Every finding on record at Menard Manor

Based on interview and record review the facility failed to immediately notify and consult with the resident's physician when a significant change in a resident physical, mental, or psychosocial status (that was a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 3 residents reviewed for change in condition. The facility failed to immediately inform MD on 3/13/2026 of Resident #1's change in condition after she had a fall on 3/13/2026. This failure could place residents at risk of serious decrease in health due to delayed treatment. During a record review of Resident #1's face sheet dated 3/20/2026 revealed, [AGE] year old female (Resident #1) was admitted to facility on 5/16/2024 with diagnoses of unsteadiness on feet, muscle weakness, osteoporosis (a chronic bone disease characterized by decreased bone mass and density). During a record review of Resident #1's quarterly MDS dated [DATE] revealed, a BIMS score of 3 indicating severe cognitive impairment. Section GG of MDS revealed Resident #1 required substantial maximum assistance for transfers and used a wheelchair for mobility. Section P of MDS revealed Resident #1 used chair alarms and bed alarms daily. During a record review of Resident #1's care plan dated 2/20/2026 revealed, Resident #1 was at high risk for falls related to gait/balance problems Resident #1 would be free of falls through the review date. Follow facility fall protocol. During a record review of Resident #1's physician orders dated 3/20/2026 revealed, this resident is unable to understand and exercise rights related to dementia with an order date of 10/22/2022, no end date, self-release belt to wheelchair with a start date of 11/7/2024, no end date, smart quiet pressure pad alarm to bed for safety with a start date 11/8/2024, no end date. During a record review of Resident #1's progress notes generated by RN C dated 3/13/2026 at 6:00am revealed, at 4:50 am she heard a voice call out. RN C went down the hall and observed Resident #1 on the floor in the corner of her bedroom with her head and left shoulder propped up against the wall; Resident #1 was seated on her left hip. Neurological checks were initiated and were within normal limits. Resident #1 had a knot on her left forehead with a scrape. Wound was cleansed and left open to air. No other injuries were noted. Resident #1 complained of pain to the left side of her head and her left foot. Resident #1 rated the pain to her head and lower extremity at a 7 and PRN hydrocodone pain medication was administered. Administration was notified of fall at approximately 5:10.am. The responsible party was notified of fall at 7:01am. During a record review of Resident #1's progress notes generated by LVN W on 3/13/2026 at 6:57pm revealed PRN pain medication was administered due to Resident #1 complaining of severe head pain and left lower extremity pain with range of motion. On 3/13/2026 at 7:23pm Resident #1 was transferred to emergency room by her request due to pain and the responsible party agreed. At this time Resident #1 had a change in neurological checks of generalized weakness and slow to open eyes during assessment; grips weak.Prior to transferring Resident #1 to emergency room LVN W utilized on call system used after hours and notified MD on call of increased pain and MD gave orders to send to emergency room. Resident #1 returned from emergency room on 3/13/2026 at 11:53pm and CT scan (non-invasive medical imaging test that produces images of bones, blood vessels, and soft tissues) of head and x-ray (imaging test used to visualize bones) of lower foot and ankle were clear. Attempted to interview LVN W 3 times and no return call. During an observation on 3/20/2026 at 9:35a.m, revealed, Resident #1 continued to have a raised area with bruising to the left side of her head. Fall equipment including bed alarm and fall mat was in place. Resident #1 was not interview able. During an interview on 3/20/2026 at 2:02 p.m., RN C stated she did not notify the MD at the time of the incident. RN C stated she did notify the responsible party and administration at the time of the incident. RN C stated she knew about the on-call system for notifying on-call physicians but failed to use it. RN C stated after the incident she received one on one training regarding utilizing the on-call system called Third Eye to notify the MD of events that occurred outside of normal business hours. RN C stated that the risk of not notifying the MD at the time of the incident could be an injury with delay in care. During an interview on 3/20/2026 at 4:04pm with the Administrator, she stated that the expectations for incidents were to notify administrative staff. She stated the nurse should have utilized the on-call system outside of normal business hours to notify the MD. Administrator stated the risk of not doing so could lead to injuries not being recognized. During an interview on 3/20/2026 at 4:07pm with Resident #1 MD he stated that he cannot be on call all the time because he was the only doctor in the area. The MD stated the facility has an on-call program for afterhours called Third Eye that the facility can utilize outside normal business hours. The MD stated that if there was an injury, he would expect them to notify him immediately. If there is no injury, the on-call system should be utilized and 2 hours after the incident would be a sufficient timeframe. The MD stated nurses have some autonomy in being able to decide when something needs to be addressed. The MD stated there is a risk to the residents anytime we misjudge a situation. The MD stated Resident #1 had no negative outcome from not notifying the MD after the incident.MD stated failing to notify him immediately if there was an injury could result in delay of care. During a record review of the facility's policy dated 11/5/2013 titled Incident/Accident Reporting Policy and Procedure revealed, 5. It is always necessary to notify family and physician no matter how insignificant an incident may seem. During a record review of the facilities policy dated 6/12/2024 titled Resident Rights Policy and Procedure revealed:Residents have the right to:Receive all care necessary for them to have the highest possible level of health. During a record review of facilities policy undated titled Managing Falls and Fall Risk did not include steps to take after a fall for notifying MD. Policy stated that the physician will help the staff reconsider possible causes that may not previously have been identified.

Based on observation, interview and record review, the facility failed to prepare, distribute and serve food under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation. The ceiling fan located above the stove, dishwasher and prep table had lint and dust build up. The Maintenance Supervisor was not wearing a beard restraint when he entered the kitchen on several occasions and while food was present and open to air. [NAME] B coughed while preparing food without covering her mouth, failed to wash her hands correctly, put her bare hands into cooked food, and did not properly sanitize the thermometer while taking temperatures of food. These failures could place the residents that consumed food prepared in the kitchen at risk of food-borne illness. Findings included: Findings included: During an observation and interview on 12/09/2025 at 11:05 AM an initial tour of the kitchen was conducted. There was a ceiling fan above the dishwasher, prep table and stove area which had a buildup of dust and lint. The DS said it needed to be cleaned as that could cause some of the lint to fall on the food and that would be unsanitary. The DS said they would get it cleaned and that they had a cleaning schedule and provided a copy of the document. During an observation on 12/10/2025 at 3:45 PM the MS was observed on a couple of occasions entering the kitchen without a beard restraint. The kitchen staff was observed cooking food on the stove top and so the food was uncovered when the MS was in the kitchen. During an observation and interview on 12/10/2025 at 3:58 PM the DS was made aware of the observations of the MS in the kitchen without a beard restraint. At this time the MS was again in the kitchen and was made aware of him having to use a beard restraint whenever he was in the kitchen. The MS said, My bad and that he would make sure to wear a restraint when in the kitchen. The DS said she would make sure the MS wore a beard restraint whenever he entered the kitchen to prevent possible contamination. During an interview on 12/11/2025 at 5:25 PM the Administrator was made aware of the observation of the ceiling fan in the kitchen and the MS in the kitchen without a beard restraint. The Administrator said both of those things had the potential to lead to contamination and the issues had been resolved. Record review of the facility policy titled Cleaning and sanitation of dining and food service areas dated 2021 indicated in part: The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written comprehensive cleaning schedule. The director of food and nutrition services will determine all cleaning and sanitation tasks needed for department. Staff will be trained on the frequency of cleaning as necessary. Staff will be held accountable for cleaning assignments. Record review of the facility policy titled Food safety and sanitation dated 2012 indicated in part: All local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. Employees are required to have their hair styled so that it does not touch the collar and to wear clean aprons, clothes and shoes. Hair restraints are required and should cover all hair on the head. [NAME] nets are required when facial hair is visible. Record review of the 2022 Food Code U.S. Food and Drug Administration indicated in part: Hair restraints. Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils , and linens ; and unwrapped single -service and single -use articles. https://www.fda.gov/food/retail-food-protection/fda-food-code. Accessed on 12/29/2025.

Based on observation, interview and record review the facility failed to assure drugs and biologicals were stored properly in 1 of 1 medication room reviewed for expired medications and drug storage. The medication room contained 1 opened vial of insulin that was not dated when it was opened. The medication refrigerator contained 1 opened multi-use vial of Tuberculin PPD that had expired[PH1] . (Tuberculin is a sterile liquid containing the growth products of or specific substances extracted from the tubercle bacillus and used in intradermal skin tests for the diagnosis of tuberculosis). This deficient practice could place residents and staff at risk for not getting an accurate screening for Tuberculosis and at risk of not receiving the therapeutic dose of medication. Findings included: [PH1]Include the dateFindings included: During an observation and interview on 12/10/2025 at 10:18 AM the medication room was inspected with LVN A present. In the medication room was a small basket that contained insulin supplies to include an opened insulin vial. The insulin vial nor the box it was stored in had an open date inscribed on it. The vial was about a quarter full of insulin. The LVN said she was not sure when the vial had been opened and that whenever she opened the new insulin she would always write the open date on it. LVN A said the insulin was usually good for 28 days after being opened and then had to be discarded. The LVN said she had not noticed that insulin did not have an open date till just now. LVN A said she would discard it and get a new bottle of insulin. The LVN said that if that insulin was administered it might not have the effect it was meant to do as it might have been expired by now and there was no way to tell when to discard it without an open date on it. The insulin box had directions that indicated Discard unused portion 28 days after first opening. The medication refrigerator was then inspected. Inside the refrigerator was an open box of tuberculin solution that indicated Opened: 10/31 Expires: 11/28. The tuberculin box indicated Once entered, vial should be discarded after 30 days. LVN A said the tuberculin solution should have been removed from the refrigerator as it had expired. The LVN said if the expired solution was used it could lead to an incorrect reading and that she would be replacing the solution. LVN A said it was up to each nurse that worked the floor to keep up with the removal of expired items. During an interview on 12/11/2025 at 5:28 PM the DON was made aware of the observation of the undated insulin and expired TB vial. The DON said the night shift charge nurse was supposed to check the medication room for expired medications and remove them. The DON said the charge nurse failed to do their job and she as the DON failed to make sure the charge nurse was doing their job. The DON said the TB being expired could lead to inaccurate readings and could affect several residents as it was used to test for possible positive TB. The DON said the insulin may not provide the desired effect if it was expired. During an interview on 12/11/2025 at 5:28 PM the Administrator was made aware of the observation of the undated insulin and expired TB vial. The Administrator said both of those things had the potential to lead to inaccurate readings and not be as effective as they were made to be and could affect several residents. Record review of the facility's policy and procedure titled Insulin pens and dated 09/26/2018 indicated in part: It is the policy of (facility name) to use insulin pens in order to improve the accuracy of insulin dosing and provide increased resident comfort. Insulin pens must be clearly labeled with the resident's name, physician name, date dispensed, type of insulin, amount to be given, frequency and expiration date. If the label is missing, the pen will not be used, a new pen must be ordered from the pharmacy. Insulin pens must be disposed of after 28 days or according to manufacturer's recommendations. Record review of the facility's policy and procedure titled Drugs and biological distribution, labeling, packaging and storage and dated 08/31/2023 indicated in part: It is the responsibility of the night shift charge nurse to do a twice a month inventory of all drugs and biologicals to check expiration dates and ensure expired drugs do not remain stored in areas where they are available for continued use. This twice a month inventory of expiration dates will be done in all med storage areas, including med storage refrigerator and all medication and treatment carts. And medications that will be expiring within the next 30 days will be marked with an orange sticker.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for two of four (Residents #1 and #26) residents reviewed for infection control, in that: The facility failed to ensure CNA E and CNA F donned PPE while performing personal care for Resident #26. The facility failed to provide PPE for residents in need of EBP for Resident #1 This failure could place residents at risk for spread of infectious diseases. Findings included:Resident #1 Review of Resident #1's admission Record, dated 12/10/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including, Hydronephrosis (swelling of the kidney due to an obstruction of the urinary tract), bladder obstruction, and bladder cancer. Review of Resident #1's admission MDS, dated [DATE], revealed:He had a BIMS score of 7 of 15 (indicating severe cognitive impairment) and showed no signs of delirium. He had an indwelling catheter. Review of Resident #1's Care Plan, revised on 11/4/25, revealed:Focus: Resident has an ADL self-care performance deficit related to Muscle Weakness (generalized) and unspecified lack of coordination due to diagnosis of urinary tract infection/ sepsis. Goal: Resident will increase strength and independence with all ADLs through the review date. Interventions included: Toilet Use - Resident had an indwelling catheter; care each shift. Empty catheter drainage bag each shift. Review of Resident #1's Care Plan, revised 11/5/25, revealed:Focus - Resident had an indwelling catheter 16 French/30 ml (size of catheter) foley catheter related to status post dilation of urethral and ureteral stent placement, prostate cancer. Goal: Resident will be/remain free from catheter-related trauma through review date Interventions included nothing regarding EBP Review of Resident #1's Physician Order Summary, dated 12/10/25, revealed no orders about EBP precautions. Observation on 12/09/25 at 2:43 PM, revealed no PPE on door or accessible in Resident #1's room. Resident #26Review of Resident #26's admission Record, dated 12/11/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis that included stroke, dementia with agitation, acquired absence of other part of urinary tract (colostomy), and other artificial openings or urinary tract status (colostomy). Review of Resident #26's admission MDS, dated [DATE], revealed:Review of his BIMS was 3 of 15 (indicating severe cognitive impairments) with no signs of delirium. He had range of motion impairment of the upper and lower extremity on one side, and he used a wheelchair. He needed substantial/maximum assistance with transfers. He had an ostomy. Review of Resident #26's Care Plan, updated 9/19/25 revealed:Focus: Resident has (stage 1) pressure ulcer (left heel) and potential for further pressure ulcer development related to altered mobility, and bowel incontinence due to recent stroke. Goal: Resident's pressure ulcer will show signs of healing and remain free from infection by/through altered mobility, and bowel incontinence due to recent stroke; and Resident will have intact skin, free of redness, blisters or discoloration by/through review dateInterventions included: Use lift or draw sheet to move Resident in bed. Review of Resident #26's care plan, updated 9/19/25, revealed:Focus: Resident has a urostomy related to bladder cancer.Goal: Resident will show no signs or symptoms of urinary infection through review date. Review of Resident #26's Physician Order Summary Report, dated 12/11/25 revealed no order for EBP. Observation on 12/10/2025 at 1:18 PM, revealed CNA E and CNA F did not put on PPE as they entered Resident #26's room, Resident #26's colostomy hung out of his shirt. CNA F and CNA E performed a mechanical lift transfer from the wheelchair to the bed. Observation on 12/10/2025 at 4:54 PM, CNA E stated the aides would wear PPE for any residents with sores or on isolation. CNA E stated they would need to check if there was any other situations. During an interview on 12/11/2025 at 4:27 PM, the DON and ADON stated the expectation for staff for enhanced barrier protection was anyone with something like an open wound. The ADON stated anyone with an ostomy, a foley catheter was supposed to be on EBP. The ADON stated the staff knew there was an order for the EBP and it should be on the task sheet. The ADON stated there should be PPE on door. The DON stated Resident #1 needed PPE available. The ADON stated it happened because the facility had moved so many people around the facility it must have been missed. The ADON stated it was a lack of monitoring on her part and the outcome could be the spread of infection. Interview on 12/11/25 at 5:02 PM, the Administrator was informed of the EBP observations and stated the facility would have to retrain the staff. The Administrator stated she understood the issue with EBP. Review of the EBP Policy and Procedure, undated, revealed:Supplement enhanced barrier precautions for the prevention of transmission of multi-resistant organisms.Enhanced barrier precaution (EBP) refers to an infection control intervention designed to reduce transmission of Multi-drug Organism that employs targeted gown and gloves use during high contact resident care activities.Procedure:The Facility will ensure staff comply with enhanced barrier precautions.The enhanced barrier precautions standing order will be implemented for residents with any of the following: wounds and or indwelling medical devices even if the resident is not known to be infected or colonized with a MRDO. The facility will ensure gowns and gloves are available immediately near or outside of the residence room.The facility will ensure PPE for enhanced barrier precautions is only necessary when performing high contact care areas and may not need to be donned prior to entering the resident room. High contact resident care activities include:iii transferring.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accident hazards/supervision (Resident #26). The facility failed to ensure CNA E and CNA F demonstrated appropriate transfer techniques while using the mechanical lift for Resident #26. These failures could place residents at risk for injuries. The findings included: Review of Resident #26's admission Record, dated 12/11/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke, dementia with agitation, acquired absence of other part of urinary tract (colostomy), and other artificial openings or urinary tract status (colostomy). Review of Resident #26's admission MDS, dated [DATE], revealed he had a BIMS of 3 out of 15 which indicated severe cognitive impairment with no signs of delirium. Resident #26 had a range of motion impairment of the upper and lower extremity on one side, and he used a wheelchair, he needed substantial/maximum assistance with transfers, and he had an ostomy. Review of Resident #26's Care Plan, updated 9/19/25 revealed:Focus: Resident has (stage 1) pressure ulcer (left heel) and potential for further pressure ulcer development related to altered mobility, and bowel incontinence due to recent stroke. Goal: Resident's pressure ulcer will show signs of healing and remain free from infection by/through altered mobility, and bowel incontinence due to recent stroke; and Resident will have intact skin, free of redness, blisters or discoloration by/through review dateInterventions included: Use lift or draw sheet to move Resident in bed. Review of Resident #26's care plan, updated 9/19/25, revealed:Focus: Resident has a urostomy related to bladder cancer.Goal: Resident will show no signs or symptoms of urinary infection through review date. Observation on 12/10/2025 at 1:18 PM, revealed Resident #26 was in his wheelchair, his colostomy bag was hanging out of his shirt. CNA F locked the mechanical lift and hooked Resident #26 to the sling. Both CNAs put on gloves. CNA E began to lift Resident #26 into the air and said he did not feel it was a safe transfer because of the initial positioning of the sling; Resident #1's body was mostly out of the sling. CNA E lowered Resident #26 back into the wheelchair and both aides repositioned the sling under Resident #26's body and hooked it back to the boom. Resident #26 complained of his ear hurting as his head hung off the back of the sling. CNA E again operated the lift to an up position; Resident #26 was half in and half out of the sling. After seeing how Resident #26 was positioned in the sling, CNA E asked Resident #26 to hold onto the sling. CNA F moved the wheelchair and the fall mat from the bed and then stabilized Resident #26 until the aides got to the bed. CNA E locked the lift. CNA E commented he should have moved the fall mat prior to the transfer. CNA E lowered Resident #26 onto the bed and Resident #26 was on the edge of the bed. While lowering the resident onto the mattress, the right wheel of the lift came off of the ground. CNA E checked Resident #26's position and repositioned the lift so Resident #26 would be closer to the middle of the bed. Resident #26 was placed in the bed with no further incident, no injury and stated he was comfortable. During an interview on 12/11/2025 at 4:27 PM, the DON and ADON was informed of the lift observation. The ADON stated so much can happen. The DON stated staff were trained on how to use the mechanical lift on hire and annually during the skills check-off. The ADON stated the potential outcome to the residents would be skin tears and injury. The ADON stated the nurses were responsible for monitoring transfers and she also worked the floor and had not seen any issues. Interview on 12/11/25 at 5:02 PM, the Administrator was informed of the mechanical lift observation. She stated she understood the concern with the transfer. Review of the facility's policy and procedure on Safe Mechanical Lifting, undated, revealed:It is the policy of the facility to ensure resident and employee safety when transferring residents with any mechanical lift.1) Two nursing staff members who have been trained and have shown proficiency in the proper use of the mechanical lift are to be present every time a resident is transferred using a mechanical lift.2) All mechanical lifts will be operated according to manufacturer's recommendations.

Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Resident #1 and Resident #2) reviewed for care plans. 1. The facility failed to have a care plan in place to accurately address Resident #1 diagnosis of diabetes. 2. The facility failed to ensure Resident #2's care plan accurately reflected her 1/2 side-rail use. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Resident #1 Record review of the admission record indicated Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had medical diagnoses that included Burn of unspecified degree of lower back, burn of third degree to left thigh, burn of third degree of right thigh, acquired absence of the right leg above the knee, acquired absence of the left leg above the knee, hypertension (high blood pressure), and type II diabetes. Record review of Resident #1's Annual MDS assessment dated [DATE] revealed his Cognitive Skills for Daily Decision Making to be Cognitively intact. He required maximum assistance with transfers and was independent for all ADL's except for bathing. He relied on electronic wheelchair for mobility. Under section I for Active diagnosis Diabetes was selected. Record review of Resident #1's order summary dated 9/12/24 included, Pioglitazone HCl Tablet 30 mg - give 1 tablet by mouth one time a day related to type 2 diabetes mellitus with unspecified complications. Record review of Resident #1's care plan dated 09/11/2024 revealed no care plan for Diabetes. Interview on 09/12/24 at 10:41 AM with the MDS coordinator stated anything out of the ordinary will be in a care plan like specific request or needs, anything triggered by MDS, diagnosis. For diabetes there would need to be care planned to monitor resident because the exposure to hot and colds, hypo/hyper glycemia side effects, clean feet daily, podiatrist, if they have any infection consult doctors, any wounds watch closely nail care by licensed nurses. The MDS coordinator stated that she does not believe there to be a negative outcome for this specific resident to not have diabetes care planned because he does not have any complications due to his diabetes. RESIDENT #2 Review of Resident #2's Admission Record, dated 9/11/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stroke, paralysis affecting the right dominant side, and difficulty swallowing. Review of Resident #2's quarterly MDS Assessment, dated 8/15/24 revealed: Her mental status score was 9 of 15 (indicating moderate cognitive impairment). She needed substantial to maximum assistance with rolling to theft and right. She was incontinent of bowel and bladder. She was on an antidepressant, an antibiotic, an opiate, and a diuretic. Restraints were not identified as in use, including the use of side rails. Review of Resident #2's Care Plan updated 7/26/23 revealed: Resident #2 had an ADL self-care performance deficit related to Muscle Weakness (generalized), other lack of coordination, and need for assistance with personal care due to diagnosis of hemiplegia (paralysis), unspecified affecting right dominant side, Cerebrovascular Disease (stroke) and Major Depressive Disorder. The identified goal was Resident #2 will maintain current level of function in (ADLs) through the review date. Identified interventions included: Bed Mobility: Resident #2 required (substantial/maximum assistance) by (1-2) staff to turn and reposition and to move from lying to sitting on the side of the bed and sitting to lying, turn and reposition in bed every 2 hours, ensure proper padding and body alignment, keep heels off of the mattress. Bed Mobility: Resident #2 uses (1/4 rails) to maximize independence with turning and repositioning in bed. Observation and interview on 9/10/24 at 12:30 p.m. revealed Resident #2 sitting in her doorway watching the traffic. Resident #2 gave permission for surveyor to look in her room. Resident #2 had a 1/2 side rail that was positioned at the halfway point of her bed which would restrict Resident #2's movement. Resident #2 stated the side rail did not bother her and it did not keep her in the bed if she did not want to be in it. In an interview on 9/12/24 at 11:31 a.m. the MDS Coordinator stated she also did the care plans for the facility. The MDS Coordinator stated she care planed Resident #2 as having 1/4 side rails because that was what the staff told her (the MDS Coordinator) what Resident #2 had on her bed. The MDS Coordinator stated she updated Resident #2's care plan to reflect 1/4 side rails the most recent care plan cycle and prior to that she (Resident #2) was care planned for 1/2 side rails. The MDS Coordinator stated Resident #2 had the old fashioned kind of side rails that screwed into the bottom of the bed. The MDS Coordinator admitted she did not go to look at Resident #2's room but got all of Resident #2's resident interviews after Resident #2's therapy exercises. The MDS Coordinator stated, it was my understanding everyone had new bed. Review of facility policy titled Comprehensive Care Plans undated revealed, in part: A comprehensive person-centered care plan is developed and implemented for each resident, consistent with the resident's rights, that include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview, and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 2 of 4 residents (Resident #2 and Resident #3) reviewed for dietary services in that: The residents with puree diet did not receive consistent portion sizes of the puree desert. The facility served zero sugar pudding cups in place of the fortified pudding for lunch for Resident #2 and Resident #3. These failures could place residents at risk for poor food intake, weight loss, and diminished quality of life. Findings included: Observation and interview of the noon meal on 9/11/24 at 11:25 a.m. revealed six 4 oz bowls of pureed dessert - three of the bowls were almost completely full, one approximately half full, and the last two were approximately 25% full. At 11:52 a.m. the first puree desert went out. The DM said the dessert bowls did not have the same portion sizes. The DM also saw the sugar free pudding left out for the fortified meal program and stated zero sugar pudding was not appropriate for a fortified program. The DM stated there was a weight loss problem in the building. In an interview on 9/11/24 at 1:38 p.m. the DM stated she thought the kitchen observation went well. She stated fortified meal not being served was completely on her since she did not notice the sugar free pudding was laid out. In an interview on 9/11/24 at 2:38 p.m. DM stated there were five residents on a fortified diet. In an interview on 9/11/24 at 2:48 pm. the Administrator stated she expected to see fortified foods to have recipes. The Administrator said generally there was hot cereal for breakfast and pudding for lunch. The Administrator said there was usually something in the food to add calories or protein like butter, powdered milk. The Administrator stated zero sugar pudding cups would not be fortified. The Administrator said she had told the dietary department they could not just give residents a pudding cup and have it be considered a fortified diet. RESIDENT #2 Review of Resident #2 Admission Record, dated 9/11/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stroke, paralysis affecting the right dominant side, and difficulty swallowing. Review of Resident #2's quarterly MDS Assessment, dated 8/15/24 revealed: Her mental status score was 9 of 15 (indicating moderate cognitive impairment). She ate with set-up from staff. She weighed 150 pounds and had a weight loss of 5% or more in the last month or 10% or more in the last 6 months was no or unknown. Review of Resident #2's Care Plan, revised on 5/23/24 revealed Resident #2 had a nutritional problem or potential nutritional problem as evidenced by signs or symptoms or dehydration and history of skin break down, weight loss, and therapeutic diet of Regular with large egg portion with breakfast and fortified meal program. The goal was Resident #2 would maintain adequate nutritional status as evidenced by maintaining weight within (x)% of 130 pounds, no signs or symptoms of malnutrition and consuming at least 75% of at least 2 meals daily though the review date. Identified interventions included: provide and serve diet as ordered. Monitor and record each meal. Review of Resident #2's Order Summary revealed orders large egg portions with breakfast, fortified meal plan dated 1/9/23. Review of Resident #2's Nutrition/ Dietary Note, dated 6/11/24 revealed her weight had increased 12 pounds in the last three months. RESIDENT #3 Review of Resident #3's Admission Record, dated 9/12/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, protein-calorie malnutrition, and stroke. Review of Resident #3's Annual MDS Assessment, dated 8/29/24, revealed: She had a mental status score of 15 of 15 (indicating she was cognitively intact). She needed set-up assistance from the staff to eat. She weighed 126 points and had significant weight loss not on physician-prescribed weight loss program. Review of Resident #3's Care Plan revised on 6/5/24 revealed Resident #3 had a nutritional problem or potential nutritional problem as evidenced by need for mechanically altered diet (pureed texture) and need for therapeutic diet of large egg portions with breakfast, and fortified meal plan due to weight loss and a stage II pressure ulcer (bed sore) to right gluteus (butt cheek). The identified goal was Resident #3 would maintain adequate nutritional status as evidenced by maintaining weight within 10% of 129 pounds, no signs or symptoms of malnutrition, and consuming at least 75% of at least two meals daily through the review date. Identified interventions included Resident #3 currently was eating tomato soup or soft/pureed soup with no texture related to pain in gums/mouth. Snacks with protein twice a day, chocolate milk twice a day. Review of Resident #3's Order Summary Report, dated 9/11/24, revealed diet orders of regular diet pureed texture, large egg portions with breakfast and fortified meal plan, start date 6/21/24. Review of Resident #3's Nutrition Dietary Note dated 9/6/24 revealed she had gained 5 pounds in the last 30 days and the dietician felt her weight fluctations were likely due to medications. Review of portion sizes for the 9/11/24 menu revealed residents were to receive a #20 scoop (approximately 3 Tablespoons, or slight less than half the 4 oz bowl). Review of the Fortified Diet Program, undated, revealed: Foods/Snacks suggested to added calories and/or protein: cake, cheese/cottage cheese, chocolate/flavored milk, cookies, dry cereal, ice cream/ice cream bars, pies, pudding, snack crackers, yogurt. Food items/Ingredients to add additional calories: some individuals primary need to increase calories in the diet but have difficulty consuming additional volume. This may be the case for persons with decreased appetite, under nutrition, unintentional weight loss or other conditions. The following are suggestions of ways to increase calories by adding ingredients to foods already offered at the meal. Margarine or butter; mayonnaise; cream/ half or half, sour cream, honey, corn syrup, jam and jelly, cheese, non-fat dried milk, brown sugar and sugar, whipped cream. Recipe for fortified pudding: Portion sized 1/2 cup. Ingredients: Milk, whole, milk non-fat dry, pudding mix instant, any flavor; whipped topping dry, prepare according to package directions. Recipe for fortified soup. Portion size: 6 oz Ingredients: condensed soup, condensed cream, whole milk, shredded cheddar cheese.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #32 and Resident #1) of 5 residents reviewed for infection control. CNA A failed to change her gloves after they became contaminated during incontinent care while assisting Resident #32. CNA's I & J failed to use enhanced barrier precautions (EBP) during transferring Resident #1 from his bed to his wheelchair. (EBP - refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). These failures could place resident's risk for cross contamination and the spread of infection. Finding include: Record review of Resident #32's admission record dated 09/10/2024 indicated he was admitted to the facility on [DATE]. Diagnoses included dementia and stroke. He was [AGE] years of age. Record review of Resident #32's care plan dated 07/16/2024 indicated in part: Focus: Resident has incontinence r/t DX. Dementia, Cerebral infarction (stroke). Goal: Resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Resident uses (large) disposable briefs. Clean peri-area with each incontinence episode. Record review of Resident #32's MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making = Severely impaired - never/rarely made decisions. Urinary continence = Always incontinent. Bowel continence = Always incontinent. During an observation on 09/10/24 at 10:54 AM CNA A performed incontinent care for Resident #32. CNA A put gloves on and undid Resident #32's brief from the back and wiped his rectal area with some wet wipes. It was noted that the resident had some bowel movement. CNA A continued to wipe the resident's rectal area and then removed the soiled brief. While still wearing the same gloves, CNA A took a clean brief and placed it under the resident's buttocks. While still wearing the same gloves, CNA A then wiped Resident #32's penis with some wet wipes. During an interview on 09/10/24 at 01:50 PM CNA A said she should have changed gloves after she wiped Resident #32's rectal which had some bowel movement. CNA A said she should have changed gloves before she wiped the resident's penis area as she was still wearing the same gloves, she used to wipe the bowel movement. CNA A said she normally changed her gloves before going from dirty to clean. CNA A said if she did not change her gloves that could lead to cross contamination. CNA A said she had gotten nervous and forgot to change her gloves before applying the new brief and cleaning Resident #32's penis area. During an interview on 09/11/24 at 05:45 PM the DON was made aware of the observation of incontinent care performed by CNA A. The DON said CNA A should have changed her gloves and washed her hands before touching the new brief and performed incontinent care to Resident #32's penis area. The DON said they monitored staff for incontinent care by performing competency checks. The DON said if the CNA did not change her gloves at the appropriate time that could lead to the spread of germs and infections. The DON said the failure probably occurred because the CNA got nervous. During an interview on 09/12/24 at 04:15 PM the Administrator said CNA A should have changed her gloves before going from dirty to clean. The Administrator said the CNA probably got nervous and did not change her gloves as indicated. The Administrator said the CNA not changing her gloves could lead to cross contamination. Resident #1 Record review of the admission record indicated Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had medical diagnoses that included Burn of unspecified degree of lower back, burn of third degree to left thigh, burn of third degree of right thigh, acquired absence of the right leg above the knee, acquired absence of the left leg above the knee, hypertension (high blood pressure), and type II diabetes. Record review of Resident #1's Annual MDS assessment dated [DATE] revealed his Cognitive Skills for Daily Decision Making to be Cognitively intact. He required maximum assistance with transfers and was independent for all ADL's except for bathing. He relied on electronic wheelchair for mobility. Under section H for Bowel and Bladder indwelling catheter was selected. Under section M - Skin conditions resident has a stage 1 or greater, a scar over a bony prominence, or a non-removable dressing or device. was selected. Record review of Resident #1's order summary dated 9/12/24 included, Enhanced Barrier Precautions every shift related to wounds/Foley catheter Observation of a Hoyer lift transfer on 09/11/24 at 04:00 PM with CNA I and CNA J for Resident #1 revealed Neither CNA I or CNA J donned EBP for the transfer of the resident. Both did wash hands and donned gloves prior to direct care. During the transfer both CNAs touched the resident's bed, bedding, clothes, wheelchair, and foley catheter tubing and bag. An interview on 09/11/24 at 04:30 PM with both CNA I and CNA J both revealed they did not believe they needed to don full enhanced barrier precaution PPE due to not directly touching the foley catheter. Both stated it was their understanding that unless they were directly cleaning or maneuvering the foley they do not have to have on extra PPE. Record review of the facility policy titled perineal care/Incontinent care-male dated 09/20/2007 indicated in part: It is the policy of this facility to provide perineal/incontinent care on male residents as needed without contaminating the urethral area with germs from the rectal area. Properly clean hands before procedures. Wash rinse and dry the remaining area including the penis, scrotum and outward to the thighs. Turn resident on side. Wash, rinse and dry the remaining area including the rectum and buttocks without returning to the urethral area. Wash, rinse and dry from clean to dirty area leaving entire area clean and dry. Remove soiled linen and gloves and place in appropriate place. Wash hands or use hand sanitizer. Record review of the facility undated policy titled Handwashing policy and procedure indicated in part: Handwashing shall be regarded by this facility as the single most important means of preventing the spread of infections. All personnel shall follow our established handwashing procedure to prevent the spread of infection and disease to other personnel, residents and visitors. Employees must perform appropriate twenty (20) second handwashing procedure under the following conditions: After removing gloves. The use of gloves does not replace handwashing. Record review of the facility document titled Infection control guidelines for all nursing procedures dated 07/26/2016 indicated in part: Purpose - to provide guidelines for general infection control while caring for residents. Standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. Employees must wash their hands for 10 to 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions - Before and after direct contact with residents; After removing gloves.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure: Staff did not re-glove using the same single use glove. Staff did not cross contaminated the kitchen after touching the trash can lid and the did not immediately wash their hands. Staff did not handle food with their bare hands. Staff did not put food on cooking surfaces without ensuring they were covered. The walk-in refrigerator was maintained in a sanitary manner. These failures could affect residents who received meals prepared from the kitchen at risk for food borne illness and cross contamination. Findings included: Observation on 9/10/24 at 10:24 a.m. of the dry storage revealed a container of bullion on the floor underneath the shelves. The cook picked it up and put it on the shelf with the rest of the containers of bullion without wiping it down. Observation on 9/10/24 at 10:30 a.m. of the walk-in refrigerator revealed: the eggs used were not pasteurized. There was a dried puddle of dripped food on the floor. There was food debris shoved to the back of the corners of the wall and corners underneath the shelves. Observation of the noon meal preparation on 9/11/24 beginning at 9:53 a.m. revealed: At 10:04 a.m. [NAME] D took her glove off, pulled a spoon out of the drawer and pulled the same glove back on. At 10:50 a.m. [NAME] E lifted the lid of the trash can with her gloved hand, threw something out, went to the refrigerator opened it, put in a cup of fluid, picked up some unused cups off the table, returned them to the shelf placed them with the other clean, unused cups and then took off her gloves and washed her hands. At 11:30 [NAME] G cut open a bag of lettuce for the evening meal with his bare hands, emptied the lettuce into a large bowl and then evened the lettuce in the bowl by pushing it with his bare hands. At 11:52 a.m. [NAME] E opened the oven drawer to show surveyor that [NAME] G put potatoes on the rack in the oven with no foil and not on a pan. In an interview and observation on 9/11/24 at 1:38 the DM stated she thought the kitchen task went well until [NAME] G came in. The DM said usually when she told [NAME] G to correct something he did. The DM looked at the walk-in refrigerator and stated under the wire shelves were not clean and had food debris just pushed to the back. Surveyor reviewed other observations made through the cooking preparation. The DM stated when [NAME] E did not wash her hand after touching the trash can lid and then touched other surfaces was cross-contamination. The DM asked why someone would take off a single use glove and put it back on. The DM said it was not acceptable to handle food with a bare hand at any time because of the risk of contamination. In an interview on 9/11/24 at 2:48 p.m. the Administrator was informed of the kitchen observations. The Administrator asked for clarification that food was handled with bare hands and not by the packaging. The Administrator stated no one re-gloves when informed of the staff re-gloving to prepare food. The Administrator said she brought the foot pedal trash cans because the kitchen had so many problems with cross contamination prior to this survey. Review of the cleaning schedule for the kitchen revealed the evening dietary aide was responsible for cleaning refrigerators out inside and out daily and the last time this was done was 9/5/24. Review of in-service dated 7/10/24 revealed: Bare Hand Contact with Food and use of Plastic Gloves. Policy: single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. Staff will use clean barrier such as single-use gloves, tongs, deli paper, and spatulas when handling food. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed: after handling garbage or garbage cans. (Cook D attended the in-service)

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent resident abuse for 1 of 4 (Resident #10) residents reviewed for abuse. The facility failed to ensure the housekeeping supervisor, per the facility's policy, immediately reported witnessed suspected roughness towards Resident #10 by CNA C on 09/07/24 to the Administrator, DON, or ADON. The housekeeper supervisor reported the allegation until 09/10/24. The housekeeper supervisor believed CNA C was rough with Resident #10 and wanted to see the video of the incident to see if CNA C was indeed abusive to the resident as she was not sure the incident occurred. Theses failures could place residents at risk for unsafe environment and further abuse. Findings included: Record review of the facility's policy and procedure, titled Abuse, neglect and exploitation policy dated 07/19/24 indicated in Part: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by: prohibiting and preventing abuse, neglect, exploitation and misappropriation of resident property, investigating any such allegations. Training new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures and dementia management and resident abuse prevention. Reporting/Response - Report all alleged violations to the Administrator, state agency and to all other required agencies (e.g. law enforcement, adult protective services, etc. when applicable) within specified timeframes: Immediately but not later than 2 hours after the allegation is made. Record review of Resident #10's admission record dated 09/12/2024 indicated she was admitted to the facility on [DATE] with diagnoses of weakness, stroke, and depression. She was [AGE] years of age. Record review of Resident #10's care plan dated 07/17/2024 indicated in part: Focus: Resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to vascular dementia. Goal: Resident will maintain involvement in cognitive stimulation, social activities as desired through review date. Interventions: Resident needs assistance/escort to activity functions. Record review of Resident #10's MDS dated [DATE] indicated in part: BIMS = 12 indicating resident was moderately impaired. During an observation and interview on 09/11/2024 at 01:15 PM, Resident #10 was in her room sitting down in recliner awake and alert. Resident #10 was asked if she has had any issues with staff being rude or ugly to her and she said no that staff were very nice to her and she meant all staff and had no complaints about any of the staff. Resident #10 was asked if she had-had any problems with the staff being rude to her in the dining room some days ago, resident said no, resident then was asked specifically if she recalled an aide being rude or rough to her in the dining room due to her falling asleep at the dining room table. Resident #10 said that if she had fallen asleep then it was possible that staff had to really shake her up to get her to wake up as she was hard to arouse when asleep. Resident #10 said she did not feel like she had been mistreated by the aide and still had no complaints about the staff. During this interview Resident #10 did not appear to be in any distress and appeared to be at peace and comfortable at the facility. During a telephone interview on 09/11/2024 at 03:34 PM the housekeeping supervisor said she had witnessed the incident on Saturday September the 7th 2024 and waited until Monday September the 9th 2024 to report it in person to the Administrator. The housekeeping supervisor said unfortunately the Administrator was off on Monday, so she ended up not reporting it until Tuesday which was yesterday 09/10/2024. The housekeeping supervisor said she had not reported it right away because she first wanted to see the video of the incident to see if CNA C had indeed been abusive to Resident #10. The housekeeping supervisor said when she witnessed the incident on Sunday September the 7th it seemed that the CNA had been kind of rough with Resident #10 but that the resident had not cried out in pain or anything like that. The housekeeping supervisor said she was not sure if CNA C was indeed rough and the reason, she did not report it right away, she said the resident's family member was also present during the incident, but he had not said anything. The housekeeping supervisor said she had been trained to report abuse right away and she probably should have done that instead of waiting until Tuesday. The housekeeping supervisor said she had never seen CNA C being rude or rough to other residents and she had never heard of CNA C being abusive to residents. The housekeeping supervisor said if she did not report any type of abuse right away then the abuse could continue as the perpetrator would continue to have access to the residents. During a telephone interview on 09/12/2024 at 02:50 PM CNA C said on Saturday 09/07/2024 the residents were done with lunch, and the nursing staff were in the process of assisting the residents from the dining room back to their rooms. CNA C said Resident #10 would fall asleep in her wheelchair and could be hard to arouse at times. CNA C said she woke Resident #10 up and then wheeled her to her room. CNA C said at no time did she shake or talk ugly to the resident. CNA C said she would never mistreat any resident and that she loved her job and was very upset because she got suspended. CNA C said she had worked that Saturday 09/07/2024 and no one had said anything to her about being rude or rough with Resident #10. CNA C said she had also worked Sunday 09/08/2024 and was scheduled off for Monday and Tuesday 09/09/2024 through 09/10/2024 but that on Tuesday 09/10/24 the Administrator called her to come in and write a statement about what occurred and was then suspended and that currently she was still suspended. During an interview on 09/12/2024 at 04:10 PM the Administrator said she was aware that housekeeper supervisor should have not waited until Tuesday 09/10/24 to report a suspected allegation of abuse that she believed she witnessed on Saturday 09/07/24. The Administrator said the housekeeper supervisor had just recently been re-trained on reporting abuse immediately and did not understand why the supervisor had waited until Tuesday to report the allegation. The Administrator said the housekeeper supervisor failing to report the abuse immediately could lead to the perpetrator still working at the facility. The Administrator said she had viewed the video of the alleged abuse was could not verify if the abuse had indeed occurred by CNA C but had still suspended the CNA.

Based on interview and record review, the facility failed to ensure allegations of abuse were reported immediately, but not later than 2 hours after the allegation was made, or if the events that caused the allegation did not involve abuse or result in bodily injury not later than 24 hours, to Administrator for 1 of 4 residents (Resident #10 )reviewed for abuse in that: The housekeeper supervisor did not report that she thought she witnessed CNA C be rough with Resident #10 to the Administrator within 2 hours of the incident. This deficient practice could place residents at risk for not having all allegations of abuse and neglect reported to the State Survey Agency in a timely manner. Findings included: Record review of Resident #10's admission record dated 09/12/2024 indicated she was admitted to the facility on [DATE] with diagnoses of weakness, stroke, and depression. She was [AGE] years of age. Record review of Resident #10's care plan dated 07/17/2024 indicated in part: Focus: Resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to vascular dementia. Goal: Resident will maintain involvement in cognitive stimulation, social activities as desired through review date. Interventions: Resident needs assistance/escort to activity functions. Record review of Resident #10's MDS dated [DATE] indicated in part: BIMS = 12 indicating resident was moderately impaired. During an observation and interview on 09/11/2024 at 01:15 PM, Resident #10 was in her room sitting down in recliner awake and alert. Resident #10 was asked if she has had any issues with staff being rude or ugly to her and she said no that staff were very nice to her and she meant all staff and had no complaints about any of the staff. Resident #10 was asked if she had-had any problems with the staff being rude to her in the dining room some days ago, resident said no, resident then was asked specifically if she recalled an aide being rude or rough to her in the dining room due to her falling asleep at the dining room table. Resident #10 said that if she had fallen asleep then it was possible that staff had to really shake her up to get her to wake up as she was hard to arouse when asleep. Resident #10 said she did not feel like she had been mistreated by the aide and still had no complaints about the staff. During this interview Resident #10 did not appear to be in any distress and appeared to be at peace and comfortable at the facility. During a telephone interview on 09/11/2024 at 03:34 PM the housekeeping supervisor said she had witnessed the incident on Saturday September the 7th 2024 and waited until Monday September the 9th 2024 to report it in person to the Administrator. The housekeeping supervisor said unfortunately the Administrator was off on Monday, so she ended up not reporting it until Tuesday which was yesterday 09/10/2024. The housekeeping supervisor said she had not reported it right away because she first wanted to see the video of the incident to see if CNA C had indeed been abusive to Resident #10. The housekeeping supervisor said when she witnessed the incident on Sunday September the 7th it seemed that the CNA had been kind of rough with Resident #10 but that the resident had not cried out in pain or anything like that. The housekeeping supervisor said she was not sure if CNA C was indeed rough and the reason, she did not report it right away, she said the resident's family member was also present during the incident, but he had not said anything. The housekeeping supervisor said she had been trained to report abuse right away and she probably should have done that instead of waiting until Tuesday. The housekeeping supervisor said she had never seen CNA C being rude or rough to other residents and she had never heard of CNA C being abusive to residents. The housekeeping supervisor said if she did not report any type of abuse right away then the abuse could continue as the perpetrator would continue to have access to the residents. During a telephone interview on 09/12/2024 at 02:50 PM CNA C said on Saturday 09/07/2024 the residents were done with lunch, and the nursing staff were in the process of assisting the residents from the dining room back to their rooms. CNA C said Resident #10 would fall asleep in her wheelchair and could be hard to arouse at times. CNA C said she woke Resident #10 up and then wheeled her to her room. CNA C said at no time did she shake or talk ugly to the resident. CNA C said she would never mistreat any resident and that she loved her job and was very upset because she got suspended. CNA C said she had worked that Saturday 09/07/2024 and no one had said anything to her about being rude or rough with Resident #10. CNA C said she had also worked Sunday 09/08/2024 and was scheduled off for Monday and Tuesday 09/09/2024 through 09/10/2024 but that on Tuesday 09/10/24 the Administrator called her to come in and write a statement about what occurred and was then suspended and that currently she was still suspended. During an interview on 09/12/2024 at 04:10 PM the Administrator said she was aware that housekeeper supervisor should have not waited until Tuesday 09/10/24 to report an allegation of abuse that she believed she witnessed on Saturday 09/07/24. The Administrator said the housekeeper supervisor had just recently been re-trained on reporting abuse immediately and did not understand why the supervisor had waited until Tuesday to report the allegation. The Administrator said the housekeeper supervisor failing to report the abuse immediately could lead to the perpetrator still working at the facility. The Administrator said she had viewed the video of the alleged abuse was could not verify if the abuse had indeed occurred by CNA C but had still suspended the CNA. Record review of the facility's policy and procedure, titled Abuse, neglect and exploitation policy dated 07/19/24 indicated in Part: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by: prohibiting and preventing abuse, neglect, exploitation and misappropriation of resident property, investigating any such allegations. Training new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures and dementia management and resident abuse prevention. Reporting/Response - Report all alleged violations to the Administrator, state agency and to all other required agencies (e.g. law enforcement, adult protective services, etc. when applicable) within specified timeframes: Immediately but not later than 2 hours after the allegation is made.

Based on observation, interview and record review, the facility failed to ensure one Resident (Resident #32) of one reviewed for Percutaneous Endoscopic Gastrostomy - PEG (a tube inserted through the abdomen into the stomach for the purpose of administering liquid nutrition and medications) received the appropriate treatment and services to prevent complications and aspiration. LVN B failed to check PEG tube residual prior to administering Resident #32's medication as ordered by the physician. This failure could place residents receiving tube feedings at risk for aspiration pneumonia, dehydration, and metabolic abnormalities which could result in additional medical treatment and a decline in the resident's health. Findings include. Record review of Resident #32's admission record dated 09/10/2024 indicated he was admitted to the facility on [DATE]. Diagnoses included dysphagia (difficulty swallowing), dementia and stroke. He was [AGE] years of age. Record review of Resident #32's order summary report dated 09/11/2024 indicated in part: Check PEG placement with stethoscope prior to feedings. Check residual before each feeding, if greater than 60ml, hold feeding and re-check in one hour. If less than 60ml may resume feeding. Record review of Resident #32's care plan dated 07/16/2024 indicated in part: Focus: Resident requires tube feeding (PEG) r/t Dysphagia. Goal: Resident will maintain adequate nutritional and hydration status and weight will stabilize, with no signs and symptoms of malnutrition or dehydration through review date. Interventions: Check for tube placement with stethoscope and gastric contents/residual volume per facility protocol and record. Hold feed if greater than (60) cc aspirate., hold feeding for 1 hour, recheck and if less than 60cc may resume. Record review of Resident #32's MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making = Severely impaired - never/rarely made decisions. During an observation on 09/11/24 at 10:16 AM LVN B administered Resident #32's medication and feeding formula through the resident's PEG tube. LVN B placed the syringe without the plunger into Resident #32's PEG tube and did not check for residual by aspirating the stomach contents. LVN B then proceeded to administer the medications and the formula feeding through the resident's PEG tube. During an interview on 09/12/24 at 09:15 AM LVN B said that prior to administering Resident #32's medication she had checked for residual by placing the syringe in the resident's PEG tube and lowering the tube to see if any residual came up into the syringe. LVN B said she did not like to pull on the syringe plunger to check for residual because that would freak her out. LVN B said she thought that lowering the PEG tube to check for residual was a proper way to check for residual. LVN B said she was not aware of the facility's policy on how to check for PEG residual. LVN B said that it was her fault for not checking the residual correctly and should have aspirated for stomach contents. During an interview on 09/12/24 at 03:42 PM the DON was made aware of the observation of LVN B performing the PEG residual check for Resident #32. The DON said she had never heard of someone checking for PEG residual by lowering the PEG tube. The DON said the correct way was to place the syringe in the PEG tube and pull on the plunger to retrieve the stomach contents. The DON said the failure occurred because LVN B did not check for residual the correct way. The DON said she did rounds to monitor the nurses doing their job on a daily basis. During an interview on 09/12/24 at 04:12 PM the Administrator said LVN B was expected to follow the doctor's order and check for stomach contents before administering medications or feedings. The Administrator said she did not know why the LVN had not followed the orders. Record review of the facility's policy Gastrostomy tube procedure dated 05/28/98 indicated in part: Check tube placement and patency by aspirating stomach contents or by injecting 10 ml air into tube while listening with a stethoscope for a whooshing sound.

Based on observations, interviews, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 1 of 4 (Resident #2) residents reviewed for bed rails. The facility failed to ensure Resident #2's 1/2 side rail was installed correctly. The facility failed to correctly care plan Resident #2's side rails. These failures could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living. Findings included: Review of Resident #2's Admission Record, dated 9/11/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stroke, paralysis affecting the right dominant side, and difficulty swallowing. Review of Resident #2's quarterly MDS Assessment, dated 8/15/24 revealed: Her mental status score was 9 of 15 (indicating moderate cognitive impairment). She needed substantial to maximum assistance with rolling to theft and right. She was incontinent of bowel and bladder. She was on an antidepressant, an antibiotic, an opiate, and a diuretic. Restraints were not identified as in use, including the use of side rails. Review of Resident #2's Care Plan updated 7/26/23 revealed: Resident #2 had an ADL self-care performance deficit related to Muscle Weakness (generalized), other lack of coordination, and need for assistance with personal care due to diagnosis of hemiplegia (paralysis), unspecified affecting right dominant side, Cerebrovascular Disease (stroke) and Major Depressive Disorder. The identified goal was Resident #2 will maintain current level of function in (ADLs) through the review date. Identified interventions included: Bed Mobility: Resident #2 required (substantial/maximum assistance) by (1-2) staff to turn and reposition and to move from lying to sitting on the side of the bed and sitting to lying, turn and reposition in bed every 2 hours, ensure proper padding and body alignment, keep heels off of the mattress. Bed Mobility: Resident #2 uses (1/4 rails) to maximize independence with turning and repositioning in bed. Review of Resident #2's Mobility Assessment, dated 8/15/24, revealed Resident #2's Ability to maintain normal head and trunk alignment was poor. Right side shoulder movement was poor. Left side shoulder movement was moderate. Right side elbow movement was poor. Left side elbow movement was moderate Right side wrist and elbow movement was poor. Left side wrist and elbow movement was moderate. Hip movement on the left and right side was poor. Knee movement of the left and right side were poor. Mobility and balance in all aspects was considered poor. Review of Resident #2's quarterly Restraint Evaluation, dated 8/8/24, revealed: contributing factors to the restraint were poor balance, confusion, short-term memory loss, and diagnosis contributing to increased risk of falls. The type of restraint in use was 1/2 side rails. The devices were indicated as an enabler and to promote greater functional independence. Review of the Restraint Consent, dated 7/28/22, revealed Resident #2's responsible party initialed for 1/2 bed rails as an enabler. Observation and interview on 9/10/24 at 12:30 p.m. revealed Resident #2 sitting in her doorway watching the traffic. Resident #2 gave permission for surveyor to look in her room. Resident #2 had a 1/2 side rail that was positioned at the halfway point of her bed which would restrict Resident #2's movement. Resident #2 stated the side rail did not bother her and it did not keep her in the bed if she did not want to be in it. In an interview on 9/12/24 at 11:31 a.m. the MDS Coordinator stated she also did the care plans for the facility. The MDS Coordinator stated she care planed Resident #2 as having 1/4 side rails because that was what the staff told her (the MDS Coordinator) what Resident #2 had on her bed. The MDS Coordinator stated she updated Resident #2's care plan to reflect 1/4 side rails the most recent care plan cycle and prior to that she (Resident #2) was care planned for 1/2 side rails. The MDS Coordinator stated Resident #2 had the old fashioned kind of side rails that screwed into the bottom of the bed. The MDS Coordinator admitted she did not go to look at Resident #2's room but got all of Resident #2's resident interviews after Resident #2's therapy exercises. The MDS Coordinator stated, it was my understanding everyone had new bed. Observation and interview on 9/12/24 at 12:11 p.m. the Maintenance Director stated the facility ordered 30 bed and he had so far put together 24 of them. He said he had to put them together and then inspect them. The Maintenance Director stated the old bed were operated by a crank or were a hospice provided bed. The Maintenance Director was shown Resident #2's rails which were now 75% of the way up the bed. The Maintenance Director looked at the rails and said that is not alright! The Maintenance Director checked the rail, and it was very loose. The Surveyor explained on 9/10/24 the rail was at the half- way point of the bed. The Maintenance Director said that will be changed as soon as possible. Someone tried to make these into rails. No one told me they were moving a rail. In an interview on 9/12/24 at 1:43 p.m. the DON stated the facility did not have a side rail policy. The DON stated the facility practice was to get a consent for half rails so if the facility decided it was needed as an enabler, they had the family sign for it. The DON admitted she had not been keeping up with the assessments to prove ongoing need for the side rails since she started working at the facility. The DON said the Maintenance Director, MDS Coordinator and her were talking about how Resident #2's side rail could get to the middle of the bed and the only thing they could think of was if the head of the bed was raised it might move the rail. The DON said Resident #2 was able to use the rail on one side and was able to hold onto it during incontinent care. The DON said she never considered the side rail a restraint. In an interview on 9/12/24 at 3:20 p.m. the Administrator stated the Maintenance Director informed her about the half rail. The Administrator said she did not know how it happened unless it wiggled that way and it loosened and maybe a CNA or housekeeper tightened it. The Administrator stated the Maintenance Director was swapping out beds.

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. This failure could affect any resident in the facility, placing them at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. The findings included: Review of the PBJ Staffing Data Report CASPER Report 1705D for FY Quarter 3 2024 (April 1 - June 30) revealed the following dates to not have licensed nursing staff 04/07 (SU); 04/20 (SA); 04/21 (SU) 05/05 (SU); 05/19 (SU) 06/09 (SU); 6/15 (SA); 06/16 (SU). The facility was able to prove on the above listed dates to have at least one licensed nursing staff working. The facility provided actually working hours of staff. However , after an interview on 09/11/24 at 01:21 PM Payroll H revealed that he failed to submit approximately 155 different shifts worked by agency staff. Payroll H stated that he had made two separate PDFs of staff one for agency and one for core staff. Payroll H stated that he did not merge the document like he intended and failed to report these shifts worked. Payroll H is the person in charge of submitting staffing information. Payroll H stated he will ensure all information relating to staffing information. No policy in place.

Based on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents, hazards, and supervision. CNA A, CNA B, and CNA C failed to follow the plan of care which required a 2 person assist to transfer Resident #1 with the Hoyer Lift on 11/26/23. Resident #1 was transferred to a local hospital and an x-ray confirmed a proximal tibia and fibula fracture (break, in the shinbone just below the knee). The failure resulted in actual harm to Resident #1 on 11/28/2023. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. The failure placed residents at the facility who require the Hoyer lift at risk for pain or serious injuries. Findings included: Record review of Resident #1's Face Sheet, dated 03/14/2024, revealed an [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), chronic pain (frequent), and presence of left artificial knee joint (knee replacement). Record review of Resident #1's quarterly MDS assessment, dated 02/08/2024, revealed Resident #1 had a BIMS score of 07, which indicated severe cognitive impairment, and lower extremity impairment on both sides and was dependent on chair to bed transfer. Record review of Resident #1's quarterly Mobility Assessment, dated 11/09/2023 revealed Resident #1 required a sling lift / Hoyer lift. Record review of Resident #1's Care Plan, last reviewed on 02/08/2024, revealed Resident #1 was dependent on 2 staff using the Reliant 450 sling lift / Hoyer lift for all transfers. Record review of facility's Provider Investigation Report revealed on 11/26/2023 at approximately 6:00 pm, CNA A, CNA B, and CNA C transferred Resident #1 from her wheelchair to her bed without using the Hoyer lift. Record review of progress notes dated 11/27/2023 at 8:09 am revealed Resident #1 complained of right knee pain. The doctor was notified, and x-ray was ordered. Record review of the radiology report, dated 11/27/2023, revealed a proximal tibia and fibula fracture. Record review of progress notes dated 11/27/2023 at 1:40 pm, revealed a doctor order to immobilize the right knee and refer Resident #1 to the orthopedic surgeon to be seen on 11/28/2023. Record review of progress notes dated 11/28/2023 at 11:36 am, the doctor sent Resident #1 to the local hospital for assessment instead of sending her to the orthopedic surgeon upon assessment. Resident #1 returned to the facility with an immobilizer brace on her right knee. Record review of the local hospital Emergency Department discharge summary dated 11/28/2023 revealed Resident #1 had a fracture of the tibia and fibula of right knee. Knee immobilizer placed and returned to nursing facility. Injury was non-surgical as Resident #1 was not weight bearing. In an interview on 3/14/2024 at 2:00 pm, Resident #1 stated her knee was completely well now. Resident #1 said that was the only time the Hoyer lift had not been used during transfers. In an interview on 03/15/2024 at 9:54 am, the DON said the three CNAs took Resident #1 to her room, CNA A bear hugged (a tough tight embrace) resident and stood her up as CNA B held the handles of the wheelchair and CNA C held her legs. When they pivoted Resident #1's right foot got caught on her wheelchair and twisted when they laid her down on the bed. The CNA's said the reason they did not use the Hoyer lift was they were trying to get everyone laid down as they were running late. The CNA's denied they had transferred Resident #1 without using the Hoyer lift in the past. The DON said corrective action was taken for CNA A, CNA B, and CNA C for not following Resident #1's care plan on how to properly transfer a resident. The CNAs had to complete a competency checkoff on use of the Hoyer lift. In-services were completed on how to move a resident from the bed to the wheelchair and instructions for safe bed mobility. In an interview on 03/15/2024 at 1:30 pm, CNA B said they got in a hurry and decided to transfer Resident #1 without the Hoyer lift. She stated she held the legs of Resident #1. CNA B denied she had transferred a resident that required the Hoyer lift without using it in the past. In an interview on 03/15/2024 at 1:35 pm, CNA A said they were in a hurry as it was time for their shift to end, and they decided to transfer Resident #1 without using the Hoyer lift. He said he bear hugged Resident #1 and stood her up while CNA B held the handles of the wheelchair. He said they pivoted slowly and sat the resident on the bed. CNA C said something about her foot, but he (CNA A) couldn't see it. CNA A said he had never transferred a resident without the use of a Hoyer lift that required it before. CNA C was not available for an interview., Record review of CNA C's written statement, dated 11/29/2023 stated CNA A bear hugged Resident #1 and CNA C held onto the handles of the wheelchair. Record review of CNA A, CNA B, and CNA C employee files revealed a correction action record dated 11/29/2023 and signed by the employee. Competency check offs for use of the Hoyer lift were completed on 11/30/2023. In-service training for moving a patient from bed to a wheelchair and caregiver guide and instructions for safe bed mobility were completed on 11/30/2023. Record review of the facility policy [Facility name] Safe Mechanical Lifting Policy and Procedure, dated as revised 08/02/2016, revealed the following [in part]: Policy: It is the policy of [facility name] to ensure resident and employee safety when transferring residents with a mechanical lift.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents, 1 of 1 Medication Carts and 1 of 1 Medication Storage Rooms reviewed for pharmacy services. - The facility failed to ensure the Medication Cart did not include two expired cards of Morphine Sulfate 15mg tablets. - The facility failed to ensure the Medication Storage Room did not contain one expired card of Baclofen 10 mg and one expired box of Albuterol Sulfate Inhalation Solution 1.25mg/3ml. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and worsening of symptoms of diseases. Findings Included: Medication Storage Room In an observation on 08/09/23 at 10:00 AM, inventory of the Medication Room with CMA A revealed: - one card (83 tablets) of Baclofen 10mg, expired 08/02/23 - one box (24 packages) of Albuterol Sulfate Inhalation Solution 1.25mg/3ml, expired 07/23 Medication Cart In an observation 08/09/23 at 10:45AM, inventory of the Medication Cart with CMA A revealed: - one card (8 tablets) of Morphine Sulfate 15mg, expired 08/02/23 - one card (5 tablets) of Morphine 15mg, expired 08/02/23 In an interview on 08/10/23 at 9:00 AM, the DON stated the night shift nurse checks the expired meds on the 25th of each month and the Pharmacist comes out each month and hand picks meds to review for expiration dates. The DON stated there was a policy regarding checking and handling of expired meds. In an interview on 08/10/23 at 2:15 PM, CMA A stated the night nurse checks for expired meds when she orders meds. The MA stated she also checks for expired dates on the medications before she administers the medication. In an interview on 08/10/23 at 3:20 PM, the Administrator stated she wrote the policy on Drugs and Biologicals Distribution and would implement retraining and monitoring of the staff to ensure the policy was followed. Record review of the facility policy titled Drugs and Biologicals Distribution updated on 10/11/2018 reads in part: The facility will do a monthly inventory of all drugs and biologicals to check expiration dates and ensure expired drugs do not remain stored in areas where they are available for continued use. This monthly inventory of expiration dates will be done in all med storage areas, including med storage refrigerator and all medication and treatment carts.

Based on interview and record review, the facility failed to use the services of a RN for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage (January 2023, February 2023, and March 2023). The facility did not have the required 8 consecutive hours of RN coverage during the months of January 2023 (4 days), February 2023 (3 days), and March 2023 (1 days). This failure could place residents at risk for not having their nursing care and medical needs met. Findings included: Review of PBJ [Payroll Based Journal] Staffing Data Report, with a run date of 08/04/2023 revealed No RN Hours was triggered for the fiscal year Quarter 2 2023 (January 1 - March 31). The infraction dates were 01/08 (SU); 01/15 (SU); 01/21 (SA); 01/22 (SU); 02/04 (SA); 02/05 (SU); 02/12 (SU); 03/11 (SA); 03/18 (SA). Record review of the January 2023 time sheets indicated no RN worked on Sunday 01/08/23, Sunday 01/15/2023, Saturday 01/21/2023, and Sunday 01/22/2023. Record review of the February 2023 time sheets indicated no RN worked on Saturday 02/04/2023, Sunday 02/05/2023, and Sunday 02/12/2023. Record review of the March 2023 time sheets indicated no RN worked on Saturday 03/11/2023. In an interview on 8/10/23 at 1:50 PM, the ADON stated that the facility had requested agency RN coverage for all the days listed on the PBJ report. She stated that the days listed on the report were all due to last minute call ins and because they were such a rural facility, getting someone to cover the shifts was very difficult. The ADON stated that the facility used multiple staffing agencies from surrounding cities, and they were not able to get anyone last minute for those shifts. She stated the facility did not have a policy to address the time frame for calling in, and that employees were instructed to call in in a timely manner so that management could try to cover the shift. The ADON stated that the facility had four RNs on staff and was using agency RNs for weekend coverage to avoid having any gaps in coverage like what they experienced in January, February, and March. She stated there have been no staffing issues since March 2023. In an interview on 8/10/23 at 2:15 PM, the DON stated that on the dates listed on the PBJ report for no RN coverage, the facility was unable to get coverage from any of their contracted staffing agencies. She stated that the facility used 4 staffing agencies routinely, but they had contracts with 11. She stated that some of the agency contracts were only for long-term staffing, so they were not contacted. She stated the agencies that were for short-term contracts did not have anyone available to send to fill the shifts. The DON stated all shifts listed on the PBJ report for no RN coverage were last minute call-ins. She stated the call-ins in January were due to family deaths and were unavoidable. She stated the facility only had 2 RNs on staff in January 2023, and 1 full time RN and 1 PRN RN in February 2023 and March 2023. At the time of survey, there were 4 staff RNs (including the DON) and the rest are agency. The DON stated the facility had been advertising for RN positions but because of the rural location of the facility there were a limited number of applicants. The DON stated the facility had a staff satisfaction PIP in place to help with RN retention and that she had petitioned the facility's board of directors for salary increases to help bring in more applicants. She stated there had been no staffing issues since March. In an interview on 8/10/23 at 3:20 PM, the Administrator stated that the two RNs scheduled to work in January were aunt and niece and they had deaths in the family so the call-ins were related. The facility tried to have all shifts covered but, on those occasions, they were not able to find anyone through the agencies they contracted with. She stated that from January 2023 through March 2023, they did not have any other RNs employed at the facility. She stated the facility had a long stretch where they were advertising for RN positions with no applicants. The Administrator stated that due to the rural location of the facility it was difficult for them to find staff. She stated that currently, they had several RNs on staff and agency RNs available and the DON and ADON were aware of the need to have RN coverage every day. She stated RN coverage had not been an issue since March 2023.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen in that the facility: - failed to label and date food items. - failed to maintain cleanliness in the kitchen. - kitchen staff did not practice proper sanitization. - failed to store plates/bowls inverted. - failed to maintain clean equipment (refrigerator and food prep table). These failures could place residents who received meals prepared in the kitchen at risk for food borne illness and cross-contamination. The findings include: Observation of kitchen on 06/27/2022 between 11:35 AM - 12:10PM revealed the following: - 3 shelf rolling cart placed in between steam table and clean side of dishwasher table being used for storage of plates, divided plates, bowls, and serving trays, uncovered and all bowls, plates and trays stored resident/food contact surface side up - Large stand mixer on raw wood cart that was approximately 6-8 inches off the floor next to stove observed with no protective cover - Refrigerator doors visibly dirty with dry, flaky white substance noted at door handles - Cabinet doors above industrial coffee machine have exposed wood which could not be sanitized - Freezer noted with tray holding 2 plastic wrapped cuts of meat with no label or date - Stack of disposable food trays with fold over lids stored on shelf not inverted - 2 approximately 6-by-6-inch floor tiles completely detached from floor at floor drain in front of dishwasher - 3 approximately 6-by-6-inch floor tiles completely detached from floor in front of sink - Tape around storage shelf under food prep table holding pots and pans, visibly dirty and peeling off in large pieces at 2 of 4 corners; this tape was curling upwards toward the pots and pans on the shelf - Cook observed using thermometer that was sitting uncovered on dirty counter to check food temperatures without cleaning probe with alcohol prior to inserting into food for 3 separate containers, using a rag to wipe food off in between uses before getting alcohol pads to clean probe - Food prep table visibly dirty with food particles for 45 minutes after meal prep completed During observation and interview on 06/28/22 at 02:30 PM, Cook A observed placing clean cutting board with lettuce and tomatoes on prep table without sanitizing prep surface, he began chopping lettuce and tomatoes for dinner salad. When asked if he had cleaned the table first, he said no. Cook A removed everything from prep table, changed his gloves and sanitized the surface. He then resumed chopping vegetables. In an interview on 06/28/22 02:40 PM, the Food Service Director stated her expectation was all surfaces are to be sanitized immediately before and after use. She stated Cook A should have wiped the prep table down before he began chopping food on it. Observation on 06/28/22 at 02:45 PM, revealed rolling cart used for storage of plates, bowls and remained uncovered with plates, bowls, and trays resident/food contact surface side up. Observed a fly walking across one plate on the cart. In an interview on 06/28/22 03:00 PM, Cook A stated the cart holding the plates, bowls and trays has been kept in the same spot with everything face up since he started working in the facility around 5 months ago. He stated that he believed it has always been stored that way. He stated that he understood the reason for the pots and pans to be kept inverted when not in use but had never thought about the need for plates and bowls to be stored the same way. In an interview on 06/28/22 at 3:05 PM, the Food Service Director stated that pots and pans are to be stored inverted. She stated that she was unsure why they have not been storing plates, bowls, and trays in the same way. She stated that they have never stored plates, bowls and trays inverted, nor have they ever placed a cover over they cart that they are stored on. In an interview on 06/29/22 at 12:35 PM, the Administrator stated that she was unsure what the policy was for sanitizing prep surfaces in the kitchen. She stated that she assumed it was to be done when the kitchen staff first arrived in the morning and before they let at night, but that she would have to check with the Food Service Director to find out what the facility policy indicated. She stated she was unaware of what the policy was for storing resident food service equipment and dinnerware. Review of facility's policy, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices dated December 2008 on 06/29/22 revealed, in part, All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. Review of facility's policy, Preventing Foodborne Illness - Food Handling dated November 2010 an 06/29/22 revealed, in part, Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations. Review of facility's policy, Refrigerators and Freezers dated December 2008 on 06/29/22 revealed, in part, All food shall be appropriately dated to ensure proper rotation by expiration dates. 'Received' dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Expiration dates on unopened foods will be observed and 'use by' dates indicated once food is opened. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. Review of facility's policy, Sanitization dated October 2008 on 06/29/22 revealed, in part, The food service area shall be maintained in a clean and sanitary manor. All kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. All utensils, counters, shelves, and equipment shall be kept clean, maintained and in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair. All equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solution. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.

Based on interview and record review, the facility failed to ensure a discharge MDS was electronically completed and transmitted to the CMS System within 14 days after completion for one (Resident #1) of one resident reviewed for discharge assessments. The facility failed to complete and transmit Resident #1's and discharge MDS assessment within 14 days of completion. This failure could place the residents at risk of having incomplete records. Findings include: Record review of Resident #1's admission record dated 06/28/22 indicated she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's electronic MDS assessments revealed Resident #1 did not have a discharge MDS completed and transmitted. The discharge MDS was in progress on 06/28/22 and was greater than 120 days late . During an interview on 06/28/22 at 04:30 PM, the MDS Coordinator said she had just noticed she had not transmitted Resident #1's MDS. She said she just missed it but would get that done right now, she also said it would probably not get accepted now since it was late. During an interview on 06/29/22 at 11:10 AM, the Administrator said the MDS coordinator had forgotten to complete Resident #1's MDS timely. Said the DON would monitor the MDS coordinator to make sure they were done timely. Said the MDS just got missed and it was an isolated incident. Record review of facility's undated policy, resident assessment policy and procedure indicated in part: Facility will electronically transmit to CMS resident entry and death in facility tracking records required by the RAI and OBRA assessments, including admission, annual, quarterly, significant change, significant correction and discharge assessments. Automated data processing requirement: The facility will complete an MDS for a resident by entering MDS data into the facility's assessment software within 7 days after completing the MDS and electronically transmit the MDS data to CMS within 14 days after completing the MDS.

Based on interview and record review, the facility failed to notify the physician to alter treatment for 1 of 3 residents (Resident #1) reviewed for notification. -The facility failed to notify the Physician when an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1. This failure could affect residents by placing them at risk for not receiving appropriate care and interventions. Findings included: Record review of Resident #1's Admission Record (Face Sheet) dated [DATE] indicated a [AGE] year-old male with an admitted [DATE]. Resident #1 's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Admission MDS dated [DATE] indicated he had a BIMS of 5 indicating extensive cognitive impairment. He was an Extensive assist of one person for ADLs. Record review of Resident #1's Care Plan dated [DATE] revealed the following: Focus: [Resident #1] was exposed to COVID-19. [DATE] [Resident #1] is Positive for Covid-19. Date Initiated [DATE], Revision on [DATE]. Goal: [Resident #1's] COVID-19 infection will resolve and there will be no further spread of infection through the review date. Interventions: [Resident #1] was placed under quarantine and will remain in quarantine for ,d+[DATE] days. He may be removed from Quarantine if he does not develop signs and symptoms of COVID-19. COVID 19 screening every shift. All meals to be served in disposable containers. No group activities Focus: [Resident #1] is resistive to care (assistance with cares) related diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #1] will cooperate with care through next review date. Interventions: Allow [Resident #1] to make decisions about treatment regime, to provide sense of control. Educate [Resident #1]/family/caregivers of the possible outcomes of not complying with treatment or care .Focused: [Resident #1] has a nutritional problem or potentional nutritional problem related to BMI of 16.7, need for mechanical soft (per family's request) and therapeutic diet of Ensure plus 2 with every meal, Date Initiated: [DATE] Goal: [Resident #1] will have gradual weight gain to within 10% of ideal body weight .Interventions: .Mighty Shake (HS) at 7pm daily. Resource 2.0 by mouth four times a day. During an interview with the Responsible Party of Resident #1 on [DATE] at 4:00pm, she said that Resident #1 was supposed to have received intravenous fluids (IV) on [DATE] and that the facility was not able to administer them to Resident #1 due to the pharmacy not having the product in stock. The Responsible Party for Resident #1 expressed concern that Resident #1 had not received the IV fluids, was positive for COVID 19 and had declined with his nutrition and intake over the past few days. The Responsible Party said that she was phoned by the facility the morning of [DATE] and the DON had informed her of the need to transfer Resident #1 to the hospital due to a decline in his condition. The Responsible Party stated that the DON informed her that Resident #1 had a low oxygen level of ,d+[DATE]% on room air, decreased lung sounds and in irregular heart rate. Record review of Resident #1's electronic physician orders, unsigned, dated [DATE] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] [MEDICATION(S)] Solution Use 250ml intravenously one time only related to Covid-19 for one day, Start Date [DATE] 1800 (6:00 pm). [MEDICATION(S)] [MEDICATION(S)] Solution Use 100ml/hr intravenously one time only related to Covid-19 for 1 day Start date [DATE] 1830 (6:30 pm). Unsigned, Physician A. According to the National Center of Biotechnology Information, Ringer's [MEDICATION(S)] solution, or [MEDICATION(S)] Ringer's solution, is a type of [MEDICATION(S)], crystalloid fluid further classified as a balanced or buffered solution used for fluid replacement. Accessed on [DATE] https://www.ncbi.nlm.nih.gov/books/NBK 3/ Record review of Resident #1's electronic progress notes revealed the following entries: [DATE] 09:47am, Spoke w/daughter, [Responsible Party], and [Physician A], Daughter is concerned about the possibility of dehydration with decrease in res. PO intake. Received N/O (new order) for labs and to start a SL (saline lock) and give LR ([MEDICATION(S)] Ringer's) 250ml bolus then at 100mlhr until the 1-liter bag completed. Daughter aware and voices understanding and appreciation. Electronically Signed, [ADON] [DATE] 12:15pm Assisted resident with CNA to w/c with gait belt. Res. Was able to bear weight and walk with rolling walker. He ate ,d+[DATE]% of lunch (mainly because he didn't like the food) offered substitute but refused. He did drink 100% of his Ensure Plus, loaded on VA van in in w/c to go to [larger city] for Bamianivimab Infusion and update given to daughter [Responsible Party]. Electronically Signed, [ADON] [DATE] 17:00 (5:00PM) Received a call from [Nurse Practitioner] of Physician A, at [local medical clinic] regarding concerns from Responsible Party for Resident #1. Responsible Party works at [local clinic] with [Nurse Practitioner] and stated she spoke with Physician A about the concerns and [Physician A] stated he wasn't aware of Resident's current status per [Responsible Party]. [Nurse Practitioner] stated that [Responsible Party] reported that her dad was declining significantly, the he hadn't eaten in five days and was only drinking when someone would offer him a drink through a straw. [Responsible Party] stated he was drinking very little amounts and that she was concerned he was just going to lay there and get sicker. I explained to [Nurse Practitioner] that [Resident #1] went for his monoclonal infusion today and the he was able to ambulate with a walker to the van. That he was still alert and answering yes and no questions. [Resident #1] vital signs were stable, and he was doing well as of today. I explained to [Nurse Practitioner] he had a poor appetite prior to COVID and yes, his appetite had decreased but he is still eating and drinking small amounts. I explained to [Nurse Practitioner] that we have told this to [Responsible Party] multiple times and she becomes very emotional. I explained to [Nurse Practitioner] that we are allowing [Responsible Party] to come in and visit her dad as long as she wears full PPE. [Nurse Practitioner] verbalized understanding and agreed that maybe [Responsible Party] is being emotional but wants to make sure that the nurses are reporting residents' assessments to [Physician A] regularly and reporting any changes in his status. I verbalized understanding and ensured her we would notify [Physician A] with changes. Electronically Signed, [DON] Record review of Resident #1's electronic MAR, revealed the order for [MEDICATION(S)] Ringer's solution 250ml intravenously one time only related to COVID-19 on [DATE], a 9 was indicated in the box and RN A's initials were in the box. An additional order for [MEDICATION(S)] Ringer's solution 100ml intravenously one time only related to COVID-19 was also ordered on [DATE], the box had a 9 and had RN A's initials in the box. According to the key code on the last page of the electronic MAR, revealed that a chart code 9 indicated to Other/see Progress Notes. Record review of Resident #1's electronic progress notes revealed the following entries: [DATE] 18:58 (6:58pm), Continue to be COVID positive, Afebrile. Daughter is here and helping drink fluids .We assisted him to the rest room, and he is very slow. Denies cough, lungs are clear Electronically Signed, [RN A] [DATE] 19:29 (7:29 pm), Resident came from infusion in [larger city] and they left in Saline lock, but it did not give me any blood. So, he agreed to let me stick him with a 22 gauge in the right forearm. First attempt, I was able to get the CMP (complete metabolic panel) and CRP (C-Reactive Protein), but then the vein blew, and I was not able to get the CBC (complete blood count). Daughter was present and did not want him to get a second stick. His fluids have not arrived from [pharmacy]. He tolerated the infusion well, but said he was very tired from the van drive. Electronically Signed by RN A. [DATE] 19:33 (7:33pm), Medication Administration Note: [MEDICATION(S)] [MEDICATION(S)] Solution .Did not come from pharmacy Electronically signed by RN A. [DATE] 19:43 (7:43pm), Spoke with pharmacy and asked why LR IV solution wasn't delivered, she stated the one bag they had was expired and they would have more out in the morning. Relayed message to charge nurse [RN A] to let daughter know who was in the facility with resident at the time. Electronically Signed [ADON] [DATE] 20:01 (8:01pm), Orders Administration Note, [MEDICATION(S)] [MEDICATION(S)] Solution .not here, electronically signed by RN A. [DATE] 09:23, Resident continues to be in COVID 19 + isolation unit, assessed resident, resident lying in bed, unable to turn head towards me when asked, resident moans/mumbles when asked questions, unable to answer any questions or unable to shake his head yes or no to answer questions. Resident asked to squeeze my fingers and unable to follow commands. Resident 02 saturation ranging ,d+[DATE]%, heart rate ranging from ,d+[DATE] beats per minute, irregular; lungs diminished on left side. Notified [ADON] to call patient's daughter, MPOA, and ask if she would like resident sent to hospital due to his decline. Electronically signed, [DON] [DATE] 10:30am, Discharge Summary, This nurse outside the room with DON, called responsible party, informed of residents decline and asked her if she would want him sent out to the ER, she asked what his vitals were, I told them to her, She hesitated, so I asked her again if it was okay if we send him and she stated 'yes'. Electronically signed, [ADON] Record review of the Hospitalist History and Physical from [Local emergency room ] dated [DATE] 4:50pm, revealed the following, 'History of Present Illness, [Resident #1] is a [AGE] year old with pertinent past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] .Apparently he was in his normal stated of health until he was diagnosed with COVID on [DATE] over the last few days, he has had a progressive [CONDITION(S)] now with confusion and change in his lung sounds and subsequently transferred to our facility. Here he is required 2 liters of oxygen to maintain adequate 02 saturations . Review of systems: unable to obtain secondary to patients altered mental status .Physical Exam: B ,d+[DATE], Pulse 105, Temp 98.1, Respirations 25, weight 127 pounds Sp02% 91%. Eyes: Pink conjunctivae .Lungs: Coarse normal respiratory effort .Skin: Warm and dry without tenting and no rash [CONDITION(S)] or ulcers .Labs personally reviewed and are significant for : Sodium 145, Potassium 3.1 (L) low, BUN 32 (H) Problem List: Active Problems: Essential hypertension, COVID-19 [CONDITION(S)] pneumonia, [CONDITION(S)]. Electronically Signed Physician B. In an interview on [DATE] at 4:27pm, Physician A said he was the physician for Resident #1. Physician A said that he makes routine visits to the facility and assesses residents every Wednesday afternoon, however he did not make an in house visit on [DATE] due to a prior engagement. Physician A said that the facility uses a protected health text message system to notify him for Resident notifications and receive orders for residents at the facility. Physician A said that he depended on the staff to 'apprise' him of any changes in condition for any resident, but specifically residents that were positive for covid, he has not been making performing physical assessments unless necessary, he is able to utilize a zoom video if necessary. Physician A said that he recalled giving the order for Resident #1 to receive [MEDICATION(S)] [MEDICATION(S)] on Wednesday. Physician A said that he worked with Responsible Party of Resident #1 and she had expressed concerns to him that Resident #1 was not drinking very well and asked about ordering some IV fluids, he said the ADON had taken the order for the IV fluids and at the time of this interview, he had not been made aware that the fluids not administered. Physician A said that he was contacted earlier in the day, by the DON and said that Resident #1 had declined, and an order was given to send him to the emergency room for further workup. Physician A said that if an order cannot be carried out he would need to be notified by the facility staff as soon as the facility becomes aware that the order is not able to be administered so he can make other arrangements if necessary. In an interview on [DATE] at 4:58pm, the ADON said she had taken the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON said that the [MEDICATION(S)] [MEDICATION(S)] solution had not been administered to Resident #1 due to the pharmacy not having it in stock. The ADON said that she had spoken to the pharmacist on Wednesday [DATE] regarding the order and that the order was received after the first delivery had occurred and that the pharmacy would send it out on the second delivery of the day, which usually occurred around 7:00 pm. The ADON said that shouldn't be a problem due to Resident #1 was going to receive an infusion that afternoon anyway and would not be in the building to administer the IV fluids anyhow. The ADON said that RN A phoned her just shortly after the pharmacy had made their second delivery and informed her that the IV fluids were not delivered. The ADON called the pharmacy at 7:48pm and the pharmacy explained that the [MEDICATION(S)] [MEDICATION(S)] they had in stock was expired but that it had been ordered and would be delivered first thing Thursday morning around ,d+[DATE]:00 am ([DATE]). The ADON said that she did not notify the DON or Physician A to inform them that the [MEDICATION(S)] [MEDICATION(S)] was not delivered. The ADON said that the Responsible Party for Resident #1 was in the building and she knew that RN A had informed her. The ADON said that she should have called Physician A or her DON to let them know that the order could not be administered. In an interview on [DATE] at 5:05pm, RN A said that she was the nurse for the 2pm-10pm shift on [DATE] and had recalled the order to administer IV fluids, specifically [MEDICATION(S)] [MEDICATION(S)] Solution to Resident #1. RN A said that she received a delivery from the pharmacy and looked for the [MEDICATION(S)] Ringer's Solution. RN A said that she realized it was not delivered and called the ADON to notify her that it was not delivered. RN A said that the ADON informed her that if it is expired, then they can't bring it and we will start it in the morning. RN A said that the ADON did not direct her to contact Physician A. RN A said that the Responsible Party for Resident #1 was in the facility with Resident #1 at this time and RN A said that she communicated with the Responsible Party that the IV fluids were not delivered and would not be administered until in the morning. RN A said that she understood the IV fluids had been ordered due to the daughter felt like Resident #1 was dehydrated and had contacted Physician A. RN A said that Resident #1 seemed stable, not showing any signs or symptoms of dehydration, had decreased intake but that it was not anything new, RN A said that he already had been noted to have a poor appetite prior to his COVID 19 diagnosis. RN A said that signs and symptoms of dehydration would be poor skin turgor, dry mucous membranes and that severe dehydration would be increase heartrate and decreased blood pressure. RN A said that Resident #1 did not exhibit any signs or symptoms of dehydration on her shift, his heartrate was in the low 100's, but that was normal for him. In an interview on [DATE] at 5:25pm, the DON said she was aware on [DATE] that the Responsible Party for Resident #1 had requested Physician A to order IV fluids because she was concerned, he was not eating and drinking enough. The DON said that when the Responsible Party spoke with Physician A, Physician A then called the ADON and gave a verbal order for the IV fluids. The DON said that she was aware that the pharmacy was scheduled to deliver the IV fluids on the second delivery and that usually was around 7:30pm. The DON said that Resident #1 was receiving an infusion Wednesday afternoon and that the IV fluids were to be administered after he returned to the facility and that the IV site from the infusion would still be accessible to administer the IV fluids. The DON said that she was not notified until this morning ([DATE]) that the IV fluids were not delivered by the pharmacy and that they were not administered to the resident. The DON said that she should have been notified and she was not. The DON said that if she would have been notified by the ADON or RN A she could have made the proper notifications to Physician A or she could have obtained the IV fluids from a local hospital and had the hospital charge the facility for them. The DON said that her expectation when a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said that in this incident, Physician A should have definitely been notified that the pharmacy could not obtain the IV fluids and deliver them last night. The DON said that Resident #1 had already been identified with poor nutritional intake since the middle of July and the facility had interventions in place and Resident #1 appeared to be stable until this morning when a notable decline was observed, Resident #1 was lethargic, his heartrate was irregular, lung sounds were diminished. The DON said that Physician A was notified immediately upon the change of condition this morning and Resident #1 had been sent to a local hospital for further evaluation. Record review of the facility's policy entitled [Facility Name] Notification to Physician, dated [DATE], revealed the policy was written specifically for the previous Medical Director and did not address notification to the physician if an order could not be administered. In an interview on [DATE] at approximately 2:30pm, the DON said that the facility policies are written by herself and the Administrator and they did not have a policy regarding notification of changes specific to medication administration or a pharmacy services policy.