Every finding on record at Neshoba County Nursing Home

Based on interviews, record reviews, facility policy reviews, and the facility's investigation, the facility failed to provide adequate supervision to prevent residents who were identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for two (2) of 19 residents residing on the secured Alzheimer's unit. Resident #1 and Resident #2. On 1/20/26 at approximately 1:32 PM to 1:35 PM Resident #1 entered the door alarm code and Resident #1 and Resident #2 exited the facility undetected by staff. Resident #1 was unattended and unsupervised until located by law enforcement 29 miles from the facility and returned to the facility at 3:50 PM. Resident #2 was identified by staff to be outside on facility property and was assisted back into the facility at 1:48 PM. The elopement placed Resident #1, Resident #2, and other residents at risk for wandering and elopement, in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. During the investigation, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 1/20/26 and existed at 42 CFR: 483.25 (d)(1)(2)- Free of Accidents Hazards/Supervision/Devices (F689) - Scope and Severity J. The SA notified the facility's Administrator of the IJ and SQC on 2/2/26 at 4:30 PM and provided the Administrator with the IJ template. Based on the facility's implementation of corrective actions on 1/21/26, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 1/22/26, prior to the SA's entrance on 2/2/26.Findings Include: A review of the facility's policy, Elopement and Wandering Residents, revealed This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Record review of the Encounter Information and Diagnosis List forms revealed that the facility admitted Resident #1 on 9/18/25 with diagnoses that included Cerebral Infarct and Schizophrenia. Record review of the Minimum Data Set Assessment (MDS), with an Assessment Reference Date (ARD) of 12/17/25 revealed a Brief Interview for Mental Status (BIMS) score of three (3), indicating that Resident #1 is severely cognitively impaired. Record review of Resident #1's Elopement Risk Score, dated 1/7/26, revealed that his score was 95 indicating he was at risk for elopement. Record review of the Encounter Information and Diagnosis List forms revealed that the facility admitted Resident #2 on 2/12/25 with diagnosis of Dementia. Record review of the MDS, with an ARD of 11/6/25 revealed a BIMS score of five (5), indicating that Resident #2 is severely cognitively impaired. Record review of Resident #2 Elopement Risk Score, dated 1/7/26, revealed that his score was 95 indicating he was at risk for elopement. A record review of the facility's investigation revealed Resident #1 entered the door code and opened the door at the end of the locked Alzheimer unit between 1:32PM and 1:35 PM on 01/20/26. Resident #1 and Resident #2 exited the facility. Resident #2 was seen on facility property and brought back into the facility by staff at approximately 1:48 PM. Resident #1 was noted to be missing at 1:52 PM. A Code Yellow (code for missing resident) was called and a room to room search for Resident #1 was initiated. When he was not located Resident #1's Responsible Party (RP) was called, along with the local County Sheriff's office. Resident #1 was believed to have phoned his girlfriend from his personal cell phone; she gave him the door code to get out of the locked unit and sent someone to pick him up. Facility staff phoned Resident #1's cell phone and it was determined by the road sounds that he had already been picked up by someone and was in a vehicle at that time, which was within 30 minutes of him leaving the facility. Resident #1 was asked who he was with, where he was and where he was going, but resident hung up the cell phone. Resident #1 was located in a different county by their local deputies at his home at approximately 3:00 PM. Resident #1 was transported back to the facility by county sheriff deputies and arrived at the facility at 3:50 PM. In an interview with the Administrator (ADM) on 2/2/26 at 1:30 PM, she verified that on 1/20/26 between 1:32 PM and 1:35 PM Resident #1 and Resident #2 exited the building through the back door of the unit and then left the courtyard through the gate. She stated staff responded to the alarm but did not see anyone outside. At around 1:48 PM Resident #2 was seen by a staff member outside on facility property and was brought back in. She stated Resident #2 confirmed that Resident #1 opened the door and they went out and then Resident #1 patted him on the shoulder and walked off. She further verified that Resident #1 was not located on the unit and a code yellow was called and a multifacility search was initiated. When Resident #1 was not found the Resident's Representative (RR) and local law enforcement was notified. Staff called Resident's cell phone and law enforcement was able to locate him on Highway 21, using the phone signal. Resident was located at his former home address and arrived back at the facility at 3:50 PM on 01/20/26. During an interview with Registered Nurse (RN) #1 on 2/2/26 at 2:00 PM she stated on 1/20/26 she was at the nurse's station with another RN when a door alarm sounded. She stated that the other RN responded to the alarm but did not see anyone outside. Approximately 20 minutes later one of the Certified Nursing Assistants (CNA) reported that Resident #2 was outside on facility property but, Resident #1 was missing. She stated that the other RN called a Code Yellow and a room-to-room search was initiated, but the resident could not be located. During an interview with CNA #1 on 2/2/226 at 2:15 PM, she stated that she had last seen Resident #1 and Resident #2 right after their lunch around 1:00 PM leaving the dining area. She stated she then went to lunch and returned a little after 1:30 PM, and upon her return a door alarm was sounding. She stated she went to the door that leads to the courtyard and did not see anyone outside. In an interview with CNA #2 on 2/2/26 at 2:20 PM, she stated she had last seen Resident #1 and Resident #2 around 1:00 PM leaving the dining room. She stated that while in the room caring for another resident, she saw Resident #2 outside on facility property and alerted the staff. She stated that Resident #1 told her that Resident #2 let him outside. She stated that they did not see Resident #2, so they notified the nurse and a Code Yellow was called. She stated that they have given the door code to family and visitors in the past so that they can get in and out of the unit. She further stated Resident #1 was wearing a pullover shirt, black leather jacket, long pants and tennis shoes. Resident #2 was wearing a long shirt, sweatpants and gray shoes. Telephone interview with Resident #1's RR on 2/2/26 at 2:40 PM, she stated she believed that Resident #1's girlfriend gave him the door code and arranged a ride for him back to his home. She did not have contact information/name for resident's girlfriend. She stated that no family members gave him a ride to his home and she was unaware of who did. Interview with Resident #2 on 2/2/26 at 2:55 PM, he stated that Resident #1 opened the door and let him outside. He stated he just went out for some fresh air and came back inside. Interview with Resident #1 on 2/2/26 at 3:00 PM he stated that he knew the code to the back door so he entered it and left the facility. He stated that he just wanted to go home. Resident #1 denied getting the code from anyone else. He stated he walked to the school near Highway 21 where his cousin picked him up and took him home. Record review of local historical weather revealed it was between 45 and 50 degrees between 1:30 PM and 4:00 PM on 1/20/26. Corrective Action Plan The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 2/2/26: On 01/20/26 at approximately 1:32-1:35 PM, the door alarm sounded to exit door into enclosed courtyard of Facility Alzheimer's Unit. Certified Nurse Aide (CNA) Staff Member noted no residents visualized in courtyard and silenced the alarm. On 01/20/26 at approximately 1:48-1:50 PM, Certified Nurse Aide noted resident # 2 standing outside of Alzheimer's Unit. On 01/20/26, at approximately 1:50 PM, CNA Staff immediately recovered resident # 2 and returned him to unit and immediately placed on one-to-one monitoring to ensure safety. Resident # 2 stated that resident # 1 let him out. On 01/20/26 at approximately 1:52PM, a resident head count performed on Unit with all residents accounted for except resident #1. On 01/20/26 at approximately 1:59 PM, the Unit Manager initiated Code Yellow. On 01/20/26 at approximately 1:59 PM, Facility Administration and Law Enforcement were notified. On 01/20/26 at approximately 2:00 PM, multifacility property search was initiated by all departments of the Nursing Home and Hospital. On 01/20/26 at approximately 2:15 PM, Facility Administrator obtained residents cellphone number from Residents responsible party and called resident. Law enforcement was able to ping cellphone location. On 01/20/26 at approximately 2:25 PM, residents responsible party arrived at facility and informed facility administration that she knew her dad was headed home. Responsible party stated resident called his sister and informed her he had busted out and headed home with assistance of his girlfriend and girlfriend's family per private auto. On 01/20/26 at approximately 3:00 PM, resident was located by Sheriff's Department at his home address. On 01/20/26 at 3:50 PM, Resident # 1 returned to facility by Sheriff's Department and was immediately placed one to one monitoring by unit manager to ensure safety. On 01/20/26 at 3:57 PM, the Mississippi State Department of Health notified via hotline by Assistant Director of Nursing. On 01/20/26 at 4:00 PM, Resident # 1 was assessed by the Unit Manager for any distress or injury with no abnormal findings. On 01/20/26 at approximately 4:00 PM, all the exit doors to Alzheimer's unit codes were changed to secure unit by Maintenance staff. On 01/20/26 at 6:00 PM, Assistant Director of Nursing initiated Elopement and Wandering In-service with all staff and all staff to be in serviced on next scheduled working day. No staff will be allowed to work until in-service are completed. This Inservice included Policy and Procedures for elopement and wandering, security of door code privacy, resident supervision, and safety. On 01/20/26 at 8:00 PM, the Administrator, Director of Nursing and Assistant Director of Nursing reviewed Elopement and Wandering Resident Polices with no changes. On 01/20/26 at 8:30 PM, Assistant Director of Nursing reviewed 100% of Alzheimer's Unit Residents Elopement Care plans with no issues noted. On 01/21/26 at 1:30 PM, a doorbell was obtained and installed by maintenance staff on unit to allow visitors to call unit for visitation access. No visitor will have access to unit codes. On 01/21/26 at 2:00 PM, Quality and Regulatory Affairs Director held Post Elopement Event Review/ Quality Assurance Meeting to review safety Measures and ongoing monitoring. Medical Director was in attendance via phone. Other staff in attendance were Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Unit Managers, Quality Assurance Nurse, Director of Facility Maintenance, Director of Security, Infection Preventionist, Quality and Regulatory Affairs representative. Event details, root cause analysis with corrective actions that have been implemented were discussed by the committee with no recommended changes at this time. Committee agreed to continue current monitoring and will follow up at later date to review monitoring. On 01/21/26 at 3:00 PM, the Safety alarm was placed on exit gate by Maintenance staff of Alzheimer's unit to notify staff when gate in courtyard is ajar. On 01/21/26 at approximately 3:00 PM, Safety Alarm Checks initiated to ensure door closed and proper alarm functioning by Facility Administrator and nursing to continue every shift. On 01/22/26 at 07:00 AM, Resident # 1 was changed to every fifteen-minute checks. On 01/22/26 at approximately 2:00 PM, the Information Technology Director ordered Badge access for all entry/exit doors on Alzheimer's unit and will be installed upon arrival. On 01/22/26 at 7:38 PM, the Assistant Director of Nursing submitted a written investigation report via email to Mississippi State Department of Health. On 01/26/26 at approximately 09:00 AM, Activity Staff member scheduled by Activity Director Monday through Friday 09:00 AM - 5:00 PM, for increased monitoring and activities on Alzheimer's unit. On 01/26/26 at 5:00 PM, the Assistant Director of Nursing placed resident # 1 back on one-to-one monitoring for increased exit seeking behaviors and will remain ongoing unless acute status changes. On 01/27/26 at approximately 11:00 AM, live view cameras with screen installed at nurses' station for increased supervision of all entrance/exit doors to Alzheimer's unit by Information Technology Director. On 01/27/26 at 08:00 AM, the Director of Facility Maintenance ordered hallway mirrors for increased visualization of hallways and exit doors, and these will be installed upon arrival. On 01/30/26 at 11:00 AM, Quality and Regulatory Affairs Director held a follow up facility quality assurance meeting to discuss ongoing Elopement Plan, effectiveness, and monitoring. The committee recommended no changes to current plan. Attendees included: Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Unit Managers, Quality Assurance Performance improvement nurse, Minimum Data Set Coordinator, Licensed Dietician, Activities Director, Director of Environmental Services, Director of Facility Maintenance, Director of Rehab, Director of Social Services, Dietary Director, Infection Preventionist, Medicare Coordinator, Emergence Operations Plan Director, Facility Family Nurse Practitioner, Quality and Regulatory Affairs Representative. All corrective actions were completed on 1/21/26 and the facility alleges the IJ was removed on 1/22/26. Validation: The State Agency (SA) validation of the Corrective Action Plan was made on-site during the Complaint Investigation (CI) MS #2722725 through observation, record review and interviews on 2/3/26. The SA determined all corrective actions were completed on 1/21/26 and the IJ was removed on 1/22/26.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the kitchen equipment and surrounding areas were maintained in a clean and sanitary condition for two (2) of three (3) kitchen tours. Findings Include Record review of the facility policy titled, General Sanitation of the Kitchen undated, revealed The staff shall maintain the sanitation of the kitchen through compliance with a written comprehensive cleaning schedule.4. A cleaning schedule will be posted. Employees will be trained on the cleaning schedule and how to perform duties. Employees will initial and date tasks when completed . During the initial kitchen tour on 9/29/25 at 12:20 PM, observation of the deep fryer revealed a thick yellow and black substance with food particles built up down the entire right side of the fryer. The left side of the stove had splattered buildup, and underneath the fryer was a thick, greasy substance with food particles extending across the surrounding floor. On 10/01/25 at 9:15 AM, during an interview and concurrent observation, the Dietary Manager (DM) revealed that fryer oil is to be changed weekly and that the fryer's exterior is to be cleaned at that time, with staff required to initial and date the task upon completion. The DM confirmed that the fryer's right side had thick yellow and black buildup with food particles, and the left side of the stove had splattered buildup. He stated, It looks like it has not been cleaned in a while. The DM further confirmed the greasy buildup underneath and around the fryer should have been mopped and acknowledged that cleaning the floors was not currently included in the cleaning schedule, but should be, to ensure completion. On 10/01/25 at 9:25 AM, an interview and review of the Weekly Cleaning Schedule for September 2025 with the DM revealed initials indicating fryer cleaning was completed. The DM confirmed that the fryer cleaning task specifies Interior/Exterior. He acknowledged, I can see where this could be just initialed as done without it actually being done, because obviously by the looks of things we can see that it was not cleaned like it should have been and that is unacceptable. On 10/01/25 at 9:30 AM, an interview with Dietary Supervisor (DS) #1 stated that cleaning the floors is everyone's responsibility, even if not listed on the schedule, and confirmed that the greasy buildup under the fryer and the dirty fryer and stove were not acceptable. She stated the kitchen should always be kept clean and sanitary. During an interview on 10/01/25 at 3:45 PM, the Administrator (ADM) revealed that the expectation is that the kitchen where resident meals are prepared is always kept clean and sanitary to prevent any potential foodborne illness.

Based on observation, interviews, record review, and facility policy review, the facility failed to implement a care plan for Activities of Daily Living (ADLs) (Resident #5, #64, #105), wandering (Resident #57), gastrostomy (Resident #64), and therapeutic diet (Resident #134) for five (5) of 26 resident care plans reviewed. Resident #5, #57, #64, #105, and #134 Findings Include Review of the facility policy titled, Comprehensive Care Plan undated revealed under Policy.It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #5 Record review of Resident #5's LTC (Long Term Care) ADL (Activities of Daily Living) Function 2 (Two) Plan revealed that she required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Her interventions included provide assistance to support level of need. An observation of Resident #5 on 9/29/25 at 3:58 PM and on 09/30/25 at 2:28 PM, revealed that she had multiple gray chin hairs measuring approximately one-half of an inch in length. Resident #5 was pleasantly confused and unable to answer simple questions. During an interview on 09/30/25 at 2:38 PM with Licensed Practical Nurse (LPN) #1confirmed that Resident #5 had multiple gray hairs on her chin. She revealed that the Certified Nurse Assistants (CNA) were supposed to remove facial hair if needed during their bath time and it was included in the residents Care Plan about personal grooming. An interview on 09/30/25 at 4:11 PM with the Director of Nursing (DON) revealed that the purpose of the care plan was to formulate a plan of care specific to each resident so the staff can refer to it and know what care each resident needs. DON confirmed that ADL care was included on Resident #5's Care Plan and since her facial hair was left unattended, her care plan was not followed and she stated, We will get that taken care of. An interview on 10/02/25 at 8:25 AM with Certified Nursing Assistant (CNA) #1 revealed that bathing, grooming and personal hygiene care was on the care plans, and this included facial hair removal. Record review of Resident #5's Profile History Report revealed under ADLs to ensure facial hair is removed as needed. Record review of Resident #5's demographic information revealed that she admitted on [DATE] and that she had diagnoses that included Alzheimer's, Unspecified Dementia, and Insomnia. Record review of Resident #5's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/25 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 03 which indicated that she had severe cognitive deficits. Resident #57 Record review of Resident #57's Elopement Risk POC (plan of care) revealed under Interventions: Utilize wander alert device During an observation with Resident #57 on 9/29/25 at 12:40 PM and again on 9/30/25 at 9:42 AM she was sitting in her recliner in her room reading a book and a wander alert bracelet was observed lying on a built-in cabinet in the room. During an observation and interview with Registered Nurse (RN) #1 on 9/30/25 at 2:36 PM, she confirmed Resident #57 was not wearing her wander alert device. An interview with the MDS Nurse on 10/2/25 at 10:01 AM confirmed that the purpose of the care plan was to make the staff aware of the type of care to provide for the residents. She confirmed the care plan was not followed for Resident #57's wander alert bracelet. Record review of Resident #57's demographic information revealed the facility admitted the resident on 10/14/24 with medical diagnoses that included Alzheimer's Disease.Record review of the MDS with an ARD of 9/26/25 revealed under Section C, a BIMS score of 3, indicating Resident #57 was severely cognitively impaired. Resident #64 Review of the LTC ADL FUNCTION for Resident #64 revealed: The resident requires total staff assist with all his ADL care. Record review of Resident #64's Feeding Tube POC (Plan of Care) revealed under, Interventions: Ensure tube placement, auscultation, aspiration prior to use. On 9/29/25 at 2:35 PM and again on 9/30/25 at 2:55 PM and observation of Resident #64 revealed long, thumb nails, approximately one-eighth (1/8) in length, jagged with a brown substance underneath. Resident #64's fingers on both hands were closed tightly. On 9/30/25 at 12:10 PM, and observation with Resident #64 revealed LPN #5 flushed the resident's enteral tube with water and administered medications without first verifying placement of the tube.During an interview with LPN #5 on 9/30/25 at 12:21 PM, she confirmed she did not check placement of Resident #64's gastrostomy tube prior to flushing and giving the ordered medications. An interview with the MDS Nurse on 10/2/25 at 10:04 AM confirmed the care plan was not followed for Resident #64's enteral tube. Record review of Resident #64's demographic information revealed the facility admitted the resident on 1/23/19 with medical diagnoses that included Anoxic Brain Injury and that the resident receives feeding through a gastrostomy.Record review of the MDS with an ARD of 7/14/25 revealed under Section C that cognitive skills for daily decision making were severely impaired. Resident #105 Record review of Resident #105's LTC (Long Term Care) ADL Function 2 (Two) Plan, revealed that he required mainly extensive assistance with his ADL self-performance and is dependent for shower/bath and personal hygiene. Resident #105's interventions included, Nail care weekly-keep nails clean and neat. Observations on 09/29/25 at 1:10 PM and on 09/30/25 at 2:53 PM, revealed that Resident #105 had long fingernails on both hands that were approximately one-half of an inch long past the tips of the fingers. During an observation and interview on 09/30/25, at 2:55 PM with LPN #1 in Resident #105's room, she confirmed that the resident's nails were long and needed to be clipped. She revealed that resident fingernails were supposed to be trimmed weekly and was included in the care plan. An interview on 09/30/25 at 4:09 PM with the DON confirmed that ADL care was included on Resident #105's Care Plan and since his fingernails were left long, his care plan was not followed. Record review of Resident #105's demographic information revealed that the facility admitted the resident on 03/06/25 with diagnoses that included Left Hemiplegia, Acute Brainstem Stroke, and Dementia. Record review of Resident #105's MDS with an ARD of 08/27/25 revealed under Section C a BIMS Score of 03 which indicated that he had severe cognitive deficits. RESIDENT #134 Record review of Resident #134's Nutritional Status Care Plan effective 09/24/25, revealed interventions to include a pureed diet with nectar thickened liquids. An observation and interview on 09/30/25 at 11:32 AM of Resident #134's lunch meal revealed that he had nectar thickened water, nectar thickened sweet tea, and a carton of regular consistency creamy strawberry Glucerna on his tray. An observation also revealed Certified Nursing Assistant (CNA) #2, open his Glucerna and insert a straw into the container for him to drink. CNA #2 confirmed that the Glucerna was not nectar consistency like the water and sweet tea. An interview on 09/30/25 at 4:05 PM with Director of Nursing (DON) confirmed that Resident #134's Pureed Diet with Nectar thickened liquids was included on his care plan and because he was provided with regular consistency Glucerna, his care plan was not followed Record review of Resident #134's meal ticket dated 09/30/25, revealed that he was ordered to have Mechanical Soft, Nectar Thick Diet and this included Glucerna (Thicken) on his meal tray. Record review of Resident #134's Physician Order Review revealed a diet order dated 09/24/25 for nectar/mildly thick beverage, Glucerna with L/S (Lunch/Supper). Aspiration Precautions Needed. Record review of Resident #134's demographic information revealed the facility admitted the resident on 09/24/25 with diagnoses that included Right Thalamic Infarction, Stroke, and Communication Impairment. Record review of Resident #134's MDS with an ARD of 03/12/25 under Section C revealed a BIMS Score of 15 which indicated that he had no cognitive deficits.

Based on observations, interviews, record review and facility policy review, the facility failed to ensure the possibility of the spread of infection by respiratory equipment not being stored properly for one (1) of two (2) residents observed receiving nebulizer treatments (Resident # 53). Findings Include Review of the facility policy titled Nebulizer Therapy with an approval date of 8/06/25 revealed, It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. An observation on 9/29/25 at 4:30 PM and again on 9/30/25 at 1:45 PM revealed Resident #53's nebulizer was sitting on top of the resident's oxygen concentrator with the mouthpiece uncovered and not stored in a clean or protected manner. During an observation and interview with the Clinical Services Director on 9/30/25 at 3:30 PM, she confirmed that Resident # 53's mouthpiece was not stored properly. She stated that It should be covered, stored in a clean bag or container because leaving it out like that could cause an infection. On 10/01/25 at 10:15 AM an interview with the Director of Nursing (DON) confirmed that nebulizer mouthpieces should always be stored in a bag to prevent contamination. Record Review of LTC Physician Order Review/Renewal reveals Resident #53 has an order for Ipratropium-Albuterol 3 mL (milliliters) Inhale solution two times a day as needed for wheezing. Record review of the Face Sheet revealed that the facility admitted Resident #53 on 9/15/2022 with a medical diagnosis that Airway-centered interstitial fibrosis. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/01/25 revealed under section C, a Brief Interview for Mental Status (BIMS) score of 12 which indicated Resident #64 was moderately cognitively impaired.

Based on observation, interview, record review, and facility policy review, the facility failed to provide a prescribed therapeutic diet for one (1) of 50 sampled residents. Resident #134.Findings Include: Review of the facility policy titled, Thickened Liquids revealed, It is the policy of the (proper name) facility that residents receive liquids as they are ordered and recommended by their physician and or speech language pathologist. An observation and interview on 09/30/25 at 11:32 AM of Resident #134's lunch meal revealed that he had nectar thickened water, nectar thickened sweet tea, and a carton of regular consistency creamy strawberry Glucerna on his tray. An observation also revealed Certified Nursing Assistant (CNA) #2, open his Glucerna and insert a straw into the container for him to drink. CNA #2 confirmed that the Glucerna was not nectar consistency like the water and sweet tea. During an observation and interview on 09/30/25 at 11:36 AM in Resident #134's room with Registered Nurse (RN) #1, she confirmed that the Strawberry Glucerna that was on Resident #134's meal tray was regular consistency. She revealed that not providing his prescribed nectar thickened liquids could cause him to choke and aspirate. She also confirmed that Resident #134's meal ticket on his tray showed that he was supposed to be getting thickened Glucerna with his meal. RN #1 removed the Glucerna from Resident #134's tray and left the room. An interview on 09/30/25 at 4:05 PM with the Director of Nursing (DON), revealed that Resident #134's meal was supposed to come from the kitchen ready to consume and this included the addition of thickener to his Glucerna. She also confirmed that by not providing Resident #134 with the thickened Glucerna, this could result in aspiration and lead to respiratory problems. An interview on 10/01/25 at 9:40 AM with the Dietary Manager (DM) confirmed that Resident #134 should have received thickened Glucerna from the kitchen. He also confirmed that all staff who prepared resident plates for meals were supposed to look at meal tickets and make sure they matched what was on the trays. He admitted that it was ultimately the responsibility of the Dietary Supervisor to ensure that a resident received the proper prescribed diet. An interview on 10/01/25 at 11:05 AM with the Dietary Supervisor (DS) #2 confirmed that Resident #134 should have received nectar thickened Glucerna yesterday and by not receiving the prescribed diet, he could have gotten strangled. She revealed that when a resident had a meal ticket that included Glucerna (thickened), they were supposed to pour the Glucerna in a separate glass and add thickener to it to make the right consistency. She admitted that everyone on the serving line was supposed to check to ensure the meal ticket orders matched what they served. Dietary Supervisor #2 added that she normally caught those mistakes and stated, I just missed it yesterday. Record review of Resident #134's meal ticket dated 09/30/25, revealed that he was ordered to have a Mechanical Soft, Nectar Thick Diet and this included Glucerna (Thicken) on his meal tray. Record review of Resident #134's Physician Order Review revealed a diet order dated 09/24/25 for nectar/mildly thick beverage, Glucerna with L/S (Lunch/Supper). Aspiration Precautions Needed. Record review of Resident #134's Face Sheet revealed an admission date of 09/24/25 and that he had diagnoses that included Right Thalamic Infarction, Stroke, and Communication Impairment. Record review of Resident #134's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 03/12/25 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that he had no cognitive deficits.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure the safe storage and security of medications for one (1) of 128 residents reviewed during initial tour. Resident #101 Findings Include: Review of the facility policy titled General Rules for Residents and Sponsors (undated) revealed under section .5: Residents are not permitted to keep any medications in their room unless the interdisciplinary team has determined that this practice is safe and ordered by the physician.An observation and interview with Resident #101 on 9/29/25 at 12:42 PM revealed she was lying in bed with a Symbicort inhaler and a Spiriva inhaler lying on a table in the room. Resident #101 stated the nurse had forgotten to come back and get them after she took them that morning.Record review of the Medication Administration Record (MAR) revealed an order dated 7/14/25, Tiotropium (Spiriva Respimat) 1.25 mcg(microgram)/INH (inhalation aerosol), inhale 2 puffs daily. The MAR also revealed an order dated 7/22/24, Budesonide-formoterol 80 mcg (microgram)– 4.5 mcg(microgram)/INH (inhalation aerosol), inhale 1 puff BID (twice daily).An interview with Registered Nurse (RN) #1 on 9/30/25 at 2:30 PM revealed Resident #101 did not have an order to self-administer medications. RN #1 stated the nurse should always remain in the room and watch the resident take the medication appropriately, and medications should never be left unattended. She explained that leaving medications in the room could result in the resident taking too much or another resident gaining access to the medication.An interview with Licensed Practical Nurse (LPN) #3 on 9/30/25 at 2:49 PM confirmed she was responsible for leaving the inhalers in Resident #101's room. She explained she had to step next door to assist another resident and left the medications on the TV stand. LPN #3 acknowledged that leaving medications at the bedside could harm Resident #101 if she took too much or could pose a risk if another resident accessed the medication.An interview with the Director of Nursing (DON) on 9/30/25 at 4:00 PM revealed her expectations were that all medications must be securely stored in the medication carts and never left in a resident's room.Record review of Resident #101's demographic information revealed the facility admitted resident on 8/17/20 with a medical diagnosis that included Atherosclerotic Heart Disease.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/10/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, indicating Resident #101 was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure proper placement of a gastrostomy tube prior to medication administration for one (1) of two (2) enteral tubes reviewed. Resident #64 Findings Include:Review of the facility policy titled Enteral Tube Medication, unrevised, revealed under Policy Explanation and Compliance Guidelines: 8. Enteral tube placement must be checked via auscultation and/or aspiration before any fluids or medication are administered.During an observation on 9/30/25 at 12:10 PM with Resident #64, Licensed Practical Nurse (LPN) #5 flushed the resident's enteral tube with water and administered medications without first verifying placement of the tube.An interview with LPN #5 on 9/30/25 at 12:21 PM confirmed that she did not check placement of Resident #64's enteral tube prior to administering medications and that it should have been done to ensure the tube was in the proper place to prevent aspiration. She admitted that the nursing staff was supposed to follow standards of practice by aspirating gastric contents of the tube to verify placement. An interview with the Director of Nursing (DON) on 9/30/25 at 4:02 PM confirmed enteral tube placement should be verified prior to flushes or medication administration to ensure the tube had not migrated, which could lead to aspiration.Record review of Resident #64's demographic information revealed the facility admitted resident on 1/23/19 with medical diagnoses that included Anoxic Brain Injury and that the resident receives feedings through a gastrostomy.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure that a resident identified as an elopement risk had the physician prescribed wander alert bracelet applied for one (1) of four (4) residents reviewed for accident hazards. Resident #57 Findings Include:Review of the facility policy titled Code Alert Policy, unrevised, revealed under Policy: To prevent wandering residents from leaving the facility or attempting to leave the facility by alerting the nursing staff of their exit through the doors . Procedure: Wandering residents who are deemed to be a Flight Risk will have a code alert bracelet placed on their wrist or ankle.The staff nurse will check each transmitter and the door each shift and document on the code alert TAR (treatment administration record) in the EHR (electronic health record) if the transmitters and doors are functioning correctly .An observation and interview with Resident #57 on 9/29/25 at 12:40 PM revealed she was sitting in her recliner in her room reading a book with a wander alert bracelet lying on a book shelf. Resident #57 stated, That's something somebody gave me.An observation of Resident #57 on 9/30/25 at 9:42 AM revealed she was again in her recliner reading and the wander alert bracelet remained on the book shelf.Record review of Resident #57's Physician Orders revealed an order dated 10/14/24: Code Bracelet/Wander Alert TAR (treatment administration record) BID (twice daily), code alert, ensure code alert is intact.An observation and interview with Registered Nurse (RN) #1 on 9/30/25 at 2:36 PM revealed Resident #57 was supposed to be wearing a wander alert bracelet because she had Alzheimer's disease and was ambulatory. RN #1 stated Resident #57 had the bracelet for her safety so she would not get out of the facility. During the observation with Resident #57, RN #1 confirmed the resident did not have the bracelet on and stated the nurses were responsible for checking the placement of the device twice daily and documenting it under the task section in the medical record.An interview with the Director of Nursing (DON) on 9/30/25 at 4:06 PM confirmed Resident #57 was at risk for elopement by not wearing the wander device as ordered.Record review of Resident #57's demographic information revealed the facility admitted the resident on 10/14/24 with medical diagnoses that included Alzheimer's Disease.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/26/25 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 3, indicating Resident #57 was severely cognitively impaired.

Based on observation, interview, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care related to nail care (Resident #64, Resident #105) and shaving (Resident #5) for 3 (three) of 50 sampled residents. Findings Include: Review of the facility policy titled Activities of Daily Living revealed under Policy Explanation and Compliance Guidelines: .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #5 On 9/29/25 at 3:38 PM and again on 9/29/25 at 3:58 PM Resident #5 was observed with multiple scattered gray chin hairs that measured approximately one-half (1/2) inch. She was pleasantly confused and unable to answer simple questions. On 09/30/25 at 2:38 PM, an observation and interview with Resident #5 and Licensed Practical Nurse (LPN #1) confirmed that the resident had multiple gray hairs on her chin. She admitted that the resident's facial hair should have been removed when she received her bath and that Certified Nurse Assistants (CNA) were supposed to assess facial hair as part of their personal hygiene but that this was not done. On 09/30/25 at 4:11 PM, an interview with the Director of Nursing (DON) stated that she expected residents to be well groomed and that includes facial hair. She confirmed that the CNAs were supposed to remove facial hair on the resident's shower days. On 10/02/25 at 8:25 AM, an interview with CNA #1 confirmed that they were supposed to assess residents during their bath and if we see facial hair, we take care of it. She admitted that Resident #5 was bad to have facial hair and wouldn't want to be seen that way. She stated that Resident #5 should not be presented in public around other residents with that facial hair. On 10/02/25 at 8:30 AM, an interview with LPN #2, confirmed that personal hygiene included removal of facial hair and if women have peach fuzz or any facial hairs, we are supposed to take care of it. LPN #2 also stated, I don't want to walk around with a beard being a woman. Record review of Resident #5's Removal of Facial or Bodily Hair Consent revealed that the consent was signed allowing the staff to shave her face/body hair and was signed on 11/19/24. Record review of Resident #5's Profile History Report revealed that under ADLS, to ensure facial hair is removed as needed. Record review of Resident #5's demographic information revealed that the facility admitted the resident on 11/19/24 with diagnoses that included Alzheimer's, Unspecified Dementia, and Insomnia. Record review of Resident #5's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/25 under Section C revealed a BIMS score of 03 which indicated that she had severe cognitive deficits. Resident #64 An observation on 9/29/25 at 2:35 PM and again on 9/30/25 at 2:55 PM of Resident #64 revealed the resident lying in bed with long, thumb nails, approximately one-eighth (1/8) in length, jagged with a brown substance underneath and his hands were closed into a fist. An observation and interview on 9/30/25 at 3:00 PM at Resident #64's bedside with the Director of Clinical Services confirmed the resident's thumb nails were long and dirty. She opened his hands and revealed that all his fingernails were long with a brown substance underneath. No broken skin was observed on either hand. She stated, If his nails are not kept trimmed and clean, he could easily get a break in his skin and develop an infection. On 10/01/25 at 9:00 AM the DON was interviewed regarding the facility's expectations for fingernail care. The DON stated, Staff are expected to keep residents' fingernails trimmed and clean. Long or dirty nails could cause a break in the skin and lead to infection. Record review of Resident #64's demographic information revealed that the facility admitted resident on 2/11/19 with a medical diagnosis that included Anoxic brain injury. Record review of the MDS with an ARD of 7/14/25 revealed under Section C that cognitive skills for daily decision making were severely impaired. Resident #105 On 09/29/25 at 1:10 PM and again on 09/30/25 at 2:53 PM, Resident 105 was observed with long fingernails on both hands that were approximately half of an inch long past the fingertips. On 09/30/25 at 2:55 PM, an observation and interview with LPN #1 confirmed that Resident #105's fingernails were long and needed trimming. She revealed that long fingernails could cause skin tears and possible skin infections. She admitted that Resident #105 was on the schedule for his nails to be clipped every Friday on the day shift and she confirmed that his fingernails had not been clipped in a while. On 09/30/25 at 4:09 PM, an interview with the DON confirmed that the CNA's were supposed to check fingernails and clip them if needed unless the resident was a diabetic. She revealed that fingernail care was supposed to be done weekly on every resident as part of their personal hygiene and grooming needs and expected residents to be well-groomed which included nail care. Record review of Resident #105's demographic information revealed that the facility admitted the resident on 03/06/25 with diagnoses that included Left Hemiplegia, Acute Brainstem Stroke, and Dementia. Record review of Resident #105's MDS with an ARD of 08/27/25 revealed under Section C a BIMS Score of 03 which indicated that he had severe cognitive deficits.

Based on observation, interview, record review and facility policy review, the facility failed to ensure that the use of a bed alarm did not constitute a physical restraint for one (1) of four (4) residents reviewed for restraints (Resident #62). Findings Include: Review of the facility policy titled, Restraint Free Environment with an approval date of 6/27/2025 revealed, Each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience, and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. An observation and interview on 9/29/25 at 1:15 PM with Resident #62, revealed the resident lying in bed with her hands clenched, body appearing stiff and her bed alarm was sounding despite only slight movement. She stated, If I misbehave, this thing beeps, I have to be still. The alarm kept sounding and Licensed Practical Nurse (LPN) #5. entered the room and adjusted the bed alarm without success. She removed it and placed another one. When asked about the reason for the bed alarm, she stated, She falls a lot. During an interview on 9/30/25 at 11:06 AM with the Director of Clinical Services, she stated the bed alarm was in place so that the staff could hear her try and get up and they could assist her so that she would not fall. She stated, The bed alarm should not restrain them or keep them from moving freely and that she was unaware her bed alarm was sounding at the slightest movement. On 9/30/25 at 2:40 PM, an interview with Resident #62, she stated, I dislike the alarm immensely. She revealed that it wakes her up during the night when it sounds and scares her. Record Review of the Bed Alarm Assessment for Resident #62 revealed it was conducted on 9/03/2025. Record Review of the Use of bed/chair alarm Informed Consent for Resident #62 revealed the consent was signed on 12/16/24. Record review of Resident #62's demographic information revealed that the facility admitted resident on 11/15/2023 with a medical diagnosis that included Dementia. Record review of Resident #62's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/20/25 revealed under section C, a Brief Interview for Mental Status BIMS score of 03 which indicated that the resident was severely cognitively impaired.

Based on observation, interviews, record review, and policy review, the facility failed to prevent verbal abuse to Resident #1 for one (1) of three (3) residents reviewed for abuse/neglect. Findings Include: The facility policy titled Abuse, Neglect, and Exploitation dated approved 03/04/2025 read: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. Interview on 03/25/24 at 12:20 PM with the facility Administrator revealed that Hospital Dietary Employee #1 and Resident #1 had words in the dining area a few weeks ago when the resident had returned to the facility from being out on a pass. He stated the resident was requesting food in the dining room area of the facility when this incident occurred. The Administrator confirmed that on 03/08/24 when the verbal altercation between Dietary Employee #1 and Resident #1 occurred, Hospital Dietary Employee #1 was given a written warning at that time due to poor customer service. Record review of the Disciplinary Warning Notice #1, dated 3/8/24, issued to Dietary Employee #1 read: Date of Incident 3/8/24 Time of Incident 10:00 AM Shift AM Action Taken: Written Warning. Report of Incident: Dietary Manager and Administrator had a meeting with (Dietary Employee #1) to discuss her actions involving a resident. We discussed why they were wrong. How to not let it happen again. And the outcome if this type of behavior continues. The Disciplinary Warning Notice revealed Dietary Employee #1 received a verbal warning on 9/13/23. The document was signed by the (Dietary Manager) and dated 3/8/24. Record review of the Disciplinary Warning Notice #2 , dated 3/22/24, issued to (Dietary Employee #1) read: Date of Incident: 3/1/24-3/2/24 Time of Incident: Day Shift: AM Report of Incident: HIPPA violation 3 Day suspension and also admitted to telling Boyfriend about a resident. Will reassign HIPPA Inservice's when employee returns to work on Monday March 25th. Supervisor's recommendation to employee: 3-day suspension starting 3/22/24. Return to work on 3/25/24. Signed by the dietary manager and the employee on 3/22/24. Interview and observation on 03/25/24 at 12:45 PM with Resident #1 revealed he stated since he had been admitted to the facility, approximately four (4) weeks prior, that a female dietary worker had given him a hard time about his food choices and food requests. Resident #1 stated that almost daily he would go to the dietary department and either ask for more food or ask for something different to eat. When this dietary worker, Hospital Dietary Employee #1, was present, she would smart off at him or tell him that he should eat what was served. Resident #1 stated that he and Hospital Dietary Employee #1 would exchange words almost daily and that she would get loud with him arguing and fussing and he got loud back at her. Resident #1 stated that he went to the facility Administrator and the facility nurses and told them that he was getting into arguments with the dietary worker (Hospital Dietary Employee #1) about his food requests and that she was rude and verbally loud toward him. Resident #1 stated that the dietary worker would begin the arguments with him and that they both would cuss at each other. Resident #1 also stated that the administrator and the dietary worker had a meeting on 03/8/24 with him and Hospital Dietary Employee #1. During the meeting Hospital Dietary Employee #1 was told to give Resident #1 double portions at each meal to attempt to satisfy his hunger. Resident #1 stated that he thought the matter would be resolved after the dietary worker was told to give him double portions. Resident #1 stated that on 03/9/24, he signed himself out, as he always had, to go to the store across the street from the facility. While at the store, Resident #1 was approached by an unknown male and the male told him that he was the boyfriend of the dietary worker and that he would beat his ass in the ground if he ever talked to his girlfriend mean again. Resident #1 stated that the Hospital Dietary Employee #1 continued to work at the facility in the dietary department. Resident #1 stated that he had not seen her at the facility for a few days until the morning of 03/25/24 where she was working in the dietary department. Interview on 03/25/24 at 1:45 PM with the Assistant Director of Nursing (ADON) revealed that from her understanding, Certified Nursing Assistant (CNA) #1 was with Resident #1 when the verbal altercation between him and the dietary worker occurred. Interview on 03/25/24 at 2:00 PM with the CNA #1 revealed that she had been asked by Resident #1 for some more food and she had advised him to go to the dietary department and ask for whatever he wanted. He told CNA #1 that there was a female in the dietary department that gave him a hard time and talked badly to him when he asked for food. CNA #1 stated that she told Resident #1 that she would push him down to the dietary department in his wheelchair and that she would be with him, and she would do the talking and ask for whatever he wanted. CNA #1 stated that Resident #1 sat quietly in his wheelchair, and she asked the dietary worker #1 for the food for Resident #1. The dietary worker #1 loudly and offensively began talking about the resident as if he was not sitting there. The dietary worker stated that Resident #1 needed to eat the food that was sent to his room and stop coming down asking for food. The dietary worker stated that she was tired of Resident #1 asking for more food and that he didn't need to be in the nursing home. CNA #1 stated that the arguing and fussing between the female dietary worker and Resident #1 was bad and loud. CNA #1 stated that she reported the incident to the Director of Nursing (DON) and then later that afternoon the DON. CNA #1 failed to remove Resident #1 from the situation before the altercation escalated. Interview on 03/25/24 at 2:45 PM with the Administrator revealed that he had talked to CNA #1, but she had never told him or the DON the details or content of the argument between Resident #1 and Dietary Worker #1. The Administrator stated that he did not obtain any written statements from anyone and that he had not determined the incident to be verbal abuse, but that it was poor customer service. The Administrator did confirm Dietary Employee #1 had been suspended for 3 days for telling her boyfriend who the resident was and what he looked like that led to the resident being threatened while the resident was out on pass at a convenience store next door to the facility. The Administrator confirmed that Dietary Employee #1 returned to work on 3/25/24 after 3-day suspension. Interview on 03/25/24 at 4:30 PM with the Ombudsman revealed that she had gone to the facility on [DATE] for a regular visit with residents when Resident #1 had told her about the incident at the facility after he had been approached at the store across the street by the boyfriend of a facility dietary worker and that she was still working at the facility. The Ombudsman confirmed that when she was visiting the facility on 3/13/24 that the dietary worker was working at the facility and had not been suspended or terminated. Interview on 03/26/24 at 3:00 PM with the Director of Nurses (DON) revealed that she had talked to the CNA #1, and originally CNA #1 had not told her the full details of the incident between Resident #1 and the Dietary Worker #1. The DON stated that she talked to CNA #1 again today and that she gave the details more clearly of what had happened between Resident #1 and the Hospital Dietary Employee #1 on 03/08/24. The DON stated that when they interviewed the second dietary worker, she denied hearing the Hospital Dietary Employee #1 threaten Resident #1. The DON stated that she now understood that the facility is responsible for residents' safety when they are out alone on pass and that no employees, including hospital employees, should be allowed to talk to residents in a harsh manner. Record review of the face sheet for Resident #1 revealed that he had been admitted to the facility on [DATE] and revealed a Brief Interview of Mental Status (BIMS) score of 15 from the Minimum Data Set (MDS) dated [DATE] which documented that Resident #1 had no cognitive impairments.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure food items in the kitchen refrigerators were dated and labeled and failed to ensure kitchen equipment was clean for two (2) of three (3) kitchen tours. Findings Include: Record review of the facility policy titled, Food Storage undated, revealed Food is stored, prepared and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination .13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. f .Meat, fish, and poultry should be stored on lower shelves . Record review of the facility policy titled, Ice undated, revealed, Ice will be produced and handled in a manner to keep it free from contamination .2. Ice machines will be maintained in a clean and sanitary condition to prevent ice contamination. Record review of the Weekly Cleaning Schedule, undated, revealed under Task to be completed, 3 compartment Refrigerator, 2 compartment Refrigerator. No Date/initials were recorded on the schedule. An observation and interview during the initial tour of the kitchen on 12/12/23 at 10:00 AM, with Dietary worker #1 revealed a 2-compartment refrigerator with two (2) opened, undated 5-pound (lb) containers with a manufacturing label of Tuna Salad. An undated 5 lb clear container with a manufacturer label of Chicken Salad. A 5 lb opened and undated clear container with a manufacturer label of Pimento cheese. A bag of rolls identified by Dietary Worker #1, that was unlabeled and undated. Dietary Worker #1 confirmed these food items are always supposed to be dated and labeled. She revealed foods out of date could make a resident sick. The inside of the refrigerator was noted with food substances on the bottom of the refrigerator. Dietary Worker #1 confirmed the inside of the refrigerator needed to be cleaned. She revealed no cleaning schedule is being used but revealed we need to use one to make sure things are getting done. An observation of the three (3) compartment refrigerator revealed a half tomato identified by Dietary Worker #1 wrapped in clear plastic wrap was unlabeled and undated. She revealed this needs to go into the trash. A large clear bag was identified by Dietary Worker #1 as cheddar cheese with no label or date. A brown shipping box with no label or date was observed sitting on the third shelf of the refrigerator, Dietary Worker #1 identified the food as a thawing turkey. She revealed this shouldn't be on this shelf but should be on the bottom shelf and should be labeled and dated. A rectangular metal pan unlabeled and undated, Dietary Worker #1 identified the food as chopped turkey. She confirmed this should be labeled and dated so we know how long it's been here. An observation of the bottom of the refrigerator was noted with dried and liquid substances throughout. The outside of the refrigerator was noted with dried substances and smudges. Dietary Worker #1 confirmed this refrigerator needs a good cleaning also. An observation inside the ice maker revealed the white plastic covering was noted with black and brown speckled substances. Dietary Worker #2 revealed maintenance is supposed to clean the inside of the ice makers. We wipe down the outside. She confirmed there was a black and brown substance inside of the icemaker and revealed that it shouldn't be there, and she wasn't sure when it was last cleaned. During an interview and observation on 12/13/23 at 9:50 AM, the Dietary Manager (DM) revealed I was out yesterday, but they told me of the stuff that was found. The DM revealed there is a cleaning schedule, but we don't use it. The staff know they are supposed to keep the equipment clean and the food items are always to be labeled and dated. During an observation of the ice maker, the DM confirmed there were black and brown specks of substance. He revealed I'm not sure when it was last cleaned but it needs to be cleaned. He revealed he is ultimately responsible for ensuring the kitchen equipment is kept clean and that includes the ice maker. He revealed maintenance is responsible for cleaning it monthly. During an interview and observation on 12/13/23 at 10:00 AM, the Maintenance Supervisor revealed it is the responsibility of the maintenance department to clean and sanitize the ice maker monthly. He confirmed that the ice maker had a lot of black substances inside and revealed it looked like mold. He confirmed it doesn't look like it has been cleaned in a while. During an interview and observation on 12/13/23 at 10:10 AM, Maintenance Worker #2 confirmed that we are responsible for cleaning the inside of the ice maker monthly. He confirmed that the ice maker doesn't look clean and that the black substance throughout the top looks like mildew. He confirmed, I guess I didn't clean it and it could potentially cause sickness to a patient. An interview and record review of the cleaning schedule on 12/14/23 at 11:00 AM, the DM confirmed all kitchen equipment is on the cleaning schedule form, but we haven't been using the form. He revealed it's the responsibility of all the dietary workers to clean the equipment but ultimately, it's my responsibility to make sure that everything is in place to ensure the tasks are completed.

Based on observations, resident and staff interviews, record review and facility policy review, the facility failed to address a grievance discussed in resident council for the use of bed rails for five (5) of 12 residents that attended resident council. Resident #15, Resident #27, Resident #37, Resident #61, and Resident #66. Findings Include: Record review of the facility policy titled Resident and Family Grievances undated revealed under, Policy Explanation and Compliance Guidelines: . 8. Grievances may be voiced in the following forums: . d. Verbal complaint during resident or family council meetings . An interview with the Resident Council President (Res #27) on 12/12/23 at 12:25 PM, revealed that the residents had discussed the facility's removal of the bed rails during a previous meeting. She revealed that most of the residents want them back so that it would make it easier for them to move from side to side and turn themselves in the bed. Record review of the Resident Council meeting minutes dated 11/01/23 revealed 12 residents discussed being upset about rails being taken off their beds and a desire to have them back. Record review of the 2023 Grievance Log revealed no grievances were documented related to bed rails. The Resident Council meeting was held on 12/13/23 at 3:00 PM with 12 active resident council members present. Residents #15, Resident #27, Resident #37, Resident #61 and Resident #66 revealed their biggest concern was the facility removed all the bed rails. Resident #66 revealed she relied on her bed rails for safety, turning over in bed and pulling herself up. She revealed that now she must lie one way once she's in the bed and was unable to turn over. She revealed she had to grab onto the mattress for repositioning in bed and the entire mattress moved, which she stated was unsafe. Resident #61 revealed he wanted his side rails for turning over in bed and to assist him with getting out of bed. Resident #15, Resident #27 and Resident #37 revealed they also depended on their side rails to turn over in bed and to stay pulled up in the bed. All residents agreed they had discussed the bed rail issue with multiple staff members during a previous resident council meeting. Resident # 37 revealed she was told by staff that they had to remove them by law because they could not have anything that confined them. Resident #100 that was in attendance revealed they were told it was a state guideline that the facility was unable to allow bed rails. The residents all voiced that the facility went throughout the entire building, removing all the bed rails except for a few and they wanted them back. An interview with Social Services (SS) #1 on 12/14/23 at 9:10 AM revealed she did not attend any recent resident council meetings and no concerns had been brought to her attention out of the meetings. She revealed the residents come to her with any problems and she will initiate a grievance report. She revealed the facility held meetings where they discussed the status of the grievances and how it was handled. She stated that Resident #27 had come to her after the bed rails were removed and requested an explanation. The resident revealed to her that she needed the bed rails to turn herself in bed and to assist with getting out of bed. SS #1 revealed that the nursing department explained to the resident why the bed rails had been removed, and the resident never returned to her to voice a complaint. She stated that a grievance had not been entered for any of the residents that voiced their concerns with the removal of the bed rails in the resident council meeting dated 11/01/23. She confirmed that issues or concerns discussed in resident council that had not been addressed and resolved should be considered an unresolved grievance. An interview with Activity Director #1 on 12/14/23 at 9:05 AM, revealed that she was aware of the residents' concerns regarding removal of bed rails. She confirmed that she was present in the meeting on 11/01/23 when the residents discussed that they needed the rails for getting up, pulling themselves up and rolling over in bed. She revealed that a list was made of the residents that requested to have their rails back, and it was given to the Director of Nursing (DON). She confirmed that the residents' voiced concerns should have been written up as a grievance and acted upon. An interview with the Administrator in Training (AIT) on 12/14/23 at 10:03 AM, confirmed that the residents' concerns related to the removal of bed rails discussed in a previous resident council meeting should have been written up as a grievance. She acknowledged that issues and concerns that are mentioned in resident council that have not been addressed by the facility should be considered an unresolved grievance. She revealed that the facility misinterpreted the information that was provided to the facility related to bed rail usage and removed the residents' bed rails thinking they were doing the right thing and now realize they were not. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/23 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicates that Resident #15 is cognitively intact. Record review of the MDS with an ARD of 11/15/23 revealed under section C, a BIMS summary score of 14, which indicates Resident #27 is cognitively intact. Record review of the MDS with an ARD of 11/28/23 revealed under section C, a BIMS summary score of 15, which indicates Resident #37 is cognitively intact. Record review of the MDS with an ARD of 9/26/23 revealed under section C, a BIMS summary score of 14, which indicates Resident #61 is cognitively intact. Record review of the MDS with an ARD of 10/09/23 revealed, under section C, a BIMS summary score of 15, which indicates Resident # 66 is cognitively intact. Record review of the MDS with an ARD of 12/12/23 revealed under section C, a BIMS summary score of 15, which indicates Resident #100 is cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide dignity to residents as evidenced by leaving urinary catheter bags uncovered for two (2) of five (5) residents with a catheter. Resident #24 and Resident #89. Findings Include: Review of facility policy titled, Resident Rights, revealed, The resident has the right to a dignified existence .8. Privacy and confidentiality: The resident has a right to personal privacy . Review of a statement on facility letterhead dated 12/14/23 and signed by the Director of Nursing (DON) revealed, We do not currently have included in our policy that catheter bags have to be covered in dignity bag. Resident #24 An observation and interview on 12/12/23 at 12:01 PM, revealed Resident #24 sitting in her wheelchair. A urinary catheter bag with no privacy cover was observed hanging on the bottom of the back of the wheelchair. Observation and interview on 12/13/23 at 2:55 PM, observed Resident #24 lying in bed with the catheter bag placed in front of the privacy bag and not in the privacy covering. On 12/13/23 at 3:05 PM an observation and interview with the Director of Nursing (DON) confirmed the catheter bag is always to be in a privacy bag, if we are out of privacy bags, we use a pillowcase. She revealed this makes no sense for the catheter to be placed in front of the privacy bag instead of in it. Record review of the form LTC Physician Order Review/Renewal revealed Urinary Catheter Care with original order date of 08/28/23 ensure catheter bag is covered for dignity. Record review of Resident #24's LTC Physician Order Review/Renewal revealed she was admitted to the facility on [DATE] with diagnoses that included Bladder retention, Acquired hydronephrosis and Chronic renal failure. Record review of Resident #24's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/23/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #89 An observation on 12/12/23 at 10:45 AM, revealed Resident #89 lying in bed with a urinary catheter bag with no privacy covering hanging from the left side of the bottom of the bed visible from the hallway. Record review of the LTC Physician Order Review/Renewal physician orders physician order's dated 11/26/23 revealed, twice a day (BID), ensure catheter bag is covered for dignity. During an interview on 12/13/23 at 3:22 PM with the Director of Nursing (DON) confirmed that the urinary catheter bag is always to be covered in a privacy bag because that is a dignity and privacy issue for the resident. She revealed all nursing staff know that the catheter bags are supposed to be kept covered. She confirmed when the unit managers make their rounds, they are continually reminding the aides to make sure the bags are covered for privacy. Record review of Resident #89's LTC Physician Order Review/Renewal revealed she was admitted to the facility on [DATE] with diagnoses that included Indwelling Foley Catheter present and Congestive Heart failure. Record review of Resident #89's MDS with ARD of 10/3/23, revealed a BIMS score of 12 which indicates the resident had moderate cognitive impairment.

Based on observation, resident and staff interview, record review and facility policy review the facility failed to accommodate a resident's mobility needs for (2) two of (3) three sampled residents reviewed for mobility needs. (Resident #82, and #83) Findings include: Review of the facility policy titled, Use of Assistive Device, revealed Policy: The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity. Policy Explanation and Compliance Guidelines: 1.) Assistive devices are tool, products, types of equipment, or technology that may help individuals perform tasks and activities . 39807 Resident #82 An interview and observation on 12/12/23 at 11:10 AM, revealed the resident has a bariatric bed with no side rails. The resident stated, I used to have half rails on my bed, and I could use them to pull myself up and around in the bed, but the facility took my rails off of my bed and I want them back. The resident confirmed that the facility said they were taking all rails off the beds because they have to. The resident confirmed that she is mobile and active and liked having the rails to help turn herself and reposition while in the bed. An interview, on 12/15/23 at 8:00 AM, with the Director of Nursing (DON), regarding removal of the side rails for Resident #82, the DON stated, The resident has a bariatric bed and can move around. The DON confirmed that she was not aware the resident wanted her rails back or needed them back on. The DON confirmed that the facility was told by the Administrator to remove all the side rails from the beds. Record review of Bed Rail Use Assessment Form dated 07/06/2023 revealed that Resident # 82 benefits from the use of bed rails to assist resident with turning side to side and provides the resident with a feeling of comfort and security for fear of falling out of bed. The bed rail assessment also revealed that there was no potential risk of using the bed rails. A record review of the facility form LTC Physician Order Review/Renewal for Resident #82 revealed that she was admitted to the facility on [DATE] with a diagnoses including Depression, Endogenous obesity, Weakness, and Osteoporosis. Record review of the Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. 46013 Resident #83 An interview on 12/12/23 at 10:30 AM, with Resident #83 revealed They took my side rails and now I don't have anything to hold on to when I get up. It's hard for me to hold on to my table and the arm of the bedside commode when I'm trying to transfer to the commode. She revealed she had complained about this and was told it was because of the State that the side rail was removed. She revealed I've even tried to hold on to the bedside table, but it moves around and isn't safe. An interview on 12/13/23 at 2:30 PM, Resident #83 revealed that maintenance came in one day and just removed them. She revealed Registered Nurse (RN) #4 came in and said that the State said it was a new rule and we had to take them off. She revealed I told her and anyone who would listen to me that I needed the bar to hold onto. She stated I used it to hold onto when I got up out of bed to use the bedside commode and to position myself in the bed. The resident revealed nobody came back in to see what I needed to help me with positioning since they took them away. An interview on 12/13/23 at 3:50 PM, with the Director of Nurses (DON) revealed Resident #83 was assessed for side rails on 6/28/23 but the side rail wasn't removed until 8/30/23. The DON confirmed that Resident #83 had been positioning herself using the rail and using it to get to her bedside commode but since she could get up on her own, we removed the side rails because that's what we thought we were supposed to do. She stated we didn't give the resident the option of signing a consent form to keep the side rails because she could get in and out of bed. The DON confirmed that according to the Bed Rail Use Assessment that was completed on 8/30/23, the resident had requested to keep her side rails and confirmed it was for mobility/transferring assistance. She confirmed that nothing was put in place for mobility or transferring assistance when the side rails were removed. An interview on 12/13/23 at 4:00 PM, with Licensed Practical Nurse (LPN) #1 confirmed that the resident had requested to keep the rails and that she was using them for mobility and transferring. Record review of Bed Rail Use Assessment Form with date of assessment 6/28/23 revealed, that the Resident #83 requested to keep rails for Mobility/transferring assistance. Under Benefit(s) to using the bed rails(s) Assists resident with turning side to side, provides resident with a feeling of comfort and security for fear of falling out of bed, and assists with balance while attempting to stand/standing was marked Yes. Record review of the Physician Order Review/Renewal revealed Resident #83 was admitted to the facility on [DATE] with diagnoses that included Risk for falls, Primary osteoarthritis of left knee, Osteoporosis, and Osteoarthritis. Record review of Resident #83's MDS with ARD of 10/19/23, revealed a BIMS score of 14 which indicates the resident is cognitively intact.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to implement a care plan for a trapeze bar for (Resident #81), a side rail use care plan for (Resident #1), and a care plan for two handle adaptive cups for (Resident #41 and Resident #60) for four (4) of 29 resident care plans reviewed. Findings include: Review of the facility policy titled, Comprehensive Care Plans, revealed Policy: It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that identified in the resident's assessment . Resident #1 Review of the care plan titled, LTC (Long-Term Care) Falls IPOC (Individual Pan of Care), last updated 9/28/23, revealed Interventions: upper side rails 1/2 x (time) (2) two activated 9/28/23 . On 12/12/23 at 10:30 AM an observation revealed Resident #1 lying in bed with side rails up times four (4). A review of the care plans for Resident #1 with Registered Nurse (RN)/ Charge Nurse #2 on 12/13/23 at 2:35 PM, she revealed Resident #1 was to have the bilateral upper side rails up only and confirmed staff were not following his care plan. An interview with Certified Nurse Assistant (CNA) #3 on 12/13/23 at 2:55 PM, she revealed after review of Resident #1's Kardex profile report, he should only have two side rails up on his bed. CNA #3 confirmed she did put all four side rails up because she felt that is what the sister would want to keep him safe. CNA # 3 confirmed she did not follow the plan of care for Resident #1. Review of the Profile History report for Resident #1 revealed, ADLS-upper side rails 1/2 x (2) two. An interview with the Director of Nursing (DON) on 12/13/23 at 3:00 PM, she confirmed staff were not following the care plan for Resident #1 regarding side rails and revealed the purpose of the care plan is to direct resident specific care and failing to follow the plan of care may result in the incorrect care of a resident. Record review of the LTC (Long-Term Care) Order Review /Renewal Form Resident #1 was admitted by the facility on 1/25/19 with diagnoses of Epilepsy and recurrent seizures, Cerebral palsy, and other abnormal involuntary movements. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 11/02/23, revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 5 which indicated that he was severely cognitively impaired. Resident #81 Review of the care plan titled, LTC ADL Rehab (Rehabilitation) IPOC, last updated 11/07/23, revealed Interventions: Trapeze bar to increase mobility in bed. A review of the Activities of Daily Living (ADL) care plan with Registered Nurse (RN)/Charge Nurse # 2 on 12/13/23 at 2:46 PM, she revealed Resident #81 had a Trapeze bar to increase mobility in bed added to his plan of care as starting 11/7/23 and confirmed there was not a trapeze bar on Resident #81's bed. An interview with the Director of Nursing on 12/13/23 at 3:40 PM, she confirmed staff were not following the care plan related to the trapeze bar for Resident #81. Review of the LTC (Long-Term Care) Order Review /Renewal Form Resident #81 was admitted by the facility on 5/28/20 with diagnoses of Hemiplegia of left nondominant side and Cerebrovascular accident. Record review of the MDS Section C with an ARD of 11/02/23, revealed that Resident # 81 had a BIMS score of 12 which indicated that he was moderately cognitively impaired. Resident #41 Record review of Resident #41's Nutritional Care Plan revealed, ADAP (adaptive) equip (equipment):2 handled cup . An observation of Resident # 41 during lunch meal on 12/12/23 at 11:57 AM revealed the resident being fed by staff. 8 ounces of iced tea and water provided in a clear plastic cup along with a bottled Ensure. Observation did not reveal a 2-handled cup for the lunch meal. Record review of Resident #41's Physician Order Review/Renewal revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Anxiety, Alzheimer's Disease, Cerebrovascular Disease, Major Depressive Disorder and Self-Care Deficit. Record review of the MDS with an ARD of 11/9/23 revealed under section C, a BIMS summary score of 3, indicating Resident #41 is severely cognitively impaired. Resident #60 Record review of Resident #60's Nutritional Care Plan revealed, Handled cup with lid per occupational therapy (OT) rec (recommendations) . An observation of Resident # 60 during a lunch meal on 12/12/23 at 11:52 AM, revealed the resident feeding herself ice cream. 8 ounces of iced tea and water provided in a clear plastic cup, along with a 12 ounce can of sprite and a bottled Ensure. Observation did not reveal a handled cup for the lunch meal. An interview with the Registered Dietician (RD) on 12/12/23 at 12:05 PM, confirmed that the handled cup for Resident #41 and #60 should have been sent out by the Dietary Department with the lunch meal. An interview with the Director of Nursing (DON) on 12/15/23 at 8:36 AM confirmed that the facility did not follow the care plan for Resident #41 and #60's 2-handled cup with meals. An interview with the MDS Nurse on 12/15/23 at 9:10 AM revealed the purpose of the care plan was to provide the staff with guidelines for resident care. She revealed that if it's on the care plan, it should be done. She confirmed that Resident #41 and Resident #60's care plan was not followed for the 2 handled cup with meals. Record review of Resident #60 LTC Physician Order Review/Renewal revealed the resident was admitted to the facility on [DATE] with diagnosis that included Dementia, Rheumatoid Arthrirtis and Pressure ulcer stage 1. Record review of the MDS with an ARD of 10/13/23 revealed a BIMS score of 07, indicating Resident #60 had severe cognitive impairment. 47874

Based on staff interview, record review and facility policy review the facility failed to follow physician orders for a resident with side rails for one (1) of 27 sampled residents (Resident # 1). Findings include: A statement provided on facility letter head revealed, We do not currently have a policy on Following Physician Orders. Review of the Job Summary for Registered Nurses (RN) and Licensed Practical Nurse (LPN) provided by the Administrator in Training revealed, Duties and Responsibilities: Follows physician's orders in giving nursing care. An observation on 12/12/23 at 10:30 AM revealed Resident #1 lying in bed with side rails up times four (4). A review of the LTC (Long-Term Care) Order Review /Renewal Form revealed a physician's order for Resident #1 dated 9/28/23, upper side rails 1/2 x 2 (two) due to DX (diagnosis) of seizures and cerebral palsy with spastic involuntary movements. Review of the Bed Rail Use Assessment Form dated 9/8/23 and 12/5/23 for Resident #1 revealed, Recommended type: 1/2 length rail -left, right upper. A review of the physician's orders for Resident #1 with Registered Nurse (RN)/Charge Nurse #2 on 12/13/23 at 2:35 PM, she revealed Resident #1 was to have the bilateral upper side rails up only. An observation at the same time of Resident #1 with RN /Charge Nurse #2 she confirmed that Resident #1 had all 4 side rails up on his bed and stated he should not have all four rails up. She then revealed staff were not following the physicians order plan placed the resident at increased risk of injury with the use of the four rails. An interview with the Director of Nursing (DON) on 12/13/23 at 3:00 PM, she revealed Resident #1 should only have his top two side rails up and confirmed staff were not following the physician's orders placing the resident at increased risk for injury. Review of the LTC Order Review /Renewal Form Resident #1 was admitted by the facility on 1/25/19 with diagnoses of Epilepsy and recurrent seizures, Cerebral palsy, and other abnormal involuntary movements. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 11/02/23, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated that he was severely cognitively impaired.

Based on resident and staff interview, record review and facility policy review the facility failed to accommodate a residents mobility needs for (1) one of (3) three sampled residents reviewed for mobility needs. Resident #81 Findings include: Review of the facility policy titled, Use of Assistive Device, revealed, Policy: The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity . Policy Explanation and Compliance Guidelines: 1.) Assistive devices are tool, products, types of equipment, or technology that may help individuals perform tasks and activities . An interview with Resident #81 on 12/12/23 at 11:28 AM, he revealed the first part of November someone came and took his side rails off and stated he used the rails to help the staff with turning and positioning him and the staff said they can't use bed rails anymore. An observation at that same time revealed no side rails on Resident #81's bed. An interview with Resident #81 on 12/13/23 at 3:15 PM, revealed that a staff member he did not know came in earlier and asked about his trapeze bar for his bed and said she would make sure he got one put on the bed. Resident #81 then stated, I forgot the staff told me back in November when my side rails were taken off that they were going to put a trapeze bar on my bed and that was over a month ago. The resident confirmed he did tell staff he would try the trapeze bar to help with moving in bed. An interview with Registered Nurse/Charge Nurse (RN) #2 on 12/13/23 at 2:46 PM revealed Resident #81 should have a Trapeze bar to increase mobility in bed as of 11/7/23. An observation of Resident #81's bed RN/Charge Nurse #1 confirmed there was not a trapeze bar to the bed. An interview with the Maintenance Supervisor at 3:10 PM, he revealed had not received a requisition to apply a trapeze bar to Resident #81's bed. A record review of the requisitions submitted for November 2023 revealed no requisition for a trapeze bar. An interview with the Director of Nursing on 12/13/23 at 3:40 PM, she confirmed that Resident #81 should have had a trapeze bar applied to his bed on 11/7/23 when the side rails were removed to aide in his bed mobility and somehow it got missed and revealed a concern from not applying the trapeze bar is Resident #81 may have a decline in bed mobility status and would not be able to assist in his care. An interview with the Administrator on 12/14/23 at 9:20 AM, he revealed nursing staff was instructed to assess all residents using side rails to determine their needs. He confirmed Resident #81 should have had a trapeze bar placed on his bed to assist in his bed mobility and a physicians order should have been added for tracking instead of just adding the trapeze as an intervention. The Administrator confirmed the facility did not provide the equipment to accommodate the resident's bed mobility needs. An interview with RN #3 on 12/15/23 at 8:33 AM, she revealed she initiated the trapeze order for Resident # 81 because she thought the resident would benefit from the trapeze bar and confirmed she should have followed up to ensure the resident got the trapeze bar but did not. Review of the LTC (Long-Term Care) Order Review /Renewal Form revealed the resident was admitted to the facility on [DATE] with diagnoses of Hemiplegia of left nondominant side and Cerebrovascular accident. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 11/02/23, revealed that Resident # 81 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated that he was moderately cognitively impaired.

Based on resident and staff interview, record review and facility policy review the facility failed to accommodate hydration needs for a resident when a water pitcher was not in accessible reach of the resident for (1) one of 109 residents with water pitchers. (Resident # 50) Findings include: Review of the facility policy titled, Hydration, revealed Policy: Water will be placed where it is easily accessible to the resident. During an observation down Hallway 1 on 12/12/23 at 10:25 AM, Resident #50 was overheard hollering out for help from his room. Upon entering the room Resident #50 was observed sitting in a reclining wheelchair. When asked if he needed help, the resident stated, I need some water. The water pitcher was located on a bedside table that was across the room from where the resident was sitting in his chair. The State Agency went directly to the nurse station and notified a staff member that Resident #50 requested a drink of water. She replied, We'll get him some. During the continued initial survey rounds on 12/12/23 at 10:45 AM, Resident #50 was heard from the hallway stating, I'm so thirsty so thirsty somebody please get me some water. Upon entrance to the room Resident #50 revealed again he could not reach his water pitcher and needed someone to get it for him because he is unable to get it. An observation revealed the water pitcher was sitting on the bedside table across the room from the resident. An observation and interview with Registered Nurse (RN) #3 on 12/12/23 at 10:48 AM, she confirmed Resident #50 was unable to reach his water pitcher and was unable to propel his wheelchair and get to the water pitcher. RN #3 also confirmed Resident #50 is capable of of drinking from the water pitcher independently and the water pitcher should have been placed in residents reach at all times and the revealed concerns from the resident not having his water in reach is that it placed the resident at risk for increased thirst and possibly dehydration. An interview with the Director of Nursing on 12/13/23 at 2:45 PM, she revealed Resident #50 should have had his water pitcher always placed in his reach. She confirmed by not having the water pitcher in reach staff were not meeting the residents needs and placed the resident at increased risk for dehydration. Review of the LTC (Long-Term Care) Order Review /Renewal Form Resident #87 was admitted by the facility on 11/07/19 with diagnoses of Self- Care deficit and at risk for deficient fluid volume. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 11/08/23, revealed that Resident # 50 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated that he was moderately cognitively impaired.

Based on observation, staff interview, record review, and facility policy review the facility failed to provide a PEG (percutaneous endoscopic gastrostomy) tube feeding as ordered for one (1) of five (5) residents with PEG tubes observed during survey. Resident #54. Findings include: A review of the facility policy titled Standard Guidelines for Enteral Nutrition, revealed, .Provide the enteral feedings as ordered. An observation, on 12/13/23 at 7:30 AM of Resident #54's feeding pump at bedside, is observed as being turned off at that time. No feeding was infusing at the current time and the bag was empty. The feeding bag hanging had the date of 12/12/23 and 1700 written on it. An interview, on 12/13/23 at 7:35 AM with Licensed Practical Nurse (LPN) #1 confirmed that the bag hanging had 12/12/23 1700 written on it and that it is empty and that the pump is cut off. LPN #1 confirmed that the resident not having his feeding could cause him to be dehydrated or have weight loss. A record review of Resident #54's Physician Order revealed .Jevity 1.5 at 60ml(milliliters)/hour continuous via PEG. An interview, on 12/13/23 at 8:15 AM, with LPN #1 confirmed that she had just hung the Jevity 1.5 at 60cc/hour. LPN stated, There wasn't any feeding at the nurse's station, we had to get it from the kitchen, and they just brought it to the nursing station. LPN #1 stated, I called the night nurse, LPN #2 to see when the feeding ran out and she said it ran out at 6:00 AM on 12/13/23 and that she didn't have any more to put in the bag because the kitchen had not brought the feeding to the nurse's station. An interview, on 12/13/23 at 3:30 PM with the Administrator in Training (AIT), confirmed that Resident #54 should receive Jevity 1.5, 60cc/hour continuous. AIT stated They should have ordered the Jevity 1.5 from the kitchen on 12/12/23 so that they would not run out. AIT confirmed that the nurses also have a key to the kitchen so they could have gone and got it themselves from the kitchen. An interview on 12/14/23 at 3:15 PM with Registered Dietician (RD), regarding the weight loss for the resident and she stated that the resident had a 180-day weight loss of 15 percent. The RD stated that the weight loss occurred before the resident received his peg tube on 09/29/23 and the resident has not had any weight loss in the last month. An interview, on 12/14/23 at 6:00 PM with LPN #3 confirmed that she had placed 3 cans of Jevity 1.5 (711 milliliters) in his bag for his peg feeding at approximately 5:00 PM on 12/12/23 and that it should have lasted approximately 12 hours. An interview on 12/14/23 at 6:30 PM with LPN #2 confirmed that Resident #54's feeding pump ran out of feeding at approximately 6:00 AM on 12/13/23 and that the feeding that was ordered from the kitchen had not come to the nursing station to refill the bag. A review of the LTC (Long-Term Care) Order Review /Renewal form for Resident #54 revealed that he was admitted to the facility on [DATE] with diagnoses chronic obstructive pulmonary disease, constipation, and vascular dementia. Record review of the Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/23 revealed a Brief Interview for Mental Status (BIMS) score of 04 which indicated Resident #54 was severely cognitively impaired.

Based on observation, staff interview, record review and facility policy review, the facility failed to notify the physician of a significant change with Resident #12 related to skin concerns for one (1) of 14 records reviewed. Findings include: Review of the facility's policy entitled, Policy for Notification of Physician and Responsible Party (Reviewed 06/15/11), confirmed resident's physician, legal representative or family member must have been informed when there was a significant change in resident's physical status and a need to alter treatment. Observation and interview on 8/12/15 at 2:00 PM of Resident #12 receiving incontinent care revealed the resident had nickel sized ulcerations to right buttock and scrotum. Observation reveled Certified Nursing Assistant (CNA) #1 applied cream to those areas. When asked what type of cream was being used, CNA #1 stated, [MEDICATION NAME]. CNA #1 and CNA #2 confirmed skin issues are reported to the nurse when observed on residents. Review of treatment record for Resident #12 revealed the facility started a treatment on 08/05/15 of Calazine to buttocks QS (every shift) x 7 days and re-eval. Review of the August physician orders revealed no physician's order for this treatment. Review of the weekly Routine Skin Assessment, dated 08/04/15, revealed Resident #12 had redness from scratches. A review of the Routine Skin Assessment, dated 08/11/15, revealed Resident #12 had redness to buttocks and scrotum. [MEDICATION NAME] applied. Review of the nurse's notes from 08/04/15 to 08/12/15 revealed there was no documentation regarding identified skin issues or notification of the physician of the skin issues for Resident #12. Interview on 08/12/15 at 3:05 PM with Registered Nurse (RN) #4, confirmed body audits were performed on a weekly basis and he/she did the assessments on Resident #12. RN #4 revealed he/she was aware of skin issues to scrotum on 08/04/15; however, it was not reflected on Routine Skin Assessment. RN #4 revealed it was the nurse's responsibility to notify the physician of any skin issues for residents. When asked why the physician was not notified, RN #4 stated, I just didn't do it. RN #4 confirmed there was not an order on the chart for the Calazine started on 08/05/15. Interview on 08/13/15 at 9:15 AM with CNA #1 about when the wound appeared revealed the place on scrotum has been there a few days. Review of the Face Sheet revealed the facility admitted Resident #12 on 05/03/10 with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/17/15 revealed Resident #12 had severe cognitive impairment on the Brief Interview for Mental Status (BIMS) per staff interview.

Based on record review, staff interview, and facility policy review, the facility failed to develop and implement comprehensive care plans to address skin/wound assessments, wound/skin care treatments, and bladder incontinence for three (3) of twenty-four (24) care plans reviewed, Resident #5, Resident #12, and Resident #19. Findings include: Review of the facility's policy entitled, Care Plan Policy, (undated), revealed the care plan will address prevention of avoidable decline in order to attain the resident's highest practicable physical well-being. Define and implement interventions in accordance with resident's needs, goals, and recognized standards of practice. 3) Monitor and evaluate the resident's response to the plan of care. It further revealed the resident's care plan would include, measurable objectives and timetables to meet a resident's nursing, mental, and psychosocial needs as identified in the comprehensive assessment. The care plan policy also read, interventions will already have been implemented to address priority problems prior to completion of the comprehensive admission care plan. Resident #5 Review of the Comprehensive Care Plan for Resident #5 for an Unstageable Ulcer to the left heel revealed no interventions to address weekly skin assessment of the Decubitus Ulcer. An interview with the Director of Nursing (DON) on 08/12/15 at 2:30 PM confirmed there were no interventions in place to address weekly skin assessments or weekly measurements for the wound. The DON stated the care plan would be revised to include these interventions. Review of the Physicians Orders dated August 2015 revealed Resident #5 was admitted by the facility on 08/01/13 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/07/15 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated Resident #5 was moderately cognitively impaired. Further review of the MDS revealed Resident #5 was coded a yes for Stage one (I) or higher pressure ulcers, and a one (1) for an unstaged slough/eschar area. Resident #12 Review of the care plan for Resident #12 revealed a problem addressing risk for skin breakdown related to [DIAGNOSES REDACTED]. Further review of this care plan revealed skin issue that was being treated as of 08/05/15 had not been addressed and there were no interventions in place to address prevention of Resident #12 scratching him/herself on the Care Plan. Review of treatment record on 8/12/15 at 2:25 PM revealed a treatment was started on 08/05/15 for Calazine to buttocks QS (every shift) x 7 days and re-eval. Review of the weekly Routine Skin Assessment for Resident #12 dated 08/04/15 revealed documentation of redness from scratches and the 08/11/15 documentation revealed redness to buttocks and scrotum. [MEDICATION NAME] applied. Interview on 8/12/15 at 3:15 PM with Director of Nursing (DON), revealed the nurses noting the physician's orders [REDACTED]. Interview on 8/13/15 at 11:45 with Registered Nurse #3 confirmed the nurse noting the order is supposed to update the care plan. Review of the Face Sheet revealed the facility admitted Resident #12 on 05/03/10 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/17/15 revealed Resident #12 had severe cognitive impairment on the Brief Interview for Mental Status (BIMS) per staff interview. Resident #18 Review of the medical record on 8/13/15 at 11:15 AM revealed no interim care plan in place for new admit Resident #18. Interview with RN #3 revealed care plans are not placed on the chart until 14 days following admission. When asked how do nurses know what measures to follow to address the resident's care, RN #3 stated, I've been here 4 years and we've always gone by the orders on the chart until the care plan is done. Review of the Face Sheet revealed Resident #18 was admitted on [DATE]. Review of the admission orders [REDACTED]. Resident #19 Review of Resident 19's care plan revealed there was not a care plan developed for Urinary Incontinence. Review of the admission MDS assessment with an ARD of 07/20/15, revealed the Care Area Assessment (CAA) triggered for Urinary Incontinence and a care plan would be developed for Resident #19. Interview on 08/13/15 at 11:45 AM with RN #3, confirmed the care plan was not developed after triggering on admission MDS assessment. When asked why care plan wasn't done, RN #3 stated, I guess I just missed it. Review of the Face Sheet revealed the facility admitted Resident #19 on 07/13/15. Review of the admission orders [REDACTED]. Review of the admission MDS assessment dated [DATE] revealed Resident #19 scored a 15 on the BIMS which indicated cognitively intact.

Based on record review, staff interview, and observation, the facility failed to provide care for the highest wellbeing of a resident as evidenced by failure to notify the physician or update care plans for a resident with non-pressure related skin ulcers after areas were identified for Resident #12 for one (1) of eight (8) residents reviewed at risk for skin concerns. Findings include: Resident #12 On 08/12/15 at 2:00 PM, an observation of Resident #12's incontinent care revealed the resident had nickel size ulcerations on the right side of buttocks and scrotum. Observation revealed Resident #12 appeared to be in pain as evidenced by facial grimacing and body jerking when being wiped. CNA #1 applied cream to the resident's right buttocks and scrotum. CNA #1 explained to the surveyor that the cream being applied was [MEDICATION NAME]. CNA #1 stated any skin issues found on a resident were reported to the nurse. Review of the written and cumulative Physician order [REDACTED]. Review of the nurse's notes from 08/04/15 to 08/12/15 revealed there was no documentation regarding identified skin issues or notification of the physician of the skin issues for Resident #12. A review of the Treatment Record revealed the facility initiated a treatment on 08/05/15 for Calazine to buttocks QS (every shift) x 7 days and re-eval. A review of the 08/04/15 Routine Skin Assessment revealed Resident #12 had redness from scratching and the assessment on 08/11/15 revealed the resident had redness to buttocks and scrotum. Interview on 08/12/15 at 3:05 PM with Registered Nurse (RN) #4, confirmed body audits were performed on a weekly basis and he/she had done the assessments on Resident #12. RN #4 revealed he/she was aware of skin issues to scrotum on 08/04/15; however it was not reflected on Routine Skin Assessment on that date. RN #4 revealed it is the nurse's responsibility to notify the physician of any skin issues for residents. When asked why physician was not notified, RN #4 stated, I just didn't do it. RN #4 confirmed there was not an order written [REDACTED]. Further review of this care plan revealed the skin issue being treated as of 08/05/15 had not been addressed, and there were no interventions implemented to address prevention of Resident #12 scratching himself. Interview with CNA #1 on 08/13/15 at 9:15 AM revealed the place on Resident #12's scrotum had been there a few days. Review of the Face Sheet revealed the facility admitted Resident #12 on 05/03/10 with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/17/15 revealed Resident #12 had severe cognitive impairment on the Brief Interview for Mental Status (BIMS) per staff interview.