Every finding on record at Manly Specialty Care

Based on clinical record review, facility policy review, and staff interviews the facility failed to report allegations of abuse to the Iowa Department of Inspections, Appeals, and Licensing (DIAL) for 2 of 3 residents reviewed (Resident #5, Resident #39, and Resident #20). The investigation determined the facility failed to report when Resident #39 pushed Resident #5 in one incident and grabbed her in another incident. in addition, the facility failed to report when Resident #39 poked Resident #20 in the head. The facility reported a census of 36 residents. Findings include:Resident #39's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Resident #39 experienced verbal behavioral symptoms directed towards others for 1 to 3 days in the lookback period. The MDS listed Resident #39 as independent with walking 10 feet and 50 feet with two turns. She didn't use a wheelchair or a scooter. The MDS included diagnoses of non-Alzheimer's dementia, Alzheimer's disease, anxiety, and depression. Review of the facility report list to DIAL lacked documentation of reporting an allegation of resident-to-resident abuse involving Resident #39 on 1/31/26, 2/4/26, and 2/17/26. 1. The Behavior Note dated 1/31/26 at 4:17 PM indicated Resident #39 went into another resident's room (Resident #5). Resident #39 yelled at Resident #5, tried to get her out of her bed, and pushed her. In addition, Resident #39 got into a third resident's face and yelled at them to get out of her seat.2. The Behavior Note dated 2/4/25 at 9:37 PM reflected during supper Resident #39 got in another resident's space and slapping the air in front of her to get the resident's attention. Resident #39 took their supper and dumped it on another resident's plate. Resident #39 told them they to eat it after they already ate off of the plate. Resident #39 then started to lightly poke another resident in the head. The staff stepped in between to intervene. Resident #39 grabbed the staff's left wrist and thumb hard. Resident #39 bent the staff's thumb all the way back and knocked the staff member's radio out of their hand as they went to radio for help. Resident #39 called the staff member a b*tch and said they got them; no one was to help them. On 3/3/26 at 2:40 PM the Administrator reported the incident on 2/4/26 was not reported to DIAL when Resident #39 poked another resident in the head. On 3/4/26 at 7:45 AM the Director of Nursing (DON) reported the incident on 2/4/26 was not reported because they felt it could go either way because it was charted that she didn't poke her hard. She reported she was not sure who the resident was so will find out. On 3/4/26 at 8:06 AM the DON reported Resident #20 as the other resident in the incident on 2/4/26. 3. The SPN - Focused Evaluation Noted dated 2/17/26 at 1:50 PM indicated Resident #39 grabbed another resident's arm and held it until someone separated them. The note lacked documentation of the identity of the other resident. On 3/5/26 at 1:30 PM the DON reported Resident #5 as the resident grabbed by Resident #39 on 2/17/26. On 3/5/26 at 8:20 AM The DON and Administrator reported they reported the resident-to-resident incident on 1/31/26, but not the incident on 2/4/26. They reported after reviewing, they saw where they should have reported the incident. The facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevent Program revised April 2021 documented to report allegations within the required timeframe by federal requirements.

Based on clinical record review, policy review and staff interview, the facility failed to document non-pharmacological interventions prior to administering anti-anxiety medication for anxiety and/or restlessness for 1 of 1 resident sampled (Resident #39). The facility identified a census of 36. Findings include:Resident #39's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 4, indicating a severe cognitive loss. The MDS listed diagnoses of non-Alzheimer's dementia, depression, and anxiety. Resident #39's Medication Administration Record (MAR) for February documented Haloperidol (an antipsychotic medication) 0.5 milligrams (mg). Administer every 8 hours as needed for agitation and irritability. Resident #39's MAR for February 2026 documentation reflected the nurse administered Haloperidol on the 15th, 18th, 20th, 22nd, 23rd, 24th, 25th, 26th, 27th and 28th. The supplemental documentation lacked documentation of nonpharmacological interventions tried prior to administering Haloperidol. Resident #39's March 2026 MAR documented Haloperidol 0.5 mg. Administer every 8 hours as needed for agitation and irritability. The documentation reflected the nurse administered Haloperidol on the 2nd and 3rd. The supplemental documentation lacked documentation of nonpharmacological interventions tried prior to administering the medication. The Care Plan undated indicated Resident #39 utilized psychotropic medications. The Targeted Goal of 3/15/26 aimed for Resident #39 to remain free of complications related to the use of psychotropic medication. The Care Plan Intervention directed staff to document the number of target behaviors, the behaviors observed, and interventions for Antipsychotic medication. Resident #39's Progress Notes lacked documentation of interventions prior to giving the as needed Haloperidol. On 3/4/26 at 9:48 AM Staff A, Registered Nurse (RN), reported the nurses should document the interventions tried in the progress notes prior to giving the psychotropic medication. On 3/4/26 at 9:50 AM Staff B, RN, said the nurses should document the interventions tried prior to giving a psychotropic medication in the progress notes. On 3/4/26 at 9:54 AM the MDS coordinator reported the staff should document the as needed psychotropic medications, the behaviors, and interventions tried prior to giving in the supplemental documents. She reported the staff did the supplemental documentation once each shift. She reported since it is done once a shift she could not say when the behaviors happened or what interventions the staff tried for each medication since it is done once a shift. On 3/4/26 at 10:32 AM the Director of Nursing (DON) reported the nurses should chart the behaviors and interventions done prior to giving as needed psychotropic medications in the chart. She acknowledged the resident's chart lacked documentation on several occasions. The facility policy titled Antipsychotic Medication Use revised December 2016 directed to not use antipsychotic medications unless behavioral symptoms are not sufficiently relieved by non-pharmacological interventions.

Based on clinical record review, facility policy review, and staff interviews the facility failed to investigate and review interventions to ensure interviews are adequate to prevent further abuse for a known resident with a history of aggression for resident-to-resident abuse for 2 of 3 resident reviewed. (Residents #5, #20, and #39). Resident #39 grabbed Resident #5 and poked Resident #20 in the head. The facility reported a census of 36 residents. Findings include:1. Resident #39's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Resident #39 experienced verbal behavioral symptoms directed towards others for 1 to 3 days in the lookback period. The MDS listed Resident #39 as independent with walking 10 feet and 50 feet with two turns. She didn't use a wheelchair or a scooter. The MDS included diagnoses of non-Alzheimer's dementia, Alzheimer's disease, anxiety, and depression. The Care Plan Focus revised 2/13/26 indicated Resident #39 had a behavior problem and can become verbally aggressive towards staff and residents. The Care Plan documented the following interventions:a. 1/19/26: Resident #39 has a history of taking other residents' food, drinks, or personal belongings away from them stating they stole it from her. Please offer Resident #39 her own drink and food. The staff know of Resident #39's history and retrieve items at a later time. b. 2/2/26: Resident #39 gets upset with other residents and yells at them, or goes into their room and wake them up. Please intervene and redirect. c. 2/12/26: Resident #39 has placed her hands on another resident. Staff need to be aware and monitor their Interactions. d. 2/13/26: Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner, divert attention as needed. Remove from the situation and take to an alternate location as needed.The Care Plan lacked interventions related to her aggression and what to do when she got aggressive to protect her and other residents. 1. The Behavior Note dated 1/31/26 at 4:17 PM indicated Resident #39 went into another resident's room (Resident #5). Resident #39 yelled at Resident #5, tried to get her out of her bed, and pushed her. In addition, Resident #39 got into a third resident's face and yelled at them to get out of her seat.The note lacked documentation of the identity of the third resident involved.2. The Behavior Note dated 2/4/25 at 9:37 PM reflected during supper Resident #39 got in another resident's space and slapping the air in front of her to get the resident's attention. Resident #39 took their supper and dumped it on another resident's plate. Resident #39 told them they to eat it after they already ate off of the plate. Resident #39 then started to lightly poke another resident in the head. The staff stepped in between to intervene. Resident #39 grabbed the staff's left wrist and thumb hard. Resident #39 bent the staff's thumb all the way back and knocked the staff member's radio out of their hand as they went to radio for help. Resident #39 called the staff member a b*tch and said they got them; no one was to help them. Further review lacked documentation of the residents involved in the incident during supper.On 3/4/26 at 7:45 AM the Director of Nursing (DON) reported the facility didn't report the incident on 2/4/26 because they felt it could go either way, as the documentation indicated she didn't poke her hard. She added she didn't know who the resident was, so she would find out. On 3/4/26 at 8:06 AM the DON reported Resident #20 as the other resident in the incident on 2/4/26. 3. The SPN - Focused Evaluation Noted dated 2/17/26 at 1:50 PM indicated Resident #39 grabbed another resident's arm and held it until someone separated them. The note lacked documentation of the identity of the other resident. The review of the list of incidents reported by the facility to DIAL lacked documentation of incidents of resident-to-resident abuse on 1/31/26, 2/4/26, and 2/17/26. On 3/5/26 at 8:20 AM The DON and Administrator reported they didn't do investigations for the incidents on 1/31/26 and 2/4/26, as they didn't have an incident report. They confirmed the staff didn't do an assessment after the incidents to make sure the other residents didn't have injuries, psychosocial harm, and they didn't initiate follow-ups after the incident. On 3/5/26 1:28 PM observed the DON coming out of a room behind the nurses' station with a statement about the 2/17/26 incident. On 3/5/26 at 1:30 PM the DON reported Resident #5 as the resident grabbed by Resident #39 on 2/17/26. Review of the DON's investigation lacked documentation of identity of the other resident in the incident on 2/17/26. On 3/5/26 at 1:40 PM the DON reported she talked with Staff D, Registered Nurse (RN), on the 17th to clarify the incident of Resident #39 grabbing another resident's arm. She reported she was clarifying Staff D's statement she got from that day and had her sign it that day. She added that is why she walked out with the paper after seeing Staff D. She reported she wanted to make sure that is what she reported. The DON reported she did not do a follow up in the chart like she did with the other resident-to-resident incidents she clarified. She acknowledged the documentation didn't match the statement. She reported Staff D declared Resident #5 as the other resident. She acknowledged the facility didn't have a follow-up with Resident #5, documentation at the time, or an assessment of Resident #5. On 3/5/26 at 2:38 PM Staff D, described the incident on 2/17/26 as Resident #39 had her hand on her forearm, leaning towards the other resident's face, she told the other resident they wore her clothes. Staff D reported Resident #39 wasn't upset or agitated but Staff D told Resident #39 her name and asked her to remove her hand from the other resident's forearm. Resident #39 moved her hand as soon as Staff D said something to her. Staff D reported she didn't remember who the other resident was. When asked when they discussed the incident, Staff D wouldn't give a date but reported when asked by the DON to clarify. The facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevent Program revised April 2021 documented to report allegations within the required timeframe by federal requirements.

Based on observations, staff interviews and policy review the facility failed to maintain a sanitary kitchen; failed to serve and prepare food in accordance with professional standards for food safety to reduce the risk of cross contamination and food borne illness. The facility reported a census of 36 residents. Findings include:On 3/2/26 at 11:00 AM observed the ice machine covered in a mineral deposit build-up all over the sides of the machine. Inside the ice machine noted mineral deposit build-up streaks and small pin point black particles in the ice machine on the white plastic baffle (A shield that directs falling ice to the back of the bin, preventing it from jamming the door). On 3/3/26 at 3:54 PM observation of the Ice machine remained the same as the previous day. On 3/4/26 at 8:20 AM the Maintenance Supervisor reported he deep cleaned and descaled the ice machine every 6 months and the kitchen cleaned it weekly. He reported it has been an ongoing issue with the ice machine mineral deposit build-up. He reported nothing gets it fully cleaned. On 3/4/26 at 10:55 AM the Dietary Manager reported the ice machine is cleaned every other week. She reported she can't get the buildup off the machine and can't get the inside clean. She explained she tried several different products to get it cleaned but it just doesn't get cleaned. The facility policy title Ice Machine and Ice Storage Chests revised January 2012 documents the facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions. Further review of the policy lacked direction if following the instructions the ice machine can't get cleaned properly what the facility should do.

Based on record review, facility policy review and staff interviews the facility failed to ensure staff protected and prevented resident-to-resident abuse for 1 of 3 reviewed (Resident #45). Resident #39 hit Resident #45 on the right upper arm. At the time of the incident Resident #45 sat with a staff member. The staff member failed to intervene until after Resident #39 hit Resident #45. Resident #39 had a known history of resident-to-resident altercations and the facility failed to evaluate the effectiveness of the interventions to prevent harm to other residents, see F609 and F610 for additional information regarding additional incidents. The facility reported a census of 36 residents. Findings include:Resident #39's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Resident #39 experienced verbal behavioral symptoms directed towards others for 1 to 3 days in the lookback period. The MDS listed Resident #39 as independent with walking 10 feet and 50 feet with two turns. She didn't use a wheelchair or a scooter. The MDS included diagnoses of non-Alzheimer's dementia, Alzheimer's disease, anxiety, and depression. Resident #39's Care Plan with a Focus area revised on 2/13/26 I have a behavior problem and can become verbally aggressive towards staff and residents. The Care Plan Focus revised 2/13/26 indicated Resident #39 had a behavior problem and can become verbally aggressive towards staff and residents. The Care Plan documented the following interventions:a. 1/19/26: Resident #39 has a history of taking other residents' food, drinks, or personal belongings away from them stating they stole it from her. Please offer Resident #39 her own drink and food. The staff know of Resident #39's history and retrieve items at a later time. b. 2/2/26: Resident #39 gets upset with other residents and yells at them, or goes into their room and wake them up. Please intervene and redirect. c. 2/12/26: Resident #39 has placed her hands on another resident. Staff need to be aware and monitor their Interactions. d. 2/13/26: Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner, divert attention as needed. Remove from the situation and take to an alternate location as needed.The Facility Incident Report documented on 3/3/26 indicated Resident #39 approached Staff C, Certified Nurse Aide (CNA), and tried to grab her belongings as she left work for the day. Staff C set them behind her. When Resident #39 attempted to strike Staff C, Staff C responded that was not nice. Afterwards, Resident #39 went to a dining room table where Resident #45 sat. As Resident #45 talked, Resident #39 told them to shut up and slapped Resident #45 on her right arm. Staff C sat between the residents to separate them. On 3/4/26 at 7:27 PM Staff C confirmed they worked at the time of the incident on 3/3/26. Staff C reported as they prepared to finish and leave their shift, she sat at the table with Resident #45 visiting when Resident #39 came and asked whose coat it was. Staff C reported it was hers and pushed it further under her feet at the table. Resident #39 yelled and swung at her but hit the air. Staff C said oh you must not be in a good mood. She continued to talk to Resident #45 at the table, when Resident #39 sat in a chair on the other side of Resident #45 away from Staff C. As Resident #45 talked to Staff C, Resident #39 proceeded to tell Resident #45 to shut up and then hit her on the shoulder. Staff C reported she got up right after the incident and got between the residents. Staff C reported she is well aware of Resident #39's behaviors and aggression but reported she is hard to redirect so it is best to just let her walk around and do her thing. She reported she knew about Resident #39 being aggressive toward staff and other residents. On 3/5/26 at 8:25 AM the Director of Nursing (DON) reported when a resident in the unit gets agitated or upset, the staff should redirect the resident away from other residents. They need to try to figure out why the resident is upset or agitated and separate them from other residents to protect the other residents. The facility policy titled Identifying Types of Abuse revised April 2021 defined physical abuse as not limited to hitting, slapping, biting, punching or kicking.The facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevent Program revised April 2021 instructed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on facility records, review of the Facility Assessment, and staff interviews, the facility failed to have a clinically qualified nutrition professional who met the required qualifications of a Certified Dietary Manager or a full time Registered Dietician. The facility reported a census of 41 residents. Findings Include: On 2/24/25 at 10:20 AM, Staff A, [NAME] stated the facility didn't have a kitchen manager and haven't had one for approximately six months. She stated worked there for approximately three years. Staff A stated she assisted with some duties such as ordering supplies but she is not officially the kitchen manager. On 2/26/25 at 10:12 AM, the Administrator stated the prior Certified Dietary Manager, still worked at the facility but no longer in that position worked approximately 25 hours a week. He added she occasionally did pick up extra shifts. The Facility Assessment, dated 12/17/24 indicated the facility personnel should include a Registered Dietitian and Nutrition Services Staff. It further stated each department is led by a department manager. In addition, the Facility Assessment instructed the facility is to employ one full time Dietary Manager. On 2/26/25 at 4:16 PM, the Registered Dietitian stated she visited the facility approximately once a month. She stated the corporation has a traveling Certified Dietary Manager, who went to the facility several times to help out. On 2/27/25 at 9:34 AM, Staff F, Cook, stated she was the prior Dietary Manager for the building.

Based on observation, staff interviews, guidance from the 2022 Food and Drug Administration (FDA) Food Code, and facility policy, the facility failed to serve food within the acceptable temperature range. The facility reported a census of 41 residents. Findings include: Continuous observation of lunch service stated on 2/26/25 at 11:05 AM. Observed Staff A, Cook, preparing the foods for the residents who required a pureed diet. After completing the task, she was ready to begin lunch service and proceeded to take the food temperatures of all foods prior to serving. All hot foods were found to be at an appropriate temperature. When she checked the cold foods, she documented the following at 11:23 AM: Chilled Pears 41.5 degree Fahrenheit ( F) Chef salad 45 F Milk 38.9 F Cottage cheese 45 F Staff A left all items out at room temperature. Staff A gathered menu cards and other items needed for meal service, and service began at 11:30 AM. As Staff A prepared plates for each resident of the facility, noted several residents requested deli sandwiches in place of the scheduled entree. Witnessed a tray of deli sandwiches on a shelf above the steam table. No observed logged temperature of the lunch meat prior to serving. On 2/26/25 at 11:44 AM, Staff A placed the chef salad on the serving cart for Resident #34, 21 minutes after it had temped at 45 F at room temperature. Meal service was complete at 12:14 AM. The staff served all of the chef salads and cottage cheese. On 2/25/25 at 12:16 PM, when asked about the cold items being too warm when she took the food temperatures, Staff A replied they just came out of the refrigerator and she serves them, regardless of the temperature. On 2/26/25 at 4:15 PM, the Registered Dietitian stated she expected cold foods to be returned to the refrigerator and not served until they were at 41 F or colder. The facility policy Food Preparation and Service, revised April 2019 documented the following: a. The danger zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. b. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. c. The longer foods remain in the danger zone, the greater the risk for growth of harmful pathogens. Therefore, PHF (potentially hazardous food) must be maintained below 41 F or above 135 F. The 2022 FDA Food Code directed Time/Temperature control for safety food shall be maintained: a. At 57 C (135 F) or above b. At 5 C (41 F) or less

Based on observation, facility documentation, staff, and resident interview, the facility failed to follow the posted menu and serve the appropriate portions for 3 of 3 residents who received pureed diets (Residents #13, #21, and #24). In addition, the facility failed to serve the ordered therapeutic menu for 5 of 5 residents with an order for low sodium diets. Additionally, 2 residents, (Residents #8 and #11) didn't get the substitution menu as they requested. 2 other residents (Residents #20 and #38) didn't receive their double proteins as directed on their menu cards. In addition, the facility had 19 residents with an order for the NIP (Nutritional Intervention Program), adding extra foods/calorie/nutrition to their meals. Of the 19 residents with the NIP on their menu cards, 9 of them didn't receive any extra food on their trays. The facility reported a census of 41 residents. Findings Include: Posted lunch menu for 2/26/25: Baked [NAME] Chicken, 4 ounces (oz) Poultry Gravy, 2 oz Garden [NAME] 1/2 cup or White [NAME] 1/2 (for residents on low sodium diet) Herbed [NAME] Beans 1/2 cup Wheat Roll Margarine Chilled Pears 1/2 cup During a continuous lunch observation on 2/26/25 starting at 11:05 AM, Staff A, Cook, reported she had 2 residents in the building on a puree diet but she always makes a little extra. Staff A performed hand hygiene, then took an unmeasured amount of baked rosemary chicken and placed it in the food processor using tongs. She added an unmeasured amount of broth. She described it as roughly three servings. After pureeing the food to the appropriate texture, she obtained 3 bowls and used a 4 oz, #8 scoop, and divided the puree into the 3 bowls. The food processor still had some chicken puree left in the bowl. Using a spatula, she took the leftover chicken and placed it in the fourth bowl. She placed lids on all of the bowls, and placed the 3 full bowls into the microwave, then she set the fourth bowl aside separately. No observation occurred of Staff A measuring the total volume of the puree prior to separating it into bowls. Staff A next used a 4 oz, #8 scoop and pureed 2 servings of green beans along with the juice to an appropriate texture. She divided the mixture into 2 bowls with no measurements. Staff A stated they pureed the fruit prior to the beginning of the observation. No observation occurred of Staff A pureeing any dinner rolls as directed on the menu. Staff A checked beginning food temperatures and gathered supplies. She performed hand hygiene and was ready to begin serving lunch at 11:30 AM. Staff A first prepared plates for the CCDI Unit (Chronic Confusion Dementing Illness, a locked unit for dementia residents). Resident #13, who resides on the CCDI, had a puree diet order. She received the pureed chicken with gravy, pureed green beans, and pureed fruit. Her meal didn't include a dinner roll. Service continued with multiple regular diet residents. Some residents requested substitute meals, some receiving deli sandwiches and some receiving grilled cheese in place of the main entree. Resident #21 received the next puree diet tray. This tray included pureed chicken with gravy, green beans, and pears, again they didn't receive a dinner roll. Resident #24 received the final puree diet tray. She received pureed chicken with gravy and pears, without a dinner roll. Per her menu card, she wished to have mashed potatoes rather than green beans. On 2/26/25 at 11:42 AM, Staff A took a bowl to the hot water dispenser and put an unmeasured amount of hot water in the bowl. She added an unmeasured amount of instant mashed potato flakes to the bowl, stirred it, and placed it on the tray for service with no measurement and/or temperature taken. Resident #37, low sodium diet ordered, received the next meal tray. He received garden rice rather than the white rice ordered for low sodium diet residents. Resident #40 received the next prepared plate. He received a wheat roll, making him the only resident of the entire building to receive a wheat roll as directed on the posted menu. When making his plate, Staff A obtained a single dinner roll from a zipped bag and provided it to him. No other dinner rolls were seen during the observation. In addition, noted Residents #5, #16, #23 & #30 all had orders for a low sodium diet. All of them also received garden rice rather than white rice. Resident #8 requested a grilled cheese sandwich per her menu card. Staff A stated she ran out of grilled cheese sandwiches, so she provided a ham salad sandwich as a substitute. Resident #20's menu card instructed to give double portions of protein. He had ordered a deli sandwich and he received the same deli sandwich as the other residents. No double proteins were observed. Resident #38 also had double proteins ordered on her menu card. She received green beans, pears and a single serving of cottage cheese. She did not receive any chicken or other protein. (Drinks were not observed). Resident #11's menu card directed he requested a grilled cheese sandwich. Instead, he also received a ham salad sandwich. On 2/26/25 at 11:50 AM Staff A stated the facility ran out of ice cream, but they had a truck coming the following day. On 2/26/25 at 12:00 PM, Staff A said Staff C, Restorative Aide Certified Nurse Aide (RA, CNA), on the evening shift tallied all of the requests and didn't tally the grilled cheese sandwiches correctly so they didn't make enough. With 6 residents still remaining to get their meal, observed the steam table empty of the seasoned green beans. Staff A asked one of the dietary aides to open and warm up some wax beans to serve to the remaining residents. Service ended on 2/26/25 at 12:13 PM. On 2/26/25 at 12:16 PM, Staff A stated she knew the low sodium residents were supposed to receive white rice and she forgot to make it so she served the garden rice instead. She stated her normal process to puree is to puree the correct serving size and divide into bowls. An observation revealed a laminated document titled Puree Process hanging on the bulletin board near the steam table. It detailed step by step instructions of pureeing food. Step 4 read measure the total volume of the food after it is pureed. Step 5 directed to divide the total volume of the pureed food by the original number of portions, with instruction to see the Puree Scoop Chart for reference. When questioned about the puree instructions hanging on the bulletin board, Staff A replied she didn't know that adding broth, etc. would change the volume of the pureed food. Staff A stated she remembered they used to have a chart but she hadn't seen it in a long time. She stated she remembered a long time ago they had education on pureeing and using the chart but she forgot it as it happened so long ago. Staff A stated she had worked at the facility for three years. When asked how the residents choose their meals, and how that gets printed onto the menu cards, she responded the Restorative Aides take the meal orders. During the meal service observed several tray cards listed with the NIP alert on them (Nutritional Intervention Program). When questioned about what food to give to the NIP residents, Staff A replied the residents who received cottage cheese were the NIP residents. Upon a subsequent review of all menu cards, it revealed 19 residents had the NIP alert on their tray cards. The following 9 residents either had no additional foods ordered, or ordered but didn't receive due to food stock. a. Resident #6 no extra calories/food for the NIP alert on menu card or meal plate b. Resident #29 ordered ice cream on the menu card, but did not receive c. Resident #40 ordered ice cream on the menu card, but did not receive d. Resident #20 no extra calories/food for the NIP alert on menu card or meal plate e. Resident #31 ordered ice cream on the menu card, but did not receive f. Resident #9 no extra calories/food for the NIP alert on menu card or meal plate g. Resident #25 no extra calories/food for the NIP alert on menu card or meal plate h. Resident #13, ordered ice cream on the menu card, but did not receive i. Resident #10 no extra calories/food for the NIP alert on menu card or meal plate On 2/26/25 at 1:19 PM, Staff B, Certified Nurse Aide/Restorative Aide (CNA, RA), explained whoever worked as the Restorative Aide on Mondays took the meal orders for all residents for Tuesday and Wednesday meals. On Wednesdays, they took the orders for Thursdays and Fridays, and on Fridays, they take the orders for Saturday, Sunday and Monday. She stated when she takes the orders, she goes to each resident who is cognitively aware and able to make choices. She reads them the menu, as well as the alternative menu and they choose what foods they want. She stated for the residents who are not cognitively aware and unable to make menu choices, she chose the foods she knew they enjoyed based on her knowing the residents well. She stated she worked at the facility for 5 years, so she generally knew the residents' likes and dislikes. She stated she then entered the orders into the computer and prints the meal tickets and gets them to the kitchen. On 2/26/25 at 1:24 PM, Staff C stated she takes orders from the residents as they come to the therapy room for Restorative exercise. She stated the residents who didn't come to Restorative, she went room to room or to the dining room to get everyone's orders. She stated the residents who can't make their own choices, she gives them what she knows they like. When asked about the residents on pureed diets, she stated she normally gave them the entree and a fruit. When asked why only one person in the entire facility received the dinner roll from the menu, she stated a lot of people just don't like bread and butter. When asked if they took the weight loss and the NIP program into account for the residents who can't make choices, and not being served the carbohydrates on the menu, she stated not really. On 2/26/25 at 4:16 PM, the Registered Dietitian (RD) stated if they didn't have enough grilled cheese sandwiches prepared, they should have stopped service and more made. She stated they are easy enough to make, and she expected them to provide those. In regards to only one resident receiving the dinner roll, she stated the cognitively aware residents can make their own choices. But residents who can't make choices should be provided the entire menu. The RD stated the NIP program is case by case. She stated everyone on NIP should receive some extra item, whether that is cottage cheese or yogurt or ice cream, etc. But should receive something on their trays. The RD said she expected the number of servings plus one additional to be completed in the puree process, then after pureeing, the staff need to use the volume method per the chart for the correct serving size. She received notification the kitchen didn't have an observed volume method chart. On 2/26/25 at 4:49 PM, Resident #8, who received a ham salad sandwich, instead of the grilled cheese she ordered, stated she remembered the ham sandwich and enjoyed it. She stated she thought she ordered something else but couldn't recall what. She stated she sometimes felt very rushed when they took the orders, and receives seconds to make a choice. She said overall the food could be better but it is okay. On 2/27/25 at 11:15 AM, the Director of Nursing stated she thought the program for the menu cards indicated that if residents couldn't to select their menu, they should get the full meal, within their ordered diet. She stated she would verify the process.

Based on record review, policy review and staff interviews, the facility failed to ensure all residents received medication as ordered by a physician; and failed to prevent potentially serious medication errors when staff administered the wrong medications or dosage from 5/8/24 to 2/21/25 for 8 of 8 residents reviewed (Residents #6, #8, #35, 38, #44, #145, #146, #147, and #148). The facility reported a census of 41 residents. Findings include: During a confidential interview staff reported concerns with frequent medication errors and reported concerns that Staff G, Registered Nurse (RN), had several medication errors. The staff member reported they felt the facility didn't look into the medication errors to correct the issue. The facility provided the following Incident Reports related to medication errors: a. 5/8/24: Resident #148 received the wrong medications. Resident #148 received amiodarone (treat heart rhythm problems), colchicine (used to treat inflammation and pain), metoprolol (used to treat high blood pressure), potassium chloride and sertraline (antidepressant). b. 6/16/24: Resident #146 received half the dose of Lyrica (nerve pain medication) then she should have. c. 7/12/24: Resident #8 received the wrong dose of Clozapine (sedative medication used to help with panic attacks, anxiety, and seizures). She received double her ordered dosage. d. 7/17/24 7/19/24: Resident #35 received a double dose of Buspirone (treat anxiety) for 3 days in a row. e. 8/15/24 8/16/24: Resident #38 received hydrochlorothiazide (diuretic) that the provider discontinued for 2 days in a row. f. 9/25/24: Resident #145 received a double dose of Hiprex (antibiotic for urinary tract infections). g. 10/5/24: Resident #6 received both AM and MD doses of Gabapentin (nerve pain medication) at the same time. h. 12/29/24: Resident #44 received Famotidine instead of Lasix (diuretic) i. 1/15/25: Resident #38 received PRN (as needed) oxycodone (narcotic pain mediation) doses just an hour apart and is every 4 hours PRN and was given 3 hours sooner than should have received it. Oxycodone can cause respiratory distress and death when taken in high doses. j. 1/24/25: Resident #147 received lisinopril 20mg and Lisinopril HCTZ 20mg. Lisinopril was discontinued. Both are blood pressure medications. k. 1/28/25: Resident #147 received Glimepiride (diabetic medication) and lisinopril (blood pressure medication) and both medications were discontinued. l. 2/21/25: Resident #38 received Novolog (short acting insulin) 24 units instead of Glargine (long acting insulin) 24 units. 1. Resident #38's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score as a 14, indicating intact cognition. The MDS listed Resident #38 received insulin injections for 7 days in the lookback period. In addition, Resident #38 received a diuretic medication (used to flush the system of excess fluid) in the lookback period. Resident #38 received an opioid within the 7-day lookback period. Resident #38's August 2024 Medication Administration Record (MAR) included an order dated 7/25/24 and discontinued 8/14/24. 8/15/24 and 8/16/24 included x's indicating no active order as documentation. Staff G documented the morning and midmorning medications that day on the MAR. Resident #38's January 2025 MAR listed an order dated 3/4/24 for Oxycodone oral tablet 10 milligrams by mouth every 4 hours as needed for pain. Documentation reflected Staff H, RN, gave Resident #38 Oxycodone on 1/15/25 at 5:35 AM, then Staff G documented giving her Oxycodone on 1/15/25 at 6:52 AM. The Incident, Accident, Unusual Occurrence Note dated 1/17/25 at 9:21 PM identified Resident #38 notified the nurse and Certified Nurse Aide (CNA) that she received 2 doses of her Oxycodone the morning of her surgery (1/15/25). The nurse who worked that day gave a dose of Oxycodone approximately 1 hour after the first nurse gave the medication. Resident #38's Individual Narcotic Record dated 1/9/25 through 2/24/25 documented Staff G gave her 1 Oxycodone at 6:30 AM, after the previous nurse gave a dose at 5:35 AM. Resident #38's February 2025 MAR include an order for the following: a. Insulin glargine (long-acting insulin) solution 100 units/ml dated 1/16/25. Inject 24 units subcutaneously once a day for type 2 diabetes with hyperglycemia (high blood sugar). - Staff I, Licensed Practical Nurse (LPN), documented administering medication on 2/21/25. b. Novolog (rapid-acting insulin) solution dated 5/3/24. Inject 3 units subcutaneously 4 times a day for blood sugars above 150 due to type 2 diabetes with hyperglycemia. - Staff I documented 4, vitals outside of parameters for admission, for the morning, mid-morning, and evening doses. The Incident, Accident, Unusual Occurrence Note dated 2/21/25 at 12:32 PM reflected the nurse administered 24 units of Novolog insulin instead of the ordered 24 units of glargine. The provider ordered to check her blood sugars every 15 minutes for the next 2 hours. 2. Resident #147's January 2025 MAR included the following orders dated: a. 11/2/24, discontinued 1/27/25: Lisinopril-HCTZ (medication use to control blood pressure with a diuretic). b. 1/28/25, discontinued 2/5/25: Lisinopril oral tablet 20 mg. Give 1 tablet by mouth once a day for high blood pressure (hypertension). c. 1/23/25, discontinued 1/27/25: Glimepiride oral tablet 1 mg. Give 1 tablet by mouth once a day for diabetic. d. 12/19/24, discontinued 1/22/25: Glipizide oral tablet 5 mg. Give 0.5 (half) a tablet by mouth once a day for type 2 diabetes. The Incident, Accident, Unusual Occurrence Note dated 1/25/25 at 11:55 AM indicated on 1/24/25 Resident #147 received Lisinopril 20 mg (medication without diuretic to control blood pressure) and Lisinopril-HCTZ. Resident #147 only had an order for Lisinopril-HCTZ. The Nurses Note dated 1/27/25 at 1:57 PM indicated the diabetic center called to give an order to stop glimepiride and start metformin 500 mg. In addition, they ordered to stop the combination Lisinopril (Lisinopril-HCTZ) and start Lisinopril 20 mg once a day. The Incident, Accident, Unusual Occurrence Note dated 1/29/25 at 1:44 AM indicated on 1/28/25 Resident #147 received Glimepiride and Lisinopril. The provider discontinued the medication on 1/27/25. The Nurse removed the medication from the cart. 3. Resident #6's MDS assessment dated [DATE] identified a BIMS score of 12, indicating moderately impaired cognition. The MDS listed Resident #6 received an anticonvulsant (antiseizure) in the lookback period. Resident #6's October 2024 MAR listed an order for gabapentin (anticonvulsant) oral capsule 300 mg. Give 1 capsule by mouth 3 times a day related to polyneuropathy (pain caused by impaired nerves). - Documented as administered by Staff G on 10/5/25 for the morning and midmorning doses. The Incident, Accident, Unusual Occurrence Note dated 10/5/24 at 6:27 PM reflected Resident #6 reported she received 2 gabapentin 300 mg capsules at the same time for lunch when she usually only received one. During an interview 2/26/25 at 11:28 AM the Director of Nursing (DON) reported the facility did meetings to discuss medication errors. She reported she wrote Staff G up in August for the medication error. She didn't have further write ups since the first medication error Staff G did. She reported she didn't do any audits with medication administrations. They assigned all the nurses and medication aides an on line course to complete on common medication errors. On 2/26/25 at 12:18 PM the DON reported Staff G hadn't completed hers yet, but, noted it is due by the end of March 2025. During an interview 2/27/25 at 8:10 AM the DON reported she reported she discussed with Staff G on the phone on the frequent mediation error and Staff G reported it happened because staff interrupted her at the cart during her medication pass. Review of the facility policy titled Administering Medications revised April 2019 directed the staff to administer medications in accordance with the prescriber's orders, including any required time frame. In addition, the policy instructed the staff that the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on clinical record review, facility policy review, resident and staff interview the facility failed to update resident Care Plans for 2 of 12 residents reviewed (Residents #7 and #33) for Care Planning. The facility reported a census of 41 residents. Findings include: 1. Resident #7's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. The MDS included diagnoses of anxiety disorder, bipolar disorder and post-traumatic stress disorder. On 2/24/25 at 3:56 PM, Resident #7 reported Resident #33 is mean to her and makes her cry. She stated Resident #33 bullied her and she reported it to the Administrator. On 2/25/25 at 11:03 AM, the Administrator stated that Resident #33 gets very annoyed quickly with Resident #7. He stated both residents enjoy spending a lot of the day in the dining area and Resident #7 tends to ask a lot of questions. He stated Resident #33 has reached a point that she gets annoyed very quickly with Resident #7. He stated staff has had discussions with Resident #33 regarding the way she speaks to Resident #7. He stated staff is always in the area and are to intervene before anything more comes of it and to spend time with Resident #7 if she is in a mood of asking a lot of questions and to attempt to distract her from speaking with Resident #33. The Care Plan of Resident #7, review date 12/6/24, failed to address any conflict with other residents. 2. Resident #33's MDS assessment dated [DATE], identified a BIMS score of 11, indicating moderate cognitive impairment. The MDS included a diagnosis of non-Alzheimer's dementia. The MDS lacked documentation of Resident #33 exhibiting behaviors towards others in the 7-day lookback period. The Care Plan reviewed 2/19/25, lacked Resident #33 having any negative or aggressive behaviors directed towards others. The Appointment/Visit Note dated 9/24/24 at 11:18 AM reflected Resident #33 saw the mental health provider via telehealth. The provider ordered no changes and to revisit in 3 months. The Behavior Note dated 11/23/24 at 3:50 PM indicated as Resident #33 waited for coffee from the kitchen staff, another resident barged by her and started to talk to the kitchen staff. Resident #33 started yelling at the other resident. The other resident stated Resident #33 hit her and she started to cry. Resident #33 denied hitting her on purpose and accidentally bumped her with her arm. The Appointment/Visit Note dated 12/10/24 at 11:51 AM indicated Resident #33 saw the mental health provider. The provider noted no concerns, listed Resident #33 as stable, may switch visits to as needed (PRN). The Behavior Note dated 2/26/25 at 6:17 PM reflected Resident #33 became agitated with another resident during lunch that day and spoke harshly to them. The Communication - with Resident dated 2/27/25 at 1:42 PM identified the DON and the Social Worker spoke with Resident #33 about the incident with the other resident who left the dining room in tears. Resident #33 said she would try to be more mindful before making remarks out loud. Resident #33 asked them to tap her on the shoulder and tell her when she is being rude. She asked they quietly whisper it to her, instead of yelling it across the dining room. The Social Worker would add the intervention to the Care Plan. On 2/27/25 at 8:01 AM, the MDS Coordinator stated she worked at the facility since December 2024. She explained she is new to the job and is working on updating the Care Plans. She stated the DON notified her when the Care Plan is missing something but otherwise she updates them as she completes the MDS assessments for each resident and as the residents have Care Conferences. On 2/27/25 at 11:04 AM, Staff B, Certified Nurse Aide (CNA), stated she knew of issues between Resident #7 and Resident #33. She explained they moved Resident #7 to a dining table further away from Resident #33. She stated on the prior day, Resident #7 had an altercation with another resident during lunch (Resident #45). She stated Resident #45 became upset when Resident #7 yelled at her and asked for assistance to go back to her room. Staff B stated she assisted Resident #45 to fill out a grievance form and turned into the DON. She denied knowing of staff receiving any education regarding interventions for Resident #7 when she is verbally aggressive. On 2/27/25 at 11:15 AM, the DON stated the Social Worker handled the new grievance form regarding Resident #33. She stated Resident #33 is on services with the psychiatrist who rounds in the facility and has received services for some time. She stated she has her next appointment in approximately 2 weeks. The Care Plan of Resident #33 failed to identify the resident receiving any psychiatric/mental health therapy. The Care Planning Interdisciplinary Team, policy revised September 2013 documented the facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive Care Plan for each resident.

Based on observations, clinical record review, and staff interview, the facility failed to follow the comprehensive Care Plan for 1 of 12 (Resident #24) reviewed for Care Plans. The facility reported a census of 41 residents. Findings include: Resident #24's Minimum Data Set (MDS) assessment dated [DATE] listed they required partial/moderate assistance for eating. The MDS included diagnoses of cerebral Infarction (stroke), multiple sclerosis, and dysphagia (difficulty swallowing). The Care Plan Focuses dated a. 5/16/23 indicated Resident #24 required assistance at meal time. The Interventions directed: i. She required one on one (1:1) with feeding. ii. Encourage her to take small bites and alternate bites with drinks, then tuck and swallow. b. 1/22/25 reflected Resident #24 had a nutritional risk related to stroke, Alzheimer's disease and multiple sclerosis. The Interventions directed i. She needed assistance with eating. ii. Recommend 1:1 supervision during eating to promote safety with use of swallow strategies, go slow, alternate liquids and solids, swallow twice to clear residue, and remain upright after meals for 30 minutes. A continuous observation on 2/26/25 starting at 7:56 AM, witnessed Resident #24, not yet served her meal, sitting at the dining room table. - At 8:02 AM, Resident #24 received her meal and she began drinking a glass of chocolate milk. A staff member sitting at the same table, didn't provide any observed direct assistance at first. When Resident #24 failed to feed herself, the staff member gave her a spoon, but she placed it back on the table. - At 8:05 AM, witnessed the staff member get up and leave the table. On 2/26/25 at 8:07 AM, watched Resident #24 begin to feed herself her bowl of pureed biscuits and gravy. Observed Staff B, Certified Nurse Aide (CNA), in the nearby area but they didn't provide any direct assistance to Resident #24. - At 8:08 AM, Staff C, CNA, asked Resident #24 if she could place her clothing protector on her, and assisted her with the protector. Staff C brought the bowl of biscuit and gravy closer to Resident #24. Watched Resident #24 continue to feed herself without staff assistance or cues provided. - At 8:13 AM, the Director of Nursing (DON) sat down at the table adjacent to Resident #24, overseeing the residents eating, monitoring for safety. - At 8:16 AM, observed another staff member enter the room. She took an empty chair from Resident #24's table, and placed it at the table where the DON sat and spoke with her. Neither staff member appeared to watch Resident #24. Staff C stood nearby in another area of the dining room. Resident #24 drank her full glass of chocolate milk prior to starting to eat the biscuits and gravy. While she ate, Resident #24 didn't drink anything since she began to eat. - At 8:16 AM, Staff D, Certified Medication Aide (CMA), brought a chair to the table and sat down. Witnessed Staff D and Staff C have a conversation as Resident #24 ate her breakfast. As Staff A, Cook, rounded, they noted Resident #24's drink glass empty and provided a second glass of chocolate milk. Resident #24 picked it up and took some drinks. - At 8:19 AM, Staff C left the area briefly, returned with a gait belt and spoke to another resident. Staff C remained in the area until 8:22. Resident #24 continued to eat her breakfast by herself throughout the observation. No observations of staff providing 1:1 assistance or reminding Resident #24 to alternate drinks and bites or to do chin tucking exercises. - At 8:24 AM, witnessed Resident #24 take 2 3 drinks of milk and returned to her biscuits and gravy. Staff D sat at the table speaking to another resident at the table, they offered no cues or assistance to Resident #24. A continuous observation on 2/27/25 starting at 8:14 AM revealed Resident #24 sat at the table with an empty glass of milk and she eating herself. No staff sat at the table with Resident #24. Staff E, CNA, sat at the next table. - At 8:16 AM, Staff B stopped and visited with Resident #24 briefly and then went on to other residents. - At 8:23 AM, Staff C arrived in the dining room, then Staff B left the area. Staff C sat down at a table to assist another resident as Resident #24 continued to eat by herself. On 2/27/25 at 8:25 AM, Staff E sat down at the table with a computer and her own food. She ate her own meal while she visited with another staff member. No observation of interaction from Staff E with Resident #24. Two minutes later, Staff E moved to the next table. On 2/27/25 at 8:29 AM, watched Resident #24 pickup and tip her nearly empty bowl. It appeared like she was looking to see if she had more food in the bowl. After receiving no assistance, Resident #24 put the bowl on the table and pushed herself away from the table. Staff E stood and assisted her to leave the dining room. On 2/27/25 at 11:04 AM, Staff B stated Resident #24 required set up assistance generally for meals. She stated it depended on the day, as some days she needs help. She stated she believed Resident #24 had swallowing problems in the past but they got better since she started the pureed diet. On 2/27/25 at 11:15 AM, the DON stated she would verify if Resident #24 needed to still receive 1:1 assistance at meals. She stated she didn't feel that was accurate any longer but that the CNAs should follow the Care Plan.

Based on record review, staff interviews, and Resident Assessment Instrument (RAI) Manual the facility failed to accurately code 2 of 12 residents' (Residents #1 and #33) Minimum Data Set (MDS) Assessment. The facility reported a census of 41 residents. Findings include: 1. Resident #1's Preadmission Screening and Resident Review (PASRR) assessment dated [DATE] listed her as a Level II PASRR due to a serious mental illness. Resident #1's annual MDS assessment dated [DATE] coded Resident #1 as a PASRR level I (a person without a serious mental illness). During an interview on 2/27/25 at 8:05 AM, the Social Services Coordinator reported Resident #1 had a level II PASRR approved with specialized services. During an interview on 2/27/25 at 8:35 AM the Assistant Director of Nursing (ADON) reported they had some confusion on Resident #1's PASRR, that is why the MDS didn't get coded as a level II. On 2/27/25 at 8:46 AM the Director of Nursing (DON) reported the facility didn't have a policy for MDS. She reported they follow the RAI Manual. The RAI Manual revised October 2024 directed to code yes for Level II PASRR, if PASRR Level II screening determined the resident had a serious mental illness. 46873 2. Resident #33's MDS assessment dated [DATE], identified a BIMS score of 11, indicating moderate cognitive impairment. The MDS included a diagnosis of non-Alzheimer's dementia. The MDS lacked documentation of Resident #33 exhibiting behaviors towards others in the 7-day lookback period. On 2/24/25 at 3:56 PM, Resident #7 reported Resident #33 is mean to her and makes her cry. She stated Resident #33 bullied her and she reported it to the Administrator. On 2/25/25 at 11:03 AM, the Administrator stated that Resident #33 gets very annoyed quickly with Resident #7. He stated both residents enjoyed spending a lot of the day in the dining area and Resident #7 tends to ask a lot of questions. He stated Resident #33 reached a point that she gets annoyed very quickly with Resident #7. He stated the staff discussed with Resident #33 regarding the way she speaks to Resident #7. He stated staff are always in the area and intervene before anything more happened. The staff are to spend time with Resident #7, if she is in a mood of asking a lot of questions, in an attempt to distract her from speaking to Resident #33. The Grievance/Concern Investigation form filed 2/6/25 documented Resident #7 filed a concern with the facility reporting that Resident #33 called her a derogatory name on 2/5/25. Resident #33's MDS assessment dated [DATE] documented she displayed no verbal behavioral symptoms directed towards others during the 7-day lookback period. The 2024 RAI Manual, under Steps for Assessment of question E0200 directed: 1. Review the medical record for the 7 day lookback period. 2. Interview staff, across all shifts and disciplines, as well as others who had close interactions with the resident during the 7 day lookback period, including family or friends who visit frequently or have frequent contact with the resident. 3. Observe the resident in a variety of situations during the 7 day lookback period. The 2024 RAI Manual listed additional Coding Instructions: Code 0, behavior not exhibited: if the behavioral symptoms were not present in the previous 7 days. Use this code if the resident never exhibited these symptoms or if they previously exhibited the behavior but hasn't in the previous 7 days. Code 1, behavior of this type occurred 1 3 days: if they exhibited the behavior for 1 3 days of the previous 7 days, regardless of the number or severity of episodes that occur on any one of those days. Code 2, behavior of this type occurred 4 6 days, but less than daily: if they exhibited the behavior for 4 6 of the previous 7 days, regardless of the number or severity of episodes that occur on any of those days. Code 3, behavior of this type occurred daily: if they exhibited the behavior daily, regardless of the number or severity of episodes that occurred on any of the days in the previous 7 days.

Based on observations, interviews and record review, the facility failed to provide the Dietitian approved menu for 4 of 4 residents who were on a pureed diet (Residents #12, #22, #37 and #38). During the lunch observation on 4/24/24, observed four residents did not receive pureed bread per therapeutic menu. The facility reported a census of 37 residents. Findings include: 1. A doctor's order dated 1/26/24, directed that Resident #12 receive a pureed texture diet. A Minimum Data Set (MDS) assessment dated [DATE], documented that Resident #12 was not able to complete the Brief Interview for Mental Status (BIMS). Resident #12 required substantial/maximal assistance for eating. The helper did and provided more than half the effort. The assessment indicated Resident #12 ate a mechanically altered diet, for example pureed food. 2. A doctor's order dated 11/20/23, directed that Resident #22 receive a pureed texture diet. A Minimum Data Set (MDS) assessment dated [DATE], documented that Resident #22 was not able to complete a Brief Interview for [NAME] Status (BIMS). It documented that Resident #22 required partial to moderate assistance for eating. The helper does less than half of the effort. It documented mechanically altered diet for example pureed food. 3. A doctor's order dated 11/20/23, directed that Resident #37 receive a pureed texture diet. An MDS assessment dated [DATE], documented that Resident #37 scored a 3 out of 15 on the BIMS. This indicated that this resident had severely impaired cognition. It documented that Resident #37 required supervision or touching assistance. The helper provided verbal cues and /or touching /steadying and /or contact guard assistance as resident completes the activity. The MDS indicated Resident #37 received some assistance throughout the activity or intermittently. It documented mechanically altered diet for example pureed food. 4. A doctor's order dated 11/20/23, directed that Resident #38 receive a pureed texture diet. An MDS assessment dated [DATE], documented that Resident #38 scored 0 out of 15 on the BIMS. This indicated that this resident had severely impaired cognition. It documented that Resident #38 was dependent for eating. The helper does all the effort and the resident does none of the effort to complete the activity. It documented mechanically altered diet for example pureed food. On therapeutic Spread Report Spring/Summer Menu '24, it directed that residents on a puree diet were to receive puree bread for lunch. On 4/24/24 at 11:00 AM., Staff B, Cook pureed meat (beef roast) and potato/carrot vegetable side. She stated those were the only things she was pureeing as they were serving pudding for dessert. On 4/24/24 at 12:15 PM, when asked about there not being pureed bread for the residents who received a pureed diet, Staff B answered that she has never served pureed bread. She stated she wouldn't even know how to puree it. The Certified Dietary Manager (CDM) stated she has not served pureed bread before. The CDM acknowledged the menu listed the bread for lunch that day. Both the CDM and the cook stated they did not and have not served pureed bread. On 4/24/24 at 3:45 PM, the Administrator acknowledged the concern regarding not pureeing bread as part of the lunch today. He stated their Dietitian is working on this. He acknowledged that both the CDM and Staff B both stated they have never pureed the bread. He acknowledged that this was a concern related to the Dietitian approving the diets as meeting the nutritional needs for each diet. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON), acknowledged the same concerns earlier on this day. On 4/24/24 at 4:01 PM, Staff C, Registered Dietitian stated that she had been in the facility before, on 2/20/24, and asked to see the pureed process. Bread was not on the menu the day she had asked. Staff C stated she remembered they had talked about pureeing the bread when it was on the menu. She stated it was the cook that said it, but doesn't remember her name. Staff C stated they had a new therapeutic diet menu that came out for spring and summer. Staff C stated that Staff D, Dietitian was the new Dietitian. Staff C stated they should be pureeing bread when it is on the menu. On 4/24/24 at 4:09 PM, Staff D stated she did not have any knowledge of the kitchen not pureeing bread. Staff D stated that when she signed therapeutic Spread Report Spring/Summer '24 menus she was signing that the daily diets were nutritionally adequate. She stated that the residents certainly can vary from the diets. Staff D stated they should have pureed the bread for the menu. She stated she would definitely be talking to the kitchen staff about following the menus and pureeing the bread. Staff D stated she had not been at this facility for very long. She stated she hadn't seen anyone puree bread there nor had she heard anyone talk about not being able to puree bread. She stated she had only watched a few meal services since she started there. On 4/25/24 at 8:20 AM., Staff D stated that the tickets (used for plating at meal times) for the ladies who received a puree diet, did not have bread listed on them. When asked who filled out the tickets, she stated sometimes it's the CDM and other times it's the CNA's. This Dietitian stated that some of the residents cannot say and acknowledged they should offer bread if listed on the menu for pureed diets. On 4/25/24 at 10:45 AM., the CDM stated she is the one who took the bread off for yesterday's lunch meal. She stated she had tried pureed bread with the 4 ladies once before and they did not like it so she stopped serving it when it's just plain bread and butter or toast on the menu. She acknowledged that this changed the number of calories, carbohydrates, and nutrients offered for the day and that it veered off the planned menu approved by a Dietitian. The CDM stated she had not let the Dietitian know about the removal of bread. This CDM stated that when there is a ham sandwich they puree the bread right in with the ham or if it's a cheeseburger they puree the bun right in with the burger. She stated that she could puree the toast right in with the eggs for breakfast instead of omitting the toast and that they could have pureed the bread right in with the roast beef yesterday as well. She said they would start including the breads with the main meals. A Menus policy revised on October 2017, directed to develop and prepare menus to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. It directed that deviations from posted menus are recorded (including the reason for the substitution and/or deviation) and archived.

Based on observation, record review, staff interview and policy review the facility failed perform proper hand hygiene and proper personal protective equipment guidelines to prevent the spread of potential infection and germs during peri cares for 1 of 1 resident reviewed (Resident # 13). The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) assessment completed for Resident #13 on 4/12/24 documented the diagnoses of septicemia, recurrent enterocolitis (inflammation in your intestines) due to clostridium difficile (a contagious infection that causes diarrhea), and hypertension (high blood pressure). During an observation on 4/23/24 at 11:30 AM, Staff A, Certified Nursing Assistant (CNA), assisting Resident #13 off of the bedpan. Staff A did hand hygiene, then applied a gown and gloves. Staff A did Resident #13's peri-care. After completing the peri-care, she used the same dirty gloves to grab a clean brief and place it under the resident. Without hand hygiene or removing their gloves, Staff A pulled Resident #13's gown down and grabbed the full-body mechanical lift sling and placed it under the resident, then removed her gloves. During an interview on 4/23/24 at 11:50 AM, the Assistant Director of Nursing (ADON) reported she expected staff to change gloves after doing peri care prior to touch a clean brief During an interview on 4/24/24 at 2:55 PM, the Director of Nursing (DON) reported she expected the staff to changes gloves from dirty to clean. Review of the facility policy titled Perineal Care revised February 2018 lacked direction for removing gloves after completing peri-care prior to touching any clean surface.

Based on interviews and record review, the facility failed to forward a pharmacy recommendation for the physician to re evaluate the renewal of a 14-day PRN (as needed) Haloperidol (Haldol)(antipsychotic) for 1 of 5 residents reviewed for medication regimen review (Resident #33). The facility reported a census of 37 residents. Findings include: A Condensed Summary of All Recommendation written by the pharmacist on 1/3/24, directed that the Haloperidol (Haldol)(anti-psychotic medication) 2 mg (milligrams) every 4 hours PRN (as needed) for anxiety delusions ordered for Resident #33 on 12/22/23, documented that the order needed to have the mandatory 14-day end date (1/5/24) per CMS Regulations due to the use of PRN antipsychotics for acute situations. It documented that at the end of the 14 days, the Physician can re evaluate the resident in person to determine if they need another 14-day PRN order. A January 2024 Medication Administration Record (MAR), documented haloperidol 1 mg give 2 tablets by mouth as needed for anxiety and or delusions. It documented the start date was 12/22/23 and the discontinue date was 1/23/24 The MAR included 28 times Resident #33 received the medication from 1/6/24 through 1/23/24 On 4/24/24 at 3:30 PM, the Assistant Director of Nursing (ADON), stated she didn't know what happened. She couldn't provide the rationale to continue the PRN Haldol, nor could she provide information the provider reviewed and set a stop date for the PRN Haldol. She stated they should have definitely forwarded the information to the physician. The ADON acknowledged they didn't discontinue Resident #33's PRN Haldol order after 14 days. A PRN Medication Policy dated December 2016, directed to not renew PRN orders for antipsychotic medications beyond 14 days unless the healthcare practitioner has the resident for the appropriateness of that medications.

Based on observations, interviews, and record review, the facility failed to properly care for and accurately document pressure ulcers for 1 of 3 residents reviewed (Resident #23). During a pressure ulcer dressing change, observed the staff failed to use a cleanser to clean Resident #23's sacral/coccyx (tailbone area) pressure ulcer. During record review of this resident's pressure ulcers, determined the facility didn't update the stages of the pressure ulcers with worsening changes. The facility reported a census of 37 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: NOTE: Regardless of the staging system or wound definitions used by the facility, the facility is responsible for completing the MDS utilizing the staging guidelines found in the RAI (Resident Assessment Instrument) Manual. Stage 1 Pressure Injury (PI): Non blanchable erythema of intact skin Intact skin with a localized area of non blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below). Stage 2 Pressure Ulcer (PU): Partial thickness skin loss with exposed dermis Partial thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar is not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: Full thickness skin loss Full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Stage 4 Pressure Ulcer: Full thickness skin and tissue loss Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI. Unstageable Pressure Ulcer: Obscured full thickness skin and tissue loss Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Other staging considerations include: o Deep Tissue Pressure Injury (DTPI): Persistent non blanchable deep red, maroon or purple discoloration Intact skin with localized area of persistent non blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. A Minimum Data Set (MDS) assessment dated [DATE], documented that Resident #23 had 2 Stage 1 pressure ulcers and 1 Stage 3 pressure ulcer. It documented that Resident #23 had no Stage 2, Stage 4, unstageable pressure ulcers or deep tissue injuries. A Doctor's order dated 4/13/24 and discontinued on 4/23/24, directed staff to cleanse sacral wound with cleanser and pat dry. Apply calcium alginate cover (highly absorbent biodegradable dressing) with large Mepilex (highly absorbent foam dressing) daily and PRN (as needed). On 4/23/24 at 10:48 AM., the Director of Nursing (DON) and Staff E, Licensed Practical Nurse (LPN) washed hands and applied gloves and gowns. Staff E removed the larger dressing from resident's sacral area. Staff E then used a damp towel and patted at site and then used the dry part of the towel to pat it dry. Staff E then removed smaller dressing from coccyx. Noted a yellow slough was covering the wound. Staff E then placed a small dressing of calcium alginate cut into a circle to fit the wound over the wound. She then placed a large Mepilex dressing over the smaller wound dressing. Staff E said Resident #23 had a dressing change daily. Staff E stated the Mepilex didn't have a date upon removal. When asked about cleaning the wound, Staff E stated she didn't know if she was to use wound cleanser to the wound, she would have to look. Staff E stated she just dampened part of the towel. The DON stated she would have to look at the doctor's orders as orders can differ from resident to resident. The DON did not know if he had an order to use wound cleanser. The DON acknowledged concern the nurse used a dampened towel but didn't clean the wound between removing the old dressing and applying the new one. On 4/23/24 at 12:39 PM, Staff F, Advanced Registered Nurse Practitioner (ARNP) stated she would redo the wound order, to have the wound cleaned more effectively and make sure it doesn't get infected. She acknowledged the concern of not cleaning the wound effectively. She stated she took Resident #23 on her caseload approximately a month ago. She stated Staff G, ARNP, had Resident #23 on her caseload before Staff F took over. On 4/23/24 at 1:06 PM, when told about the sacral/coccyx dressing change observation, Staff G stated that the cleaning was not sufficient. She stated she knew they used the wound cleanser on his legs. Staff G stated it definitely was not appropriate to clean the wound with a towel dampened with water to clean his coccyx wound. Staff G stated she would say soap and water with sterile dressing and/or a wound cleanser would be appropriate. Staff G stated that the pressure ulcers on this resident heals were unstageable the last time she saw them. A Doctor's order dated 4/24/24, directed staff to cleanse sacral wound with wound cleanser and pat dry. Apply calcium alginate with large Mepilex daily and PRN. A Skin and Wound Evaluation dated 4/22/24, documented a Stage 3 coccyx pressure ulcer with slough covering 80 percent of the wound. A Skin and Wound Evaluation dated 4/6/24, documented a Stage 1 pressure ulcer on Resident #23's right heel. The picture showed open areas on his heel. A Care Plan revised on 4/22/24, documented that this resident had a Stage 1 pressure ulcer to right heel and a stage 3 pressure ulcer to his left heel. It documented that Resident #23 had a Stage 3 pressure area to coccyx. It documented that Resident #23 needed wound care as ordered by his physician. On 4/23/24 at 1:00 PM, the Assistant Director of Nursing (ADON) stated the stage of the coccyx pressure ulcer should be unstageable due the slough covering it. She stated that the Stage 1 pressure ulcer on the right heel they should code it as Stage 2 after verifying there is depth to the wound on 4/6/24. On 4/23/24 at 1:30 PM, the Director of Nursing (DON) acknowledged the concerns with not staging the pressure ulcers properly. A Wound Care policy revised October 2016, directed to verify the physician's order for this procedure. Assemble the equipment and supplies as needed. Prepare antiseptic (as ordered). Wash tissue around the wound where the dressing covers the wound, tape or gauze with antiseptic or soap and water. Apply treatments as indicated.

Based on clinical record review and staff interview, the facility failed to complete a new Preadmission and Resident Review (PASRR) evaluation as required for 1 of 1 reviewed (Resident # 36). The facility reported a census of 37 residents. Findings include: Resident #36's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 11 indicating moderately cognitive impaired. The MDS include diagnoses of depression, Bipolar disorder, and dementia. Resident #36's Notice PASRR Level II Outcome dated 10/16/23 listed the date the short term approval ends as 4/13/24. During an interview on 4/24/24 at 4:20 PM, the MDS Coordinator reported they submitted a new PASRR on 4/13/24 for review and the it was determined on 4/18/24. The MDS Coordinator reported she didn't know she needed to have a new PASRR completed and determined prior to the expiration of the approved short term ending. During an interview on 4/24/24 at 4:50 PM, the Administrator reported the facility didn't have a policy for PASRR. He reported the facility followed the regulations.

Based on clinical record review and staff interview the facility failed to send notice to State Long Term Care Ombudsman of transfer for 2 of 3 residents reviewed (Residents #13 and #26). The facility reported a census of 37 residents. Findings include: 1. The Progress Note written on 11/20/23 at 6:43 PM for Resident #13 documented the resident was on therapeutic leave with family. The Progress Note written on 1/1/24 at 6:08 PM for Resident #13 listed they admitted to the hospital. The Readmission Assessment completed on 1/3/24 at 3:28 PM. The Progress Note written on 2/8/24 at 12:22 PM for Resident #13 documented the resident went to the emergency room (ER). The Progress Note written on 2/8/24 at 4:31 PM reflected the hospital admitted them. The Progress Note written on 3/13/24 at 7:46 AM for Resident #13 documented the resident went to the ER. Readmission Assessment completed on 3/20/24 at 3:08 PM. Review of the Ombudsman reports for January 2024, February 2024 and March 2024 lacked documentation of resident transferring to the hospital. The November 2023 Ombudsman report lacked documentation of therapeutic leave. During an interview on 4/23/24 at 2:51 PM the Administrator verbalized the facility runs a report on the Electronic Health Record (EHR) program for the report the facility fills out for ombudsman reports. He didn't know why they missed those residents in those months. During an interview on 4/23/24 at 3:37 PM the Administrator reports the facility does not have a policy for ombudsman reporting. He reported the facility followed the regulations for reporting. 2. The Progress Note written on 9/29/23 at 11:38 PM for Resident #26 documented the resident went to the ER. The Progress Note written on 9/30/23 at 2:20 AM documented the resident returned to the facility from ER. The Progress Note written on 11/26/23 at 11:00 PM for Resident #26 documented the resident went to the ER. The Progress Note written on 11/27/23 at 1:25 AM indicated the hospital admitted them. The Progress Note written on 3/3/24 at 11:05 PM for Resident #26 documented the resident went to the ER. The Progress Note written on 3/4/24 at 12:14 AM documented the resident would return to the facility. Review of the Ombudsman reports for September 2023, November 2023, and March 2024 lacked documentation of resident transferring to the hospital.

Based on facility record review, staff interview, and policy review, the facility failed to have the minimum required members at the Quality Assessment and Assurance (QAA) meetings to identify issues with respect to which quality assessment and assurance activities are necessary. The facility reported a census of 37 residents. Findings include: Review of the facility QAA sign in sheets revealed the Administrator, Medical Director, Director of Nursing (DON), Infection Preventionist and one other staff member were present at the meetings for the first 4 of 6 quarters reviewed. During an interview of 4/25/24 at 10:15 AM, the Director of Nursing (DON) reported she thought the regulation only required a total of five members needed to be present not the six the regulation required. Review of the facility's Quality Assurance and Performance Improvement (QAPI) Program undated revealed the QAA Committee was to meet at least quarterly and would include the Administrator, DON, Medical Director, Infection Preventionist, and Representatives from six other departments, as requested by the Administrator.

Based on interview with staff, family and medical professionals, and record and policy review the facility failed to adequately plan for resident's discharge for 1 of 4 residents reviewed. Resident #1 was admitted to the facility after surgery to install a feeding tube. The facility failed to teach her how to use the feeding tube pump, and failed to ensure she had all the needed supplies and medications when she returned home. This failure resulted in the hospitalization of the resident related to dehydration, failure to thrive and urinary tract infection, therefore causing an Immediate Jeopardy to the health, safety and security of the residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of 1/1/24, on 1/10/24 at 9:57 AM. The facility removed the Immediate Jeopardy on 1/10/24 with the following actions: a. Staff education completed on proper discharge procedure to assure that the resident that are transferred/ discharged have proper orientation and planning of the discharge. b. Discharge orders must include needed home health or devices and or new medications ordered. c. Social Services and or designee would make follow up calls the next business day after discharge to determine if needs are met following discharge. d. Any training that takes place would be documented in the electronic record and on the discharge summary, the resident or family member must sign and copies would be sent with the resident and/or family. e. Any discharge conversations would be documented in the electronic chart. The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education on proper discharge procedure. The facility reported a census of 40 residents. Findings Include: According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). She was admitted to the facility on [DATE] after major surgery involving the gastrointestinal tract with a feeding tube. The Care Plan for Resident #1, initiated on 12/8/23, showed a focus area of transitional care planning upon discharge. The resident had a feeding JG (gastrojejunostomy) tube. Staff were directed to discuss with the resident and family any concerns about tube feedings and potential complications. She was provided a diet order for regular texture and thin liquids. The resident was at nutritional risk due to recent surgery of the gastrointestinal (GI) system, malignant neoplasm (cancer) of pancreas, and secondary malignant neoplasm of lymph node. She needed assistance of one staff with eating, hygiene, toileting and transfers. The following documentation was included in the Nursing Progress Notes: a. On 12/26/23 at 2:00 PM, the resident continued with Physical and Occupational Therapy (PT/OT). Receiving continuous feedings through G-tube. Medications crushed and push through the gastric port on the G-tube. Stand-by assist with transfers JP drain located on lower left quadrant of abdomen. Education provided: safety precautions, self-administration of medication tube feeding. b. On 12/28/23 at 3:30 AM she was given medication for complaints of nausea. c. On 12/28/23 at 8:19 PM, the resident had some anxiety and was given antianxiety medication. d. On 12/29/23 at 11:20 AM in a communication to the physician, the residents skilled level of stay would end on 12/31/23. She would discharge home with family on 1/1/24. Orders and treatments sent to the pharmacy. e. On 12/29/23 at 11:27 AM, the resident denied the right to appeal the decision of the insurance company to discontinue payment as of 12/31/23, and she planned to discharge on 1/1/24. f. On 12/29/23 at 12:12 PM, phone call to a Home Health Agency (HHA) A, and left a voice mail awaiting returned call. g. On 12/29/23 at 12:20 PM, phone call to HHA, B, left a voice mail. h. On 12/30/23 at 1:41 PM, the resident plans to discharge on 1/1/24 education provided on safety precautions and self-administration of medications tube feeding. i. On 12/31/23 at 5:55 AM, the resident had discomfort in abdomen, dysuria, and feeling uncomfortable. Pain medication given. j. On 12/31/23 at 8:30 AM, a urinalysis (UA) with culture and sensitivity was ordered for frequency and low abdominal discomfort. k. On 12/31/23 at 11:11 AM, the J-G tube blew open after an hour of nurses attempting to unclog tube. The daughter came and took resident to the emergency room to have tube replaced. l. On 12/31/23 at 5:27 PM, the resident returned from the hospital after the tube had been replaced by radiology. m. On 1/1/24 at 2:50 AM, nurse called the lab to request that the UA results be sent to the provider the UA was grossly positive, Order for Bactrim antibiotic for 5 days. Signed by the resident on 1/1/24 at 12:31 PM, the Discharge Planning/Recapitulation of Stay dated 12/29/23, 11:32 AM, included the following information: a. Community Agency Contact Waiting on return call from Home Health Services, due to the holiday will not hear back until Tuesday. b. Medical Equipment Arrangements; box was checked yes. Provider name, contact and details were left blank. c. Scheduled Appointments and Tests was left blank. d. Summary of Resident's status cooperative and compliant with all cares, willing and ready to learn e. Date and time pharmacy was contacted: 12/29/23 at 1:00 PM. On 1/8/23 at 3:03 PM, a representative from a Home Health Supplies company said that Resident #1 was admitted to the hospital on Friday, 1/5/24 after she had been at home for 4 days without her enteral feedings and was only eating small bites of food as she could tolerate. The representative said that she got a call from the facility, Staff E, Licensed Practical Nurse (LPN), on the 29th of December. Staff E said that Resident #1 would be discharged to home on 1/1/24. The representative said that because the discharge date was a holiday, they wouldn't be able to get to her that day. Staff E told her that it would be okay if they got there on 1/2/24 and told her that the resident just needed an IV pole for her feeding pump. When the delivery man brought her the pole to her home, the resident told him she needed a pump. The resident called back to the facility to tell them she didn't have a pump and Staff E then called back to the supply company (1/3/24) and ordered the feeding pump for continuous feeding. The representative said that the pump required a prescription and insurance confirmation which slows the process so they were not able to get it the pump to her. The resident went in to see the oncologist on 1/4/24 and was sent to the hospital with failure to thrive and dehydration. Telephone intake notes from the Medical Supply Company (MSC) showed that on 1/3/24 at 8:51 AM, Staff E called and requested the intravenous (IV) pole and that it would be private pay. Resident #1 called them on 1/3/24 at 2:21 PM asking when she could expect to get the pump. The representative called the facility and Staff E asked her if they would get a pump to her. Staff E indicated that she would send the insurance information, however, Medicare would only pay for the pump if all of the supplies came from one source so she would need the insurance information. On 1/3/24 at 4:33 PM, the representative contacted the cancer center where the resident had an appointment for the following day to see if they could help get supplies and formula to the resident. On 1/5/24 at 11:24 AM, the MSC received orders from the cancer center for all of the needed supplies and formula. Insurance was approved. On 1/5/24 at 3:05 PM The resident was being admitted to the hospital through the emergency department. On 1/9/24 at 8:11 AM a family member for Resident #1 said that they understood, at the time of admission to the facility, the nurses would provide teaching to the resident on how to manage her feeding tube before discharge. She was also under the understanding that Home Health services would come into the home and assist. On 1/9/24 at 8:14 AM, a second family member said that the resident was discharged from the nursing home because the insurance would not pay for any more days. In her opinion, the resident was not ready to be discharged , she was very weak. The nursing home had told her that they would arrange for a home health nurse to come in and help and that did not happen. The resident was unable to do her own feedings and they were just handed some papers from the nursing home and they said that home health would be contacting them. One day a delivery driver dropped off an IV pole and set it up for them but he was not able to educate them on the pump and they didn't have any supplies for the pump. When no one showed up to get the feedings set up or show them how, she finally sent the resident to the hospital. On 1/9/24 at 10:52 AM, a Social Worker (SW) at the hospital said that she first met Resident #1 on 1/4/24 as a new referral. The SW was brought in to talk to the resident after the dietician had visited with her. The resident told her that she had the feeding formula to go into the tube but did not have the pump. She needed a prescription for the pump so insurance would pay, and she had not been educated on how to use it. The SW said that the resident was very weak and almost fell during their visit. The resident told her that she had several falls at home. The dietician and the SW arranged for home nursing and supplies, but because they didn't have anyone available to go into home on the weekend, they decided to have her admitted to the hospital until they could get her stabilized with home services. When the SW asked the resident if anything had been arranged from the facility, the resident seemed to think it was supposed to happen but I haven't seen anybody. The resident did not say that she refused the services upon discharge from the facility, and when the SW offered it to her, she responded yes, please. According to the hospital report dated 1/5/24 at 9:14 PM, Resident #1 presented to the hospital with primary problems of failure to thrive, dehydration, poor nutritional intake and urinary tract infection. She was sent to the emergency department from the cancer center due to weakness and decreased oral intake that worsened over the previous 4 days. She ate approximated 5 bites of food a day, had increased unsteadiness on her walker and had a fall at home on 1/4/24. On 1/9/24 at 10:33 AM, Staff C, Licensed Practical Nurse (LPN), said that she worked full time at the facility and mentioned that they did have some trouble with the resident's feeding tube clogging with one of her medications. Staff C said that she educated the resident on how to push her medications but she did not show her how to use the feeding pump. Staff C said that the day before the resident was discharged she told Staff C that she wasn't ready to leave and thought that home health would be in to assist with the feedings. The resident didn't feel that she had any options. On 1/9/24 at 7:30 AM, Staff D, Registered Nurse (RN) said that she worked full time on the overnight shift. She said that the resident didn't have the correct drain and they had taped it together. The bile would get stuck and they often had to irrigate the drain. Staff D said that the resident was forgetful and she didn't think she could do her own feedings. The resident was also very weak and needed many reminders. On 1/9/24 at 8:00 AM, Staff L, RN said that he's had a lot of experience with feeding tubes. He said that Resident #1 was not able to do her own feedings while she was at the facility because she was very week, would get anxious. He did not go into depth to educate her on how to use the pump and thought that the discharge nurse would have educated her. On 1/9/24 at 9:48 AM, Staff F, LPN said that she worked full time at the facility and Resident #1 hadn't ever touched the feeding pump while she was with her. The first day that Staff F worked with the resident, she wanted to push the water through her tube and she was able to do that, but after that day, the resident didn't show aby interest in learning. She was always tired, often sick and didn't have the energy to learn. Staff F said that the nursing staff hadn't been told that they were expected to educate her on the use of the pump. They had trouble with the tube getting clogged and she didn't know if the resident would have been able to manage that problem on her own. On 1/9/24 at 9:19 AM Staff E, LPN said that she had been arranging the discharges since they were without a social worker for a period of time. She said that when a resident was being discharged , they would get the physician's order, set up follow up appointments and any training or education that the resident needed would be provided by the floor nurses. When the home health services were needed, they would call whatever agency was the closest to the residents' home and follow up with the resident within 48 hours. Staff E said that Resident #1 did not want home health services so she sent all the needed supplies, with her upon discharge. She said that the resident had been educated on the use of the pump by the floor nurses, and she was made aware that she had a right to appeal the decision of the insurance company to discontinue payment, but the resident didn't feel it would do any good. Staff E said that they discussed the Medicaid option but the resident didn't want to go through the process. She said that the family had not been included in any education on the use of the feeding tube or pump and the resident went home with her daughter and grandchildren and would get help from them. The chart lacked documentation of the options presented to the resident and her response. Staff E maintained that she did a follow up call to Resident #1 and she said she that she was doing well. On 1/9/24 at 1:17 PM Staff F said that she was the nurse when Resident #1 was discharged and she packed up everything that they had for supplies for the feedings. There were bags of syringes, bags for draining and several boxes of formula. Staff F couldn't say for sure if there was tubing but she sent everything they had for her. She said the resident was alert and understood that she was going home. She reminded the resident that no one would be there with the pole and pump until the next day and she understood. Staff F said that the resident had gone for a day without the feedings when she would go out to her daughter's house. The feeding was unhooked just shortly before the resident left the facility. On 1/9/24 3:15 PM, The Director of Nursing (DON) acknowledged that they needed to do some teaching for Resident #1, especially when they had challenges with the tube busting a couple of times. When they found it was the medication that was dissolving they educated her on taking that orally. She said they had conversations about her managing the feeding tube and it had been her goal to manage the feedings herself. The DON said that she did have some concerns about her daughter that was living with her because she had some mental health issues, the resident was not relying on the daughter to help her because she was not stable. They did a couple of trial home visits which she reported went okay, but the DON said that she was not at the facility the day that the resident was discharged so she did not know specifically how she felt about not having any help in the home to manage the feeding tube. On 1/9/24 at 3:02 PM, the oncologist that saw Resident #1 on 1/4/24 said that the patient had been in bad shape. She said the resident reported that she had many falls at home because she had been so weak. She was surprised that after the resident had two visits to the emergency room with ruptured feeding tubes and then was to be expected to manage it by herself. When asked if she thought that the resident was strong enough to manage her own feeding tube, she said absolutely not. She said that in her professional opinion, the lack of support, education and supplies lead to the resident's hospitalization . The resident did not hesitate to accept their offer for help with feedings and social services. On 1/9/24 at 12:18 PM, several additions were made to the electronic discharge summary for Resident #1: a. Feeding tube formula and instructions included the name of the formula and stated that it was sent with the resident. b. Preferences and habits included resident is able to consume food and liquids by mouth, feeding tube is present and main source of nutrients. Resident does like to have fruits for breakfast. c. Summary of Resident Status: resident is aware with discharge being on a holiday she will not get feeding tube pole and pump until Tuesday. She does not want to wait until it is ready to leave the facility On 1/9/24 at 3:28 PM, the resident said that she was still in the hospital but said she was doing so much better. She was on an antibiotic for a urinary tract infection (UTI) and an infection in the intestines. She said that the nursing home did not offer or ask if she wanted help in the home. She said that she had been educated on how to administer her medications via feeding tube, but she hadn't been taught how to use the pump and the feedings. She said when she got home, she didn't have any idea what to expect and she started making phone calls to the facility and to the medical supply company. Resident #1 said that when she went home, she was eating odds and ends by mouth, just a few bites a day was all she could tolerate. She said that she had been told by the facility that someone would come to set up the pump and show her how to use it, but had not offered follow up nursing services. She said that it was her understanding that she would be getting supplies and equipment on the day of discharge. On 1/10/24 at 7:02 AM, Staff E said that she got a phone call from the resident 1/2/24 from the resident because she had a couple of missed calls on her phone. Staff E told her that it was probably the supply company calling about her pole and her pump. Later that day, Staff E got a call from the supply company about insurance coverage for the pump and she said she sent the insurance information to them. She denied getting any more calls after that. Review of the notes from the supply company and a fax from the facility both show that these interactions occurred in the afternoon of 1/3/24. On 1/10/24 at 8:00 AM, a pharmacist from the resident's pharmacy acknowledged they got a list of medications for the resident's discharge home. She said that there were several challenges with getting some of her medications, and acknowledged that the list did not include an antibiotic for a UTI. According to the facility policy titled: Transfer or Discharge Documentation Each resident was permitted to remain in the facility and not be transferred or discharged unless the resident had failed after reasonable and appropriate notice to apply for a stay at the facility. When a resident was transferred or discharged from the facility, an appropriate notice would be provided to the resident and/or legal representative. All special instructions or precautions for ongoing care, would be provided at discharge

Based on observation, record review, resident and staff interviews and review of the facility job description document, the facility failed to ensure one of four resident received adequate supervision in order prevent hazards from self and the health service supervisor failed to supervise the implementation of the care plan in order to ensure the personal alarm device was activated (Resident #1). The facility identified a census of 41 residents. Findings include: Resident #1 had a Minimum Data Set Assessment (MDS) with a reference date of 10/17/13, identified Resident #1 had [DIAGNOSES REDACTED]. According to a Resident Status Sheet (not dated), the resident had been admitted (to the facility) with a right hip fracture, required 2 staff assistance with ambulation and required a personal sensor alarm (PSA) at all times. According to a Care Plan dated 10/19/13, the resident had a problem with a potential for injury from falls and a self-care deficit related to malaise and general muscle weakness. The approaches directed the staff to do the following: a. A PSA at all times (on the resident). b. Changed PSA to a Deluxe PSA on at all times. (dated 10/21/13) c. 2 (staff members) to assist with all transfers. (dated 10/21/13) d. An abduction pillow while in bed. (dated 10/21/13) According to a Treatment Administration Record (TAR) form dated October 2013, the resident required the following interventions: a. A PSA placed at all times which had been initialed on 10/17/13 on all 3 shifts which reflected the alarm as placed and functional. b. An abduction pillow placed while in bed. (dated 10/20/13) According to a Safety Device Monitoring Form dated October 2013, the resident's alarm had been checked and functional on 10/17/13 for the 6 a.m. to 6 p.m. and 6 p.m. to 6 a.m. shifts. According to an AccuNurse entry dated 10/17/13 at 4:33 p.m., the resident had been transferred to his/her chair with the extensive assistance of two staff members however the alarm had not been activated. According to an Incident/Accident/Unusual Occurrences Form dated 10/17/13 at 7 p.m., the resident had been found sitting on the floor in the dining room of the CCDI unit in front of the wheel chair pedals with his/her legs bent and leaning to the left while holding onto the wheel chair. The resident had been assisted up with 2 staff assistance without any problems. According to an Internal Quality Assurance Investigation Form dated 10/17/13, the PSA on the resident's wheel chair had not been turned on. A Fall Investigation form dated 10/17/13; identified contributing factors related to the fall had been the alarms not sounding. The resident had been last observed 5 minutes prior to the fall. According to the facilities Nurse's Notes, the resident had the following entries in his/her clinical record: On 10/17/13 at 9:50 p.m. - at 7 p.m. the resident had been found sitting in front of the wheel chair pedals on the floor in the CCDI unit dining area. The resident had been leaning to the left, holding on to the wheel chair. The staff assisted the resident up with 2 staff assist and without a problem. The resident bore weight per usual and had no complaints at that time. 10/18/13 at 2:55 a.m. - The resident had been talking out loud to himself/herself rubbing his/her right hip and had only slept short periods of time. The staff administered an as needed pain medication for discomfort. 10/18/13 at 2 p.m. - The staff reported increased pain with transfers and a decreased ability to bear weight to the right lower extremity. Facial grimacing and verbal complaints of pain had been noted with the nurses attempt to lift his/her right leg while he/she had been lying down. The resident had been unable to perform range of motion assessment due to pain. The resident had been out for breakfast and lunch that day but had been very sleepy. 10/18/13 at 2:10 p.m. - The physician had been notified and the facility received an order to transport the resident to the emergency room for evaluation and x-ray. 10/18/13 at 2:45 p.m. - The ambulance arrived and transferred the resident to the hospital. According to a History and Physical form dated 10/18/13, the resident's bipolar arthroplastic joint had been posterior and laterally displaced. According to a Clinical Summary form dated 10/20/13 at 12:59 p.m., the resident had a closed reduction/relocation of the right hemi-arthroplasty on 10/19/13 at 8:10 a.m. According to a Clinical Summary form dated 10/20/13, the facility staff were directed to place an abduction pillow between the resident's knees while in bed. During an interview 10/31/13 at 10:15 a.m., Staff A (Certified Nursing Assistant-CNA) confirmed she and Staff B, CNA transferred the resident from the bed to the wheelchair on 10/17/13 before supper but she could not remember if she turned on the alarm or not. The staff member also confirmed the resident had been left unattended in the dining room after supper because she went to break and the other CNA assisted another resident to the bathroom. During an interview 10/31/13 at 10:15 a.m. and 11:35 a.m., Staff B (Certified Nursing Assistant) confirmed she transferred the resident from bed to the wheel chair on 10/17/13 before supper with Staff A but could not remember if she turned on the alarm or not. During an interview 10/31/13 at 10:35 a.m., Staff G (Certified Nursing Assistant)CNA indicated on 10/17/13 she started work at 6 p.m. working with Staff A in the CCDI unit. The staff member stated at approximately 6:30 p.m. while staff A had been on break, she assisted another resident to the restroom, across the hall from the dining area. While in the resident's room she left the door slightly ajar to enable her to hear any alarm that may have sounded. Approximately 5 minutes later she returned to the dining/lounge area and found the resident positioned on the floor, with his/her legs bent at the knee, leaning to the left side, next to the wheel chair holding onto the sides of the chair as if he/she slid out of the wheel chair with no alarm sounding. Resident #5 and another resident had been standing around the wheel chair not trying to help the resident but rather trying to make sure he/she had been OK. The staff member asked the residents if they had shut off the alarm and both of the residents denied doing so. The staff member called Staff D, Licensed Practical Nurse (LPN) who responded immediately and assessed the resident which resulted in no signs of a dislocation or pain. The staff placed a gait belt and transferred the resident per 2 assist to the wheel chair. When Staff A returned from break they took the resident to his/her room, performed bedtime (HS) cares, transferred the resident per gait belt and 2 assist to bed and positioned him/her for comfort. The resident had been checked and changed through the night and slept well until 3 a.m. when he/she complained of pain but no deformity had been noted. Staff G informed Staff D about the resident's complaint of pain but there had been no other occurrences that night. During an interview 11/1/13 at 10:25 a.m., Staff D (licensed practical nurse-LPN) indicated on 10/17/13 she had been called to the CCDI (chronic confusion or a dementing illness) unit sometime before 7 p.m. because the resident had fallen. When she entered the unit the resident had been positioned on the floor, leaning against the wheel chair with his/her knees bent, with no alarm sounding and several residents standing around him/her. When she assessed the resident nothing had been out of place and the resident denied pain. The staff members then placed a gait belt and transferred the resident per 2 assist into the wheel chair. The staff member indicated that she returned to the unit when the resident had been positioned in bed and rechecked his/her vitals and performed a full body assessment with no deformities or pain observed and that nothing else had been reported to her through the night. During an interview 11/1/13 at 11:30 a.m., Staff F, Registered Nurse (RN) indicated on 10/25/13 she had been called to the resident's room in the morning and found the resident positioned in bed with his/her right leg bent back and to the side. The staff member placed her right hand on the resident's right thigh and her left hand under the resident ' s right knee and slowly lifted the knee and let the leg slide back into place with no abnormal sounds noted. The resident showed no signs of pain until the staff member laid the right leg down on the bed. The resident then requested to go to the bathroom but refused the use of a bed pan so the staff transferred him/her to the commode utilizing a gait belt and 2 staff assistance. During the transfer the resident had been observed not bearing weight on the right foot/leg during the pivot transfer but the staff member thought that had been normal due to the resident's recent surgery. The staff member left the room after the transfer as everything appeared to go fine but asked Staff C, Certified Medication Aide (CMA) to administer the resident something for pain. At around lunch time the staff member noticed the resident as positioned in the wheelchair, leaning forward and balancing his/her weight on his/her elbows positioned on the arm rests of the chair. The staff member asked the resident if he/she could sit back in the chair. As the resident attempted to lean back he/she grimaced in pain and said he/she could not and that is when the staff member knew something had been wrong. At that point she called the physician and sent the resident to the emergency room . On 10/31/13 at 9:30 a.m. the Director of Nursing was interviewed and stated the Certified Nursing Assistants are unsure if they had turned on the alarm and the facility takes ownership since it is never the resident's fault. After the incident, the facility purchased new alarms that are not easy to disarm. According to the facilities Unit Hall form (not dated), the staff check list of duties each shift included the following: a. all safety alarms in place/turned on and functioning. According to the Care Initiatives Job Description forms dated 5/11 for both an LPN and RN Charge Nurse position, the purpose of that position had been as follows: Under general supervision of the DON (Director of Nursing) or Nurse Supervisor, the Charge Nurse directed the provision of resident care services for a particular shift and/or unit and supervises the nursing staff assigned to that unit/shift, with responsibility and accountability for assuring that quality nursing care and service to the facility residents/families, compliance with applicable laws and regulations, and adherence to company policy/procedure occur on that unit/shift. Performed direct nursing services to residents, in accordance with individual plans of care and physicians' orders. Technical assistance, professional guidance, and quality monitoring were provided by Administrator, DON, Regional Consultants, and other nursing professionals on staff, Medical Director.