used. An interview was conducted with Nurse #2 on 08/22/24 at 11:12 AM. She stated the topical solution was for wound care and it had not been used for quite a while. She explained she checked the medication cart in the morning and did not know why she missed the topical solution. She acknowledged that the topical solution should be removed from the medication cart as it was expired. During an interview conducted on 08/22/24 at 11:25 AM, the Director of Nursing (DON) stated Latanoprost should be stored in the refrigerator until it was opened. Once it was opened, it could be stored in room temperature for up to 42 days. She stated that the facility had conducted in-service after the previous survey and the administrative staff had audited the medication carts and storage rooms as outlined in the auditing tools. She did not understand why the staff missed the expired eye drops and the topical solution. It was her expectation for the facility to remain free of expired medications. An interview was conducted with the Administrator on 08/22/24 at 6:51 PM. She expected the facility to remain free of expired medication and discard eye drops in a timely manner as specified by the manufacturer's guidelines.

Based on record review and staff interviews, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (abbreviated as ARD and referring to the last day of the assessment period) for 1 of 6 sampled residents (Resident #6). Findings included: Resident #6 was admitted to the facility on [DATE]. Review of Resident #6's electronic health record revealed an annual MDS assessment with an ARD of 08/01/24 was noted as in progress. During a telephone interview on 08/22/24 at 6:09 PM, the Corporate MDS Consultant confirmed Resident #6's annual MDS assessment dated [DATE] was not completed within the regulatory timeframe. He explained the facility had been without a MDS Coordinator for some time and the staff that had been assisting from other facilities had focused on current MDS assessments to prevent more from being completed late. The Corporate MDS Consultant stated he was actively working on completing the MDS assessments that were currently late and hoped to have them all caught up by next week. During an interview on 08/22/24 at 7:00 PM, the Administrator stated she realized there was an issue with the timely completion of MDS assessments when she did an audit for the Plan of Correction from the recertification survey on 07/19/24. She stated the issue was discussed with the Corporate MDS Consultant but they had not had enough time to get them all caught back up. The Administrator felt the breakdown was due primarily to only having one permanent MDS Coordinator completing assessments and now that they have hired an additional MDS Coordinator, they would be able to stay caught up with completing MDS assessments. The Administrator stated it was her expectation for MDS assessments to be completed within the regulatory timeframes.

Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (abbreviated as ARD and referring to the last day of the observation period) for 3 of 6 sampled residents (Residents #2, #3, and #5). Findings included: 1. Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's Electronic Health Record (EHR) on 08/22/24 revealed a quarterly MDS assessment with an ARD of 07/23/24 was noted as in progress. During a telephone interview on 08/22/24 at 6:09 PM, the Corporate MDS Consultant confirmed Resident #2's quarterly MDS assessment dated [DATE] was not completed within the regulatory timeframe. He explained the facility had been without a MDS Coordinator for some time and the staff that had been assisting from other facilities had focused on current MDS assessments to prevent more from being completed late. The Corporate MDS Consultant stated he was actively working on completing the MDS assessments that were currently late and hoped to have them all caught up by next week. During an interview on 08/22/24 at 7:00 PM, the Administrator stated she realized there was an issue with the timely completion of MDS assessments when she did an audit for the Plan of Correction from the recertification survey on 07/19/24. She stated the issue was discussed with the Corporate MDS Consultant but they had not had enough time to get them all caught back up. The Administrator felt the breakdown was due primarily to only having one permanent MDS Coordinator completing assessments and now that they have hired an additional MDS Coordinator, they would be able to stay caught up with completing MDS assessments. The Administrator stated it was her expectation for MDS assessments to be completed within the regulatory timeframes. 2. Resident #5 was admitted to the facility on [DATE]. Review of Resident #5's Electronic Health Record (EHR) on 08/22/24 revealed a quarterly MDS assessment with an ARD of 07/26/24 was noted as in progress. During a telephone interview on 08/22/24 at 6:09 PM, the Corporate MDS Consultant confirmed Resident #5's quarterly MDS assessment dated [DATE] was not completed within the regulatory timeframe. He explained the facility had been without a MDS Coordinator for some time and the staff that had been assisting from other facilities had focused on current MDS assessments to prevent more from being completed late. The Corporate MDS Consultant stated he was actively working on completing the MDS assessments that were currently late and hoped to have them all caught up by next week. During an interview on 08/22/24 at 7:00 PM, the Administrator stated she realized there was an issue with the timely completion of MDS assessments when she did an audit for the Plan of Correction from the recertification survey on 07/19/24. She stated the issue was discussed with the Corporate MDS Consultant but they had not had enough time to get them all caught back up. The Administrator felt the breakdown was due primarily to only having one permanent MDS Coordinator completing assessments and now that they have hired an additional MDS Coordinator, they would be able to stay caught up with completing MDS assessments. The Administrator stated it was her expectation for MDS assessments to be completed within the regulatory timeframes. 3. Resident #3 was admitted to the facility on [DATE]. Review of Resident #3's Electronic Health Record (EHR) on 08/22/24 revealed a quarterly MDS assessment with an ARD of 08/06/24 was noted as in progress. During a telephone interview on 08/22/24 at 6:09 PM, the Corporate MDS Consultant confirmed Resident #3's quarterly MDS assessment dated [DATE] was not completed within the regulatory timeframe. He explained the facility had been without a MDS Coordinator for some time and the staff that had been assisting from other facilities had focused on current MDS assessments to prevent more from being completed late. The Corporate MDS Consultant stated he was actively working on completing the MDS assessments that were currently late and hoped to have them all caught up by next week. During an interview on 08/22/24 at 7:00 PM, the Administrator stated she realized there was an issue with the timely completion of MDS assessments when she did an audit for the Plan of Correction from the recertification survey on 07/19/24. She stated the issue was discussed with the Corporate MDS Consultant but they had not had enough time to get them all caught back up. The Administrator felt the breakdown was due primarily to only having one permanent MDS Coordinator completing assessments and now that they have hired an additional MDS Coordinator, they would be able to stay caught up with completing MDS assessments. The Administrator stated it was her expectation for MDS assessments to be completed within the regulatory timeframes.

Based on record review and staff interviews, the facility failed to complete a discharge-return anticipated Minimum Data Set (MDS) within 14 days of the discharge date and an entry tracking record within 14 days of the admitted for 1 of 6 sampled residents (Resident #5). Findings included: Resident #5 was admitted to the facility on [DATE]. Review of Resident #5's electronic health record on 08/22/24 revealed the following: a. A discharge-return anticipated MDS assessment dated [DATE] noted a status of in progress. b. An entry tracking record dated 07/24/24 noted a status of in progress. During a telephone interview on 08/22/24 at 6:09 PM, the Corporate MDS Consultant confirmed Resident #5's entry tracking record and discharge MDS assessment were not completed within the regulatory timeframe. He explained the facility had been without a MDS Coordinator for some time and the staff that had been assisting from other facilities had focused on current MDS assessments to prevent more from being completed late. The Corporate MDS Consultant stated he was actively working on completing the MDS assessments that were currently late and hoped to have them all caught up by next week. During an interview on 08/22/24 at 7:00 PM, the Administrator stated she realized there was an issue with the timely completion of MDS assessments when she did an audit for the Plan of Correction from the recertification survey on 07/19/24. She stated the issue was discussed with the Corporate MDS Consultant but they had not had enough time to get them all caught back up. The Administrator felt the breakdown was due primarily to only having one permanent MDS Coordinator completing assessments and now that they have hired an additional MDS Coordinator, they would be able to stay caught up with completing MDS assessments. The Administrator stated it was her expectation for MDS assessments to be completed within the regulatory timeframes.

Based on observation, record review and Responsible Party, Physician Assistant, resident and staff interviews, the facility failed to include a resident's transfer status in the comprehensive care plan for staff to safely transfer a resident from the wheelchair to bed resulting in the resident falling to the floor (Resident #44) and failed to transfer a dependent resident from the bed to the wheelchair using a mechanical lift and two-person assistance as indicated on the care plan (Resident #8) for 2 of 3 residents reviewed for accidents and mobility. On the evening of 05/17/24, Nurse Aide #1 attempted to independently transfer Resident #44 to the bed resulting in Resident #44 falling to the floor onto her left side. Upon initial nurse assessment, Resident #44 complained of no pain and had a small topical abrasion to the left elbow with no other obvious injuries identified. Later that same evening, Resident #44 complained of hip pain, the on-call provider was notified and new orders for a STAT (immediate) x-ray was obtained. Early in the morning of 05/18/24, x-rays revealed Resident #44 had an acute (sudden in onset) left intertrochanteric fracture (type of hip fracture that occurs between the two bony points of the thighbone where the muscles of the thigh and hip attach) with mild displacement (when the bone breaks in two or more parts and moves so that the two ends do not line up straight) with varus (occurs when the broken bones are turned toward the center of the body) angulation. Resident #44 was admitted to the hospital on 05/18/24 for evaluation and treatment, underwent surgical repair for the hip fracture and returned to the facility on [DATE]. Findings included: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses that included right foot pathological fracture, muscle weakness, abnormal posture, right and left hip contractures, and age-related physical debility. A Physical Therapy (PT) evaluation and plan of treatment dated 04/03/23 revealed in part, Resident #44 reported she had not walked or stood for at least a year and was unable. She required total dependence with transfer to bed from wheelchair due to both lower extremity weakness and non-weight bearing on the right leg due to fracture. She was unable to complete sit-to-stand as she could not stand but was able to complete wheelchair to bed transfer with PT assistance. She was able to assist with upper extremities but very little with lower extremities. Resident #44 was maximum assistance with bed mobility tasks due to inability to move her legs on her own but did use her upper extremities to help as able. An Activity of Daily Living (ADL) care plan, initiated on 04/19/23, revealed Resident #44 had an ADL self-care performance deficit related to inability to move bilateral legs, needs assistance. There were no interventions regarding transfer status until the care plan was revised on 05/21/24 which noted Resident #44 required total staff assistance with transfers. The annual Minimum Data Set (MDS) dated [DATE] assessed Resident #44 with intact cognition. Resident #44 required partial to moderate staff assistance for sit-to-stand and chair/bed-to-chair transfers. An incident/accident report dated 05/17/24 completed by Nurse #3 revealed around 8:00 PM, she was notified by Nurse Aide (NA) #1 that Resident #44 had fallen out of her motorized wheelchair onto the floor. NA #1 reported that as she was turning down the covers on Resident #44's bed, Resident #44 was sitting toward the edge of the seat of the motorized wheelchair when she (Resident #44) accidentally hit the hand control causing it to jerk backwards and Resident #44 fell forward onto the floor. Upon assessment, Nurse #3 noted Resident #44's passive range of motion was within normal limits and Resident #44 voiced no complaints of pain. The only injury identified at the time of Nurse #3's assessment was a small topical abrasion to the left elbow and a bandaid was applied. Around 10:00 PM, Resident #44 complained of left hip pain, as needed Tylenol was administered and ice applied to her left hip. The on-call provider was notified and provided orders for a 2-view STAT x-ray of the left hip. Radiology results dated 05/18/24 revealed in part, Resident #44 had an acute left intertrochanteric fracture with mild displacement with varus angulation. A physician's order dated 05/18/24 read, send to emergency room (ER) due to left femoral fracture with displacement. Review of hospital records dated 05/20/24 revealed on 05/18/24 Resident #44 who is paralyzed from the legs down presented to the ER for evaluation of left hip pain after being dropped by staff while being transferred between surfaces. X-rays obtained revealed she had an acute minimally displaced left intertrochanteric fracture. On 05/18/24, Resident #44 underwent a successful cephalomedullary intertrochanteric nailing (surgical procedure to treat displaced intertrochanteric femur fractures) and was discharged back to the facility on [DATE]. During an interview on 07/17/24 at 3:15 PM and follow-up interviews on 07/18/24 at 8:55 AM and 07/18/24 at 4:18 PM, Resident #44 revealed NA #1 had dropped her to the floor while trying to transfer her from the motorized wheelchair to her bed. Resident #44 could not recall the date but stated she was seated in her motorized wheelchair in-between the door of the room and wall of the bathroom door approximately 6 feet from the foot of her bed when NA #1 had come into the room to assist her with getting into bed for the night. Resident #44 recalled when NA #1 stated she was going to transfer her to the bed, Resident #44 told NA #1 that she needed to move closer to the bed because she too heavy and too far away for NA #1 to lift her but NA #1 told her no, I can lift you. Resident #44 stated she never hit the hand control on the motorized wheelchair causing her to fall forward onto the floor. She explained NA #1 stood in front of the motorized wheelchair, put her arms underneath Resident #44's arms, and lifted her up. She stated NA #1 took 2 steps backwards toward the bed while lifting Resident #44 and was then dropped to the floor landing on her left side. Resident #44 did not recall having any immediate pain but stated she did have pain later and was sent out to the hospital due to a fracture. During a telephone interview on 07/19/24 at 2:28 PM, Resident #44's Responsible Party (RP) revealed on the evening of 05/17/24 she was notified that while being transferred, Resident #44 hit the hand control on the motorized wheelchair causing her to fall out onto the floor and her (RP) immediate response was to ask why the motorized wheelchair was left on if staff were transferring her out of it. Then early the next morning (05/18/24) she received a call that Resident #44 was in pain, x-rays were obtained and she was being sent out to the hospital. When the RP arrived at the hospital, she asked Resident #44 how she had hit the hand control on the motorized wheelchair and Resident #44 stated she didn't. Resident #44 told the RP that the NA had dropped her when trying to transfer her without using a mechanical lift. The RP stated she immediately called and spoke with the Administrator who confirmed that when they interviewed the NA, she admitted attempting to transfer Resident #44 without assistance or using a mechanical lift. During a telephone interview on 07/18/24 at 12:05 PM, NA #1 revealed she typically worked 7:00 PM to 7:00 AM and confirmed she was assigned to provide care to Resident #44 the evening of 05/17/24 when Resident #44 fell . NA #1 stated that night (05/17/24) was the first time she had attempted to transfer Resident #44 because she was usually already in bed when she started her shift at 7:00 PM. She explained when she checked the Kardex (NA reference guide that summarizes a resident's needs) there was nothing listed regarding Resident #44's transfer status and she did not think to ask anyone about Resident #44's transfer status or for assistance because at first, she thought she would be able to transfer Resident #44 herself. NA #1 recalled Resident #44 was facing the bed while seated in her motorized wheelchair in-between the door of the room and wall of the bathroom, when she (NA #1) put her arms underneath Resident #44's arms, started to lift her up and quickly realized she wouldn't be able to lift her so she sat Resident #44 back down on the seat of the motorized wheelchair. NA #1 could not recall for certain if she or Resident #44 hit the hand control on the motorized wheelchair but stated it jerked backwards and then Resident #44 fell forward onto the floor landing on her left side. NA #1 stated she only lifted Resident #44 up from the seat but not away from the wheelchair and did not drop Resident #44 to the floor. When asked why she thought Resident #44 would state that NA #1 had dropped her while trying to lift and move her to the bed, NA #1 provided no response. NA #1 stated when Resident #44 fell to the floor, she made sure Resident #44 was ok, told her not to move and then left the room to inform Nurse #3 what happened. During a telephone interview on 07/18/24 at 11:57 PM, Nurse #3 confirmed she was notified by NA #1 that Resident #44 had fallen to the floor and she immediately went to the room to assess Resident #44. When she entered the room, she recalled Resident #44 was lying on her left side on the floor in front of her motorized wheelchair with her head toward the bed. Nurse #3 stated upon assessment, Resident #44 had no obvious or visible signs of fracture and she displayed no non-verbal indicators of pain such as grimacing nor voiced any complaints of pain when she (Nurse #3) lifted her legs up and outward to assess her range of motion. Nurse #3 stated she and NA #1 assisted Resident #44 up off the floor and into bed. Later that evening, Nurse #3 stated Resident #44 started complaining of pain, she notified the on-call provider, obtained orders for an x-ray and when the results revealed a hip fracture, Resident #44 was sent out to the hospital. Nurse #3 recalled when she initially assessed Resident #44, she had asked her what happened and all Resident #44 would state was that lady did it or that lady dropped me. Nurse #3 could not recall for certain Resident #44's exact wording but stated that Resident #44 was a reliable historian and did imply the fall was NA #1's fault. Nurse #3 stated when she talked with NA #1 about the incident, NA #1 gave two different versions of what happened. NA #1 first stated that Resident #44 was sitting on the edge of the motorized wheelchair and while NA #1 was getting the bed ready, Resident #44 accidentally hit the hand control of the motorized wheelchair causing it to go backwards and Resident #44 fell forward onto the floor. Then later when Nurse #3 asked NA #1 to write a statement, NA #1 revealed she had tried to lift Resident #44 from the motorized wheelchair to transfer her to the bed but couldn't and accidentally hit the hand control of the motorized wheelchair causing Resident #44 to fall out of the motorized wheelchair onto the floor. Nurse #3 stated based on how Resident #44 was lying on the floor when she first entered the room, NA #1's description of what happened didn't seem plausible as she would have expected for Resident #44 to have landed on her knees or stomach and not on her side if she had fell forward out of the motorized wheelchair. Nurse #3 recalled when she asked NA #1 why she tried to transfer Resident #44 independently, NA #1 stated she was not aware of Resident #44's transfer status or that she required a two-person assist. Nurse #3 stated even though she was certain she had told NA #1 of Resident #44's transfer status, NA #1 never asked anyone what level of assistance Resident #44 required before attempting to transfer her independently which she (Nurse #3) felt ultimately caused Resident #44 to fall to the floor. During an interview on 07/18/24 at 4:28 PM, the Rehab Director revealed when a resident admitted to the facility, upon initial assessment therapy specified the specific type of mechanical lift to be used if that was determined to be the safest way to transfer, otherwise, they would indicate 2-person total assist which she explained could be 2 staff members providing physical assistance without the use of a mechanical lift. The Rehab Director stated Resident #44 was unable to use her lower extremities or stand on her own but could bear weight on her legs with maximum staff assistance which she described as the person assisting performed 100 percent of the work. The Rehab Director stated when Resident #44 was first admitted , she was evaluated by PT on 04/03/23 as a 2-person total assist unless the staff member was trained with using a sliding board and then one-person could assist. The Rehab Director stated with therapy, Resident #44 transitioned to a sit-to-stand mechanical lift with 2-person assist that was still her current baseline. During interviews on 07/18/24 at 11:26 AM and 07/19/24 at 10:46 AM, the Director of Nursing (DON) stated it was the facility's policy to always have 2 staff members when transferring residents using a mechanical lift. The DON recalled Resident #44 stating that NA #1 was going to transfer her to the bed but she accidentally hit the hand control of the motorized wheelchair and fell to the floor. She stated Resident #44 had not mentioned anything about a mechanical lift being in the room. The DON stated when she talked with NA #1 about what happened, NA #1's stories did not remain consistent. At first, NA #1 stated Resident #44 was on the edge of the seat of the motorized wheelchair, Resident #44 hit the hand control which caused it to jerk backwards and Resident #44 fell forward onto the floor. Then later, NA #1 stated she had tried to independently transfer her without a mechanical lift but realized she couldn't and when she sat Resident #44 back into the seat of the motorized wheelchair somehow the hand control was accidentally hit which caused Resident #44 to fall forward onto the floor. The DON stated when she and Nurse #3 discussed the incident, they didn't find NA #1's story plausible based on how Resident #44 was observed on the floor by Nurse #3. The DON stated through their investigation, they determined the fall was the result of NA #1 transferring Resident #44 without 2-person assist and staff education regarding safe transfers and residents transfer status was initiated. During an interview on 07/19/24 at 11:15 AM, the Administrator revealed she spoke with Resident #44 when she returned from the hospital and Resident #44 stated the fall occurred when NA #1 was transferring her from the motorized wheelchair. She stated Resident #44 indicated the poor girl was trying to transfer her but couldn't do it and she (Resident #44) did not know what happened during the transfer to cause NA #1 to drop her. The Administrator stated that based on what NA #1 and Resident #44 both stated happened as well as how Resident #44 was observed on the floor by Nurse #3, they determined NA #1's account of what happened didn't seem plausible since Resident #44 had landed on her side and not on her hands or knees which was what they would have expected to happen if someone fell forward out of the wheelchair as NA #1 had stated. She stated she had staff assess the palms of Resident #44's hands and forehead to see if there were any carpet burns indicative of her falling forward out of the chair onto the floor but there was nothing. The Administrator stated she felt the incident scared NA #1 which led her not to disclose certain details about what happened and during the course of the investigation, it was determined that NA #1 did in fact attempt to lift Resident #44 out of the motorized wheelchair without the use of a mechanical lift or additional staff assistance. The Administrator stated she was not certain if the hand control of Resident #44's motorized wheelchair was hit by accident, if at all; however, she did not think the outcome would have been any different as NA #1 did not follow proper protocol for transferring a resident and if she was unsure of Resident #44's transfer status she should have asked someone. During an interview on 07/18/24 at 11:30 AM, the Physician Assistant (PA) stated she was not at the facility on 05/17/24 when Resident #44 fell but she did examine her upon her return to the facility from the hospital. The PA stated she would expect for staff to follow PT recommendations regarding a resident's transfer status. 37538 2. Resident #8 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis and right foot drop. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and dependent on staff for transfers from the bed to the chair. There had been no falls since the previous assessment and Resident #8 used a wheelchair/scooter for mobility. The activities of daily living care plan last reviewed on 05/30/24 identified Resident #8 as having a deficit in her ability to perform self-care. Her deficit was related to musculoskeletal impairment due to the diagnosis of multiple sclerosis. The goal was to maintain the current level of functioning through the review date. One of the interventions in place required staff use a total mechanical lift with 2-person assistance. During an interview on 07/15/24 at 11:08 AM Resident #8 revealed she needed staff assistance with transfers and used a powered wheelchair for mobility. She stated the nursing staff used different techniques to transfer her and sometimes one-person assistance was provided. She revealed nursing staff had physically lifted her from underneath her arms or used a mechanical lift with a sling. She revealed it hurt her left shoulder when staff physically lifted her under the arms. Resident #8 denied any falls had occurred while a resident at the facility. Review of the Kardex updated on 07/19/24 revealed the guidance for transferring Resident #8 was to use the total mechanical lift with 2-person assistance. During an observation and interview on 07/19/24 at 8:18 AM Resident #8 was in bed and stated someone would need to assist her out of bed but she preferred to wait at this time. Resident #8 stated some of the nursing staff continued to transfer her without the use of the mechanical lift and two-person assistance. During an observation on 07/19/24 at 9:55 AM NA #2 exited the room with no mechanical lift. At 10:00 AM Resident #8 was observed out of the bed and sitting in her power wheelchair brushing her hair with no signs of distress or pain. Resident #8 revealed she was transferred by NA #2 without the use of a mechanical lift and was able to transfer without incident. A total mechanical lift was available on the hall where Resident #8's room was located. An interview was conducted on 07/19/24 at 10:25 AM with NA #2. NA #2 confirmed she had transferred Resident #8 from the bed to the wheelchair using one-person physical assistance. She did not ask for help and stated she felt safe transferring Resident #8 by herself because the resident could bear weight on one leg and was able to stand and pivot and she had used a gait belt during the transfer. She revealed a total mechanical lift was available and could be used to transfer the resident, but she was not directed to use it and stated it was more difficult to have two-person assist when transferring Resident #8. She did have access to Resident #8's care plan/Kardex and could review the level of assistance needed prior to transferring and stated she had not recently checked it. NA #2 revealed she worked as needed and recently started working on the floor as a NA. She stated if she noticed a change in the resident's ability to transfer, she would notify the nurse and there was a form to fill out and give to therapy or she would verbally tell the Rehab Director or other therapist. NA #2 confirmed she had not informed therapy or anyone Resident #8 was able bear weight and pivot with 1 person assistance using a gait belt to transfer from the bed to wheelchair. During an interview on 07/19/24 at 10:46 AM the Director of Nursing (DON) was made aware NA #2 transferred Resident #8 using one person assist and without the use of a total mechanical lift. The DON stated Resident #8 required two-person assistance using the total mechanical lift for transfers and she had spoken to the nursing staff about where to find transfer status and safety for residents using the Kardex. She stated NA #2 should not have transferred Resident #8 without using the total mechanical lift with 2-person assistance. An interview was conducted on 07/19/24 at 11:06 AM with the Administrator. The Administrator confirmed Resident #8's care plan was to use the total mechanical lift with two-person assistance for transfers. The Administrator stated she expected NA #2 to check the care plan before providing care prior to transferring a resident.

Based on observations and staff interviews the facility failed to maintain a clean fan in the food preparation area of 1 of 1 kitchen; maintain clean walls and a clean ceiling in 1 of 1 walk-in cooler; label and date open food items, discard expired food, and discard food with signs of spoilage in 1 of 1 walk-in cooler; date milkshakes to identify their use-by date in 1of 1 walk-in cooler; date an opened food item in 1 of 1 walk-in freezer; discard expired food items in 1 of 1 kitchen; and ensure food and beverage items were labeled and dated and date milkshakes to identify their use-by date in 2 of 2 nourishment rooms (activity room refrigerator and ,d+[DATE] hall). These practices had the potential to affect food served to the residents. Findings included: 1. An initial observation of the kitchen on [DATE] at 09:28 AM revealed a fan with gray debris to the front and back covers mounted on the wall near the walk-in cooler blowing toward the food preparation area. An additional observation of the kitchen on [DATE] at 12:12 PM revealed a fan with gray debris to the front and back covers mounted on the wall near the walk-in cooler blowing toward the food preparation area. An interview with the Dietary Manager on [DATE] at 12:12 PM revealed he expected the fan to be clean and free of debris. He explained he had only been employed at the facility around a month and he was not sure if there was a deep cleaning schedule or who was responsible for cleaning the fan. An interview with the Administrator on [DATE] at 4:16 PM revealed she expected all kitchen fans to be clean and free of debris. 2. An initial observation of the walk-in cooler on [DATE] at 09:29 AM revealed a thick build-up of gray debris near the ceiling light and on the wall of the entry door. An additional observation of the walk-in cooler on [DATE] at 12:15 PM revealed a thick build-up of gray debris near the ceiling light and on the wall of the entry door. An interview with the Dietary Manager on [DATE] at 12:15 PM revealed he expected the cooler to be clean and free of debris. He explained he had only been employed at the facility around a month and he was not sure if there was a deep cleaning schedule or who was responsible for cleaning the cooler. An interview with the Administrator on [DATE] at 4:16 PM revealed she expected the walk-in cooler to be clean and free of debris. 3. An initial observation of the walk-in cooler on [DATE] at 09:30 AM revealed the following: (a). an opened and undated pack of sliced cheese (b). an opened and undated 5-pound container of cottage cheese (c). an opened and undated container of shredded cheese (d). 2 opened and undated loaves of bread which did not contain an expiration date (e). 3 heads of iceberg lettuce with brown discoloration (f). an unopened 32-ounce bag of collard greens with a best-by date of [DATE] (g). an opened and undated 5-pound bag of shredded carrots (h). a cardboard box of 12 fully thawed 4-ounce manufactured milkshakes with no label to indicate the date they were removed from the freezer or the expiration date An additional observation of the walk-in cooler on [DATE] at 12:20 PM revealed 3 heads of iceberg lettuce with brown discoloration and 2 opened and undated loaves of bread which did not contain an expiration date sitting on a shelf. An interview with the Dietary Manager on [DATE] at 12:20 PM revealed he expected all food items to be labeled and dated by the person placing the item in the cooler. He stated it was the responsibility of each dietary staff member to check for and discard any food with signs of spoilage or expired food. The Dietary Manager stated he was not sure of the shelf life of thawed manufactured milkshakes. A follow-up interview with the Dietary Manager on [DATE] at 2:46 PM revealed thawed manufactured milkshakes were good for 14 days after being thawed and he expected dietary staff to date the milkshakes when they were removed from the freezer. An interview with the Administrator on [DATE] at 4:16 PM revealed she expected all food items to be labeled and dated when placed in the cooler, food to be used or discarded on or by the best-by date, food with signs of spoilage to be discarded, and manufactured milkshakes to be used or discarded within 14 days of being thawed. 4. An initial observation of the walk-in freezer on [DATE] at 09:38 AM revealed an opened and undated bag of French fries. An additional observation of the walk-in freezer on [DATE] at 12:22 PM revealed an opened and undated bag of French fries. An interview with the Dietary Manager on [DATE] at 12:22 PM revealed he expected all opened food items to be labeled and dated by the person placing the item in the freezer. An interview with the Administrator on [DATE] at 4:16 PM revealed she expected all opened food items to be dated when placed in the freezer. 5. An initial observation of a food preparation table on [DATE] at 09:40 AM revealed a bin of all-purpose flour with a use-by date of [DATE], a bin of breadcrumbs with a use-by date of [DATE], and a bin of sugar with a use-by date of [DATE]. An additional observation of a food preparation table on [DATE] at 12:25 PM revealed a bin of all-purpose flour with a use-by date of [DATE], a bin of breadcrumbs with a use-by date of [DATE], and a bin of sugar with a use-by date of [DATE]. An interview with the Dietary Manager on [DATE] at 12:25 PM revealed all dietary staff were responsible for checking for and discarding expired food items daily. An interview with the Administrator on [DATE] at 4:16 PM revealed she expected all food items to be used or discarded by the use-by date. 6. (a) An observation of the activity room refrigerator on [DATE] at 7:15 AM revealed 7 fully thawed 4-ounce manufactured milkshakes with no label to indicate the date they were removed from the freezer or the expiration date. (b). An observation of the ,d+[DATE] hall nourishment room refrigerator on [DATE] at 07:25 AM revealed the following: -an opened and unlabeled 33.8-ounce bottle of water -an opened and unlabeled 6-ounce can of pineapple juice -an opened and unlabeled 20-ounce bottle of diet soda -an opened and unlabeled prepacked container of salad with a best-by date of [DATE] -an opened and unlabeled 16.9-ounce bottle of diet soda -an undated and unlabeled container of cake -1 fully thawed 4-ounce manufactured milkshake with no label to indicate when it was removed from the freezer or the expiration date An interview with the Dietary Manager on [DATE] at 7:45 AM revealed dietary aides were responsible each shift for ensuring all food and beverages were labeled and dated and discarding any items that were not labeled or dated. He stated dietary aides were also responsible for ensuring manufactured milkshakes were used or discarded 14 days after being thawed. An interview with the Administrator on [DATE] at 4:16 PM revealed she expected all food and beverage items in nourishment rooms to be labeled and dated and manufactured milkshakes to be used or discarded within 14 days of being thawed.

Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of falls, functional limitation in range of motion, anticoagulant (blood thinner) use, weight loss, colostomy status, and bowel incontinence for 5 of 18 sampled residents (Residents #44, #17, #2, #7, and #13). Findings included: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses that included abnormal gait and muscle weakness. An incident/accident report dated 05/17/24 revealed Resident #44 had a witnessed fall from her wheelchair to the floor. Upon nurse assessment, Resident #44 had a small topical abrasion to the left elbow, passive range of motion was within normal limits and she voiced no complaints of pain. Approximately 2 hours later, Resident #44 complained of left hip pain, the on-call provider was notified and orders were obtained for a STAT (immediate) left hip x-ray. Review of left hip x-ray results dated 05/18/24 revealed Resident #44 had an acute (sudden in onset) intertrochanteric femoral (hip) fracture with mild displacement. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had an intertrochanteric fracture of left femur. Further review revealed that Resident #44 did not fall any time in the last month or 2 to 6 months prior to admission or reentry and did not have any fracture related to a fall in the 6 months prior to admission or reentry. The facility's MDS Coordinator was unavailable for interview during the investigation. During a telephone interview on 07/19/24 at 3:28 PM with the Director of Nursing (DON) present, the Corporate MDS Consultant revealed Resident #44's significant change MDS assessment dated [DATE] should have accurately reflected she had a fall with fracture in the last month. The MDS Consultant explained the facility's MDS Coordinator was currently out due to health problems and he felt the coding inaccuracies were likely due to an oversight. During an interview on 07/19/24 at 4:10 PM, the Administrator stated she expected for MDS assessments to be completed accurately. 2. Resident #17 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the right dominant side and right hand contracture. A physician's order dated 02/27/24 for Resident #17 read, Xarelto (anticoagulant medication) 20 milligrams (mg) every evening related to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the May 2024 Medication Administration Record for Resident #17 revealed Xarelto 20 mg was initialed as administered every evening per physician order. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was not taking anticoagulant medication and he had no impairment of his upper extremities. The activities of daily living Care Area Assessment (CAA) associated with the annual MDS assessment dated [DATE] revealed in part, Resident #17 had a right hand contracture and received anticoagulant medication daily. During a telephone interview on 07/19/24 at 3:28 PM with the Director of Nursing (DON) present, the Corporate MDS Consultant revealed Resident #17's annual MDS assessment dated [DATE] should have reflected that he had upper extremity impairment due to right hand contracture and that he received anticoagulant medication during the MDS assessment period. The Corporate MDS Consultant explained the facility's MDS Coordinator was currently out due to health problems and he felt the coding inaccuracies were likely due to an oversight. During an interview on 07/19/24 at 4:10 PM, the Administrator stated she expected for MDS assessments to be completed accurately. 39037 3. Resident #13 was admitted to the facility 01/23/24 with diagnoses including malnutrition and muscle weakness. Resident #13's weights for the past 6 months were as follows: 01/29/24 137 pounds 02/26/24 124 pounds 03/0424 131 pounds 04/01/24 118.2 pounds 05/01/24 114.8 pounds 06/01/24 113.8 pounds Review of Resident #13's weights from January 2024, through June 2024, reflected a 20.39% weight loss over the last 6 months. Review of Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired and did not reflect that she had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The facility's MDS Coordinator was unavailable for interview during the investigation. In a telephone interview with the Corporate MDS Coordinator on 07/19/24 at 3:35 PM he confirmed Resident #13's quarterly MDS dated [DATE] should have been coded to reflect a 10% weight loss over the past 6 months. He explained the facility's MDS Coordinator had recently been having a number of health problems and he felt that contributed to the error in MDS coding. An interview with the Administrator on 07/19/24 at 4:05 PM revealed she expected MDS assessments to be coded correctly. 4. Resident #7 was admitted to the facility 03/27/24 with diagnoses including anemia and malnutrition. Review of Resident #7's admission MDS assessment dated [DATE] revealed she was moderately cognitively impaired and bowel continence was not rated. The facility's MDS Coordinator was unavailable for interview during the investigation. In a telephone interview with the Corporate MDS Coordinator on 07/19/24 at 3:35 PM he confirmed Resident #7's admission MDS dated [DATE] should have been coded to reflect she was incontinent of bowel. He explained the facility's MDS Coordinator had recently been having a number of health problems and he felt that contributed to the error in MDS coding. An interview with the Administrator on 07/19/24 at 4:05 PM revealed she expected MDS assessments to be coded correctly. 5. Resident #2 was admitted to the facility 04/17/13 with diagnoses including malnutrition. Review of Resident #2's colostomy (a surgically created opening from the colon through the abdomen) care plan last revised 02/15/24 revealed she removed her colostomy pouch and wafer frequently and interventions included providing colostomy care as ordered and as needed and assessing the skin around the stoma site for signs of irritation with each wafer change. Resident #2 had a Physician order dated 05/06/24 to change her colostomy bag and wafer every 2 days and as needed. Review of Resident #2's quarterly MDS assessment dated [DATE] revealed she was not coded as having an appliance, including a colostomy. The facility's MDS Coordinator was unavailable for interview during the investigation. In a telephone interview with the Corporate MDS Coordinator on 07/19/24 at 3:35 PM he confirmed Resident #2's quarterly MDS dated [DATE] should have been coded to reflect Resident #2 had a colostomy. He explained the facility's MDS Coordinator had recently been having a number of health problems and he felt that contributed to the error in MDS coding. An interview with the Administrator on 07/19/24 at 4:05 PM revealed she expected MDS assessments to be coded correctly.

Based on record review, observations, and interviews with staff the facility failed to date two open and in use bottles of medicated eye drops being stored at room temperature on 1 of 4 medication carts (Hall 400 med cart) and failed to date three in use multi-dose vials of tuberculin purified protein derivative (a diagnostic antigen used in testing for tuberculosis) and failed to remove expired medications and influenza vaccines from 2 of 2 medication room refrigerators (medication room for halls 200, 300, 400, 500, and 600) reviewed for medication storage and labeling. Findings revealed: a. Review of manufacturer's package insert for latanoprost eye drops read in part, store unopened bottle(s) under refrigeration at 36 to 46 F. Once it was opened for use, it may be stored at room temperature for 6 weeks. An observation of the Hall 400 med cart and interview with Nurse #1 were conducted on 07/18/24 at 4:26 PM. Two opened bottles of latanoprost 0.005% were being stored at room temperature with no open date of when it was put in use. Nurse #1 stated latanoprost eye drops were kept in the refrigerator and should be dated when removed and could be left at room temperature in the med cart when in use. Nurse #1 was unsure how long the latanoprost eye drops were in use and revealed she had not administered them and usually was not assigned to administer medications from the Hall 400 med cart. During an interview on 07/19/24 at 12:35 PM the Director of Nursing (DON) revealed latanoprost eye drops were stored in the refrigerator and should be dated when removed and placed on the medication cart for in use. During an interview on 07/19/24 at 4:41 PM the Administrator revealed it was the expectation the nurse who removed the latanoprost eye drops from the refrigerator and placed it on the medication cart for use to date the bottle. b. Review of manufacturer's package insert for tuberculin read in part, this product should be stored between 36 and 46 F and vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. An observation of the medication storage room for halls 200, 300, and 400 with the DON was conducted on 07/18/24 at 4:03 PM. Stored in the refrigerator were two open vials of tuberculin purified protein derivative with no date of when they were put in use. The DON revealed she was unsure when the 2 vials were opened. An observation of the medication storage room for halls 500, and 600 with the DON was conducted on 07/19/24 at 12:37 PM. Stored in the refrigerator was one open vial of tuberculin purified protein derivative with no date of when it was put in use, four boxes containing 10 individual influenza vaccines with an expiration date 06/30/24 and five acetaminophen suppositories with the expiration date 06/24/24. The DON revealed either her or the Assistant Director of Nursing checked the refrigerators in the medication rooms for unlabeled and expired medications and the Infection Preventionist was responsible for checking the expiration dates on the influenza vaccines. During an interview on 07/19/24 at 3:47 PM the Infection Preventionist revealed she was not aware she was supposed to check the expiration dates for the influenza vaccines stored in the medication rooms. An interview was conducted on 07/19/24 at 4:41 PM with the Administrator. The Administrator revealed the nurses administered the tuberculin purified protein derivative and were responsible for dating the vial when accessed and put in use. She revealed it was her expectation the medication rooms were regularly checked and expired medications and vaccines were removed from the refrigerator.

Based on observation of the meal service tray line, record review, and Registered Dietician and dietary staff interviews the facility failed to provide all food items as specified by the planned menu for residents receiving a pureed (foods that have a smooth consistency and don't have to be chewed) diet. This practice had the potential to affect 6 of 6 residents receiving a pureed diet. Findings included: During a continuous observation of the lunch meal tray line on 07/17/24 from 11:50 AM until 12:50 PM [NAME] #1 plated pureed chicken and dumplings and pureed beets using a 4-ounce serving utensil. No pureed bread was provided on pureed meal trays. Review of the menu revealed the following portions were to be served on 07/17/24 for the lunch meal: -pureed chicken and dumplings 4-ounce serving -pureed beets 4-ounce serving -1 serving of pureed bread mix Cook #1 was unable to be interviewed during the survey. An interview with the Dietary Manager on 07/17/24 at 1:05 PM revealed [NAME] #1 was responsible for following the menu and he was not sure why she had not prepared pureed bread. A telephone interview with the Registered Dietician (RD) on 07/17/24 at 1:26 PM revealed she expected dietary staff to follow the menu as planned and she was not sure why pureed bread had not been prepared. An interview with the Administrator on 07/19/24 at 4:16 PM revealed she expected menus to be followed as planned unless a substitution approved by the RD was provided.

The facility failed to ensure the physician's order for an advanced directive matched the medical orders for scope of treatment (MOST) form signed by the resident's family for 1 of 18 residents (Resident #270) reviewed for advanced directives. The findings included: Resident #270 was admitted to the facility on [DATE]. Review of the brief interview for mental status (BIMS) interview dated [DATE] revealed that Resident #270 was moderately cognitively impaired. Review of the baseline care plan dated [DATE] revealed resident #270 was documented as a full code (lifesaving efforts such as Cardiopulmonary Resuscitation (CPR) were to be conducted). Review of the physician's orders dated [DATE] revealed an order for the resident to be a full code. Review of the MOST form dated [DATE] revealed (section A) do not resuscitate (DNR) (lifesaving efforts such as CPR are not to be conducted) with (section B) limited interventions to use medical treatment, intravenous (IV) fluid and cardiac monitoring as indicated. Do not use intubation or mechanical ventilation. May consider the use of less invasive airway support such as BIPAP or CPAP. Also provide comfort measures. Transfer to hospital if indicated. Avoid intensive care. (section C) Antibiotics if indicated. (section D) IV fluids if indicated and no feeding tube. (section E) Signed by Resident #270's family. An interview with the Assistant Director of Nursing (ADON) on [DATE] at 1:26 PM revealed that the facility received situation, background, assessment, recommendation (SBAR) report (a communication framework that nurses used to share important information about a patient's condition with other health care team members) from the hospital which included code status as full code. The ADON entered the order for Resident #270's code status of full code into the electronic health record. It was expressed to the family and Resident #270 upon arrival to the facility that they could change Resident #270's code status if they wanted from full code to DNR. The family of Resident #270 decided to change her code status from full code to DNR with limited interventions upon Resident #270's admission. The facility interdisciplinary team (IDT) reviewed all new residents code status the following business day to ensure accuracy in the event the families or residents made changes upon admission. Resident #270 was admitted on Friday [DATE] so her code status and the MOST form should have been reviewed Monday [DATE] to ensure they matched but it must have been overlooked. When asked what would have happened if Resident #270 had an emergency that required her code status, the ADON stated that staff were trained to check in the physical chart for the MOST form for the most up to date code status for new residents before providing medical intervention. An interview with the Director of Nursing (DON) on [DATE] at 1:46 PM revealed that if residents were DNR the facility would confirm that with the resident or family and ensure the code status orders and MOST/ DNR forms match. The MOST form was filled out at admission and reviewed with the physician. She stated her expectation was that code status ordered in the electronic health record should match the MOST form for the resident. An interview with the Executive Director on [DATE] at 10:57 AM revealed that her expectation was the order for the code status should match the MOST form signed by the family.

Based on record review, observations, and interviews with staff, the facility failed to provide oral hygiene assistance for a dependent resident with visibly dirty dentures and teeth for 1 of 11 residents reviewed for activities of daily living (Resident #64). Findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses including dementia and seizure disorder. The admission Minimum Data Set assessment dated [DATE] revealed Resident #64's cognition was severely impaired and setup assistance was needed with oral hygiene. The activities of daily living care plan last reviewed on 06/18/24 revealed Resident #64 required assistance to maintain or attain the highest level of functioning. Interventions included to assist with activities of daily living care as needed. Observations on 07/15/24 at 2:20 PM and 07/16/24 at 3:27 PM revealed Resident #64's upper denture and lower teeth appeared dirty with a visible white colored buildup of debris on several of the front upper and lower teeth. An observation and interview was conducted on 07/18/24 at 11:35 AM with the Director of Nursing (DON). Resident #64 removed his lower plate and upper denture and gave them to the DON. A white colored buildup was observed on several of the teeth and gums of the upper denture and lower plate. The DON stated she was not sure when Resident #64 last received assistance with oral hygiene, but both the upper denture and lower plate needed to be cleaned and she placed them in a denture cup to soak. It was shared with the DON previous observations were made and there had been no change in the appearance of Resident #64's teeth that continued to appear dirty with a white colored buildup. An interview was conducted on 07/18/24 at 12:03 PM with NA #3. NA #3 revealed she was not aware Resident #64 had dentures and usually was not on her assignment. She stated Resident #64 needed setup assistance and confirmed she had not provided assistance for oral hygiene on 7/16/24 or 07/18/24. When asked why setup assistance for oral hygiene was not provided NA #3 reiterated, she was not aware Resident #64 had dentures. A follow-up observation and interview was conducted on 07/18/24 at 3:52 PM with the DON. The DON stated oral care was done in morning when getting residents up and dentures were soaked overnight. Resident #64 showed his upper and lower teeth that appeared clean with no visible white colored buildup of debris. During an interview on 07/19/24 at 4:46 PM the Administrator revealed NA staff were expected to provide assistance with oral hygiene daily and as needed when teeth were visibly dirty.

Based on observations, record review, Registered Dietitian, Physician Assistant, and staff interviews, the facility failed to follow a physicians order to administer the correct amount of a high protein, fiber fortified nutritional supplement as recommended by the Registered Dietitian for 1 of 2 residents reviewed for tube feeding (Resident #15). Findings included: Resident #15 was admitted to the facility on [DATE] with multiple diagnoses that included dysphagia (difficulty swallowing) following cerebral infarction (stroke) and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was severely impaired with cognitive skills for daily decision making and was dependent on staff assistance for all self-care tasks, bed mobility and transfers. Resident #15 received tube feeding while a resident and received 51% or more of total calories and 501 cubic centimeters (cc) or more of fluid intake via tube feeding. Review of Resident #15's comprehensive care plans, last reviewed/revised on 05/31/24, revealed a plan that addressed her nutritional needs related to tube feedings. Interventions included to provide total staff assistance with tube feeding and water flushes, see physician orders for current tube feeding orders, and the Registered Dietitian (RD) to make recommendations for changes to tube feeding as needed. A RD progress note dated 06/05/24 revealed in part, Resident #15's estimated oral intake was exceeding her estimated calorie and protein needs but was not meeting her estimated fluid needs as evidenced by recent laboratory results indicating poor hydration status. The RD recommended either 1) decreasing the fortified nutritional supplement 1.5 tube feedings to 55 milliliters (ml)/hour (hr.) with water flushes of 20 ml/hr. for 22 hours from 8:00 PM to 6:00 AM or 2) change to fortified nutritional supplement 1.2 tube feedings at 70 ml/hr. with water flushes of 10 ml/hr. for 22 hours from 8:00 PM to 6:00 AM. A physician order dated 06/27/24 for Resident #15 read in part, fortified nutritional supplement 1.5 at 55 ml/hr. and add water flushes of 20 ml/hr. for 22 hours, from 8:00 PM to 6:00 AM two times a day. Review of Resident #15's July 2024 Medication Administration Record (MAR) revealed tube feedings were initialed as completed per physician order. An observation of Resident #15 on 07/15/24 at 11:37 AM revealed her tube feeding was running through the pump at 50 ml/hr. with water flushes at 20 ml/hr. The bottle of tube feeding was dated 07/15/24 at 6:00 PM. A second observation of Resident #15 on 07/16/24 at 8:16 AM revealed her tube feeding was running through the pump at 50 ml/hr. with water flushes at 20 ml/hr. The bottle of tube feeding was dated 07/16/24 at 11:00 PM and initialed by Nurse #2. An observation and interview was conducted with the Director of Nursing (DON) on 07/16/24 at 8:30 AM. The DON confirmed that Resident #15's tube feeding was set at 50 ml/hr. and should have been set at 55 ml/hr. The DON stated the physician order should be followed for the proper tube feeding settings and felt Nurse #2 likely just misread the order. During a telephone interview on 07/16/24 at 4:51 PM, the RD revealed her recommendations for tube feedings depended on what the provider agreed with and/or what the resident could tolerate. The RD stated that since she didn't observe Resident #15's tube feeding settings at 50 ml/hr. or speak with Nurse #2, she could not state what her expectation was regarding why her recommendation for Resident #15 to receive tube feedings at 55 ml/hr. was not followed. Telephone attempts for an interview with Nurse #2 on 07/18/24 at 10:51 AM and 07/18/24 at 3:02 PM were unsuccessful. During an interview on 07/18/24 at 10:59 AM, the Physician Assistant stated that she would like for staff to follow the tube feeding orders recommended by the RD. During an interview on 07/18/24 at 5:09 PM, the Administrator stated she was not clinical and could not state what she would expect without first talking to Nurse #2 to see why Resident #15's tube feeding settings did not match the physician's order.

Based on record review, observations, and staff and resident interviews the facility failed to honor food preferences for 1 of 3 residents reviewed for food preferences (Resident #9). Findings included: Resident #9 was admitted to the facility 06/12/22 with diagnoses including anemia and malnutrition. Review of Resident #9's Physician orders revealed an order dated 06/08/24 for a regular diet. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 was cognitively intact, required set-up or clean-up assistance with eating, and no weight loss or weight gain. Resident #9's nutrition care plan last revised on 06/18/24 revealed she had a potential nutritional problem related to coughing during meals. Interventions included providing and serving diet as ordered and assuring Resident #9 was out of bed for all meals. An interview with Resident #9 on 07/15/24 at 11:47 AM revealed she had asked dietary staff (the Dietary Manager and other dietary employees) multiple times for yogurt with each meal and had not received yogurt on her meal trays. Resident #9 was observed with her meal trays on 07/15/24 at 12:36 PM, 07/16/24 at 8:32 AM, and 07/17/24 at 8:20 AM. No yogurt was observed on her meal trays and no request for yogurt with all meals was observed on her meal ticket until 07/17/24. An interview with the Dietary Manager on 07/16/24 at 12:12 PM revealed he was aware Resident #9 had requested to receive yogurt on all her meal trays, yogurt was available from the kitchen, and he was not aware of any concerns that she had not been receiving yogurt per her preference. He stated he had not performed any audits of meal trays to ensure residents were receiving food per their preference since he began employment approximately one month ago. An interview with the Administrator on 07/19/24 at 4:16 PM revealed she expected residents' food preferences to be followed.