Every finding on record at North Crest Living Center

Based on Electronic Health Records (EHR) review, document review, Medication Administration Record - Treatment Administration Record (MAR-TAR), staff interview and policy review the facility failed to notify the primary care physician with the resident's lab results from a Urine Analysis (UA) for 1 of 3 residents (Residents #1) reviewed. The facility reported a census of 57 residents.Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. The MDS documented utilization of indwelling catheter.Review of Resident #1's EHR titled, Orders documented a physician's order started 8/11/25 to change indwelling catheter with 22 French on the 11th of the month. EHR titled, Orders also documented a physician's order to obtain UA and send out one time only for 1 day dated 6/6/25.Review of Resident #1's EHR titled, Orders documented a physician's order started 7/29/25 to change indwelling catheter with 22 French as needed related to obstructive and reflux uropathy.Review of Resident #1's EHR titled, Progress Report documented on 8/6/25 at 7:08 AM a new order to obtain and send out UA d/t aggressive behaviors with orders added to EHR. EHR titled, Progress Report documented on 8/6/25 at 9:38 PM UA was obtained and taken to the lab at that time.Review of Resident #1's document with fax date of 8/7/25 titled, Urinalysis Results documented bacteria 4+, red blood cells 51-100 with reference range of 0-2, white blood cells 3-5 with reference range of 0-2, urine appearance of turbid with reference range of clear, ph urine greater than or equal to 9 with reference range of 5-8, leukocyte esterase urine large with reference range of negative, protein 300 with reference range of negative, ketones trace with reference range of negative and blood in urine moderate with reference range of negative. UA also documented a culture to follow. Review of UA documented no review from nursing staff and no physician notification.Review of Resident #1's document with fax date of 8/9/25 titled, Bacteria Culture Results documented Preliminary report of greater than 100,00 CFU/mL proteus mirabilis and greater than 100,00 CFU/mL gram negative rod with antibiotic susceptibility. Review of Bacteria Culture Results documented no review from nursing staff and no physician notification.Review of Resident #1's EHR titled, Progress Notes documented no reception of faxes on 8/7/25 or 8/9/25. Further review of EHR titled, Progress Notes documented no notification to Resident #1's physician of either fax results.Review of Resident #1's EHR titled, Progress Notes documented on 8/18/25 Staff B, Medical Doctor (MD) / Primary Care Physician for Resident #1 was notified of Resident #1's hospitalization with admission to the hospital for acute respiratory failure related to sepsis secondary to urinary tract infection.On 8/26/25 at 8:47 AM Staff A, Registered Nurse (RN) acknowledged she was the charge nurse on 8/7/25. Staff A stated once the lab results are sent back to the facility the charge nurse would receive the lab results. Staff A explained when there was a nurse for the memory hall and a nurse working the park hall it was the facility's expectation that the charge nurse would take care of lab results faxed to the facility. Staff A stated the lab results were sent back through the fax machine but now it is her understanding it is sent through an email. Staff A acknowledged she was still figuring out the processes at the facility. Staff A stated everything that she received and processed she signed when she processes them. Staff A stated she had not received the faxed UA for Resident #1 on 8/7/25. On 8/26/25 at 9:00 AM Staff B, MD stated the main cause of hospitalization for Resident #1 was due to respiratory failure due to aspiration and does not believe knowledge of the lab or starting antibiotics would have prevented the hospitalization. Staff B, MD explained the results of the UA and Bacteria Culture Results should have been sent to him, that was a professional standard. Review of the email dated 8/22/25 from Staff C, Medical Records Staff to the DON documented Staff C understood she was a part of the fail safe for lab results processing. Results with no signatures get printed out and given to the nurses.On 8/26/25 at 8:31 AM the Director of Nursing (DON) acknowledged she could not find when the lab results were sent to the physician once received by the facility from the lab. The DON stated as the results come back from the lab the results should be sent off to the doctor for review. The DON stated she had noticed the missed physician notification on 8/22/25 and started educating the nurses at the facility about physician notification and handling of lab results. The DON stated she had updated the nurses on the follow up portions for the lab results to the physician. The DON explained it was a situation that warranted a mass audit to be sure nothing was missed in the process. Review of policy updated 9/24 titled, Physician Order Guideline documented it was the policy of the facility to secure physician orders for care and services for residents as required by state and federal law. Physician orders will be dated and signed according to state and federal guidelines. Unclear or incomplete written orders will be reviewed with the physician. Any order clarification will be documented on the physician's telephone order form. Faxed orders will be accepted under the following conditions: the physician signs and retains the original copy of the faxed order and the physician provides the original copy, if requested.Review of document updated 8/22/25 titled, Labs documented when lab results are received the receiving nurse was to send to the physician and update the awaiting physician section.

Based on Electronic Health Record (EHR) review, Medication Administration Record - Treatment Administration Record (MAR-TAR) review, policy review and staff interviews the facility failed to provide appropriate interventions for the urinary catheter to provide appropriate services to prevent urinary tract infections to 1 of 3 residents reviewed (Resident #1). The facility reported a census of 57 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS documented utilization of an indwelling catheter.Review of Resident #1's EHR titled, Orders documented a physician's order dated 7/29/25 to flush the indwelling catheter as needed for clogging / dysfunction as needed with 30-60mL sterile water.Review of Resident #1's MAR-TAR documented a physician's order with a start date of 7/29/25 to flush the indwelling catheter as needed for clogging / dysfunction with 30-60mL sterile water. Review of Resident #1's MAR-TAR documented no utilization of the as needed catheter flush for the month of August.Review of Resident #1's EHR titled, Progress Notes documented no utilization of the as needed catheter flush for the month of August.Review of Residents #1's EHR titled, Task B&B-Catheter Care from 8/6/25 through 8/17/25 documented Resident #1's output each shift of less than or equal to 100mL on 8/6/25 at 8:36 PM of 100mL, 8/9/25 at 7:58 AM of 100mL, 8/10/25 9:59 PM of 50mL, 8/11/25 at 7:59 PM of 100mL, 8/14/25 at 8:47 PM of 0cc, 8/16/25 at 8:42 PM of 0cc, 8/17/25 at 5:32 AM of 0cc and 8/17/25 at 8:48 PM of 0cc.Review of Resident #1's EHR titled, Progress Notes documented on 8/18/25 Staff B, Medical Doctor (MD) / Primary Care Physician for Resident #1 was notified of Resident #1's hospitalization with admission to the hospital for acute respiratory failure related to sepsis secondary to urinary tract infection.On 8/26/25 at 2:45 PM Staff D, Physician's Assistant (PA) for Resident #1's Urologist stated if Resident #1 had 100mL or less per 8 hour shift the expectation was a catheter flush and if needed a catheter change would have been completed. Staff D stated if the catheter was leaking and wet briefs were noticed a flush should have been completed. Staff D explained that less than 100mL or no output could indicate the catheter was clogged or there was some dysfunction. On 8/26/25 at 1:58 PM Staff E, Registered Nurse (RN) stated if Resident #1 had bladder spasms or the urine was coming out of the penis, if there was discoloration, sediment or with decrease in output an as needed flush should be completed . Staff E stated if Resident #1 had 0mL output from his catheter; she would utilize the PRN flush. Staff E stated if 100mL was a decrease for Resident #1 she would flush his catheter. On 8/26/25 at 2:16 PM Staff F, Licensed Practical Nurse (LPN) acknowledged she had worked with Resident #1. Staff F stated she would use the as needed flush if Resident #1 had only 100mL and Resident #1 usually had 200mL. Staff F stated if there was decrease in output or there was no output she would utilize the as needed catheter flush. Staff F stated if there was no output for a shift Resident #1 would require a flush. Staff F acknowledged 100mL would also require a flush. Staff F explained if the as needed flush order was utilized it would be signed off in the MAR-TAR and a Progress Note would be entered. On 8/26/25 at 3:12 PM Staff G, LPN explained if she worked a shift and Resident #1 had no output she would have utilized the as needed flush order. Staff G stated if there is 100mL on days and 50mL on the pm shift Resident #1 would require a flush. Staff G explained the catheter should have been flushed when 100mL or less per shift. On 8/26/25 at 11:51 AM the DON stated the Certified Nursing Assistant (CNA) should be letting the nurse know with little to no output from any resident. The DON explained the flushing should be utilized at the nurses discretion. The DON acknowledged if the output was 50cc then the nurse should have investigated the output further. She stated she felt like the concern was a documentation issue. The DON stated if there was a decrease in output the nurse should have been notified. The DON acknowledged no output from Resident #1's catheter could indicate dysfunction or the catheter was clogged.Review of policy updated 10/24 titled, Catheters documented the policy was to provide guidance in the preventive measures for controlling common infections for residents with a urinary catheter as part of the overall infection control policy. The facility was committed to providing a safe and healthy environment for residents and to minimize or prevent the spread of infection. Catheters are to be changed per orders.

Based on observation, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a catheter, that was on Enhanced Barrier Precautions (EBP) for 1 of 3 reviewed (Resident #3). The facility reported a census of 57 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS documented utilization of an indwelling catheter.Review of Resident #3's EHR titled, Orders documented a physician's order started 8/4/25 to change indwelling catheter with 16 French monthly and as needed. Review of Resident #1's EHR titled, Orders documented a physician's order started 7/29/25 to change indwelling catheter with 16 French monthly and as needed. Observation on 8/25/25 at 3:10 PM of catheter care completed on Resident #3 by Staff H, Certified Nursing Assistant (CNA) and Staff I, CNA with EBP signage posted in Resident #3's room revealed Staff H present in the room with Resident #3 sitting on the commode. Staff H left the room and asked another staff member to help with peri care. Staff H returned to Resident #3's room with Staff I. Staff H and Staff I applied gloves, neither staff completed hand hygiene or applied a gown, Staff H utilized a gait belt to assist Resident #3 with standing, Staff I obtained wipes, Staff I removed peri wipes from the bag, cleansed catheter and penis while standing behind Resident #3, cleansed buttocks with 2 peri wipes, pulled Resident #3's brief up, pulled Resident #3's pants up, Staff H assisted Resident #3 with transfer to the wheelchair, Staff H removed gloves, Staff H completed hand hygiene, Staff I removed gloves, Staff I gathered trash in trash bag, Staff I removed the trash bag, Staff I exited Resident #3's room, Staff I walked down the hall to the soiled utility room, Staff I opened the door, placed garbage in the trash barrel and Staff I completed hand hygiene in the hall outside the soiled utility room. On 8/25/25 at 3:30 PM Staff H stated he was not required to wear a gown when Resident #3 was on the commode. Staff H stated when he was not working directly with the bodily fluids the gown would not be expected. Staff H acknowledged that other CNA was not wearing the gown at the time of catheter care and peri care. Staff H explained Resident #3 was having a BM there is no expectation for gown application. Staff H stated with Enhanced Barrier Precautions (EBP) he was supposed to gown and glove for catheter and peri cares but not required when Resident #3 was having a bowel movement. On 8/25/25 at 3:56 PM Staff I, stated the only time she would apply a gown was when she emptied Resident #3's catheter. On 8/25/25 at 4:05 PM the DON stated the facility's expectation was that gowns would be worn by the staff that transferred the resident and the staff completing care on the resident. On 8/26/25 at 2:16 PM Staff F, Licensed Practical Nurse (LPN) stated when there was any care provided to a resident with catheters the staff are required to wear a gown, gloves and complete hand hygiene before and after application of gloves or resident contact. On 8/26/25 at 4:17 PM the DON stated hand hygiene should be completed prior to resident care, after resident care, before applying gloves and after removal of gloves. The DON stated the staff should have worn gowns with the resident cares on Resident #3. Review of policy updated 11/24 titled, Enhanced Barrier Precautions (EBP) documented EBP was used to prevent the spread of Multi-Drug Resistant Organisms (MDRO) to residents. EBP precautions apply when a resident is not known to be infected or is known to be infected with a CDC-targeted MDRO and has a wound or indwelling medical device. Indwelling medical devices include urinary catheters.Review of policy updated 8/24 titled, Hand Hygiene documented hand hygiene will be completed before anticipated contact with resident, after contact with a resident, after contact with blood, body fluids, visibly contaminated surfaces, after contact with objects in the residents room, after removing Personal Protective Equipment (PPE).

Based on document review, staff interviews, and facility plan review the facility failed to demonstrate good faith attempts to correct quality deficiencies based on issues that were identified with repeat deficiencies in 3 areas and corrections developed in a Performance Improvement Plan (PIP) that remained incomplete in a reasonable time frame. The facility reported a census of 61 residents. Findings include:Review of document titled, Provider History Report documented previous recertification survey on 9/18/24 with deficiencies F0625 notice of bed hold policy before/upon transfer with a correction date of 10/19/24, F0656 Develop/implement Comprehensive care plan with correction date of 10/19/24, and F0658 services provided meet professional standards with correction date of 10/19/24.Review of document dated 7/7/25 titled, Performance Improvement Plan (PIP) documented an objective and goal to meet and maintain compliance with F880. Also documented actions steps to ensure noted catheters have appropriate orders and care plans with a target completion date of 7/25/25.On 7/24/25 at 11:38 AM the DON acknowledged all of the residents at the facility that utilized catheters did not have care plans with a focus, goal or interventions related to the use of the catheter. The DON stated her expectation was that a care plan would have been developed with a focus, goal and interventions related to the use of a catheter. The DON acknowledged the facility did not have an order in place for one of the residents prior to surveyors entrance at the facility.On 7/24/25 at 11:19 AM the Administrator explained the PIP about federal regulation tag 880 was a result of a mock survey and received the results of the survey on 7/18/25. The Administrator acknowledged the orders for the catheter that had not been entered prior to the survey team entrance on 7/21/25 should not have taken that long to enter. The Administrator stated the target date can be changed and extended if the PIP did not meet the goal date. The Administrator stated the facility does not have routine orders and needs to have routine orders especially for catheters. The Administrator acknowledged the resident that he reviewed did not have a care plan related to catheter with focus, goals and interventions documented. The Administrator stated the care plans for the resident with catheters could be entered by the day's end and the facility had written the PIP for a target completion date of 7/25/24. The Administrator stated he felt he was going to receive a regulatory violation related to repeat deficiencies for QAPI.Review of the document dated 3/19/25 titled, Quality Assurance and Performance Improvement Program documented North Crest Living Center Quality Assurance and Performance Improvement Committee abides by guiding principles that included setting goals for performance and measured progress towards those goals. With goals that included striving for a deficiency free survey and monthly meetings with review of correction compliance for plans of correction.

Based on observation, interview and record review the facility failed to follow infection control standards of practice. Laundry staff failed to wear Personal Protective Equipment (PPE) while sorting laundry, and the facility failed to ensure that they had consistent implementation of the responsibilities of the Infection Preventionist (IP). The facility reported a census of 61 residents. Findings include:On 7/24/25 at 6:48 AM, observed Staff L, Environmental Aide in the laundry room sorting dirty laundry items without a gown or gloves. She quickly went to get a gown but was unsure how to put it on. She first put it on backwards, with the ties in the front, then she took it off and put it on the correct way with the ties in the back. She went back to sorting the laundry but failed to apply disposable gloves. On 7/24/25 at 8:15 AM, the Director of Nursing (DON) explained that she was taking over the responsibilities as Infection Preventionist as they discovered that the Assistant Director of Nursing (ADON) was not completing the required tasks and was terminated. She said that she found residents that should have been on Enhanced Barrier Precautions (EBP) did not have signage at the doors or appropriate PPE. Some had signage that didn't need to be on EBP. The DON maps of infections for April and May but none for June or July. According to the facility policy titled: Infection Prevention and Control Program revised on 1/2024. The designated Infection Preventionist (IP) serves as a consultant to our staff on infectious diseases, resident room placement implementing of isolation precautions, staff and resident exposures, surveillance and epidemiological investigations of exposure of infectious diseases. The intent of the regulation was to ensure that the facility develops and implements protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic. Laundry and direct care staff shall handle, store, process, and transport linens so as to prevent spread of infection. The Facility assessment dated [DATE] showed that the Services Provided included infection prevention and control. Identification and containment of infections, prevent of infections, Antibiotic stewardship and isolation precautions.

Based on Electronic Health Record (EHR) review, document review, policy review and staff interviews the facility failed to provide a comprehensive care plan that included goals or interventions for residents with a catheter, depression and anxiety for 6 of 10 residents reviewed (Resident #1, #3 and #5, #6, #7 and #34). The facility reported a census of 61 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment. Review of Resident #1's MDS dated [DATE] documented utilization of an indwelling catheter. Review of Resident #1's EHR titled, Care Plan revealed no focus, goal or intervention developed for utilization of a catheter. 2. The MDS dated [DATE] for Resident #3 documented a BIMS of 15 indicating no cognitive impairment. Review of Resident #3's MDS dated [DATE] documented utilization of an indwelling catheter. Review of Resident #3’s EHR titled, Care Plan revealed no focus, goal or intervention developed for utilization of a catheter. 3. The MDS dated [DATE] for Resident #5 documented a BIMS of 9 indicating moderate cognitive impairment. Review of Resident #5's MDS dated [DATE] documented utilization of an indwelling catheter. Review of Resident #5’s EHR titled, Care Plan revealed no focus, goal or intervention developed for utilization of a catheter. On 7/24/25 at 11:38 AM the DON acknowledged all of the residents at the facility that utilized catheters did not have care plans with a focus, goal or interventions related to the use of a catheter at that time. The DON stated her expectation was that a care plan would have been developed with a focus, goal and interventions related to the use of a catheter. On 7/24/25 at 11:19 AM the Administrator acknowledged the facility did not have things in place for Resident #6. The Administrator stated the care plans for the residents with catheters could have been entered today and the facility had written the PIP (performance improvement plan) with a target completion date of 7/25/24. Review of an undated policy titled, Goals and Objectives, Care Plans documented Care plan goals and objectives are defined as the desired outcome for a specific resident problem. Care plan goals and objectives are derived from information contained in the resident’s comprehensive assessment and : are resident oriented, are behaviorally stated, are measurable and contain timetables to meet the resident’s needs in accordance with the comprehensive assessment. Goals and objectives are entered on the resident’s care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. 4. The MDS assessment dated [DATE] for Resident #6 documented reentry into the facility on 7/17/25 from a short term hospital stay. In an interview on 7/23/25 at 9:36 AM, Resident #6 reported the catheter was inserted at the hospital because she had surgery for a right foot fracture related to a fall. The resident reported the hospital kept the catheter inserted because she was non-weight bearing. The Medical Diagnosis report for Resident #6 included diagnoses of a closed fracture of the lower end right tibia and urinary retention. The Hospital Discharge Instructions for Resident #6 dated 7/14/25 showed diagnoses of a major ankle injury and closed fracture of distal end of the right fibula and tibia. The Progress Note dated 7/17/25 at 3:39 PM showed the facility received report from the hospital that Resident #6 had a right ankle fracture with right lower leg wrapped, foley catheter placed and the resident’s activity level would be two person assist and non-weight bearing to right side. The Care Plan for Resident #6 failed to show an updated activity level of non-weight bearing to the right side, a presence of a catheter, or information regarding the fracture of the right tibia and fibula. On 7/24/25 at 11:38 AM the DON acknowledged all of the residents at the facility that utilized catheters did not have care plans with a focus, goal or interventions related to the use of a catheter. The DON stated her expectation was that a care plan would have been developed with a focus, goal and interventions related to the use of a catheter. The DON stated Resident #6 does now have an order for a catheter. The DON acknowledged the facility did not have an order in place prior to surveyors entrance at the facility. On 7/24/25 at 11:19 AM the Administrator acknowledged the facility did not have things in place for Resident #6. The Administrator reported the orders and diagnosis should not take that long. The Administrator acknowledged the Resident #6 did not have a care plan related to catheter with interventions. The Administrator stated the care plans for the resident with catheters could be entered today. 5. The MDS for Resident #7 dated 6/20/25 identified a Brief Interview for Mental Status (BIMS) score of 13/15 indicating normal cognition. The MDS included diagnoses of anxiety, and depression. The document identified no areas of behavior or mood during the reporting period. The MDS identified Resident #7 took antianxiety and antidepressant medications during the last 7 days of the assessment period. Review of Resident #7’s MAR-TAR dated 7/25 identified the resident was prescribed: Alprazolam .25 mg three times a day (TID) for anxiety written 7/21/25. Bupropion XL 150 mg extended release (ER) daily (QD) written 9/12/23 and revised 12/17/24. The Physician Orders provided to monitor every shift for target behaviors: (refusal of cares, yelling out, physical aggression toward self/others, Spontaneous crying, False Beliefs, Wandering, and/or self-isolating. Document Interventions. 0-Not Present 1-Redirection 2-Music Therapy/Room Temp Adjustment. 3-1:1 4-Physical Touch/Repositioning 5-Offer Snack/Fluids 6-Remove resident from environment written 12/6/23. The Physician Order for documentation of target behaviors was not individualized to the resident. Review of EMR Progress Notes 1/1/25 to 7/24/25 revealed entries for provision of Alprazolam .25 mg as needed up TID for resident complaints of anxiety. The entries did not provide description of anxiety signs or symptoms. The facility provided document, Psychiatric Note dated 5/20/25, revealed Resident #7 received Individual Psychotherapy due to a mental health diagnosis of generalized anxiety disorder. The document disclosed the resident presented with symptoms of anxiety, fatigue, goal-directed activity decreased, sleep decreased and socially isolating. Resident #7's Care Plan dated 6/25/25 revealed a focus of inability to keep all diagnoses or medications initiated on 9/16/24. The interventions for staff included to notify the doctor of what they can do to help, medications and warnings were located in the chart, and to look at other areas of the medical chart if something was missing. An additional focus identified high risk medications dated 9/30/24 had staff interventions of identification of adverse reactions to antianxiety and antidepressant medications. The Care Plan failed to identify target behaviors related to the use of antianxiety medications and antidepression medications. The document further failed to identify non-pharmacological interventions related to the use of the medications. 6. The MDS for Resident #34 dated 5/22/25 identified a BIMS score of 10/15 indicating moderate cognitive impairment. The MDS included a diagnosis of non-Alzheimer’s Dementia. The document identified no signs/symptoms of mood, but identified wandering 1-3 days during the reporting period. The MDS identified Resident #34 took antidepressant medication during the last 7 days of the assessment period. The EMR Medical Diagnoses revealed a diagnosis of insomnia dated 6/3/25. Review of Resident #34’s MAR-TAR 7/25 identified the following orders: Trazodone 100 mg for insomnia dated 4/18/25. Duloxetine 30 mg for unspecified dementia dated 1/17/25. An order for recording the number of hours slept related to unspecified dementia contained data from 2 hours to 8+ hours. An order was provided to monitor every shift for target behaviors: (refusal of cares, yelling out, physical aggression toward self/others, Spontaneous crying, False Beliefs, Wandering, and/or self-isolating. Document Interventions. 0-Not Present 1-Redirection 2-Music Therapy/Room Temp Adjustment. 3-1:1 4-Physical Touch/Repositioning 5-Offer Snack/Fluids 6-Remove resident from environment written 10/15/24. The Physician Order of monitoring of target behaviors was not resident specific. A facility document, Pharmacy Note to Attending Physician/Prescriber dated 2/26/25, revealed the use of Trazodone for insomnia and Duloxetine for depression could be seen as duplicative therapy as both medications were classified as antidepressants. The document contained statements that Trazodone was a dual purpose medication utilized for treatment of insomnia and the provider indicated the use of both antidepressants outweighed the risks. Resident #34’s Care Plan revealed a focus for medications identified as high risk dated 11/18/24. Staff interventions revealed side effects of antidepressant medication included insomnia dated 11/18/24. A focus of down in the dumps dated 11/18/24 revealed an intervention for staff to let family and doctor know if the resident’s mood was more down in the dumps dated 11/18/24. A focus of inability to keep all diagnoses or medications dated 11/18/24. The interventions for staff included to notify the doctor of what they can do to help, medications and warnings were located in the chart, and to look at other areas of the medical chart if something was missing. The Care Plan failed to identify the use of medications classified as antidepressants for uses other than depression and resident specific behaviors related to them, and resident specific behaviors related to being down in the dumps. On 7/23/25 at 12:35 PM the MDS Coordinator stated the Care Plan Focus of down in the dumps was dependent upon the resident and what they were going through. The staff recognized the focus area related to not keeping all diagnoses or medications and interventions to refer to medical charts, let the doctor know what they can do to help, medication lists/warnings were in chart, and refer to other areas of the medical chart if something was missing in this area of the chart was not personalized to an individual resident as it was on multiple residents’ charts. The staff stated with the Focus and intervention it directed people to look in the chart for identified behaviors which could be located in the Depression Screening if the resident had one. The staff acknowledged she could not easily identify anxiety or depression behaviors for either of the residents. On 7/23/25 at 2:08 PM the Director of Nursing (DON) stated a Care Plan Focus of down in the dumps could be an identified area of concern but expected the Interventions identify the specific signs/symptoms or target behaviors for depression and/or anxiety. The DON concurred if behaviors were identified in the EMR in assessments they should be identified in the Care Plan. On 7/24/25 at 10:50 AM the Administrator concurred general statements regarding behaviors (example down in the dumps) did not identify specific behaviors related to an individual. The facility’s policy, Goals and Objectives, Care Plans, undated, revealed Care Plan goals/objectives were resident oriented, behaviorally stated and measurable. It was noted that goals/objectives were entered on the resident’s Care Plan so all disciplines had access to the information and could report on whether the desired outcomes were being achieved.

Based on observations, resident interviews, staff interviews, document and policy review the facility failed to provide food at an appetizing temperature to 4 of 24 residents reviewed (Resident #1, #11, #20 and #27). The facility reported a census of 61 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #11 documented a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 7/21/25 at 10:57 AM Resident #11 stated she ate all of her meals in her room. Resident #11 explained that at least twice a week the food is brought to her room cold. Resident #11 stated the staff leave before she eats and she does not turn the light on to have them reheat the food. Resident #11 stated no specific meal is cold but all have been. Resident #11 stated the meals have been brought to her room cold a couple times in the last week. 2. The MDS dated [DATE] for Resident #20 documented a BIMS of 9 indicating moderate cognitive impairment. On 7/21/2025 at 10:44 AM Resident #20 stated the food was brought to his room cold about twice a week. Resident #20 stated he ate all of his meals in his room. On 7/21/25 at 12:22 PM an observation of the lunch meal service revealed room trays were being plated with the last lid applied at 12:24 PM. Request for sample tray with tray placed in place of the first tray that was put on the delivery cart. Sample tray taken to the kitchen just after the first room tray was delivered to resident. The temperature from the food on the sample tray checked by Staff I, [NAME] was; ham 105 degrees, cauliflower 124.5 degrees and sweet potato fries 109.6 degrees. Staff J, Certified Dietary Manager (CDM) present when temperatures of the test tray was obtained. On 7/21/25 at 12:31 PM Staff J, CDM acknowledged the food temperatures were less than she expected. Staff J stated the room trays are usually hotter than today’s service. Staff J explained she felt the food delivered to the residents rooms should be above 130 degrees. On 7/22/25 at 2:01 PM Staff K, Registered Dietitian (RD) stated the point of service food needs to be 140 degrees delivered to the resident. On 7/22/25 at 3:27 PM the Administrator stated he did not believe there was an exact temperature for the food to get to the resident in their rooms with room trays. The Administrator stated palatability is different for each resident. The Administrator stated he did not think Staff K had given the correct answer for point of service temperatures. The Administrator stated he did not know how to fix an issue that he was unaware of. The Administrator stated he had not heard any of the residents complain about the food temperatures at the facility. Review of document titled, FDA Food Code 2022 documented Time – maximum up to 4 hours (B) If time without temperature control is used as the public health control up to a maximum of 4 hours: (1) Except as specified in (B)(2), the FOOD shall have an initial temperature of 5°C (41ºF) or less when removed from cold holding temperature control, or 57°C (135°F) or greater when removed from hot holding temperature control. Review of a policy dated 12/4/24 titled, Resident Nutrition Services provided by the Administrator documented to minimize the risk of foodborne illness, the time that potentially hazardous foods remain in the “danger zone” (41 to 135) will be kept to a minimum. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded. 3. The MDS dated [DATE] for Resident #27 documented a BIMS of 12 which indicated moderate cognitive impairment. The MDS identified Resident #27 understood and expressed ideas and wants. The Care Plan for Resident #27 indicated a regular diet. On 7/21/25 at 11:44 AM Resident #27 reported the meat is often tough, dry, cold and hard to chew. The resident stated, I just don't eat it. When asked how often this occurred per week the resident replied, all the time. The resident reported the vegetables are not hot, half cooked, cold and rubbery. The resident consumes meals in her room. 4. The MDS dated [DATE] for Resident #1 revealed a BIMS score of 8/15 indicating moderate cognitive impairment. The MDS included diagnoses of benign prostatic hyperplasia, renal insufficiency/failure/end stage renal disease, neurogenic bladder, cerebrovascular accident (CVA), transient ischemic attack (TIA), or stroke. The document revealed the resident ate with supervision or touching assistance. The resident’s Care Plan dated 7/2/25 identified an activities of daily living (ADL) focus dated 4/18/25 and the interventions for staff did not indicate staff needed to assist the resident. On 7/21/25 at 12:10 PM Resident #1 stated that sometimes the food is cold when he gets it. The resident stated he may eat in his room. The resident stated he had a Reuban sandwich that was “cold like the icebox”, and did not have sauerkraut or Thousand Island dressing. On 7/24/25 at 10:55 AM the Administrator acknowledged he had heard a concern during the survey process of complaints of food temperatures. The Administrator stated that palatable for residents was subjective, and that he had not had any complaints regarding food temperatures from residents or from Resident Council.

Based on staff interview, record review and policy review the facility failed to ensure they followed through with antibiotic stewardship practices. The facility reported a census of 61 residents. Findings include:On 7/24/25 at 8:15 AM, the Director of Nursing (DON) explained that she took over the responsibilities as Infection Preventionist (IP) early in June as she discovered that the previous IP was not completing the tasks as directed. She displayed a spreadsheet that she recently developed to use for antibiotic tracking. The spreadsheet lacked any resident information. When asked how any residents were on an antibiotic, she looked through the electronic chart and said there was just one resident. She was not aware of any tools that the nurses were using, such as the McGeer (criteria for infection surveillance) that could help them determine the resident's need for antibiotics. According to the Department of Health and Human Services Centers for Medicare and Medicaid Services Resident Matrix, provided at the start of the recertification, the facility had 6 residents that were on antibiotics at the time of survey. According to the facility policy titled: Infection Prevention and Control Program revised on 1/2024, the designated IP served as a consultant to the staff on infectious diseases, resident room placement implementing of isolation precautions, staff and resident exposures, surveillance and epidemiological investigations of exposure of infectious diseases. The intent of the regulation was to ensure that the facility developed and implemented protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic are prescribed the appropriate antibiotic. The facility would develop promote and implement a facility wide system to monitor the use of antibiotics.

Based on record review, staff interview and policy review, the facility failed to inform residents of their options and costs when services were no longer covered by Medicare Part A for 3 of 3 residents reviewed (Resident #50, #43 and #5). The facility reported a census of 61 residents. Findings include:1) According to the Minimum Data Set (MDS) dated [DATE], Resident #50 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident was totally dependent on staff for dressing, toileting, and hygiene. The Care Plan for Resident #50, last updated on 6/13/25, showed that staff would provide a restorative program 3-6 times a week due to parkinsonism. The diagnoses include intestinal obstruction, history of falling, anxiety disorder, and osteoporosis. The census tab in the electronic record indicated that Medicare Part A services ended on 4/10/25 for Resident #50, and on 6/12/25 the resident was private pay. A Beneficiary Protection Notification Review (BPNR) for Resident #50 showed that Form CMS (Centers for Medicare/Medicare Services) -10055 was not provided to the resident and lacked an explanation. 2) The MDS dated [DATE], showed that Resident #43 had a BIMS score of 12 (moderate cognitive deficit). The resident was totally dependent on staff for sit to stand and toilet transfers.The Care Plan updated on 5/21/25, showed the resident needed help with Activities of Daily Living (ADL) and planned to go home after working with Physical Therapy and Occupational Therapy (PT/OT). The diagnoses included chronic kidney disease, Type 2 diabetes mellitus and a history of urinary tract infections. According to the census tab in the electronic chart, Resident #43 had Medicare Part A coverage on 6/10/25 and private pay on 7/22/25. The BPNR indicated the last day of Medicare Part A for Resident #43 was 7/21/25 and the CMS-1055 Form was not provided to the resident. 3) According to the MDS dated [DATE], Resident #5 had a BIMS score of 9 (moderate cognitive deficit). He was totally dependent on staff for hygiene, toileting, dressing and transfers. The Care Plan revised on 3/14/25, showed the resident wanted to return home and he would participate in the restorative program due to muscle weakness. The census tab in the electronic chart showed Resident #43 had Medicare Part A services beginning 12/26/24, and was private pay on 2/13/25.A review of the BPNR documentation showed that Medicare Part A services ended on 2/12/25 and the resident was provided Form CMS-10055 to review the options. The chart lacked a 10055 form for Resident #5. On 7/23/2025 at 10:00 AM, the Social Worker (SW) said that she was fairly new to the position, and was not familiar with the CMS form 10055. She looked through the binder left behind by the previous SW and did not see any copies of the form. She did an internet search for the form, reviewed the questions and options presented to residents, and agreed that residents needed to know about the daily amount that would be expected if they chose to pay private and that they had the right to appeal. According to the undated, facility policy titled: Form Instructions, Advance Beneficiary Notice of Non-coverage (ABN); notifiers must complete the column under Blank (F) to ensure the beneficiary had all available information to make an informed decision about whether or not to obtain potentially non-covered services. The beneficiary or his or her representative must choose only one of three options listed in Blank (G). The beneficiary or representative must sign the notice to indicate that he or she had received the notice and understood its contents.

Based on Electronic Health Records (EHR) review, observations, resident interview, and staff interview the facility failed to provide the residents with a comfortable / clean homelike environment. Resident rooms found with various debris on the floor and application of bed linen not completed in a timely manner for 3 of 24 residents reviewed (Resident #15, #22 and #24). The facility reported a census of 61 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #22 documented a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment. An observation on 7/21/25 at 11:52 AM of room [ROOM NUMBER]-B revealed a pile of sheets in the center of the bed. No sheets present in place on the bed. Review of document dated 7/24/25 titled, All Resident List documented Resident #22 resided in room [ROOM NUMBER] bed B. On 7/21/25 at 11:52 AM Resident #22 stated he got himself ready that morning. Resident #22 stated the staff usually get him ready but they did not that morning. Resident #22 stated he was not sure why the staff did not help him that morning but he can be impatient. Resident #22 stated the staff never came in to make the bed. Resident #22 stated he likes to lay down after breakfast but he was not able to that morning. Resident #22 stated the staff got his roommate up and made his bed but did not help him. Resident #22 stated he was very irritated. On 7/21/25 at 4:49 PM Staff F, Certified Nurse Assistant, (CNA) stated if the bed is due to be stripped that day then she strips the bed when she gets the resident up. Staff F explained then housekeeping will sanitize the bed and she would make the bed after breakfast. Staff F stated if the bed was not due to be stripped then she would make the bed when she got the resident up for the day. Staff F stated she did not have enough bottom sheets the morning of 7/21/25 so she did not make the beds in rooms 206, 216 first bed and 219-B until about 2:00 PM. On 7/21/25 4:55 PM Staff G, Certified Nurse Assistant (CNA) stated that morning (7/21/25) the facility did not have any bottom sheet available. Staff G stated laundry was behind that morning. Staff G stated housekeeping was normally in the building about 7am. Staff F stated room [ROOM NUMBER], 216 and 219 were the beds that did not have sheets that were not bed strips that morning. Staff G stated room [ROOM NUMBER]’s bed was made about 1:00 PM. Staff G stated the bottom sheets were not available until after 1:00 PM. Staff G stated laundry was made aware the CNA’s needed bottom sheets to make beds. On 7/23/25 at 12:26 PM Staff H, Laundry Assistant, Housekeeping Assistant, and Maintenance Employee acknowledged he worked in laundry on the morning of 7/21/25. Staff H stated he came into work at 7:00 AM that day. Staff H stated he typically came into work and took all the carts out of the laundry room, looked at the clothing covered barrels and put them into the washing machine. Staff H stated he then goes around collecting dirty linen and washing the linen. Staff H stated he did that routine twice a day, the second time between 10:00 AM and 10:30 AM. Staff H stated on 7/21/25 he asked the Director of Nursing (DON) if he should put more bottom sheets out for the staff. Staff H stated he washed the bottom sheets in the second load of that day and put the sheets out. Staff H stated the sheets were put out with the linen before lunch after 10:00 am. Staff H stated no one told him the residents did not have bottom sheets for their beds or asked him to wash bottom sheets. Staff H stated he noticed the amount of linen had been getting low that was why he asked to put the bottom sheets out. Staff H stated if he would have known the residents were out of bottom sheets and the staff needed bottom sheets to make beds he could have had the linen out about 9:30 AM or 10:00 AM. Staff H stated the staff do not run out of linen frequently but the last couple weeks the linen had been running low. On 7/23/25 at 12:37 PM the Administrator stated he heard on the morning of 7/21/25 that there was a process problem. The Administrator stated he needed to research the situation more. The Administrator stated he did not know if bottom sheets were left in the dryer or washer. The Administrator stated he placed a linen order today. The Administrator stated the facility was not out of linen. The Administrator stated nobody told him on 7/23/25 that there were no bottom sheets. The Administrator stated maybe on Sunday the laundry was not washed the way it should have been. The Administrator stated there was a lack of communication from staff and that was where the breakdown occurred. The Administrator stated the facility had enough linen. The Administrator stated he would expect the staff would have notified laundry or the Administrator there were no bottom sheets. The Administrator acknowledged the linen should have been on the bed prior to lunch. 2. Observation on 7/21/2025 at 10:25 AM, showed Resident #24’s floor with small, ripped pieces of paper, an unmade bed, and two pairs of shoes within the walking area. Resident #24 reported his shoes are never put away and the bed is unmade. The observation also showed the roommate's bed remained not made and four pieces of used Kleenex on the floor. Resident #24 reported the floor of the room is dirty five days a week. A follow up observation on 7/21/25 at 1:11 PM, showed Resident #24’s room to be in the same condition. 3. Observation on 7/21/25 at 1:11 PM, showed Resident #15’s room with 10 pieces of flattened cotton scattered on the floor. A follow up observation on 7/21/25 at 1:12 PM, showed Resident #15’s room to be in the same condition. An additional follow up observation on 7/22/25 at 9:22 AM, showed approximately 6 pieces of flattened cotton remained on the floor. A policy request for a homelike environment, routine housekeeping in rooms or application of bed linen was requested but not presented by the Administration.

Based on clinical record review and staff interview the facility failed to identify non-pharmacological interventions and targeted behaviors on the care plan related to high risk medications in 3 out of 5 sampled residents reviewed (Resident #2, #13 and #37). The facility reported a census of 61 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 documented diagnoses of anxiety, dementia and Chronic Obstructive Pulmonary Disease (COPD). The MDS showed the Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. The Clinical Physician Orders for Resident #13 showed the following orders:a. Morphine (opioid medication) every two as needed for pain or shortness of breath with a start date of 3/25/25.b. Lorazepam (antipsychotic medication) every four hours for restlessness/anxiety as needed with a start date of 5/29/25. The Care Plan identified Resident #13 was prescribed high risk medications for anxiety and pain. The Care Plan lacked non-pharmacological interventions to use prior to opioid medication usage and non-pharmacological interventions and targeted behaviors with antipsychotic medications. The July Medication Administration Record for Resident #13 showed Lorazepam administration occurred on the following dates:a. 7/7/25 at 11:02 PMb. 7/12/25 at 7:27 PM and at 11:30 PMc. 7/15/25 at 10:54 PM In an interview on 7/24/25 at 9:28 AM, Staff N, Registered Nurse (RN) reported that she would expect to find direction regarding non-pharmacological interventions to use prior to opioid medication usage and non-pharmacological interventions and targeted behaviors with antipsychotic medications. In an interview on 7/24/25 at 10:01 AM, the Director of Nursing, (DON) reported the care plan should include non-pharmacological interventions to use prior to opioid medication usage and non-pharmacological interventions and targeted behaviors with antipsychotic medications. The DON reported the facility usually placed the information on the Medication Administration Record and now planned to also include the same information on the care plans. 2. The MDS for Resident #2 dated 4/18/25 documented a BIMS score of 10/15 indicating moderate cognitive impairment. The MDS included diagnoses of Non-Alzheimer’s Dementia, traumatic brain disorder (TBI), anxiety disorder, depression, and psychotic disorder. The document identified no concerns with mood or behaviors during the reporting period. The MDS identified Resident #2 took antipsychotic and antidepressant medications during the last 7 days of the assessment period. The electronic medical record (EMR) Medical Diagnoses printed 7/24/25 identified additional diagnoses of unspecified mood disorder, obsessive compulsive disorder (OCD), unspecified disorder of adult personality and behavior, delusional disorders, other specified mental disorders due to known physiological condition and personality change due to known physiological condition. Review of Resident #2’s 7/25 Medication Administration Record (MAR)-Treatment Administration Record (TAR) identified the resident was prescribed a. Risperidone 1 mg 1 tablet twice daily (BID) for unspecified mood (affective disorder) b. Sertraline 100 mg 2 tablets daily (QD) for depression c. Lorazepam 2mg/ml .25 ml every 4 hours as needed for anxiety The Physician Orders identified staff to monitor every shift for target behaviors: (refusal of cares, yelling out, physical aggression toward self/others, Spontaneous crying, False Beliefs, Wandering, and/or self-isolating. Document Interventions. 0-Not Present 1-Redirection 2-Music Therapy/Room Temp Adjustment. 3-1:1 4-Physical Touch/Repositioning 5-Offer Snack/Fluids 6-Remove resident from environment, date started 4/24/24. The facility failed to identify resident specific target behaviors for monitoring. Resident #2’s Care Plan dated 7/15/25 contained a Focus of medications considered high risk with interventions for staff including adverse reactions to psychotropic medications, adverse reactions to antidepressant medications, and adverse reactions to antianxiety medications. A focus of not keeping all diagnoses or medications initiated 2/3/25, had a goal of wanting the medical record to be part of the Care Plan. Interventions for staff included letting the physician know if they can do something to help, refer to medication list and warnings in the chart, and to see the medical chart if something is missing in this part of the chart dated 2/3/25. A focus of down in the dumps started 2/3/25 with a goal of wanting to be as happy as possible revised 7/15/25 revealed an Intervention of letting family and doctor know if it seems like mood is more down in the dumps created on 2/3/25. The Care Plan failed to identify target behaviors related to the use of psychotropic medications and non-pharmacological interventions. The Care Plan failed to have focus areas with goals and interventions related to psychiatric diagnosis. 3. The MDS for Resident #37 dated 6/25/25 identified a BIMS score of 3/15 indicating severe cognitive impairment. The MDS included diagnoses of Alzheimer’s, Non-Alzheimer’s Dementia, anxiety, and depression. The document identified mood feelings of feeling down, depressed, or hopeless in 2-6 days in the last 2 weeks of the reporting period. The MDS identified Resident #37 took antipsychotic, antianxiety and antidepressant medications during the last 7 days of the assessment period. Review of Resident #37’s 7/25 MAR-TAR identified the resident was prescribed: a. Donepezil 10 mg 1 tab QD for mood disorder b. Lorazepam 2 mg/ml .5 ml BID for anxiety disorder c. Olanzapine 10 mg 1 tab BID for major depressive disorder d. Sertraline 100 mg 2 tabs QD for mood disorder e. Lorazepam 2 mg/ml .75 ml every 2 hours as needed (PRN) for anxiety The Physician Orders identified staff to monitor every shift for target behaviors: (refusal of cares, yelling out, physical aggression toward self/others, Spontaneous crying, False Beliefs, Wandering, and/or self-isolating. Document Interventions. 0-Not Present 1-Redirection 2-Music Therapy/Room Temp Adjustment. 3-1:1 4-Physical Touch/Repositioning 5-Offer Snack/Fluids 6-Remove resident from environment, date started 10/14/24. The Physician Orders did not identify target behaviors related to the medications prescribed. Resident #37’s Care Plan dated 7/1/25 identified a focus of getting anxious dated 10/14/24 with a goal to be as happy as possible revised 7/1/25. The interventions for staff included to call family when anxious and to notify family and doctor if more down in the dumps/anxious dated 10/14/24. A focus of medications considered high risk dated 10/17/24 had a goal of no significant negative outcomes secondary to these medications with revision on 7/1/25. The interventions for staff included monitor/document/report PRN adverse reactions to psychotropic, antidepressant and antianxiety medications. A focus of not keeping all diagnoses or medications dated 10/17/24 with a goal of current medical record to be considered part of the Care Plan revised on 7/1/25 had interventions of notification to physician to let them know how they can help, medication list and warnings were in the chart, refer to other areas of the medical chart if there was something missing in this part of the chart. The Care Plan failed to identify the target behaviors related to the use of antipsychotic medications and depression. The document failed to identify person centered target behaviors related to anxiety. On 7/23/25 at 12:35 PM the MDS Coordinator stated a Care Plan Focus containing a down in the dumps statement would have different meanings for different residents depending on what they were going through. The staff stated the Care Plan Focus of not keeping all diagnoses or medications provided interventions for staff to refer to the medical chart for further information on behaviors for residents. The MDS coordinator acknowledged those focus areas and interventions neither provided individualization for each resident nor specifics related to use of antipsychotic medications and individualized target behaviors for either resident. On 7/23/25 at 2:08 PM the DON stated Care Plans should contain individualized behaviors for residents. The DON concurred generic statements of down in the dumps did not provide individualization for residents. On 7/24/25 at 10:50 AM the Administrator concurred general statements regarding behaviors did not identify specific behaviors related to antipsychotic, antidepressant or antianxiety medications for each resident. The facility’s policy, Goals and Objectives, Care Plans, undated, revealed Care Plan goals/objectives were resident oriented, behaviorally stated and measurable. It was noted that goals/objectives were entered on the resident’s Care Plan so all disciplines had access to the information and could report on whether the desired outcomes were being achieved. The facility did not provide a policy related to psychotropic medications.

Based on Electronic Health Record (EHR) review, staff interview, and facility policy, the facility failed to ensure bed hold notice was sent to the resident and or the resident's responsible person when the resident transferred out of the facility for 1 of 1 residents reviewed (Residents #60). The facility reported a census of 61 residents. Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #60 documented a Brief Interview of Mental Status (BIMS) score of 14 indicating no cognitive impairment. Review of Resident #60's EHR documented no bed hold Review of Resident #60's EHR dated 5/14/25 at 9:27 PM titled, Progress Notes documented Resident #60 was transferred to the hospital with shortness of breath and chest pain with pain to the jaw and neck. Progress Note documented Resident #60 could not speak related to discomfort and Resident #60 requested to be transferred to the hospital. Resident #60's EHR titled, Progress Notes documented the resident remained at the hospital 5/15/25 or 5/16/25. On 7/24/25 at 11:10 AM the DON acknowledged the bed hold form was not completed for Resident #60. The DON stated after Resident #60 was sent to the hospital she had noticed there was no documentation of the bed hold in the progress note assessment related to Resident #60's hospital transfer. The DON explained when she questioned the social worker if the bed hold was completed she was told the bed hold was completed. The DON stated she had determined at the time later the bed hold form was not completed at all. The DON explained her expectation was that the bed hold would have been completed or the resident's representative would have been notified and the bed hold would have been completed over the phone. The DON acknowledged she could not find documentation that the bed hold was completed.On 7/24/25 at 11:15 AM the Administrator stated the facility's expectation was the bed hold would have been completed per the federal regulation and the facility's policy. The Administrator acknowledged that was not completed appropriately during Resident #60's transfer to the hospital on 5/14/25. The Administrator acknowledged Resident #60 was insured by managed Medicare coverage.Review of undated policy titled, Bed Hold Policy documented Medicare insurance did not offer bed hold coverage. Therefore, Medicare, Managed Medicare, and Private Pay residents may choose to hold the room, at the current room and board rates, until the resident's return to the facility. Resident/Resident's Representative must verify that they wish to have their bed held, within 24 hours of being admitted to the hospital, or their bed will be relinquished. Verification of bed-hold must be made prior to the start of a Resident's vacation or therapeutic leave from the facility.

Based on observation, resident interview, staff interviews, record review and policy review the facility failed to obtain and follow physicians' orders for 2 of 21 of residents (Resident #36 and #6). Staff chose to hold insulin for Resident #36 without obtaining doctor-specified parameters on when to hold the insulin and failed to notify the doctor when the insulin hadn't been given. Resident #6 had an indwelling urinary catheter, staff failed to obtain an order for the device. The facility reported a census of 61 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #36 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). He was independent with hygiene, toileting, dressing, transferring and walking. His diagnoses included: diabetes mellitus, renal insufficiency, schizophrenia, anxiety disorder and adult failure to thrive. The Care Plan updated on 5/1/25, showed that Resident #36 needed a therapeutic diet related to diagnosis of diabetes mellitus. Staff were to monitor blood sugars as ordered. The Care Plan lacked directive for insulin use. The orders tab in the electronic chart showed that Resident #36 had an order dated 3/24/25 at 7:30 AM, for a fast-acting insulin to be give three times a day, before his meals. In an observation on 7/22/25 at 9:01 AM, Staff B Licensed Practical Nurse (LPN) prepared 5 units of fast acting insulin, and brought it to the resident in his room. Resident #36 was in bed and said that he had completed his breakfast, and the kitchen staff had already picked up the tray. A review of the Medication Administration Record (MAR) for June and July, showed that on the following dates, the fast acting insulin was not given to Resident #36: June 9th, 12th, 15th, 17th, 18th, 23rd, 24th, 27th, and 30th. July 5th, 8th, 13th, 15th, 18th, 21st, and 23rd. The Nursing Progress Notes lacked documentation that the physician had been notified the insulin had been held on these dates. A review of the Blood Sugar Summary for Resident #36 revealed that from June 1 – July 22, the readings did not go below 81 milligrams per deciliter (normal range being 70-100 mg/dL.) On 7/23/25 at 9:32 AM, Staff C, Registered Nurse (RN) said that she chose not to give Resident #36 his short acting insulin that morning because his blood sugar was low. She said she used her nursing judgement to decide that the blood sugar was too low. Staff C acknowledged that there were no doctor-ordered blood glucose parameters established, but she agreed that it would be helpful. She did not know how other nurses determined or decided when to hold the insulin. On 7/23/2025 at 9:19 AM Staff B, Licensed Practical Nurse (LPN) said that Resident #36 tended to have low blood glucose in the mornings, and he was getting Glucerna but the doctor hadn’t established any parameters on when to hold his insulin. On 7/22/2025 at 3:30 PM, the Nurse Practitioner (NP) acknowledged that there weren’t blood sugar parameters established for Resident #36, and she wasn’t aware of how often the insulin was being held. On 7/23/2025 at 10:50 AM, the Director of Nursing (DON) agreed that they should have asked the doctor for directives on when to hold the short acting insulin. She said that the nurses should have called to let the doctor know when the medication was being held. 2) The MDS assessment dated [DATE] for Resident #6 documented reentry into the facility on 7/17/25 from a short term hospital stay. In an interview on 7/23/2025 at 9:36 AM, Resident #6 reported the catheter was inserted at the hospital because she had surgery for a right foot fracture related to a fall. The resident reported the hospital kept the catheter inserted because she was non-weight bearing. The Medical Diagnosis report for Resident #6 included urinary retention. The Progress Note dated 7/17/25 at 3:39 PM showed the facility received report from the hospital that Resident #6 would return with a foley catheter placed. The Progress Note dated 7/19/25 at 2:06 PM for Resident #6 showed the catheter to be patent and draining yellow urine. The Clinical Physician Orders for Resident #6 failed to show orders related to a foley catheter. The Physician Orders policy last revised on January 2024 identified the following: It is the policy of this facility to secure physician orders for care and services for residents as required by state and federal law. Physician orders will be dated and signed according to state and federal guidelines. PROCEDURE- Physician orders will include the medication and/or treatment and a correlating medical diagnosis or reason. Medication orders will include: Name of drug Route Dosage Frequency Diagnosis Stop date (i.e., antibiotics) if appropriate Unclear or incomplete written orders will be reviewed with the physician. Any order clarification will be documented on the Physician’s Telephone Order form. Faxed orders will be accepted under the following conditions: Physician signs and retains the original copy of the faxed order. Physician provides the original copy, if requested. It is not necessary for the physician to re-sign the facsimile order unless required by State law. The original may be sent to the facility at a later time and substituted for the facsimile copy. With order changes, discontinue the current order prior to initiating the new order. Inform resident/responsible party and/or family member of changes in physician orders. Communicate orders to the pharmacy, as applicable. On 7/24/25 at 11:38 AM the DON stated Resident #6 does now have an order for a catheter. The DON acknowledged the facility did not have an order in place prior to surveyors entrance at the facility. On 7/24/25 at 11:19 AM the Administrator acknowledged the facility did not have things in place for Resident #6. The Administrator reported the orders and diagnosis should not take that long. The Administrator stated the orders for all the residents should be entered at this time. The Administrator stated the facility does not have routine orders and needs to have routine orders especially for catheters.

Based on observations, electronic medical record (EMR) reviews, staff interviews, and policy review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 1 residents reviewed, requiring the use of oxygen (Resident #47). The facility reported a census of 61 residents. Findings include: The Minimum Data Set (MDS) for Resident #47 dated 7/17/25 identified a Brief Interview for Mental Status (BIMS) score of 12/15 indicating moderate cognitive impairment. The MDS documented diagnoses that included: heart failure, hypertension, anxiety disorder, obstructive sleep apnea, and pulmonary hypertension. The document provided the resident utilized oxygen upon admission and while a resident, and that oxygen was continuous on admission.Resident #32's Care Plan dated 7/23/25 identified a focus area of oxygen therapy related to ineffective gas exchange. Interventions for staff included oxygen at 3-5 liters (L). The 7/25 Medication Administration Record (MAR)-Treatment Administration Order (TAR) did not provide orders or instructions for changing oxygen tubing. On 7/21/25 at 10:23 AM Resident #47 stated she utilized oxygen at 3L since 2018.Observed on 7/21/25 at 10:23 AM the resident with a nasal cannula and undated oxygen tubing.Observed on 7/22/25 at 2:40 PM the resident's concentrator outside of the bathroom set at 3L with undated oxygen tubing.Observed on 7/23/25 at 1:00 PM Resident #47's oxygen tubing was undated. On 7/23/25 at 2:40 PM the Director of Nursing (DON) stated that oxygen tubing was changed on Monday nights as part of the Nigh Shift responsibilities. The DON stated upon further document review there should have been an order for oxygen tubing change. Review of Resident #47's MAR-TAR the DON acknowledged there was no order for tubing replacement. On 7/24/25 at 10:50 AM the Administrator expected there should be a way to audit the changing of oxygen tubing. On 7/24/25 at 12:46 PM the Administrator revealed the facility did not have an oxygen tubing policy, but rather they followed manufacturer recommendations. The Administrator indicated nasal cannulas be changed every 2 weeks and supply tubing every month, and the facility expectation is it be changed every week currently.

Based on observations, staff interviews, Electronic Medical Record (EMR) review, and policy review, the facility failed to provide appropriate treatment and services to meet a resident's highest practicable physical, mental, and psychosocial well-being for a resident diagnosed with dementia for 1 of 1 residents reviewed (Resident #37). The facility had a census of 61. Findings include:The Minimum Data Set (MDS) for Resident #37 dated 6/25/25 identified a BIMS score of 3/15 indicating severe cognitive impairment. The MDS included diagnoses of Alzheimer's, Non-Alzheimer's Dementia, anxiety, and depression. The document identified mood feelings of feeling down, depressed, or hopeless in 2-6 days in the last 2 weeks of the reporting period. The MDS identified Resident #37 took antipsychotic, antianxiety and antidepressant medications during the last 7 days of the assessment period.The 7/25 Medication/Treatment Administration Record (MAR-TAR) identified an order dated 10/14/24 for nursing to monitor every shift for target behaviors: (refusal of cares, yelling out, physical aggression toward self/others, Spontaneous crying, False Beliefs, Wandering, and/or self-isolating. Document Interventions. 0-Not Present 1-Redirection 2-Music Therapy/Room Temp Adjustment. 3-1:1 4-Physical Touch/Repositioning 5-Offer Snack/Fluids 6-Remove resident from environment.The Physician's Order failed to be individualized to Resident #37's diagnosis of dementia and behaviors associated with the diagnosis.Resident #37's Care Plan dated 7/1/25 identified a focus dated 10/14/24 of the resident being a social butterfly with the goal to remind/invite the resident to activities revised on 7/1/25. Interventions for this focus included providing assistance during the activities, inviting the resident to the activities, and activities the resident enjoyed. A 7/1/25 revised focus revealed the resident did not do very well on the memory test due to being forgetful with a goal of the resident making as many decisions as possible with the family helping revised 7/1/25. Interventions dated 10/17/24 for the focus included notification to the Power of Attorney (POA) with updates/need for important decisions to be made and the resident requires reminders sometimes. The Care Plan failed to identify Resident #37's specific diagnosis of dementia and specific interventions related to that diagnosis. The Care Plan failed to provide revisions to reflect the change in the resident's abilities to participate and complete tasks, techniques for staff to intervene with the resident, and goals that were measurable. The EMR review of activities completed during the previous 30 days found the following:a.) Group Activities - the resident attended 2/15 opportunities offered, and refused 13/15 opportunities offered.b.) One to Once Activities - 0 activities documented.c.) Independent Activity - 0 activities documented.On 7/21/25 from 9:45 AM - 11:30 AM observed Resident #37 awake and seated at the nurses station in a tilt and space wheelchair without any activities.On 7/22/25 at 9:54 AM observed Resident #37 sleeping at the nurses station.On 7/22/25 at 10:50 AM observed Resident #37 sleeping during a group activity. On 7/22/25 at 2:38 PM observed Resident #37 seated at the nurse's station, awake and without an activity while a group activity was happening. On 7/23/25 at 9:33 AM Staff D, Certified Nurses Assistant (CNA), stated Resident #37 tends to get out of her wheelchair (w/c) so the staff will place her at the nurses station for closer monitoring. The staff stated sometimes they will give the resident an activity to do. Staff D stated the resident will do a sewing activity or an interactive activity with lights and colors, but some activities were broken. Staff D stated she has asked the resident to select all objects of a color and the resident could complete. On 7/23/25 at 9:45 AM Staff B, Licensed Practical Nurse (LPN), stated residents who were at higher fall risk may sit around the nurses station for heightened awareness. The staff stated some residents will engage with each other, watch people, or do activities. The staff stated activities were kept at the nurses station in cubbies for staff to provide to the residents. Staff B stated when a resident was observed to be sleeping they would ask staff to take the residents back to their rooms to lie down. On 7/23/25 at 9:50 AM the Director of Nursing (DON) stated high fall risk residents may be placed at the nurses station for increased safety awareness as there were more staff in that area. The staff stated the residents will engage with each other and if they were noted to be sleeping they should go back to their rooms to lie down. The DON acknowledged that residents should be offered activities and some residents like to watch people. On 7/23/25 at 12:35 PM the MDS Coordinator stated there was not a specific focus on the Care Plan related to the diagnosis of dementia. The staff stated there might be a cognition focus with interventions including whether a resident could participate, acknowledging all residents can participate at some level, and how to assist the resident to participate. The MDS Coordinator stated a goal could be wanting to make her own decision or having family help make that decision, and the intervention would be reminding the staff the resident can tell staff what they want or need. When asked about Resident #37 sitting at the nurses station with other residents, the staff responded it depended on the resident and what they liked to do. The MDS Coordinator stated some individuals liked to sit and watch, others completed activities and the activities were kept in cubbies at the nurses station. The staff acknowledged Resident #37's Care Plan did not have specifics related to her diagnosis of dementia, activities that reflected her preferences, and staff guidelines to address the resident's current level of functioning. The MDS Coordinator acknowledged if something was not on the Care Plan staff, especially Agency Staff, would not know what to do with residents or where to find activities. On 7/23/25 at 2:08 PM the DON stated residents with a diagnosis of dementia may not have a specific Care Plan Focus related to the diagnosis, measurable goals, and the interventions for staff to use to engage with the resident at their current level of functioning. On 7/24/25 at 12:05 PM the Activity Director stated Resident #37 participated in group activities or individualized activities. The staff stated the resident liked to come to parties and get manicures in a group or individualized activities. The staff stated the resident used to come out and participate more in games prior to the progression of the disease. The Activity Director stated the documentation for attendance or participation would be in the EMR.On 7/24/25 at 10:45 AM the Administrator expected all residents to be engaged in activities to the best of their ability. The Administrator stated Resident #37 had a gradual decline over the past several months. The facility's policy, Dementia Clinical Protocol - undated, revealed the interdisciplinary team (IDT) would identify a resident-centered Care Plan to maximize remaining function and quality of life. The document provided the IDT would identify and document the resident's condition and level of support needed for care planning and review changing needs as they arise. The policy provided the IDT would adjust interventions and the overall plan on the individuals' responses to interventions, progression of dementia, development of new medical conditions or other relevant factors.

Based on clinical record review, staff interview, and policy review the facility failed to ensure that staff obtained signed consents and were educated on the influenza immunization before it was administered. The facility reported a census of 61 residents.Findings include:1) According to the Minimum Data Set (MDS) dated [DATE], Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). His diagnoses included arthritis, non-Alzheimer's Dementia, anxiety disorder and cerebrovascular disease. The Care Plan for Resident #11, updated on 11/12/24, showed that her immune system had aged and staff were to encourage the resident to follow current guidelines for influenza and pneumonia vaccines. The tab titled: Vaccines, showed that Resident #11 received the Influenza vaccine on 10/3/24. The chart lacked a consent and documentation that education had been provided. 2) The MDS dated [DATE], indicated that Resident #7 had a BIMS score of 13 (moderate cognitive deficits). She was totally dependent on staff for hygiene, dressing, toileting and transferring. The Care Plan updated on 3/26/25, showed that she had a compromised immune system, the resident would be encouraged to meet the current guideline for influenza vaccines. The tab titled: Vaccines, showed that Resident #7 had the Influenza vaccine on 10/7/24. The chart lacked a consent and documentation that education had been provided. 3) The MDS dated [DATE] for Resident #14 showed that she had a BIMS score of 15 (intact cognitive ability). She was independent with toileting, dressing, hygiene, transfers and walking. The Care Plan updated on 10/1/24 showed that the resident was on supplemental oxygen therapy related to Congestive Heart Failure (CHF). The tab titled: Vaccines, showed that Resident #14 received the Influenza vaccine on 10/8/24. The chart lacked a signed consent or documentation that education had been provided. On 7/23/25 at 10:50 AM, the Director of Nursing (DON) said that she recognized that immunization processes needed improvement and she was working on a Performance Improvement Plan (PIP). Immunizations would be addressed in the IDT meetings and they would give consent and education at that time for the upcoming influenza season. She said that they were electronically signed but she didn't have documentation that education was provided. The Administrator said that with verbal consent, he would like to see that there were 2 witnesses and he preferred that there was actually signatures not just verbal. The DON came back later after looking through notes and found that the plan she had for the care plan meetings was not being followed through with and the residents were not always given education. She pointed to the PIP they have established related to federal tag 880 concerns and they have immunizations listed, however, consents and educations were not specifically noted on the PIP but she said she would get to it as she would be going through the immunization needs. I asked for a policy on signed vs. verbal consents. they were going to look. According to the facility policy titled: Influenza Vaccine; dated 6/2024, prior to the vaccination, the resident or resident's legal representative, would be provided information and education regarding the benefits and potential side effects of the influenzas' vaccine. Provision of such education would be documented in the resident's medical record.

Based on staff interview, clinical record review and policy review the facility failed to ensure that staff obtained signed consents and were educated on the COVID-19 immunization before it was administered. The facility reported a census of 61 residents.Findings include:1) According to the Minimum Data Set (MDS) dated [DATE], Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). His diagnoses included arthritis, non-Alzheimer's Dementia, anxiety disorder and cerebrovascular disease. The Care Plan for Resident #11, updated on 11/12/24, showed that her immune system had aged and staff were to encourage the resident to follow current guidelines for COVID-19 vaccines. The tab titled: Vaccines, showed that Resident #11 received the COVID-19 vaccine on 10/3/24. The chart lacked a consent and documentation that education had been provided. 2) The MDS dated [DATE], indicated that Resident #7 had a BIMS score of 13 (moderate cognitive deficits). She was totally dependent on staff for hygiene, dressing, toileting and transferring. The Care Plan updated on 3/26/25, showed that she had a compromised immune system, the resident would be encouraged to meet the current guideline for COVID-19 vaccines. The tab titled: Vaccines, showed that Resident #7 had the COVID-19 vaccine on 11/4/24. The chart lacked a consent and documentation that education had been provided. 3) The MDS, dated [DATE] for Resident #14, showed that she had a BIMS score of 15 (intact cognitive ability). She was independent with toileting, dressing, hygiene, transfers and walking. The Care Plan updated on 10/1/24 showed that the resident was on supplemental oxygen therapy related to Congestive Heart Failure (CHF). The tab titled: Vaccines, showed that Resident #14 received the COVID-19 vaccine on 11/4/24. The chart lacked a signed consent or documentation that education had been provided. On 7/23/25 at 10:50 AM, the Director of Nursing (DON) said that she recognized that immunization processes needed improvement and she was working on a Performance Improvement Plan (PIP). The plan lacked specifics related to immunizations, but it would be addressed, and planning would take place during the Interdisciplinary Team (IDT) meetings in July. She thought that the residents could give consent and would be provided education at that time for the upcoming influenza season. The DON said that consents were electronically signed but she didn't have documentation that education was provided and did not include a second witness for verbal consents. The Administrator said that with verbal consent, he would like to see that there were 2 witnesses and he preferred that there were actual signatures not just verbal. According to the facility policy titled: Utilization of Vaccinations, last revised on 1/2024; Consent for the COVID vaccine would be acquired from the resident and physician. The Immunization Informed Consent Record included an attestation that the resident received relevant vaccine information that provided current Center for Disease Control (CDC) information about vaccines and that the resident elected to receive the vaccine. The benefits and potential side effects had been explained and the resident understood the information. A signed and dated copy of the form would be placed in the resident's permanent medical record.

Based on staffing reviews, interviews, and Facility Assessment review the facility failed to provide adequate nursing staff to assure residents safety and well-being. The facility reported a census of 56 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #7 dated 7/23/24 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated normal cognition. Resident #7 on 9/16/24 at 1:09 PM stated call lights can take longer than 15 minutes to answer. The resident stated he would watch the clock to determine the length of time for answering. Staff C, Certified Nursing Assistant (CNA), on 9/18/24 at 1:05 PM stated working on the weekends was more difficult as there were less staff. Staff C stated due to the lower staffing on the weekends, and occasionally during the week, the staff could not answer the call lights as efficiently and resident cares could be affected. Review of Quarter 3 2024 (April, May, June) Scheduled Hours and Per Patient Date (PPD) data revealed the following weekday to weekend comparison: April: Week of 4/1 weekday average 3.29, weekend average 2.69 Week of 4/8 weekday average 3.53, weekend average 3.07 Week of 4/15 weekday average 3.25, weekend average 2.87 Week of 4/22 weekday average 3.25, weekend average 2.74 Week of 4/29 weekday average 3.08, weekend average 2.44 May: Week of 5/6 weekday average 3.15, weekend average 2.92 Week of 5/13 weekday average 3.06, weekend average 2.65 Week of 5/20 weekday average 2.87, weekend 2.91 Week of 5/27 weekday average 3.1, weekend average 3.09 June: Week of 6/3 weekday average 3.44, weekend average 3.3 Week of 6/10 weekday average 3.21, weekend average 2.52 Week of 6/17 weekday average 3.03, weekend average 2.83 Week of 6/24 weekday average 3.21, weekend average 2.48 On 9/19/24 at 8:45 AM Staff D, Scheduler, stated the data for staffing hours and PPD was correct. The staff stated during the weekdays there were 2 staff scheduled as bath aides and restorative aides, and on the weekends 1 staff as bath aide and 1 staff as restorative aide. On 9/19/24 at 9:35 AM the Administrator and Director of Nursing (DON) concurred the weekend hours reported and PPD would accurately reflect 1 less bath aide and 1 less restorative aide on the weekends as compared to the weekday schedule. The DON and the Administrator stated the Facility Assessment was updated on 4/29/24. The Facility assessment dated [DATE] revealed the budgeted goal is a PPD of 3.

Based on observation, resident interview, staff interview, and policy review the facility failed to follow standard precautions while separating laundry, and following enhanced barrier precautions (EBP). The facility further failed to establish a facility wide written infection prevention control policy. The facility reported a census of 56 residents. Findings include: 1. Observation 9/17/24 at 11:17 AM Staff E revealed laundry is being separated without gloves and gowns. Staff E further revealed that laundry is separated, and then hand sanitizer is utilized. Gloves were noted around the corner from the washing machines on a shelf at this time. During this observation it was also noted there were no gowns in the laundry room. Interview 9/17/24 at 11:21 AM Staff E revealed that staff should be wearing gloves and gowns while separating laundry with the positive Covid-19 cases in the building. Interview 9/17/24 at 11:40 AM with the Director of Nursing (DON) revealed that gloves should be worn when separating laundry, but as far as when Covid is in the building she would have to read the regulations if gowns should be worn. The DON further revealed that Covid positive rooms should have laundry separated into different bags. Interview 9/17/24 at 12:05 PM with the Administrator revealed that laundry personnel should be wearing gloves when separating laundry. When asked if gowns should be worn while separating laundry with Covid positive residents in the facility the Administrator revealed he believed that all the laundry should be able to be washed together as the water temp is a higher temperature. The Administrator revealed he would have to read the regulations. Interview 9/18/24 at 12:44 PM Staff F Certified Nurse Aide (CNA) revealed that staff had been trained on EBP like Covid. Staff E further revealed that she knew of EBP with residents with Covid. Staff E revealed she would have to ask about EBP with other residents. Interview 9/18/24 at 12:46 PM Staff G CNA revealed she wears EBP for residents with Covid-19. Staff G further revealed residents with EBP would have gowns, and gloves outside of the resident rooms. Staff G then revealed that she is unaware of anyone else in the facility who would be on EBP at this time other than the Covid residents. Follow up interview 9/18/24 at 12:50 PM with Staff F revealed if a resident was on EBP it would be noted in the resident's care plan. Staff F then revealed wearing a gown as a staff depended on who was completing the cares. Interview 9/18/24 at 12:57 PM with the Infection Preventionist (IP) revealed her expectation would be for laundry personnel to separate laundry with gloves and gowns on. The IP further revealed that residents with catheters and wounds would have EBP in the care plans, and would have EBP supplies in the residents' room. The IP then revealed her expectations that staff would be trained on EBP. Interview 9/18/24 at 1:26 PM with the DON revealed her expectation is for staff to be educated and follow EBP for residents who require EBP. Follow up interview 9/18/24 at 1:58 PM with the Administrator revealed his expectations are for an infection control policy to be created. The Administrator further revealed his expectation for EBP to be followed. 2. Review of Resident #49's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed Resident #49 utilizes an indwelling catheter. Interview 9/19/24 at 7:25 AM with Resident #49 revealed staff do not wear gowns when providing catheter care. Resident #49 further revealed the staff just wear their normal clothing. Review of Resident #49's Care Plan with a revision date of 9/9/24 revealed no information regarding an indwelling foley catheter or EBP. Review of a Physician's Order with printed date of 7/16/24 revealed an order for insertion of a Foley catheter until Resident #49's appointment with an outside urology clinic. Review of another Physician's Order with a date of 7/22/24 revealed an order to leave the indwelling catheter in place and follow up in 3 weeks. Observation 9/19/24 at 8:05 AM Staff H CNA completed hand hygiene and donned gloves to drain Resident #49's Foley catheter drainage bag. No gown was observed during the procedure. Interview 9/19/24 8:10 AM with Staff H revealed that there was no education on EBP. Staff H further revealed that she was not aware she was supposed to be wearing a gown when draining catheters or providing catheter cares. Follow up interview 9/19/24 at 11:10 AM with the DON revealed that the facility does not have an infection control policy that is reviewed annually. The DON further revealed her expectation would be for the facility to have a facility wide Infection prevention and control policy that is reviewed annually. Centers for Disease Control and Prevention website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), visited 9/19/24 and updated 7/12/22 revealed recent changes included, additional rationale for the use of Enhanced Barrier Precautions (EBP) in nursing homes, including the high prevalence of multidrug-resistant organism (MDRO) colonization among residents in this setting. Expanded residents for whom EBP applies to include any resident with an indwelling medical device or wound (regardless of MDRO colonization or infection status). Expanded MDROs for which EBP applies. Clarified that, in the majority of situations, EBP are to be continued for the duration of a resident's admission. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care.

Based on clinical record review, staff interviews and policy review, the facility failed to obtain complete resident records to honor the resident wishes as stated on the Iowa Physician Order for Scope and Treatment. The facility failed to obtain a physician order for DNR for 1 of 14 residents (Resident #32) reviewed. The facility reported a census of 56 residents. Findings include: According to the documents, Code Status Form and and the Iowa Physician Orders for Scope of Treatment (IPOST), signed by Resident #32 on [DATE] and physician on [DATE], the resident indicated a do not resuscitate (DNR) with limited interventions, no artificial nutrition by tube, and transfer to the hospital. Review of Resident #32's Clinical Physician Orders in the electronic medical records, signed physician orders for ,d+[DATE] and ,d+[DATE], the facility failed to obtain a signed order for a DNR status. On [DATE] at 8:30 AM Staff A, Social Worker, confirmed Resident #32 had a DNR status and there was not a physician order in the electronic medical record. On [DATE] at 9:25 AM the Administrator stated orders for a DNR status should be reflected in the medical record. Review of the facility provided document, CPR Guideline, undated, revealed the facility will provide or withhold cardiopulmonary resuscitation (CPR) based on the resident wishes and physician orders. The document further revealed DNR orders will be obtained following state specific guidelines and regulations.

Based on observation, record review and resident, family and staff interviews the facility failed to ensure the resident environment remains as free of accident hazards as possible. Boiling water from a pot was used to make hot chocolate and then served to Resident #1 which resulted in burning of the resident's mouth. The resident required hospitalization and pain control for the [CONDITION(S)]. The facility's failure resulted in an immediate jeopardy to resident's health and safety. The facility reported a census 46 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment tool dated 6/27/22 documented a Brief Interview Mental Status (BIMS) score of 13. A BIMS score of 13 suggested Resident #1 had no cognitive impairment. The MDS documented she was independent with set up help for eating and limited assistance of one staff for personal hygiene which included brushing her teeth. The MDS listed the following diagnoses: stroke, nontraumatic [CONDITION(S)], [CONDITION(S)], renal failure, diabetes mellitus, dementia, and anxiety. The care plan focus area dated 10/5/21 documented Resident #1 needed assistance with her Activities of Daily Living (ADLs) because she had muscle weakness and decreased mobility due to a stroke that affected her right side. The care plan encouraged staff to offer set up help with meals but Resident #1 was able to feed herself. The care plan documented the resident wore a full set of dentures and ha no natural teeth in place. She was independent with oral and denture care after set up help. Clinical record documented Resident #1 was to receive a regular texture diet with regular consistency fluids with a start date of 2/4/22 and end date of 8/1/22. When she returned to the facility on [DATE] her diet was changed to a puree diet, regular consistency. The following progress note was documented in Resident #1's Electronic Health Record (EHR): - 7/22/22 at 5:48 AM around 4:30 AM the Certified Nursing Assistant (CNA) who had provided care to the resident noted Resident #1 to be warm to the touch and the resident's initial temperature was 104.1 degrees Fahrenheit. The resident was lethargic but aroused when prompted but then fell back asleep. Her oxygen saturation was at 77% on 2 liters (L) of oxygen via nasal cannula. Resident was repositioned, her oxygen was turned up to 4L and her oxygen saturation increased to 92%. She remained warm and lethargic with a temperature of 103.7 degrees Fahrenheit. Resident was sent to the emergency room (ER) for further evaluation. - 7/22/22 at 10:06 AM the resident's daughter reported she was being admitted for slight pneumonia and will be kept overnight, at least. -7/23/22 at 8:54 AM the resident's daughter came to the facility to pick some clothing for her. She reported the resident may be aspirating due to the sores on her lips, tongue and in her mouth. Ears, Nose and Throat (ENT) will be evaluating her today. -8/1/22 at 9:14 PM Resident #1 remained on Skilled Level of Care (SLOC) for acute hypoxic respiratory failure due to lower respiratory infection and oral [CONDITION(S)]. Her lips and inside of her mouth have pinpoint open areas of redness. She is on a puree diet at this time with thickened liquids, required set up help only. -8/2/22 at 4:54 AM Resident's lips are dry with thick, caked on debris. Oral gives were provided and lip balm applied. The inside of her mouth and outer lips have a tiny amount of bloody drainage. On 7/22/22 a History and Physical was completed by the Hospitalist, documented the following information: Resident #1 presented with severe mucosal pain -difficulty speaking due to pain and inflammation. Yesterday she went to drink her hot chocolate with her dentures in, and it caused severe mucosal [CONDITION(S)]. She denies any aspiration like events. Overnight she was febrile, found to have a temperature of 105 degrees Fahrenheit around 5:00 AM and was sent to the ER. A head, ears, nose and throat assessment revealed the following: normocephalic (normal sized head), thick coating to oral mucosa - tongue and lower gums, left sided [MEDICATION(S)] coating also. Under the plan section she documented: magic mouthwash before meals and at bedtime (ACHS), will need to monitor oral mucosa/inflammation closely to avoid worsening respiratory status. Also suffered an extensive oral burn last night due to hot liquid. Clear demarcation of burn on [MEDICATION(S)] membranes in her mouth. Has reduced mobility of her tongue with increased risk for aspiration. On 7/22/22 the ER physician provided the following ER note: Resident #1 transferred to the ER with complaints of fever and hypoxemia. Shortly prior to arrival the resident was noted to have a temperature of 103 degrees at the nursing home. The Emergency Medical Services (EMS) noted oxygen saturation of 76% on 2L of oxygen. She was brought in on a nonrebreather and was titrated down to 2L at which she was running 91-92% oxygen saturation. Her oxygen was turned off and she promptly dropped to about 81-83% oxygen saturation. At 7:47 AM her case was discussed with the hospitalist and will be admitted for further treatment and evaluation. On 7/22/22 an ENT otolaryngologist saw the resident and dictated the following report: Resident #1 had been drinking some hot chocolate with her dentures in and it caused some severe mucosal [CONDITION(S)]. She stated that because it was so hot she just tried to swallow it very quickly. On July 23, the Oral Surgery Department was consulted and they discussed the concern for desquamation, magic mouthwash and lukewarm saline rinses, have been doing this since then. She did have some increased oxygen requirements and Pulmonology was involved in her care. This morning the resident was evaluated by Speech and Language Pathology department, who have cleared her for pureed diet. She has desquamation and a white discoloration of her oral cavity and mucosa on her tongue, lower lips, and gums, specifically worse on the left side over the alveolar ridge. She has been encouraged to not use her lower denture for a least two weeks as everything heals. On 7/22/22 the Speech Therapy dictated the following note: Resident #1 reported, she did not usually sound like this, her tongue is not working right. The therapist noted white issue on her tongue and lips following a burn from yesterday. She was drinking hot chocolate yesterday and burned her tongue and bottom lip. She reported increased difficulty with swallowing since then due to her tongue swelling and reduced mobility. Noted to have moderate oral stage dysphagia due to inability to wear her lower dentures and difficulty with oral bolus control due to lingual swelling. Resident #1 would benefit from modified diet to decrease discomfort and effort with plans to upgrade as swelling decreases. On 7/23/22 the Hospitalist dictated the following note: Resident #1 possibly moving her tongue a little better today. She continued to have a very sore mouth. The Hospitalist spoke with the oral surgeon-nothing to do but watch and continue with lukewarm saline rinses-once desquamation begins, need to observe for exposed bone/muscle, etc. Under the assessment section she documented mucosal thermal burn-magic mouthwash before meals and had bedtime (ACHS), lukewarm saline rinses at least three times a day. Will need to monitor oral mucosa/inflammation closely to avoid worsening respiratory status. On 7/23/22 the Speech Therapist dictated the following note: resident was taking nothing by mouth (NPO) due to significant difficulty managing any by mouth status post [CONDITION(S)] on her tong, palate, inner lips, gingva, with subsequent lingual [CONDITION(S)]. The physician was considering a feeding tube due to probably aspiration. On 7/24/22 the Hospitalist dictated the following note: On 7/24/22 Resident #1 was at high risk for nutritional deficit. It will be quite awhile before her mouth will heal. The resident and her daughter agree to a feeding tube. Her mouth continues to be sore and she was not safe for oral nutrition/fluids-high risk for aspiration. On 7/25/22 an [MEDICATION(S)] Radiology consult note documented: Resident #1 had a moderate to large hiatal hernia making the placement of a feeding tube unsuccessful. On 7/25/22 the Hospitalist dictated the following note: Resident #1 still had difficulty swallowing and talking. Placement of a feeding tube was not successful because of her large hiatal hernia. Oral mucosa with large areas of thermal burn. They will ask Gastrointestinal (GI) department to see her for a feeding tube placement. On 7/25/22 GI consult note documented: on interview Resident #1 denied a history of dysphagia. Only began having trouble swallowing at the nurse home after she drank a cup of scalding hot chocolate and burned her tongue. On 7/26/22 the Speech Therapist dictated the following note: Resident #1 with improving oral stage swallow with continued throat clearing with then and mildly thick liquids. Tolerated puree by ½ teaspoons and sips of moderately thick liquids with success. Remains high risk for aspiration. On 7/26/22 a GI progress note included the following information: Resident #1 was sitting up in a chair. An Registered Nurse (RN) at the bedside feeding her small bites of full liquid diet. The Speech and Language Pathologist had placed her on a pureed diet. She seems to be tolerating full liquid diet much better today. Hopefully they can advance this and avoid any tube feedings whatsoever. On 7/26/22 the following hospital progress note was documented: today Resident #1 was moving her tongue better-there was also now some pink healthy tissue visible on the inferior aspect of her tongue. She was not able to swallow pills yet, although her swallowing has improved today. On 7/27/22 Speech Therapy dictated the following note: Resident #1 seen at her bedside to address swallow function. She reported her lips were really hurting today and felt like they were way out there. Nursing present during session to provide medications. Educated on recommendation to crush medications unless they were not able to be crushed. She was given trials of mildly thick liquids by teaspoon and spoon. She denied sensation of sticking with intake. Continue with puree diet, upgrade to mildly thick liquids and crush medications. On 7/27/22 the Hospitalist dictated the following note: some of the mucosal tissue is now sloughing and being replaced by healthy mucosa. The resident seems to be able to speak easier and tongue movement had improved. Her diet has advanced by speech. She tolerated puddings which now opens the opportunity to give her medications that can be crushed. Lips were sore and peeling, respiratory status was improving. On 7/28/22 a GI noted documented the following: resident sitting up working with physical therapy. She was able to take pudding with her medications and was drinking supplements. Speech therapy continues to work with her. On 7/29/22 a hospital note documented the following: Resident #1 was subjectively better. Oral intake was gradually improving, tolerating full liquids and puree diet. She stated her mouth sores were improving. On 7/27/22 at 11:52 AM Resident #1 stated she went to drink her hot chocolate and it was hot. Resident #1 stated she did not want to spit out the hot chocolate in front of her tablemates so she swallowed it. It burned her throat when she swallowed it and could feel it burning her tongue. During our conversation, she was hard to understand as if her tongue was swollen. She added after that, she sat her cup down, to let it cool while she ate. When asked who her tablemates were she could not remember but stated they are so nice. She did not tell anyone in the facility what had happened but it did not hurt. She was asked who completes her oral care such as taking her dentures out and cleaning her mouth, she stated she does that all by herself. When asked about her injuries she stated she felt her throat swell, had [CONDITION(S)] to her lips, inside of her mouth and tongue. She indicated she was able to eat a little but now and was happy she does not need a feeding tube. She added her fever that morning just came out of nowhere. On 7/27/11 at 11:52 AM Resident #1 was in her hospital bed sitting up. Noted her lower lip to have brownish colored loose skin/scabs, even on her bilateral mouth creases. The inner portion of her top lip also had brownish colored loose skin/scabs. Her tongue had a thick white/beige color coating to it. The facility investigative file included the following: - On 7/22/22 at 5:05am Resident #1 was sent to the hospital for increased fever and shortness of breath and was admitted with pneumonia. On 7/22/22 the resident's daughter sent an email to the Administrator, DON, and Admissions Director about her mother saying that she burnt her mouth on her hot chocolate Thursday, 7/21/22. Resident #1 told her daughter on Wednesday she burnt her mouth on her hot chocolate. When her daughter asked her mom why she didn't spit out the hot chocolate Resident #1 answered, I could not spit it out in front of my tablemates, and I do not know why I didn't tell anyone about this situation. -On 7/25/22 at lunch time the Administrator tested the hot water in a coffee cup. The hot water read 160 degrees Fahrenheit. Once the hot chocolate mix was added and mixed it in, the temperature dropped to 140 degrees Fahrenheit. She spoke with the Dietary Staff and instructed them to ensure the temperature of the water is no higher than 135 degrees Fahrenheit and to a log the temps of hot liquids to ensure the temperature was not higher than 135 degrees Fahrenheit. -On 7/25/22 DON went up to the hospital to visit Resident #1. She was in good spirits and able to answer questions appropriately. Her lips were noted to have dried, yellowish moist injured skin and her tongue and [MEDICATION(S)] areas of her mouth had grayish white patches. Her account of the hot chocolate was unchanged although she was unable to recall the exact date of the incident. When asked her reasoning for not reporting the incident, she merely stated I didn't think much of it. Haven't you ever burned your mouth on something hot? She stated she just swallowed the hot chocolate to avoid embarrassment with her tablemates. She reported that they found a large hernia (hiatal hernia) in her stomach. She asked about how everyone was at the facility and stated she was anxious to come back home. -On 7/25/22 the Administrator and DON conducted the following interviews: o Staff F Dietary Aide remembered she gave Resident #1 the hot chocolate on the morning and afternoon of 7/20/22. She did not remember if she complained of any pain or that the hot chocolate was too hot. o Staff G Dietary Aide reported Resident #1 did not come out for dinner on 7/21/22 and did not want a room tray. She added that Resident #1 usually asks for hot chocolate for break and lunch. o Staff C Certified Nursing Assistant (CNA) was Resident #1's CNA from 6:00 PM-10:00 PM on 7/21/22 and helped her on the overnight shift. He reported that Resident #1 had no complaints, and he did not see any blisters. Staff C stated that when Resident #1 pulled her call light 7/22/22 morning, she had spit up and he helped her clean her dentures and wash out her mouth. He stated that she was confused and that's when he called the nurse in. He stated he believed she might have had some thrush and he noted that to the nurse. He noted that he saw blisters the same time the nurse did on the morning of 7/22/22 before she was sent out to the hospital. o On 7/25/22 the DON placed a call to Resident #1's PCP and she spoke with the Hospitalist. She reported they noted demarcations in her mouth upon arrive to the ER. The Hospitalist felt that Resident #1's dentures retained the heat and caused further injury to her mouth. o Interventions: all hot liquids will be dispensed from the coffee machine. The dietary staff will check log the temperature of hot liquids prior to serving, ensuring that the liquid temperature is not above 135 degrees Fahrenheit. A dietary meeting was held on 7/26/22 to educate all changes to staff on the new temperature requirement. On 7/28/22 at 5:05 PM Resident #1's daughter stated she received a call about 5:00 AM that they were transporting her to the hospital with a temperature of 104 degrees Fahrenheit and fever blisters. She went to the hospital and stated there was redness around her lips, outside of her lips like she had drank from a cup. She said it reminded her of a kid drinking chocolate milk and the milk ring was left on their lips and mouth creases. She stated the right side of her mouth crease and lower lip, on the outside was black and her tongue was completely white. She added the hospitalist stated since Resident #1 had her dentures in, they held on to the heat in her mouth making the [CONDITION(S)] worse. She questioned her mom on why she did not spit out the hot liquid, she stated she did not want to do that to in front of her tablemates. The resident's daughter added that is just her etiquettecy. She stated the sores look better than it did the first day and she is eating puree food and a lot of ice cream. On 7/28/22 at 4:13 PM Staff B Licensed Practical Nurse (LPN) stated about 4:00 AM or later the CNA came to him and stated Resident #1 was running a temperature. Staff B went in to assess her and she was hot to the touch. He checked her temperature multiple times and the lowest temperature he obtained was 103.7 degrees Fahrenheit. He stated the resident was lethargic, she would respond by fall back asleep. He obtained a verbal order to send her to the ER for evaluation. He had noticed she had spit up some frothy stuff and it was on her chin so he asked the CNAs to make sure she was cleaned up before she left. When asked if he noted any injuries to her lips, mouth or tongue he stated as she was getting on the gurney he saw white spots on the bottom portion of her lips. Staff B was asked if any staff members had reported injuries to him he stated just the fever. He did add as the squad was leaving the CNA asked if he saw what looked fever blisters on her lips. Staff B was asked if Resident #1 was a reliable historian he stated normally yes, but that morning no because she was so confused. Staff B was asked if there was anything unusual about Resident #1 during his shift before being sent to the hospital, he stated just that she did not want to eat dinner. That was not typical of her but honestly did not think too much of it. He added Staff C noticed she was confused that night, he checked her oxygen saturations they were low so they put oxygen on her, completed some breathing exercises and she reported she felt better. On 7/28/22 at 4:57 PM Staff C CNA stated he worked the nightshift when Resident #1 was sent out the ER. He stated she was having some breathing issues, was hot, they put her oxygen on her, she had spit up so they cleaned out her mouth. He had noticed white spots on her tongue that looked like thrush. He added he's a CNA so he can't diagnose but that's what it looked like on the center of her tongue. He stated she had what looked like fever blisters on her bottom lips; she had a fever of like 102-103 degrees Fahrenheit. He was asked how Resident #1 was throughout his shift the stated about 10:00 PM she was confused, so he checked or oxygen saturation and it was in the lower 80's so they pumped her oxygen up. She was not normally confused but will get that way when her oxygen is low. When asked if she had reported any concerns to him during his shift, he stated no. On 7/29/22 at 8:35 AM Resident #1's Primary Care Provider (PCP) stated she spoke with the hospitalist that saw her in the ER, her daughter and the facility's Director of Nursing (DON). So all of her information was secondhand. She stated the hospitalist and ENT doctor believe the heat was held in her mouth because the resident had her dentures in at the time. The daughter told her the resident did not want to spit out the water in front of her tablemates. The PCP was asked if there was ever a discussion of the injuries being thrush versus thermal [CONDITION(S)]; she read the notes and stated they definitely talk about it being [CONDITION(S)] from hot liquid. On 7/29/22 at 3:37 PM Staff D Dietary Aide stated they boil the water on the stove for hot chocolate. She added if the resident can't determine if the water was too hot for them, staff will help cool it down for them but putting ice in it. For the ones that are cognitively with it, staff will let them know it was hot and to let it cool down. They will give the resident ice for their hot beverages if they ask for it. Staff D stated they were not checking the temperature of the hot beverages prior to Resident #1's incident; but now they do. On 7/29/22 at 3:43 PM Staff E Cook stated before the incident with Resident #1 they would serve the hot chocolate without obtaining a temperature first. Now they are to make sure the temperature of hot beverage was at or below 135 degrees Fahrenheit. On 7/29/22 at 3:48 PM Staff A Dietary Aide stated before the incident with Resident #1, dietary staff would boil the water for hot chocolate. She added they were not obtaining the water temperature before serving it to the residents. She stated now the cooks will make sure the hot water was not over 135 degrees Fahrenheit before being served. On 8/2/22 at 11:33 AM the Hospitalist reported seeing Resident #1 in the ER and that her oral [CONDITION(S)] were extensive. She had her dentures in when she drank the hot chocolate and that was what trapped the water and heat it. The [CONDITION(S)] were to her mouth, floor of mouth, palate, [MEDICATION(S)] mucosa and lips. When asked if it could have been thrush, she stated not even a thought in her mind; these were thermal [CONDITION(S)] based on the outline of them. There were several days the resident was not able to talk or swallow normally and had talked about placing a feeding tube. Resident #1's injuries began to improve so the feeding tube was not inserted. There was health tissue growing back and she was healing well before she was discharged to back to the facility. On 8/2/22 at 11:15 AM the Administrator stated when they went through their food policies they found one for hot liquids dated back to 1989. They did not have a current one they were using alongside their Food Temperature policy from 2013. On 7/26/22 they implemented a new policy the required the cooks to obtain the temperature of hot beverages, ensure they are at or below 135 degrees Fahrenheit before being served to the residents. All dietary staff were trained on the new policy. The policy is also placed in the breakroom for nursing staff to read and follow as well. An email with the expectations were sent to all staff. On 8/2/22 at 12:43 PM the Dietary Manager stated prior to the incident with Resident #1 they would boil water on the stove and put in service pots for just the hot water. Coffee was served straight from the coffee pot. When asked if the facility had policies about serving hot liquids, she stated just the one they found in their book from 1989. She believed the policy stated hot liquids could be served between 180-190 degrees Fahrenheit, but she was not 100% certain. They wrote a new policy last Tuesday 7/26/22 that encouraged cooks to obtain the temperature of hot fluids prior to service. The temperature must be at or below 135 degrees Fahrenheit prior to service. She added their dietician checked with her other facility and there is nothing in writing on what hot water should be served at. On 8/2/22 at 1:29 PM Staff F Dietary Aide stated she did give Resident #1 her hot chocolate. When asked where she received the water, she stated the put it on the stove to heat it up. They then scoop it out and put it in a pot/kettle. That is where she got the water to serve Resident #1 her hot chocolate. When asked how long from the time the water was placed in the pot/kettle to the time she served her, she stated about 20 minutes. Staff F stated the resident did not drink the hot chocolate in front of her, she did not obtain the temperature of the water prior to serving it to her and was unsure if the cook did. She could not tell if the water was too hot before serving her the hot water for her hot chocolate. She indicated now the cooks were to obtain the temperature of hot liquids and the staff know it was safe to be served. When asked at temperature was considered safe for hot liquids to be served, she stated 135 degrees Fahrenheit. The facility's policy titled Cooks' Responsibilities For Meal Service dated 1989 documented a guide for optimum temperatures at the point of service to include hot beverages at 185 degrees Fahrenheit. The facility's policy tilted Hot Liquids that was implemented, per the Administrator on 7/26/22, documented all hot liquids will come from the coffee dispenser and must be at a temperature of no greater than 135 degrees Fahrenheit. All hot liquids will be temped prior to serving the residents. All hot liquids will be poured into the carafe and then the liquid will be poured into a cup and be temped before being served to the residents. The temperature must be not greater than 135 degrees. The Cook will be responsible for temping all hot liquids and recording the temperature of all hot liquids for all three meals. The facility was notified of the Immediate Jeopardy on 8/2/22. The IJ was removed on 7/26/2022 prior to our entrance into the facility. The IJ will be past noncompliance as the facility implemented the following interventions to prevent [CONDITION(S)] from hot beverages: On 7/26/22 the Administrator educated all dietary staff of the new hot liquid policy and had them sign that they were educated. All dietary cooks started logging the hot liquids on 7/26/22. On 7/26/22 the Administrator started monitoring the hot liquid logs after each meal for all three meals and continued until the Dietary Manager returned from vacation on 8/1/22. The Dietary Manager will continue to monitor these logs after each for all three meals and will review the logs the following business day for weekend purposes. The Dietary Manager will monitor each hot liquid temperature log after every meal for three months and bring each log to their monthly Quality Assurance (QA) meetings for three months of longer if needed. On 7/27/22 at 10:41 Staff A Dietary Aide provided a cup of hot water and a thermometer. The water temperature was obtained, with her present, and read 104 degrees Fahrenheit. At 11:33 AM the same cup of hot water was temped at 80 degrees Fahrenheit.

Based on record review and interviews, the facility failed to implement timely interventions after a resident sustained [REDACTED].#6). The facility reported a census of 58 residents. Findings include: 1. The Minimum Date Set (MDS) for Resident #6 and a reference date of 8/20/12 revealed pertinent [DIAGNOSES REDACTED]. The same assessment revealed the resident independent of all activities of daily living (ADL's). The assessment documented the resident frequently incontinent of bladder. The Brief Interview for Mental Status (BIMS) score to equal 9 which represents moderately impaired cognition. The assessment identified the resident received a scheduled pain medication regimen to management his/her pain needs. Record review of the Resident's Care Plan dated 8/29/12 included, a problem of pain related to [MEDICAL CONDITION] disk disease, gout and occasional complaints of pain in hands and knees. The goal documented to include: pain will be managed with staff intervention. The Fall Report dated 9/29/12 at 8:15 p.m. written by Staff A Licensed Practical Nurse (LPN) documented Resident #6 reported he/she fell backwards when attempting to close his/her closet door. The resident reported he/she did not hit his/her head. The nurse documented the resident was in extreme pain and had been unable to perform ROM to right lower extremity (RLE) and right upper extremity (RUE) ;and his/her hip appeared slightly rotated. The resident had been left on the floor until squad arrived to prevent any further injury. The nurse documented she attempted to page the MD (physician) several times beginning at 8:15 p.m. and finally received a call back at 9:15 p.m. The nurse documented she spoke with the resident's family member and received approval to send the resident to the emergency room . The nurse documented she received a call back from the physician right after speaking with the family member. The nurse documented the squad arrived to the facility shortly afterwards. The resident reported a pain level of 8. Review of the Nurse's Notes dated 9/29/12 at 2204 (10:04 PM) revealed: the resident complained of (c/o) extreme pain to right wrist, unable to perform ROM, upon touching area, resident winced and moaned in pain. Large amount of swelling and bruising, dark purple in color, to outer aspect of wrist upon fall. The right side is the resident's effected side from the [MEDICAL CONDITION]. The resident also c/o pain in right hip, unable to perform ROM and doing so, the resident hollered out in pain. The resident rated the pain at an 8 of 0-10 scale. The right hip appeared to be rotated. Unable to complete assessment for further injury, due to severe pain. The resident, left in place, to prevent further injury, until the squad could take the resident to the emergency department (ED). Pillows used to position the resident and a staff member was sitting with resident the entire time while waiting for squad to take resident to ED. The notes documented the nurse placed the first call to the on call physician at approximately 8:20 p.m. with no response back from the physician. The nurse documented she attempted to call the on call service several times with no response. The nurse documented the on call service informed her that two physicians were paged and called their home numbers with no response. The nurse documented she called the family member at this time and called the on call medical director but had no response. The ADON (assistant director of nursing) then called and received an ok to speak with family member who is power of attorney (POA) and received permission to send the resident to the ER to be treated and evaluated. After speaking with ADON, the family member was called again. After speaking with family member, she received permission to send Resident #6 (to ED). The nurse documented after hanging up the phone with the family member, a physician called back and she received verbal orders to send the resident to the hospital. The nurse documented 911 was called and shorty after that the resident was sent to the hospital. Review of the Physician's Telephone Orders revealed an order dated 9/29/12 for Resident #6, send to Hospital for treatment and evaluated (no time of when the order had obtained). Review of the ED (emergency department) Physician Note dated 9/29/12 at 2133 (9:33 PM) revealed the patient presents following a fall. [MEDICATION NAME] 2 mg intravenous (IV push) during assessment at 2142, 9:42 PM. Review of the Hospital Pain/Nausea Assessment/Reassessment dated [DATE] at 11:02 PM revealed pain level at that time to equal 5 and the resident's acceptable pain level of 3. Review of the Final Radiology Report dated 9/29/12 revealed comminuted intraarticular fracture at the right distal radius. Probable smaller fracture at the distal aspect of the ulna, in the region of the styloid process. Osteopenia/[MEDICAL CONDITION]. [MEDICAL CONDITION] changes. Review of the Final Radiology Report dated 9/29/12 revealed a pelvis x-ray, single view, impression; acute comminuted fracture at the proximal aspect of the right femur, involving the intertrochanteric region. Bony [MEDICAL CONDITION] changes. Suspect osteopenia/[MEDICAL CONDITIONS] vascular disease. The Medical Director and Director of Nursing submitted a typed document to the surveyor regarding the timeliness of Resident #6's transfer to the hospital after the fall. The document identified the Medical Director stated there is no Standard of Practice for the amount of time or to determine when the delay has been too long. The document identified if the staff is not able to get in touch with the on call physician, the next step would be to get permission from the resident's Responsibility as in this situation. The Medical Director identified the timing of the transfer did not adversely affect the resident's outcome. During interview on 1/15/13 at 12:47 PM, Resident #6's primary care physician stated he had not been aware the resident had been on the floor for an hour. The physician stated they should have sent Resident #6 to the emergency room . The resident's physician stated he expected nursing to treat it as an emergency and get residents evaluated right away, not one (1) hour later. During an interview with the Staff A, LPN on 1/14/13 at 3:45 pm., she stated after Resident #6 fell , she could not examine under the resident's clothing due to the resident's severe pain. Staff A stated Resident #6 was alert and oriented and pillows were placed to keep the resident's comfortable. Staff A stated she did not think to ask Resident #6's permission to send him/her to the emergency room . Staff A stated she called the on call (physician) service with no returned call. Staff A stated probably 5-10 minutes later she tried calling again and again. Staff A stated she called the ER and they said they would page the physician, and she had no returned calls from the physician(s). Staff A stated she had no return call from any physician. Staff A stated she was unsure of the time frame and called the medical director and the resident's family member of the fall. Staff A stated she still did not have a call back (from the physician). Staff A stated a half hour (1/2) passed so she called Resident #6's family member back and obtained permission to send the resident to the emergency room . Staff A stated the physician then called and gave her orders to send the resident to the ED. Staff A stated she thought she had to have a (physician's) order to send the resident to the ED. Staff A stated in nursing school she learned that you had to have a physician's orders [REDACTED]. Staff A reported Resident #6 had been there for an hour (1) before she left for the ED and had been in severe pain when staff tried to move him/her. During interview on 1/21/13 at 10:42 AM, Staff B, Licensed Practical Nurse (LPN), she stated she entered the resident's room, found the resident on the floor, half way leaning on the door, propped up on left elbow, leg rotated slightly, she stated she obtained help from Staff A, LPN and Staff A took over the incident, and Staff B went back to the floor to continue administering medications and treatments. She stated, in her opinion, she would have called the emergency room physician for orders. She stated, she did not know Staff A, had problems obtaining orders until after the resident had been transferred. During interview on 1/14/13 at 4:30 PM, Staff C, Certified Nursing Assistant (CNA) stated she sat with Resident #6 following h/her fall. She stated she offered water and talked to her for comfort. She stated when the resident tried to move h/her right arm, h/she c/o pain shooting up h/her arm. She stated she had sat and monitored the resident approximately 20 minutes, taking turns with two other aides. Review of the Emergency Care, General Guidelines, Procedure 365, Briggs Corporation, 2006 directed the licensed nurse if she/he could not reach the attending physician, to call alternate physician, (if not available, contact physician responsible for emergency care of residents or arrange transportation to an appropriate facility for emergency care).