Every finding on record at Manna Post Acute

Based on observation, interview, and facility policy review, the facility failed to date, label, and/or cover food products stored in the kitchen. This failure had the potential to create an environment for food-borne illnesses which could affect 122 of 124 residents who consume food prepared from the facility's kitchen.Findings include: Review of the facility's policy titled, Food Storage and Retention Guide, which indicated, . that at a minimum, all food shall be labeled with the item name and the date opened. Further: The dietary department is responsible for routinely reviewing these guides to ensure that all food items are used within safe storage timeframes and that expired, unlabeled, or compromised items are promptly removed from service. During an observation on 05/19/26 from 9:25 AM to 10:05 AM, with the Dietary Manager (DM), revealed the following: - The main refrigerator contained six slices of turkey in plastic wrap with no date label. - 24 hardboiled eggs in plastic wrap with no date label. - A rack of 24 pork ribs wrapped in plastic with no date label. - The main freezer storage room contained lima beans in two bags with no date label, and two 24-packs of hamburger rolls with no date labels. During an interview on 05/19/26 at 10:15 AM, the DM confirmed the above observations and stated that staff should date all refrigerated products once the food items were opened. The DM confirmed that staff should also date all frozen items once they were opened. The DM also stated that there was no schedule for checking all food for date labels or expired food.

Based on observation, interview, record review, and facility policy review, the facility failed to obtain a physician's order for isolation. Additionally, the facility did not ensure that appropriate isolation waste receptacles were available in the resident's room, and staff improperly disposed of isolation materials in the residents personal trash can for 1 of 1 resident, (Resident (R)28), reviewed for transmission based precautions out of a total of 24 sampled residents. These failures created a risk of contamination and increased the likelihood of transmitting infection to others. Findings include: Review of the facility policy titled, Isolation- Transmission- Based Precautions & Enhanced Barrier Precautions, with a revision date of 09/22 indicated, . Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to others. Policy Interpretation and Implementation: . 2. Transmission-based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person.4. The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission-based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. Contact Precautions: 1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. 2. Contact precautions are also use in situations when a resident is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, even before a specific organisms has been identified. Review of R28's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R28 was admitted to the facility on [DATE], with a diagnosis including but not limited to extended spectrum beta lactamase (ESBL) resistance. Review of R28's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/01/26 and located under the MDS tab of the EMR, revealed R28 had a Brief Interview for Mental Status (BIMS) of 4 out of 15, indicating severe cognitive impairment and Multidrug-Resistant Organism (MDRO). Review of R28's Order Summary Report, dated 05/26 and located under the Orders tab of the EMR revealed R28 had no physicians order for transmission-based precautions. Review of R28's Care Plan, revised and reviewed on 05/08/26 and located under the Care Plan tab of the EMR revealed: . [The] resident is at risk for complications related to urinary tract infection (UTI). and contact precautions related to UTI/ESBL. During an observation on 05/19/26 at 3:32 PM, R28 was lying in bed receiving intravenous fluids and was on contact isolation. During an interview on 05/19/26 at 3:33 PM, Certified Nursing Assistant (CNA)2 verified R28 had ESBL in her urine and that R28 was on contact isolation. No separate trash cans (red or yellow) were present in room for isolation materials to be disposed in. During an observation on 05/20/26 at 2:22 PM, R28 was in her room and had no separate trash cans for isolation personal protective equipment (PPE). During an observation on 05/21/26 at 10:41 AM, Resident 28 was in her room with no separate trash cans for contact isolation PPE. During an interview and observation on 05/21/26 at 1:03 PM, in R28's room, Licensed Practical Nurse (LPN)2 confirmed R28 only had a personal trash can in her room for PPE disposal. LPN2 was not sure if there should be separate waste receptacles for personal trash and isolation PPE/waste materials. LPN2 was unable to find a physician's order for transmission-based isolation. During an interview and observation on 05/21/26 at 1:19 PM, in R28's room, the Director of Nursing (DON) stated, We have never had that policy before. PPE goes in the personal trash can and should come out after each time. The DON then confirmed there was unremoved PPE in R28's personal trash can, that R28 was in her room, and no other staff were present in the room. The DON then said, There should've been an extra trash can or at least one by the door. The DON revealed there had been a physician's order for transmission-based isolation.

Based on observation, interview, record review, and facility policy review, the facility failed to follow physician's order for oxygen administration and to have storage bags present in accordance with professional standards of practice, while administering oxygen to 2 residents (Resident (R)3 and R93) of 2 reviewed for respiratory care out of a total sample of 24 residents.Findings include: Review of the facility policy titled, Oxygen Administration, with a revision date of 10/18 noted, . The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for the procedure. Review the physician's order for oxygen administration. 1. Review of R3's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE], with diagnoses including but not limited to respiratory failure with hypercapnia, chronic pulmonary edema, bronchitis, seasonal allergies, and chronic obstructive pulmonary disease (COPD). Review of R3's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/01/26, and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS also indicated R3 received oxygen therapy. Review of R3's Order Summary Report, located under the Orders tab of the EMR revealed oxygen at four liters per minute (LPM) through nasal cannula, start date 06/09/24. Review of R3's Care Plan, revised on 04/12/26 and located under the Care Plan tab of the EMR revealed respiratory/oxygen use: Resident is at risk for respiratory complications related to chronic bronchitis, COPD, seasonal allergies, and chronic pulmonary edema. Oxygen as ordered. During an observation on 05/19/26 at 2:12 PM, R3 was in his room receiving oxygen through nasal cannula at three LPM with no storage bag present. During an observation on 05/21/26 at 9:54 AM, R3 was receiving oxygen through nasal cannula at three and a half LPM with no storage bag present. During an interview and observation on 05/21/26 at 1:07 PM, at R3' bedside, Licensed Practical Nurse (LPN)1 confirmed R3 was receiving three and a half liters of oxygen. LPN1 confirmed the physicians order was for four liters of oxygen. LPN1 confirmed there was no storage bag present and since R3 goes outside to smoke a storage bag would be needed to keep the resident's oxygen tubing from becoming dirty. 2. Review of R93's admission Record, located under the Profile tab of the EMR revealed R93 was admitted on [DATE], with a diagnosis including but not limited to acute respiratory failure with hypoxia. Review of R93's quarterly MDS, with an ARD of 05/05/26 and located under the MDS tab of the EMR, revealed R93 had a BIMS score of 00 out of 15, indicating severe cognitive impairment. The MDS also indicated R93 received oxygen. Review of R93's Order Summary Report, located under the Orders tab of the EMR revealed oxygen at five liters through nasal cannula every shift to keep oxygen above 90, start date 09/18/24. Review of R93's Care Plan, revised on 12/15/25 and located under the Care Plan tab of the EMR revealed respiratory/oxygen use: Resident is at risk for respiratory complications related to history of acute respiratory failure with hypoxia and recent pneumonia. Administer oxygen as ordered. During an observation on 05/19/26 at 3:17 PM, R93 was in his room receiving oxygen through nasal cannula at three and a half LPM with no storage bag present. During an observation on 05/20/26 9:51 AM, R93 was in his room receiving oxygen through nasal cannula at three LPM with no storage bag present. During an interview and observation on 05/21/26 at 1:03 PM, at R93's bedside, LPN2 confirmed R93 was receiving four and a half liters of oxygen. LPN2 confirmed the physician order was for five liters of oxygen. LPN2 confirmed there was no storage bag present. During an interview on 05/21/26 at 1:03 PM, the Director of Nursing (DON) confirmed physician orders for oxygen should be followed and that storage bags should be present.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure Resident (R)3's fingernails were kept clean and trimmed for 1 of 1 resident reviewed for activities of daily living out of 24 sampled residents. Findings include: Review of the facility policy titled, Fingernails/Toenails, Care of, with a revision date of 02/18 noted, . The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Documentation. The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given. 2. The name and title of the individual(s) who administered the nail care. 6. If the resident refused the treatment, the reason(s) why and the intervention taken. 7. The signature and title of the person recording the date. Reporting: 1. Notify the supervisor if the resident refuses the care. 2. Report other information in accordance with facility policy and professional standards of practice. Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, with a revision date of 03/18 noted, . Residents will be provided with care, treatment and services to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive services necessary to maintain good nutrition, grooming and person and oral hygiene. Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming and or oral care). Review of the admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE], with diagnoses including but not limited to neuralgia and neuritis. Review of R3's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/01/26, and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out 15, which indicated intact cognition. The MDS further indicated R3 had upper extremity impairment on one side, and the resident required supervision or touching assistance for personal hygiene. Review of R3's Care Plan, with a review date of 06/12/24, and located under the Care Plan tab of the EMR revealed R3 required assistance from supervision to touching assistance with activities for daily living (ADLs) and required assistance with morning (AM) and evening (PM) care that included personal hygiene as needed. Review of R3's Progress Notes, located under the Progress Notes tab of the EMR reveled from 04/21/26 through 05/21/26, R3 did not refuse any care. Review of R3's Hygiene, located under the Task tab of the EMR revealed from 04/22/26 through 05/21/26, R3 did not refuse care. During an observation and interview on 05/19/26 at 2:16 PM, R3 revealed staff would not cut his fingernails even when he asked. R3's fingernails were observed with a brown/red substance underneath them and were over one fourth inch long. During an observation on 05/21/26 at 9:39 AM, R3's fingernails were over one fourth inch long and dirty with a brown/red substance underneath them. During an interview and observation on 05/21/26 at 1:04 PM, Certified Nursing Assistant (CNA)1, at R3's bedside, confirmed the resident's fingernails were approximately one fourth inch long, dirty with a brown substance underneath them. She confirmed they should be clean and trimmed. During an interview and observation on 05/21/26 at 1:07 PM, Licensed Practical Nurse (LPN)1, at R3's bedside, confirmed the resident's fingernails were over one fourth inch, substance underneath was dark in color and might be food. She confirmed the resident's fingernails were supposed to be cleaned and trimmed every Sunday because that was nail care day and they should also be cleaned and trimmed as needed to reduce infection and for sanitary reasons.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure Resident (R)93, who was admitted to the facility with a contracture, was provided with the services to prevent further decrease in range of motion/mobility for 1 out of 2 residents reviewed for contractures out of a total sample of 24 residents.Findings include: Review of the facility policy titled, Resident Mobility and Range of Motion, revised on 07/17 noted, . 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Policy Interpretation and Implementation: . 6. Interventions may include therapies, the provision of necessary equipment, and/or exercise and will be based on professional standards or practice and be consistent with state laws and practice acts. Review of R93's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R93 was admitted to the facility on [DATE], with diagnoses including but not limited to contracture right hand and contracture left hand. Review of R93's quarterly Minimum Data Set (MDS), located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 05/05/26, revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severe cognitive impairment. The MDS also revealed R93 had upper extremity impairment on both sides. Review of R93's Order Summary Report, located under the Orders tab of the EMR revealed cushion carrots to bilateral hands every shift for contraction, start date 02/04/26. Review of R93's Care Plan, initiated on 02/05/26 and located under the Care Plan tab of the EMR revealed carrots to bilateral hands as ordered. Review of R93's Progress Notes, located under the Progress Notes tab of the EMR from 04/21/26 thought 05/21/26, did not indicate R93 had any behaviors or refusal of device. During an observation on 05/19/26 at 2:49 PM, R93 had a palm guard in the right contracted hand. The left hand was contracted with no device. During an observation on 05/20/26 at 9:51 AM, R93 had a palm guard in the right contracted hand, and no device in the left hand that was contracted. During an observation on 05/21/26 at 10:36 AM, R3 had no palm guard in the right contracted hand, and the left hand was contracted with no device. During an interview and observation on 05/21/26 at 1:13 PM, at R93's bedside, Licensed Practical Nurse (LPN)2, confirmed R93's hands were hard to open and that the resident should have a device placed in his palm to prevent further contracture. During an interview on 05/21/26 at 1:19 PM, the Director of Nursing (DON) confirmed R93 should have a device placed in his bilateral contracted hands.

Based on review of the facility policy, Center for Disease Control (CDC) website, observation, interviews, and record review, the facility failed to ensure infection control was maintained for (Resident (R) 42 for 1 of 1 residents reviewed for infection control. Findings include; Review of the facility policy revised October 2018, titled Clostridium Difficile recorded in the policy statement, Measures are taken to prevent the occurrence of Clostridium Difficile infections among residents. Precautions are taking while caring for residents with C. Difficile to prevent transmission to other residents. Review of the facility policy revised September 2022, titled, Isolation-Transmission Based Precautions and Enhanced Barrier Precautions under policy statement states, Transmission based precautions are initiated when a resident develops signs and symptoms of a transmissible infections, has a laboratory confirmed infection, and is at risk of transmitting the infection to other residents. Under Contact Precautions, the policy records, Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the residents environment. Contact precautions are also used in situations when a resident is experiencing diarrhea . from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen before a specific organism can be identified. The individual on contact precautions is placed in a private room if possible. Review of the CDC website for C. diff states, Clostridium Difficile (C. Diff) is a germ that causes diarrhea and colitis (an inflammation of the colon) and can be life threatening. When C. diff germs are outside the body, they become spores. These spores are an inactive form of the germ and have a protective coating allowing them them to live for months or years on surfaces .The germs become active again when you swallow these spores and they reach the intestines. Cleaning and disinfecting surfaces can reduce risk of C. diff infection. Isolate and initiate contact precautions for suspected or confirmed C. diff infection. Perform daily cleaning of patient rooms using a C. Difficile sporicidal agent. Record review of R42 revealed he was admitted to the facility on [DATE] with diagnoses that include but not limited to congestive heart failure and cerebral infarction Record review of R42's Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/05/2025 revealed he had a Brief Interview Mental Status (BIMS) score of 15, indicating he was cognitively intact. Record review of progress notes of R42's record recorded a Situation, Background, Assessment, Response (SBAR) on 4/22/2025 at 16:34. Nursing observations, evaluation, and recommendations are: R42 has multiple loose mucousy yellow stools, Primary Care Provider responded with the following feedback: Recommendations: check stool for C-Diff, contact precautions. Record review of laboratory findings of R42 revealed C-diff collected on 04/23/2025, with results on 04/26/2025, positive for C-Difficile toxin. On 04/29/2025 at 5:16 PM, an interview with Licensed Practical Nurse (LPN)3 confirmed contact precautions for R42. She stated, his roommate uses the regular toilet and R42 uses the other, across the room from the toilet. LPN3 entered the room to the bathroom, a bedside commode without a bucket was observed. She said, When R42 is in bed, he doesn't need the commode, he uses his brief. An observation and interview with R42's roommate on 04/29/2025 at 5:17 PM revealed he was in his room sitting in a chair with visitors. When asked which commode he uses, he said, I use the glass one, the white one. My roommate and I use the same one. An observation and interview was conducted with R42 on 04/29/2025 at 5:19 PM. R42 was observed sitting in his wheelchair outside of his room by the door. When asked which commode he uses, R42 stated, I use the white one, the regular toilet. On 04/29/2025 at 5:21 PM, a second interview with LPN3 reiterated that the roommate of R42 uses the regular porcelain toilet and R42 uses the bedside commode. On 04/29/2025 at 5:31 PM, an interview was conducted with the Assistant Director of Nurses, (ADON). She confirmed she was the Infection Control nurse. She stated, The room mate should have a bedside commode. That way when they empty it into the regular commode, there is no chance of cross contamination. The ADON confirmed R42 was on contact precautions. On 04/30/25 at 10:49 AM, an interview was conducted with Housekeeper (HSK)1. HSK1 was across the hall from the contact isolation room, at the end room of the unit, cleaning in a bathroom. HSK1 stated, When cleaning resident rooms, I grab the gown from the door and get the trash. After breakfast, I do the floors. After lunch, we do bathrooms and wear a mask. For rooms with signage, we use the sink to wash our hands. As far as I know, it's the same as the other rooms, everything else is the same. I try to stay away from those residents in the room. I change the mop bucket water every 3 rooms for all rooms. I use the same cleaner they give me. On 04/30/2025 at 11:02 AM, an interview was conducted with the Head of Housekeeping. He said, The only thing our disinfectant doesn't kill is C-Diff. Every 3 rooms we change out the mop heads and water, unless there are a lot of urine or feces. They change out the mop heads every time they change out the water. Any isolation room, they change it after they clean that room. The only thing that differs from an isolation room is they have to change out the water and mop head. Isolation rooms are more wiped down. The signage is on the door and behind it tells you what to wear going in. There is a 1 minute time wait period. They use a mop bucket with bleach water. They will take a bottle of bleach into isolation rooms. It's only good for 24 hours. On 04/30/2025 at 11:23 AM, the Head of Housekeeping went to HSK1's cleaning cart. It was parked/locked outside. The Head of Housekeeping confirmed HSK1 was at lunch. He unlocked the cart and looked for a bottle of bleach. He confirmed there was no bleach bottle on his cart. On 04/30/2025 at 11:30 AM, a follow up interview was conducted with the Head of Housekeeping. He said, It does concern me that he doesn't have bleach on his cart. He returned to the laundry room closet to look for a bottle of bleach he may have left in the closet. He did not see it. He said, Most will use bleach because they do not know what the residents have. I make up the bleach bottles, I pour the bleach. I did not make a bottle of bleach water for HSK1's cart this morning. The bleach water is good for 24 hours. I am not aware of any C-diff. In the morning meeting, it is sometimes mentioned. Nursing will tell me privately, and I tell my housekeepers to clean that room with bleach. I'm not aware of anyone with C-Diff right now. On 04/30/2025 at 11:40 AM, an interview with the ADON and the Director of Nurses (DON) was conducted. They both stated, Everyone is informed of infections in a room with the signage that is placed outside the door or room, for all staff members. We don't specifically tell anyone in a meeting about who has what, not even to other department managers. The signage, on the back will tell them how to handle a room upon entering. On 05/01/2025 at 5:45 PM, an additional interview with the ADON and DON was conducted regarding cleaning and disinfecting isolation rooms with C-Diff. They both confirmed if the cleaner that was used was not approved to kill C-Diff, it is a problem and could potentially spread the spores. On 05/01/2025 at 6:37 PM, a follow up interview was conducted with the DON. She stated, We follow contact precautions, we do not have a policy for Enteric Precautions. C-Diff will fall under contact. We do not use hand rubs, we wash hands only.

Based on review of the facility policy, observation and interview, the facility failed to provide privacy for nine (9) Resident (R) Council members (R8, R11, R100, R13, R80, R61, R35, R72, R38), who participated in a group interview with the surveyor. During the group interview in the facility's small dining room, two (2) staff persons passed through going to an outside smoking area and another two (2) staff persons passed on the opposite side going towards 200 hall. Findings include: Review of the facility policy, Resident Council effective date 12/31/2015 states, The activity staff arrange for a room for Council meeting. The Council meeting is held at regular scheduled intervals, at minimum monthly. The date, location and time is clearly posted on the activity schedule. On 04/30/25 at 11:30 AM, a Resident Council Meeting was held in the small dining room of the facility with the surveyor. The current Resident Council President was in attendance, with eight (8) other residents in attendance. There were no privacy doors attached to dining room. The Activity Director (AD) attempted to redirect staff and posted a sign Meeting in Progress. However, observations during the meeting revealed staff walking through the dining room to the 200 hallway and smoking area outside. During an interview on 04/30/25 at approximately 11:30 AM with R72, R13, R35, R80 and R38 all acknowledged and confirmed the facility's monthly Resident Council meetings were held in the dining room. At this time, R72 and R13 stated, Staff walks through all the time, going to the smoking area or walking to the other hall. During an interview on 04/30/25 at approximately 11:40 AM, R61 reported less staff were walking through today secondary to the presence of the surveyors. R61 stated, They are on their toes cause y'all are here, but usually they do not care. During an interview on 04/30/25 at approximately 3:00 PM the AD stated, Resident Council usually meets monthly in the large dining room or small dining room. AD stated there is not a space that allows for total privacy for meetings; however, the areas being used are common areas and he attempts to curtail staff and visitors from coming into areas, but is not always successful. AD stated he would speak with the Administrator about finding a private area that could be used. During an observation and interview on 05/01/25 at approximately 8:45 AM with Administrator, revealed he spoke with the AD and understands concerns of resident having privacy during Resident Council meetings. The Administrator stated the [NAME] Hall Day Room could possibly be an area that may be used as a space that provides privacy for Resident Council meetings. The Administrator stated he would have housekeeping clean out the dayroom. During an observation, the [NAME] Hall Day Room appeared to be accommodating with a door for privacy for Resident Council Meetings. An observation at approximately 9:15 AM of the dayroom after some furnishings and equipment were removed, the room appears spacious and offers privacy for Resident Council meetings to be held. The Administrator confirmed the area will be used for Resident Council meetings going forward. 49800

Based on observation, record review and interview, the facility failed to follow physician orders for fluid restriction for Resident (R) 42, for 1 of 1 resident reviewed for dehydration. Findings include; Record review of R42 revealed he was admitted to the facility on [DATE] with diagnoses that include but not limited to; congestive heart failure, cerebral infarction, stiffness of right hand and acute respiratory failure with hypoxia (tissue and organs are not receiving enough oxygen). Record review of R42's Admission Minimum Data Set (MDS) with an assessment reference date of 02/05/2025, recorded his Brief Interview Mental Status (BIMS) score of 15, indicated he was cognitively intact. Record review of R42's physician order dated 04/07/2025 revealed an order, 1500 milliliters (ml) in 24 hours, fluid restriction. First shift, 870 ml, (Breakfast Tray 360 ml, Lunch Tray 240, Med Pass 270); 2nd Shift 510 ml (Supper Tray 240, Med Pass 270); 3rd Shift 120 ml, every shift for heart failure. Additional physician orders dated 02/24/2025 recorded, Congestive Heart Failure (CHF) Weight. If the resident has a 3-lb or more weight gain, re-weigh the resident, document both weights, and notify the provider. Record review of R42 physician orders dated 04/22/2025 of Furosemide Injection (medication that helps get rid of excess fluid) Solution 10 milligram(mg)/ml (Furosemide), Inject 20 mg intramuscularly (IM) one time only for edema for 1 day. Additionally, another order to administer Torsemide Oral Tablet (medication that helps get rid of excess fluid) 10 MG by mouth every morning for edema (swelling in the tissues) for 3 days. Record review of R42's Medication Administration Record recorded Torsemide 10 mg was given daily on 04/22/2025 through 04/24/2025 for edema. Record review of R42's Fluid Intake Record with lookback of 14 days (04/17/2025-04/30/2025) recorded on 2 days that R42 received 1780 ml on 04/20/2025 and 1800 ml on 04/25/2025, which coincides with R42 receiving additional medication for the excess fluid and swelling. An observation and interview with R42 on 04/29/2025 at 2:20 PM revealed he was wearing a tubigrip on his right arm, used for swelling/edema. He stated, I'm on a fluid restriction. They took my water pitcher away from me. They told me they were trying to get the fluid down. Observation revealed there was not a water pitcher at his bedside. On 05/01/2025 at 9:47 AM, an interview with the Certified Dietary Manager (CDM) revealed, R42 is on a 1500 ml fluid restriction. His sodium diet is restricted, meaning no added salt packet on his tray. Breakfast, he gets 360 ml on his breakfast tray then 240 ml on his lunch and supper tray. 840 ml from us, the kitchen in 24 hours. Nursing gives him 270 ml on 1st shift. 2nd shift gives him 270 ml and 3rd shift gives 120 ml of fluids. Totals 1500 ml. He is on the fluid restriction for heart failure, or CHF. On 05/01/2025 at 10:02 AM, an interview with Registered Nurse (RN)1/Unit Manager revealed, R42 is on a 1500 ml fluid restriction. We had to send him out one time, he was having shortness of breath. That was on 2/20/2025, for respiratory distress. He was in the hospital for a week. He was admitted with the fluid restrictions. Nursing gives him 270 ml on 1st shift. 2nd shift gives him 270 ml and, 3rd shift gives him 120 ml. The Certified Nurse Assistant (CNA) will not give the resident fluids who are on fluid restriction. The nurses are giving the fluids with medication administration. He is on the restriction for heart failure. On 4/20/2025, he received 1780 ml, more than what was ordered. On 4/25/2025, he received 2400 ml. This coincides with the medication he received. I don't monitor the fluid restriction to see the input. On 05/01/2025 at 10:19 AM, an interview with the Nurse Practitioner (NP) revealed, R42 is on fluid restriction. After reviewing the Fluid Intake Record, she confirmed these dates (04/20/2025 and 04/25/2025) coincide with needing additional diuretic medication. She stated, He has dependent edema in his legs and his one arm, I ordered tubi grip. I go off the symptoms of the patient when I write orders. On 05/01/2025 at 5:28 PM, an Interview with the Assistant Director of Nurses (ADON) revealed she reviewed the fluid intake record for R42. She stated, He did receive more fluids than he was supposed too. RN1/Unit Manager and the NP came and spoke to us about that. We reviewed the fluid intake on him and it does confirm it. On 5/01/2025 at 5:49 PM, an interview with the Director of Nurses (DON) revealed, We do not have a policy on fluid restriction, we follow the physician order.

Based on facility policy, observation, interview and record review, the facility failed to remove expired, discontinued medications and biologicals from the medication room, treatment cart and medication cart. Additionally, the facility failed to ensure narcotic refrigerated medications were stored in permanently affixed compartments for 2 of 2 units reviewed for medication storage. Findings include; Review of the facility policy with a revision date of [DATE], titled, Medication Labeling and Storage revealed If the facility has discontinued, outdated, or deteriorated medications or biolgicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Controlled substances and other drugs subject to abuse are separately locked in permanently affixed compartments. An observation on [DATE] at 8:40 AM of the TCU Unit Long Hall Treatment Cart with Registered Nurse (RN)1 revealed the following: 2 tubes of Santyl ointment, undated, open with partial contents removed and no box. An open tube of Clotrimazole Betamethasone Cream 1% was in the cart, however the resident was discharged from the facility. RN1 confirmed the residents had been discharged and the medication should have been removed from the treatment cart. An observation of the Medication Room on the TCU Unit on [DATE] at 8:50 AM with RN1 revealed in the refrigerator, there was insulin labeled and unopened, Insulin Lispro LOT #D745111A. Additionally, an intravenous (IV) Start Kit with an expiration date of [DATE], LOT# 229629. RN1 confirmed the resident had been discharged and confirmed the IV start kit was expired and should have been removed from the med room. On [DATE] at 1:33 PM, an observation with Licensed Practical Nurse (LPN)1 of Station 1, Medication Room revealed the following: 2 Lorazepam in the narcotic kit in the med room. A second locked box was also observed in the refrigerator. LPN1 stated, They are for each cart. Only 1 nurses' cart has meds in here, each cart has their own box for narcotics only. The narcotics boxes were removed and LPN1 brought one out and reviewed the contents. There were 2 Ativan tablets observed in the locked toolbox. LPN1 stated, These are not permanently attached to the refrigerator, we can take them out as needed. On [DATE] at 1:45 PM, an observation of a medication cart with LPN2 revealed the following: 14 pills in the bottom of 2 drawers of the med cart. Also, a bottle of Fish Oil Stock LOT # 23103 with an expiration date of ,d+[DATE] was observed, and a container of Fiber Powder with an expiration date of [DATE], lot number 4039604. LPN2 stated, The carts are checked often for dates, the pharmacy comes in also and checks them for expiration dates and lose pills. On [DATE] at 5:35 PM, during an interview with the Assistant Director of Nurses, (ADON), she confirmed the narcotic boxes are not permanently affixed to the refrigerators in the med rooms. She stated, The nurse that is on the carts is responsible for cart checks, the unit managers also go through the carts. On Tuesday morning, our pharmacy had just left. They went through all our med carts. I was told they found 14 loose pills on one. On [DATE] at 5:45 PM, the Director of Nurses (DON) confirmed the narcotic boxes were not permanently affixed to the refrigerators.

Based on observations and interviews, the facility failed to provide dignity for Resident (R)32 by having a Foley catheter, not in a privacy bag, exposed for the public to see who walk past his room on multiple occasions. The findings include: A review of the facility policy titled Resident's Rights with a revision date of August 2022 revealed that Employees shall treat all residents with Kindness, Respect, and Dignity. A review of the facility policy titled Urinary Drainage Bag Protocol with no revision date revealed- The drainage bag will be placed in a privacy bag. R32 was admitted to the facility on [DATE] with diagnoses including, but not limited to benign prostatic hyperplasia with lower urinary tract symptoms. R32's Brief Interview for Mental Status (BIMS) was a 06 out of 15, indicating R32 is severely cognitively impaired as of 3/15/2025 on the Quarterly MDS (Minimum Data Set). A review of R32's Care Plan, last revised in April 2025, revealed, Bladder: At risk for complications with urinary system related to indwelling catheter, diagnosis of urinary retention and neurogenic bladder, ESBL IN URINE. Interventions: Privacy cover to catheter bag as indicated to promote dignity. First observation and interview on 4/29/2025 at 2:50 PM of R32 revealed the room door open, privacy curtain pulled back, R32 was lying in his bed, awake and looking towards the hall. The catheter bag was exposed, with no privacy bag. Observation revealed staff, other residents, and visitors walked past R32's room in the hallway. R32 states he is bed-bound and dependent on staff for activities of daily living. Additional observations on 4/30/2025 at 10:08 AM, 4/30/2025 at 11:45 AM, and 4/30/2025 at 2:26 PM revealed the catheter remained visible without a privacy bag. Interview with Licensed Practical Nurse (LPN)2 on 04/30/2025 at 2:26 PM confirmed the findings regarding R32's catheter bag not being covered and exposed for the people who walk by his room to see. LPN2 stated that all residents with a catheter are required to have a privacy bag to protect their dignity. She stated R32 had a hospitalization a few days prior and had a new catheter placed, and upon return, one should have been placed at that time. An interview with the Assistant Director of Nursing (ADON) on 4/30/2025 at 2:47 PM confirmed the findings above and revealed that a privacy bag should be placed to protect the resident's dignity.

Based on observation, record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one (Resident (R) 18) of 30 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the resident. Findings include: Review of R18's undated Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R18 was admitted to the facility on [DATE] with a primary diagnosis of chronic obstructive pulmonary disease, and comorbidities including anxiety disorder (DO), bipolar disorder (DO), and major depressive disorder (MDD). Review of R18's Physician Orders, dated 06/29/23 and located in the EMR under the Orders tab, revealed R18 was to receive Zoloft (an antidepressant) 50 mg (milligram) tablet every morning for MDD. Review of R18's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/23 and located in the EMR under the MDS tab, revealed R18 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R18 was cognitively intact. The MDS recorded R18 did not receive an antidepressant during the seven-day look-back period. During an interview on 09/07/23 at 10:07 AM, Licensed Practical Nurse (LPN)5 confirmed that R18 was taking Zoloft 50mg for depression. During an interview on 09/07/23 at 11:11 AM, the Director of Nursing (DON) confirmed that R18 was taking Zoloft 50mg for depression, had no significant behaviors, and was stable at the present time. During an interview on 09/08/23 at 3:54 PM, the MDS Coordinator confirmed that R18 was taking Zoloft 50mg for depression since 06/29/23 and that the quarterly MDS assessment was miscoded for antidepressant usage. Additionally, the MDS Coordinator confirmed that the facility used the RAI Manual as the policy for all MDS assessments.

Based on interview and record review, the facility failed to refer two (Resident (R) 50 and R2) of three sampled residents reviewed for Preadmission Screening and Resident Review (PASRR) for a Level II PASRR resident review after the resident received a new diagnosis of a mental illness and/or experienced a significant change in status assessment related to their mental illness. This had the potential to cause R50 and R2 to not receive necessary mental health services. Findings include: 1. Review of R50's Preadmission Screening and Resident Review (PASRR) Level I Screening Tool, dated 08/14/23 and located under the Misc (Miscellaneous) tab of the electronic medical record (EMR), revealed R50 had a diagnosis or evidence of a major mental illness and had a significant impairment in functioning related to a suspected or known diagnosis of mental illness of anxiety, depression, and bipolar. Review of R50's Admission Record, located under the Profile tab of the EMR, revealed R50 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, unspecified; type 2 diabetes mellitus with ketoacidosis and diabetic polyneuropathy without coma; and generalized anxiety disorder. Review of R50's Diagnoses, listed under the Med Diag [Medical Diagnoses] tab of the EMR, revealed R50 was diagnosed as having bipolar disorder, unspecified and anxiety disorder on 08/17/23. Review of R50's entire clinical record revealed no documentation that a new PASRR Level I Screening Tool was completed for R50 after receiving a diagnosis of bipolar disorder. On 09/07/23 at 11:16 AM, the Social Service Director (SSD) confirmed a new Level I PASRR and referral for a Level II PASRR should have been completed for R50 after receiving the diagnosis of a mental illness. 2. Review of R2's Admission Record, located under the Profile tab of the EMR, revealed R2 was admitted to the facility on [DATE] with diagnoses that included dysphagia. Review of R2's Preadmission Screening and Resident Review (PASRR) Level I Screening Tool, dated 05/11/17 and located under the Misc (Miscellaneous) tab of the EMR, revealed R2 had a diagnosis or evidence of a major mental illness which included depression, bipolar and anxiety. Review of R2's Diagnoses, listed under the Med Diag tab of the EMR, revealed R2 was diagnosed as having depression, bipolar disease, and anxiety. Review of R2's entire EMR revealed the resident experienced escalating behaviors requiring the use of a new medication for bi-polar disease on 07/23/23. The chart revealed no documentation that a new Level 1 PASRR screening had been completed after the onset of behavior issues that caused the change in requiring medications. On 09/07/23 at 11:16 AM, the Social Service Director (SSD), confirmed a new PASRR Level I and referral for a Level II had not been completed for R2 after the resident experienced a significant change in assessment. On 09/07/23 at 1:16 PM, the Administrator confirmed the facility had never done PASRR screening. The Administrator reported the PASRRs were completed at the hospital, and there was no follow-up in the facility. The Administrator confirmed no new PASRR has been completed on R2 after the resident had increased behaviors that required medication changes.

Based on interview and record review, the facility failed to honor food preferences for one (Resident (R) 212) of 32 sampled residents reviewed for food preferences. R212 was served a food item that was recorded as a food dislike on her meal ticket. Findings include: Review of R212's Admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R212 was admitted to the facility on [DATE] with diagnoses that included moderate protein-calorie malnutrition and dysphagia. Review of R212's meal tracker diet order slip, provided by the Kitchen Manager (KM), revealed documentation that R212 disliked carrots and peas. During an interview on 09/06/23 at 11:30 AM, R212; who was alert and oriented to person, place, and time; stated she did not like peas but had been served peas three times since her admission on 8/30/23. R212 stated she had informed the staff she did not like peas. During an interview on 09/07/23 at 2:01 PM, the KM stated the Certified Dietary Manager (CDM) visited with new residents to find out their food likes and dislikes. KM further stated she input the residents' food likes and dislikes into the meal tracker diet order. KM stated the meal tickets were printed daily and revealed an alternative meal item for resident's dislikes. KM stated R212's meal tracker diet order revealed R212 did not like peas or carrots. When asked why R212 was served peas when it was listed as a dislike for the resident, KM stated that sometimes staff did not pay attention to the dislikes.

Based on observation, interview and record review, the facility failed to develop and implement a person-centered comprehensive plan of care with measurable goals and plans related to the use of a wander guard alarm for one resident (Resident (R) R105) of 30 sampled residents reviewed for care plans. Findings include: Review of the Minimum Data Set (MDS) 3.0 RAI Manual, dated 10/2019, indicated, . Care Area Assessment (CAA) Process. This process is designed to assist the assessor to systematically interpret the information recorded on the MDS . The CAA process helps the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident . Specific components of the CAA process include: - Care Area Triggers (CATs) are specific resident responses for one or a combination of MDS elements. The triggers identify residents who have or are at risk for developing specific functional problems and require further assessment . The MDS does not constitute a comprehensive assessment. Rather, it is a preliminary assessment to identify potential resident problems, strengths, and preferences. Care Areas are triggered by MDS item responses that indicate the need for additional assessment based on problem identification, known as triggered care areas, which form a critical link between the MDS and decisions about care planning . Review of R105's electronic medical record (EMR) Admission Record, located under the Profile tab of the EMR, indicated the resident was admitted to the facility on [DATE] for post-acute care due to fractures of the left ribs, and lumbar vertebra from a fall. Review of R105's admission MDS, with an Assessment Reference Date (ARD) of 07/24/23 and located under the MDS tab of the EMR, revealed R105 had a Brief Interview of Mental Status (BIMS) score of five out of 15 which indicated the resident had severe cognitive impairment. Review of R105's Care Plan located under the Care Plan tab of the EMR, revealed no documentation of a focus, goal, or interventions related to the use of a wander guard alarm. During an observation on 09/07/23 at 1:30 PM, R105 was observed in his room. A wander guard alarm was noted on the resident's right ankle. During an interview on 09/07/23 at 3:50 PM, Licensed Professional Nurse (LPN)4 revealed that she was working when R105 tried to exit the door by the kitchen. LPN4 stated she called the doctor and received a verbal order to place a wander guard alarm on the resident's right ankle. LPN4 stated, I forgot to put the order in the system. During an interview on 09/07/23 at 3:55 PM, the Director of Nursing (DON) confirmed LPN4 missed adding the wander guard alarm to R105's orders, so it did not trigger for inclusion into the resident's care plan. The DON stated she did not know R105 had a wander guard alarm.

Based on interview, record review, and facility policy review, the facility failed to ensure one (Resident (R) 18) of two sampled residents reviewed for smoking was free of potential accidents while residing in the facility. Specifically, R18 did not receive a quarterly smoking assessment. This had the potential for increased risk of injury related to smoking for the resident. Findings include: Review of the facility's policy titled, Smoking Policy-Residents, revised 08/2022, revealed, . The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker . A resident's ability to smoke safely will be re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff . Review of R18's undated Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R18 was admitted to the facility on [DATE] with a primary diagnosis of chronic obstructive pulmonary disease. Review of R18's Care Plan, located in the EMR under the Care Plan tab, revealed R18 was a cigarette smoker and was to have quarterly, annual, and significant change smoking assessments. Review of R18's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/23 and located in the EMR under the MDS tab, revealed R18 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R18's Social History Assessment (Admission/Annual,) located in the EMR under the Evaluations tab, indicated that a R18 was a smoker upon admission. Review of R18's smoking assessments, located under the Assessments tab of the EMR, revealed an admission smoking assessment was completed for R18 on 04/17/23. There was no documentation of a quarterly smoking assessment for the resident during the month of 07/2023. During an interview on 09/07/23 at 10:57 AM, the Director of Nursing (DON) confirmed that R18 had a smoking admission assessment on 04/17/23. The DON confirmed a quarterly assessment was not done during 07/2023 but should have been. Additionally, the DON stated that it was not any specific department's responsibility to perform the smoking assessment, but the assessments needed to be performed upon admission, quarterly, and upon significant change. During an interview on 09/07/23 at 12:16 PM with the Social Services Director (SSD) confirmed that R18 had a smoking admission assessment on 04/17/23, and no quarterly assessment was performed in July 2023 but should have been.

Based on interview, record review, and facility policy review, the facility failed to complete a thorough investigation of an accident resulting in a fracture for one (Resident (R) 83) of eight sampled resident reviewed for accidents. There was no evidence the facility interviewed all staff on duty at the time of the accident to help determine the cause of the accident. This lack of investigation had the potential to place other dependent residents at risk for injury. Findings include: Review of the facility's policy titled, Incidents and Accidents- Investigating and Reporting, revised 07/2017, revealed, . 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the incident or accident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the incident/accident took place. b. The nature of the injury/illness . c. The circumstances surrounding the incident/accident. d. Where the incident/accident took place. e. The name(s) of witnesses and their accounts of the incident/accident. f. The injured person's account of the incident/accident. g. The date/time the provider was notified. h. When a fall results in a significant injury or condition change, notify the provider immediately . Review of R83's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed a re-admitted on 03/11/22 with a primary diagnosis of unspecified sequelae of cerebral infarction. Review of R83's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/18/23 and located in the EMR under the MDS tab, revealed R83 had a Brief Interview for Mental Status (BIMS) score of three, indicating the resident was severely cognitively impaired. The MDS recorded the resident required extensive one person assistance for bed mobility, locomotion on the unit, dressing, toileting, and hygiene; two person assistance with transfers; and had no falls since admission. Review of R83's Care Plan, located in the EMR under the Care Plan tab and initiated on 01/09/20, indicated R83 was at risk for falls related to muscle weakness and a history of cerebral vascular accident (CVA/stroke). Interventions included for the resident's bed to be at its' lowest position. This intervention was initiated on 11/16/21. Review of R83's eINTERACT Change In Condition Evaluation - V 5.,1 provided by the facility and dated 07/17/23 at 7:24 AM, revealed R83 sustained a fall, was unresponsive, and . Resident was found lying on the floor, on his back, next to his bed. His bed was raided [sic] high. His blankets were covering him and he had a pillow under his head. Resident was unresponsive, and received orders from on call to transfer resident to the ER [emergency room ] . The fall was noted to have occurred on 07/17/23 at 3:50 AM per Registered Nurse (RN1) documentation. Review of R83's hospital Radiology Report, dated 07/17/23 at 12:18 PM, confirmed R83 sustained a left clavicular fracture and a grade two laceration of the spleen. Review of R83's 24 hour Initial Report provided by the facility and dated 07/17/23, revealed . Type of Injury of Unknown Source: Injury of known source: Minimally displaced comminuted fracture of the left distal clavicle . Resident was observed next to his own bed. NP [Nurse Practitioner], RR [Resident Representative], and Police notified. Investigation started immediately. 5 day report to follow. The date of the reportable incident was listed as 07/17/23 at 3:50 AM. No additional witness statements were included in the investigation. Review of R83's 5 Day Report, provided by the facility and dated 07/19/23, revealed, . The resident was observed lying on floor next to is [sic] bed. His blankets covering and his pillow was under head. Resident was unresponsive only to pain. On call provider ordered resident to transfer to ER [emergency room ] for evaluation and treatment . Minimally displaced comminuted fracture of the left distal clavicle . Summary Report of Facility Investigation: Injury of known source occurred when resident fell out of bed and landed on his back with a 2-3 foot drop. Per hospital notes resident was found to have a splenic laceration with no active bleeding and a left distal clavicle fracture. Resident returned with a sling to left upper extremity. Per ortro [sic] fracture is non operative. Care plan reviewed and revised. Staff following plan of care. No additional witness statements were included in the investigation. During an interview on 09/07/23 at 11:40 AM, Registered Nurse (RN1) confirmed that on 07/17/23 at 3:50 AM R83 was found on the floor, wrapped up in blankets, and that it looked like he had pulled his pillow down with him onto the floor, and the pillow was underneath his head. RN1 stated the resident was lying on his back, his eyes were open, but he was not responding to her. RN1 stated prior to her finding him on the floor, the certified nurse aides (CNA2, CNA7) had gone in to change the resident's brief. During an interview on 09/07/23 at 9:23 AM, R83 stated that he did not remember falling out of bed but remembered having broken a bone and needing to wear a sling for a while. R83 stated that he can't move his left arm/shoulder much anymore but that it did not bother him. During an interview on 09/07/23 at 10:20 AM, Licensed Practical Nurse (LPN5) confirmed that R83 sustained a fall on 07/17/23 resulting in a fracture, but stated she was unaware of the splenic laceration. LPN5 stated she thought that the resident had intentionally rolled himself out of the bed. Regarding investigations, LPN5 stated the nurse on duty was expected to start the investigation and obtain witness statements from any staff on duty that may have been involved in the resident's care or had knowledge of the incident. During an interview on 09/07/23 at 11:18 AM, the Director of Nurses (DON) stated that she was aware of R83's fall on 07/17/23 but did not handle the investigation due to her handling a different reportable investigation at that time. The DON stated she had deferred the investigation to the Administrator. During an interview on 09/07/23 at 1:25 PM, the Administrator confirmed that R83 sustained a fall on 07/17/23 which resulted in a left clavicular fracture and splenic laceration. Upon review of the investigation provided by the Administrator, it was brought to his attention that no staff witness statements were included in the packet provided. The Administrator stated that at the time of the fall he asked the CNAs to submit their witness statements and slide them under his office door; however, they did not do so. The Administrator stated he would contact them and ask them to submit their statements that day. During an interview on 09/07/23 at 4:09 PM, CNA2 stated that she was working on a different hall on the night of 07/17/23 and that her co-worker called her to come assist with R83. CNA2 stated R83 was noted to be on the floor, lying on his back with a pillow under his head, and would open his eyes and mumble, but was unable to answer any questions. CNA2 stated when the paramedics came to pick R83 up, he moaned in pain when the paramedics touched his hip/leg area. CNA2 stated she was not sure how R83 sustained the fall and confirmed that she had not been asked any questions regarding her assistance in his care, nor had she been asked to provide a witness statement until 09/07/23. During an interview on 09/07/23 at 4:54 PM, CNA7 stated that on the night of 07/17/23, she was doing rounds and noticed that R83's bedside table items were on the floor and that R83 was on the floor. CNA7 stated R83 was lying on his back, on the floor next to his bed, that he had a pillow under his head, and was wearing a shirt and a brief. CNA7 stated R83 was not covered with anything and was unresponsive. CNA7 stated R83's bed was at mid-level (not too high, but not low). CNA7 stated that R83 had a history of playing with his remote and would raise and lower his bed. CNA7 stated when she found R83on the floor, she called for CNA2 and RN1. CNA7 stated when RN1 realized that R83 was unresponsive, vital signs were obtained, the physician was notified, and then the resident was sent out to the hospital. CNA7 stated when the paramedics arrived, R83 began to moan when they moved his legs. During an interview on 09/07/23 at 6:07 PM, the Administrator stated that he felt that the fall sustained on 07/17/23 by R83 was intentional. When asked why he felt this way, the Administrator stated that R83 sustained two more falls on 07/20/23, at which time staff reported the resident intentionally rolled himself out of the bed. When the Administrator was asked for witness statements for those falls, he could not provide witness statements for them either. The Administrator stated that he would contact the staff that were on duty and provide them as soon as he obtained them. The Administrator did not confirm or deny if witness statements should have been obtained to ensure that a complete and thorough investigation had been completed.

Based on observation, interview, and record review, the facility failed provide or clean respiratory equipment for four of five sampled residents (Residents (R)11, R30, R56 and R87) reviewed for oxygen therapy. The facility further failed to ensure an order was received for the use of oxygen for R56. Findings include: 1. Review of the electronic medical record (EMR) under the Census tab, revealed R11 was admitted to the facility on [DATE]. Review of R11's EMR under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R11's EMR under the Orders tab revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 12/28/21 at 12:25 PM, R11 was sitting up in bed and stated he used the oxygen only at night. R11's concentrator was observed with one filter on the back of the machine. The filter had a thick coating of dust. During an observation on 12/30/21 at 9:40 AM the concentrator filter had a thick coating of dust. 2. Review of the EMR under the Census tab, revealed R30 was admitted to the facility on [DATE]. Review of R30's EMR under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R30's EMR revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 12/29/21 at 5:05 PM, R30 was laying in bed asleep and wearing the oxygen nasal cannula attached to the concentrator. During an observation on 12/30/21 at 9:16 AM, R30 was up in a reclining chair and was wearing the oxygen nasal cannula attached to the concentrator. During both observations there was no filter located in the filter holder on the back of the concentrator. 3. Review of the EMR under the Census tab, revealed R56 was admitted to the facility on [DATE]. Review of R56's EMR under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R56's EMR under the Orders tab, revealed no evidence of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 12/29/21 at 5:15 PM and 12/30/21 at 9:10 AM, R56 was laying in bed and wearing the oxygen nasal cannula attached to the concentrator. The filter on the back of the concentrator revealed that a portion of the filter protruded one and a half inches above the filter holder and the filter had a layer of dust over it. 4. Review of the EMR under the Census tab, revealed R87 was admitted to the facility on [DATE]. Under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R87's EMR revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During observations on 12/28/21 at 12:10 PM and on 12/30/21 at 9:05 AM, R87 was lying in bed and wearing the oxygen nasal cannula which was attached to the concentrator. The filter on the back of the concentrator revealed a layer of dust. During an interview on 12/30/21 at 1:30 PM, the Director of Nursing (DON), was shown R11, R56 and R87's oxygen concentrator filters. The DON agreed the filters were dirty and the expectation was the filters would be cleaned nightly by the night shift nurses. The DON said she was not aware the filters were not being cleaned. The DON said R56's oxygen orders must have dropped off the orders list and needed to be re-written. The DON confirmed the oxygen concentrator filter was missing from R30's concentrator and did not have an explanation why the filter was missing.

Based on record review, interviews and review of facility policy, the facility failed to ensure an ordered lab draw was completed to ensure a resident received an ordered antibiotic. This resulted in a significant medication error for one (Resident (R) 62) of five residents reviewed for unnecessary medications. Findings include: Review of the facility's policy titled, Medication Administration Schedule revised November 2020, instructed: .3. Scheduled medications are administered within one hour of the prescribed time .4. Scheduled medications designated as time-critical (medication may cause harm or sub-therapeutic effect if administered before or after the scheduled time .are administered at the scheduled time or 30 minutes before or after the scheduled time .8. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R62's undated Face Sheet found in the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R62's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/10/21, found in the MDS tab of the EMR, documented R62 had a Brief Interview for Mental Status (BIMS) score of 15 of 15 possible points, indicating the resident was cognitively intact. Review of R62's undated Order Summary Report found in the Orders tab of the EMR, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview with R62 on 12/27/21 at 2:20 PM, revealed the resident had a peripherally inserted central catheter (PICC) line in her right arm for antibiotic therapy. R62 revealed she needed a few more weeks of antibiotics and therapy before she could go home. Review of a Health Status Note located in the Progress Note tab of the EMR dated 12/26/21 at 1:17 PM revealed, during nurse report upon the start of my shift, I was notified the ordered lab draw for resident [R62] was not obtained and the ordered [MEDICATION(S)] IV was not administered due to the lab not being obtained. This nurse contacted [Omnicare] pharmacy at approx. [approximately] 0800 regarding resident's [R62] [MEDICATION(S)] trough and administration order. This nurse advises the Pharmacist, the [MEDICATION(S)] trough .that was ordered to be drawn on this day before the dose at 0500 was not completed due to the lab did not report to the facility. This nurse offered a STAT [immediate] lab draw to be obtained and continue to administer the [MEDICATION(S)] IV later than the scheduled dose. The Pharmacist advised this nurse that the blood level would be inaccurate due to the timing of the last dose being administered . NP [Nurse Practitioner] notified . During an interview on 12/29/21 at 4:12 PM the Director of Nursing (DON) revealed the nurse who was on duty at the time of the missed lab for the dosing of R62's [MEDICATION(S)] order was an agency nurse and not a facility employee, and the DON didn't think she would be back. The DON confirmed it was her expectation medications would be administered as ordered, including any necessary lab draws for dosing purposes. The DON further confirmed the lab draws were essential for proper dosing of [MEDICATION(S)] and stated they [facility] were re-educating staff now.

Based on observation and staff interview, the facility failed to ensure kitchen staff handled cooked food appropriately during food temping and meal serving. Also, the facility did not ensure that the kitchen dishware were dried and stored according to standard practice and that the solution to sanitize surfaces contained the appropriate amount of sanitation concentration for one of one kitchen and one of one dining-room observed. Findings: During the initial dinning observation on 2/24/20 at 12:17 PM, the meal-server touched utensils, dishware, meal tickets, and refrigerator door and cornbread with the same gloved hands. On 2/25/20 at 12:16 PM, the same meal-server did the same. S/he, wearing the same gloves, grabbed meal tickets, dishware, fruit cup, and dinner roll. Certified Dietary Manager (CDM) #2 confirmed that the server did not handle cooked food properly. The server used the same gloved hands to touch several items, including meal tickets, and grabbed the dinner rolls and place them on the residents' plate. In a follow-up visit to the kitchen on 2/26/20 at 8:55 AM, one of one red bucket observed for sanitation did not contain the recommended sanitation concentration (did not see it being used). The food and nutrition services director did the testing. There were also three wet nesting containers (wet containers stocked-up on top of each other) During food temping, on 2/26/20 at 11:45 AM, the cook touched the last cooked food item, Salisbury- steak, with the same gloved hands she used during the entire temping process. S/he touched surfaces, utensils, thermometer and wipes, and the steak with the same gloved hands. The CDM #1 confirmed that (s/he) also observed the cook touching the meat with the same gloved hands.

Based on observations, record reviews, interviews and review of the facility's Feeding the Impaired Residents policy, the facility failed to ensure that residents were treated with dignity and respect for 3 of 3 residents triggered for dignity and 1 of 3 triggered for pressure ulcer treatment. Resident #14 not served or eating while roommate was served and eating. Residents #63 and #107 with staff standing while feeding the residents. Resident #109 with nurse observed putting dressing on resident wound then writing on the dressing after it was placed on the resident's ankle. The findings included: The facility admitted Resident #107 on 7/21/17 with [DIAGNOSES REDACTED]. During random meal observation on 2/24/20 at approximately 1:53 PM, Certified Nursing Aide (CNA)#1 was observed standing in room [ROOM NUMBER] while feeding Resident #107 who was in bed. The resident's bed was observed in a high position. A folding chair was observed in corner of room while CNA was standing while feeding the resident. The facility admitted Resident #14 on 3/18/19 with [DIAGNOSES REDACTED]. A random observation on 2/25/20 at approximately 8:18 AM revealed Resident #14 in room [ROOM NUMBER] with his/her roommate served and eating breaking while Resident #14 was not served or eating breakfast and the privacy curtain was not pulled. Resident #14 tube feeding was also not in progress at the time of the observation. The facility admitted Resident #63 on 9/26/18 with [DIAGNOSES REDACTED]. A random observation on 2/25/20 at approximately 8:23 AM revealed Certified Nursing Aide (CNA) #2 standing in room [ROOM NUMBER] while feeding Resident #63 who was in bed. Resident #63's bed was not in a high position (at level of CNA) who was standing while feeding the resident. An interview and observation on 2/25/20 at approximately 8:37 AM with Licensed Practical Nurse (LPN) #5 revealed Resident #14 roommate seated at bedside table eating his/her breakfast while Resident #14 was not served or eating breakfast with privacy curtains not pulled/closed. LPN #5 stated the privacy curtains should have been pulled since both residents in room were not served and eating. LPN #5 preceded to close the privacy curtains. An interview on 2/25/20 at approximately 8:41 AM with CNA #2 confirmed he/she was standing while feeding Resident #63 who was in bed. CNA #2 stated he/she should not have been standing and that he/she was standing because she could not find a chair. An interview on 2/25/20 at approximately 9 AM with the Director of Nursing (DON) revealed it was acceptable for staff to stand while feeding resident if the resident and staff was at the same level. A copy of the facility's policy on standing while feeding residents was requested. A review on the facility's policy Feeding the Impaired Residents on 2/26/20 at approximately 7:33 AM, under Steps in the Procedure #10 indicated staff were to Sit at bedside in chair while feeding the resident. There was no documentation to indicate the staff should stand while feeding residents. Reviewed Resident #107 care plan. There was no documentation in the resident's care plan to indicate staff should be standing when feeding the resident. An interview on 2/27/20 at approximately 9:16 AM with CNA #1 revealed he/she confirmed observation of standing while feeding Resident #107 who was in bed. CNA #1 further stated he/she was under the impression it was acceptable to stand while feeding a resident if were at the same eye level. The facility admitted Resident #109 with [DIAGNOSES REDACTED]. Wound care for Resident #109 was observed on 2/25/20 at 2:32 PM. At the completion of the wound care, Registered Nurse (RN) #3 Placed a dressing over the resident's right ankle. RN #3 then proceeded to write the date on the dressing. During an interview with RN #3, on 2/27/20 at 9:46 AM, RN #3 confirmed s/he dated the dressing after it was applied to the resident's ankle. RN #3 stated this is a dignity issue and s/he should not have written on the dressing after it was placed on the resident. During an interview with the Director of Nursing (DON), on 2/27/20 at 9:57 AM, the DON stated RN #3 had come to her/him after the wound care and reported on the treatment s/he provided. The DON stated RN #3 told her/him s/he had written on the residents dressing after placing the dressing on the residents ankle. The DON stated s/he educated RN #3 that this is a dignity issue and nursing can not write on residents after dressings are placed. The DON stated RN #3 was re-educated.