Every finding on record at Pavilion-Ths, Llc

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure infection control practices to prevent the spread of communicable diseases for 1 of 2 (Resident #6) residents sampled reviewed for the use of Enhanced Barrier Precautions (EBP). The findings include: Review of the undated facility policy titled, Enhanced Barrier Precautions, revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Initiation of Enhanced Barrier Precautions.An order for enhanced barrier precautions will be obtained for residents with any of the following.indwelling medical devices.hemodialysis catheters.even if the resident is not known to be infected or colonized.Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility until.discontinuation of the indwelling medical device that placed them at a higher risk. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease, Dementia, and Chronic Kidney Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was moderately cognitively impaired. Resident #6 received hemodialysis and had a central IV (plastic tube placed directly into a vein) access site. Review of the Physician's Orders dated 6/1/2026, revealed .Dialysis at [named clinic] MWF [Monday, Wednesday, Friday] at 1000 [10:00 AM].Start Date.5/20/2026.Monitor Perma-cath [a soft, flexible tube placed into a large vein to provide immediate, long-term access to the bloodstream, most commonly used for hemodialysis] site to Rt [Right] Upper Chest Q [every] shift.Start Date.5/18/2026. The facility failed to obtain a physician order for the use of EBP in accordance with facility policy. Review of the care plan dated 6/6/2026, revealed the facility failed to include EBP in Resident #6's care plan. Observation of Resident #6's doorway and room on 6/15/2026 at 10:36 AM and 2:49 PM and on 6/16/2026 at 8:20 AM and 3:14 PM, revealed no visible EBP signage. There was no indication Resident #6 was on EBP. During an interview on 6/17/2026 at 2:27 PM, the Infection Control Preventionist (ICP) was asked which residents would require EBP. The ICP stated, .any outside to inside devices.dialysis patients. The ICP was asked if they obtained a Physician Order for EBP. The ICP stated, .it is care planned only, we do not have an order, and we put a sign up [EBP signage that is placed outside resident's door]. The ICP was asked if EBP was included in Resident #6's care plan. The ICP stated, I don't see it care planned and she should be [care planned for EBP] .she's not on my master list [ICP list of all residents on isolation] . The ICP was asked if Resident #6 should have the EBP signage outside her door. The ICP stated, Yes she should. During an observation and interview outside Resident #6's room on 6/17/2026 at 2:51 PM, the ICP was asked if Resident #6 had EBP signage outside her door. The ICP stated, No, it does not have one [EBP signage] and it should.

Based on policy review, medical record review, observation, and interview, the facility failed to follow the Physician's Order for wound treatment on 1 of 2 (Resident #2) residents reviewed for pressure ulcers. The findings include: 1. Review of the facility's policy titled Wound Treatment Management, dated 2025, revealed .Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.The facility will follow specific physician orders for providing wound care. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Pressure Ulcer Sacral Region, and Cerebrovascular Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment which indicated he was severely cognitively impaired. Resident #2 required assistance with activities of daily living (ADLs) and had an unhealed, unstageable pressure ulcer present on admission. Review of the Care Plan dated 6/1/2026, revealed .admitted with a sacral DTI [Deep Tissue Injury] d/t [due to] necrosis [unnatural death of cells and living tissue in the body]. He has risk potential for pressure related injury development.Date Initiated.3/14/2026.Sacrum: DO NOT REMOVE or disturb the wound bed. Change the secondary dressing(s) xeroform [a non-adhering wound dressing made of fine-mesh gauze], non-adherent [gauze pad] and cover dressing with care as per the recommendations.Date Initiated.6/1/2026. Review of the Physician's Order dated 6/5/2026, revealed Sacrum: DO NOT REMOVE or disturb the wound bed. Change the secondary dressing(s) hydrogel [a water or glycerin-based gel], non-adherent [gauze pad] and cover dressing with care as per the recommendations.every day shift AND as needed. Observation of wound care in Resident #2's room on 6/17/2026 at 10:27 AM, revealed Licensed Practical Nurse (LPN) D gathered 2 packages of sterile gauze pads, 1 sterile Q-Tip (cotton tip applicator), 1 sterile nonadherent pad, and 1 sterile border gauze dressing. LPN D was assisting Resident #2 on his side while LPN A removed the dressing from the wound area. LPN A discarded used dressing, removed gloves, washed hands, and put on a clean pair of gloves. LPN A opened the sterile nonadherent pad, cut to appropriate size to cover wound, placed over wound, and then covered with the sterile border gauze. LPN A failed to apply hydrogel as Physician's order stated. During an interview on 6/17/2026 at 4:20 PM, the Director of Nursing (DON) was asked how often the wound care doctor comes to see the wounds. The DON stated, He comes once or twice a week depending on the treatments. He writes the orders and the [named LPN D], inputs the orders in the computer . The DON was shown the Wound Doctor's orders for the treatment to Resident #2's wound. The DON stated, I would expect the nurse to follow the order that is currently written on the TAR [Treatment Administration Record]. I would expect [staff] to put the hydrogel on the wound bed at every dressing change . During an interview on 6/17/2026 at 5:30 PM, the Wound Care Doctor was asked if nursing staff were expected to apply hydrogel to Resident #2's wound daily with dressing change. The Wound Care Doctor stated, .Yes.

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow Physician's Orders for oxygen therapy for 1 of 1 (Resident #20) residents reviewed for respiratory care. The findings include: Review of the undated facility policy titled, Oxygen Administration, revealed .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.Oxygen is administered under orders of a physician. Review of the undated facility policy titled, Oxygen Concentrator, revealed .The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrations.Oxygen is administered under orders of the attending physician.The nurse shall verify physician's orders for the rate of flow and route of administration of oxygen. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, and Anxiety. Review of the Physician's Order dated 6/1/2026, revealed .O2 [Oxygen] @ [at] 2L/M [liters per minute] BNC [by nasal canula] at all times.Start Date.3/18/2025. Review of the Care Plan dated 6/1/2026, revealed .[named resident] has a dx [diagnosis] of COPD. He is at risk for recurrent infections and respiratory distress .Give oxygen therapy as ordered by the physician. O2 at 2 L/M via [by way of] nasal cannula . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired. Resident #20 had upper extremity impairment on both sides and received oxygen therapy. Observation in the dining room on 6/15/2026 at 10:46 AM and 12:05 PM and on 6/16/2026 at 8:11 AM, revealed Resident #20 sitting in the dining room not receiving oxygen therapy and no portable oxygen tank or concentrator present. Observation in Resident #20's room on 6/16/2026 at 8:50 AM, revealed Resident #20 sitting in the room not receiving oxygen therapy and oxygen concentrator turned off. Observation in Resident #20's room on 6/16/2026 at 3:07 PM, revealed Resident #20 sitting in the room receiving oxygen therapy at 2.5 L/M BNC. The facility failed to ensure Resident #20 received continuous oxygen therapy at the rate ordered by the Physician. During an interview on 6/16/2026 at 3:09 PM, Licensed Practical Nurse (LPN) B was asked what the Physician's Order for Resident #20's oxygen was. LPN B stated, .2 Liters. LPN B was asked if the Physician's Order was for continuous (at all times) or PRN (as needed). LPN B stated, At all times. During an observation and interview in Resident #20's room on 6/16/2026 at 3:11 PM, LPN B was asked what Resident #20's oxygen flow rate was set on. LPN B stated, He's actually at 2.5 [L/M]. LPN B was asked what Resident #20's oxygen should have been set on. LPN B stated, 2 [L/M]. LPN B was asked if Resident #20 would have been able to adjust the flow rate himself. LPN B stated, No. Observation in the dining room on 6/17/2026 at 11:23 AM, revealed Resident #20 sitting in dining room not receiving oxygen therapy and no portable oxygen tank or concentrator present. During an interview on 6/17/2026 at 11:26 AM, LPN C was asked what the Physician's Order for Resident #20's oxygen was. LPN C stated, 2 Liters as tolerated. LPN C was asked if Resident #20's oxygen was ordered to be continuous. LPN C stated, As tolerated, so if he's pulling it off, he can leave it off for a little while. LPN C was asked if Resident #20 had been removing his nasal canula on that date. LPN C stated, Not that I know of. During an interview on 6/17/2026 at 11:46 AM the Director of Nursing (DON) was asked what the Physician's Order for Resident #20's oxygen was. The DON stated, 2 Liters per nasal canula. The DON was asked if the oxygen order was continuous or PRN. The DON stated, Continuous. The DON was asked if Resident #20 should be receiving oxygen at that time. The DON stated, Yes. During an observation and interview in the dining room on 6/17/2026 at 11:48 AM, the DON was asked if Resident #20 was receiving oxygen. The DON stated, No, he does not have it [oxygen BNC] on, and yes, he should have it [oxygen BNC] on.

Based on policy review, medical record review, observation, and interview, the facility failed to implement a person-centered care plan to address the code status for 21 of 24 (Resident #2, #4, #5, #9, #11, #15, #16, #17, #19, #22, #25, #27, #29, #32, #33, #34, #45, #48, #51, #207 and #257) sampled residents and failed to implement a fall intervention for 1 (Resident #18) of 6 residents reviewed for accidents. The findings include: 1. Review of the undated facility policy titled, Comprehensive Care Plans, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing .needs .The comprehensive care plan will describe, at a minimum .The services that are to be furnished to attain or maintain the residen' s highest practicable physical, mental, and psychosocial well-being . Review of the undated facility policy titled, Residents' Rights Regarding Treatment and Advance Directives, revealed .It is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate advance directives .Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State Law .relating to the provision of health care when the individual is incapacitated .During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any change related to any advance directives .Decisions regarding the advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process .Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care . Review of the undated facility policy titled, Accidents and Supervision, revealed, .The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes .Implementing interventions to reduce hazard(s) and risk(s) . Review of the undated Frequent Flyer Program, revealed, As a way to alert staff of high risk patients that have fallen, we will adopt the following program .When a patient falls, they are identified by an airplane on the door. The plane will be placed on the outside of the patient's door . 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Anemia, and Dementia. Review of the facility form titled, Physician Orders for Scope of Treatment (POST), dated [DATE], revealed Resident #2 elected Cardiopulmonary Resuscitation (CPR), full treatment, Antibiotics, IV fluids and feeding tube. Review of the Care Plan dated [DATE], revealed the facility failed to include the CPR code status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderately impaired cognition. 3. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Cerebrovascular Disease, Thyrotoxicosis, Chronic Ischemic Heart Disease, and Dementia. Review of the POST form dated [DATE], revealed Resident #4 elected Do Not Attempt Resuscitation (DNR), Comfort Measures, and no artificial nutrition by tube. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #4 was severely cognitively impaired. Review of the Care Plan for Resident #4 dated [DATE], revealed the facility failed to include the CPR code status. 4. Review of the medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Humerus Fracture, Urinary Tract Infection, Dementia, Osteoporosis, and Congestive Heart Failure. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated Resident #5 was moderately cognitively impaired. Review of the POST form dated [DATE], revealed Resident #5 elected CPR. Review of the Care Plan for Resident #5 dated [DATE], revealed the facility failed to include the CPR code status. 5. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dysphagia, and Chronic Obstructive Pulmonary Disease. Review of the POST form dated [DATE], revealed Resident #9 elected DNR, Comfort Measures, and no artificial nutrition by tube. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #9 was severely cognitively impaired. Review of the Care Plan dated [DATE], revealed the facility failed to include the CPR code status. 6. Review of the medical record revealed Resident #11 admitted to the facility on [DATE], with diagnoses including Epilepsy, Need for assistance with personal care, and Hypertension. Review of the POST form dated [DATE], revealed Resident #11 elected DNR, comfort measures, and no artificial nutrition. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #11 was cognitively intact. Review of the Care Plan dated [DATE], revealed the facility failed to include CPR code status. 7. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Osteoarthritis, Anxiety, Depression, and Insomnia. Review of the POST form dated [DATE], revealed Resident #15 elected DNR. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #15 was cognitively intact. Review of the Care Plan dated [DATE], revealed the facility failed to include the CPR code status. 8. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Atrial Fibrillation, Congestive Heart Failure, and Cardiac Arrhythmia. Review of the POST form dated [DATE], revealed Resident #16 elected CPR, Resuscitate, Limited Additional Intervention, no artificial nutrition by tube. Review of the POST form dated [DATE], revealed Resident #16 elected DNR, Limited Additional Intervention, and a Defined trial period of artificial nutrition by tube. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 5, which indicated Resident #16 was severely cognitively impaired. Review of the Care Plan dated [DATE], revealed the facility failed to include the CPR code status. 9. Review of medical records revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Lymphedema, and Chronic Ischemic Heart Disease. Review of the POST form dated [DATE], revealed Resident #17 elected DNR, Comfort Measures, and No artificial nutrition by tube. Review of significant change MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #17 was severely cognitively impaired. Review of the Care Plan dated [DATE], revealed the facility failed to include the CPR code status. 10. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Coronary Artery Disease, Diabetes, Hypertension, Congestive Heart Failure, and Cardiac Pacemaker. Review of facility document titled, Advanced Care Plan, dated [DATE], revealed an assigned agent to make health care decisions for Resident #19, and an alternate agent to make health care decisions for Resident #19, effective only when Resident #19 no longer had the capacity, included Quality of Life, Treatment, and Organ Donation directives per Resident #16's decisions. Review of the POST form dated [DATE], revealed Resident #19 elected CPR, Limited Additional Interventions, and a Defined trial period of artificial nutrition by tube. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #19 was cognitively intact. Review of the Care Plan dated [DATE], revealed the facility failed to include the CPR code status. 11. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus, Aphasia, and Osteoarthritis. Review of the POST form dated [DATE], revealed Resident #22 family member elected DNR, limited additional interventions, and no artificial nutrition by tube. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 5, which indicated Resident #22 was severely cognitively impaired. Review of the Care Plan dated [DATE], revealed the facility failed to include CPR code status. 12. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Chronic Diastolic Heart Failure, Atherosclerotic Heart Disease, and Bipolar Disorder. Review of the POST form dated [DATE], revealed Resident #25 elected DNR, comfort measures, and no artificial nutrition. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #25 was severely cognitively impaired. Review of the Care Plan dated [DATE], revealed the facility failed to include the CPR Code Status. 13. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety Disorder and Depression. Review of the POST form dated [DATE], revealed Resident #27 elected DNR, Comfort Measures, and no artificial nutrition by tube. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated Resident #27 was moderately cognitively impaired. Review of the Care Plan dated [DATE], revealed the facility failed to include CPR code status. 14. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE], with diagnoses including Methicillin Susceptible Staphylococcus, Cellulitis, Benign Prostatic Hyperplasia, Urinary Retention, and Testicular Hypofunction. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #29 was cognitively intact. Review of the POST form dated [DATE], revealed Resident #29 elected CPR. Review of the Care Plan dated [DATE], revealed the facility failed to include the CPR code status. 15. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Acute Respiratory Failure, Dysphagia, and Dementia. Review of the POST form dated [DATE], revealed Resident #32's Power of Attorney (POA) elected DNR, limited additional interventions, and no artificial nutrition. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #32 was cognitively intact. Review of the Care Plan dated [DATE], revealed the facility failed to include the CPR code status. 16. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Fracture of Left Femur, Orthopedic Aftercare, Repeated Falls, and Acute Kidney Failure. Review of the POST form dated [DATE], revealed Resident #33 elected CPR and Full Treatment. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #33 was cognitively intact. Review of the Care Plan dated [DATE], revealed the facility failed to include the CPR code status. 17. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Major Depressive Disorder and Type 2 Diabetes Mellitus. Review of the POST form dated [DATE], revealed Resident #34 elected DNR, Comfort Measures, and no artificial administered nutrition by tube. Review of the quarterly MDS assessment dated [DATE], revealed a score of 00, which indicated Resident #34 was severely cognitively impaired. Review of Care Plan dated [DATE], revealed the facility failed to include the CPR code status. 18. Review of the medical record revealed Resident #45 was admitted to facility on [DATE], with diagnoses including Hypertension, Chronic Kidney Disease, Myocardial Infarction, and Diabetes. Review of the medical record revealed Resident #45 had a Durable Health Care Power of Attorney dated [DATE]. Review of the POST form dated [DATE], revealed Resident #45 elected CPR, Full Treatment, and a Defined trial period of artificial nutrition. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #45 was severely cognitively impaired. Review of Care Plan dated [DATE], revealed the facility failed to include CPR code status. 19. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE], with diagnoses including Fracture of Left Femur, Tachycardia, Severe Protein-Calorie Malnutrition, and Alzheimer's Disease. Review of the POST form dated [DATE], revealed Resident #48's daughter was appointed as agent for decision making to include medical treatments and health care decisions. Review of the POST form dated [DATE], revealed Resident #48 elected DNR, Comfort Measures, and No Artificial Nutrition by tube. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #48 was severely cognitively impaired. Review of the Care Plan dated [DATE], revealed the facility failed to include the CPR code status. 20. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Cellulitis of Right Lower Limb, Cellulitis of Left Lower Limb, acute Kidney Failure, and Diabetes. Review of the Care Plan dated [DATE], revealed the facility failed to include the CPR code status. Review of the POST form dated [DATE], revealed Resident #51's preference for CPR, Full Treatment, and a Defined trial period of artificial nutrition by tube. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #51 was cognitively intact. 21. Review of the medical record revealed Resident #207 was admitted to the facility on [DATE], with diagnoses including Pneumonitis due to Inhalation of Food and Vomit, Sepsis, Chronic Obstructive Pulmonary Disease, Acute Kidney Failure, Cystitis, Dysphagia, and Hypertension. Review of the facility document titled, Durable General Power of Attorney, dated [DATE], revealed Resident #207's son had Durable General Power of Attorney to include medical. Review of the facility document titled, Health Care Directive (Living Will), dated [DATE], revealed Resident #207's son was appointed as agent for all matters relating to health with no concerns noted. Review of the Care Plan dated [DATE], revealed the facility failed to include the CPR code status. 22. Review of the medical record revealed Resident #257 was admitted to the facility on [DATE], with diagnoses including Multiple Fractures of Pelvis with Stable Disruption, Fatty Liver disease, and Opioid Dependence. Review of the POST form dated [DATE], revealed Resident #257 elected CPR, Full Treatment, and a Defined trial period of artificial nutrition by tube. Review of the Care Plan dated [DATE], revealed the facility failed to include the CPR code status. 23. During an interview on [DATE] at 10:12 AM, the MDS Coordinator stated, .I usually don't care plan a resident's DNR status . During an interview on [DATE] at 7:50 PM, the DON was asked if a resident's care plan should be person centered. The DON stated, Yes. The DON was asked if the code status would be a part of the person centered care plan. The DON stated, .it would be important to have the post form on the chart . 24. Review of the medical record revealed Resident #18 admitted to the facility on [DATE], with diagnoses including Dementia, Major Depressive Disorder, and Osteoporosis. Review of the Quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #18 was severely cognitively impaired, required partial/moderate assistance with sit to stand and chair/bed-to-chair transfers, and had sustained 2 falls since admission. Review of Resident #18's comprehensive care plan dated [DATE], revealed a focus for falls. Resident #18 had a total of eleven falls ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].) An intervention for Frequent Flyers (patients at high risk for falls will have a plane placed on the outside of the patient's door to alert staff)was dated [DATE]. During an interview on [DATE] at 12:40 PM, Certified Nursing Assistant (CNA) A was asked to explain the frequent flyer program. CNA A stated, .the airplane picture or the plastic airplane on the door lets the staff know the resident is at high risk for falls .not to leave the resident alone .toilet them frequently .check on them frequently . During an observation and interview on [DATE] at 12:45 PM, CNA A and Registered Nurse (RN) D were asked if Resident #18 had an airplane on her door to alert the staff she was a high fall risk, both employees stated, .No . During an interview on [DATE] at 7:50 PM, the DON was asked if Resident #18's intervention for falls was to place her on the frequent flyer program. The DON stated Yes. The DON was asked if Resident #18 should she have an airplane on her door to alert staff. The DON stated, Yes.

Based on facility policy review, medical record review and interview, the facility failed to accurately address an advanced directive for 1 (Resident #16) of 24 residents reviewed. The findings include: 1. Review of the undated facility policy titled, Residents' Rights Regarding Treatment and Advance Directives, revealed .It is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate advance directives .Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State Law .relating to the provision of health care when the individual is incapacitated .On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive .The facility will provide the resident or resident representative information .about the right to refuse medical or surgical treatment and formulate an advance directive .During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any change related to any advance directives .Decisions regarding the advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process .Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care . Review of the undated facility policy titled, Cardiopulmonary Resuscitation (CPR), revealed It is the policy of this facility to adhere to residents' rights to formulate advance directives .If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and .In accordance with the resident's advance directives .In the absence of advance directives or a Do Not Resuscitate order .Staff will maintain current CPR certification for healthcare providers through a CPR provider whose training . 1. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses which included Hypertensive Heart (High Blood Pressure changes in the Heart) and Chronic Kidney disease with Heart Failure and Stage 1 through Stage 4 Chronic Kidney Disease, or Unspecified chronic Kidney Disease, Permanent Atrial Fibrillation (irregular heart beat), Chronic Systolic (Congestive) Heart Failure, and Essential (Primary) Hypertension (High Blood Pressure). Review of the facility form titled, Physician Orders for Scope of Treatment (POST), dated [DATE], revealed Resident #16 elected CPR, resuscitate, limited additional Intervention, no artificial nutrition by tube. Review of the physician orders for Resident #16 order dated [DATE] revealed an order to admit to [Named] hospice. Review of the facility form titled, Physician Orders for Scope of Treatment (POST), dated [DATE], revealed Resident #16 elected Do Not Resuscitate (DNR), limited additional intervention, and defined trial period of artificial nutrition by tube. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitively impairment, and on Hospice while a Resident. Review of the Care Plan dated [DATE], for Resident #16 revealed a focus on hospice with no intervention for advance directives. The facility failed to focus on Advance Directives or CPR code status. Review of the POST form dated [DATE], revealed cardiopulmonary resuscitation (CPR), resuscitate, limited additional intervention, no artificial nutrition by tube. Review of Resident #16's hospice chart revealed a POST form dated [DATE], Cardiopulmonary Resuscitation Do Not Attempt Resuscitation with limited additional interventions, and defined trial of artificial nutrition by tube. During an interview on [DATE] at12:30, Registered Nurse (RN) D confirmed Resident #16's paper chart contained a POST form stating resuscitate and the hospice chart contained a POST form stating do not attempt resuscitation. During an interview on [DATE] at 7:50 PM, the Director of Nursing (DON) confirmed the discrepancy of Resident #16's code status in the hospice record and the facility chart. The DON was asked if the POST form in the hospice record and the facility record should be the same. The DON stated, Yes.

Based on facility policy review, medical record review, observation, and interview, the facility failed to obtain a physician's orders related to skin care treatments for 1 of 3 (Resident #33) residents reviewed for skin conditions. The findings include: Review of the undated facility policy titled, Wound Treatment Management, revealed .In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders .Treatments will be documented on the Treatment Administration Record . Review of the undated facility policy titled, Physician Orders/Verbal Orders, revealed, .Physician orders may be received by telephone, by a licensed nurse or other licensed or registered health care specialist who are legally authorized to do so .Repeat any prescribed orders back to the physician .Enter the order into the medical record . Review of the undated facility policy titled, Documentation of Wound Treatments, revealed .Wound assessments are documented upon admission, weekly, and as needed .Type of wound .Measurements .Description of wound characteristics .Wound treatments are documented at the time of each treatment . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Fracture of Left Femur, Orthopedic Aftercare, Repeated Falls, and Acute Kidney Failure. Review of the facility form titled, admit/readmit screener, dated 2/28/2025, revealed .skin integrity .Right elbow .skin tear . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #33 was cognitively intact. Review of the care plan dated 3/6/2025, revealed there were no interventions to address the skin tear to the right elbow. Review of the Nurses Note dated 3/6/2025 at 3:25 PM, recorded as a late entry and documented on 3/10/2025 at 3:26 PM, revealed .STI [Skin Tear Injury] to Rt [Right] elbow noted on admit [admission] has not required tx [treatment] and is scabbed . Review of the physician's order for Resident #33 dated 3/2025, revealed the physician's order failed to address the skin conditions to the right elbow. Review of the facility form titled, Non-Pressure Skin Report, dated 3/8/2025, 3/14/2025m and 3/22/2025, failed to address skin conditions to Resident #33's right elbow. During an observation and interview in the Resident's room on 3/25/2025 at 8:51 AM, revealed a border gauze to Resident #33's right elbow region. Resident #33 stated, .have a spot on my arm .they put a bandage on it, I asked for one because it bleeds .groin is sore .they will apply cream if I ask . Observation in the Resident's room on 3/26/2025 at 8:24 AM, revealed Resident #33's right arm was exposed with a border gauze pulled up and attached on one side with slight blood-tinged area. A small opened area with no scab was observed to the right elbow region. During an interview on 3/26/2025 at 10:51 AM, Licensed Practical Nurse (LPN) E was asked if Resident #33 had a skin condition to her right arm. LPN E stated .she had a place on her right elbow, but I haven't heard anything about it recently . LPN E was asked if Resident #33 had complained of irritation in her groin, LPN E confirmed that they put protective barrier cream to her groin and that the area had been monitored. LPN E confirmed there was no treatment order for Resident #33's right elbow or groin. During an interview on 3/27/2025 at 7:50 PM, the Director of Nursing (DON) was asked if a resident required barrier cream application or had an open area that required a bandage should there be a physician's order for that care. The DON stated, Yes.

Based on facility policy review, observation, and interview, the facility failed to provide a safe, sanitary, and homelike environment for 6 of 32 (Resident #8, 11, 14, 25, 27, 31, 33, 48, 51, 207) resident rooms observed. The finding include: 1. Review of the facility policy titled, Storage of Bedpans and Urinals, dated 2024, revealed .Bedpans and urinals are for single resident use only. [NAME] with the resident's name and discard upon discharge. Store bedpans and urinals in the resident's bathroom after placing in a plastic bag or as per facility policy . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Pseudobulbar Affect, Hypertensive Heart Disease with Heart Failure, Peripheral Vascular Disease, and Unspecified Dementia, unspecified severity with Psychotic Disturbance. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #8 was cognitively intact. Observation in the bathroom of Resident #8 on 3/24/2025 at 12:10 PM, 3/25/2025 at 10:40 AM, and 3/26/2025 at 8:33 AM, revealed a yellow bedpan located between the grab bar and wall behind the toilet was unlabeled and unbagged. 3. Resident #11 and #14 were roommates. a. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Epilepsy, Need for assistance with personal care, and Essential Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #11 was cognitively intact. b. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Dysarthria, and Cerebral Infarction. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #14 was cognitively intact. c. Observation in the shared bathroom of Resident #11 and Resident #14 on 3/24/2025 at 12:04 PM and 1:07 PM, revealed a bed pan located between the grab bar and the wall behind the toilet was unlabeled and unbagged. During an observation and interview in Resident #11 and Resident #14's bathroom on 3/26/2024 at 8:55 AM, RN IP/Unit Manager confirmed the bedpan should be labeled and bagged. 4. Resident #25 and #27 were roommates. a. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Chronic Diastolic Heart Failure, Atherosclerotic Heart Disease and Bipolar Disorder. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #25 was severely cognitively impaired. b. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety Disorder and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated Resident #27 was moderately cognitively impaired. c. Observation in the shared bathroom of Resident #25 and Resident #27 on 3/24/2025 at 11:40 AM, 3/25/2025 at 9:05 AM, and 3/26/2026 at 8:22 AM, revealed the bedpan labeled for Resident #27 was unbagged. 5. Resident #31 and #33 were roommates. a. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE], with diagnoses including Acute Cystitis, Fracture of Left Humerus, Dislocation of Right Shoulder, and Dementia. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated Resident #31 was moderately cognitively impaired. b. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Fracture of Left Femur, Orthopedic Aftercare, Repeated Falls, and Acute Kidney Failure. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #33 was cognitively intact. c. Observation in the shared bathroom of Resident #31 and Resident #33 on 3/25/2025 at 8:59 AM and 3:33 PM, and 3/26/2025 at 8:24 AM, revealed an unlabeled and unbagged bedpan lying on top of the shower chair. 6. Resident #48 and #51 were roommates. a. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including Fracture of Left Femur, Severe Protein-Calorie Malnutrition, and Mood disturbance, and Alzheimer's Disease. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 3 which indicated Resident #48 was severely cognitively impaired. b. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Cellulitis of Right Lower Limb, Cellulitis of Left Lower Limb, Acute Kidney Failure, Repeated Falls, and Type II Diabetes Mellitus. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #51 was cognitively intact. c. Observation in the shared bathroom of Resident #48 and Resident #51 on 3/24/2025 at 12:47 PM, 3/25/2025 at 10:42 AM, and 3/26/2025 at 8:28 AM, revealed a unlabeled and unbagged pink bedpan between the grab rail and wall behind the toilet. During an observation and interview in the shared bathroom of Resident #48 and Resident #51 on 03/26/25 at 8:58 AM, the RN/IP Unit Manager confirmed a pink bedpan located between the grab bar and wall behind the toilet was unlabeled. 7. Review of the medical record revealed Resident #207 was admitted to the facility on [DATE] with diagnoses including Pneumonitis due to Inhalation of Food and Vomit, Sepsis, Chronic Obstructive Pulmonary Disease, Acute Kidney Failure, Cystitis, Dysphagia, and Hypertension. Review of medical records revealed Resident #207 was a new Admission with no MDS assessment available. Observation in the bathroom of Resident #207 on 03/24/25 at 12:27 PM and 3/25/2025 at 10:37 AM, revealed a yellow bedpan and a pink bedpan located between the grab bar and the wall behind the toilet was unlabeled and unbagged. Observation and interview in the bathroom of Resident #207 on 3/26/2025 at 9:15 AM, revealed the RN/IP Unit Manager confirmed there was one yellow bedpan and one pink bedpan located between the grab bar and wall behind the toilet that was unlabeled. 8. During an interview on 03/26/25 at 8:47 AM, the RN/IP/Unit Manager confirmed bedpans and urinals should be stored in the resident's bathrooms, labeled with the resident's name, and stored after use, placing in a plastic bag. The RN/IP Unit Manager stated, If a bedpan doesn't have a name on it, it goes in the trash. The same for urinals, and/or denture cups. During an interview on 3/27/2025 at 7:50 PM, the Director of Nursing (DON) was asked should bed pans be labeled with the resident's name and stored in a plastic bag. The DON stated Yes.

Based on facility policy review, medical record review, observation and interview, the facility failed to store foods in a safe and sanitary manner as evidenced by expired foods in the walk-in refrigerator and on the shelf in the dry storage room and serve food in a safe and sanitary manner for 1 of 30 residents (#31) during the lunch meal on [DATE]. The findings include: Facility policy review, Date Marking for Food Safety, undated, revealed .The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest .The Head Cook, or designee, shall be responsible for checking daily for food items that are expiring, and shall discard accordingly . Facility policy review, Handling Serving a Meal, undated, revealed .Avoid handling actual unwrapped food items with bare hands . Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further medical record review of Resident #31's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #31 required set up supervision with eating. Observation on [DATE] at 8:45 AM in the kitchen walk-in refrigerator with the Certified Dietary Manager (CDM), Food Service Director (FSD), revealed Mustard Potato Salad, 11 pound (LB) container and Cottage Cheese, 11 LB container, use by date [DATE]. Observation on [DATE] at 8:48 AM in the kitchen dry storage with the Certified Dietary Manager, FSD, revealed ,[DATE] fluid ounce (237 OZ) containers of Thicken Dairy Drink, expiration date [DATE]. Observation on [DATE] in the Magnolia Dining Room at 12:30 PM revealed Certified Nurse Assistant (CNA) #3 setting up Resident #31's lunch tray and touched Resident #31's sandwich with her left bare hand to reposition the sandwich, then she secured the sandwich with her left bare hand to cut it, then she picked up half of the sandwich with her left bare hand to give it to the resident. Observation and interview with the CDM on [DATE] at 8:45 AM in the walk in refrigerator and at 8:48 AM in the dry storage area confirmed the mustard potato salad, cottage cheese and the thickened dairy drink were expired. Interview with CNA #3 on [DATE] at 12:33 PM in the Magnolia Dining room revealed CNA #3 when asked what was the process of handling a resident's food when setting up the meal, she stated, I was not supposed to touch the food with my hands. Interview with the Director of Nursing on [DATE] at 10:37 AM in her office confirmed staff were not to touch food with bare hands.

Based on facility policy review, observation and interview, the facility failed to properly secure a oxygen cylinder for 1 of 34 rooms observed. The findings include: Review of the undated facility policy Oxygen Safety revealed .Cylinders will be properly chained or supported in racks or other fastenings to secure all cylinders from falling, whether connected, unconnected, full or empty . Observation on 11/5/18 at 9:10 AM and 9:50 AM in room [ROOM NUMBER] revealed an oxygen cylinder on the floor standing up in front of a wheelchair unsupported. Interview with the Director Of Nursing (DON) on 11/5/18 at 5:16 PM in her office revealed she was not aware of the oxygen cylinder on the floor, not appropriately stored. The DON confirmed the oxygen cylinder should be stored when not in use, and when they are in use they are supposed to be stored in the cylinder holder. \

Based on facility policy review, medical record review, observation, and interview, the facility failed to label and date oxygen and nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) tubing and humidified canisters for 1 resident (#11) of 13 residents reviewed receiving respiratory treatments. The findings include: Review of the facility policy Departmental (Respiratory Therapy)-Prevention of Infection, revised 4/07 and addendum dated 7/28/10, revealed .Keep the oxygen cannulae and tubing used PRN (as needed) in a plastic bag when not in use (Nebulizers/Continuous Aerosol, store the circuit in a plastic bag, marked with date and resident's name, between uses) Discard the administration set up every 7 days (Oxygen cannulas will be changed every two weeks and as needed and whenever visibly soiled) whenever a cannula /mask is not in use it is to be placed in a zip lock bag on the concentrator . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with readmission on 4/17/17 with [DIAGNOSES REDACTED]. Medical record review of the (MONTH) (YEAR) physician orders revealed .PRN 02 (oxygen) @ (at) 2L/min (liters per minute) via NC (nasal cannula) for 02 sats (saturation) below 90% (percent) . Medical record review of the Quarterly Minimum Data Set (MDS) for Resident #11 dated 10/19/18 revealed the resident was receiving oxygen therapy. Observations on 11/5/18 at 10:01 AM, 11:49 AM, 2:59 PM and 4:08 PM, revealed Resident #11 had an oxygen concentrator in her room not in use with the oxygen tubing and humidified water canister not dated. Further observation in the resident's room revealed Resident #11 had a nebulizer machine with tubing attached and the tubing not dated or stored in a plastic bag. Observation of Resident #11 on 11/5/18 at 4:08 PM in the resident's room with Licensed Practical Nurse (LPN) #1 present revealed the resident's oxygen tubing, nebulizer tubing, and humidified water canister were not dated. Further interview with LPN #1 confirmed the oxygen tubing, humidified water, and nebulizer tubing were to be changed and dated weekly. Interview with the Director of Nursing (DON) on 11/6/18 at 8:17 AM in her office confirmed oxygen tubing and humidified water canisters were to be changed and dated every two weeks and nebulizer tubing were to be changed and dated weekly. Further interview with the DON revealed staff were to date tubing and bottles when changed.

Based on medical record review, observation and interview, the facility failed to obtain physician orders [REDACTED].#54) of 13 residents receiving respiratory treatment. The findings include: Medical record review revealed Resident #54 was admitted to the facility on [DATE], was discharged on [DATE] to the hospital, was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 11/5/18 at 9:49 AM, at 3:58 PM, and 4:01 PM, and on 11/6/18 at 8:12 AM, revealed Resident #54 in the room, in bed, with the oxygen concentrator in operation. Further observation revealed the resident was receiving the oxygen at 2 liters per minute by a nasal cannula. Observation on 11/5/18 at 12:50 PM revealed Resident #54 with a nasal cannula in place, in a wheelchair in the main dining room receiving oxygen from a portable oxygen tank set at 2 liters per minute. Medical record review of the physician orders [REDACTED]. Interview with Licensed Practical Nurse (LPN) #2 on 11/6/18 at 8:48 AM at the 100/200 nursing station revealed the LPN was responsible for Resident #54 and the resident was receiving oxygen. Further interview confirmed the medical record did not have a physician order [REDACTED]. Further interview confirmed the medical record did not have a Standing Order form signed by the physician. Interview with LPN #3, Nurse Manager, on 11/6/18 at 9:13 AM at the 100/200 nursing station confirmed the medical record for Resident #54 did not contain physician order [REDACTED].

Based on medical record review and interview, the facility failed to follow a physician's order for 1 resident (#65) of 27 residents reviewed. The findings included: Medical record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Telephone Orders Audit dated 7/24/17 revealed the following order was written for Resident #65 .(1) taper off [MEDICATION NAME] (antidepressant) QOD (every other day) x (times) 1 wk (week), then DC (discontinue) (2) [MEDICATION NAME] (antidepressant) 50 mg (milligrams) . Medical record review of the 7/2017 through 8/2017 Medication Review Report revealed an order dated 8/8/17 for [MEDICATION NAME] 100 mg every other day for 1 week then DC and an order dated 8/8/17 for [MEDICATION NAME] 50 mg. Interview with Licensed Practical Nurse (LPN) #2 on 9/6/17 at 4:05 PM at the 100/200 hall nursing station confirmed she wrote the Physician's Telephone Orders Audit dated 7/24/17 for Resident #65. Further interview revealed the resident's daughter requested the 7/24/17 order be held until the daughter was able to review the genetic testing results for the resident. Further interview with LPN #2 confirmed the order on the Medication Review Report was dated 8/8/17 and not 7/24/17 as written. Interview with the Director of Nursing (DON) on 9/6/17 at 4:20 PM in her office confirmed the Physician's Order dated 7/24/17 for Resident #65 was not started until 8/9/17. The DON confirmed the facility failed to follow the Physician's Telephone Order Audit dated 7/24/17 as written for Resident #65.

Based on review of facility policy, medical record review, and interview, the facility failed to notify the physician of the family's request to hold a medication order for 1 resident (#65) of 27 residents reviewed. The findings included: Review of facility policy, Change in a Resident's Condition of Status, revised 4/5/16 revealed .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .A need to alter the resident's medical treatment significantly . Medical record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #65 was severely cognitively impaired. Medical record review of a Physician's Telephone Orders Audit dated 7/24/17 revealed .(1) taper off [MEDICATION NAME] (antidepressant) QOD (every other day) x (times) 1 wk (week), then DC (discontinue), (2) [MEDICATION NAME] (antidepressant) 50 mg (milligrams) . Medical record review of the 7/2017 through 8/2017 Medication Review Report revealed an order dated 8/8/17 for [MEDICATION NAME] 100 mg every other day for 1 week then DC and an order dated 8/8/17 for [MEDICATION NAME] 50 mg. Interview with Licensed Practical Nurse (LPN) #2 on 9/6/17 at 4:05 PM at the 100/200 hall nursing station confirmed she wrote the Physician's Telephone Orders Audit dated 7/24/17 for Resident #65. Further interview revealed the resident's daughter requested the 7/24/17 order be held until the daughter was able to review the genetic testing results for the resident. Continued interview with LPN #2 confirmed the facility failed to notify the prescribing Physician for clarification of the medication order. Interview with Director of Nursing (DON) on 9/6/17 at 4:20 PM in her office confirmed the facility failed to notify the prescribing Physician for clarification of the medication order dated 7/24/17 for Resident #65.

Based on medical record review, observation, review of the Non-pressure Skin Report, and interview, the facility failed to follow the care plan to report a change in skin condition for 1 resident (#79) of 27 residents reviewed. The findings included: Medical record review revealed Resident #79 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 7/3/17 revealed Resident #79 was .at risk for potential pressure ulcer development with Interventions .weekly skin assessment, daily skin inspection, report new .areas to charge nurse for evaluation . Observation on 9/5/17 at 2:18 PM revealed Resident #79 in her room in the wheelchair with a darkened bruise on the top of the right hand. Medical record review of the 9/6/17 Non-pressure Skin Report written by Registered Nurse (RN) #1 revealed no issue was identified regarding the skin condition. Observation on 9/7/17 at 7:42 AM in the main dining room revealed Resident #79 was in a wheelchair seated by the table self eating her meal. Further observation revealed the right hand bruise was now darker purple in color. Interview with Certified Nurse Aide (CNA #1) on 9/7/17 at 10:50 AM at the 100/200 hall nursing station confirmed she had provided care for the resident the past 2 days. Further interview revealed the CNA was not aware of the bruise. Interview with the Licensed Practical Nurse (LPN #1) on 9/7/17 at 1:45 PM at the 100/200 nursing station confirmed she had provided direct care to Resident #79. Further interview revealed the LPN was not aware of the bruise on the right hand, .no one reported it to me . Interview with Rehabilitation Staff #2 on 9/7/17 at 1:55 PM in the rehabilitation office confirmed she had been providing therapy for Resident #79 for several days and had seen the right hand bruise .a few days ago .she bruises easily . Interview with the Director of Nursing on 9/7/17 at 2:54 PM in the conference room confirmed someone didn't follow the care plan.

Based on medical record review, observation, review of the skin report, and interview, the facility failed to accurately assess a bruise on the skin report for 1 resident (#79) of 27 residents reviewed. The findings included: Medical record review revealed Resident #79 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 9/5/17 at 2:18 PM revealed Resident #79 in her room in the wheelchair with a darkened bruise on the top of the right hand. Medical record review of the 9/6/17 Non-pressure Skin Report written by Registered Nurse (RN) #1 revealed no issue was identified regarding the skin condition. Observation on 9/7/17 at 7:42 AM in the main dining room revealed Resident #79 was in a wheelchair seated by the table self eating her meal. Further observation revealed the right hand bruise was now darker purple in color. Interview with Certified Nurse Aide (CNA) #1 on 9/7/17 at 10:50 AM at the 100/200 hall nursing station confirmed she had provided care for the resident the past 2 days. The CNA revealed the resident used her left hand to move her right hand so the resident could and did easily bump into something. Further interview revealed the CNA was not aware of the bruise. Interview with the Licensed Practical Nurse (LPN) #1 on 9/7/17 at 1:45 PM at the 100/200 hall nursing station confirmed she had provided direct care to Resident #79. Further interview revealed the LPN was not aware of the bruise on the right hand, .no one reported it to me . Interview with Rehabilitation Staff #2 on 9/7/17 at 1:55 PM in the rehabilitation office confirmed she had been providing therapy for Resident #79 for several days and had seen the right hand bruise .a few days ago .she bruises easily . Interview with Registered Nurse (RN #1), with the Director of Nursing (DON) present, on 9/7/17 at 2:15 PM by the medication cart on the 200 hall confirmed the RN had done the skin assessment for Resident #79 on 9/6/17. Further interview confirmed the RN did not document the bruise on the skin report, but had .noted the bruise for awhile, at least for 2 days, and I put nothing new on report . When the RN was asked what she was to document on the skin report the RN stated .I am to record whatever the skin status is regardless of what it is or how long it's been there . Interview with the DON confirmed the facility failed to accurately assess the skin status of the resident.

Based on observation, review of manufacturer's instructions, interview, and review of maintenance records, the facility failed to properly maintain the hot water temperature probe of the dishwasher in the dietary department. The findings included: Observation of the dietary department on August 19, 2013, at 2:30 p.m., revealed the hot water in the dishwasher was not reaching a water temperature of 155 degrees (per manufacturer's instructions) for the wash cycle. Continued observation revealed staff manually engaged the probe and ran three cycles through the dishwasher before the correct wash and rinse temperatures were achieved. Interview with the Dietary Manager on August 19, 2013, at 2:40 p.m., in the dietary department confirmed the hot water temperature probe had been malfunctioning for approximately two weeks and the Maintenance Director was to have ordered a replacement part. Observation of the dietary department on August 21, 2013, at 8:38 a.m., revealed the dishwasher hot water temperature probe had not been replaced. Review of a faxed invoice revealed the "...hot water probe replacement part..." was ordered on August 21, 2013, at 10:45 a.m. Interview with the Dietary Manager and the Maintenance Director on August 21, 2013, at 10:55 a.m., in the Magnolia dining room confirmed the hot water temperature probe was not functioning properly for approximately two weeks and the needed replacement part had not been ordered until August 21, 2013.

Based on observation, interview, and review of facility policy, the facility failed to follow proper food storage in dietary department and in one of three dining rooms. The findings included: Observation of the dietary department on August 19, 2013, at 9:50 a.m., revealed in the walk-in freezer, on the right hand center shelf, a box containing raw beef, breads, and bags of apple sticks belonging to the facility, along with frozen entrees labeled with a resident's name. Interview with the Dietary Manager in the dietary department on August 19, 2013, at 9:55 a.m., confirmed the facility combined stock dietary food with one resident's personal food brought in from an outside source by a family member. Observation of the dietary department on August 19, 2013, at 10:00 a.m., revealed in the walk-in refrigerator, on the left top shelf, a tray of raw bacon and raw sausage. Continued observation revealed stored under the raw bacon and sausage, were plastic containers of peaches, lima beans, and apples, and a resealed bag of shredded cheese. Interview with the Dietary Manager in the walk-in refrigerator on August 19, 2013, at 10:05 a.m., confirmed the raw bacon and sausage were stored above the plastic containers of peaches, lima beans, and apples and the sealed bag of shredded cheese. Observation of the Magnolia dining room and storage cabinets on August 19, 2013, at 12:45 p.m., revealed in the upper center cabinet, an opened, undated, and unsecured ream of crackers. Continued observation revealed in the far right drawer a gait belt was stored with crackers. Interview with Certified Nursing Assistant (CNA) #1, in the Magnolia dining room, on August 19, 2013, at 12:45 p.m., confirmed the open ream of crackers was undated, the gait belt was stored along with the crackers, and equipment was not to be stored with the food. Observation of the dietary department on August 19, 2013, at 2:45 p.m., revealed a rolling plate warming cart filled with clean plates stored in the stock dry storage room, with the electrical cord laying on top between the plates, and no cover over the plates. Interview with the Dietary Manager in the dietary department on August 19, 2013, at 2:45 p.m., confirmed the dinner plates were to be covered. Review of facility policy, Food Storage, revised April 2006 revealed "...food storage areas shall be maintained in a clean, safe, and sanitary manner..." Observation of the dietary department on August 19, 2013, at 2:49 p.m., revealed a covered stationary mixer ready for use. Continued observation revealed on the stationary mixer was cream colored dried debris on the splash guard and underside of the mixer. Interview with the Dietary Manager in the dietary department on August 19, 2013, at 2:50 p.m., confirmed there was dried debris on the stationary mixer and the machine had not been used that day.

Based on observation and interview, the facility failed to perform hand hygiene during medication pass for two residents (#106, #24) of five residents observed during medication pass. The findings included: Observation on August 20, 2013, at 8:20 a.m., on the 300 hall, revealed Licensed Practical Nurse (LPN) #1 removed medications from the drawer of the medication cart, dispensed medications in a medication cup, and opened the trash lid with the bare hands to throw trash in the trash can on the medication cart. Continued observation revealed the trash bag had fallen in the trash can and LPN #1 touched the trash bag to open it up. Continued observation revealed without washing the hands, LPN #1 dispensed pudding in a cup, poured water in a cup, entered resident # 24's room and administered the medications. Continued observation revealed LPN #1 returned to the medication cart, sanitized the hands, removed medications from the drawer and dispensed them to a cup. Continued observation revealed LPN #1 again touched the trash can lid to open it, rearranged the trash bag in the trash can, and without performing hand hygiene, took the medications to resident #106's room and administered the medications to the resident. Interview with LPN #1 on August 20, 2013 at 8:35 a.m., at the medication cart on the 300 hall, confirmed LPN #1 touched the trash bag during the medication pass and did not perform hand hygiene after touching the trash bag and dispensing the medications.

Based on medical record review and interview, the facility failed to provide an accurate assessment for weight loss of one resident (#87) of thirty-three residents reviewed. The findings included: Resident #87 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Nutritional assessment dated [DATE], revealed the resident's weight was 137 pounds. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident's weight was 129 pounds (a decrease of eight pounds and a 5.8% (percent) (weight loss) and the MDS indicated the resident had not had a significant weight loss. Medical record review of the resident's Weight Record and Dietary notes revealed the resident weighed 129 pounds on March 25, 2013, and had a significant weight loss of 5% within the last 30 days. Interview with the MDS Coordinator on August 21, 2013, at 10:13 a.m., in the MDS Coordinator's office, confirmed the resident had a 5% weight loss and the MDS was inaccurate.

Based on observation and interview, the facility failed to respect the dignity of one resident (#50) of thirty-three residents reviewed. The findings included: Resident #50 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on August 19, 2013, at 12:26 p.m., in the resident's room, revealed Unit Manager #1 was standing next to the resident's bed with the resident lying on the side, and uncovered with the incontinence brief showing. Continued observation revealed the privacy curtain was not pulled completely around the resident's bed. Further observation revealed the resident's bathroom door was at the foot of resident #50's bed, the roommate's spouse came out of the bathroom, and was able to observe resident #50 in bed with the brief showing. Interview with Unit Manager #1 on August 19, 2013, at 12:30 p.m., in the resident's room confirmed the resident's dignity was not respected.