Every finding on record at Milaca Elim Meadows Health Care Center

Based on observation and interview, the facility failed to ensure the hood vent over the flat top cooking surface and deep [NAME] was free of grease buildup in the secondary kitchen of the dining room. In addition, the facility failed to ensure the grates on a cooling fan were free of debris in the secondary kitchen of the dining room. This had the potential to affect all residents, staff and visitors who had food prepared in the secondary kitchen. During initial tour of main and secondary kitchens in the facility on 12/15/25 at 12:15 p.m., the secondary kitchen observed was a metal hood vent located over the float cook top and deep fryer. There was yellow substance noted in drips along the length of the hood-vent running approximately five inches down the angle of the metal hood. In the top of the hood there were three lightbulbs covered with glass bulb covers. On the bulb covers was a coating of yellow substance with a drip that hung from the far-left bulb. When observed on 12/16/25 at 12:56 p.m., the yellow substance remained on the hood vent and the lightbulb covers in the secondary kitchen. During observation and interview on 12/16/25 at 2:42 p.m., observed a white, stand-up, oscillating fan about three feet tall in the secondary kitchen, the grates of the fan contained a brown/yellow substance with black and brown dust particles clung to the substance. The cook stated the white fan was a cooling fan to help the kitchen staff cool down when the kitchen got hot. The cook uncertain about the cleaning schedule for the cooling fan. The cook stated the kitchen staff removed the vent covers and cleaned them every night, but they could and should have been cleaning off the metal hood. Maintenance would have cleaned the bulb covers. The cook stated the cleaning of the hood and bulb covers were important to ensure there was no grease that dropped onto food while it was being cooked. Facility policy Food and Nutrition Services reviewed 1/10/25, indicated all counter, shelves and equipment shall be kept clean and maintained in good repair.

Based on interview and document review, the facility failed to ensure the completed quarterly Minimum Data Set (MDS) was accurately coded to reflect hospice services for 1 of 2 residents (R15) reviewed for MDS accuracy. Findings include:The CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.20.1, dated 10/2025, identified each section of the MDS along with various instructions how to code and/or complete them. The section labeled, Section O: Special Treatments, Procedures, and Programs, listed directions to record any special treatments or programs the resident received during the specified time period (i.e., assessment reference date; ARD). This included, Hemodialysis . and Hospice Care, , The manual outlined, Code peritoneal or renal dialysis which occurs at the nursing home or at another facility. Additionally, the directions also indicated Code residents identified as being in a hospice program . where any array of services is provided for the palliation and management of terminal illness .A review of R10's admission face sheet, dated 12/18/25, identified R10 had the diagnosis of chronic kidney disease, stage three, typically treated with medications, diet and exercise. R10's face sheet identified R10 was enrolled with hospice services. R10's diagnoses listing included chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs). R10's care plan, last reviewed/revised 12/15/25, indicated R10 was enrolled in a hospice program with the admitting diagnosis of COPD. A review of the facility Matrix completed by the facility indicated R10 was enrolled in hospice. A review of the Minimum Data Set (MDS) dated [DATE], section O, was marked to indicate R10 was receiving dialysis. The MDS did not indicate R10 received hospice services.During interview on 12/18/2025 at 1:36 p.m., the MDS Coordinator identified dialysis had been marked in error and indicated she should have marked hospice instead. The facility policy, last reviewed 3/10/25, identified the Long-Term Care Facility RAI process will be used to complete a comprehensive of a resident's needs, strengths, goals, life history and preferences. Assessments are to be completed per the guidelines of the RAI Manual, in compliance with Centers for Medicare and Medicaid Services (CMS) and any state regulations.

Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene was completed during observations of personal cares completed with 1 of 2 residents (R5) observed during personal cares. Findings include: R5's Resident Face Sheet, printed 12/18/25, diagnoses included urinary retention with indwelling catheter and pressure ulcer of sacral region (tailbone). Review of R5's physician's orders included catheter care.R5's care plan, last reviewed on 11/26/25, identified R5 required an indwelling urinary catheter related to numerous and ongoing ischemic (an area with decreased blood flow) injuries and pressure wounds. The care plan identified R5 required enhanced barrier precautions (EBP) (use of gown and gloves during high-contact care activities) related to chronic wounds and indwelling catheter. The care plan directed staff to wear gown and gloves for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing personal hygiene, changing briefs or assisting with toileting, and catheter care.The undated nursing assisting care sheet identified R5 was on EBP.During interview on 12/15/25 at 4:52 p.m., R5 acknowledged she had a pressure ulcer, however, stated she was unsure when it started. During observation of morning cares and interview following on 12/17/25 at 7:58 a.m., as nursing assistant (NA)-D assisted R5. Prior to entering R5's room, NA-D was observed properly donning (putting on) both gown and gloves, after performing hand hygiene. Upon entering room, NA-D explained to R5 that she was going to provide assist with personal cares. NA-D obtained a basin with warm water and washcloths to perform cares. NA-D placed supplies at bedside. After assisting R5 to wash face and upper body, NA-D assisted R5 to remove hospital gown and into a sweatshirt. R5t had an incontinence brief in place. NA-D proceeded to loosen tabs, lower brief and performed frontal peri care. NA-D was wearing gloves and gown throughout cares. While cleansing with washcloth, a clean fold was used to maintain cleanliness with washing. Once soiled on all folds, the washcloth was set aside with soiled linen and a fresh washcloth was used. The catheter was cleansed downward from the meatus (opening into the urinary tract). NA-D was then joined by NA-E, who had donned gown and gloves prior to entering room, to assist with completion of peri care. R5 was positioned on her side, facing NA-E. NA-D proceeded to perform peri care and cleansing of stool for R5. Once peri care was completed, and brief was placed into position, R5 was assisted by NA-D and NA-E to place sling by rolling resident from side to side. Once sling was in place, R5 was again in a back lying position. The tabs to the incontinent brief were secured. NA-D removed soiled gloves and disposed of them. NA-D did not perform hand hygiene or replace gloves. NA-E proceeded to wear gloves, however, had not had direct contact aside from maintaining side lying position. R5 sling was then attached to the mechanical lift. Once mechanical lift was in place, NA-D placed catheter bag on0top of R5's brief for transfer into wheelchair. R5 was placed in wheelchair, and the lift was removed from the sling. R5 was covered with a lap robe. NA-D, while still not wearing gloves, proceeded to place a cover on the catheter bag, and attached the catheter bag to the frame under the wheelchair. R5 was provided assist to brush her hair and was provided with her glasses by NA-E. Once R5 was positioned into wheelchair and covered with a lap robe. NA-D proceeded to remove her protective gown and placed it with the linens and placed them in the hamper. NA-E was observed to remove and dispose of gloves, and removed gown. NA-E placed the gown in the soiled linen hamper. Upon exiting the room, hand hygiene was performed by both NA-D and NA-E using alcohol-based hand sanitizer. Following completion of morning cares, NA-D was interviewed. NA-D stated the gown and gloves were used due to R5 having the wound and catheter in place. NA-D stated staff were to wear both gown and gloves. NA-D stated the use of gown and gloves was to protect R5 from infections, as well as protecting staff. NA-D stated she did not think about the need to perform hand hygiene and replace gloves once peri care was complete and soiled gloves were removed. NA-D stated not using gloves was not sanitary. During interview on 12/17/25 at 1:41 p.m., with the Infection Control Nurse/Assistant Director of Nursing (ADON), the ADON stated her expectation was for hand washing/hand hygiene to be performed routinely throughout provision of cares. ADON went on to state staff should wash hands with soap after three times of use of alcohol-based hand sanitizer. Upon review of the provision of care to residents with enhanced barrier precautions, ADON stated hand hygiene was to be performed prior to entering room, and prior to donning the gown. Once hand hygiene has been performed, staff were to don gown and gloves. Staff were then to gather supplies and prep items for use with cares. Throughout provision of cares, when staff had completed a dirty task, they were to remove soiled gloves, perform hand hygiene, and don fresh gloves and proceed with cares. This process should be repeated whenever gloves became soiled with cares. ADON stated prior to leaving the room, staff were expected to remove gloves and dispose of them. Staff should then remove gown and place the gown in the soiled linen. Once that is completed, staff were to perform hand hygiene upon exiting room and prior to performing cares for others. ADON reviewed the signage for enhanced barrier precautions and staff were to wear glove and a gown during High-Contact Resident Care Activities. ADON verified a urinary catheter was classified as a device for enhanced barrier precautions. During interview on 12/18/25 at 12:54 p.m., licensed practical nurse (LPN)-C, clinical coordinator, stated gloves must be used at all times while providing direct resident care, including transferring with lift, adjusting in chair, and placement of catheter bag. LPN-C stated if gloves become soiled with provision of care, they should be removed, disposed of, hand hygiene performed, and new gloves donned. A facility policy, last reviewed 7/2/25, identified it was the policy of Cassia that handwashing/alcohol-based hand sanitizer be regarded as the single most important means of preventing the spread of microorganisms/transmission of infection. The policy identified the purpose of hand washing was to prevent heal care associated infections and promote employee health and safety. The facility policy, Transmission based precautions, enhanced barrier precautions and empiric precautions, last reviewed/revised 9/29/25, identified the use of EBP were used for residents who met criteria, which included a chronic wound, regardless of MDRO status, as well as used with residents with an indwelling medical device (which included indwelling urinary catheter). The policy identified high contact care activities required gown and glove use. These activities included provision of hygiene, changing briefs or associated toileting, device care or use, and wound care. The policy indicates a sign will be place on the resident's door to provide guidance to those entering the room.

Based on observation, interview and document review, the facility failed to comprehensively assess safety with self-administration of medication for 1 of 2 residents (R&) who self-administered medication after set up. R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had intact cognition. Diagnoses included displaced femur fracture, chronic kidney disease, congestive heart failure and dementia. On 12/16/2025 at 4:07 p.m., R7 was seated in a recliner in her room watching television. The RN-A walked into the room, placed a paper cup containing medications onto the table next to R7 then walked out of the room. The paper cup contained two medications, one oval shaped brown colored and one round pink colored pill. R7 stated the nurses always just bring them to and I take them when I am ready to. When interviewed on 12/16/2025 at 4:20 p.m., registered nurse (RN)-A stated a resident could self-administer medications if there was an order and a self-administer medication assessment (SAM) was completed, the unit coordinator (UC) completed the SAM for residents. RN-A displayed R7's electronic medication administration record (EMAR) on the computer screen. On the screen was noted medication administration - self-administration OK after set up. A review of R7's electronic medical record (EMR) indicated R7 had an order dated 9/9/25, OK to self admin meds after set up. However, there was no SAM completed until 11/4/25, which indicated R7 did not want to self-administer medications. When interviewed on 12/16/2025 at 4:22 p.m., UC stated when a resident wanted to self-administer medication an assessment needed to be completed with an observation to indicate the resident was safe to self-administer their medication and there needed to be a provider order that allowed for self-administration. When asked if R7 was able to self-administer medication, UC logged out of the EMR, stated R7 was alert and oriented, and did not have an order nor an assessment to self-administer. When asked about observation of the nurse leaving medications in R7's room to self-administer Regarding the observation of RN-A leaving medications in R7's room for R7 to self-administer, UC stated that was not the right thing to do, UC then went back into EMR, located order for the OK to self-administer, UC identified order was obtained on 9/9/25, and an assessment with observation was not completed until 11/4/25. UC confirmed the assessment indicated R7 did not want to self-administer medications. UC stated seeing the order for self-administration was missed when the assessment was completed on 11/4/25, UC will need to complete a new assessment with observation. When interviewed on 12/18/2025 at 10:55 a.m., director of nursing (DON) stated was not aware if there was a time frame for the SAM to be completed when there was an order for OK to self-administer. DON stated roughly a couple of days between would be appropriate, would not want it to go over a week or a month before the SAM was done. The facility policy Self-Administration of Medications dated 10/20/25, indicated Self-Administration of medication assessment will be completed

Based on observation, interview and document review, the facility failed to ensure a mobility device was in good repair for 1 of 2 residents (R49), reviewed for accidents.R49's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R49 had severe cognitive impairment and was independent with ambulation and transfers with use of a cane.R49's care plan dated 08/28/2025, indicated R49 ambulated independently, used a cane/staff. R49's care plan further indicated R49 was high risk for falls.Progress note dated 11/20/25 at 6:19 p.m., indicated R49 was more confused than baseline. R49 had very unsteady gait and the walking stick resident used had been broken and temporarily mended for weeks. Have reported to daughter he needed a new one with the level of weight he applied on it being unsteady and she stated it is fine.On 12/15/25 at 10:29 a.m., R49 was observed seated in recliner in his room with a walking stick about five feet in length rested against his chest. About halfway up the length of the walking stick there was clear packaging like tape wrapped around the stick. Spouse stated the walking stick had broken and was taped together. Follow up observations on 12/16/25 at 4:04 p.m., taped walking stick was leaning against R49's recliner. On 12/17/25 at 7:19 a.m., taped walking stick was leaning against nightstand next to the bed where R49 was sleeping. On 12/17/25 at 10:42 a.m., and at 1:30 p.m., R49 was seated in recliner in the room with the taped walking stick rested against his chest. When interviewed on 12/17/25 at 2:01 p.m., nursing assistant (NA)-A stated R49 had ambulated independently with the walking stick frequently, more recently has been utilizing a wheelchair or she encourages him to use a walker. NA-A stated R49's balance was not that great, she did not trust the walking stick stability but was unsure of where the tape had come from. When interviewed on 12/17/25, at 2:30 p.m. licensed practical nurse (LPN)-B stated R49 had walked out of the dining room using the walking stick after breakfast this morning. LPN-B stated R49 had always used the walking stick since he admitted but since recent decline in status the last several weeks has been utilizing a wheelchair most of the time. Observation at 12/18/25 at 9:45 a.m., R49 was seated in dining room in wheelchair with walking stick resting against his chest. When NA approached and assisted R49 from the dining room utilizing the wheelchair, it was noted the tape had been removed from the walking stick. When interviewed at that time, R49's spouse stated someone from the facility had glued the walking stick. Walking stick was observed to have a U-shaped crack approximately five inches long approximately halfway up the walking stick with gluelike substance observed in the crack area. When interviewed on 12/18/25 at 11:22 a.m., Maintenance (Maint)- B stated the walking stick had a split that went along the grain of the wood, but was not fully split apart. Maint-B stated was able to apply some pressure to separate the wood to get the heavy-duty glue into the crack, used a activating agent to set the glue which hardened instantly. Maint -B stated the walking stick would probably break elsewhere before the repair area would break again, would take a lot of pressure to break the walking stick. When interviewed on 12/18/25 at 10:50 a.m., director of nursing (DON) stated was not aware the walking stick was broken, the walking stick was R49's personal property. DON was made aware of the walking stick condition the prior evening (12/17/25) and in the morning had retrieved the walking stick and provided a cane to R49. DON stated had removed the tape, saw the break, then got maintenance who used heavy duty glue to repair the break. DON stated if the repair had not held, would have spoken with the family regarding the walking stick being a fall risk. Facility Safety policy reviewed 7/1/25, indicated assistive devices will be adjusted to meet the residents physical condition, reviewed for appropriate fit and working order.

Based on interview and document review, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 2 of 5 residents (R7, R16) reviewed whose Medicare A coverage ended and then remained in the facility. R7's Centers for Medicare and Medicaid Services (CMS)-10123 signed as received on 8/27/25, identified a last covered day (LCD) of 8/29/25, when R7's Medicare coverage would end. R7's undated Census Records listing identified R7's payer source changed from Medicare Part A to Private Pay, and remained in the facility. R7 signed a SNFABN on 8/29/25, however, there was no estimated cost per day provided in the notification. R16's CMS-10123 signed as received on 10/7/25, identified a last covered day (LCD) of 10/10/25, when R16's Medicare coverage would end. R16's undated Census Records listing identified R16's payer source changed from Medicare Part A to Medicaid, and remained in the facility. R16's medical record was reviewed and lacked any evidence a SNFABN had been provided to explain the estimated cost per day or provide rationale or explanation of the extended care services or items to be furnished, reduced, or terminated. When interviewed on 12/18/25, at 9:20 a.m. admission coordinator (AC) stated missed putting the estimated cost for R7 on the SNFABN, AC did not realize that information was not entered. R7 is private pay. AC stated for R16 the CMS-10123 had been provided but the SNFABN was not yet due until Saturday (10/11/25) however, AC did not notice the SNFABN had not been provided to R16 until surveyors had requested the copy for review. AC stated R16 was private pay while awaiting Medicaid decision. AC stated it was important to provide the SNFABN with estimated cost per day so the resident/resident representative would be aware of what their potential financial responsibility would be. Facility policy regarding beneficiary notifications was requested, however, none was provided.

Based on interview and document review, the facility failed to notify the Ombudsman of transfers and discharge for 1 of 3 residents (R61) reviewed for discharge and/or hospitalizationR61's admission minimum data set (MDS) dated [DATE], indicated R61 admitted on [DATE], and was cognitively intact. R61 had diagnoses of hypertension, atrial fibrillation, end stage renal disease, quadriplegia, and diabetes.R61's discharge MDS dated [DATE], indicated R61 discharged to home. Review of the October-November 2025 Ombudsman log identified residents who transferred to the hospital, however, the log failed to identify notification to the Ombudsman was completed for any residents who discharged from the facility. When interviewed on 12/18/25 at 9:14 a.m., social service director (SSD) stated she was trained to send Ombudsman notifications either monthly or each time a resident was sent to the hospital. SSD stated was not aware of the need to inform the Ombudsman's office of residents discharged from the facility. Facility policy Discharge Planning and Ombudsman Notification reviewed 4/28/25, indicated notice to the ombudsman is required for emergency transfers.

Based on interview and document review, the facility failed to ensure a comprehensive, person-centered care plan was developed, accurate, and revised to assure assessed care needs were implemented for 1 of 2 residents (R54) reviewed for care planning. Findings include: R54's Admission Minimum Data Set (MDS), 12/09/2024; indicated R54 had diagnoses including coronary artery disease (CAD), depression, anxiety and asthma. In review of R54's Face Sheet, print date of 1/08/25, additional diagnoses included emphysema, malignant neoplasm of unspecified part of unspecified bronchus or lung and a personal history of nicotine dependence. Upon entering R54's room for an interview on 1/06/25 at 2:21 p.m., R54's person smelled of cigarette smoke. R54 stated that she had just come back from the outside resident smoking area. R54 stated that she has not smoked as much since admission due to the cold weather, and mainly smokes late afternoon / early evening when family and friends visit. A review of R54's Smoking Risk assessment, dated 12/17/24, resident's smoking frequency of smoking was dependent on R54's stress level. R54 agreed to allow the unit nurse to store her cigarettes and lighter during her stay when not outside smoking. The facility deemed R54 to be able to smoke independently. However, review of R54's care plan (creation date of 12/19/24) and the nursing assistant care sheet for the unit, it was noted both lack documentation that R54 was a smoker. Attempts were made throughout survey (1/06/25 - 1/09/25) to observed R54 smoking, however, do to the cold temperatures, R54 did not go outside to smoke. During an interview on 1/08/25 at 10:47 a.m., nursing assistant (NA)-A and registered nurse (RN)-A, reviewed the unit's nursing assistant care sheet (undated). Both NA-A and RN-A verified the care sheet did not identify R54 as a smoker. However, both staff members were aware of R54 being a smoker. During interview on 1/08/25 at 11:05 AM, the unit manager (LPN)-A and director or nursing (DON) were noted to be sitting in the unit managers office. The unit manager, after review of R54's care plan, verified the resident's care plan did not address R54 as a smoker and what if anything the facility staff (including agency pool staff) needed to do to monitor R54. Both staff members stated it was important to have the information available to assure resident safety and whereabouts when smoking. In review of the facility's policy, entitled: Care Plan and Baseline Care Plan (last revised 10/14/22) indicted the following: 3. The interdisciplinary team, in conjunction with the resident, resident's family, significant other or resident representative, shall develop a comprehensive person-centered care plan for each resident. This comprehensive care plan will be in the [electronic health record] by day 21 of the stay or 7 days after completion of the comprehensive initial MDS, whichever comes first. 4. The resident care plan is constantly changing. It should be updated routinely in the electronic record to reflect resident's current condition. The resident care plan is reviewed for accuracy, updated with quarterly MDS review, and all other scheduled MDS assessments.

Based on observation, interview and document review, the facility failed to ensure residents received appropriate catheter care as ordered by the provider to maintain urinary catheter function for 1 of 1 residents (R37) who was reviewed for indwelling urinary catheter use. This had the potential to impact R37's catheter function and cause an increase risk of infection. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], indicated he was cognitively intake, had an indwelling urinary catheter and required extensive assist with toileting and personal hygiene. R37's Resident Face Sheet, printed 11/29/23, identified R37 had benign prostatic hyperplasia (an enlarged prostate which can block the flow of urine out of the bladder), with lower urinary tract symptoms. R37's diagnoses also included bladder neck obstruction and urinary tract infection, site not specified. R33's care plan dated 10/26/23, indicated the R37 had an indwelling catheter related to neuromuscular dysfunction of the bladder (a bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves). The care plan directed staff to assess the drainage (urine) every shift and as indicated. Staff were directed to record the amount, type, color and odor of the urine. The care plan directed staff to change catheter per the provider order. The care plan directed staff to avoid obstructions in the drainage and to not allow tubing or any part of the drainage system to touch the floor. The care plan did not include information regarding orders for catheter irrigation. A review of the Treatments Administrative History was completed for the dates of 11/1/23 to 11/29/23, and identified R37 was to receive Foley flushes with 40 cc's (cubic centimeters-a unit of measurement) of saline every hour to irrigate cath (catheter) if (output was) less than 300 cc's every shift per provider order of 5/30/23. R37's record indicated R37 received a Foley flush on 11/26/23, at 1:43 p.m. for other reasons. The document also identified R37's catheter was changed on 11/26/23 at 1:42 p.m. for other reasons, which was noted he felt like he had to continue to void. On this same document, Treatments Administrative History, R37's Catheter Output was to be monitored every shift. A review of this information recorded on the following dates and shifts, R37's output was less than 300 ml (milliliters-a unit of measurement-equal to cc's): 11/1/23 Days 200 ml output; 11/2/23 Days 200 ml output, and Evenings 250 ml output; 11/5/23 Days 250 ml output; 11/7/23 Days 100 ml output; 11/8/23 Days 200 ml output; 11/10/23 Days 200 ml output; 11/11/23 Days 200 ml output; 11/12/23 Days 200 ml output. 11/15/23 Days 200 ml output, and Evenings 250 ml output; 11/16/23 Days 200 ml output; 11/17/23 Days output 250 ml and Evenings 200 ml output; 11/18/23 Days 200 ml output; 11/20/23 Days 200 ml output; 11/21/23 Days 200 ml output, Evenings 250 ml output, and Nights 250 ml; 11/22/23 Days 200 ml output; 11/23/23 Days 200 ml output and Nights 150 ml output; 11/24/23 Days 200 ml output and Evenings 250 ml; 11/25/23 Days 200 ml output and Evenings 250 ml; and 11/26/23 Days 200 ml output. During interview on 11/28/23, at 4:30 p.m. licensed practical nurse (LPN)-A/Clinical Coordinator, stated the information relayed on the Treatments Administrative History were not reflective of a complete complete record for outputs. LPN-A stated this information was documented in a different area, and stated she would provide it to me for review. During interview on 11/29/23, at 10:30 a.m. licensed practical nurse (LPN)-A-Clinical Coordinator provided me with a document titled Vitals Report. A brief review of the information was completed during interview with LPN-A at which time it was noted on multiple occasions, there were shifts when R37 had less than 300 ml of urine output. In clarification, LPN-A stated the entries after 7:00 a.m. were for the output total for the day shift. Upon immediate review of the information, LPN-A stated a catheter flush should have been done on multiple occasions based on the shift outputs, however, LPN-A verified the documentation indicated it had only been done on one occasion in the month of November. A full review was completed of the document labeled Vitals Report indicated urinary outputs of less than 300 ml, with some descriptive entries, on the following occasion: 11/2/23 at 2014 (8:14 p.m.) was an output of 250 ml described as straw yellow. 11/5/23 at 1348 (1:48 p.m.) urine output was 250 ml and characteristics of blood tinged. 11/17/23 at 1:19 p.m. the output was 250 ml and was not described. 11/17/23 at 8:27 p.m. urine output was 200 ml and was described as brown and dark. 11/21/23 at 8:51 p.m. urine output was 250 ml and was described as straw yellow. 11/22/23 at 4:40 a.m. the urine output was 250 ml and was described as brown and dark. 11/24/23 at 4:36 a.m. urine output was 150 ml and lacked description of urine appearance. 11/24/23 at 8:22 p.m. urine output was 250 ml and urine was described as brown and dark. 11/26/23 at 10:23 p.m. urinary output was 250 ml and lacked description of urine appearance. 11/27/23 at 8:22 p.m. urinary output was 250 ml and was described as brown/dark. 11/25/23 8:23 p.m. urinary output of 250 ml, with description not provided. Upon review of the above listed entries, it was noted there were 11 occasions documented where the criteria was met for the orders to flush the catheter, however, it was only done on 1/11 occasions. A review of the facility policy, Catheter Irrigation, reviewed 4/13/23, identified catheter irrigation was to be completed as ordered by the provider, and directed the licensed nurse to verify the order for irrigation and solution to be used. Once the procedure was completed, the policy directs the staff to document the procedure in the electronic health record.

Based on observation, interview and document review, the facility failed to ensure confidential information was not readily available for all residents, staff, and visitors to view for 1 of 1 resident (R24) observed to have private information visible on an open computer screen in a common area. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 was cognitively intact, was able to clearly communicate her needs and wishes and required substantial to maximal assistance with activities of daily living (ADL). On 11/27/23, from 5:26 p.m. to 5:41 p.m., R24's picture and medications were displayed on an open computer screen that was left unattended on the nurse's medication cart in the common hallway by the nurse's station. At 5:30 p.m., a visitor walked past the medication cart and looked in the direction of the open computer screen where R24's personal information was visible on screen. At 5:31 p.m., co-resident, R46 who was cognitively intact, walked past medication cart and looked in the direction of the open computer screen where R24's personal information was visible on screen. At 5:33 p.m.,a visitor walked past the med cart and looked in the direction of the open computer screen where R24's personal information was visible on screen. At 5:36 p.m., R46 walked up to medication cart and stood at cart looking around the top of cart. At 5:39 p.m., registered nurse (RN)-A walked up to the medication cart, placed paper on medication cart, acknowledged R46 and walked away to put medications in medication room. RN-A did not redirect R46 away from cart and did not close computer screen. At 5:41 p.m., RN-A walked up to the medication cart, acknowledged R46 and started viewing R24's information that was present on screen. On 11/27/23, at 5:41 p.m., RN-A stated that when leaving the medication cart she makes sure the screen is locked with no resident information visible. RN-A confirmed she did not close the screen and R24's personal information was visible on screen. On 11/28/23, at 4:29 p.m., licensed practical nurse care coordinator (LPN)-A stated she expected the nurse to ensure that the Electronic Mediation Admission Record (EMAR) was closed and no resident personal information was visible before walking away from cart. LPN-A stated this was important due to HIPPA laws and protecting resident's privacy. On 11/28/23, at 4:24 p.m., director of nursing (DON) stated she expected staff to close the computer screen down so no personal information can be seen by others when leaving the medication cart. DON stated it was important so the resident's personal information can not be seen by others due to HIPPA. The Notice of Privacy Practices policy dated 2/23/2020 indicated we are required by law to maintain the privacy and security of your protected health information. Additional policies were requested with none received.

Based on interview and document review, the facility failed to assure the use of PRN (as needed) psychotropic medications (a drug which affects mood/behavior) were limited to 14 days, or had a physician specified, time limited, order for 1 of 1 resident, R57, reviewed for Hospice. Findings include: R57's Admission Minimum Data Set (MDS) of 11/4/23 identified R57 had moderate cognitive impairment. R57's diagnoses listing included both anxiety and major depression. The PHQ-9 completed with this assessment identified R57 had mild depression, based on answers provided on the Patient Health Questionnaire (PHQ-9). R57's Resident Face Sheet, dated 11/29/23, included multiple diagnoses which included encounter for palliative care (specialized medical care for people living with a serious illness), history of falling, major depression (single episode), and anxiety disorder. R57's Care Plan identified R57 had enrolled into hospice services prior to admission to the facility. The care plan identified R57 had an order for Lorazepam 0.25 mg PRN every four hours as needed for anxiety. R57 was also identified as having orders in place for routine dosing of an antidepressant medication. The care plan directed staff to attempt dose reductions per regulatory guidelines, as condition warranted, and per provider order. The care plan also directed staff to monitor behavior symptoms and to offer one to one interactions and activities during periods of anxiousness. The care plan indicated the facility worked with resident, hospice, and staff to meet resident needs. During interview on 11/27/23, at 6:42 p.m. R57 stated he received pain medication routinely and also had a medication for anxiety. R57 stated he had been taking them prior to his admission to the facility. A review of the PRN Medications Administration History indicated client had lorazepam 0.5 mg ordered every four hours as needed. This order was initiated on 10/31/23 and was open-ended. The documentation did not reflect use of this medication since his admission. On 11/28/23, at 3:51 p.m. licensed practical nurse (LPN)-A/Clinical Coordinator stated R57 had the lorazepam ordered PRN for anxiety, however, he had not used it at the facility. LPN-A stated antianxiety medications were to have a stop date, and this should have been identified upon initial receipt of order, as well as when the record was prepped for provider visit for the provider visit. On 11/29/23, at 11:45 a.m. and interview was completed with the director of nursing (DON) and the lack of stop date was reviewed. The DON stated the antianxiety medication should have a stop date of 14 days, unless there was a different end date specified. A review of the facility policy, titled Medication Management, reviewed 5/24/22, indicated the consulting pharmacist reviewed all psychotropic medication for appropriate indications of use, monitoring for efficacy, potential adverse effects and potential for dose reduction. The policy identified target behavior symptoms were to be identified as soon as possible after admission of resident, and were to be documented in the electronic health record. The policy lacked definition as to the required time limiting component of 14 days with PRN usage of psychotropic medications, unless otherwise identified by the provider with time limits outlined and documented within the medical record.

Based on observations, interviews, and document review, the facility failed to ensure a system to safeguard narcotic medication for 1 of 3 residents (R1) reviewed, and whose narcotic medication was diverted by 1 of 1 registered nurse (RN-A) for personal use. Findings include: R1's face sheet showed an admitted [DATE], for aftercare following left foot amputation. R1's care plan identified pain as a problem and the approaches included administration of pain medications as ordered. R1's medications included an order dated 5/24/23, for oxycodone 5 mg (milligram) 1 tablet by mouth every 4 hours as needed for severe pain. R1's medication administration history record indicated that R1 had not received any oxycodone 5 mg tablet from 5/24/23, until it was discontinued on 6/15/23. During interview on 6/21/23 at 10:19 a.m., licensed practical nurse (LPN)-A explained that two staff nurses count narcotics at the end of each shift, by the off-going and in-coming staff. LPN-A stated that one nurse holds the narcotic book, reads the non-highlighted lines (with page #) in the index (contents page), and then flips through the sheets to look for the actual page indicated or with corresponding page # while the other nurse looks for the identified stock medication in the narcotic lockbox/drawer. LPN-A stated, she would not search for an actual sheet/page in the narcotic book if the line with that page was highlighted in the index. LPN-A stated there had been no issues in a long time but within the last two weeks, administration sent a reminder to make sure we're keeping up with the books and the meds [medications] on hand and to make sure all medications in the pages have end dates. During interview and observation on 6/21/23 at 10:26 a.m., LPN-B stated that two nurses do narcotic counts every staff turnover. LPN-B brought out a narcotic book and demonstrated the narcotic count showing that nurses would pay attention to the information (page #, name of resident, name of medication) on what was not yellowed-out in the index and then look for the actual page, which contain a sticker that should match the information. LPN-B stated that the second nurse would look for the identified medication in the narcotic lockbox/drawer. LPN-B also stated that if a medication was discontinued for any reason, it would be yellowed-out or highlighted in the index and the actual page would be crossed-out to indicate that it was no longer active, and staff would not pay attention to lines/pages that were highlighted. During interview on 6/21/23 at 11:19 a.m., RN-B stated that during shift change on 6/14/23, she and another nurse were counting the narcotics on the [NAME] Unit medication cart and discovered that R1's medication card with 24 oxycodone 5 milligram (mg) tablets was not in the narcotic lockbox. RN-B stated that during the counting process, she was holding the narcotic book and read the actual sheet for page 61 that showed R1's oxycodone 5 mg with 24 tablets in stock, which was not crossed out, indicating the medication order was still active. RN-B stated that she read aloud page 61 for the other nurse to look for the medication in the lockbox, however, it was not there. RN-B stated they then observed that page 61 was highlighted in the index but there was no end date noted. RN-B also stated that they searched everywhere but could not find the medication. RN-B described that the usual practice was for staff to see the page # on the non-highlighted lines in the index and go straight to the actual page, and they also used paper clips to stick the book's used pages together. RN-B further stated they would not have checked/opened the narcotic book onto page 61 because it was already highlighted in the index (inactive), however, she happened to notice the actual sheet for page 61 because the paper clip that held page 61 together with the other used sheets/pages, fell off. RN-B added, she had to read page 61 because it was not crossed out, and that prompted the search where they discovered that the medication was missing. During interview on 6/21/23 at 8:59 a.m., the director of social services (DSS), stated having learned about the drug diversion incident on 6/15/23. The DSS stated she immediately investigated by looking at the cameras where a pool nurse unlocked the narc [narcotic] med [medication] cart, took the med card out, and put it under her clip board on top of the med cart, then continued standing there and as if doing something, then she took the clipboard and the med card, walked around, and put it in a bag at the nurses' station. She talked to the NAs [nursing assistants], and when the NAs left, she took the bag and went to the rest room and stayed there for about 26 minutes and then came out. During interview on 6/21/23 at 12:52 p.m., the assistant director of nursing (ADON) stated that their system had been working before, where the nurses would highlight the meds that had been used up/discontinued/destroyed from the index and paper clip the used pages. The used pages in the narcotic book would be crossed out to also indicate it was no longer in use. The ADON also stated that the facility's system still did not fail because their staff discovered the missing medication, discovered who did it, and did the necessary reports. The ADON characterized the staff who diverted the drug as a criminal and smart and further stated that if she only had crossed page 61 out, then it wouldn't have been caught. (Identifying a fault in the facility's current system). During interview on 6/22/23 at 9:17 a.m., RN-C stated, What we do when we count is one nurse will count the meds in the lockbox and the other nurse will check the book, go to the page number written in the med card. RN-C added that if the medications were not in the cart, they would not look for the page in the book. RN-C stated that she received an email from the ADON sent on 6/20/23, but that she had not read through it personally and was unsure if there were any recent changes in the process of narcotic counting. RN-C then opened computer to read her email, and stated the reminders included how to identify drug diversion, and when counting narcotics, the person with the book should lead the counting. RN-C acknowledged that drug diversion could still happen because the one holding the book would only focus on reading the non-highlighted lines and would not be looking for the actual page if the line for that page was already highlighted in the index, and that if the narcotic was not in the lockbox, it would not be known. During interview on 6/22/23 at 9:26 a.m., LPN-D stated that she was taught that narcotic counting was to be done at the end of each shift by the oncoming and leaving staff. LPN-D stated when she was oncoming, she counts the actual medications and when she is leaving, she holds the book and leads the counting. LPN-D stated that has been the process since she started in 2013. LPN-D explained that if the line identifying the page number, resident's name, and medication, was highlighted in the index, they won't be looking for the actual page where the remaining amount for that medication would be documented. LPN-D acknowledged the possibility to miss accounting for narcotics if they were already taken out from the narcotic lockbox and had been highlighted in the index and crossed out in the corresponding actual page. LPN-D further stated she did not know a better alternative. During interview on 6/22/23 at 9:51 a.m., the director of nursing (DON) acknowledged that the facility's practice for narcotic counting did not change much even after the drug diversion incident. The DON stated that the education sent out to staff was kind of a reminder of the same process that has been in place for a long time. The DON stated, I don't know what would be a different way and further stated the facility would consult a corporate nurse if there was a different system that other facility's have. During observations with the facility's camera recorded video on 6/22/23 at 10:21 a.m., a female person opened a medication cart, took out what looked like a medication card (bubble pack), and put it under a clip board on top of medication cart. There were 2 other female individuals who showed up, they talked to the female on the med cart, and they left. The female on the medication cart took the clip board including what she put underneath and walked around towards the nurses' station, where she was bending to a bag. She carried the bag on her shoulders and walked towards what the DSS said as the location of a public restroom. The facility's narcotic register showed in the index, a highlighted line for page 61 (R1's name, the prescribing physician's name, oxycodone 5 mg, prescription number, and 5/24/23 as start date), which indicated it was no longer active, even though, it did not indicate an end date. The corresponding sign out sheet for page 61 documented R1's oxycodone 5 mg tablet with the quantity received as 24, and R1 did not use any. A review of the local police department's incident report, dated 6/15/23 and modified on 6/16/23, indicated that on 6/15/23, a police officer summoned RN-A to show up at the police department for a statement regarding the allegation of narcotic theft. The report also indicated that on 6/16/23 at 9:50 a.m., RN-A appeared at the police department and readily confessed to the police officer that she did take R1's narcotics. The facility's policy titled, Medication Management, dated 7/16/18 and reviewed on 2/20/23 with a subtitle Narcotic Count, indicated after verifying the correct amount of controlled substances delivered, apply the second voided label for that medication to the bound narcotic register; log the controlled medication in the front index of the bound narcotic register on the numbered line corresponding to the page on which the medication was entered; and the date, time, dose, nurse's signature and quantity remaining are entered in the bound narcotic register with each dose given. The policy also indicated that controlled substances or narcotics are counted at the end of each shift; the count is done by having 1 nurse look at the index and corresponding sign out page; a 2nd nurse confirms the quantity remaining in the corresponding medication card, box or bottle; and if a medication is missing or cannot be accounted for, notify director of nursing immediately (or designee) who will determine the appropriate course of action. The facility's document titled, Drug Diversion Re-education - Facility Narcotic Management, dated 6/16/23, reiterated the following: all medications in the narcotic book are entered in the front ledger and the corresponding page with all the required information; when a page is no longer active for any reason other than reaching 0 (zero), there will be a corresponding note with the licensed employees initials on the bottom of the page and follow instructions (i.e. moved to page #); anytime medication is removed the page will be crossed off in the front ledger with a highlighter and the date of removal or D/C (discontinuation) will be transcribed in the last column of the ledger; the actual page will have a line through it with the initials of the nurse; counts will be performed by the oncoming nurse who will read the mediation cards while the off going nurse leads the counting and reads the book by looking at the front ledger and then find the corresponding page.

Based on observations, interviews, and records review, the facility did not ensure safe disposition of controlled substances for 2 of 3 residents (R2 and R3) reviewed for medication management, for not documenting medication disposal and not pulling out discontinued medication from stock and updating the records. Findings include: Documentation of medication disposal R2's minimum data set (MDS) history showed an admitted [DATE], with a corresponding discharge date of [DATE]. The MDS indicated primary diagnoses of fractures and other multiple traumas. The medication orders for R2 included tramadol 50 mg (milligram) by mouth for moderate to severe pain, with a start date of 2/14/23 and discontinued on 4/20/23. The facility's narcotic register showed on page 22 of the index that R2's supply of tramadol 50 mg tablet started on 4/4/23 and ended on 4/24/23. However, the corresponding actual page 22 was not crossed out, showing 30 tablets of tramadol 50 mg remaining. R2's medication administration record also showed that R2 did not receive any tramadol from 4/4/23 to 4/24/23. During interview on 6/21/23 at 10:26 a.m., licensed practical nurse (LPN) B verified that the narcotic register showed a stock of 30 tablets for R2's tramadol 50 mg, however, the medication was not in the narcotic lockbox. During interview on 6/21/23 at 11:54 a.m., the director of nursing (DON) verified that there was no stock for R2's tramadol 50 mg medications in the medication cart, and although page 22 was highlighted in the index of the narcotic register, the actual page 22 showed a remaining amount of 30 tablets. The DON stated the process whenever a medication went into destruction, sent home, or returned to pharmacy, it should be documented. The DON verified that there was lack of documentation to show where R2's tramadol 50 mg was disposed. During interview on 6/21/23 at 1:36 PM the DON, assistant director of nursing (ADON) and Unit Coordinator (UC)-A verified that the facility discharged R2 to the hospital on 4/20/23. They also verified the discharging nurse did not document anything about medication disposal and that there was no record to show an inventory of what family members took out when they came to pick up R2's belongings when R2 decided to go home instead of returning to facility. During interview on 6/21/23 at 3:50 p.m., UC-A stated she had called R2's family member (FM)-A, who informed UC-A that FM-B picked up R2's belongings including the medications from the facility. During interview on 6/21/23 at 3:45 p.m., LPN C verified she was the nurse on duty on 4/24/23, when R2's family member came in to pick up R2's belongings. LPN-C stated that UC-B okayed to release the narcotics. LPN-C stated handing the medications to FM-B. LPN-C also stated she could not remember if she documented about the medication disposal saying, It was a long time ago in April. During interview on 6/22/23 at 7:52 a.m., FM-B stated taking R2's belongings home including tramadol which was to be given to R2 as needed. During follow-up interview on 6/22/23 at 9:51 a.m., the DON acknowledged that staff did not follow facility protocol for R2's medication disposal. The DON stated it was human error that it was missed. Pulling out discontinued medication R3's face sheet showed an admitted [DATE] for orthopedic aftercare following surgical amputation. The medication orders for R3 included tramadol 50 mg by mouth every 6 hours as needed for moderate to severe pain with a start date of 5/16/23 and an end date of 5/22/23. The facility's narcotic register showed in the index that page 55 contained R3's tramadol 50 mg with a start date of 5/16/23 but with no end date. During observation on 6/21/23 at 10:26 a.m., R3's tramadol 50 mg (8 tablets) were still in stock at the west unit's narcotic lockbox. LPN-B verified that R3 did not take any of the tramadol since order date of 5/16/23. LPN B also verified that the medication was discontinued on 5/22/23 but the medications remain in the narcotic lockbox. During interview on 6/22/23 at 9:51 a.m., the DON stated that the ADON and the UC-A did an inventory of all the carts after the drug diversion incident but the DON did not say anything about R3's discontinued medication that remained in stock after the audit. The DON stated, What I can say is that when the med was discontinued [LPN A] was training a new nurse, and the new nurse was working on the cart, and it was missed. The DON acknowledged that staff did not follow medication management policy for R3's tramadol and stated they did not get back to the cart to pull out the medication and update the narcotic register. On 6/22/23 at 12:26 p.m., attempted a call to the pharmacy consultant for interview but did not receive a return call. The facility provided a document titled, Policy and Procedure Manual, Version 2.0, 08.27.19, subtitled, Consultant Pharmacist Services Duties, which directed the consultant pharmacist to check the medication storage rooms, and medication carts for proper storage of medications, and submitting a written report and recommendation; and assisting in the accounting, destruction, and reconciliation of unused controlled and noncontrolled substances as requested. The facility's Medication Management policy with latest review date of 2/20/23, subtitled, Narcotic Count, indicated that narcotics will be counted at the end of each shift. The policy also indicated that when a resident is discharged with orders for controlled substances staff should obtain a physician's order with ok to discharge resident with each specific controlled substance. The policy's subtitled Medication Disposition indicated that as soon as practicable after discontinuance, death or discharge the following should occur: a) Complete medication disposition form indicating the prescription number and quantity of each medication and indicating whether it was sent home with resident or is being sent to the DON for destruction; b) Complete information in the bound narcotic ledger indicating that the medication has been removed for destruction. This documentation is to be co-signed by the DON (designee) upon removal of the medication from the medication cart; c) Complete the information in the index at the front of the bound narcotic ledger that the medication has been removed and yellow-out that line in the index; DON (or designee) will complete the certificate and inventory destruction form. This form will be double checked against medications being destroyed by second nurse during the destruction process.

Based on observation, interview and document review, the facility failed to ensure handwashing was performed during medication pass for 1 of 8 residents (R57) observed for medications. In addition, the facility failed to follow manufacturer instructions to discard opened tube feeding formula at least every 12 hours, for 1 of 1 residents (R33) reviewed for tube feeding. Also, the facility failed to disinfect a mechanical lift between use for 3 of 7 residents (R9, R3, and R24) observed for transfers with a mechanical lift. Findings include: R57's admission Minimum Data Set (MDS) dated [DATE], identified cognitively intact and diagnoses with right ankle surgery and was receiving intravenous (IV) antibiotics and wound vacuum. R57 was dependent upon staff for transfers and personal hygiene. During medication pass observation on 12/20/22, at 4:45 p.m. licensed practical nurse (LPN)-A began setting up evening medication for R57 which consisted of Eliquis (anticoagulant) and a of normal saline 0.9% in a 10 milliliter (ml) commercially filled syringe. Upon entering R57's room, LPN-A provided resident water and the dose of Eliquis, the donned disposable gloves to flush R57's PICC line (peripherally inserted central catheter) located on resident's left arm. LPN-A removed the end cap for the PICC line, and using a alcohol prep pad disinfected the needle-less connector. After aspirating for blood, to check for patency, LPN-A flushed the PICC and placed a new sterile end cap on. LPN-A then placed the empty syringe on one gloved hand doffing the syringe inside, then doffed the other glove around it as well. LPN-A then exited the room without any form of hand hygiene, walked to the medication cart disposing of the used gloves and syringe. LPN then pulled keys out of her pocket , opening the medication storage room quickly returning unused end caps then returned to the medication cart, signing off on the medication and PICC line flush all without any form of hand hygiene. When interviewed on 12/20/22, at 5:00 p.m. LPN-A stated she had forgotten to wash or disinfect her hands before leaving the R57's room and should have. During an interview on 12/21/22, at 10:09 a.m. the infection preventionist nurse (IP) stated it would be the expectation to perform hand hygiene before LPN-A left the room, especially while R57 was on precautions. The facility policy titled, Hand Hygiene (revised date of 8/12/22) indicated the following: Hand washing / sanitizing is necessary: 1. Before and after providing care to resident 2. before and between passing meal trays. 3. before eating or handling food. 4. Before and after using the bathroom. 5. After coughing/sneezing, blowing nose, or combing to touching your hair. 6. After removing gloves. 7. After each resident contact. 8. After touching environmental surfaces or equipment near residents. 9. After contact with your own face or mask. 10. Before and after smoking. 11. After handling dressings, catheters, bed pans, specimen or urine. 12. Before any invasive procedure such as administering injections. 13. When hands are visibly soiled. 14. After removing personal protective equipment (PPE). 45842 R33's quarterly MDS dated [DATE], identified a traumatic brain injury and received nourishment via parenteral/intravenous feeding and was dependent upon staff for feeding. R33's diagnosis list printed on 12/21/22, included diagnoses of traumatic brain injury with loss of consciousness, hydrocephalus-swelling of the brain, encounter for attention to tracheostomy and encounter for attention to gastrostomy-tube (G-tube) in the stomach to assist in feeding. R33's care plan printed 12/21/22, indicated a concern with nutrition related to tube feedings. Interventions included if cans were used for feeding all equipment had to be changed every twenty-four (24) hours (HRS) and if the prepackaged bottles were used the bottle had to be changed every forty-eight (48) hours. R33's Physician Order Report printed 12/21/22, indicated R33 had order started on 11/22/22, for enteral feeding: Jevity 1.5 bolus, 6 ounce per G-Tube four times a day. During observation on 12/19/22, 03:03 p.m. a 1000 milliliter (ML) bottle of Jevity 1.5 cal tube feeding solution was noted on R33's bedside table along side other tube feeding equipment. The bottle was noted to have the date 12/17/22 written on the side of the bottle in large letters. The bottle was noted to have approximately 50-75 ML of tan solution in the bottle. The cap had the same tan solution on top of the cap and the seal protecting the solution had been punctured. There was no Tubing attached to the bottle. During interview on 12/19/22, at 03:15 p.m. Registered nurse (RN)-A stated she had performed R33's scheduled tube feeding bolus at noon that day. RN-A stated she had used a 1000 ML closed system bottle to perform the scheduled feeding. RN-A entered R33's room and acknowledged the bottle dated 12/17/22, was the bottle use for the feeding that day. RN-stated nursing would open a new bottle and leave it at bedside so all nurses could use it for bolus feeding, and the bottle would get changed about every 2 days, maybe a little longer. RN-A stated that procedure had been done since R33's order had changed in November. RN-A stated she believed it would be ok to change the large tube feeding bottles every 48 HRS. During interview on 12/19/22, at 03:21 p.m. the registered dietician (RD) stated if a 1000 cc bottle of tube feeding was used as an enclosed system, where there was no break between the bottle, tubing and the resident, then everything would be changed every 48 HRS. If there was an opening in the bottle that did not have tubing attached to it, then the tube feeding bottle would need to be changed every 24 HRS. RD entered R33's room and acknowledge the current bottle was not considered an enclosed system and was not safe to use past 48 HRS. The RD stated the current bottle had not been safe to use for the last 24 HRS. The RD stated it would be important to change out bottles of tube feeding every 24 HRS so the increased risk of infection would be prevented. During interview on 12/21/22, at 1:03 p.m. the director of nursing (DON) stated she expected staff would follow the protocol and would use tube feeding in the appropriate timeframe and get a new bottle when time. Jevity Enteral Nutrition Formula information sheet, undated, identified the solution could only be open and at room temperature for a maximum of 12 hours to prevent from bacteria growth. The facility policy Tube Feeding/enteral feeding-Gravity or Bolus Feeding last revised 5/17/21 indicated formula should have been discarded eight HRS after opened. 47263 On 12/20/22, at 4:49 p.m. nursing assistant (NA)-B stated she had education on personal protective equipment (PPE) and infection prevention. NA-B stated when she sanitizes equipment she looks at facility signs posted if she is not sure what wipes to use or how long stuff should be wet to for proper sanitization. On 12/21/22, at 8:42 a.m. NA-A came out of R9's room and placed a hoyer lift in the south hallway. Shortly after, NA-A returned and took the hoyer lift into R3's room. On 12/21/22, at 08:50 AM NA-A brought hoyer lift out of R3's room and did not wipe lift down. NA-A then grabbed the same lift and entered R24's room with the lift. NA-A was asked to step out of the room and share process for cleaning equipment between residents. NA-A pointed at the wipe container stored on the hoyer lift, and stated, we use these wipes, and we usually wipe stuff down in the room or hall after we leave room. NA-A opened the wipe container to show a couple wipes left in the container. NA-A verified the wipes were mostly dry to touch but stated she would still use the wipes. NA-A stated she did not know about dwell times, or that times were listed on the container for how long equipment needed to remain wet to ensure proper sanitization between residents. NA-A verified the wipe container listed a two-minute dwell time. NA-A verified she did not sanitize the hoyer before entering R9, R3 or R24's room. On 12/21/22, at 10:09 a.m. the infection preventionist (IP) verified staff should be using appropriate wipes between residents to disinfect all high touch surfaces on the hoyer. The wipes should be saturated, they may dry out if the top is left open. On 12/22/22, at 1:10 p.m. the director of nursing (DON) verified that staff should sanitize equipment with appropriate wipes between patient use.

Based on observation, interview, and document review, the facility failed to ensure assessed and identified preferences for rising were honored for 1 of 1 residents (R45) reviewed for choices and who voiced they were not assisted timely with rising in the morning. Findings include: R45's quarterly Minimum Data Set (MDS), dated [DATE], identified R45 had intact cognition and was totally dependent on staff for transfers and bed mobility. R45's care plan, last reviewed 8/11/21, identified R45 was alert and orientated and able to make her needs known outlining, Allow choices/included in decisions about daily routine. Further, the care plan identified a section labeled, Personal Preferences, which directed, Wants to be up around 7:30 or 8:00 A.M. On 9/13/21, at 8:48 a.m. R45 was observed to be laying in bed in her room in a night gown. R45 was interviewed at this time and voiced she typically was not assisted with morning cares and rising, until nine, nine thirty every morning as the staff have, a lot of people to get up. R45 stated her preference would be to get up at, about eight [8:00 a.m.] or so, but reiterated remaining in bed until staff were available to care for her, has to be acceptable as the floor staff didn't have enough help to get to everyone timely. Immediately following this interview, two nursing assistants (NA) entered R45's room with a mechanical lift to assist her with rising and morning care. When interviewed on 9/15/21, at 10:48 a.m. NA-A stated R45 was often one of the last residents to be assisted with morning cares and rising due to the amount of assistance she required. NA-A stated she was unaware R45 had ever voiced a preference for her morning rising time but added, If she wants to start getting up earlier, we [could] do that. R45's recently completed Care Conference Summary, dated 8/3/21, identified a quarterly care conference was held with R45 in attendance and involved in her care planning. The summary provided a section to answer and record R45's preferences for bathing, wake time, bed time, activity preferences and food(s). This recorded a checkmark next to the option which read, Wake time, along with additional text reading, 0730 [7:30 a.m.]. On 9/15/21, at 12:04 p.m. the social services designee (SSD)-A was interviewed. She explained resident preferences and choices where entered into the care plan and reviewed routinely with residents at their respective care conferences. SSD-A reviewed R45's most recently completed Care Conference Summary and verified it recorded R45 as having a preference for a 7:30 a.m. wake-time. SSD-A stated such preferences, should be on her [R45] group sheet which the NA(s) use to alert them to such preferences so they can be honored and implemented. SSD-A and the surveyor then reviewed these 'group sheets' which identified R45's preference for a 7:30 a.m. wake time was not listed. At 12:16 p.m. licensed practical nurse manager (LPN)-A joined the interview. LPN-A explained the information on R45's care plan, including her preference for wake time, was still accessible to the NA(s) through their phone-type devices they use while on the floor. LPN-A stated the amount of assistance R45 required for morning care and rising shouldn't matter, and they would look at that and address it with the staff. LPN-A voiced it was important to ensure resident preferences and choices were honored as best able as it's her [R45] house and doing so provides her with some control in her life. On 9/6/21, at 11:31 a.m. the assistant director of nursing (ADON) was interviewed and voiced staff should do their best to meet their [residents] preferences with the means available. ADON stated she felt the floor staff strived to do this on a daily basis; however, she acknowledged they could some days likely work to get R45 up earlier. ADON expressed it was important to honor resident preferences and choices, as best able, as the facility provided person centered care and it helps the resident to make them feel like they're at home. A provided Resident Dignity, Choices and Preferences policy, dated 2/2020, identified the facility will . put protocols in place to honor resident's choices and preferences as able. The policy continued, Resident's choices and preferences will be reviewed upon admission and at quarterly care conferences. These preferences will be care planned as appropriate.

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene and grooming was provided for 2 of 3 residents (R6, R41) reviewed for activities of daily living (ADLs) and who were dependent on staff for care. Findings include: R6's admission Minimum Data Set (MDS), dated [DATE], identified R6 had severe cognitive impairment and required extensive assistance with personal hygiene. Further, the MDS identified R6 demonstrated no rejection-of-care type behaviors. R6's care plan, dated 9/9/21, identified R6 required total assistance to complete his grooming and listed a goal which read, Resident will be clean and well-groomed by staff through [review date]. The care plan directed, GROOMING: Staff to provide total assist with grooming. However, the care plan lacked any preference or statements regarding preferences R6 wished for or had pertaining to his fingernail care (i.e., he did not want long fingernails trimmed). On 9/13/21, at approximately 10:20 a.m. R6 was observed seated in his wheelchair. R6 had visibly long fingernails on both hands, with several of his nails having a visible, dark-colored substance or debris present under them adjacent to the nail bed. During subsequent observations, on 9/14/21 at 4:32 p.m., and 9/15/21 at 10:25 a.m., R6 continued to have long fingernails with a dark substance and/or debris present underneath several of the nails. R6 was interviewed at this time at voiced one of the girls helps him complete his fingernail care. R6 stated he wanted his nails trimmed and added he thought the floor staff will eventually help him do such. R6's progress note, dated 9/8/21, identified R6 received his bath and had no new skin issues. The note lacked evidence if R6 had been offered and/or refused nail care. Further, R6's medical record lacked evidence R6 had been offered and declined nail care in the past weeks. On 9/15/21, at 10:36 a.m. nursing assistant (NA)-A was interviewed and described R6 as typically pretty pleasant and not usually resistive to personal hygiene and grooming cares. NA-A explained nail care should be completed after [their] baths and then observed R6's fingernails at the request of the surveyor. NA-A stated R6's nails were slightly overgrown and needed to be clipped. NA-A stated if R6 had been recently offered nail care and refused it, then R6's refusal should be recorded in the nurses' notes or their behavioral charting. When interviewed on 9/15/21, at 1:35 p.m. licensed practical nurse (LPN)-B stated R6 was not diabetic and the NA(s) should be helping him to complete personal hygiene and grooming. LPN-B explained nail care should be done weekly with their baths, and if such care was offered and refused, then it would be recorded in the nurses notes or on the resident' bath sheet. LPN-B stated it was important to ensure nail care was provided to promote a resident's dignity and to have them look good. On 9/15/21, at 2:38 p.m. licensed practical nurse manager (LPN)-A was interviewed. LPN-A verified R6 required physical assistance to complete his grooming and personal hygiene, and any refused care(s), including nail care, should be recorded in the progress notes or bath sheet(s). LPN-A stated she no longer had the completed bath sheets to provide for review; however, acknowledged there was no recorded refusals of care for R6 in his progress notes. LPN-A expressed R6's nail care should be provided during his weekly bath and added R6 did have a history of dry skin which could cause him to itch himself. LPN-A stated nail care should be completed as long, potentially soiled nails, could cause an infection control issue and for R6's overall cleanliness. When interviewed on 9/6/21, at 11:36 a.m. the assistant director of nursing (ADON) stated she was aware R6's nail care had been found not completed by the survey team and voiced the NA(s) should be offering such care on the resident's scheduled bath day. ADON expressed she was not certain where the break down was which caused this to get missed or overlooked. ADON stated it was important to ensure nail care was provided for infection control clearly as long, soiled nails could cause a skin infection if R6 scratched himself. R41's significant change of status MDS dated [DATE], was scored a 99, which indicated the staff were unable to complete the cognitive status assessment, however, the admission MDS of 5/1/21 indicated R41 had severe cognitive impairment. The MDS of 7/26/21, indicated R41 required extensive assistance with personal grooming, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's care plan, with a start date of 4/27/21, which was reviewed/revised 8/17/21, indicated R41 was dependent on staff for grooming, and indicated, Staff to provide assistance with washing and nail care as resident allows d/t (due to) hand pain and prefers[sic]. The careplan goal indicated The resident will maintain ability to participate ability to participate in grooming choices. R41's careplan, revised on 9/16/21, indicated R41 was at risk for altered comfort in arm and hand pain. R41's goal statement of that date indicated, Resident's pain management goal is: ____ with no identified goal outlined, and the blank space left empty. Staff were directed to: Monitor for level of pain; Medicate per orders; and notify MD/NP (Medical Doctor/Nurse Practioner) if pain is not adequately managed with current interventions. The care plan additionally identified the following non-pharmacological interventions: Offer positioning, warm blanket, ice pack, warm pack, emotional support, toileting, fluids, snack, activity, music, TV show, movie as indicated for distraction. Additionally the care plan indicated staff were to administer pain medication as ordered. The Group 5 work list for the nursing assistants, printed on 9/15/21, identified R41 received his bath on Tuesday evening. The work list did not specify who was to complete nail care for R41. On 9/14/21, at 4:41 p.m. R41 was observed in the dining room, R41's fingernails were long, extending beyond his fingertips, with the edges of some nails jagged and uneven with brown/black debris under them. On 9/15/21, at 3:54 p.m. R41 was observed sitting in his reclining chair in the commons area. Although the care sheet identified R41 received his bath routinely on Tuesday evenings, (9/14/21), R41 was observed to have his fingernails extending beyond his fingertips, with jagged edges observed and brown/black debris present under the nails. A review of the Observation Detail List Report dated 8/31/21, completed by licensed practical nurse (LPN)-C, indicated, Unable to cut nails d/t (due to) pain in fingernails and toenails. The documentation lacked any further follow up or interventions related to this. Observation Detail List Reports from 8/10/21, 8/17/21, 8/24/21, and 9/14/21, were reviewed and were noted to have been completed by LPN-C, and lacked documentation to reflect nail care was provided. Additionally, the documentation lacked the reason nail care was not completed, for example related to pain or because of R41's preference, and failed to identify assessments or interventions implemented to address this. The Observation Detail List Report of 8/3/21, completed by registered nurse (RN)-A indicated R41 had no complaints of pain, except to right hand when touched. RN-A indicated resident did not wish to receive any extra pain meds at that time. The Observation Detail List Report, under the section of Skin, specifically directed staff, Observe resident nails and provide nail care as indicated. On 9/15/21, at 3:59 p.m. after having reviewed R41's documentation, LPN-C stated they had not trimmed R41's fingernails or toenails with his bath last evening. LPN-C went on to state they, personally, had never trimmed R41's nails, however, stated they were aware R41 was resistive at times. After viewing R41's nails, LPN-C described R41's nails as being long and dirty. LPN-C stated this was of concern due to the potential for the dirtiness of the nails, and the potential for infections when he scratched himself. Additionally, LPN-C identified R41 fed himself finger foods and this was not very sanitary. LPN-C stated the nurse practitioner should have been consulted at that time regarding possible interventions with pain management or to review other ideas to perform nail care. LPN-C stated she was now planning on placing a resident concern form for the NP. On 9/16/21, at 11:33 a.m., LPN-A stated it was difficult to communicate with R41 at times, and R41 had become angry at times with others touching his right hand due to complaints of pain. LPN-A stated if R41 had refused to have nail care performed, staff should have continued to approach at a later time. If the staff was unable to complete cares, this was to be passed on to the upcoming shifts via the 24 hour board in report. LPN-A stated even if the nails were not trimmed, R41's nails should have been cleaned and should appear free from debris. LPN-A stated lack of completion of routine nail care was an infection control concern, as R41 was known to scratch himself. Additionally, LPN stated it would be a dignity issue due to the appearance of nails. On 9/16/21, at 1:57 p.m. the assistant director of nursing (ADON) identified it was a personal choice of R41 if he did not wish to have his nails cleaned and trimmed, however, if it was because of pain, it would be important to try to determine the cause of pain and implement interventions appropriately. Additionally, the ADON stated a message should have been left for the NP to evaluate and review what was occurring, what interventions were currently in place, and assess the effectiveness of the interventions. This review should have included a review of medications, as well as non-pharmaceutical interventions as well. ADON stated if R41 was experiencing pain with provision of nail care she would have anticipated follow through to evaluate interventions. A provided Bathing: Shower or Tub Bath policy, dated 12/2019, identified each resident would be provided a, at least, weekly bath or shower. The policy directed, Trim finger and toenails as needed.

Based on interview and document review, the facility failed to ensure repeated episodes of constipation were comprehensively assessed and interventions developed to provide comfort and reduce the risk of complication for 1 of 1 resident (R6) reviewed for their bowel management. Findings include: R6's admission Minimum Data Set (MDS), dated [DATE], identified R6 had severe cognitive impairment and required extensive assistance with toilet use. Further, the MDS recorded R6 as having constipation. R6's most recent Quarterly Nursing Observation, dated 9/9/21, identified a section labeled, BOWEL and BLADDER, which outlined there had been no changes to [R6's] bowel or bladder related needs since the last comprehensive observation, and recorded R6's current bowel toileting plan as effective. Further, the assessment included a question which read, Indicate any changes from the last comprehensive bowel and bladder observation . which was answered only with, scp [see care plan]. The completed assessment lacked any evidence or dictation which identified R6 to have constipation or subsequent issue(s) with his bowels despite his most recent MDS recording him as having constipation. Further, R6's care plan, revised 9/9/21, identified R6 as being frequently incontinent of bowel and bladder along with his specific toileting plan. However, the care plan lacked any specific outlined problem statement or interventions to address R6's constipation despite being marked as present on his MDS completed 6/14/21. On 9/15/21, at 10:25 a.m. R6 was seated in a wheelchair by the dining room and voiced he had a gut ache. R6 was questioned on his bowels and expressed they were not too good which he described as usual. Further, R6 stated he would be open to more intervention to help promote more regular bowel movements. R6's Search Vitals Results, dated 8/16/21 to 9/16/21, identified R6's recorded bowel movements (BM) in his EMR completed every shift. This identified R6 had no BM(s) recorded on 8/16/21 or 8/17/21; however, had large-sized BM(s) recorded on 8/18/21 and 8/19/21. There were no further BM(s) recorded until 8/21/21 (two days later); and then R6 was identified as having no further BM(s) recorded until 8/26/21 (five days later). The next BM(s) for R6 were recorded on 8/29/21 (three days later), 9/1/21 (three days later), and 9/3/21 (two days later). However, R6 then had no recorded BM(s) until 9/7/21 (four days later), and then 9/10/21 (three days later). R6 then was recorded as going from 9/11/21 to 9/14/21 (three days) without a BM. The remainder of days and shift entries all recorded, None, to indicate there was no BM had by R6. R6's corresponding progress note(s), dated 8/15/21 to 9/15/21, identified the following: On 8/25/21, R6 was recorded as being constipated. The note outlined, Prune juice and Senna plus [a stool softener with [MEDICATION(S)]] given per orders . No results noted as of yet, will pass information onto oncoming staff. A corresponding physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/28/21 (four days later), R6 was recorded as having constipation. The note outlined prune juice was given with no results as of the note being completed. On 9/1/21 (four days later), R6 was recorded as having constipation. The note outlined prune juice was given with no results as of the note being completed. On 9/6/21 (five days later), R6 was record as having constipation. The note outlined prune juice was given with no results as of the note being completed. On 9/10/21 (four days later), R6 was recorded as having constipation. The note outlined prune juice was given with no results as of the note being completed. Further, on 9/15/21 (five days later), R6 was again record as having constipation. R6 was given prune juice and Senna Plus; however, there were no results as of the note being completed. R6's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's subsequent MAR, dated September 2021, identified R6 had an order entered for, Bran 30 ml [by mouth] daily, on 9/2/21; however, this was recorded as being refused by R6 for several doses including on 9/2/21, 9/10/21, 9/13/21. R6 continued to receive the physician-ordered two Senna S 8.6 mg tablets twice a day, along with multiple recorded administrations of the as-needed one additional Senna S tablet (in addition to the scheduled doses) being given on 9/2/21, and 9/15/21. On 9/15/21, at 10:36 a.m. nursing assistant (NA)-A was interviewed. NA-A explained R6 was typically continent of his bowels and able to verbalize a need to defecate to staff. NA-A stated she had noticed R6 doesn't go [have a BM] very often and added she felt R6's stool appeared formed and normal; however, there was just never large amounts of it. NA-A expressed R6's poor cognition potentially caused him to just not understand he was supposed to push while seated on the toilet to have an adequate bowel movement, and she reiterated R6 appeared on their daily bowel list (used to communicate who's gone several days without a bowel movement) pretty regularly. R6's medical record was reviewed and lacked evidence R6's bowel management had been comprehensively reassessed to ensure efficacy and no further intervention was needed for his bowel management despite adjusting his bowel-related medication regimen on 8/25/21, and repeated progress note(s) outlining R6 as having ongoing constipation issues, at times requiring dietary and/or pharmaceutical intervention, and his recorded BM(s) routinely demonstrating several days in between bowel movements. When interviewed on 9/15/21, at 1:35 p.m. licensed practical nurse (LPN)-B explained a [MEDICATION(S)] sheet was printed every morning which outlined residents' who are various days without having a bowel movement; then based off the list and days gone past, various interventions from their standing orders, such as prune juice or Senna, could be given to them. LPN-B stated she had noticed R6's name had been on my list more lately and explained if the floor staff noticed any concerns with ongoing constipation, a nursing concern could be developed and placed in the mailbox for the nurse practitioner (NP) to address. At approximately 1:40 p.m. R6's hospice nurse (RN)-D joined the interview. LPN-B reviewed R6's recorded progress notes and bowel movements and herself and RN-D expressed R6 could likely be reviewed to see if more intervention, such as a daily prune juice serving and not just as-needed, could be given. On 9/15/21, at 2:29 p.m. licensed practical nurse manager (LPN)-A was interviewed. LPN-A explained a resident's bowel function and management program was assessed by the nurse on the floor and if concerns were being noticed, then they should place a nursing concern to the NP to have it addressed. LPN-A explained R6 had an as-needed dosing of Senna added to his regimen on 8/25/21, to help address his constipation; however, she acknowledged the medical record lacked evidence R6's bowel management program, including his medication use and continued documented episodes of constipation since then, had been re-assessed since to ensure the intervention was effective and more was not needed adding, It makes sense [to assess him]. Further, LPN-A stated it was important to assess a resident's bowel management program to help ensure the resident's needs are balanced and to reduce the risk of impaction or ileus (the inability of the intestine to contract normally and move waste out of the body). When interviewed on 9/6/21, at 11:36 a.m. the assistant director of nursing (ADON) stated a resident' bowel function is monitored through daily bowel reports which then directs the staff to implement an intervention (i.e., prune juice) if they have gone three or more days since having a recorded BM. ADON explained a comprehensive bowel assessment would include a review of the resident's abdomen for distention along with listening to their bowel sounds; and added doing this process would help the staff know then interventions had been effective. The ADON expressed if concerns with a resident's bowel management were noted, then a nursing concern could be completed for the physician to address. Further, ADON stated she felt the facility had policies and procedures in place to address constipation; however, added a more person centered approach could have been reviewed and assessed for R6. A provided Bowel Management Program policy, dated 2/2020, identified all residents would be monitored for bowel movements each shift and any bowel movements would be recorded in the EMR. The policy continued, Nursing staff will monitor for lack of bowel movements using the bowel management report . This will help identify resident who may be having small bowel movements daily and may need to be evaluated. Further, the policy outlined, For residents with chronic constipation, update provider as indicated for potential changes in medication and work with dietician to develop appropriate nutritional interventions for constipation.

Based on observation, interview, and document review, the facility failed to ensure recommended dental services were provided for 1 of 1 residents (R22) who required follow up visits for dental. Findings include: R22's admission Minimum Data Set (MDS) dated [DATE], identified R22 was cognitively intact, had mouth or facial pain and discomfort and difficulty with chewing. R22's MDS 3.0 Oral/Dental Assessment Form of 1/27/21 identified R22 had none of the following present; broken or loosely fitted full or partial denture, no natural teeth or tooth fragment, abnormal mouth tissue, obvious or likely cavity or broken natural teeth, inflamed or bleeding gums, mouth or facial pain, or discomfort or difficulty with chewing. Additionally, R22's Assessment Notes indicated denture was old and worn, but stable and functional. The recommendation at this time was for follow up to be done at the facility. A review of the Chart Progress Notes, Apple Tree [NAME] Rapids, dated 6/30/21 indicated R22 was seen for a limited oral evaluation which was problem focused. R22 was seen for extraction of a erupted tooth requiring removal of bone and/or sectioning of tooth. A subsequent Chart Progress Notes, Apple Tree [NAME] Rapids, dated 8/17/21, indicated R22 was seen for a comprehensive oral evaluation with radiographic exam (x-rays). At this time, findings included dental caries (cavities), with extensive caries under #30. The recommendation was made for conservative treatment on the lower jaw line (dental fillings), with the possibility of need for extraction and a partial on the lower jaw. An additional recommendation was made for a new, full, upper denture. A review of Resident Progress Notes, dated 9/11/21 identified R22 had a crown from the right lower jaw in the back which had fallen off. R22 stated the remaining tooth was sensitive but not painful. The note identified a note was left for medical records to follow up on Monday (9/13/21). The document lacked any further A document titled Apple Tree Dental, Dental Concern Information, dated 9/13/21 indicated staff were advised R22 had lost a crown over the weekend. The document indicated the pain R22 was experiencing was described as aching. On 9/13/21, at 8:58 a.m. R22 stated, When the dentist comes to the facility, they (the dentist) do x-rays and exams, and they tell you the need, but the work doesn't get done, I need my plate fixed. It's gotten worn down, and it's difficult to chew. R22 stated she had been seen in August and a treatment plan was developed, however, no appointment has been scheduled. R22 stated the crown, which had been identified as having decay and needing restoration, has now broken off. R22 stated the dentist had discussed the possibility of using that tooth to anchor her lower partials if they were needed, and now will be unable to do so. On 9/16/21, at 10:50 a.m. health unit coordinator (HUC)-A reviewed documentation from 8/17/21 and stated recommendations were made by AppleTree Referrals with this visit. Upon receipt of the documentation, this information was referred to health information (HI)-A. HI-A was responsible to coordinate services as needed. If HI-A was unable to complete the coordination, the task was delegated to HUC-A, who then completed the task. HUC-A stated after recommendations were made, the staff (HI/HUC) conferred with the resident/responsible part to determine if they wished to go outside of the facility to complete treatment, or wait until AppleTree returned to the facility. HUC-A stated R22 was able to make decisions independently regarding treatment so had she been assigned, she would have coordinated follow up appointment as directed by R22. HUC-A stated this coordination of both the dental visit, transportation, and coordination of record submission may take a couple of days, to a week or longer. Upon review of the dates, HUC-A felt this coordination would have been scheduled by the end of August, even if unable to get in immediately. HUC-A stated she had received the notification regarding the broken crown, however, had not yet addressed it as had not been in on 9/13/21 and was unaware of follow up by HI-A. HUC-A stated it was important to follow up on dental recommendations as there was the potential for food to get caught within the decayed areas. HUC-A stated there was the potential for infection, pain, and headaches if the residents did not have follow up in a timely manner. HUC-A stated AppleTree provided all visit notes to medical records, and these records are uploaded to the electronic chart. HUC-A was unsure as to who reviewed the visit notes. On 9/16/21, at 11:44 a.m. licensed practical nurse (LPN)-A/Unit Coordinator stated medical records reviewed the progress notes from the dental visits and they then route to nursing/HI/or HUC as indicated. LPN-A stated AppleTree generally coordinated follow up and assumed upon review of the notes, AppleTree would have been contacted by HI/HUC. LPN-A did review the documentation regarding R22's loss of a crown, however, did not find any follow up documented either for the recommendations of 8/17/21, or 9/11/21. LPN-A stated when dental recommendations were not followed up on, there was the potential for things to get worse, adding there could be the potential for a significantly larger cavity, pain, and potential abscess. LPN-A stated R22 was cognitively able to determine the follow up desired and identified staff should consult with her to see what was desired. On 9/16/21, and 2:05 p.m. the assistant director of nursing (ADON) stated that she was aware the information was provided to medical records following the visits with the AppleTree Dental. The ADON stated the orders were to be transcribed and appointments coordinated as identified. ADON stated if appointments and recommendations were not followed there there would be potential for pain, and identified staff was to monitor for pain and make sure follow up appointments are made as recommended. A facility policy, Dental Services, dated 5/23/19, identified the facility was responsible for assisting resident/representative in making dental appointments and arranging transportation to and from dentistry as necessary. Additionally, the policy identified a referral was to be made within 3 days for residents who had dentures who were lost or broken during their stay. The policy indicated if a referral was not made within 3 days, there was to be documentation in the resident record to identify what interventions were put into place to ensure the resident could still eat and drink adequately while awaiting dental service. The policy lacked direction as to follow through for other dental concerns, such as loss of tooth, filling, or crowns.

Based on observation, interview and document review, the facility failed to implement preventative admission droplet precautions for COVID-19 upon admission for 3 of 3 residents (R1, R2 and R3) who recently admitted . This had the potential to affect all residents currently residing in the facility during the COVID-19 Focused Infection Control Survey. Findings include: A facility provided Admit/Discharge Report, dated 7/7/20 - 8/7/20, identified three new admissions in the past 14 days still residing in the facility at the time of the COVID-19 Focused survey: a new admission (R3) admitted on [DATE]; (R1) admitted on [DATE]; (R2) admitted on [DATE]. During observations on 8/6/20, from 2:10 p.m. to 2:19 p.m. there had been a lack of indication on the outside of the room doors for R1, R2, and R3 which alerted staff that these residents were on 14 day admission droplet precautions i.e., no transmission based precaution signs or personal protective equipment (PPE) supplies/bins outside of the residents' rooms. A sign outside of these three rooms indicated, All entering room will wear a face shield and mask. When resident is out of their room, they need to wear a surgical mask until (date). R1 and R3s' identified date was 8/15/20 and R3's was 8/19/20. R3's entry tracking Minimum Data Set ((MDS) dated [DATE] identified R3 had been admitted to the facility on [DATE]. R3's progress notes from 7/31/20 through 8/6/20, confirmed his admitted on 7/31/20, following left retromastoid craniotomy for a tumor resection. Further, the progress notes identified R3 required physical assistance with activities of daily living (ADL) with a specific note on 7/31/20 at 3:00 p.m. which indicated he had been alert and oriented x4; however, a progress note dated 8/4/20, at 3:43 p.m. indicated he scored 11/15 on his BIMS (Brief Interview for Mental Status) which suggested his cognition had been moderately impaired at the time The progress notes failed to indicate R3 had been placed on COVID-19 transmission based precautions with admission. R3's medical record did not identify he was experiencing any COVID-19 symptoms. -R3's preadmission screening identified COVID-19 testing completed on 7/21/20; results were negative. -R3's Physician order [REDACTED]. -R3's care plan, dated 8/5/20, indicated he was at risk for signs/symptoms of COVID-19 with the following approaches listed: Follow facility protocol for COVID-19; Observe for signs/symptoms of COVID-19; Resident is able and willing to wear source control mask and has demonstrated the ability to don and doff that source control mask independently. The care plan failed to indicate R3 was on 14 day admission isolation precautions R1's entry tracking MDS dated [DATE] identified R1 was admitted to the facility on [DATE]. R1's progress notes from 8/1/20 through 8/6/20, confirmed his admission date of [DATE], following a urinary tract infection [MEDICAL CONDITION] and gastrointestinal (GI) bleed. Further, the progress notes identified R1 required physical assistance with ADLs upon admission; however, a progress note on 8/3/20, at 1:29 p.m. reported, Cleared by OT to be independent with toileting, SBA (stand by assist) cares and ADLs. Another progress note dated 8/5/20, at 3:59 p.m. identified R1 had a BIMS (Brief Interview for Mental Status) of 15/15. This score suggested R1 had intact cognition at the time. The progress notes failed to indicate R1 had been placed on COVID-19 transmission based precautions with admission. R1's medical record did not identify he was experiencing any COVID-19 symptoms. -R1's preadmission screening identified COVID-19 testing completed on 7/21/20 and 7/23/20; results were both negative. -R1's Physician Order's listed admission orders [REDACTED]. -R1's care plan, dated 8/6/20, indicated R1 was at risk for signs/symptoms of COVID-19 with the following approaches listed: Follow facility protocol for COVID-19; Observe for signs/symptoms of COVID-19; Resident is able and willing to wear source control mask and has demonstrated the ability to don and doff that source control mask independently. The care plan failed to indicate R1 was on 14 day admission isolation precautions R2's progress notes from 8/5/20 through 8/6/20, indicated he had been admitted on [DATE], following a non-displaced oblique [MEDICAL CONDITION] femur shaft. Further, the progress notes identified R2 required physical assistance with ADLs and that he had been alert and oriented without cognitive impairment. The progress notes failed to report R2 had been placed on COVID-19 transmission based precautions with admission. R2's medical record did not identify he was experiencing any COVID-19 symptoms. -R2's preadmission screening identified COVID-19 testing completed on 8/3/20; results were negative. -R2's Physician order [REDACTED]. -R2's care plan, dated 8/6/20, indicated R2 was at risk for signs/symptoms of COVID-19 with the following approaches listed: Follow facility protocol for COVID-19; Observe for signs/symptoms of COVID-19; Resident is able and willing to wear source control mask and has demonstrated the ability to don and doff that source control mask independently. The care plan failed to indicate R2 was on 14 day admission isolation precautions. 8/6/20, at 1:50 p.m. R3 stated he remained in his room most of the day; however, had participated with therapy in the therapy gym since admission. He verified other residents/patients had been in the therapy gym at the same time he had been. R3 explained he was able to come out of his room as long as he had a surgical mask on. R3 acknowledged the facility did not restrict him to his room. On 8/6/20, at 1: 59 p.m. after R1 was observed to be in the therapy gym; engaged in therapy, an OT assistant (OTA)-A verified that out of the three residents located in the therapy gym, that R1 was the only admission to have occurred in the past 14 days. OTA-A explained as long as the residents maintained social distancing, and had on a surgical mask, they were able to use the therapy gym at the same time. OTA-A further explained therapy staff were not required to wear gowns (PPE) at the time of therapy services, neither in the therapy gym or the resident room, unless the resident had confirmed or suspected COVID-19. OTA-A denied R1 was on transmission based precautions. During interview on 8/6/20, at 2:14 p.m. trained medication assistant (TMA)-A verbalized the facility did not currently have any residents on transmission based precautions, which included R1, R2, and R3. TMA-A stated admissions in the past 14 days were able to come out of their rooms; however, they were required to wear a surgical mask. When staff entered the rooms of R1, R2, and R3, the staff were required to wear only eye protection and surgical masks; gowns were not required. TMA-A explained gowns would only be required if the resident was on transmission based precautions for confirmed or symptomatic COVID-19. When interviewed on 8/6/20, at 2:19 p.m. nursing assistant (NA)-B stated new admissions were able to leave their rooms as long as they wore masks. Rooms for residents that have returned from the hospital have signs that staff were to wear masks and goggles. On 8/6/20, at 2:27 p.m. after the social services director (SSD) was observed to exit R1's room without a gown, she was interviewed and stated staff were not required to wear a gown unless the resident was on transmission based precautions; such as confirmed or symptomatic COVID-19. SSD explained that R1 had not been on transmission based precautions since admission and the only requirement for staff who entered R1's room was they had to wear goggles and a facemask, which she read from the sign outside of R1's room. She further explained that R1 was able to leave his room; however, he was required to wear a surgical mask at the time. When interviewed on 8/6/20, at 2: 39 p.m. NA-C stated R1, R2, and R3 had not been on transmission based precautions since admission and the only requirement when staff entered those three rooms was the staff had to wear goggles and a mask. If R1, R2, or R3 wanted to leave their rooms, the residents were required to wear masks also. NA-C explained the only times that gowns were required to be worn, were when the bins (PPE) were located outside of the resident rooms and there was a sign that indicated what type of precautions the resident was on. NA-C denied having had worn a gown when she had entered the rooms of R1, R2, or R3. When interviewed on 8/6/20, at 3:11 p.m. registered nurse (RN)-A voiced there was no residents currently on isolation precautions. Newly admitted residents and those that had left the facility for medical appointments were placed on transitional precautions which consisted of placing a sign on the residents door which informed the staff they were to wear a mask and goggles when they entered the room and the resident was to wear a mask when out of the room with a date that ended 14 days after admission or the appointment. A clipboard with a column to record the date and a column for the staff to sign that they had entered the room on that date to allow for identification of staff that may be potentially exposed to COVID-19. The residents were allowed to go to the therapy gym and out of their rooms as long as a mask was worn. Additionally, RN-stated the facility had not been having issues obtaining PPE and they had an excessive amount of gowns available for staff use. On 8/6/20, at 3:48 p.m. R2 was observed in the hallway sitting in his wheelchair about 6 feet from his room doorway. He had on a surgical mask which covered his mouth but which did not cover his nose. During interview on 8/6/20, at 3:56 p.m. with director of nursing (DON) and administrator they voiced new admissions were placed on transitional precautions for 14 days, if they developed symptoms of COVID-19 they would be placed on additional precautions at that time. New admissions were to eat meals in their rooms but were able to leave their rooms and go to therapy with other residents as long as masks were worn. One resident who received a nebulized treatment (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) when receiving the treatment only, no other resident in the facility was on isolation precautions. Administrator further voiced that new admissions needing to be quarantined was not in Minnesota Department of Health (MDH). The state agency (SA) COVID-19 Toolkit: Information for Long-Term Care Facilities, dated 6/5/20, identified Isolate and restrict incoming residents discharged from hospitals, or other facilities, to their room for 14 days and Residents could be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after admission/readmission. Further, the CDC defines quarantine as the separation of people who may have been exposed to a contagious disease. With coronavirus, the recommended period to self-quarantine is 14 days.

Based on observation, interview and document review the facility failed to ensure all staff entering the facility were being actively screened (other facility staff performing the screening process) in an appropriate location (an area located before entering resident care areas) for the prevention and potential transmission of COVID-19. In addition, the facility failed to ensure all staff utilized commercial and/or handmade face masks appropriately (mask covering both mouth and nose) for the purpose of source control (reduce the likelihood of transmitting COVID-19). This had the potential to affect all 58 residents currently residing in the facility at the time of the COVID-19 focused survey. Findings include: SCREENING: On 4/21/20, at 10:35 a.m. the survey team entered the facility via the building's locked main entrance. Surveyors completed a COVID-19 symptom and screening questionnaire, reviewed by a facility' employee after. A facility employee took temperatures, assured eye protection and masks were in place, and hand hygiene was performed before allowing surveyors entrance to the facility. During the entrance conference on 4/21/20, at 10:45 a.m. the director of nursing (DON) stated the facility did not have any presumptive or confirmed cases of COVID-19. During interview on 4/21/20, at 11:10 a.m. nursing assistant (NA)-C stated all employees enter through the back door employee entrance. Then they washed their hands put on their mask and face shield walked down the hallway t other nursing station. They then had to fill out a questionaire identifying if they had symptoms or not and get their temperature checked then they went to work. On 4/21/20, at 11:16 a.m. the employee entrance was observed. There was no staff seated at the door to screen staff upon entering the the facility. There were designated wash rooms for staff to complete hand hygiene along with a room to store individualized face shields and masks. The hallway to the nursing station passed the therapy room and one resident room. During interview on 4/21/20, at 11:20 a.m. the dietary manager (DM) stated all staff enter through the back employee entrance. They are to wash their hands then obtain their personal protective equipment (PPE). The the staff walk down the hallway to the nurses station to be screened for COVID-19 symptoms before going to work. There was not a designated staff person at the back door screening staff as they come to work. During interview on 4/21/20, at 11:34 a.m. housekeeping (HSKP)-A stated she entered the facility through the designated employee entrance and would proceed to the nurses station to fill out a COVID-19 screening questionnaire. If she were to answer yes to any of the screening questions, she could not work. When interviewed on 4/21/20, at 11:50 a.m. NA-B stated she took her own temperature on 4/21/20, at the nurses station and filled out the COVID-19 screening form before beginning work. If she were to answer yes to any of the screening questions she would alert the night nurse and she could not work. During interview on 4/21/20, at 12:22 a.m. dietary aide (DA)-A stated she took her own temperature on 4/21/20, at the nurses station and filled out the COVID-19 screening form before beginning work. Further, DA-A stated another staff was not actively involved in screening for COVID-19 symptoms. On 4/21/20, at 1:35 a.m. the facility infection control preventionist (ICP) was interviewed and stated all staff entered through the back door and completed hand hygiene, grabbed their mask and face shield and went to the nursing station to be screened for COVID-19 symptoms. Active screening of facility staff included washing hands, getting PPE, having their temperature checked, filling out the COVID-19 screening questionnaire, and whoever is screening them should be watching for issues. ICP stated she checked her own temperature on 4/21/20, with no one present to confirm she did not have any COVID-19 symptoms. Furthermore, the facility was trusting staff to check their temperature, fill out the questionnaire accurately, and the screening process should be completed where there would be the least amount of contact with resident care areas. The facility policy COVID-19 Phase 2- All SNF and all CO sites, dated 4/13/20, identified healthcare workers will complete a symptom screening form, including having their temperature checked and documenting absence of shortness of breath, new or change in cough, and sore throat, upon entrance to the facility. Healthcare workers include: facility employees, hospice workers, physicians, nurse practitioners, physician assistant, PT/OT/ST therapists that provide care to residents. These forms will be reviewed by a facility designee prior to reporting to the resident care area. Employees with respiratory symptoms such as fever, cough, shortness of breath, sore throat will not be allowed to work. The policy did not identify whom (self or other employee) was expected to conduct the employee screening, the location of employee screening, or temperature parameters for staff to follow. MASKS: On 4/21/20, at 11:24 a.m. nursing assistant (NA)-A was observed with a face mask on covering only their mouth, not nose, while interacting in the dining room with 4 residents present. NA-A stated the mask was supposed to be covering her nose and mouth but the eye protection made it foggy and she could not see. On 4/21/20, at 11:34 a.m. housekeeper (HSKG)-A was observed to have a surgical face mask on covering only their mouth, not nose, while cleaning a resident room. HSKG-A stated the mask was supposed to be covering her nose and mouth but with the mask and the face shield she had a harder time breathing. During observation on 4/21/20, at 11: 46 HSKG-A continued to have her mask on covering mouth only, not nose. On 4/21/20, at 12:08 p.m. activity aid (A)-A was walking down the hallway in resident care areas with their face mask covering their mouth only, exposing their nose. A-A had a face shield on covering their face. A-A stated she was supposed to have the mask up over their nose, but with the face shield on it made it hard to breath. On 4/21/20, at 12:10 p.m. dietary aide (DA)-A was observed with a face mask on covering only their mouth, not nose, while delivering food to residents in the dining room (15 residents noted during observation). DA-A stated the mask was supposed to be covering their nose and mouth but with the eye protection it fogged up and she had a harder time seeing. On 4/21/20, at 12:22 p.m. DA-B was observed with a face mask on covering only their mouth, not nose, while walking past residents sitting in dining room. DA-B stated she was supposed to have the mask up over their nose. On 4/21/20, at 12:21 p.m. NA-C was seated next to a resident in the dining room supervising the resident eat. NA-C had their facemask off their nose, only covering their mouth. The face shield was covering their face. NA-A stated the mask frequently slid off their nose while talking. On 4/21/20, at 1:35 p.m. the facility ICP was interviewed and stated all staff are required to have the mask covering both the mouth and the nose at all times. ICP further stated they can remove this only when not in direct care areas and they should be alerting the appropriate staff if they are having issues with the mask. The facility policy COVID-19 Phase 2- All SNF and all CO sites, dated 4/13/20, identified: To provide source control, all employees will wear a mask at all times. Direct care staff including housekeepers will wear a surgical mask. Non-direct care staff can wear non-FDA regulated masks.

Based on observation, interview and record review, the facility failed to ensure residents with complicated feeding problems and swallowing difficulties received safe and appropriate assistance with eating which placed them at risk of serious harm, injury or death for 3 of 6 residents (R100, R7 and R49) in the sample who were fed by a paid feeding assistant and had not been assessed by a registered nurse. In addition to the residents in the immediate jeopardy, the facility failed to ensure 3 of 6 residents (R17, R42 and R29) had been assessed by a registered nurse to be safely fed by a paid feeding assistant. Further more, the facility failed to use a state approved paid feeding assistant training program when training their paid feeding assistants. The immediate jeopardy began on 10/19/11 at 2:00 p.m. when the facility failed to ensure that 3 of 3 residents (R100, R7 and R49) who had identified complicated feeding patterns received safe and appropriate assistance with eating that had the potential to result in serious harm. The facilities Administrator, director of nursing (DON) and the facility corporate quality assurance Registered Nurse (QARN)-E were notified of the immediate jeopardy at 2:00 p.m. on 10/19/11. The immediate jeopardy was removed on 10/20/11 at 8:41 a.m. when the facility discontinued their paid feeding assistant program and ensured only nurses and nurse aides were assisting residents to eat. The non-compliance remained at a reduced scope of severity of no actual harm with potential for more than minimal harm at a scope with a pattern. Findings include: Resident 100 (R100) had complicated feeding problems and was fed by a paid feeding assistant. During observation of the evening meal on 10/17/11 from 5:05 to 5:35 p.m. the therapeutic recreation assistant (TR)-A was observed feeding R100. R100's meal consisted of ground chicken tenders, potato salad, chunk style pears, orange juice, milk and water. TR-A used a regular tablespoon which was heaped with food while she fed R100. R100 did not swallow each bite before she would open her mouth for another bite as TR-A brought the spoon toward her mouth. R100 only swallowed every 2-3 bites. Each time R100 opened her mouth food to receive additional food, food was visible on her tongue toward the right side of her mouth. TR-A asked R100 at 5:21 p.m. if she felt alright and commented to R100 that she was not her usual "bubbly self." TR-A offered fluids every 3-5 bites of food. At 5:27 p.m. R100 asked for a drink and was given milk. At 5:28 a large bite of potato salad was given and a large amount of food had remained in her mouth from the previous bite, which she had not swallowed. R100 stated, " I am really tired" with visible food in her mouth and began to cough. R100 stated, "Oh, God!" and was wheezing with each breath as she continued to cough. At 5:30 p.m. R100 took a drink of milk and a deep breath. At 5:31 p.m. TR-A got a tissue to wipe R100's nose which was running after her coughing episode. During interview on 10/17/11 at 5:35 p.m. TR-A stated she has fed R100 a few times a week for the past few months. TR-A stated R100 was often sleepy and coughs while she eats, but today R100 was having more problems with her coughing while eating. TR-A confirmed she had not reported R100 coughing concerns to the nursing staff. TR-A identified herself as currently working in therapeutic recreation, but was also a nurses aide. During interview with assistant director of nursing (ADON)-C on 10/17/11 at 5:36 p.m. she stated TR-A was a nursing assistant as well as therapeutic recreation. ADON-C was informed of the difficulties R100 had with eating, keeping food in her mouth between bites, not swallowing with each bite and large bites being fed to her as well as her coughing episode. She stated R100 was actually on a different unit and just came to her unit to be fed. ADON-C stated no one had reported R100 was having any swallowing problems before, but would check with the ADON on that unit. During observation of the breakfast meal at 8:14 a.m. on 10/18/11, R100 was assisted by TR-B. R100 had her eyes closed and TR-B had to frequently wake R100 by touching her while being fed. At 8:15 a.m. TR-B brought a glass of juice to R100's lips and R100 would not open her mouth. At 8:16 a.m. R100 opened her mouth, drank a sip of orange juice, with her eyes closed, and she immediately started coughing. TR-B kept telling R100 to wake up and would put the juice up to her lips even though R100 appeared to be sleeping. R100 kept her eyes closed but took a bite of cereal when brought to her lips and swallowed. R100 was given another bite of cereal but moved this around in her mouth with her tongue before swallowing. At 8:18 R100 took another bite of cereal and at 8:21a.m. R100 had her eyes closed and appeared to be sleeping. TR-B was interviewed at that time and stated she worked in activities and was not a nursing assistant but had received paid feeding assistant training. She stated she had fed R100 twice a week for the past few months, usually has her eyes closed, and was always sleepy. TR-B stated she was not aware of any precautions R100 had for eating. At 8:22 a.m. R100 was ate cereal and took two sips of milk. R100 then ate a piece of a hard boiled egg, moved it around in her mouth while her mouth was still open. She then started coughing harshly, with egg pieces falling out of her mouth. At 8:26 a.m. R100 was given a bite of cereal and immediately started coughing. R100 stated "Oh, God," and continue to cough. At 8:28 a.m. the surveyor stopped ADON-A and ADON-C in the hall outside of the dining room and informed them of R100 coughing. ADON-C entered dining room to check on R100. During interview with ADON-A on 10/18/11 at 8:29 a.m. she stated no one had reported R100 had difficulty swallowing. She stated TR-B was not a nurse aide, but had received training to assist residents to eat. She further stated the dietary and therapeutic recreation staff have been trained to assist residents to eat and any resident can be fed by the paid feeding assistants who have been trained. ADON-A continued to state they do not do any assessment to determine which residents are safe to be fed by a paid feeding assistant (PFA). At 8:30 a.m. ADON-C also stated they did not complete any assessments to determine which residents could be fed by a PFA. During interview at 8:55 a.m. on 10/18/11 TR-B stated she has been feeding R100, R29, R42 and R49 for a month or more. She was not aware if any of these residents needed a special swallowing program, and there were no restrictions on any of the residents she fed. TR-B stated R100 always coughs, was sleepy and closed her eyes while being fed. TR-B stated she had not reported R100 coughing to a nurse as this was not an unusual behavior. R100 had [DIAGNOSES REDACTED]. Her quarterly Minimum Data Set ((MDS) dated [DATE] indicated she had long and short term memory problems, was totally dependent upon staff for eating and had no signs of swallowing disorders. R100's plan of care dated 8/5/11 included she required ground meat and pocketed food. R100's dietary card also did not have any special feeding instructions other than a "nosey cup" which was not used during the meal observations on 10/17/11 and 10/18/11. R100 had a "Pro Rehab Nursing Referral for therapy screen" dated 1/2/11 indicating she was pocketing food. The Progress Notes-Speech dated 1/4/11 indicated R100 "did occasionally have some residue of the bites of solid food she was offered." No formal evaluations of R100 swallowing difficulty had been completed at that time. R100 had a speech therapy evaluation on 4/14/11 due to " holding food in her mouth " and the [DIAGNOSES REDACTED]. Her diet was changed to ground meat. The speech therapist made the following recommendations, "Constant supervision, assist or encourage sitting upright 90 degrees and midline while dining, assist or encourage taking small bites/sips while dining, assist or encourage frequently alternating solids and liquids textures while dining, spend less than 60, more than 15 minutes feeding this person at mealtimes, never offer another bite/sip until the previous bite/sip has been swallowed-even if that means only one bite/sip per meal, cut large pieces into smaller, bite-sized pieces, check for pocketed food, encourage to "clear and swallow again." Do not move out of upright, 90 degrees and midline for at least 30 minutes after dining." These recommendations were not added to R100's plan of care until 10/18/11, when questioned by the surveyor, over 6 months after the SLP recommendations. During interview on 10/20/11 at 2:00 p.m. ADON-C stated R100 had been on her unit in April 2011, but she had never seen the recommendations the speech therapist had made until today. She was unable to find a communication to nursing staff regarding the speech therapists recommendations. Normally, a form would have been filled out with the recommendations and routed to her, but this had not happened. The recommendations were only given to the nurse practitioner and then filed. R100's progress notes contained the following entries: 1/20/11 "Resident receives and tolerates a regular diet...no problems noted chewing/swallowing." 2/9/11 "coughing more especially after lunch..." 4/11/11 "sandwich with ground meat served at supper. Pocketing bites of food. Frequent verbal cues needed to swallow food." 5/5/11 "...receives and tolerates a ground meat diet...no problems noted chewing/swallowing." 6/24/11 "NAR (nursing assistant registered) reported that she had difficulty chewing and swallowing at supper this shift." There was no assessment in the record by a registered nurse (RN) to determine if R100 could be safely fed by a PFA. R100 was evaluated by speech language pathologist (SLP)-D during the survey on 10/19/11. The SLP evaluation/treatment note dated 10/19/11 indicted [DIAGNOSES REDACTED]. to eat that meal safely." Further recommendations were identical to those listed on the 4/14/11 evaluation. Although R100 was identified by the Speech Language Pathologist (SLP) with dysphasia, had a complicated feeding program, and pocketed food. R100 was being fed by a PFA. Furthermore, an assessment had not been completed by an RN to determine if R100 could be safely fed by a paid feeding assistant. R7 was identified as a resident to be fed by a PFA even though R7 had [DIAGNOSES REDACTED]. R7 's minimum data set ((MDS) dated [DATE] identified R7 had memory problems, and was on a therapeutic diet. The current care plan dated 10/07/11 indicated R7 needs assist with eating, and directed staff to keep resident at 90 degree angle for 30min after meals, encourage multiple swallows of solid foods, and to alternate solids and liquids. The physician orders [REDACTED]. (DX: Pneumonitis d/t food/vomit inhal-Aspiration Pneumonia)." On 10/18/11 at 11:55 a.m., R7 was observed to be fed by dietary aide (DA)-A who was a PFA without any difficulties. The DA-A stated she did not have any difficulty assisting R7 with eating, fed her twice a week and was not aware of any special feeding precautions. DA-A stated she had to keep talking to R7 to keep her awake because R7 had difficulty staying awake while being fed. During interview on 10-18-11 at 1:45 p.m. with DA-C she stated she took the training to feed residents about 6 years ago and she currently assists with feeding in the main dining room about 1-2 times a week. She stated she usually feeds R7 and was not aware of any special instruction for feeding and if the resident had special feeding instructions it would be listed on the dietary card on the residents meal tray. R7's meal card indicated she needed a lip plate, weighted utensil and a sippy cup. The meal card did not indicate any special feeding techniques. Review of the record indicated R7 was hosptalized on [DATE] with [DIAGNOSES REDACTED]. The discharge summary dated 4/09/10 indicated R7 had aspiration pneumonia with "...diabetic diet, 1800 kilocalorie pureed with nectar liquids." The summary also indicated no acute stroke and was seen by speech therapy who recommended pureed foods, nectar thickened liquids and continue speech therapy at the nursing home. R7 was seen by speech therapy on 4/20/10 for aspiration pneumonia, altered mental status with dysphasia. The speech therapist indicated "Nursing staff and/or family might wish to attempt to provide this swallow-relevant structure: constant supervision (in physical presence of the client) while dining. Assist or encourage sitting upright 90 degrees, and midline while dining. During meal: assist or encourage taking small bites/sips while dining. Assist or encourage frequently alternating solids and liquids textures while dining. After meal: Do not move out of sitting upright, 90 degrees, and midline for at least 30 minutes after dining." Also, there was no assessment completed by the registered nurse (RN), to determine if R7 could be fed by a PFA. Review of R7's physician orders [REDACTED]. There was no indication why the diet was change from pureed to a mechanical soft. On 10/20/11 at 1:30 p.m., RN-A stated R7's diet was changed to a regular diet on 10/28/10 but was unsure why the diet changed. No additional information was provided regarding the diet change. During interview 10/19/11 at 10:34 a.m., the speech language pathologist (SLP) stated the recommendations he made 4/20/2010 should be followed by staff unless the facility had made a new referral to speech. The SLP confirmed the facility has not made any referrals for R7 since he last saw her on 4/20/10. Even though R7 was identified at risk for aspiration and SLP had a complicated feeding program, R7 was fed by a PFA. Furthermore, an assessment had not been completed by the RN to determine if R7 could be safely fed by PFA. R49 had complicated feeding problems and was identified by the facility as being fed by a paid feeding assistant. R49 [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] identified R49 was rarely understood, had short and long term memory problems, a one person limited assist with eating, and had no swallowing problems. R49 was observed on 10-17-11 at 5:18 p.m. in the west dining room being fed by RN-C. R49 appeared very sleepy and had to be prompted several times to "wake up and eat." No swallowing or chewing problems were noted at this time. Record review indicated a speech evaluation was completed on 1-21-11 which identified the following interventions: "Monitor (view client every 5 minutes) while dining. Assist or encourage to sit upright, 90 degrees, and midline while dining. Assist or encourage taking small bites/ sips while dining. Assist or encourage frequently alternating solids and liquids textures while dining. Do not move out of sitting upright, 90 degrees, and midline for at least 30 minutes after dining." R49's care plan dated 9-14-11 identified she was on regular diabetic diet, regular the resident with a "history sleepy at meals, holding/ pocketing foods." Her diet was identified as. Review of the Resident Progress notes indicated the following: 7-31-11- ... "resident would take a few bites then keep it in cheek then would spit it out." 8-3-11- ..."was pocketing food in her left cheek at supper." 8-5-11- ..."was pocketing food at supper this shift." 8-10-11- ..."was pocketing food this shift." 8-24-11-... "history of sleepy at meals. History of holding/ pocketing food." 8-26-11- ..."was pocketing food at supper. Reminded her to clean her cheeks before taking more food in." R49's dietary card which was placed on her meal tray did not list any special feeding instructions. During interview on 10-18-11 at 11:50 a.m. TR-E stated she assists residents in the West dining area about 1-3 times a week to eat and usually assists R49 to eat. She continued to stated she was a Nursing Assistant "years ago" so she did not have to take the class on how to feed residents. She verified she was no longer current on the Nursing assistant registry. During interview on 10-19-11 at 7:50 a.m. ADON-A stated R49 holds and pockets food when she is sleepy. She stated if there were special feeding recommendations it should be on the care plan. She stated "most residents on the North wing" had difficult feeding complications but some had to be sent down to the West wing to be fed because they had more staff down that wing to assist with feeding. She stated another speech evaluation was not made for R49 recently because "she has always pocketed food; that was not a change." During interview on 10-19-11 at 8:55 a.m. NA-H stated she fed R49 breakfast that morning and she would not wake up to eat or drink. NA-H stated she gave R49 a drink and she just "let it run out of her mouth down the side." NA-H stated R49 was often sleepy when they tried to feed her and she was not aware of any special feeding recommendations for R49. During interview on 10/18/11 at 11:56 a.m, (RN)-A, the facility in-service coordinator, provided a copy of the training program conducted for the paid feeding assistants. The program was not approved by the state. She stated she was not aware of any state approved training program and had not submitted her training program to the state for approval. A review of the training information provided indicated the training was not eight hours long, and did not include any communication and interpersonal skills. The facility did not maintain records verifying successful completion of a program for all PFA's. A review of the sign in sheets for training indicated the program length was only 4 to 5.75 hours in length.. The facility provided training records as follows: TR-F had no proof of PFA training, she had a nursing assistant certificate dated 9/29/1983, however, she was not currently on the nurse aid registry. TR-E had no proof of PFA training, a piece of paper labeled "planning for feeding training November 2005 and her name was listed on this sheet as "trained." TR-D had signed an "inservice sign-in sheet" with topic listed as "Feeding Assistant Training" dated 8/5/05 from 2 p.m. to 7:45 p.m. an exam and audit were part of her training packet. TR-A was found to be on the nurse aide registry and did not require special PFA training. TR-B had no proof of PFA training, a piece of paper labeled "planning for feeding training" dated November 2005 listed her as "trained." Dietary Aide (DA)-A had signed an "in-service sign in sheet" dated 10/10/06 with topic listed as "Feeding Assistant Training." The hours were listed as 9 a.m. to 2:30 p.m. an exam and audit were part of her training packet. Even though training packets were provided for 2 of the 5 staff requiring PFA training, the training offered had not been the state approved training. During interview on 10/18/11 at 1:05 p.m. with the DON, he stated the facility has utilized dietary and therapeutic recreation staff off and on since 2005 when they had trained most of their staff. He stated he did not realize dietary or therapeutic recreation staff would be considered paid feeding assistants as they were their regular staff. They had an increase in the number of residents who required assistance recently and on 9/9/11 had begun having the TR person on the special care unit feed either R100, R42, R29 or R49 in that unit's dining room and a dietary person assist either R7 or R17 in the main dining room at each meal. A schedule was provided from dietary and TR showing who would be responsible for feeding at each meal from their departments. The schedules showed coverage for day and evening shifts since 9/9/11. The DON stated prior to 9/9/11 they had an interdisciplinary team meeting to discuss moving residents to the special care unit (dementia) and determined R100, R42, R29 and R49 would be compatible with that unit's residents. He stated the unit managers chose these residents along with R7 and R17 in the main dining room as being good candidates for being fed by dietary or TR. No individualized assessment or care planning had been completed for those residents selected. During interview with SLP-D on 11/19/11 at 10:30 a.m. He indicated the PFA's have been trained as well as the nurse aides and should be able to feed anyone. He provided a letter he had written on 10/19/11 indicating he had reviewed the facility's paid feeding assistant program and found it "consistent with training and recommendations that I myself generally provide. It is my opinion that persons who have been through the attached program, conducted by a Registered Nurse, should be capable of safely feeding the following residents of the Milaca Elim Home." The following residents were listed: R100, R42, R29, R49, R7 and R17. The SLP-D stated he had only seen R100 recently and had not seen the other residents listed, or had seen them so long ago, he didn't recall any special problems or needs. Further, he was not aware of the regulation at F373. He stated when he made recommendations he would write them up and give them to the nurse in charge and was not aware of how it was communicated to the rest of the staff. He would expect his recommendations to be followed until a condition change in the resident and new orders given. A facility policy was requested for PFA, the policy provided on 12/18/11 at 1:40 p.m. by the DON was entitled "feeding assist by volunteers or family members." The policy was last updated 4/4/11, but did not include any information regarding paid feeding assistants. The Administrator, director of nursing (DON) and the facility corporate quality assurance Registered Nurse (QARN)-E were notified of the immediate jeopardy at 2:00 p.m. on 10/19/11; as a result of their failure to ensure that R100, R7 and R49, who had identified complicated feeding patterns, received safe and appropriate assistance with eating. This had the potential to result in serious harm. The facility submitted a plan to remove the immediate jeopardy on 10/19/11 at 4:00 p.m. indicating their paid feeding assistant program had been discontinued, and that all staff would be notified and the dining rooms would be monitored for compliance. On 10/20/11 between 8:00 a.m. and 8:35 a.m. the following staff were interviewed and were aware of the new plan discontinuing the paid feeding assistant program: maintenance engineer (ME)-B, dietary aide (DA)-B, housekeeper (HSK)-A, therapeutic recreation (TR)-A, TR-B, licensed practical nurse (LPN)-C, LPN-D, LPN-E, trained medication aide (TMA)-B, nursing assistant (NA)-C, NA-D, NA-E. Communication books to staff were reviewed for signatures with 59 staff signatures obtained verifying they were made aware of the discontinuation of the paid feeding assistant program. The activities director, dietary director and DON were interviewed and verified they had contacted all off duty staff. On 10/20/11 at 8:41 a.m. the facilities DON and administrator were notified the IJ had been removed. R17 was identified as a resident to be fed by a PFA even though she was on a pureed diet and had not been assessed by the RN to be fed by a PFA. R17 had [DIAGNOSES REDACTED]. R17's quarterly MDS indicated she had short term and long term memory loss. Her MDS also indicated R17 was on a mechanically altered diet and needed extensive assistance with eating. On 10/18/11 at 11:55 a.m., R17 was observed to be fed by Dietary Aide (DA)-A who was a PFA. R17 had no difficulties with eating while being fed. DA-A stated she has not had any difficulty assisting R17 with eating, feeds R17 twice a week and was not aware if they had any special feeding precautions. R17's dietary card indicated she was on a "pureed may alter texture of food." During interview on 10-18-11 at 1:45 p.m. with DA-C she stated she took the training to feed residents about 6 years ago and she currently assists with feeding in the main dining room about 1-2 times a week. She stated she usually feeds R17 and was not aware of any special instruction for feeding and stated if the resident had special feeding instructions it would be listed on the dietary card on the residents meal tray. Review of the physician orders [REDACTED]. The current plan of care updated 7/26/11 indicated R17 was at risk for weight loss and received a puree diet with regular liquids. There was no indication any assessment had been completed by the registered nurse (RN), to determine if R17 could be safely fed by a PFA. Resident 42 had complicated feeding problems, was fed by a PFA, and had not been assessed by the RN to be safely fed by a PFA. R42 was observed 10/18/11 at 12:11 p.m. being fed lunch by TR-B. No problems were noted during the meal while TR-B was assisting R42. R42 had [DIAGNOSES REDACTED]. Her quarterly MDS dated [DATE] indicated she had short and long term memory problems, required extensive assistance with eating and had no signs/symptoms of swallowing disorder. Her care plan dated 5/23/11 included need for assistance with eating with a regular diet. There were no special instructions noted on R42's dietary card. During interview on 10-18-11 at 11:50 a.m. TR-D stated she had gone through the training program so could assist residents to eat at meals. She stated she was allowed to feed anyone in the facility because she had taken the feeding class, but she had fed R42 in the last several weeks. R29 was not assessed as being safe to be fed by a paid feeding assistant. R29 [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] identified the resident as rarely understood, had short and long term memory loss, an extensive one person assist with eating, and had no swallowing problems. R29 was observed on 10-17-11 at 5:06 p.m. in the west dining room being assisted with supper by NA-G. R29 was very sleepy and NA-G had to keep waking her up to remind her to eat. She was not observed having any chewing or swallowing problems at this time. R29's care plan dated 10-4-11 indicated "will refuse full dentures at times... mechanical soft diet." R29's dietary card did not list any special feeding instructions. ADON-A was unable to provide a speech evaluation for R29 and she was unsure where the dysphasia [DIAGNOSES REDACTED]. During interview on 10-18-11 at 11:50 a.m. TR-D stated she went through the training program so she could assist residents eat at meals. She stated she was allowed to feed anyone in the facility because she had taken the feeding class, but she had fed R29 in the last several weeks. She indicated R29 is often very sleepy and puts her fingers in her mouth when they are trying to feed her. She stated R29 needs a lot of "coaxing" to eat and stay awake but she was not aware of any special feeding instructions for R29. During interview on 10-18-11 at 11:50 a.m. TR-E stated she assists residents in the West dining area about 1-3 times a week to eat and usually assists R29, R42 and R100. She stated she was a Nursing Assistant "years ago" so she did not have to take the class on how to feed residents. She verified she was no longer current on the Nursing assistant registry. During interview on 10/18/11 at 1:05 p.m. with the DON, he stated they had an increase in the number of residents who required assistance recently and on 9/9/11 started having the TR person's assist R100, R42, R29 and R49 to eat. A dietary person also assists R7 and/or R17 to eat in the main dining room at each meal.