Every finding on record at New Brighton Care Center

Based on interview and document review, the facility failed to develop and document a facility assessment that includes plans for the recruitment and retention of staff. This had the potential to affect all 43 residents.The provided facility assessment dated [DATE], included sections on how to obtain staffing records, a general staffing plan, staff assignments, staff training and competencies, however did not include a section on staff recruitment and retention. During interview on 11/18/25 at 4:20 p.m., the administrator confirmed the facility assessment did not include information on the facilities plan to maximize recruitment and retention of direct care staff. Facility policy for a facility assessment requested and not provided.

Based on interview and document review, the facility failed to submit complete and accurate direct care staffing information based on payroll and other verifiable and auditable data, for 1 of 1 quarters reviewed (quarter 3), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This had the potential to affect all 43 residents residing at the facility.Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D for April 1st to June 30th 2025, identified Excessively Low Weekend Staffing, No registered nurse (RN) Hours, and Failed to have licensed nursing coverage 24 hours a day. Report also triggered for One Star Staffing Rating. Dates identified for no RN coverage include 5/4/25, 5/31/25, 6/15/25, 6/22/2025, 6/28/25, and 6/29/25. Dates identified for not having 24 hour licensed nursing coverage included 5/3/25, 5/4/25, 5/18/25, 5/31/25, 6/1/25, 6/15/25, 6/28/25, 6/29/25. Review of schedules for April 1st to June 30th 2025, included RN coverage for all dates, 24 hour licensed nursing coverage for all dates, and staffing equal to weekdays for weekend coverage. During interview on 11/18/25 at 4:01 p.m., human resources (HR)-A stated she submitted the PBJ data quarterly. She submitted the hours worked for exempt and non-exempt staff including all agency and contracted staff. HR-A stated she did not submit the Quarter 3 data because she started after that date, However, she had submitted successful since. During interview on 11/18/25 at 4:01 p.m., administrator stated a sister agency submitted the PBJ data for Quarter 3, so she was unsure exactly where the error took place. The administrator stated it was her guess that agency hours were not calculated and submitted. The administrator was aware of the discrepancy and has audited the hours to ensure all days had RN coverage, 24 hour licensed staffing and adequate weekend staffing. Faculty policy for PBJ reporting requested and not provided.

Based on interview and record review, the facility failed to provide ongoing communication to residents about their rights for 2 of 2 residents (R12, R28) who attended the resident council meetings.R12's admission minimum data set (MDS) dated [DATE], included R12 was cognitively intact and could understand others and make herself understood.R28's quarterly MDS dated [DATE], included R28 was cognitively intact and could understand others and make herself understood.Review of resident council meeting minutes for July 2025, August 2025, September 2025 and October 2025, failed to include information on resident rights.During a meeting about resident council on 11/19/25 at 1:30 p.m., R12 and R28 confirmed they did not discuss resident rights in the resident council meetings. R12 and R28 stated they do not remember going over the resident rights during admission. R12 and R28 were not aware resident rights were posted on a bulletin board in the building.During interview on 11/20/25 at 9:23 a.m., activities director (AD)-A confirmed she organized and runs the resident council meetings. AD-A stated they do not review resident rights as part of resident council meetings. However, would answer any questions about rights that a resident specifically brought up. AD-A confirmed the meeting minutes provided were an accurate summary of what was discussed at resident council meetings.Facility provided policy on resident council dated February 2011, failed to include information on reviewing resident rights.

During observation, interview and document review, the facility failed to ensure food was prepared and distributed under sanitary conditions for 1 of 1 food trays dished up. During observation 11/19/25 starting at 11:10, cook (C - A was preparing the midday meal. C-A was wearing a pair of disposable gloves while setting up trays to be used for meal service.At 11:15 a.m., C-A left the kitchen by touching the door handle to open the door while keeping his gloves on. C-A returned less than 1 minute after holding a kitchen appliance with gloves still on his hands. C-A did not wash his hands or put new gloves on upon returning to the kitchen. C-A again opened the door with gloved hands and took a can of soup from a staff person to warm up for a resident. C-A did not wash hands or change his gloves.At 11:20, C-A placed oven mitts over gloves, took the temperature on breadsticks in the oven, and removed the oven mitts. C-A did not change his gloves or wash his hands.At 11: 23 a.m., C-A left the kitchen with gloves on by opening the door using the door knob and brushing his gloved right hand on the outside of the door. C-A returned to the kitchen wearing gloves and did not wash his hands or put on new gloves.At 11:27 a.m., C-A left the kitchen with some dirty cooking sheets with gloved hands. C-A returned to the kitchen wearing gloves and did not wash his hands or put on new gloves.At 11:35 a.m., C-A again left the kitchen with gloved hands by touching the door knob. C-A returned to the kitchen wearing gloves and did not wash his hands or put on new gloves. C-A again put oven mitts over his gloved hands to open the oven and temp a lasagna. C-A removed oven mitts, and wrote down the temperature of the lasagna with gloved hands. Gloves were not changed and hands were not washed.At 11:50 a.m., C-A starts to serve up food onto resident trays for service. C-A plated bread sticks by picking them up with gloved hand and placing them on the resident's plate.During interview on 11/19/25 12:00 p.m., the administrator stated gloves should have been changed every time a kitchen staff entered the kitchen or went from a dirty to clean task and that hands should be washed when gloves were changed.During interview on 11/20/25 at 9:02 a.m., dietary manager (DM)-D stated all employees complete infection control training online when they first start and yearly. DM-D stated she does do spot checks to ensure gloves are being worn during meal prep and services, but has not completed an audit of a meal prep for an extended period of time to ensure proper hand hygiene was being completed. During interview on 11/20/25 at 12:46 p.m., C-A confirmed he did not wash his hands and change his gloves every time he exited and reentered the kitchen. C-A stated they were taught to wash hands and change gloves whenever he went from a dirty to clean task and any time he enters the kitchen. Facility policy titled Food Preparation and Service dated 2022, included food preparation staff must adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Gloves were to be worn when handling food directly and changed between tasks.

Based on observation, interview and document review, the facility failed to ensure proper personal protective equipment (PPE) was used when providing cares for 1 of 1 resident (R37) reviewed for enhanced barrier precautions (EBP). Further, the facility failed to properly disinfect shared equipment between use for 1 of 1 glucometer (medical device used to check blood sugar levels) reviewed during medication administration.R37's admission minimum data set (MDS) dated [DATE], included R37 received nutrition through a parenteral or tube feeding source while a resident. R37's care plan dated 11/21/25, included R37 was on EBP due to his gastronomy tube (G tube or a surgically placed tube that provides direct access to the stomach for feeding, hydration or medications) . During observation on 11/19/25 at 7:04 a.m., registered nurse (RN)-A and the director of nursing (DON) entered R37's room after preparing medications for tube feeding administration. R37's door had signage for enhanced barrier precautions (EBP) including which PPE should be applied while providing cares. RN-A and DON did not don gown or gloves upon entering R37's room. RN-A and DON boosted R37 in bed by grasping draw sheet and repositioning him higher up in bed for comfort. Both RN-A and DON where in contact with bedding and resident during repositioning. RN-A completed administration of tube feeding medications while wearing gloves and following proper hand hygiene and gloving procedures. During interview on 11/19/25 at 8:00 a.m., RN-A confirmed she was not wearing a gown during administration of medications via tube feeding. RN-A confirmed R37 was on EBP and stated she had received education on EBP. RN-A stated she would wear additional PPE if she were to be doing wound care or assisting the nurse aides with changing a brief. During interview on 11/19/25 at 8:05 a.m., DON confirmed proper PPE was not worn during repositioning or administration of tube feeding medications. Facility policy for Infection Prevention and Control for Transmission-Based Precautions dated 2023, included the purposed of EBP was to prevent opportunities for transfer of multi-drug resistant organisms (MDRO) to employee's hands or clothing during cares. The policy included PPE should have been worn when providing care involving a feeding tube, or during transfers. Glucometer R36's quarterly MDS dated [DATE], included R36 was conatively intact and had diagnoses of diabetes mellitus (a disease where the body either does not produce enough insulin or not use insulin effectively), depression and arthritis. R36's order summary report dated 11/22/25, included blood glucose monitoring four times per day. During observation of medication administration on 11/19/25 at 8:14 a.m., licensed practical nurse (LPN)-A completed a blood sugar check using a shared glucometer on R36. R36 brought the shared glucometer out of R36's room and placed it on top of the medication cart in a box of glucometer testing supplies. LPN-A did not immediately clean the glucometer. At 8:27 a.m., LPN-A collected a purple top (Super Sani-Cloth germicidal) disinfecting wipe container form the nurses' station and cleaned the glucometer. LPN-A cleaned the glucometer by wiping down both sides for a total of approximately 10 seconds and discarding the wipe. During interview on 11/19/25 at 8:48 a.m., LPN-A stated he cleaned the glucometer for approximately 30 seconds. LPN-A stated he was unsure what the required contact time was for cleaning but usually cleaned for about 1 minute. LPN-A confirmed he did not clean for the 2 minutes the label specified. During interview on 11/19/25 at 10:20 a.m., director of nursing (DON) confirmed glucometers should be cleaned with a purple top disinfecting wipe per the label direction to ensure proper contact time. The DON stated it was important for infection control. The DON stated the glucometer should be wiped down immediately after use before putting it away. Facility policy for disinfecting blood glucose monitors dated 2001, included the surface should be wiped 3 times horizontally, 3 times vertically, discard the wipe and get a new one, repeat the steps followed by wrapping the meter with a disinfecting towelette for 2 minutes prior to the next use.

Based on interview and document review, the facility failed to ensure an allegation of potential abuse was reported timely to the State agency (SA), for 1 of 1 residents (R1) reviewed for an allegation of abuse. Findings include: R1's annual Minimum Data Set (MDS), dated [DATE], identified R1 was cognitively intact with mild depression. Diagnoses included bipolar disorder, anxiety, depression, morbid obesity, chronic pain, and arthritis. R1 required partial to moderate physical assistance with upper body dressing and substantial/maximum assistance with lower body dressing and bed mobility. R1's weight was 379 pounds, and she was free of upper and/or lower extremity range of motion impairments. R1's comprehensive care plan identified on 1/27/20, R1 was a vulnerable adult due to her living in a skilled nursing facility. Interventions directed any suspicions of abuse/neglect, or maltreatment, to be investigated and reported as necessary to the proper agencies. Review of facility form titled A Grievance report, provided on 5/23/25, identified R1 reported a grievance on 5/19/25, related to 'rough' cares and bedside manners on 5/18/25. A Date Parties Informed of Findings column showed a handwritten entry: still processing/investigating. Review of facility form titled A facility Grievance Form, dated 5/19/25, identified R1 reported to social worker (SW)-A that during dressing cares on 5/18/25, at approximately 4:30 p.m., nursing assistant (NA)-A was 'rough' and 'rude and crude.' During this, R1 informed NA-A that NA-A was rude to which NA-A responded, 'I've never been called rude before.' R1 reported her left shoulder was sore and requested that NA-A no longer work with her. The form identified there was a NA witness; however, the form did not identify which NA. The form's initial investigation/response section identified the director of nursing (DON), assistant director of nursing (ADON), and/or NA Manager ([NAME])-A would follow up with the NA. Additional form sections related to Summary of Investigation Conclusion, which was to be completed by department director/designee within 72-hours, designation if the quality concern was confirmed or not, Corrective Action Taken by the facility as a Result of the Concern, and a signature and date section for the resident, social services director, DON, and the administrator were all blank. Review of a provider progress note, dated 5/19/25, identified the following information: Later in the day receive[d] a phone call from nursing reporting [R1] is c/o (complaining of pain) in her shoulder after an aid[e] 'being rough taking her shirt off' and is requesting an xray [sic]. No other concerns today. Review of R1's progress notes, dated 5/18/25 through 5/27/25, lacked information related to the 5/18/25, incident and/or her 5/19/25 allegation. During an interview on 5/23/25, at 11:13 a.m., SW-A identified she was the director of social services. She stated the nursing leadership continued to work on R1's allegation. She was unaware of the status of the investigation; however, she indicated R1's shoulder x-ray was negative, and NA-A was placed on the NA agency do not return list in response to the allegation. SW-A explained she interviewed R1 about the allegation on 5/19/25, where R1 stated NA-A took off R1's dress roughly and was jerking her around. She identified R1, at times, was grievance happy, had borderline traits, and was attention seeking. SW-A identified any possible abuse claims were to be reported to the SA, especially if there was evidence of any abuse; however, she did not report R1's allegations to the SA as she did not consider R1's allegation abuse based on R1's interview. Despite this, later in the interview, SW-A stated R1's allegation should have been reported, despite no evidence, as R1 reported an allegation of rough cares, and that management was not there when the incident occurred. They should have taken R1's word for it pending their investigation. SW-A stated she would be expected to report R1's allegation within 24 hours or ideally as soon as she heard about it. During an interview on 5/23/25, at 11:29 a.m., the DON identified R1's allegation continued to be investigated. The DON stated R1's allegation was not reported to the SA as no one was hurt, along with the incident did not rise to the level of actual abuse, and R1's history related to grievances and allegations. She explained the facility utilized an abuse reporting algorithm; however, this was not utilized as R1 was not injured by the situation. R1 was content with NA-A no longer being allowed to work at the facility, and based on reports from [NAME]-A, it was her understanding R1 did not use the word rough during the interview. The DON stated she expected a SA report to be filed when there was any type of injury, within two hours of the injury. Additionally, she expected if any staff were to witness abuse, or if a resident alleged abuse, staff were to report it right away to their supervisor and the administrator. Due to this, she expected NA-B would have alerted the nurse on 5/18/25, of R1's and NA-A's interaction for an investigation to begin and administrator notification to occur right away. She confirmed she first heard about the allegation on 5/19/25. She was unable to remember the time frame she was notified. During an interview on 5/23/25, at 11:33 a.m., [NAME]-A stated any allegations of abuse were to be reported to the charge nurse and the DON immediately. Additionally, she would expect staff to report witnessed rough cares immediately to leadership. She denied any recent resident abuse allegations: however, she reported a recent event where an agency staff (NA-A) was rough with a resident (R1). This was reported to the DON right away on the morning of 5/19/25, and NA-A was placed on the due not return list. She currently was unaware of the investigation status of R1's allegation. [NAME]-A identified during her interview with R1, R1 stated NA-A pulled her shift off roughly and had a bad attitude. [NAME]-A denied R1 stated NA-A swore at her. Additionally, [NAME]-A indicated she interviewed NA-B who confirmed NA-A presented a bad attitude towards R1 and was not being gentle. [NAME]-A denied this was abuse but it was not gentle care taking. Thus, this was not reported to the SA. During an interview on 5/23/25, at 11:43 a.m., the ADON stated any witnessed abuse or abuse allegation, along with the word rough being verbalized, were to be reported to the DON and the administrator right away. Upon investigation, if there were any injuries or harm identified or if the resident used the actual word abuse, then it was reported to the SA within two hours and measures were put into place which ensured resident safety. The ADON stated abuse was anything which caused injury either physically or psychosocially, such as physical and/or verbal abuse. She explained physical abuse included, but was not limited to, intentionally being rough with a resident. The ADON stated, on 5/19/25, she was updated in the morning about R1's allegation; however, she did not personally speak with R1. She explained it was hard to say if R1's allegation rose to the level of abuse that required reporting to the SA but then followed up with a statement she did not think it did. The ADON identified they conducted their own internal investigation and based on R1's history of being hard on staff, especially pool agency staff, and their placing NA-A on the do not return list, along with R1 not being bruised or injured, based on the x-ray, along with a witness, they have pretty much completed their investigation. During an interview on 5/23/25, at 12:00 p.m., R1 stated NA-A was very aggressive with her, was rough, and felt that NA-A abused her. On 5/18/25, after church around 3:30 p.m., NA-A and NA-B assisted her to remove a dress while she laid in bed. During this, NA-A took R1's arm and bent it backwards in a very quick motion while she pulled on R1's arm to get it out of the sleeve. NA-A did not allow R1 to assist. R1 told NA-A she was rough, and NA-A responded no one had ever told her she was rough before. NA-B attempted to calm R1 down as she could see the pain in my eyes. After, NA-A attempted to get R1's other arm out of the dress; however, R1 finished this by herself as NA-A continued to state, Let's get the skirt off and the rest of the clothing. As R1 started to roll over to remove the rest of the clothing, NA-A stated, in a loud tone of voice, That was a dumb thing to do bitch. After, R1 was assisted to roll the other way and the skirt was removed. In response to the incident, NA-B stated to NA-A that she had enough of NA-A and asked her to get out of the room; however, she remained and R1 had to ask her to leave, which she finally did. R1 stated this incident caused her shoulder injury and increased pain. The pain had improved but was still sore and required continued ice pack treatment despite a negative x-ray. Additionally, R1 stated she experienced nightmares that startled her awake and made her cry as she relived the experience when she slept. She denied informing staff about the nightmares. She was relieved these improved, but she was still bothered by them. During an interview via telephone on 5/27/25, at 10:02 a.m., NA-B stated if she were to witness abuse she would take over and ask the other staff to leave and then she would update management and/or call the hotline. She denied ever witnessing abuse at the facility. She explained rough cares occurred when an aide was not being as gentle as they should be and rushed through the cares, such as pulling aggressively or not being as patient as they should. NA-B explained she witnessed NA-A pull on R1's dress sleeve to get it freed which I guess caused [R1] some discomfort. R1 told NA-A to be gentle but NA-B did not feel NA-A was overly rough: just pulling on the dress .like you would have to. NA-B explained the action was not necessarily rough but it was not as gentle as [R1] would have liked. She explained NA-A reported a headache, grumpy, and not feeling good where NA-A rushed the cares and was not as gentle as she should have been. She explained if she were the aide who helped in that situation, she would have maybe [done things] a little bit differently. She would have had R1 lean to the side, so she was not pulling so hard. She denied R1 instructed NA-A to leave the room. NA-B did not consider NA-A's actions as abuse and thus she did not feel this needed to be reported to the nurse but if the interaction were more aggressive, she would have reported it: it is a fine line between gentle and rough, but based on R1's body habitus and how we had to remove the dress. NA-B stated R1 commented on the situation to her after the incident and that R1 appeared to have increased shoulder pain as R1 utilized ice packs currently to the area and the incident from 5/18/25, may have caused the increased pain. During a telephone interview on 5/27/25, at 10:53 a.m., NA-A stated abuse occurred when staff were being too aggressive, among other things. If she witnessed abuse, she was to report to the supervisor immediately. NA-A stated on 5/18/25, she and NA-B assisted R1 to change into a gown. When she assisted R1 to take off her shirt, R1 told her firmly she was being rough. NA-A immediately stopped and asked R1 how she was rough. R1 did not respond. NA-B helped R1 remove the rest of the shirt and helped R1 with the gown, but she continued with the rest of the cares once NA-B left the room. NA-A explained, when she tried to pull the shirt bottom from under R1, she did not realize R1 could sit up and move as much as she did, so that when she pulled, R1 sat up, and the action used more effort than required. This caused the movement to be a quicker, jerking motion. She declined she was rough with the cares; however, she stated she maybe used more force then if I would have known she could move. During an interview on 5/27/25, at 1:46 p.m., the administrator expected staff to protect residents and report abuse within two hours, but as soon as possible. She then expected staff to contact her right away. Additionally, if rough care was reported, she expected staff to stop what they are doing, get additional assistance, and report the incident to the nurse. The administrator was updated and questioned if staff should report the incident. It was decided not to report as there was no injury; however, she directed the incident to be treated like a grievance. She denied knowledge of the status of the investigation as the grievance form was yet to be provided to her for her review and signature, but she reported involvement in the investigation conversations. Review of facility policy titled An Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, dated 2022, identified All reports of resident abuse, neglect, . are reported to local, state, and federal agencies (as required by current regulations). In addition, the administrator was to be immediately updated. Immediately was defined as within two hours of an allegation that involved abuse or resulted in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or serious bodily injury.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of potential abuse for 1 of 1 residents (R1) who reported an allegation of potential abuse by staff. Findings include: R1's annual Minimum Data Set (MDS), dated [DATE], identified R1 was cognitively intact with mild depression. Diagnoses included bipolar disorder, anxiety, depression, morbid obesity, chronic pain, and arthritis. R1 required partial to moderate physical assistance with upper body dressing and substantial/maximum assistance with lower body dressing and bed mobility. R1's weight was 379 pounds, and she was free of upper and/or lower extremity range of motion impairments. R1's comprehensive care plan identified, on 1/27/20, R1 experienced an activity of daily living (ADL) self-care performance deficit related to weakness, obesity, and history of a CVA (stroke). Interventions directed setup assist of one staff for upper body dressing and two staff for lower body dressing, along with the use of bilateral half siderails for R1 to assist staff during cares. In addition, the care plan identified R1 was a vulnerable adult due to her living in a skilled nursing facility. Interventions directed any suspicions of abuse/neglect, or maltreatment, were to be investigated. Review of form titled Grievance report, provided on 5/23/25, identified R1 reported a grievance on 5/19/25, related to 'rough' cares and bedside manners on 5/18/25. A Date Parties Informed of Findings column showed a handwritten entry: still processing/investigating. Review of facility Grievance Form, dated 5/19/25, identified R1 reported to social worker (SW)-A that during dressing cares on 5/18/25, at approximately 4:30 p.m., nursing assistant (NA)-A was 'rough' and 'rude and crude.' During this, R1 informed NA-A that NA-A was rude to which NA-A responded, 'I've never been called rude before.' R1 reported her left shoulder was sore and requested that NA-A no longer work with her. The form identified there was a NA witness; however, the form did not identify the NA. The form's Initial investigation/response section identified the director of nursing (DON), assistant director of nursing (ADON), and/or NA Manager ([NAME])-A would follow up with the NA. Additional form sections related to Summary of Investigation Conclusion, which was to be completed by department director/designee within 72-hours, designation if the quality concern was confirmed or not, Corrective Action Taken by the facility as a Result of the Concern, and a signature and date section for the resident, social services director, DON, and the administrator were all blank. Review of a provider progress note, dated 5/19/25, identified the following information: Later in the day receive[d] a phone call from nursing reporting [R1] is c/o (complaining of pain) in her shoulder after an aid[e] 'being rough taking her shirt off' and is requesting an xray [sic]. No other concerns today. Review of R1's progress notes, dated 5/18/25 through 5/27/25, lacked information related to the 5/18/25, incident and/or her 5/19/25 allegation. R1's medical record lacked evidence a nursing and body/skin assessment were conducted on 5/19/25, after the allegation of rough care was expressed or that R1 was monitored to address any issues related to the incident. During an interview on 5/23/25, at 11:13 a.m., SW-A identified she was the director of social services. She stated the nursing leadership continued to work on R1's allegation. She was unaware of the status of the investigation; however, she indicated R1's shoulder x-ray was negative, and NA-A was placed on the NA agency do not return list in response to the allegation. SW-A explained she interviewed R1 about the allegation on 5/19/25, where R1 stated NA-A took off R1's dress roughly and was jerking her around. She identified R1, at times, was grievance happy, had borderline traits, and was attention seeking. SW-A did not consider R1's allegation abuse based on R1's interview; however, as management did not witness the incident, they should have taken R1's word for it pending their investigation. During an interview on 5/23/25, at 11:29 a.m., the DON identified R1's allegation continued to be investigated. The DON stated their investigation identified no one was hurt and R1's allegation did not rise to the level of actual abuse. The DON indicated R1 had a history related to grievances and allegations. R1 was content with NA-A no longer being allowed to work at the facility, and based on reports from [NAME]-A, it was her understanding R1 did not use the word rough during the interview. The DON indicated she first heard about the allegation on 5/19/25, from [NAME]-A. She was unable to remember the time frame she was notified. She stated [NAME]-A was involved in the investigation and she explained staff investigated by interviewing R1, NA-A, and NA-B; however, no additional staff were interviewed for additional insight, nor any other residents to determine any additional potential concerns related to care delivered from NA-A. The DON was unaware if the three interviews conducted were documented. The DON denied staff were educated related to the concerns addressed by the allegation and/or the investigation. During an interview on 5/23/25, at 11:33 a.m., [NAME]-A denied any recent resident abuse allegations: however, she reported a recent event where an agency staff (NA-A) was rough with a resident (R1). This was reported to the DON right away on the morning of 5/19/25, and NA-A was placed on the do not return list. She currently was unaware of the investigation status of R1's allegation. [NAME]-A identified during her interview with R1, R1 stated NA-A pulled her shirt off roughly and had a bad attitude. [NAME]-A denied R1 stated NA-A swore at her. Additionally, [NAME]-A indicated she interviewed NA-B who confirmed NA-A presented a bad attitude towards R1 and was not being gentle. [NAME]-A denied this was not abuse but it was not gentle care taking. Additionally, she denied documentation related to R1 or NA-B's interview, but she requested NA-A to email her a statement. She however, did not document her interview with NA-A. [NAME]-A denied additional staff interviews or other resident interviews. Additionally, no staff were educated related to the concerns addressed by the allegation and/or the investigation. During an interview on 5/23/25, at 11:43 a.m., the ADON stated abuse was anything which caused injury either physically or psychosocially, such as physical and/or verbal abuse. She explained physical abuse included, but not limited to, intentionally being rough with a resident. The ADON stated, on 5/19/25, she was updated in the morning about R1's allegation when she reviewed a voice mail R1 left her; however, she did not personally speak with R1 as others were directed to. She explained it was hard to say if R1's allegation rose to the level of abuse but then followed up with a statement she did not think it did. The ADON identified they conducted their own internal investigation and based it on R1's history of being hard on staff, especially pool agency staff, and their placing NA-A on the do not return list, along with R1 not being bruised or injured, based on the x-ray, along with a witness, they have pretty much completed their investigation. She indicated R1 and two of the aides involved were talked to; however, she did not think any additional staff or residents were interviewed despite these interviews being something that was completed when abuse was alleged. The ADON explained education was always ongoing, but no recent education was provided related to this incident that she was aware of. During an interview on 5/23/25, at 12:00 p.m., R1 stated NA-A was very aggressive with her, was rough, and felt that NA-A abused her. On 5/18/25, after church around 3:30 p.m., NA-A and NA-B assisted her to remove a dress while she laid in bed. During this, NA-A took R1's arm and bent it backwards in a very quick motion while she pulled on R1's arm to get it out of the sleeve. NA-A did not allow R1 to assist. R1 told NA-A she was rough, and NA-A responded no one had ever told her she was rough before. NA-B attempted to calm R1 down as she could see the pain in my eyes. After, NA-A attempted to get R1's other arm out of the dress; however, R1 finished this by herself as NA-A continued to state, Let's get the skirt off and the rest of the clothing. As R1 started to roll over to remove the rest of the clothing, NA-A stated, in a loud tone of voice, That was a dumb thing to do bitch. After, R1 was assisted to roll the other way and the skirt was removed. In response to the incident, NA-B stated to NA-A that she had enough of NA-A and asked her to get out of the room; however, she remained and R1 had to ask her to leave, which she finally did. R1 stated this incident caused her shoulder injury and increased pain. The pain had improved but was still sore and required continued ice pack treatment despite a negative x-ray. Additionally, R1 stated she experienced nightmares that startled her awake and made her cry as she relived the experience when she slept. She denied informing staff about the nightmares. She was relieved these improved, but she was still bothered by them. During an interview via telephone on 5/27/25, at 10:02 a.m., NA-B stated if she were to witness abuse she would take over and ask the other staff to leave and then she would update management and/or call the hotline. She denied ever witnessing abuse at the facility. She explained rough cares occurred when an aide was not being as gentle as they should be and rushed through the cares, such as pulling aggressively or not being as patient as they should. NA-B explained she witnessed NA-A pull on R1's dress sleeve to get it freed which I guess caused [R1] some discomfort. R1 told NA-A to be gentle but NA-B did not feel NA-A was overly rough: just pulling on the dress .like you would have to. NA-B explained the action was not necessarily rough but it was not as gentle as [R1] would have liked. She explained NA-A reported a headache, grumpy, and not feeling good where NA-A rushed the cares and was not as gentle as she should have been. She explained if she were the aide who helped in that situation, she would have maybe [done things] a little bit differently. She would have had R1 lean to the side, so she was not pulling so hard. She denied R1 instructed NA-A to leave the room. NA-B did not consider NA-A's actions as abuse and thus she did not feel this needed to be reported to the nurse but if the interaction were more aggressive, she would have reported it: it is a fine line between gentle and rough, but based on R1's body habitus and how we had to remove the dress. NA-B stated R1 commented on the situation to her after the incident and that R1 appeared to have increased shoulder pain as R1 utilized ice packs currently to the area and the incident from 5/18/25, may have caused the increased pain. During a telephone interview on 5/27/25, at 10:53 a.m., NA-A stated abuse occurred when staff were being too aggressive, among other things. If she witnessed abuse, she was to report to the supervisor immediately. NA-A stated on 5/18/25, she and NA-B assisted R1 to change into a gown. When she assisted R1 to take off her shirt, R1 told her firmly she was being rough. NA-A immediately stopped and asked R1 how she was rough. R1 did not respond. NA-B helped R1 remove the rest of the shirt and helped R1 with the gown, but she continued with the rest of the cares once NA-B left the room. NA-A explained, when she tried to pull the shirt bottom from under R1, she did not realize R1 could sit up and move as much as she did, so that when she pulled, R1 sat up, and the action used more effort than required. This caused the movement to be a quicker, jerking motion. She declined she was rough with the cares; however, she stated she maybe used more force then if I would have known she could move. During an interview via telephone on 5/27/25, at 11:56 a.m., certified nurse practitioner (CNP)-A stated she received a phone call on 5/19/25, that R1 complained of shoulder pain after an aide was too rough during cares. She explained she was updated the aide was asked to leave and the facility investigated the incident. CNP-A stated she had not heard anything since related to the investigation. During an interview on 5/27/25, at 1:46 p.m., the administrator expected staff to protect residents and when rough care was reported, she expected staff to stop what they are doing, get additional assistance, and report the incident to the nurse. Based on the initial investigation, it was decided not to report as there was no injury; however, she directed the incident to be treated like a grievance and NA-A was placed on the do not return list. She denied knowledge of the status of the investigation as the grievance form was yet to be provided to her for her review and signature, but she reported involvement in the investigation conversations. An Abuse and Neglect - Clinical Protocol, dated 2018, directed the nurse was to assess the individual and document any related findings (i.e., injury assessment, pain assessment, current behavior, past 24-hour behavior(s), etc.). Additionally, the staff and physician were to monitor the resident to address any issues regarding their medical condition, mood, and function. Review of facility policy titled An Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, dated 2022, identified a section labeled Investigating Allegations. This instructed all allegations were to be thoroughly investigated. The administrator was to initiate the investigation with assistance from appropriately trained staff. The staff conducting the investigation, at a minimum, was to review documentation and evidence, the resident's medical record, interview the involved resident, the person(s) reporting the incident, any witnesses, the attending provider, staff members who have had contact with the resident during the period of the alleged incident, interview family members, and other residents whom the accused employee provided care or services to. Additionally, all events leading up to the alleged incident were to be reviewed and the investigation was to be documented completely and thoroughly. When conducting interviews, statements were obtained in writing, signed, and dated.

Based on document review and interviews the facility failed to ensure the required staffing information was posted daily. This had the potential to affect all 41 residents residing in the facility and their visitors who may wish to review the information. Findings include: During review of the staff posting documentation from April, May, June, and August 14th through October 14th the facility failed to provide evidence of the staff postings for the following dates: April: 6th, 7th, 13th, 14th, 20th, 21st, 27th, and 28th of 2024. May: 4th, 5th, 11th, 12th, 18th, 19th, 25th, and 26th of 2024. June: 1st, 2nd, 8th, 9th, 14th, 15th, 16th, 22nd, 23rd, 29th, 30th of 2024. August: 17th, 18th, 24th, 25th, and 31st of 2024. September: 1st, 7th, 8th, 14th, 15th, 21st, 27th, 28th, 29th of 2024. October: 5th, 6th, and 12th of 2024. On 10/16/24 at 4:11 p.m., the staffing coordinator (O)-C confirmed they had not been completing the staff posting on the weekends and was unaware it was required to be posted daily. On 10/17/24 at 9:47 a.m., the administrator expected the staff posting to be displayed every day. During the week the staffing coordinator was responsible for completing it and on the weekends the north nurse was to be completing and posting the staff posting. The administrator stated they were unaware the posting had not been completed on the weekends and it was important to post the staffing information to know they had enough nursing staff on site and to ensure the information was available for family and visitor to review if they wish to do so. The Daily Posting of Nursing Hours Policy dated 12/12/2022, indicated it was the policy of New [NAME] Care Center to post the staffing numbers of licensed and non-licensed nursing personnel for each shift per Centers for Medicare and Medicaid guidelines.

Based on interview and document review the facility failed to submit any data for staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (quarter 3), to the centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. Findings Include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D for quarter 3 2024 (April 1st through June 30th), identified no data had been submitted. As a result, the metric for excessively low weekend staffing, Registered Nurse (RN) hours and licensed nursing coverage was suppressed for the quarter. On 10/17/24 at 09:43 a.m., the human resources specialist (O)-B stated they were responsible for gathering and submitting the data for each quarter to CMS. O-B confirmed they had forgotten the last step and did not submit it to CMS for quarter 3. O-B stated the importance of completing and submitting this information because it could interfere with the facility's overall star rating, admissions related to the rating, and accurate staffing information being presented to the public and CMS. On 10/17/24 at 09:47 a.m., the administrator confirmed the PBJ information had not been submitted for quarter 3 of 2024, and their expectation was for it to be completed by the deadline. The Staffing, Sufficient and Competent Nursing policy last revised August 2022, lacked specific information regarding submission requirements.

Based on interview and document review, the facility failed to ensure the acting infection preventionist (IP) had completed specialized training in infection prevention and control. This had the potential to affect all 41 residents residing in the facility. Findings include: On 10/17/24 at 9:59 a.m., the interim director of nursing (DON) stated the DON and assistant director of nursing (ADON) shared IP duties. The DON stated she had not completed specialized training in infection prevention and control. On 10/17/24 at 10:29 a.m., the administrator stated the DON and the ADON had not completed specialized training in infection prevention and control. A policy related to infection preventionist specialized training was requested, but not provided.

Based on observation and interview, the facility failed to ensure insulin flexpens and eye drops were appropriately labeled with an opened on date to prevent expired medications from being administered in 3 of 3 medication carts. In addition, the facility failed to ensure controlled substances were stored in a manner to reduce the risk of theft and/or diversion in 1 of 3 medication carts, and 1 of 1 medication refrigerators. This had the potential to effect all residents. Findings include: On 10/15/24 at 7:36 a.m., the medication cart located on the [NAME] wing was reviewed. Licensed practical nurse (LPN)-A stated the top drawer contained an opened multidose bottle of Dorzolamide-timolol 2-0.5% eye drops. However, it had not been labeled with the date the bottle had been opened. On 10/16/24 at 4:26 p.m., the medication cart located on the East wing was reviewed. LPN-C stated the cart contained an opened Ozempic 4 mg/3 mL (insulin) flexpen. The flexpen and/or box had not been labeled with the date the insulin had been opened. On 10/16/24 at 4:42 p.m., the medication cart located on the North wing was reviewed. Registered nurse (RN)-A stated the second drawer on the left contained an emergency kit (e-kit) which contained controlled substances. However, the e-kit was not secured in a separately locked, permanently affixed compartment as required. Additionally, an opened bottle of Latanoprost 0.0005% eye drops had not been labeled with the date the eye drops had been opened. RN-A confirmed the e-kit was not stored in a secured, separately locked compartment as required, and the eye drops had not been labeled with the date they had been opened. On 10/16/24 at 3:28 p.m., the director of nursing (DON) stated licensed staff were expected to write the date a multi-dose vial had been opened or accessed on the product label. Additionally, licensed staff were expected to review the opened date prior to administration of a multi-dose vial so they could be properly discarded within 28 days unless the manufacturer specifies differently. At 4:56 p.m., a review of the locked medication room located on the North wing was completed with the DON. The DON opened the unlocked medication refrigerator and found four bottles of unopened liquid Ativan (controlled substance) inside a separate, permanently affixed compartment. DON stated it was unlocked and all controlled substances should be locked in a separate, permanently affixed compartment to prevent diversion. Manufacturer's directions included disposal of opened Ozempic after 56 days. Drugs.com included direction for dispose of Dorzolamide-timolol after expiration date, and Latanoprost 6 weeks after opening. The facility's Medication Labeling and Storage policy, revised 2/2023, indicted multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter of longer date for the open vial. The facility's Controlled Substances policy, revised 11/2022, indicated controlled substances are separately locked in permanently affixed compartments. All keys to controlled substance containers are on a single key ring that is different from any other keys.

Based on interview and document review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice-Centers for Medicare and Medicaid-10055 (SNFABN-CMS-10055) was provided to 2 of 3 residents (R194 and R195) reviewed for beneficiary notices. Findings include: R194's discharge Minimum Data Set (MDS) dated [DATE], indicated R194 was admitted on [DATE] and discharged on [DATE]. R194's Notice of Medicare non-coverage form-CMS-10123 (NOMNC-CMS-10123), undated, indicated R194's services would end on [DATE]. However, R194 remained in the facility until [DATE]. R194's undated SNF Beneficiary Protection Notification Review form, indicated the facility/provider initiated the discharge from Medicare Part A when benefit days were not exhausted. R194's medical record lacked evidence the SNFABN-CMS-10055 was provided to R194 or their representative as required. R195's death in facility tracking record MDS dated [DATE], indicated R195 was admitted on [DATE] under the Medicare A benefit which may cover up to 100 days according to cms.gov, and died in the facility on [DATE]. R195's NOMNC-CMS-10123, undated, indicated R195's services would end on [DATE]. R195's progress note dated [DATE], indicated R195 entered hospice care, 9 days after services ended. R195's medical record lacked evidence the SNFABN-CMS-10055 was provided to R195 or their representative as required. On [DATE] at 10:28 a.m., the director of social services (SS)-A confirmed R194 and F195 were not provided with a SNFABN-CMS-10055 and SS-A was unaware they needed to be provided. SS-A voiced the importance of providing the SNFABN-CMS-10055 to give the residents adequate time to plan for their discharge and/or appeal if they wish, and it was the residents rights to receive these notifications. On [DATE] at 09:47 a.m., The administrator stated they were aware the SNFABN-CMS-10055 were not being provided appropriately, and they had recently delegated the task of developing a process to an employee, however it was not in place at the time of the survey. The administrator stated their expectation was for the SNFABN-CMS-10055 to be provided when residents go onto and come off Medicare part A services. The Medicare Advance Beneficiary and Medicare Non-Coverage Notices policy last revised [DATE], indicated if the facility believes Medicare will not pay for an otherwise covered skilled services, the resident was notified in writing why the service may not be covered and the resident's potential liability for payment of the non-covered services.

Based on interview and document review, the facility failed to ensure a written notification of transfer was provided for 1 of 3 residents (R7) upon transfer to the hospital. In addition, the facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 1 of 3 residents (R7), reviewed for hospitalization . This had the potential to affect all residents transferred to hospital. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact. Diagnoses included diabetes, cerebral infarction (stroke), bipolar disorder, and chronic obstructive pulmonary disease (COPD). R7's clinical record indicated R7 was hospitalized from 9/4/24 through 9/6/24. R7's discharge MDS dated [DATE], indicated R7 had an unplanned discharge to a short-term general hospital and return was anticipated. R7's record lacked progress notes which indicated the circumstances of the transfer to the hospital on 9/4/24. R7's entry tracking MDS dated [DATE], indicated R7 returned from short-term general hospital on 9/6/24. However, R7's record lacked evidence a written notification of transfer was provided to the resident and/or resident representative. Additionally, R7's record lacked evidence the Ombudsman for LTC was notified of transfer to the hospital. R7's clinical record indicated R7 was hospitalized from 8/23/24 through 8/24/24. R7's discharge MDS dated [DATE], indicated R7 had a planned discharge to a short-term general hospital and return was anticipated. R7's record lacked progress notes which indicated the circumstances of the transfer to the hospital on 8/23/24. R7's entry tracking MDS dated [DATE], indicated R7 returned from short-term general hospital on 8/24/24. However, R7's record lacked evidence a written notification of transfer was provided to the resident and/or resident representative. Additionally, R7's record lacked evidence the Ombudsman for LTC was notified of transfer to the hospital. R7's clinical record indicated R7 was hospitalized from 7/10/24 through 7/12/24. R7's progress note dated 7/10/24 at 1:02 p.m., indicated R7 was sent to the hospital due to chest pain per physician orders. A subsequent progress note dated 7/12/24 at 8:06 p.m., indicated R7 was readmitted to the facility following hospitalization for atrial fibrillation. However, R7's record lacked evidence a written notification of transfer was provided to the resident and/or resident representative. Additionally, R7's record lacked evidence the Ombudsman for LTC was notified of transfer to the hospital. R7's clinical record indicated R7 was hospitalized from 6/6/24 through 6/7/24. R7's discharge MDS dated [DATE], indicated R7 had an unplanned discharge to a short-term general hospital and return was anticipated. R7's record lacked progress notes which indicated the circumstances of the transfer to the hospital on 6/6/24. R7's progress note dated 6/7/24 at 11:05 p.m., indicated R7 returned to the facility via stretcher accompanied by 3 EMS (emergency medical transport). However, R7's record lacked evidence a written notification of transfer was provided to the resident and/or resident representative. Additionally, R7's record lacked evidence the Ombudsman for LTC was notified of transfer to the hospital. R7's clinical record indicated R7 was hospitalized from 2/10/24 through 2/16/24. R7's progress note dated 2/10/24 at 5:26 p.m., indicated R7 was sent to the hospital due to uncontrolled pain in left leg per provider order. R7's entry tracking MDS dated [DATE], indicated R7 returned from short-term general hospital on 2/16/24. However, R7's record lacked evidence a written notification of transfer was provided to the resident and/or resident representative. Additionally, R7's record lacked evidence the Ombudsman for LTC was notified of transfer to the hospital. through 1/30/24. R7's discharge MDS dated [DATE], indicated R7 had an unplanned discharge to a short-term general hospital and return was anticipated. R7's record lacked progress notes which indicated the circumstances of the transfer to the hospital on 1/26/24. R7's entry tracking MDS dated [DATE], indicated R7 returned from short-term general hospital on 1/30/24. However, R7's record lacked evidence a written notification of transfer was provided to the resident and/or resident representative. Additionally, R7's record lacked evidence the Ombudsman for LTC was notified of transfer to the hospital. R7's clinical record indicated R7 was hospitalized from 10/21/23 through 11/7/23. R7's progress note dated 10/31/23 at 2:05 p.m., indicated R7 left for a surgical procedure at 5 a.m., related to right calf ulcer. R7's discharge MDS dated [DATE], indicated R7 had a planned discharge to a short-term general hospital and return was anticipated. R7's entry tracking MDS dated [DATE], indicated R7 returned from short-term general hospital on 11/7/23. However, R7's record lacked evidence a written notification of transfer was provided to the resident and/or resident representative. Additionally, R7's record lacked evidence the Ombudsman for LTC was notified of transfer to the hospital. On 10/16/24 at 2:00 p.m., the administrator verified Notice of Transfer forms were not provided to R7 and/or responsible party upon transfers for emergent and therapeutic hospitalization s on 9/4/24, 8/23/24, 7/10/24, 6/6/24, 2/10/24, 1/26/24, and 10/21/23. The administrator stated notice of transfer should have been completed by the floor nurses upon transfer, and it was important for residents to be informed and given the opportunity to decline. Additionally, the administrator acknowledged the facility had not been notifying the ombudsman of resident transfers for hospitalization . On 10/16/24 at 4:01 p.m., the director of social services verified the ombudsman notice of transfer had not been submitted to the ombudsman for R7's hospitalization s, and the ombudsman should have been notified monthly of transfers to an acute care facility. The ombudsman should have been notified so they were aware of the resident's transfer so they could contact the resident to determine if they needed any additional services or if any ombudsman follow-up was needed. The facility's Transfer or Discharge policy revised 10/22, indicated a notice of transfer for emergent or therapeutic leave is provided to the resident/representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., monthly).

Based on interview and document review, the facility failed to provide a written notice of a bed hold at the time of transfer for hospitalization for 1 of 3 residents (R7) reviewed for hospitalization . Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact. Diagnoses included diabetes, cerebral infarction (stroke), bipolar disorder, and chronic obstructive pulmonary disease (COPD). R7's clinical record indicated R7 was hospitalized from 9/4/24 through 9/6/24. R7's discharge MDS dated [DATE], indicated R7 had an unplanned discharge to a short-term general hospital and return was anticipated. R7's record lacked a progress note indicating the reason for the transfer to the hospital on 9/4/24. R7's entry tracking MDS dated [DATE], indicated R7 returned from short-term general hospital on 9/6/24. However, R7's recorded lacked evidence a bed hold notice was provided to the resident and/or responsible party at the time of transfer for hospitalization . R7's clinical record indicated R7 was hospitalized from 8/23/24 Through 8/24/24. R7's discharge MDS dated [DATE], indicated R7 had a planned discharge to a short-term general hospital and return was anticipated. R7's record lacked a progress note indicating the reason for the transfer to the hospital on 8/23/24. R7's entry tracking MDS dated [DATE], indicated R7 returned from short-term general hospital on 8/24/24. However, R7's recorded lacked evidence a bed hold notice was provided to the resident and/or responsible party at the time of transfer for hospitalization . R7's clinical record indicated R7 was hospitalized from 7/10/24 through 7/12/24. R7's progress note dated 7/10/24 at 1:02 p.m., indicated R7 was sent to the hospital due to chest pain per physician orders. A subsequent progress note dated 7/12/24 at 8:06 p.m., indicated R7 was readmitted to the facility following hospitalization for atrial fibrillation. However, R7's recorded lacked evidence a bed hold notice was provided to the resident and/or responsible party at the time of transfer for hospitalization . R7's clinical record indicated R7 was hospitalized from 6/6/24 through 6/7/24. R7's discharge MDS dated [DATE], indicated R7 had an unplanned discharge to a short-term general hospital and return was anticipated. R7's record lacked a progress note indicating the reason for the transfer to the hospital on 6/6/24. R7's progress note dated 6/7/24 at 11:05 p.m., indicated R7 returned to the facility via stretcher accompanied by 3 EMS (emergency medical transport). However, R7's recorded lacked evidence a bed hold notice was provided to the resident and/or responsible party at the time of transfer for hospitalization . R7's clinical record indicated R7 was hospitalized from 2/10/24 through 2/16/24. R7's progress note dated 2/10/24 at 5:26 p.m., indicated R7 was sent to the hospital due to uncontrolled pain in left leg per provider order. R7's entry tracking MDS dated [DATE], indicated R7 returned from short-term general hospital on 2/16/24. However, R7's recorded lacked evidence a bed hold notice was provided to the resident and/or responsible party at the time of transfer for hospitalization . R7's clinical record indicated R7 was hospitalized from 1/26/24 through 1/30/24. R7's discharge MDS dated [DATE], indicated R7 had an unplanned discharge to a short-term general hospital and return was anticipated. R7's record lacked a progress note indicating the reason for the transfer to the hospital on 1/26/24. R7's entry tracking MDS dated [DATE], indicated R7 returned from short-term general hospital on 1/30/24. However, R7's recorded lacked evidence a bed hold notice was provided to the resident and/or responsible party at the time of transfer for hospitalization . R7's clinical record indicated R7 was hospitalized from 10/21/23 through 11/7/23. R7's progress note dated 10/31/23 at 2:05 p.m., indicated R7 left for a surgical procedure at 5 a.m., related to right calf ulcer. R7's discharge MDS dated [DATE], indicated R7 had a planned discharge to a short-term general hospital and return was anticipated. R7's entry tracking MDS dated [DATE], indicated R7 returned from short-term general hospital on 11/7/23. However, R7's recorded lacked evidence a bed hold notice was provided to the resident and/or responsible party at the time of transfer for hospitalization . On 10/16/24 at 2:00 p.m., the administrator verified bed hold notices were not provided to R7 and/or responsible party upon transfers for hospitalization on [DATE], 8/23/24, 7/10/24, 6/6/24, 2/10/24, 1/26/24, and 10/21/23. The administrator stated bed hold notice at time of transfer for hospitalization was important so residents were made aware they can return to the facility, any cost to them to hold the bed, and provided the opportunity to decline a bed hold. On 10/16/24 at 4:01 p.m., the director of social services stated the floor nurses were responsible for obtaining bed hold notices at the time of transfer for hospitalization , and it was important for residents to know they would not be discharged and could return to the facility and know the cost for holding the bed. The facility's Bed-Holds and Returns policy revised 10/22, indicated residents, regardless of payer source, are provided written notice about these policies at least twice: notice 1 - well in advance of any transfer (e.g., in the admission packet); and notice 2 - at the time of transfer (or, if the transfer was an emergency, within 24 hours). Multiple attempts to provide the resident/representative with notice 2 should be documented in cases where staff were unable to reach and notify the resident/representative timely. The facility's Transfer or Discharge policy revised 10/22, indicated a notice of bed hold for emergent or therapeutic leave is provided to the resident/representative within 24 hours of transfer.

Based on interview and document review, the facility failed to ensure physician orders were followed for 1 of 1 residents (R7) reviewed for skin conditions. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact. Diagnoses included diabetes, cerebral infarction (stroke), bipolar disorder, and chronic obstructive pulmonary disease (COPD). R7's progress note dated 10/5/24 at 10:23 p.m., indicated R7 called 911 at 7:50 p.m. R7 wanted to go to the hospital because the cream (ammonium lactate) that was applied to her legs made them feel numb. R7's progress note dated 10/6/24 at 2:00 p.m., indicated R7 returned from the hospital at 1:30 p.m., with no change in condition noted, no new orders, and still complained of pain in her legs. During observation on 10/13/24 at 2:52 p.m., R7's lower extremeties were swollen and red with multiple blisters covering both legs from under the knees to the ankles. On 10/13/24 at 3:07 p.m., R7 stated approximately a week prior, she had call 911 because she had throbbing, burning pain in both of legs and feet, and had spent the night in the hospital due to the condition and pain. She needed to stay in bed due to pain when her legs were not elevated, and had an appointment with the wound clinic on 10/14/24. On 10/16/24 at 9:35 a.m., R7 stated the wound clinic physician told her that the old cream that had been ordered (ammonium lactate) caused the issue of blisters and pain in her legs. R7's Wound Clinic After Visit Summary dated 10/14/24, indicated the following skin care plan was ordered for R7's bilateral lower extremities: - skin care outside of clinic performed by facility staff - mild compression is recommended - can be removed at night and put back on first thing in the morning - avoid use of ammonium lactate topical due to history of blistering with use - moisturize daily with general lotion (such as Cetaphil or CeraVe) - gently wash legs/feet with wash cloth to displace flaky dry skin which will resolve with consistent care - compression will assist swelling reduction which in turn will minimize risk for wound recurrence R7's progress noted dated 10/14/24 at 12:17 p.m., indicated R7 had been seen by the wound clinic, no open areas were seen and no new dressing was ordered, an order for mild compression and R7 returned with Spandage white netting, and a box was placed in R7's room for morning cares. Recommendation to moisturize skin daily with CeraVe or Cetaphil after general cleanse, and orders were applied to PCC [PointClickCare clinical charting system]. However, the recommendation to avoid use of Ammonium Lactate was not indicated in the progress note. R7's October 2024 Treatment Administration Record (TAR) indicated Ammonium Lactate External Cream 12% had been applied topically at bedtime to R7's legs and feet on 10/14/24 and 10/15/24. However, the wound clinic provider had indicated the use of Ammonium Lactate should have been discontinued on 10/14/24. On 10/16/24 at 11:44 a.m., the director of nursing (DON) verified R7's TAR indicated Ammonium Lactate cream had been applied to R7's legs/feet on 10/14/24 and 10/15/24. DON stated she would have expected the nurse to discontinue the order for Ammonium Lactate, or if the nurse was unsure, the Ammonium Lactate should have been placed on hold while the nurse clarified the order with the provider. The facility's Administering Medications policy, revised 4/2019, indicated medications were administered in accordance with prescriber orders.

Based on observation, interview, and record review the facility failed to maintain infection control measures when performing wound care for 1 of 1 residents (R25) reviewed for wound care. Findings include: R25's annual minimum data set (MDS) dated [DATE], identified R25's cognition as intact and included diagnoses of diabetes mellitus (a blood disorder characterized by impaired ability of the body to maintain proper levels of sugar in the blood), heart failure and hypertension. Further, R25 had a stage 4 full thickness pressure ulcer (an injury to the skin and tissue due to pressure on the skin for a long time) with exposed bone, tendon, or muscle. R25's current care plan identified R25 had skin alteration related to stage 4 sacral ulcer. Nursing staff were to keep skin clean and dry, provide wound care per orders, observe for changes and update provider as needed. Furthermore, R25 was to receive a skin assessment per protocol and nursing staff to observe skin with personal cares. R25's nurse practitioner (NP) orders dated 10/7/24, indicated R25 needed daily dressing changes to his stage 4 pressure ulcer, required an air mattress, and was followed weekly by the wound team. A wound progress note dated 10/14/24, indicated R25 required daily foam dressing changes, instructed nursing staff to keep skin clean and dry, and R25 would continue to be followed weekly by wound care team. During observation on 10/15/24 at 8:28 a.m., licensed practical nurse (LPN-A) and LPN-B completed R25's dressing change. R25 was positioned lying in bed on his left side, exposing his buttocks towards LPN-A. A yellow disposable chux pad (a disposable absorbent sheet designed to protect surfaces) was observed tucked under R25's left hip/buttocks. A brown and grayish tan substance was noted on the chux pad. LPN-A and LPN-B performed hand hygiene and applied clean gloves. LPN-B opened dressing packages and handed LPN-A a clean chux pad; LPN-A unfolded the clean chux pad and placed it over the outer edge of the dirty yellow chux pad leaving the brown and grayish tan substance uncovered. LPN-A removed the dressing from R25's buttocks exposing the stage 4 pressure ulcer to the open air. Behind and slightly to the right of LPN-A was a free-standing oscillating fan that was turned on and blowing directly at R25's exposed wound. LPN-A sprayed wound cleaner on clean 4x4 gauze and wiped R25's wound beginning at the inner most area of wound working her way towards outer edges. LPN-A repeated this process three times and then dabbed the wound with clean, dry 4x4 gauze. LPN-B then applied an absorbent foam dressing to cover the wound. LPN-B did not initial or date the dressing. LPN-A and LPN-B removed gloves and performed hand hygiene. During interview on 10/15/24 at 8:28 a.m., LPN-B stated R25 wouldn't allow staff to remove the soiled chux pad and replace it with a clean one during dressing changes. LPN-B stated R25 did not allow staff to touch his things or turn off the fan. LPN-B stated if she could shut off the fan, she would. However, she did not ask R25 for permission and therefore left the fan on. Further, LPN-B stated R25's wound was routinely followed by the wound nurse. LPN-A stated the nursing staff would cleanse the outer aspect of the wound and complete the outer foam dressing changes daily. LPN-A stated R25 would not let her shut off the fan, however, then confirmed she had not asked to shut the fan off during dressing changes. LPN-A stated if left on, the fan could blow germs and bacteria all over the place. During interview on 10/15/24 at 2:30 p.m., director of nursing (DON) stated her expectation was to remove all soiled chux pads prior to a clean dressing change. She went on to state nursing staff should be dating and initialing all dressings so all staff would know who performed and when the last dressing change was completed. Furthermore, DON stated she expected staff to shut off any fans during dressing changes so air was not blowing directly into an open wound. DON stated this was important because a fan could blow bacteria or debris into the wound and potentially cause an infection. A policy regarding wound dressing changes was requested but not provided by the end of the survey.

Based on interview and document review, the facility failed to ensure 2 of 5 residents (R2, R3) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old, or an adult 19-[AGE] years old with specified immunocompromising conditions, had received the complete series (i.e., PPSV23 and PCV13) then the patient and provider (shared clinical decision-making) may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20). R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was [AGE] years old and diagnoses included chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. R2's immunization report, dated 10/17/24, indicated R2 received PPSV23 on 9/7/2017 and PCV13 on 12/18/2010. The record lacked evidence of shared clinical decision-making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R2 was offered or received PCV20. R3's quarterly MDS dated [DATE], indicated R3 was [AGE] years old and diagnoses included the following specified immunocompromising conditions: chronic respiratory failure and heart failure. R3's immunization report, dated 10/17/24, indicated R3 received PPSV23 on 5/21/09 and PCV13 on 8/24/18. The record lacked evidence of shared clinical decision-making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R3 was offered or received PCV20. On 10/17/24 at 9:59 a.m., director of nursing/infection preventionist (DON/IP) verified R2 and R3 had not been offered or provided education on PCV20, and there had been no shared clinical decision-making with the resident providers regarding pneumococcal immunizations. The DON/IP stated the PCV20 vaccine should have been offered when the resident became eligible and pneumococcal immunizations were important to maintain resident health. The facility's Pneumococcal Vaccine policy revised 3/22, indicated all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections in accordance with current CDC recommendations.

Based on observation, interview and document review, the facility failed to ensure proper sanitization of dishware used for meal preparation and resident service when 1 of 1 high-temperature commercial dishwashers was identified as not reaching adequate wash and rinse temperatures. In addition, the facility failed to store dishware in a manner preventing contamination. Further, the facility failed to ensure the ice dispensing machine was clean and free of excess mineral build up or cleaned on a regular schedule. This had potential to affect all 36 residents within the nursing home, staff, and visitors who consumed food from the main production kitchen and/or ice from the dining room ice machine. Dishwashing Machine During observation and interview on 11/20/23 at 12:38 p.m., the label on the side of the [NAME] AM-14 dishwasher indicated dish sanitization required a wash temperature of 150 F for a minimum of 40 seconds and rinse temperature of 180 F for a minimum of nine seconds. Dietary aide (DA)-A stated the dishwasher used hot water to sanitize and confirmed the temperatures needed to reach 150 degrees Fahrenheit ( F) during the wash cycle and 180 F during the rinse cycle. DA-A placed a tray containing three large pans and several small lids into the dishwasher, closed the door, and started the unit. The temperature began at 155 F, fell during the wash cycle to 147 F, and rose to 186 F at the start of the rinse cycle. The dishwasher door was opened immediately upon reaching 186 F prior to the nine second requirement. At 12:42 p.m., DA-A placed three trays and nine lids on the dish rack, placed the rack into the dishwasher, and started the unit. The wash cycle temperature started at 151 F and steadily decreased during the cycle until it reached 146 F. The rinse temperature reached 189 F. DA-A confirmed the temperatures did not stay elevated as required and was not sure why. The door was opened, and the dishes were placed on the storage cart. At 12:55 p.m., DA-A placed one large pan into the dishwasher. The wash cycle started at 157 F and decreased to 149 F, and the rinse cycle reached 180 F, however the dishwasher was opened prior to the end of the 9 second minimum. At 12:57 p.m., DA-A placed a tray containing three cups, four bowls, three small metal pans, two plastic covers, and several miscellaneous cooking utensils into the dishwasher and started the unit. The wash cycle started at 152 F and steadily dropped to 147 F during the cycle. At 12:59 p.m., DA-A stated any of the staff could check the dishwasher temperatures and document them on the log, and it was done randomly. They stated the dishes were clean when the pressure gauge dropped, and they opened the door after they didn't heard noise for a while. At 1:02 p.m., a tray with one large pan and four plate holders was placed into the dishwasher and the unit was started. Both wash and rinse cycle temperatures remained within acceptable limits. During observation on 11/21/23 between 9:13 a.m. and 9:16 a.m., the dishwasher was observed to reach wash and rinse temperatures of greater than 150 F and 180 F during three cycles. During interview and observation on 11/21/23 at 12:20 p.m., DA-C placed three bowls, two pitchers, one graduate, two plastic containers, and two juice cups in the dish rack and slid the rack into the dishwasher. The temperature gauge indicated it was in the fill cycle. At 12:24 p.m., DA-C started the washer and observed the wash temperature of 139 F which fell steadily to 131 F. The rinse cycle reached 145 F before the dishwasher stopped. DA-C opened the door, removed the dishes, and prepared another tray containing food processor parts. DA-C started the load at 12:26, and the wash and rinse temperatures reached 138 F and 156 F. DA-C stated those were normal temperatures for the dishwasher, and they had always been that way. DA-C stated they knew the dishes were clean because they were really hot, and staff could not touch them when they first came out of the dishwasher. DA-C began another load of dishware which started at 140 F, dropped to 136 F during the cycle, reached 185 F during the rinse cycle, but dropped to 137 F after approximately five seconds. During observation and interview on 11/21/23 at 12:30 p.m., dietary director (DD) stated the dishwasher maintenance company was at the facility recently and the dishwasher was functioning properly. He stated there was a booster heater on the unit and sometimes the temperatures fluctuated, but it should be run at 150 F for the wash cycle and 180 F for the rinse cycle to prevent foodborne illness. At 12:32 p.m., DD observed a cycle of dishware which started at 143 F and dropped to 139 F during the wash cycle. He stated the load was not clean and needed to be rewashed. At 12:34 the load was started again where temperatures started at 145 F and dropped to 140 F during the wash cycle. DD stated staff checked the dishwasher temperatures at the start, middle, and end of doing the dishes, and was not sure why it was not getting up to temperature, but identified dishes would need to be sanitized manually using the three compartment sink until it could be fixed. During interview on 11/21/23 at 12:43 p.m., administrator stated the wash cycle should reach 145 F and the rinse cycle should reach 180 F, and staff needed to make sure it hit 180 F to ensure the dishes were sanitized. The [NAME] Model AM14 Instructions dated 1/1989, indicated the minimum water temperature required for hot water dish sanitation was 150 F for a recommended 40 seconds during the wash cycle and 180 F during the rinse cycle for a recommended 18 seconds. The facility Sanitization policy dated 10/2008, indicated dishwashing machines must be operated using a wash temperature of 150 F for at least 45 seconds and a rinse temperature of 180 F for at least 12 seconds. The Dishwashing Machine Use policy dated 3/2010, indicated the operator will check temperatures using the machine gauge with each dishwashing machine cycle and monitor the gauge frequently during the machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. Fans During observation of the dish washing room on 11/20/23 at 11:57 a.m., a large fan was attached to the wall near the ceiling on the dirty side where the soiled dishes came in and another smaller fan was attached to the wall on the clean side where the clean dishes were stored and put away. Both fans were turned on, oscillating, and moving air about the room, and both were covered in thick, brown dusty substance. The fan on the clean side was located approximately three feet from a shelf containing clean cups just above the counter where clean dishes were placed when removed from the dishwasher. During observation on 11/20/23, at 12:50 p.m. the smaller fan was blowing on two trays containing 16 clean cups and a tray of 10 clean coffee cups located on the shelf above the clean dish counter. During interview on 11/20/23 at 12:59 p.m. DA-A stated the fans were usually on because the room got hot. During observation on 11/21/23 at 12:12 p.m. both fans were oscillating in the dish washing and storage area, the smaller of which was blowing on the clean dish counter which contained metal serving pans and cooking utensils just out of the dishwasher. The shelf above the counter contained 19 clean plastic cups, and a three-tiered cart which contained a baking sheet, and two clean plates was against the wall, also in the fan's range. At 12:20 p.m. DA-C placed the pans and utensils on a wire dish storage rack within the room and added three cups to the others on the shelf. During interview on 11/21/23 at 12:30 p.m. DD confirmed the fans were soiled and stated they needed to be cleaned because they did not want the dust and particles to get on the dishware and have residents eat off them. During interview on 11/21/23 at 12:43 p.m. administrator stated the fans should be cleaned for sanitation purposes and needed to be added to the dietary staff's cleaning processes. The Sanitization policy dated 10/2008, indicated clean equipment and utensils will be stored in a clean, dry locations in a way that protects them from splashes, dust, or other contamination. Ice Machine During observation on 11/22/23 at 9:24 a.m., the facility ice machine in the resident dining room was located on top of a metal table. The surfaces of the table, front of the ice machine, the dispenser chute, and the drip dray were covered in a white, speckled, crusty, residue. The plastic exterior chute from where the ice was dispensed and the area of attachment to the body of the machine also contained various areas of a black substance, with the one closest to where a cup would be placed running across the bottom of the back of chute and up approximately 1/4 inch. During interview on 11/22/23 at 9:52 a.m., dietary aide DA-B stated they did not know who cleaned the counter and ice machine in the dining room. During interview on 11/22/23 at 9:53 a.m., housekeeper (HSK)-A stated they cleaned the dining room, but the kitchen staff cleaned the ice machine. During interview on 11/22/23 at 9:55 a.m., DA-A stated was not sure who cleaned that area, but thought dietary staff cleaned the counter and maintenance cleaned the ice machine. During interview on 11/22/23 at 9:57 a.m., director of nursing (DON) observed the white and brown substances and stated it needed to be de-limed and cleaned. DON was unsure who was responsible for cleaning. During interview on 11/22/23 at 10:01 a.m., administrator observed the ice machine and identified the condition as a concern. The administrator stated maintenance did the internal cleaning quarterly and the dietary staff should be cleaning the external parts. Further, stated the machine was the main source of ice and was used for passing water to the residents, and it needed to be cleaned to prevent people from getting ill. During interview on 11/22/23 at 10:19 a.m., dietary director stated they cleaned the outside of the ice machine but did not remember how to take the plastic ice chute cover off, so maintenance helped, but it was important to keep it clean to ensure people did not get sick. The Sanitization policy dated 10/2008, indicated ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. The Nugget Ice Machines Installation, Operation, and Maintenance Manual dated 12/2017, indicated the machine needed to be cleaned and sanitized every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. If required, an extremely dirty ice machine may be taken apart for cleaning and sanitizing. In addition, the manual recommended weekly removal of the grill from scrap ice tray and weekly wiping of splash panel, scrap ice tray and grill with sanitizer and water solution.

Based on observation, interview and document review, the facility failed to ensure fans in the dish sanitization and storage area were maintained in a clean and sanitary manner to prevent dishware contamination. This had potential to affect all 36 residents within the nursing home, staff, and visitors who consumed food from the main production kitchen. Findings include: During observation of the dish washing room on 11/20/23 at 11:57 a.m., a large fan was attached to the wall near the ceiling on the dirty side where the soiled dishes came in and another smaller fan was attached to the wall on the clean side where the clean dishes were stored and put away. Both fans were turned on, oscillating, and moving air about the room, and both were covered in thick, brown dusty substance. The fan on the clean side was located approximately three feet from a shelf containing clean cups just above the counter where clean dishes were placed when removed from the dishwasher. During observation on 11/20/23, at 12:50 p.m. the smaller fan was blowing on two trays containing 16 clean cups and a tray of 10 clean coffee cups located on the shelf above the clean dish counter. During interview on 11/20/23 at 12:59 p.m. DA-A stated the fans were usually on because the room got hot. During observation on 11/21/23 at 12:12 p.m. both fans were oscillating in the dish washing and storage area, the smaller of which was blowing on the clean dish counter which contained metal serving pans and cooking utensils just out of the dishwasher. The shelf above the counter contained 19 clean plastic cups, and a three-tiered cart which contained a baking sheet, and two clean plates was against the wall, also in the fan's range. At 12:20 p.m. DA-C placed the pans and utensils on a wire dish storage rack within the room and added three cups to the others on the shelf. During interview on 11/21/23 at 12:30 p.m., DD confirmed the fans were soiled and stated they needed to be cleaned because they did not want the dust and particles to get on the dishware and have residents eat off them. During interview on 11/21/23 at 12:43 p.m. administrator stated the fans should be cleaned for sanitation purposes and needed to be added to the dietary staff's cleaning processes. The Sanitization policy dated 10/2008, indicated clean equipment and utensils will be stored in a clean, dry locations in a way that protects them from splashes, dust, or other contamination.

Based on observation, interview, and document review, the facility failed to ensure hand hygiene was completed for 3 of 3 residents (R23, R25, R24) observed during wound cares. Furthermore, the facility failed to ensure hand hygiene was completed for 1 of 1 residents (R23) reviewed for toileting. Findings include: R23 R23's quarterly Minimum Data Set (MDS) dated [DATE], indicated R23 was cognitively intact and had diagnoses of chronic venous insufficiency (poor blood flow) and bilateral lower extremity vascular wounds. Furthermore, R23's MDS indicated R23 required assist of one for toileting. An observation on 11/21/23 at 7:10 a.m., licensed practical nurse (LPN)-A entered R23's room without performing hand hygiene. R23 requested to use the bed pan. Without hand hygiene, LPN-A donned gloves and obtained R23's bedpan from the bathroom. LPN-A assisted R23 to turn in bed and placed the bedpan. LPN-A then removed gloves and without performing hand hygiene left R23's room and walked down hall to obtain washcloths. At 7:15 a.m., LPN-A entered room without performing hand hygiene and donned gloves. LPN-A assisted R23 with turning and removed the bedpan now filled with urine. The bedpan was set on the end of R23's bed while LPN-A cleaned R23 and assisted back on her back. LPN-A then removed gloves and without hand hygiene donned new gloves and picked up the bedpan and emptied the urine in the bathroom. LPN-A then removed gloves and washed hands. LPN-A then left room to obtain a clean draw sheet as R23's had gotten soiled when the bedpan was used. With new drawsheet, LPN-A returned to R23's room and assisted R23 in turning so clean draw sheet could be placed. The soiled drawsheet was placed at the end of R23's bed. Without performing hand hygiene or exchanging gloves, LPN-A adjusted R23's pillows behind her and the pillows under R23's legs. LPN-A then removed the soiled sheet and placed in a bag. LPN-A removed gloves and without performing hand hygiene donned new gloves. LPN-A then gave R23 a clean wet and dry washcloth to wash her face and eyes. LPN-A then removed gloves and performed hand hygiene before leaving the room to look for assistance to boost R23 up in bed. When interviewed on 11/21/23 at 7:35 a.m., LPN-A stated hand hygiene was needed when moving from dirty to clean and between glove changes. LPN-A verified she had not completed hand hygiene in between glove changes when R23 was assisted with the bedpan and handled soiled linen. An observation on 11/21/23 at 8:26 a.m., LPN-B and nurse practitioner (NP)-A entered R23's room to provide wound care. NP-A performed hand hygiene and donned new gloves obtained from her scrub pocket. NP-A removed R23's bilateral lower extremity dressings. NP-A removed gloves and without hand hygiene placed donned a new pair of gloves. A bottle of sterile water was obtained and R23's bilateral wounds were cleansed and wiped with gauze. The gauze used to cleanse R23's wounds had some bloody drainage. The dirty gauze was placed in the garbage and NP-A removed gloves and without performing hand hygiene placed new gloves from scrub pocket. NP-A then moistened gauze and placed on R23's left leg wound, placed and dry dressing and wrapped in kerlix dressing. NP-A then moistened another piece of gauze and placed on R23's right leg wound, placed dry gauze and wrapped in kerlix. NP-A then removed gloves performed hand hygiene before leaving R23's room. R25 R25's admission (MDS) dated [DATE], indicated R25 was cognitively intact and had diagnoses of diabetes and kidney failure. Furthermore, R25's MDS indicated R25 had a pressure wound on the left buttock. An observation on 11/21/23 at 8:00 a.m., LPN-B and NP-A entered R25's room to perform wound care. NP-A performed hand hygiene and donned gloves. R25's brief was pulled back and dressing removed from R25's bottom. NP-A then removed gloves and without hand hygiene donned new gloves that were pulled out of her scrub pocket. NP-A measured R25's wound before cleansing the wound. NP-A then removed gloves and without hand hygiene donned gloves that were pulled from her scrub pocket. R25's wound was covered. NP-A removed gloves and performed hand hygiene upon exit of R25's room. When interviewed on 11/22/23 at 8:45 a.m., NP-A stated when performing wound cares dirty areas and clean areas were kept separate and that was why so many extra gloves in her pocket. NP-A was not aware of any need to perform hand hygiene when exchanging gloves or a need to have hand sanitizer on hand when performing dressing changes. NP-A further stated if gloves were torn during care, then hand hygiene would be completed. When interviewed on 11/21/23 at 2:22 p.m., LPN-B verified NP-A had not performed hand hygiene when removing gloves and stated hand hygiene was to be completed after each glove exchange. Furthermore, LPN-B stated this was important part of infection prevention. 22580 R24 R24's quarterly MDS dated [DATE] indicated R24 was cognitively intact and had diagnoses of Atrial fibrillation (irregular,often rapid heart rate that commonly causes poor blood flow), chronic kidney disease and pressure ulcer of left buttocks, stage 4 (pressure injuries extend to muscle, tendon or bone), and indicated R24 had one stage 4 pressure ulcer that was present on admit. During observation on 11/21/23 at 7:45 a.m., LPN-B and NP-A entered R24's room to perform wound care. NP-A performed hand hygiene and donned gloves. R24's brief was pulled back and dressing removed from R24's bottom. NP-A then removed gloves and without hand hygiene donned new gloves that were pulled out of her scrub pocket. NP-A cleansed wound, removed gloves and without hand hygiene donned new gloves from her scrub pocket. and then measured R25's wound. NP-A then removed gloves and without hand hygiene donned gloves that were pulled from her scrub pocket, and covered R24's wound . NP-A removed gloves and performed hand hygiene upon exit of R24's room. When interviewed on 11/22/23 at 10:18 a.m., the director of nursing (DON) expected hand hygiene to be completed after handling dirty linens or toileting and before moving to clean areas. Hand hygiene was also required in between glove exchanges during cares. Furthermore, the DON expected all staff and providers to follow this practice to ensure infection prevention measures were being followed. A facility policy titled Standard Precautions revised 9/2022, directed staff to perform hand hygiene before and after contact with a resident, and after removing gloves.

Based on observation, interview, and document review, the facility failed to provide the appropriate modified texture diet for 2 of 8 residents (R1 and R2) whom had swallowing difficulties, and were at risk for choking. This placed R1 and R2 in immediate jeopardy for not receiving the correct modified diets as prescribed to prevent choking. In addition, 6 other residents (R4, R5, R6, R8, R9 and R10) who had a prescribed modified textured diets due to swallowing difficulties were at potential risk of receiving the wrong diet. In addition, there was 1 of 3 residents (R3) whom had an identified food allergy, received a food items which she was allergic to. The immediate jeopardy began on 6/25/20, when R1 received a NDD3 (bite-sized pieces of moist foods with near-normal texture that requires more chewing ability) diet instead of the NDD2 diet (moist/soft textured foods that are easy to chew and swallow), choked, required the [MEDICATION NAME] maneuver, oxygen and was hospitalized , and when R2 received grapes when on an altered diet. The administrator, director of nursing and associate director of nursing (ADON) were notified of the immediate jeopardy on 6/29/20, at 6:01 p.m. The immediate jeopardy was removed on 6/30/20, at 4:09 p.m. but noncompliance remained at the lower scope and severity level of G isolated, scope and severity level, which indicated actual harm that is not immediate jeopardy. Findings include: R1's admission MDS dated [DATE], indicated moderate cognitive impairment with [DIAGNOSES REDACTED]. R1 ate independently and was seeing speech therapist and complained of difficultly or pain when swallowing. R1's tray ticket indicated Diet: DYS2 Nectar Thk Liq, (dysphagia (difficulty swallowing) level 2, mechanically altered diet- moist and soft textured foods that are easy to chew- with nectar thickened liquids) small portions. R1's Initial Nutritional Evaluation dated 6/7/20, indicated R1 had, difficulty swallowing. R1's ST (speech therapist) - Therapist Progress and Discharge Summary dated 6/25/20, indicated R1's current swallowing level was nectar thick liquid, NDD2: Dysphagia-mechanical altered. R1's OT assessment dated [DATE], indicated R1 required NND2 mechanically altered diet with nectar-thick liquids and had difficulty swallowing liquids and foods. R1's incident report dated 6/25/20, included, 6/25/20 1740 (5:40 p.m.) NAR reported to RN (registered nurse) that resident was unresponsive. Resident was pale and gasping. RN initiated [MEDICATION NAME] Maneuver. CNA (certified nursing assistant) summoned nurse from adjacent station. Resident placed on floor. Staff continued chest thrusts. CNA instructed by nurse to visually check patient's mouth to see if any food could be removed. CNA was able to remove food which appeared to be bread and pork. Sats (oxygen saturation level, normal is 95-100%) increased to 95% after intervention. Prior, sats were ranging from 20-40%. Oxygen was applied by RN which resulted in regular breathing. RN called 911. Nurse called family to inform them about situation and that patient was being sent to the hospital. Upon arrival of EMS - resident was stable. Staff placed him in bed for comfort via Hoyer with head of the bed raised. Resident had emesis after being transferred the stretcher. At 1820 (6:30 p.m.) resident was taken to Regions Hospital. MD (medical doctor) and DON updated. DON placed call to Regions hospital to check on condition. Investigation initiated immediately. Administrator and ADON notified. RN informed DON that the diet resident received was incorrect. This was confirmed by the dietary aid. The patient received an NDD 3 (bite-sized pieces of moist foods with near-normal texture) diet when ordered to receive an NDD 2 diet (moist/soft textured foods that are easy to swallow). Administrator directed all staff involved in incident to document details of incident as to gather information for continued investigation. DON in constant conversation with staff regarding incident throughout evening. DON gathering information and continuing investigation. Immediate reeducation of nursing and dietary staff related to modified diets. Resident hospital speech notes reviewed. Resident was being seen by speech therapy in facility. DON followed up 6/26 Nursing and dietary policies/procedures reviewed. Education and training also reviewed for staff involved and was noted to be required. Training for registered dietary and nursing staff to be completed on 6/30/20. Registered Dietitian to provide training on diet texture, diet modifications and reading tray card. Statements reviewed with interdisciplinary team. Dietary aid interviewed. DON placed call again to Regions Hospital as well as son to check on condition. Cognition at baseline. X-ray shows infiltrate is present in left lower lobe. Incident will be reviewed at July's nursing meeting as well as at July's QAPI (quality assurance and performance improvement) meeting. When interviewed on 6/29/20, at 2:57 p.m. RN-A stated they had not receiving additional training on modified diets in the last week. RN-A further stated if the NA discovered a discrepancy, the NA should tell the nurse and the nurse could verify the order. RN-A further verified and stated, (R1) had a pulled pork sandwich and fries. It was not what (R1) was supposed to have. NDD2 was what he was supposed to get, but (R1) got the NDD3 diet. When interviewed on 6/29/20, at 3:02 p.m. the DON stated they had immediately started to train staff as they arrived to work about ensuring diets provided matched the directions on the dietary card and a high level overview of the different diet types provided in the facility. However, no monitoring was completed to ensure residents received the correct diet after the training was provided. When interviewed on 6/29/20, at 4:39 p.m. family member (FM)-A stated the facility informed (FM-A) that (R1) had been served bread and that (R1) should not have had it. The tray was handed to (R1) and then (R1) was left alone so staff could deliver the rest of the trays. Then staff returned to find (R1) not breathing quite right and the staff took food out of (R1's) mouth. FM-A stated that prior to this event, (R1) had been rehabilitating, and the family was planning for (R1) to return home. FM-A further stated the palliative care doctor told (FM-A) that the choking event was very traumatic for (R1) and (R1) was not going to improve. FM-A further stated (R1) had moved on to hospice care now. When interviewed on 6/30/20, at 11:45 a.m. dietitian (D) stated, NDD3 would be ground meat - moistened with gravy or sauce, certain vegetable would be avoided or pureed, certain fruits would be avoided or substituted - would need to be soft, can have bread, cake, vegetable should be soft mashable. When interviewed on 6/30/20, at 3:51 p.m. DON verified and stated discovering through staff interviews the night of R1's choking incident, that R1 was served the wrong diet tray. (R1) received an NDD3 instead of a 2. When interviewed on 6/30/20, at 3:58 p.m. cook (C)-C verified being the one who prepared R1's tray for dinner on 6/25/20. C-C stated, I looked at the tray ticket and thought it was a 3 but it was a 2. I was looking at it when it was still in the transport cart. R2's admission Minimum Data Set ((MDS) dated [DATE], indicated cognitively intact with [DIAGNOSES REDACTED]. R2 required extensive one person physical assistance to eat. The MDS identified R2 had a swallowing disorder and complained of difficulty or pain with swallowing. R2's Initial Nutritional Evaluation dated 6/15/20 indicated R2 had, difficulty swallowing and required a special diet of, Pureed, NDD1 along with honey thick liquids. R2's tray ticket indicated Diet: DYS1 Pur, Honey Thk Liq (pureed food with honey thickened liquid). R2's care plan initiated on 6/12/20, failed to include nutrition risks or how to manage her difficulty with swallowing. Even though R2's nutritional evaluation and admission MDS identified a swallowing disorder, her care plan failed to identify this. R2's progress note by the registered dietician dated 6/16/20, identified, Dx (diagnoses) dysphagia and s/sx (signs and symptoms) swallowing problems: c/o (complains of) difficulty and pain with swallowing which necessitates the pureed, honey thick textures. R2's progress note by registered nurse (RN)-B dated 6/23/20, at 3:03 p.m. indicated, Resident had great difficulty with medication this shift. Writer asked if she preferred applesauce or pudding. Resident chose pudding. Medications were crushed and administered with honey thick liquid to follow pudding. Resident coughed, choked, sneezed, gagged, and mouth, nose, and eyes watered for approximately 15 minutes. Resident turned red and struggled to maintain baseline breathing before administration. R2's nurse practitioner's progress note dated 6/25/20, identified, Per nursing, pt (patient) on hospice but is struggling with swallowing. Tried nectar and honey thickened per Speech therapy. However, pt is unable to swallow causing her to choke. R2's progress note by RN-C dated 6/26/20, at 12:26 a.m. indicated, Pt. (patient) continues to have complications swallowing; staff is currently attempting to find things that pt. can consume safely. During observation on 6/29/20, at 11:14 a.m. the lunch trays were prepped in the kitchen while stacked in the transport cart. There was a tray ticket on each tray with a picture of the resident. The tray tickets listed the specific information for each resident including diet type and required modifications, food allergies and special instructions. The director of dietary services stated that this was the tray preparation process the facility had been following since the COVID-19 outbreak and elimination of communal dining. During observation on 6/29/20, at 12:13 p.m. R2 was in the north common area and had a meal tray in front of her that consisted of pureed spaghetti, pureed carrots, ice cream, thickened milk, thickened juice and whole grapes. R2's tray ticket identified, DYS 1 Pur, Honey Thk Liq. R2 pointed to the dish of grapes to LPN-A whom was at the table assisting with the lunch meal and LPN-A removed the grapes from R2's tray. When interviewed on 6/29/20, at 12:32 p.m. R2 stated, I cannot eat grapes. LPN-A stated, I don't know why they gave (R2) grapes. LPN-A stated R2 was on a puree diet with honey thickened liquids as indicated on the tray ticket. LPN-A further stated R2 was at risk for choking and whole grapes were not appropriate for R2's diet. When interviewed on 6/29/20, at 12:40 p.m. dietary aide (DA)-B stated R2 required a NDD 1 (level 1 dysphagia (difficulty swallowing) diet including only pureed foods with the same texture as pudding) pureed diet with honey thickened liquids and should not have been served whole grapes. When interviewed on 6/29/20, at 12:43 p.m. director of dietary services (DDS) stated the fresh fruit indicated on the lunch menu should have been pureed and thickened grapes for anyone on an NDD1 pureed diet with thickened liquids. When interviewed on 6/29/20, at 12:52 p.m. nursing assistant (NA)-A stated the person who delivered the tray should have verified that the meal matched the diet on the tray ticket. When interviewed on 6/29/20, at 12:53 p.m. NA-B stated, I delivered (R2's) lunch tray today. NA-B further stated (NA-B) read the tray ticket and lifted the lid to the main dish, and confirmed R2 was getting a pureed meal. NA-B further stated R2 should not have been served whole grapes and did not notice them when the tray was checked. When interviewed on 6/29/20, at 12:58 p.m. LPN-A stated, Fortunately (R2) knows not to eat grapes, but if this was someone that ate alone and did not know, they could have eaten the grapes. When interviewed on 6/29/20, at 1:03 p.m. NA-A verified the point of care iPad charting system showed R2's header indicated, Diet: NDD1 (puree), texture: puree, fluid consistency: honey, special instructions: none. When interviewed on 6/29/20, at 1:09 p.m. the director of nursing (DON) stated resident's diets were indicated by orders placed upon admission or after a change in condition requiring a change in diet. The assistant director of nursing (ADON) stated point of care iPad chart was directly linked to point click care (PCC- the system that contains the electronic medical record). DON further stated the NA delivering the tray should check the tray for accuracy and if a discrepancy is discovered, they should remove the tray and notify the nurse immediately. When interviewed on 6/29/20, at 2:09 p.m. DDS stated the cooks were trained by experienced cooks upon hire, and that in-services were provided every time a new cook was hired. The dysphagia diet would have been taught to the new cook by the experience cook as well. The new cook works with an experienced cook for several weeks. The last in-service was 7/9/18, and there have been no new cooks since then. When interviewed on 6/29/20, at 2:54 p.m. NA-C stated the food on the resident's tray was supposed to be checked against the tray ticket. Upon hire, I was trained on the modified diet. NA-C further stated receiving re-education on 6/26/20, and there was an additional mandatory training scheduled for 6/30/20. R4's annual MDS dated [DATE], indicated moderate cognitive impairment with [DIAGNOSES REDACTED]. R4 required supervision and set up help for eating. R4's dietary tickets for breakfast, lunch and supper indicated, Diet: DYS 3 Adv, diabetic, ground meat. Per R4's speech therapy plan of care, dated 6/30/19, STG: Swallowing 1: In order to decrease the risk of aspirating/choking, patient will apply recommended safe feeding/swallow strategies (including bolus size/pacing control, through mastication, oral clearance between bites, cyclic ingestion of solids/liquids, and single sips of thin liquids across 90% of opps x3/3 observations. R4's care plan, last revised 6/30/20, indicated, (R4) has a nutritional problem: Inconsistent CHO (carbohydrate) intake r/t dx DM AEB elevated blood sugars >200; requires tx diet. (R4) has a dx dysphagia; requires mechanically altered diet. (R4) will tolerate diet textures without coughing, choking, s/sx aspiration. (R4) will comply with prescribed therapeutic diet. Diet: NDD3, 2gm na+, THIN LIQUIDS. Monitor intake and record q meal. Observe/document/report to Nurse, MD s/sx of dysphagia: Pocketing, Choking, Coughing, liquid spilling from mouth, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Serve meals in the dining room and provide tray set up. ST (speech therapist) recommendations: small/single bites; slow rate of intake; cyclic ingestion liquids/solids. R5's quarterly MDS dated [DATE], indicated severe cognitive impairment with [DIAGNOSES REDACTED]. R5's dietary tickets for breakfast, lunch and supper indicated, Diet: small portions, NDD3. R5's care plan, last revised 7/6/20, indicated, (R5) has a potential nutritional problem r/t dx dementia. Loose teeth, does not want DDS appointment, necessitating a mechanically altered diet. Diet: Small portions, NDD3 d/t dental status. Monitor intake and record q meal. Serve meals in the dining room. R6's admission MDS dated [DATE], indicated cognitively intact with [DIAGNOSES REDACTED]. R6 required limited one person physical assistance to eat and complained of difficulty or pain when swallowing. R6's dietary tickets for breakfast, lunch and supper indicated, Diet: DYS 3 Adv. Per R6's speech pathology initial evaluation, dated 4/21/20, Swallowing: The patient demonstrates mild oropharyngeal dysphagia; likely consistent with baseline, but swallowing appears functional for a modified diet. R6's care plan, last revised 7/6/20, indicated, Altered nutrition: Inadequate oral food intake r/t (related to) decreased appetite and hx difficulty chewing/swallowing AEB requires mechanically altered diet and supplements. Diet: NDD3, thin liquids. Monitor and record intake at all meals. Provide tray set-up. R8's significant change MDS dated [DATE], indicated cognitively intact with [DIAGNOSES REDACTED]. R8 required extensive assistance to eat and complained of difficulty or pain when swallowing. R8's dietary tickets for breakfast, lunch and supper indicated, Diet: Regular. R8's care plan, last revised 6/30/20, indicated, Nutrition: (R8) has a potential for inadequate oral intake r/t dx malignant neoplasm of the brain, [MEDICAL CONDITION], edentulism AEB weight loss PTA and hospice status. (R8) will consume food and fluid as desired for comfort and pleasure. (R8) prefers to eat meals in her room. Staff will offer to go to dining room. Resident request to eat meal in bed will be honored. (R8) eats her meal over one to two hours. Provide eating assist prn (as needed). Provide, serve diet as ordered: Regular, Regular Textures, Thin Liquids. Monitor intake and record q meal. R8's Comprehensive Nutritional Evaluation, dated 4/10/2020, indicated difficulty swallowing and included She is receiving eating assist at meals; eats in her room and is being served on disposables. Her diet has changed since readmit from hospital-switched to puree NTL (nectar thick liquids) d/t difficulty swallowing likely r/t congestion. R9's quarterly MDS dated [DATE], indicated severe cognitive impairment with [DIAGNOSES REDACTED]. R9's dietary tickets for breakfast, lunch and supper indicated, Diet: DYS 3 Adv, PUREED MEAT. R9's care plan, last revised 6/30/20, indicated, (R9) has a potential for altered nutrition status r/t dx dementia. (R9) eats in the dining room. Provide, serve diet as ordered: NDD3, pureed meat, thin liquids. Monitor intake and record q (every) meal. R10's quarterly MDS dated [DATE], indicated severe cognitive impairment with [DIAGNOSES REDACTED]. R10 required supervision and one person physical assistance to eat. R10's dietary tickets for breakfast, lunch and supper indicated Diet: DYS 3 Adv. R10's care plan, last revised 6/2/20, indicated, Potential for altered nutrition r/t DX: DM and dysphagia requiring mechanically altered diet. Diet: NDD3, thin liquids. Monitor and record intake for all meals. The facility policy Dysphagia revised 3/2018, identified how to recognize and treat dysphagia. The policy indicated the resident would be assessed by a speech-language pathologist and recommend appropriate consistency diets. The policy further indicated staff would assure proper consistencies are prepared and served. The facility policy Therapeutic Diets reviewed 4/2020, indicated attending physicians would prescribe therapeutic diets for resident's that support the resident's treatment and plan of care. An altered texture for a diet would be considered a therapeutic diet. Standard mechanically altered diets available at the facility include NDD1 (pureed), NDD2, NDD3, honey thickened liquids, nectar thickened liquids, and pudding thickened liquids. The facility policy Dining Room Audits reviewed 4/2020, indicated the food and nutrition services department would audit regularly to ensure that resident needs are met and that dining is safe. The policy instructed, the dietician, food and nutrition services manager and/or dietary supervisor will make scheduled daily meal rounds to every dining room at all meal times to audit the dining room and food service to the residents. The auditor will assess whether correct therapeutic diets and consistencies are served. A copy of these audits was requested, but not provided by the facility. When interviewed on 6/30/20, at 2:30 p.m. DDS stated, they used to do the audits twice a week. However, this had not been done in the past few months because of COVID-19 and need to change dining practices to mainly cart services rather than communal dining. The audits were not documented. The facility provided an undated National Dysphagia Diet Levels that indicated the following: NDD1 - puree, NDD2 - mechanical soft, NDD3 - dysphagia advanced, NDD4 - regular textures. The immediate jeopardy that began on 6/25/20, was removed on 6/30/20, when the facility modified the tray preparation and tray identification process to ensure all trays were checked prior to being placed on the transport cart and double checked for accuracy prior to reaching the resident. All staff who prepared food, delivered trays or assisted with feedings were educated on altered diets and when and how to review trays for accuracy. All meal tickets for residents with altered diets were changed to print on colored paper to stand out from regular diet tray cards. Audits were completed by nursing leadership to ensure tray accuracy. Staff were interviewed and could identify the tray identification process and differences in altered diets. The noncompliance remained at the lower scope and severity level of G, isolated, scope and severity level, which indicated actual harm that is not immediate jeopardy. R3's quarterly MDS dated [DATE], indicated moderate cognitive impairment with [DIAGNOSES REDACTED]. R3 also had a swallowing disorder with coughing or choking during meals or with medications. R3's care plan, last updated 6/30/20, indicated, The resident has a potential nutritional problem r/t (related to) dysphagia (difficulty swallowing) AEB (as evidenced by) requires NDD3 diet. Waiver for regular meat. Intolerance to rice starch, tomato (ok for tomato soup per her son), lettuce, popcorn, and nuts. R3's care plan did not reflect food allergies or Intolerances prior to 6/30/20. Per R3's speech therapy initial assessment, dated 9/6/17, Pt has a history of dysphasia upon her last stay at this TCU and was downgraded to an NDD3 diet with thin liquids. Referral to SLP now due to nursing and dietary staff noticing episodes of coughing, throat clearing, and emesis of phlegm during meals for the last 2 days. Swallowing difficulties are likely caused by weakness, fatigue, and lack of awareness while eating. SLP is required now to evaluate and treat in order to prevent malnutrition, respiratory compromise, and dehydration. R3's Initial Nutritional Evaluation, dated 8/22/17, included, no popcorn, hard nuts, small seeds, lettuce, and tomato. Per progress note dated 9/19/2018, Kitchen's staff notified writer that resident was coughing during breakfast. Writer came to assess resident in the DR. Resident was able to communicate verbally and stated: I am ok. Resident was removed to room for further assessment. Lung sounds were diminishes all lobes. TPR: 97.1, 76, 16, 121/67, 94%RA. Resident stated: I told you I didn't choke. I was trying to clear my throat. I had phlegm. Bethany, NP was updated in regards to the incident. Resident still wishes to have regular diet and refuses to follow the diet order which is NDD3. The Diet refusal form was signed. Writer provided the risks/benefits in regards to resident current condition and having regular diet would put resident at risk for aspiration. Resident is aware all the risks and benefits. R3's electronic medical record, allergy entry last revised on 5/18/18, indicated an active allergy to tomatoes, Reaction Note: Per son, responsible party, resident can eat tomato soup, but NOT tomatoes as she is allergic to the seeds. R3's electronic medical record, progress note dated 9/5/17 indicated, Resident admitted on NDD3 diet, multiple food intolerances Rice starch, popcorn, nuts, small seeds, tomato, and lettuce. No current orders for SLP (speech/language pathologist) but has been observed to be coughing during meals therefore therapy department will obtain orders for SLP eval and treat. R3's dietary tickets for breakfast, lunch and supper included, Observe for coughing or choking/no straw, and listed an allergy to lettuce, rice and tomatoes. When observed on 6/29/20, at 12:25 p.m. R3 sat alone at a table in the dining room. R3 was served spaghetti and whole meatballs topped with spaghetti sauce, a large slice of bread, sliced carrots, apple juice, whole milk, and applesauce for lunch. R3's tray ticked indicated, Diet: regular, allergy lettuce, allergy rice, allergy tomatoes. When interviewed on 6/29/20, at 1:00 p.m. C-A stated, (R3) She is on a regular diet, but no seeds. It says no seeds on her ticket, so we always check the tickets when we serve, usually we give her only shredded lettuce, and she doesn't like skins - like potato skins. NDD3 means the food has moisture, it should be soft and bite size, regular diet we can give every food, NDD3 we need to chop or dice them, and grind the meat, it needs to be soft. When interviewed on 6/29/20, at 1:15 p.m. R3 stated, Yeah it is hard for me to eat, the food has to be cut up, it's on my ticket to help me, I have choked before when eating, my lettuce has to be shredded up, things that gets caught in my throat. There is certain stuff I can't eat, the doctor said I can't have anything with seeds in it, and no tomatoes. They do feed me tomatoes and cucumbers once in a while - I just pick them out and throw them aside. When interviewed on 6/29/20, at 2:30 p.m. director of dietary services stated, The allergies are listed under dislikes on the meal cards- she can't have cucumber seeds, cucumber you have to do that delicately for her, no tomato seeds, when we interviewed her she said she doesn't like tomato seeds or cucumber seeds, because it gets stuck in her throat, it is a preference not an allergy. At 2:35 pm DDS stated here let me double check then went into R3's electronic Health Record through Point Click Care (PCC), reviewed the allergies listed for R3 and stated, well that is interesting . she is allergic to rice, lettuce, and tomato . I wonder if we are caught up on Optima (dietary software) let me look. It says allergy to lettuce in Optima already, but no tomato, I don't understand why I didn't get that information, I am supposed to be getting that information. At 2:45 p.m. when asked why R3 received spaghetti with tomato sauce for lunch if allergic to tomatoes, DDS stated She had it with the sauce? I thought that she had it with the tomato off, if she is truly allergic to tomatoes I just think that the nursing staff and dietary need to go through all these charts and make sure that if there is any allergies or anything that needs to be communicated with us. If I would have known that she had an allergy I would not have given it to her, we do have plain meatballs for those who cannot have tomato products. When interviewed on 6/29/20, at 2:52 p.m. dietary aid (DA)-A stated, On the meal ticket, the 'likes' means she likes to eat that, the 'dislikes' mean she doesn't like it, she don't like seeds to tomatoes it is not an allergy, she likes shredded lettuce, but she don't like the leaves, it's not an allergy, it is a dislike - she don't like the leaves and she don't like the seeds. When interviewed on 6/29/20, at 6:00 p.m. administrator stated, Like for Betty, she gets diverticulitis from the tomato seeds, so where should we be listing this on the care plan? When interviewed on 6/30/20, at 11:45 a.m. dietitian stated, I don't think that tomato was listed as an allergy in the care plan, if it were truly an allergy and she received a tomato sauce it would be the incorrect thing that should be omitted from her meals. Per the facilities policy titled, Food Allergies and Intolerances, last revised 08/17: a) Residents are assessed for a history of food allergies and intolerances upon admission and as part of the comprehensive assessment. b) All resident reported food allergies and intolerances are documented in the assessment notes and incorporated into the resident's care plan. c) Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat.