Every finding on record at Pearl of Elgin, The

Based on observations, interviews and record reviews, the facility failed to serve hot foods at meals at palatable temperatures. This applies to all 125 residents receiving oral diets at the facility.The findings include: Facility Resident Listing Report, dated 8/28/26, shows the facility census was 125 residents.On 8/30/26 at 2:17 PM, V1 (Administrator) stated all residents were receiving oral diets in the facility.1. On 8/28/26 at 12:30 PM, V14 (Food Service Director) stated he sometimes received cold food complaints from residents who received their trays in their rooms. On 8/28/26 at 12:29 PM a lunch test tray was plated in the kitchen and placed on the 100 hall meal cart. At 12:58 PM the last tray was served to residents in the 100 hall. With V14 (Food Service Manager), the test tray fish, rice and peas were all tasted and the food tasted slightly warmer than room temperature but not warm or hot. V14 tasted the fish and stated the food temperature was slightly warmer than room temperature but not warm/hot. The temperatures of the foods were measured, and the fish measured 112 degrees F (Fahrenheit), the peas measured 117 degrees F and the rice measured 120 degrees F. V14 stated the temperatures of the food should not go below 135 degrees F and should taste hot to the residents when served. Food Palatability - Hot Food Temperatures policy/procedure, undated, shows, The healthcare community prepares and serves food and beverages that is palatable, attractive and at safe and appetizing temperatures. The policy/procedure shows hot foods were to be held at 120 degrees F or above and once the food was plated for resident service the temperature of the food was expected to be less than 120 degrees F. 2. On 8/28/26 at 12:03 PM with R12, R10 (Resident Council President), R13 (Resident Council [NAME] President) and R12 all stated the hot food at the facility was often served cold to residents including the food served directly to residents in the dining room from the kitchen. R10, R12 and R13 all stated the facility residents complain about the hot foods being served cold to the facility residents during the food committee meetings, but the discussion may not be recorded in the minutes. On 8/28/26 at 10:37 AM, R1 and R2 stated the food was served cold all of the time. R1 stated the residents received eggs five days a week and they were always served cold.On 8/28/26 at 10:07 AM, R3 stated the food was served cold at meals including the eggs at breakfast. R6 stated his food also was served cold during meals.On 8/28/26 at 10:14 AM, R5 stated her breakfast that morning was served cold.On 8/28/26 at 9:57 PM, V3 (LPN-Licensed Practical Nurse) stated some of the residents complained the hot foods were served cold.On 8/28/26 at 1:12 PM, V10 (LPN) stated some residents complain that the hot food is served cold and the staff reheat the food.

Based on observations, interviews, and record reviews, the facility failed to provide timely ADL (Activities of Daily Living) care for residents who required staff assistance for toileting and bed mobility. This applies to 10 of 11 residents (R1, R2, R4, R5, R7, R10, R11, R12, R13 and R14) reviewed for call lights/ Activities of Daily Living (ADLs).The findings include:1. R11's face sheet, printed 8/28/26, shows R11's diagnoses included senile degeneration of brain, cerebral infarction, palliative care, chronic kidney disease, dementia with agitation, and major depressive disorder.MDS (Minimum Data Set), dated 7/8/26, shows R11 was frequently incontinent of bowel/bladder, required substantial/maximal assistance with toileting hygiene and was dependent on staff for chair to bed transfers. R11's care plan showed R11 required substantial assistance from staff for toileting and was totally dependent on 2 staff using a mechanical lift for transfers. R11's care plan showed R11 was incontinent with bladder, utilized incontinence briefs, and staff were to check frequently and as required for incontinence and provide incontinence care as needed.On 8/28/26 at 12:03 PM, R10 stated her roommate R11 did not receive incontinence care from staff in a timely manner. On 8/28/26 at 2:56 PM, V17 (Licensed Practical Nurse) stated R11 had not been to bed or had her incontinence brief checked for soil since 10:00 AM that morning. V17 stated R11 sat in the dining room from approximately 10:00 AM until 2:40 PM when she was put back in bed. V17 the staff must put R11 in bed to check her incontinence brief to see if the brief was soiled and required changing and the staff could not check her brief while she was sitting in her chair. On 8/28/26 at 2:44 PM, V18 (CNA/Certified Nursing Assistant) and V19 (CNA) began to change R11's incontinence brief while R11 was in bed. V18 and V19 removed R11's incontinence brief and there was a very strong urine order. V18 and V19 stated the urine order smelled strong and stated the incontinence brief was saturated with urine. Observation of the incontinence brief showed that dark yellow urine was saturating R11's incontinence brief. V18 and V19 both stated R11 was unable to call staff to inform them she needed her incontinence brief changed. V18 and V19 both stated the staff typically check dependent and incontinent residents' incontinence briefs for soil at the beginning of their shifts and at the end of their shifts, or when incontinence residents are being placed into bed.2. R10's MDS, dated [DATE], showed R10 was frequently incontinent of bladder/bowel and required supervision or touching assistance by staff for transfers and toilet use. R10's care plan showed R10 was incontinent of bowel/bladder and staff were to check R10 frequently and assist with toileting as needed.R12's MDS, dated [DATE], shows R12 was dependent on staff for transfers and toileting hygiene and was always incontinent of bowel and bladder. R12's care plan showed R12 had a history of urinary tract infections, was incontinent, and staff were to provide incontinence care after incontinence episodes as needed.R13's MDS, dated [DATE], showed R13 was always continent of bowel and bladder and R13 required set up and clean up assistance from staff for toileting hygiene and toilet transfers.On 8/28/26 at 12:03 PM, with R13, R10 (Resident Council President) and R12 stated they waited excessive amounts of time for staff to assist them with incontinence care. R12 stated she recently waited from 3:00 PM until 9:40 PM while asking staff to change her soiled incontinence brief. R12 stated R12's CNA agreed to change R12's incontinence brief at approximately 7:00 PM but at 7:00 PM the nurse told R12 that the CNA had to assist a different resident with a bed bath before changing R12. R12 stated the CNA did not come to change R12 until approximately 9:49 PM. R13 stated sometimes he waited to urinate for over an hour because he was waiting for staff to empty his full urinal. 3. R4's care plan showed R4 was incontinent and was dependent on staff for transfers. MDS, dated [DATE], shows R4 required substantial/maximal assistance from staff for toileting hygiene, was dependent on staff for transfers, and was always incontinent of bowel and frequently incontinent of urine. On 8/28/26 at 10:02 AM, R4 stated in the past week she waited over an hour for staff to come and assist her and change her soiled incontinence brief. R4 said there is enough staff, it's the training and motivation of the staff. R5's MDS, dated [DATE], shows R5 was frequently incontinent of bowel, required partial/moderate assistance from staff for toileting hygiene, and was dependent on staff for transfers. On 8/28/26 at 10:14 AM, R5 stated she sometimes has to wait approximately 45 minutes for staff to assist her with toileting. R5 stated the evening CNAs would become backed up with requests for assistance and were not able to come to assist R5 in a timely manner. R5 stated the backups consistently and needed to be addressed.5. R7's MDS, dated [DATE], shows R7 required supervision or touching assistance for transfers from the bed to her chair.On 8/28/26 at 10:23 AM, R7 stated after staff came to her room to get her roommate out of bed, she asked the staff to get her up as well. R7 stated the staff left the room and did not return to get R7 up out of bed until approximately 40-50 minutes later.6. R1's physical therapy evaluation, dated 8/23/26, shows R1 was dependent on staff for repositioning in bed and transfers.On 8/28/26 at 10:37 AM, R1 stated on 8/28/26 between 4:00 AM and 7:00 AM she was in pain lying in bed and waited for staff to come to help her reposition in bed. R1 stated she called for staff assistance four times and finally her sister called the facility front desk to ask someone to attend to R1. R1 stated she also needed her incontinence brief changed but she was in pain and told the staff when they arrived that she did not care if the staff changed her brief but just needed staff to reposition her in bed to help ease her pain. R1 stated that her roommate R2 sat in waste for over an hour while calling for staff to come help change her incontinence brief. R2 nodded in agreement and stated she waited over an hour for staff to assist her with toileting.Review of R2's care plan shows R2 was incontinent of bowel and staff were to provide a bedpan or bedside commode for R2 as needed for toileting.7. On 8/28/26 at 12:03 PM, R13 (Resident Counsel [NAME] President) stated the family of R14 approached him and complained the staff were not changing R14's incontinence brief in a timely manner and R14's brief was overflowing and soiling her pants and linens.MDS, dated [DATE], showed R14 was dependent on staff for toileting hygiene, transfers, and was always continent of urine and frequently incontinent of bowels. R14's care plan shows R14 was incontinent of bowel and bladder, wore disposable incontinence briefs, and required staff to check as required for incontinence and change clothing as needed after incontinence episodes. R14's care plan shows R14 had a history of urinary tract infections.On 8/29/26, V20 (Family) stated she often comes to the facility and R14 was sitting in wet clothes because her urine had soaked through her incontinence brief and soiled her clothing. V20 stated R14 was not being changed in a timely manner, not being changed every two hours, and sat in urine for hours. V20 stated her sister visited R14 on 7/24/26 and visited for 5 hours without staff checking R14's incontinence brief for soiling. V20 stated she arrived on 8/1/26, 8/6/26, 8/11/25, 8/14/26, 8/22/26, and 8/26/26 and R14's pants or sheets were wet with urine that had soaked through her incontinence brief. V20 stated R14 was often treated for urinary tract infections at the facility and was concerned they were caused by sitting in urine for excessive periods of time.On 8/28/26 at 12:15 PM, V1 (Administrator) stated the facility implemented a Resident Check and Change Log for R14 to document when R14's incontinence brief was checked for soiling. V1 stated the staff were expected to check R14's incontinence brief for soiling every 2 hours. Review of Resident Check and Change Logs provided 8/28/26, shows on 8/25/26 R14's incontinence brief was not checked at 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM or 10:00 PM. No further documentation was provided for the checking and changing of R14 for 8/26/26 or 8/27/26. On 8/28/26 at 2:42 PM, V3 (Licensed Practical Nurse) stated residents who were incontinent should be checked for a soiled brief every two hours. On 8/28/26 at 2:52 PM, V2 (Director of Nursing) stated the staff should check incontinent residents every two hours to see if they are soiled and need to be changed. On 8/28/26 at 3:07 PM, V1 (Administrator) stated incontinent residents who were dependent on staff for care should have their incontinence briefs checked every two hours for soiling and need for changing.Facility Policy/Procedure Urinary Continence and Incontinence - Assessment and Management, revised 2/13/25, shows, Incontinence care will be provided by nurse or CNA every shift based on incontinence needs of resident. Staff will ensure that incontinence care needs are met. Facility Policy/Procedure Call Light Use, reviewed 3/10/26, shows, Facility aims to meet resident's needs as timely as possible. The call light system is utilized to alert staff of resident's needs. 2. Residents capable of using the call light appropriately will have their all light accessible at all times. 3. Residents incapable of using the call light will have alternative means or assistive devices based on functional ability. 4. Direct care staff will check these residents during check and change rounds and ADL (Activities of Daily Living) care.

Based on interview and record review, the facility failed to administer timely and correct treatment for a resident with a UTI (Urinary Tract Infection). The facility also failed to administer medications as ordered by the provider. This failure resulted in R1 being hospitalized for metabolic encephalopathy and UTI due to not receiving the correct antibiotic to treat her UTI. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for UTI in the sample of 5.The findings include:1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, dementia, urinary tract infection, and congestive heart failure. R1's MDS (Minimum Data Set) dated May 30, 2026, showed R1 had severe cognitive impairment. A progress note dated June 1, 2026, at 10:28 PM, by V13 (RN/Registered Nurse) showed Per family member [V11 (R1's family)], resident complained of burning in urination this evening, when resident was asked, replied 'not anymore,' fluids encouraged, physician notified with order to do urinalysis/culture and sensitivity. A progress note dated June 3, 2026, at 8:36 PM, by V7 (NP/Nurse Practitioner) showed Patient is well appearing, she is sitting in dining room. She had positive UA (Urinalysis) and has been started on [nitrofurantoin monohydrate/macrocrystals (antibiotic medication)]. Culture pending. Afebrile, tolerates oral. The EMR did not show an order for nitrofurantoin monohydrate/macrocrystals on or before June 3, 2026. A progress note dated June 4, 2026, at 3:48 PM, by V6 (RN/Registered Nurse) showed UA/CS results were relayed to [V7]/[V8 (R1's Physician)].A progress note dated June 4, 2026, at 11:19 PM, by V5 (LPN/Licensed Practical Nurse) showed UA/CS (Culture and Sensitivity) laboratory results relayed and reviewed by [V10 (Infectious Disease NP)]. New order for ertapenem 1 gram daily intramuscularly injection times five days, diagnosis: UTI. Order carried out.An administration note dated June 5, 2026, at 12:06 AM, by V5 showed [V10] aware. The system has identified a possible drug allergy for the following order: Ertapenem Sodium Injection Solution Reconstituted 1 gram, inject 1 gram intramuscularly one time a day for UTI for five days. An administration note dated June 5, 2026, at 7:10 AM, by V9 (LPN) showed R1's ertapenem sodium 1 gram, was not administered due to, Contraindicated. On June 15, 2026, at 2:34 PM, V6 said on June 4, 2026, she received the urine culture results for R1 and V6 left a message at V8's office and faxed the results to the office. V6 said she did not receive a call back and endorsed the results to the next shift. V6 said when she worked on June 6, 2026, V11 inquired about R1's antibiotic dose. V6 said the antibiotic was not due to be administered to R1 on her shift and V11 requested V6 call the doctor to get a dose administered then. V6 said she called the doctor and received an order to administer a dose of antibiotics at 11:15 AM. V6 said before she called the doctor, R1's first antibiotic was scheduled to be administered June 6 at 5:00 PM. V6 said R1 was sent to the emergency room on June 6, 2026, when R1's granddaughter called emergency medical services due to R1 being lethargic and confused. R1's laboratory results dated [DATE], showed Result called to [V5] June 4, 2026, at 7:13 PM. The results continued to show R1's urine culture had growth of Escherichia coli and positive for ESBL (Extended-Spectrum Beta-Lactamases). The results showed the bacteria was resistant to the antibiotic nitrofurantoin monohydrate/macrocrystals. R1's June 2026 MAR (Medication Administration Record) showed R1 first received an antibiotic on June 6, 2026, at 11:15 AM. The MAR continued to show the antibiotic was nitrofurantoin monohydrate/macrocrystals. On June 15, 2026, at 3:43 PM, V8 (R1's Physician) said he ordered nitrofurantoin monohydrate/macrocrystals on June 5, 2026, to treat R1's UTI. V8 said he was unaware R1's urine culture and sensitivity results had come back on June 4, 2026, and showed the bacteria was resistant to nitrofurantoin monohydrate/macrocrystals. V8 said if he would have known the culture results, he would not have ordered nitrofurantoin monohydrate/macrocrystals because that antibiotic would not treat R1's UTI. V8 said he was unaware R1 was not administered antibiotics until June 6, 2026, when the nurse called to clarify the order. V8 said it takes about two days of treatment to prevent R1 from experiencing metabolic encephalopathy from a UTI. V8 said R1 was hospitalized with UTI and metabolic encephalopathy. R1's hospital records showed an Emergency Department Attending Physician Note dated June 6, 2026, at 2:47 PM, by V12 (emergency room Physician) showed Chief Complaint: Altered mental status. Patient sent from nursing facility. She does have a history of dementia and is a very poor historian. Majority of history is obtained from nursing facility records. It seems that patient was recently diagnosed with a UTI and started on oral antibiotics. Per daughter she seems to be more lethargic today and more confused than usual. Medical Decision Making: 7:30 PM, Patient resting comfortably. She seems to have some metabolic encephalopathy likely from UTI that has failed outpatient antibiotic treatment. Patient was started on intravenous antibiotics. Case was discussed with [V8] for admission. 2. R2's EMR showed R2 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, and dementia. R2's infection care plan dated May 15, 2026, showed Resident has a condition requiring antibiotics. Urinary tract infection. The care plan continued to show multiple interventions dated May 16, 2026, including Provide medication per physician orders, monitor for side effects of medication. Vital signs as indicated. An order dated May 23, 2026, showed Meropenem (antibiotic medication) intravenous solution reconstituted 1 gram, use 1 gram intravenously every 8 hours for urine ESBL for 7 days. R2's May 2026 MAR showed R2 was not administered the scheduled meropenem on May 23, 2026, at 10:00 PM, and May 29, 2026, at 10:00 PM. On June 16, 2026, at 2:06 PM, V4 (ADON/Assistant Director of Nursing) said medications should be administered as ordered by the provider. V4 said staff should document administration at the time of administering the medication. V4 said R2's May 2026 MAR does not have documentation to show meropenem was administered at 10:00 PM on May 23 and May 29, 2026. The facility does not have documentation to show R2 was administered meropenem as ordered by the provider at 10:00 PM on May 23 and May 29, 2026. 3. R3's EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction, rhabdomyolysis, and urine retention. R3's UTI care plan dated March 14, 206, showed Resident has a condition requiring antibiotics. Urinary tract infection. The care plan continued to show multiple interventions dated March 14, 2026, including Provide medications per physician orders. Monitor for side effects of medication. Vital signs as indicated. An order dated May 30, 2026, showed ampicillin (antibiotic medication) oral capsule 500 mg (milligram), give one capsule by mouth four times a day for UTI for seven days.R3's June 2026 MAR showed R3 was not administered the scheduled ampicillin on June 2, 2026, at 1:00 PM and 5:00 PM. The MAR continued to show the 1:00 PM dose had documentation to Other/See progress notes. The progress note for R3's June 2, 2026, 1:00 PM ampicillin dose documented by V9 (LPN) showed Doctor aware not available. The facility does not have documentation to show R3 was administered ampicillin on June 2, 2026, at 1:00 PM and at 5:00 PM. On June 16, 2026, at 2:06 PM, V4 said R3's June MAR showed R3 did not receive ampicillin on June 2, 2026, at 1:00 PM and 5:00 PM. V4 said medications should be administered as ordered by the provider. The facility's policy titled Administering Medications dated May 18, 2026, showed Policy Statement: Facility will ensure that medications are administered in a safe and timely manner, and as prescribed. Procedure: .3. Medications are administered in accordance with prescriber orders and medication administration times are determined by facility, resident need and benefit.

Based on the interview and record review, the facility failed to inform a resident's Power of Attorney (POA) before facilitating the completion of guardianship paperwork by another family member.This applies to 1 of 6 residents (R1) reviewed for the right exercised by the representative.Findings include:On 08/28/2025, approximately at 11:45 AM, V10 (R1's POA) said the facility facilitated the completion of R1's guardianship for another family member without her knowledge or consent. The Power of Attorney for Healthcare Statutory Form dated 02/19/2025, signed by R1, listed V10 as his healthcare agent (Power of Attorney-POA). Under the facility contact information in R1's profile, V10 is entered as the POA, responsible party for Healthcare Care, Surrogate Decision Maker, and Emergency Contact # 1.The facility provided a completed and signed evaluation report form for R1's guardianship, dated 8/12/2025, that was requested by a non-POA family member without the consent of V10, and the report was given to the non-POA family member.R1's EMR (Electronic Medical Record) showed that R1 is an [AGE] year-old male who was admitted to the facility on [DATE] for therapies, medical oversight, and assistance with activities of daily living. The SLUMS (St. Louis University Mental Status Examination), a comprehensive cognitive assessment dated [DATE], showed that R1 was cognitively impaired. R1's care plan, dated 06/27/2025, showed that R1's judgment was impaired. On 08/28/2025 at 11:30 AM, V2 (Social Services Director) stated that R1's non-POA family member provided her with a legal letterhead guardianship form on 08/05/2025 for the physician to complete the health information portion. V2 said she thought the Attorney would have been dealing with it and did not realize she needed to go through V10's (POA) authorization. V2 said she had given the form to V1(Administrator) to facilitate further. V2 said R1 never expressed to her about a change of guardianship, and she should have honored the wishes of R1 and notified V10 for the consent.On 08/28/2025 at 3:00 PM, V1 (Administrator) stated that V2 provided the form to him, and he facilitated its completion by V3 (R1's Physician). V1 stated the completed form was provided to the non-POA family member on 08/13/2025. V1 also said R1 did not express any desire to him for a change of guardianship, and he should have honored the wishes of V10 (POA), R1's previously designated POA.The facility's policy, titled Notification of Change of Condition, Discharge, and Transfer, dated 06/06/2025, states in part that The resident representative shall be notified of a change in resident rights under federal or state law or regulations .

Based on interview and record review, the facility failed to timely respond to a resident's Power of Attorney after being notified of a concern with a resident's damaged hearing aids. The facility failed to follow their grievance policy. This applies to 1 of 6 residents (R1) reviewed for grievances. The findings include: R1's EMR (Electronic Medical Record) showed R1 had hearing impairment and required the use of bilateral hearing aids. R1's MDS (Minimum Data Set) dated 8/17/2024 showed R1 had moderate cognitive impairment. On 10/15/2024 at 11:55 AM, V6 (Admissions Director) said she received an email on 7/30/2024 from an outside provider regarding V13's (R1's Power of Attorney/POA) concern of R1's missing hearing aids that were found damaged. V6 continued to say she then received another email on 8/03/2024 from V13 regarding her concern with R1's damaged hearing aids and a request to have the facility contact her. V6 said she informed the facility's management team, including V1 (Administrator), on 8/03/2024. On 10/16/2024 at 12:30 PM, V1 (Administrator) said during R1's last care plan meeting on 9/19/2024, V13 again expressed her concern regarding R1's damaged hearing aids. V1 said V13's concern had not been addressed prior because they were informed by an outside provider that R1 possibly damaged her hearing aids herself and then V13 had provided R1 with new hearing aids on 7/25/2024. V1 said the facility did not investigate or interview staff regarding R1's alleged hearing aid incident. The facility's email correspondence from V13 to the facility dated 8/03/2024, showed V13 notified V6 of her concern regarding R1's damaged hearing aids and requested for the facility to contact her. R1's Grievance Concern/Lost Item Form regarding R1's damaged hearing aids was filed on 9/19/2024, which showed a total of 51 days had passed from when the facility was initially notified of R1's concern. The facility's policy titled Grievance Program dated 5/15/2024, said Policy Statement To promote an environment and culture open to feedback positive and or negative from residents, family members, employees, physicians, and any other visitors. Definition: A grievance is a concern that cannot be resolved to the satisfaction of the person making the objection at the bedside and or immediately. Immediately: For the sake of this document, immediately is defined as within four or less hours. 2. Process .When there is a grievance it will be: i. Document on the facility Grievance Report. ii. Routed to the Grievance Officer. iii. Listed on the facility Grievance Tracking Log. iv. Discussed with appropriate individuals .as warranted. v. Investigated accordingly .

Based on observation, interview, and record review, the facility failed to follow their policy for hand hygiene during provisions of care with R59. The facility also failed to follow their water management plan for Legionella. This has the potential to affect all 121 residents residing in the facility. The findings include: 1. R59's EMR (Electronic Medical Record) showed R59 was admitted to the facility on [DATE], with diagnoses that included wedge compression fracture of thoracic vertebra (T7-T8), wedge compression of first lumbar vertebrae, dementia, and cerebrovascular disease. R59's MDS (Minimum Data Set) dated July 8, 2024, showed R59 had cognitive impairment and was dependent on staff for toileting hygiene. R59's care plan showed R59 had an indwelling urinary catheter for urinary retention and catheter care was to be provided during routine perineal care. On August 21, 2024, at 1:13 PM, V15 and V14 (Certified Nursing Assistants) used hand sanitizer, put on gown and gloves to entered R59's room. V16 explained to R59 what they were there to do. V15 went into the bathroom and grabbed an empty container used to empty R59's urinary drainage bag. V15 emptied the drainage bag and then with the same gloves started providing care to R59. V15 used a packet of disposable wipes. V15 wiped the right groin with a wipe from front to back, she disposed of that wipe and used a new wipe to clean the left groin from front to back and threw that wipe away. V15 used a new wipe and cleaned down the outer labia from front to back and a small amount bowel movement was noted on the wipe. V15 did not spread the labia and clean in between the area. R59's indwelling catheter tubing was secured to the leg and V15 wiped down the top part of the tubing that was visible and did not clean the tubing from insertion site moving down the tubing towards her knee cleaning all sides of the tube. While wearing the same gloves, V15 with the help of V14, turned R59 onto her right side facing away from V15 so she could clean the resident's backside. Once on her right side, it was noted that R59 had a small amount of stool in her incontinence brief. V15 used a new wipe and cleaned her buttock several times (with a new wipe each time) from front to back. Once R59 was clean, V15, still wearing the same gloves grabbed the protective ointment they were using on her skin and applied it to R59's buttocks. V14 had laid a new incontinence on the bed behind R59 and used the same gloves to position the incontinence brief under R59 so she could be turned onto her left side. V14 stopped V15 and told her You need to change your gloves. V15 removed her gloves and without using hand sanitizer or soap and water put on a new pair of gloves. R59's incontinence brief was secured, she was repositioned and covered back up. The facility provided their policy titled Hand Hygiene, with a revision date of June 3, 2024. The policy showed: Procedure: 1. Soap and water is required for hand hygiene when a. hands are visible soiled c. after potential exposure to body fluid h. after handling soiled or used linen, dressings, bedpans, catheters, and urinals. 2. Alcohol-based hand rub may be used for all other hand hygiene opportunities b. prior to performing a procedure such as blood glucose monitoring, invasive procedures or catheter care, c. when moving from a contaminated body site to a clean body site such as when changing a brief or wound dressing. On August 21, 2024, at 1:35 PM, V22 (Infection Preventionist Nurse) said that R59 was admitted to the facility with an indwelling urinary catheter in place. V22 said catheter care is to be done every shift. The staff need to gather their supplies and explain to resident what they will be doing. V22 said if the resident has had a bowel movement, the bowel movement should be cleaned up before doing the catheter care. After the bowel movement has been cleaned up, the staff need to remove gloves, perform hand hygiene, and put on new gloves. Staff then need to clean from the outer area moving inward and from front to back. In a female resident, the labia need to be spread and cleaned from front to back making sure to clean the tubing at the site of insertion moving away from resident and cleaning all sides of the tubing. V22 said anytime you touch something dirty when providing incontinence care, you need to remove gloves, do hand hygiene, and put on new gloves before touching anything clean. After cleaning up bowel movement, and before grabbing a container of ointment to be used on the bottom, dirty or used gloves need to be removed, hand hygiene done, and new gloves put on. This is to prevent cross contamination. 45303 2. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated August 19, 2024, at 11:00 AM, showed the facility's census was 121 residents. On August 21, 2024, at 12:53 PM, V23 (Maintenance Director) said for the water management plan, he does not keep logs of the temperature gauge check of the Hot Water Tank, mixing valve, or kitchen/laundry water temperatures. V23 continued to say he does not check the facility's water for chlorine levels. The facility does not have documentation to show the temperate gauges are checked daily or the facility's water is tested for chlorine levels. On August 20, 2024, V1 (Administrator) provided the facility's Water Management Plan dated February 21, 2024. The Plan continued to show the facility's Hazard Analysis of the facility's Cold-Water Distribution was Risk Basis: Medium Risk: Based on the potential variable chlorine present in the cold-water supply, the potential for microbiological growth in conjunction with the potential for water to be aerosolized present a medium risk at this processing step. In addition, distribution piping materials vary based on the various building ages and construction practices. Controls: 1. Systematic water flushing to move disinfectant through the piping system. 2. Emergency disinfection when indicated by added secondary disinfection to the cold-water system. 3. Temporary utilization of Point of Use Filters when indicated. 4. Identify, remove and/or mitigate potential dead-legs and/or cross connections that may exist within the distribution system. 5. Identify, remove and/or mitigate aerators/faucet flow restrictors that may exist within the distribution system. The Plan continued to show the Cold-Water Distribution's Critical Control Limit was Potable Water Oxidant: 'Free' Chlorine 0.2 to 4.0 ppm (Parts per Million); monitoring: Free Residual Oxidant Check (Chlorine; Frequency: weekly; Limit Deviation Corrective Action: Vacant resident care areas or any other area/room with plumbing fixtures are to be manually flushed for two minutes every day. The Plan continued to show the facility's Hazard Analysis of the facility's Hot Water Distribution was High Risk: The hot water system is extensive and complex. In addition, may tenants mange individual hot water heaters. There is a potential for 15-to-20-degree Fahrenheit temperature drops after the hot water supply leaved the Hot Water Heaters which can bring the water into prime temperature ranges for microbiological growth (105 degrees to 112 degrees Fahrenheit). Along with these favorable temperatures for microbiological growth, there is potential for free chlorine residuals to dissipate and leave the hot water system with low level of control. The factors for growth in conjunction with the potential for water to be aerosolized presents a high risk at this processing step. There is also potential for scalding should the Water Temperature not drop to 122 degrees Fahrenheit. In addition, distribution piping materials vary based on the various building ages and construction practices. Controls: 1. Temporary utilization of Point of Use filters when indicated. 2. Increase recirculation rate of hot water loops. 3. Identify, remove and/or mitigate potential dead-legs and/or cross connections that may exist within the distribution system. 4. Identify, remove and/or mitigate aerators/faucet flow restrictors that may exist within the distribution system. The Plan continued to show the Hot Water Distribution's Critical Control Limit was Potable Water Oxidant: 'Free' Chlorine 0.2 to 4.0 ppm (Parts per Million); monitoring: Free Residual Oxidant Check (Chlorine; Frequency: weekly; Limit Deviation Corrective Action: Vacant resident care areas or any other area/room with plumbing fixtures are to be manually flushed for two minutes every day. On August 21, 2024, at 2:33 PM, V1 (Administrator) said the facility has an updated water management plan. V1 continued to say the updated water management plan does not require chlorine testing. V1 said without chlorine testing, the facility does not know if the control limit of potable water oxidant chlorine in being met. V1 said in the new water management plan, the only monitoring for the Cold-Water Distribution and Hot Water Distribution is a yearly testing for Legionella in the facility's water. V1 continued to say there is no monitoring to mitigate the growth of Legionella in the Cold-Water Distribution or the Hot Water Distribution. V1 said the facility should have logs of daily temperature gauge checks. V1 said V23 checks the temperature gauges and V23 works Monday through Friday, so V1 is unsure who checks the temperature gauges on the weekends. The facility's policy titled Policy: Legionella Water Management Plan dated May 15, 2024, showed, Policy Statement: Our facility is committed to the prevention, detection and control of water-borne contaminants including Legionella. Procedure: 1. As part of the infection prevention and control program, our facility has a water management team . 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 4. The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) recommendations for developing a Legionella water management program. 5. The water management program includes the following elements: a. An interdisciplinary water management team; b. A detailed description and diagram of the water system in the facility, including the following: 1) Receiving; 2) Cold water distribution; 3) Heating; 4) Hot water distribution; and 5) waste. c. The identification of areas in the areas in the water system that could encourage the growth and spread of Legionella or other water borne bacteria, including: 1) Storage tanks; 2) Water heaters; 3) Filters; 4) Aerators; 5) Showerheads and hoses; 6) Misters, atomizers, air washers and humidifiers; 7) Hot tubs; 8) Fountains; and 9) Medical devices such as CPAP (Continuous Positive Airway Pressure) machines, hydrotherapy equipment; etc. d. The identification of situations that can lead to Legionella growth, such as: 1) Construction; 2) Water Main breaks; 3) Changes in municipal water quality; 4) The presence of biofilm, scale or sediment; 5) Water temperature fluctuations; 6) Water pressure changes; 7) Water stagnation and; 8) inadequate disinfection. e. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of where control measures are applied; h. A system to monitor control limits and the effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; and j. documentation of program .

Based on observation, interview and record review, the facility failed to serve mechanically ground coleslaw and pureed consistency pork riblet and bun to residents on diet order consistencies for the same. This applies to 11 of 11 residents (R5, R8, R12, R34, R41, R46, R62, R65,R71, R168, R270) reviewed for dining in the sample of 24. The findings include: 1. On August 19, 2024 at 12:11 PM, during tray line service, the pureed barbeque pork riblet was noted to be grainy with black substance in it. The pureed bread appeared granular. When taste tested , the pureed meat had hard pieces that were unable to be swallowed without being chewed. The black substance appeared to be burnt pieces from the pork riblet, as some of the riblets served for the regular consistency diet looked well done with charred ends. V17 (Food Service Manager) was notified that these items were not safe to serve. V19 (Cook) acknowledged that the black substances were from the charred pork riblets. Facility diet order sheet printed August 19, 2024 showed that R5, R46, R71, R168 and R270 were on Pureed diets. 2. On August 19, 2024 at 01:17 PM, during meal rounds, R12 was fed by V21 (Certified Nursing Assistant) in her room. R12's head of the bed was elevated between 45-75-degree angle. R12 received mechanical soft riblet on bun, French fries and a side of coleslaw which was shredded into varying lengths. R12's meal ticket showed ground creamy coleslaw. V21 was feeding R12 the ground riblet and the bun that was cut up into pieces and shredded coleslaw that were mixed together on the plate. R12 noted to start coughing profusely and V21 was prompted to call the nurse on duty. V20 (Licensed Practical Nurse) came to the room and R12 continued to cough and stated that she needs to go to the hospital. On prompting again, V20 and V21 raised the head of bed to 90-degree angle. State Personnel stepped out of the room and returned to find R12 not coughing anymore. V20 stated that R12 coughed out a piece of food which looked like the coleslaw. When asked, R12 stated that most of her teeth are missing. Other residents observed for dining that showed mechanical soft diets on tray cards and who received the shredded coleslaw were R8, R34, R41, R62 and R65. R8 was noted not to touch her coleslaw and stated, It's hard to chew and I am afraid of choking if I eat it. V17 and V19 verified that the coleslaw was shredded and not ground. Facility diet order sheet printed August 19, 2024 showed that R8, R12, R34, R41, R62 and R65 were on mechanical soft diets. On August 20, 2024 at 11:40 AM, V18 (Regional Director of Operations, Dietary) stated that the consistency for pureed foods should be like mashed potato. V18 stated that the facility should follow the spreadsheets and/or recipe for mechanical soft coleslaw. Facility Recipe for 'Creamy Coleslaw' included as follows: Shred or chop cabbage and measure and add coleslaw dressing appropriate for number of servings. For all textures modifications follow sheet for substitute. Facility Menu extension for August 19, 2024 showed that mechanical soft diet to receive ground creamy coleslaw. Facility undated policy titled Characteristics and Procedures for Consistency Modified Foods included as follows: Policy: Mechanical Soft, Dysphagia and Puree Diets will be prepared to the food characteristics listed below: Puree #440: Properly prepared pureed food has the following characteristics: 1. It is smooth without lumps, skin pieces, etc. 2. It holds its shape on a plate. 3. It is soft (pudding like consistency) 5. It does not need to be chewed. Ground: Mechanical Soft #435 (May also be called Soft, Bite Size). Properly prepared foods for residents requiring mechanical soft consistency have the following characteristics: 3. chewing is required before swallowing 4. Bite sized pieces no larger than 1/2 inch. Procedure: 2. Process in food processor until even course ground texture is achieved.

Based on interview and record review, the facility failed to follow their policy to offer pneumococcal vaccines in accordance with CDC (Centers for Disease Control and Prevention) guidelines. This applies to 5 of 5 residents (R1, R15, R21, R63, and R69) reviewed for immunizations in the sample of 24. The findings include: 1. R1's EMR (Electronic Medical Record) showed R1 was a [AGE] year-old resident admitted to the facility on [DATE]. The EMR continued to show multiple interventions including congestive heart failure, respiratory disorders, asthma, pulmonary hypertension, and hypertension. R1's Immunization Report dated August 21, 2024, at 2:36 PM, showed R1 received the PPSV23 (23-valent pneumococcal polysaccharide vaccine) on July 13, 2022. The facility does not have documentation to show R1 was offered another pneumococcal vaccine. 2. R15's EMR showed R15 was an [AGE] year-old resident admitted to the facility on [DATE]. The EMR continued to show R15 had multiple diagnoses including chronic kidney disease, acquired absence of kidney, hypertension, and hyperlipidemia. R15's Immunization Report dated August 21, 2024, at 2:34 PM, showed R15 received the PPSV23 on September 23, 2022. The facility does not have documentation to show R15 was offered another pneumococcal vaccine. 3. R21's EMR showed R21 was an [AGE] year-old resident admitted to the facility on [DATE]. The EMR continued to show R22 had multiple diagnoses including Parkinson's disease, chronic kidney disease, hypertension, heart failure, and atrial fibrillation. R21's Immunization Report dated August 21, 2024, at 2:31 PM, showed R21 received the PPSV23 on July 13, 2022. The facility does not have documentation to show R21 was offered another pneumococcal vaccine. 4. R63's EMR showed R63 was a [AGE] year-old resident admitted to the facility on [DATE]. The EMR continued to show R63 had multiple diagnoses including diastolic heart failure, atrial fibrillation, Parkinson's disease, and hypertension. R63's Immunization Report dated August 21, 2024, at 12:57 PM showed R63 had not received a pneumococcal vaccine. The report continued to show R63 required a pneumococcal vaccine. R63's Consent/Education Pneumonia assessment dated [DATE], at 2:40 PM, showed R63 consented to receive the pneumococcal vaccine. The facility does not have documentation to show R63 received a pneumococcal vaccine. On August 21, 2024, at 2:04 PM V22 said R63's EMR did not show any other consents for pneumococcal vaccine. 5. R69's EMR showed R69 was an [AGE] year-old resident admitted to the facility on [DATE]. The EMR continued to show R69 had multiple diagnoses including type 2 diabetes mellitus, chronic kidney disease, hyperlipidemia, and hypertension. R69's Immunization Report dated August 21, 2024, at 2:33 PM, showed R69 received the PPSV23 on July 13, 2022. The facility does not have documentation to show R69 was offered another pneumococcal vaccine. On August 21, 2024, at 2:04 PM, V22 (Infection Preventionist Nurse) said the facility follows the CDC's Pneumococcal Vaccine Timing for Adults. V22 continued to say R1, R15, R21, and R69 should have been offered another pneumococcal vaccine one year after the PPSV23, but none of them were offered another vaccine. On August 21, 2024, at 2:59 PM, V2 (Director of Nursing) said the facility follows CDC guidelines for pneumococcal vaccine timing. V2 continued to say R1, R15, R21, and R69 should have been offered another pneumococcal vaccine one year after receiving the PPSV23. The CDC's Pneumococcal Vaccine Timing for Adults showed adults [AGE] years and older with a prior vaccination of PPSV23 only should receive PCV20 (20-valent pneumococcal conjugate vaccine) or PCV15 (15-valent pneumococcal conjugate vaccine) after one year. The facility's policy titled Policy: Infection Control- Influenza and Pneumococcal Immunizations for Residents dated June 3, 2024, showed, Intent It is the policy of the facility to ensure that the resident receives Influenza and Pneumococcal immunizations, in accordance with State and Federal Regulations, and national guidelines. Procedure: .Pneumococcal Immunization . 5. Pneumococcal immunization will be offered in accordance with CDC immunization algorithm for PCV13 (13-valent pneumococcal conjugate vaccine) and PPSV23.

Based on interview and record review, the facility failed to ensure that residents were able to exercise their right to make a complaint without interference. The facility also failed to document resident's concerns and follow their grievance policy. This applies to 3 of 3 residents (R13, R26, and R76) reviewed for grievances in the sample of 24. The findings include: 1. R76 is a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that include Pulmonary Embolism, Chest Pain, and Sleep Apnea. R13 is a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that include Asthma, Diabetes insipidus, and Major Depressive Disorder. R26 is [AGE] year-old female admitted to the facility on [DATE], with diagnoses that include Osteoarthritis of knee, Type 2 Diabetes Mellitus, Major depressive disorder, and Dementia. All three women are cognitively intact as evidenced by their most recent Brief Interview for Mental Status (BIMS) score of 15/15. During the resident council meeting on August 20, 2024, at 1:32 PM, R76 stated she was afraid of retaliation by the staff for voicing complaints because a female staff member asked her not to complain to the surveyor the day before so the facility can pass the survey. R13 and R26 also confirmed that a female staff member also told them the same. On August 21, 2024 at 10:01 AM, R76 stated she was conflicted and concerned about retaliation when V2 (Director of Nursing) approached her and R24 and asked them not to complain about the facility to the state surveyor. R76 stated I felt intimidated. I thought that by me complaining and them not passing, whatever passing meant, then there would be changes and I would be out of a place to live. On August 21, 2024, at 10:18 AM, R26 stated that when she was told not to complain about the bad stuff at the facility by V2, she felt like they were watching her more closely and it made her feel uncomfortable. On August 21, 2024, at 11:22 AM, R13 stated when V2 told her not to complain to the state surveyors, it felt [NAME] like they wanted her to lie to make them look good. R13 stated she fears retaliation and she doesn't want any trouble. On August 21, 2024, at 2:37 PM, V25 (Social Service Director/Grievance Coordinator) stated that residents have a right to make a grievance, and they should be able to make a grievance without fear of retaliation. V25 stated residents should be able to voice concerns and grievances. This is their home. V25 stated staff should not ask residents not to complain. The facility's Resident Rights policy dated January 17, 2024 showed the following: 7. The facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. 48308 2. August 21, 2024, at 9:50 AM, R26 stated she would like resolution to her concern of having missing dentures. R26 stated she had dentures when she was admitted and around the beginning of the year, 2024, R26 stated the dentures were missing. R26 stated one morning she left her dentures cleaning in a cup on the sink in her bathroom and went to eat breakfast. R26 stated when she returned to her room after breakfast, her denture cup was gone, and she was unable to find her denture cup, but her room had been cleaned. R26 stated she reported the missing dentures to nursing staff but is unable to remember the names of the staff she told. R26's MDS dated [DATE] showed R26 was cognitively intact. R26's progress note dated April 27, 2024, showed V30 (Registered Nurse) documented R26's upper denture was missing. Review of the facility's grievance log from April 2024 through August 19, 2024, showed there was no grievance form on R26's behalf for missing dentures. On August 21, 2024, at 1:30 PM, V1 (Administrator) stated the Grievances are handled through social services first and the Social Services Director is the grievance coordinator. V1 stated grievance forms are completed for lost items if it can't be addressed immediately, staff will document on the grievance form. V1 stated when R26 raised the concern of the missing denture, staff working with R26 should have known to complete a grievance form as the staff on that unit are staff that have worked in the facility for a long time. On August 21, 2024, at 1:55 PM, V25 (Social Services Director/Grievance Coordinator) stated she is the Grievance Coordinator and if any staff become aware of a resident's missing item, the staff should complete a grievance form. V25 stated she was unaware of R26's missing dentures until the surveyor brought the concern to V1 (Administrators) attention on August 20, 2024. The Facility's grievance policy titled Grievance Program dated May 15, 2024, showed Policy .2. Process: a. grievances are formal written or verbal complaints made to the facility when prompt or bedside resolution to the satisfaction of the person making the objection was not possible. Grievances can also be made anonymously. When there is a grievance, it will be: .i. Documented on the facility Grievance Report. ii. Routed to the Grievance Officer. iii. Listed on the facility Grievance Log .v. Investigated accordingly .viii. Discussed through meetings which may be in person and/or telephone conferences .5. When a grievance is received by a staff member, they will notify their supervisor and forward the completed report to the Grievance Official.6. When a grievance is received orally, and the resident does not choose to complete a written report; then the staff member receiving the grievance will complete the report and forward it to the Grievance Official.

Based on interview and record review, the facility failed to conduct a screening for Preadmission Screening and Resident Review (PASRR) on admission to facility for a resident with mental disorder. This applies to 1 of 4 residents (R21) reviewed for PASRR in the sample of 24. The findings include: R21's face sheet included diagnoses of schizophrenia, unspecified, anxiety disorder, unspecified major depressive disorder, recurrent, moderate Parkinson's disease without dyskinesia, without mention of fluctuations. R21's quarterly MDS (Minimum Data Set) dated July 5, 2024 showed that R21 is moderately impaired in cognition. Notice of PASRR Level I Screen Outcome dated July 25, 2022 included as follows: You are receiving this notification because you received a Preadmission Screening and Resident Review (PASRR) screening. To learn more, read the additional PASRR information that came with this letter. PASRR OUTCOME Explanation: PASRR request has been canceled. On behalf of the (state agency and state agency's contracted provider) has reviewed the Preadmission Screening and Resident Review (PASRR) Level 1 screen that was completed for you by your health care professional. You received this screen because you are seeking to enter or continue to stay in a nursing facility that receives Medicaid funding. PASRR Level I screen are required by Federal law, 42 U.S.C & 1396r(e)(7). Your Level I screen has been canceled by (state agency's contracted provider) . The screen was canceled because your health care professional did not complete either the Level 1 screening form and/or submit requested documentation within the required timeframe. If you want to go to a nursing facility, the nursing facility must submit a completed Level I screening to (state agency's contracted provider). On August 20, 2024 at 9:10 AM, V3 (Admissions Director) stated that R21 has been at the facility since 2021. V3 stated that on admission, all residents get a screening for PASRR and DON (Determination of need) and 90% of the time it is done at the hospital. V3 stated that the facility does check to ensure that everyone has been screened for PASRR, but she does not know the frequency of when it is done. V3 stated that she reached out to (state agency's contracted provider) on August 19, 2024 when PASRR level I for R21 was requested for during survey and they stated that a screening for the same have to be requested for again. Facility Policy titled Admission Criteria (dated November 18, 2021) included as follows: Policy Statement: Our facility admits only residents whose medical and nursing care can be met. Procedure: 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per Medicaid Preadmission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID or RD, he or she is referred to the state PASARR representative for Level II (evaluation and determination) screening process. 1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD. 2) The social worker is responsible for making referrals to the appropriate state-designated authority.

Based on observation, interview, and record review, the facility failed to ensure that a resident's gauze central line dressing was changed every 48 hours for prevention of infection. This applies to 1 of 1 resident (R113) reviewed for intravenous therapy in the sample of 24. The findings include: R113 is a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that include local infection of the skin and subcutaneous tissue, Sepsis, and Peritoneal Abscess. R113 had an order dated August 1, 2024, to change transparent dressing using central line kit every week. Apply (brand name specialty dressing) on site, secure with (brand name stabilization device), and change cap. On August 19, 2024, at 10:52 AM, R113's right arm central line dressing was dated August 11, 2024, in red marker. The dressing was dirty and covered with a dirty sleeve. There is a piece of gauze about two inches squared around the insertion site of the central line. On top of the gauze was a transparent semipermeable membrane. R113 stated his central line dressing had not been changed recently. On August 19, 2024, at 1:28 PM, R113 stated that the nurse just changed his central line dressing. R113 central line dressing is now dated August 19, 2024 and gauze is mostly covering the insertion site with a transparent semipermeable dressing over it. On August 21, 2024, at 1:52 PM, V2 (Director of Nursing) stated their practice is to use the central line kit to change central line dressing and they place the gauze that comes in the kit underneath the transparent dressing. V2 stated that there is no (brand name specialty dressing) in the kit. V2 stated their practice is to change the central line dressing every seven days and as needed. V2 stated they change the dressing to prevent infection. V2 stated she was not aware of the facility's policy to change dressing every 48 hours when gauze is used underneath a transparent membrane. R113's electronic medication administration record document central line dressing was not being changed every 48 hours. The facility's PICC line or Midline Catheter Dressing Change procedure policy shows the following: Procedure: 14. Note: When a transparent semipermeable membrane is applied over gauze, it is considered a gauze dressing in accordance with the intravenous Nursing Society Standards and must be changed every 48 hours.

Based on observation, interview, and record review the facility failed to store insulin and house stock medication in accordance with their policy. This applies to 1 of 24 residents (R10) reviewed for medication storage in a sample of 24. The findings include: On August 20, 2024, at 10:05 AM, the XXX Hall East medication cart was reviewed with V31 (LPN/Licensed Practical Nurse). R10's Basaglar insulin pen was unopened, stored in the drawer of the medication cart and the sticker on the package showed refrigerate until opened. The pharmacy filled date on the label was August 10, 2024. V31 stated that the insulin pen should be in the refrigerator because it was not opened. R10's physician order summary showed R10 had an active order for Basaglar insulin 60 units at bedtime daily. On August 20, 2024, at 10:30 AM, the East Medication Storage room was checked with V30 (Nurse Supervisor). In the cabinet where the house stock medications are stored, there were zinc sulfate capsules 220 mg, with expiration date of October 2023, and 3 bottles of multivitamins, 100 tablets each with an expiration date of July 2024. There was no other stock of zinc sulfate capsules or multi vitamin tablets in the medication cabinet. The facility policy titled Storage of Medications dated, September of 2018, showed II. Temperature .4. Medications requiring refrigeration are kept in a refrigerator at temperature between 36F (Fahrenheit) and 46F and III. Expiration Dating .8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining.

Based on observation, interview, and record review the facility failed to have the required policy regarding missing or lost dentures and financial responsibility, in accordance with 483.55(b)(4) and failed to assist a resident in need of dentures, to obtain them. This applies to 1 of 1 resident (R26) reviewed for dental services in the sample of 24. The Findings include: R26's EMR (Electronic Medical Record) showed R26 was admitted to the facility on [DATE], with multiple diagnoses including, Diabetes type 2, bilateral primary osteoarthritis of both knees, unspecified protein-calorie malnutrition, chronic obstructive pulmonary disease, and chronic diastolic congestive heart failure. R26's payor status showed Medicaid pending. R26's MDS (Minimum Data Set) dated July 27, 2024, showed R26 to be cognitively intact, and required staff assistance with ADLs (Activities of Daily Living) including Supervision or touching assistance with eating, oral hygiene and upper body dressing, partial/moderate assistance with bed mobility and toilet transfer, and substantial assistance with lower body dressing and sit to stand, and dependent on staff with toilet hygiene, bathing and putting on footwear. R26's care plan initiated on August 8, 2024, showed personal hygiene/oral care the resident is able to cleanse her dentures with set up assistance from staff. R26's profile picture image showed she had teeth. On August 19, 2024, at 2:02 PM, R26 was sitting in her room in her wheelchair, she had one bottom tooth in her mouth, when asked if she received dental services, R26 responded she had been missing her dentures since the beginning of 2024. R26 stated she doesn't remember the exact date, but she remembered leaving her dentures in the soaking solution in a cup on the bathroom sink and when she returned after eating breakfast, the cup and the dentures were missing. R26 stated since breakfast food is usually soft, she didn't need the dentures in to eat breakfast and her room had been cleaned while she was at breakfast but could no longer find her denture cup in her room and thought the cup was knocked off the sink and into the garbage during room cleaning. R26 stated she told her assigned nursing staff at the time but does not remember which staff she told and stated she had been to the dentist twice since that time but has no idea where the replacement dentures are now. A review of the facility's grievance/concern forms from April 2024 through August 19, 2024, showed there was no grievance made on behalf of R26 concern regarding missing dentures. R26's progress note dated April 27, 2024; quarterly review written by V30 (Registered Nurse) showed R26's dentures were missing. R26's dental visit notes dated April 30, 2024, showed the treatment plan to be upper denture/lower peep denture. R26's dental visit notes dated June 8, 2024, showed the treatment plan to be upper denture, extract root tip #29, lower peep hole denture, will check coverage. No symptomatic teeth. On August 21, 2024, at 2:11 PM, V24 (Customer service for the dental office) stated when looking through R26's notes found that in response to R26's dental visit on April 30, 2024, the office sent an email to the facility's business office manager on May 1, 2024. V24 stated the email showed that the dental office described the costs for replacing R26's dentures as being $300 each for the upper and lower denture or a total cost of $600. V24 stated R26's notes showed there was no response from the facility to the May 1, 2024, email. V24 stated the notes showed the next contact from the facility regarding R26 was on August 20, 2024, requesting information regarding R26's denture replacement status. V24 stated since the financial arrangement for the cost of R26's dentures had not been completed, R26's denture replacements had not been started by the dental office. On August 21, 2024, at 1:30 PM, V1 (Administrator) stated when R26 raised the concern of the missing denture, staff working with R26 should have known to complete a grievance form as the staff on that unit are staff that have worked in the facility for a long time. V1 also stated that the dental visits are arranged by V25 (Social Services Director). On August 21, 2024, at 1:55 PM, V25 stated she does arrange for dental appointments and receives the dental visit notes from the dental office. V25 stated when she receives the dental visit notes she forwards the email to the health information staff who uploads the visit notes into the EMR of each resident. V25 was asked who in the facility reads and follows through with the treatment plans identified on the dental visit notes and V25 stated maybe nursing staff, if a preparation for a tooth extraction was ordered, but otherwise was unsure who read the notes and who arranged for follow up. The facility did not provide a policy regarding lost/missing dentures and determining financial responsibility for replacement. The facility policy titled Dental Services dated June 3, 2024, showed 2 c. Will promptly, at least within 3 days, refer residents with lost or damaged dentures for dental services .3. The facility will assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plans.

Based on observation, interview and record review, the facility failed to employ and schedule a sufficient number of competent food service staff to safely and adequately serve resident meals. This has the potential to affect all 119 residents receiving oral diets in the facility. The findings include: Facility Census and Condition of Residents, dated 9/5/23, show the facility census was 122. Diet Type Report, dated 9/7/23, shows three residents had physician orders for NPO (nothing by mouth). 1. On 9/5/23 at 10:00 AM, the only food service staff working in the kitchen were V3 (Dietary Aide), V4 (Dietary Aide/Cook), and V5 (Cook). V3 stated the day prior the food service had only two employees in the morning working to prepare and serve breakfast to the facility residents. V3 stated the food service often only has a total of three people working in the morning in the food service however the operation requires a total of four staff to be able to effectively prepare and serve food to the residents. 2. On 9/5/23 during observations in the kitchen, several sanitation concerns were identified including: - There were 4 slabs of cooked ribs uncovered sitting on a sheet pan. The sheet pan of ribs was placed in a rolling rack and above the cooked ribs was a sheet pan of raw ground beef thawing. - A green cutting board was soaking in the third compartment of the three-compartment sink. V5 (Cook) stated the third compartment contained chemical sanitizing solution. V5 tested the chemical sanitizing solution concentration which measured 100 ppm (parts per million). V5 stated the concentration should measure 200 ppm. - At 10:20 AM, six frozen packages of diced beef were sitting on a sheet pan thawing on counter. V5 stated the packages of meat arrived in a delivery earlier that morning and the product needed to be thawed for 9/7/23 dinner service. V5 stated the packages of diced beef had been sitting on the counter less than one hour and stated he did not have time to put them in the cooler when he unpacked them. V5 then took the tray of diced beef to the walk-in cooler. At 10:33 AM on the wheeled rack in the walk-in cooler, the tray of diced beef was stored under a tray of uncooked chicken. The tray of uncooked chicken had uncooked juice in the sheet pan. Eight packages of thawing ground beef were also stored on the wheeled rack above the packages of diced beef. - V5 filled a bucket with chemical sanitizing solution from the three-compartment sink. V5 placed the sanitizing bucket at the cook station. V5 measured the concentration of the chemical sanitizer which measured only 100 ppm. - During lunch service, V5 twice removed his gloves, touched garbage lid that was on the garbage to dispose of the gloves, and then performed other food service duties without washing his hands. - There was no hot water available at the hand washing sinks located in dish room and next to cook's preparation area. - The ice scoop was stored in a clear ice scoop holder mounted to wall. There was dried, brown debris inside bottom of ice holder and the bottom of the ice scoop edge was touching bottom of scoop holder and brown debris. - There were two green buckets on the floor on the dirty side of three compartment sink which were filled with damp, soiled rags. There were also several damp towels and rags were stored behind the handwashing sink handles in dish room. - There was an open package of cookies in storage room sitting on top of food boxes with unwrapped cookies sitting on the boxes and cookies on the floor - A mop with a wet mop head was stored on the floor to left of the cook area handwashing sink. There was also a wet mop head with no handle attached on floor under stove in cook's area. There were no mop buckets located in the area. - There was food debris build up below counter mixer and a smear of red/brown dried food on the clean plate warmer near the tray line. 3. On 9/07/23 at 10:02 AM, V20 (Dietitian) stated her duties at the facility included performing monthly sanitation audits of the facility food service. V20 stated she was unable to perform sanitation audits at times because of a lack of staff in the kitchen causing the Dietary Manager to be unavailable to assist with the audit. V20 stated she was aware that the staffing in the food service department was inconsistent. V20 stated she was able to perform a sanitation audit on 8/22/23 and identified several sanitation concerns in the kitchen. 4. On 9/5/23 during lunch service, the food service staff failed to serve warm food at a palatable temperature to residents. On 9/5/23 during initial tour, several facility residents expressed concerns regarding being served facility food which was cold and unpalatable. Residents also expressed concerns regarding not receiving menu items as planned on the facility menu. 5. On 9/5/23 at 11:00 AM during observation of pureed pork preparation for lunch, V5 (Cook) prepared pureed pork roast for six pureed residents with pureed diet orders. The pureed pork roast tasted dry and had lumps of unpureed pork in the mixture. 6. On 9/5/23 during lunch service, the food service staff failed to serve four residents double protein servings and supplements per physician orders. 7. On 9/5/23 during lunch service, six residents receiving pureed diets were served an inadequate amount of pureed pork as their lunch entrees. 8. On 9/5/23 during lunch service, the food service staff failed to provide two residents adaptive equipment per physician orders during lunch service. 9. On 9/5/23 during Resident Council meeting, the facility residents expressed concerns that the facility failed to serve palatable meals at acceptable temperatures. The residents also stated the facility failed to serve food items at meals as per the planned facility menu. 10. Review of facility Resident Council Meetings and Grievances showed residents expressed concerns regarding unpalatable food temperatures and residents not receiving food items as planned on the facility menus. Facility Worked Schedule, dated 8/20/23 to 9/2/23, shows the facility had only three or less dietary staff working on the AM shift (at least until 8 AM) on seven of the fourteen days reviewed. On four of those seven days there were only two dietary staff working in the kitchen from 6:00 AM to 8:00 AM. On 9/07/23 at 10:41 AM, V1 (Administrator) stated only three total kitchen staff working from 6:00 AM to 8:00 AM were insufficient to meet the dietary needs of the residents in the facility. V1 stated the kitchen should have no less than four staff (three dietary aides and one cook) working during the entire AM shift from 6:00 AM to 2:30 PM for safe and effective food service to residents.

Based on observation, interview and record review, the facility failed to serve the facility menus as planned. This has the potential to affect all 119 residents receiving oral diets in the facility. The findings include: Facility Census and Condition of Residents, dated 9/5/23, show the facility census was 122. Diet Type Report, dated 9/7/23, shows three residents had physician orders for NPO (nothing by mouth). 1. Tray tickets, dated Week 3 Tuesday Lunch, show R10, R104, R5, R82, R15, R34 all received pureed diets. Facility Therapeutic Spread Report 2023 Winter Menu, dated 1/20/23, shows one serving of pureed pork roast was to be served with a #10 scoop (2.75 ounces volume) to equal one regular 3-ounce weight portion of pork roast. On 9/5/23 at 1:00 PM at the conclusion of lunch service, V6 (Corporate Food Service Manager) weighed one serving of pureed of pork as served to pureed diets during the lunch service. The serving of pureed pork weighed a total of only 1.75 ounces. V6 stated the pureed serving should contain no less than three ounces weight of pureed pork not including any liquid that was added during the pureed process. V6 stated the food service staff mistakenly utilized a #16 scoop (2 ounces volume) instead of the #12 scoop (2.75 ounces volume) as planned on the facility menu. 2. On 9/05/23 at 1:31 PM during Resident Council meeting, R84 stated some residents get the menu items and some do not during a given meal. R88 and R31 both stated the planned general menu items are often not served at the facility at meals and R88 stated the foods listed on her meal ticket are often not served on her plate during meals. R84 stated the facility often did not serve the planned menu items because the items are missing, they do not have enough of the product, or they did not make enough for all the residents. R7 stated she was usually served dinner around 6:30 PM and they are often missing out on the planned menu items because the food service runs out of the food products. 3. On 9/5/23 at 10:37 AM, R274 stated he was not receiving food items at meals that were to be served per the facility menu. On 9/5/23 at 11:19 AM, R107 stated he was not getting served items that were on the menu. 4. Resident Council Meeting Minutes- Dietary Concerns, dated 7/27/23, shows, Portions are irregular: some get too little, and others get too much When residents make changes to their tickets, kitchen staff however still give the resident what is being served. Resident Council Meeting Minutes - Dietary Concerns, dated 5/4/23, shows Kitchen staff have been missing things on the tray that is on the ticket. Standards and Guidelines Menus and Nutritional Adequacy, dated 8/24/17, shows, 2. Menus are followed daily . Extensions are written for all diets, specifying the serving size and consistency of the item for each diet. Standards and Guidelines Diet Meets Needs of Each Resident, issued 8/24/17, shows the purpose of food and nutrition services (FNS) department is to provide high quality, nutritious, palatable, and attractive meals in a safe, sanitary manner. Food will be prepared in a form to accommodate resident allergies, intolerances, religious and cultural preferences, based on reasonable efforts. Therapeutic diets will be served as prescribed by the attending physicians or their designee . 1. To provide food that is prepared by methods that conserve nutritive value, flavor, and appearance. 2. To provide food and drink that is nutritious, palatable, attractive and at a safe and appetizing temperature to meet individual needs. 3. To promote optimal nutritional status of each resident through medial nutrition therapy in accordance with written orders for nutrition care and consistent with each individual's physical, cultural, and religious needs and personal preferences .

Based on observations, interviews, and record reviews, the facility failed to serve palatable meals to facility residents. This has the potential to affect all 119 residents receiving oral diets in the facility. The findings include: Facility Census and Condition of Residents, dated 9/5/23, show the facility census was 122. Diet Type Report, dated 9/7/23, shows three residents had physician orders for NPO (nothing by mouth). 1. On 9/5/23 at 12:02 PM with V6 (Corporate Food Service Manager) in the kitchen during lunch service, the food service staff prepared eight full plates of lunch and left them uncovered sitting on the shelf waiting for lunch servers to arrive to serve the plates to residents. At 12:04 PM, V7 (Food Service Aid) prepared three more plates and placed them on the shelf without lids next to the first eight pre-made plates. At 12:05 PM, V7 requested more tickets and began plating more plates of food and placed them on the shelf with no lids. On 9/5/23 at 12:10 PM, one of the plates sitting on the shelf was removed as a test tray. The foods were tasted, and the vegetables and noodles tasted room temperature. V6 checked the temperature of the plates in the clean plate warmer and stated the plates in the left side of the unit were not hot enough. V7 stated the plates that were in the warmer were just finished being washed in the dish room and did not have time to heat up yet. Facility staff then began passing the plates which had been sitting uncovered to the residents in the dining room without lids on the plates. 2. On 9/5/23 between 10:02 AM and 10:27 AM, the following residents stated they received cold food served at the facility: R15, R58, R71, R98, R106, R274 and R275. On 9/5/23 between 12:03 PM-12:27 PM, R49 stated the food served at the facility was served cold, R67 stated the food was no good and tasted terrible and R45 stated the food tasted terrible most of the time. 3. On 9/05/23 at 1:31 PM during the Resident Council meeting, R88 stated the facility food is sometimes very unappetizing and her eggs were usually served cold and watery. R33 stated the recently served macaroni was unpalatable and her oatmeal and eggs were served cold every day. R31 stated her eggs were cold at breakfast that morning. R84 stated her ice cream was melted and like soup when she received it on her trays. R84, R88, R31, R33, and R51 all stated the residents who were served first during meal services received hot foods, but the 500 hall residents were served last, and the trays often sat waiting to be passed which causes food to become cold. 4. On 9/07/23 at 10:02 AM, V20 (Dietitian) stated she was aware of reports of cold food temperatures at the facility and discussed the concerns with V1 (Administrator). V20 stated the food service staff were not using the plate warmer during meal service and that was the cause of the cold temperatures. V20 stated temperatures of the food on the steam table were meeting requirements, but the food service it took time and the foods lost temperature in the process. 5. Grievance, dated 3/14/23 by R320, shows a concern regarding the food being consistently served cold. 6. Resident Council Meeting Minutes- Dietary Concerns, dated 7/27/23, shows, Kitchen staff should work on their presentation. Resident Council Meeting minutes, dated 5/25/23, show, Toast is soggy when put on top of eggs, can there be an alternative? Standards and Guidelines Diet Meets Needs of Each Resident, issued 8/24/17, shows, The purpose of food and nutrition services (FNS) department is to provide high quality, nutritious, palatable and attractive meals in a safe, sanitary manner. Food will be prepared in a form to accommodate resident allergies, intolerance's, religious and cultural preferences, based on reasonable efforts. Therapeutic diets will be served as prescribed by the attending physicians or their designee . 1. To provide food that is prepared by methods that conserve nutritive value, flavor, and appearance. 2. To provide food and drink that is nutritious, palatable, attractive and at a safe and appetizing temperature to meet individual needs. 3. To promote optimal nutritional status of each resident through medial nutrition therapy in accordance with written orders for nutrition care and consistent with each individual's physical, cultural, and religious needs and personal preferences

Based on observation, interview and record review, the facility failed to ensure the facility food preparation and storage was performed in a sanitary manner and under sanitary conditions. This has the potential to affect all 119 residents receiving oral diets in the facility. The findings include: Facility Census and Condition of Residents, dated 9/5/23, show the facility census was 122. Diet Type Report, dated 9/7/23, shows three residents had physician orders for NPO (nothing by mouth). 1. On 9/05/23 at 10:00 AM the following observations were made during tour of the kitchen: - There were 4 slabs of cooked ribs uncovered sitting on a sheet pan. The sheet pan of ribs was placed in a rolling rack and above the cooked ribs was a sheet pan of raw ground beef thawing. - A green cutting board was soaking in the third compartment of the three-compartment sink. V5 (Cook) stated the third compartment contained chemical sanitizing solution. V5 tested the chemical sanitizing solution concentration which measured 100 ppm (parts per million). V5 stated the concentration should measure 200 ppm. - There was no hot water available at the hand washing sinks located in dish room and next to cook's preparation area. - The ice scoop was stored in a clear ice scoop holder mounted to wall. There was dried, brown debris inside bottom of ice holder and the bottom of the ice scoop edge was touching bottom of scoop holder and brown debris. - There were two green buckets on the floor on the dirty side of three compartment sink which were filled with damp, soiled rags. There were also several damp towels and rags were stored behind the handwashing sink handles in dish room. - There was an open package of cookies in storage room sitting on top of food boxes with unwrapped cookies sitting on the boxes and cookies on the floor. - A mop with a wet mop head was stored on the floor to left of the cook area handwashing sink. There was also a wet mop head with no handle attached on floor under stove in cook's area. There were no mop buckets located in the area. - There was food debris build up below counter mixer and a smear of red/brown dried food on the clean plate warmer near the tray line. 2. On 9/5/23 at 10:20 AM, there were six frozen packages of diced beef sitting on a sheet pan thawing on counter. V5 stated the packages of meat arrived in a delivery earlier that morning and the product needed to be thawed for 9/7/23 dinner service. V5 stated the packages of diced beef had been sitting on the counter less than one hour and stated he did not have time to put them in the cooler when he unpacked them. V5 then took the tray of diced beef to the walk-in cooler. On 9/5/23 at 10:33 AM on the wheeled rack in the walk-in cooler, the tray of diced beef were stored under a tray of uncooked chicken. The tray of uncooked chicken had uncooked juice in the sheet pan. Eight packages of thawing ground beef were also stored on the wheeled rack above the packages of diced beef. 3. On 9/5/23 at 10:24 AM, V5 filled a bucket with chemical sanitizing solution from the three-compartment sink. V5 placed the sanitizing bucket at the cook station. V5 measured the concentration of the chemical sanitizer which measured only 100 ppm. 4. On 9/5/23 at 12:20 PM, V5 removed his gloves, touched garbage lid that was on the garbage to dispose of the gloves, and then walked to dry storage without washing his hands. V5 then returned to the lunch tray line and grabbed a soup bowel without washing hands. At 12:27 PM, V5 again removed his gloves, touched a garbage lid when disposing the gloves, walked to dry storage to get tomato juice, and returned to tray line with tomato juice without washing hands. 5. On 9/07/23 at 10:02 AM, V20 (Dietitian) stated she performed a sanitation once a month. V20 stated she was unable to perform some sanitation audits due to lack of staff in the kitchen. V20 stated on 8/22/23 she did have sanitation concerns during her sanitation audits and forwarded a copy of the sanitation audits to the dietary manger. On 9/06/23 at 9:53 AM, V1 stated the facility purchased a new chemical sanitizer and the sanitizing pump had not been correctly calibrated to the new chemical which caused the chemical sanitizing concentration to be too low. Chemical Sanitizing Solution product information showed the quaternary ammonium solution concentration was to measure 200 ppm. Facility Standards and Guidelines, revised 3/23/11, shows, FNS (Food and Nutrition Services) staff will demonstrate no cross contamination at mealtimes 1. Gloves should never be used in place of hand washing. Hands must be washed before putting on gloves and when changing to a new pair 5. Hands must be washed between any contaminations. Gloves must be changed as often as soon as they become soiled or torn, and before beginning a different task. Facility Standards and Guidelines, revised 3/23/11, shows, 3. Fill third sink with hot water . or a chemical sanitizing solution used according to manufacturer's instructions. Dispense quaternary sanitizer according to manufacturer directions. Vendor will provide a dispenser that automatically measures the correct amount of sanitizer. Test the sanitizer strength using the quaternary test strips Hold the strip under the water for at least 10 seconds. Sanitizer strength should be approximately 200 ppm, adjust the amount of water or sanitizer accordingly until the correct strength is obtained Facility Standards and Guidelines Cleaning and Sanitizing of Food and Non-Food Contact Surfaces, revised 4/17/09, shows, Food contact surfaces are properly cleaned and sanitized before and after use, in order to help prevent foodborne illness and minimize bacterial growth 3. Fill second bucket with cool to lukewarm water Add chlorine bleach sanitizer to achieve a concentration of 100 parts per million. Use chlorine sanitizer test strips to verify the correct concentration. Submerge clean cloth in sanitizer solution and wipe down the freshly cleaned surface. 4. Cloths used for cleaning and sanitizing food contact surfaces are laundered daily. Buckets of soap and sanitizer solutions are changed/refreshed at least 4 times a day 5. Non-food contact surfaces are washed with soapy water per frequency identified on the facility cleaning schedule - or as visually necessary. These are then wiped down with sanitizer solution (bleach at 100 parts per million). Standards and Guidelines Thawing Foods, revised 3/2/21, shows, 1. Food and Nutrition staff will thaw frozen food items using one of the following recommended methods to avoid rapid bacterial proliferation: a. In the refrigerator, in a drip-proof container and in a manner that prevents cross contamination b. Completely submerge the item under cold water . that is running fast enough to agitate and float off loose ice particles, c. In a microwave . d. As part of a continuous cooking process. Standards and Guidelines Refrigerated Storage, dated 3/2/21, shows, FNS staff will store raw food (e.g., beef, fish, lamb, pork, and poultry) separate from each and on shelves below fruits, vegetables, or other ready-to-eat foods to prevent meat juices from dripping onto these foods. Standards and Guidelines Ice Chests, revised 3/27/21, shows The tray and the scoop should be run through a dishwasher or sterilized daily. Standards and Guidelines Environmental Services Cleaning Guidelines, revised 5/16/21, shows Mop head Mop head should be laundered after each use and allowed to dry before re-use.

Based on interview and record review the facility failed to identify and implement interventions for performance improvement regarding kitchen sanitation and ADLs (Activities of Daily Living) care. This applies to all 122 residents who reside in the facility. The findings include: On 9/7/23 at 11:35 AM, V1 (Administrator) identified rehospitalization as the only PIP (Performance Improvement Plan) that the facility is currently working on. V1 further stated that during the facility's mock survey in June 2023, by the corporate staff, concerns with sanitation, staffing and following the menus were identified in the kitchen. V1 stated there was no PIP developed nor a plan developed to improve conditions in the kitchen. V1 further stated the Quality Assurance program is not effective and could be improved. On 9/7/23 at 12:00 PM, V21 (Nurse Consultant) stated the facility has one PIP currently for rehospitalization . V21 stated when making rounds in the facility, V21 has identified ADL concerns, specifically grooming, and stated there is no PIP or working plan to address this concern. V21 stated the facility did have a mock survey completed by the corporate staff and concerns in the kitchen were identified. V21 further stated she has attended the facility's QA (Quality Assurance) committee meeting since March of 2023. V21 also stated that during the QA meeting following the mock survey on 7/24/23, neither the concerns in the kitchen nor the concerns with ADLs were discussed. On 9/7/23 at 10:02 AM, V20 (Registered Dietician) stated she performed the most recent sanitation audit in the kitchen was on 8/22/23, and identified problems with food labeling, cleaning, and sanitary storage of silverware. V20 stated she had missed the opportunity to do more sanitation audits in the kitchen previously due to lack of staff in the kitchen. V20 also stated she had relayed concerns from the residents regarding cold food to V1. Throughout this survey from 9/5/23, through 9/7/23, concerns with sanitation, staffing, and following the menus were identified in the kitchen as well as concerns with ADLs (Activities of Daily Living). The facility's policy Standards and Guidelines: Quality Assurance and Performance Improvement (QAPI) program. dated 11/28/19, showed 4. The facility shall design its QAPI program to be ongoing, comprehensive, and to address the range of care and services provided by the facility; address all systems of care and management practices.

Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and incontinence care. This applies to 9 of 9 residents (R31, R33, R39, R48, R49, R51, R84, R88 and R90) reviewed for ADLs (activities of daily living) in the sample of 24. The findings include: 1. R39 had multiple diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, based on the face sheet. R39's quarterly MDS (minimum data set) dated 8/22/23 showed that the resident was severely impaired with cognition and required extensive assistance from the staff with personal hygiene. On 9/5/23 at 11:26 AM, R39 was sitting in her wheelchair alert and verbally responsive. R39 had accumulation of facial hair above her lips. R39 wanted the staff to shave her. R39 stated, I do not want any of these, referring to the facial hair above her lips. V10 (Licensed Practical Nurse/LPN) was made aware and confirmed the facial hair above R39's lips. R39's active care plan last revised on 9/1/23 showed that the resident had an ADL self-care performance deficit. The same care plan showed multiple interventions including extensive assistance during personal hygiene. 2. R48 had multiple diagnoses which included Parkinson's disease, Alzheimer's disease, dementia without behavioral disturbance and generalized muscle weakness, based on the face sheet. R48's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition and required extensive assistance from the staff with personal hygiene. On 9/5/23 at 10:31 AM, R48 was sitting in his wheelchair inside his room. R48 was alert and verbally responsive. R48 had accumulation of long facial hair and his pants had dried food debris on the front area. R48 stated that he wanted the staff to shave him and help change his pants because he needed assistance. V19 (LPN) was present during the observation. R48's active care plan last revised on 9/1/23 showed that the resident had an ADL self-care performance deficit. 3. R49 had multiple diagnoses which included generalized osteoarthritis and dementia without behavioral disturbance, based on the face sheet. R49's quarterly MDS dated [DATE] showed that the resident was moderately impaired with cognition and required extensive assistance from the staff with personal hygiene. On 9/5/23 at 1:54 PM, R49 was sitting in her wheelchair by the hallway in front of the main dining room. R49 had scattered long and curling chin hair. R49 stated that she wanted the staff to shave her. R49 commented, They should shave me, I do not know why they don't. V10 (LPN) was made aware of R49's request to be shaven. R49's active care plan last revised on 7/3/23 showed that the resident had an ADL self-care performance deficit. The same care plan showed multiple interventions including extensive assistance during personal hygiene. 4. R90 had multiple diagnoses which included rheumatoid arthritis and dementia without behavioral disturbance, based on the face sheet. R90's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition and required extensive assistance from the staff with personal hygiene. On 9/5/23 at 10:52 AM, R90 was inside the main dining room, watching television. R90 was alert, verbally responsive but confused. R90 had accumulation of facial hair on the chin. During the observation, R90's daughters came to visit the resident. R90's daughters stated that they wanted the staff to shave/remove R90's chin hair. V19 made aware of the chin hair. R90's active care plan last revised on 8/30/23 showed that the resident had an ADL self-care performance deficit. The same care plan showed multiple interventions including extensive assistance during her personal hygiene. On 9/7/23 at 12:40 PM, V2 (Director of Nursing) stated that it is part of the nursing care and services to provide personal hygiene to the residents. V2 stated that the resident's unwanted facial hair should be removed or shaven especially for those residents needing assistance with ADL. 15845 5. The Electronic Medical Record (EMR) shows that R33, an [AGE] year-old female, with diagnoses of bilateral osteoarthritis, peripheral neuropathy, chronic obstructive pulmonary disease exacerbation, diabetes mellitus type 2, major depressive disorder, obesity, and cerebral infarction. R33 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) assessment dated [DATE] showed that R33 was cognitively intact with a BIMS (Brief Interview Mental Status) score of 14/15. The MDS also showed that R33 required extensive assistance from 1-2 staff for bed mobility, transfer, dressing and hygiene. On 9/05/23 at 10:43 AM, R33 was observed in her room. R33 was sitting in her wheelchair. R33 was observed with a long facial hair surrounding her chin and upper lip and looked like a moustache. When asked how R33 feels about her facial hair, R33 responded I do not like it, I like to have it shaved and I have been asking for it for a while, I even asked for a razor, they (staff) never did anything about it. V11 (Unit Charge Nurse) was present during this observation and said, I will ask a CNA (Certified Nurse Assistant) to shave her. R33 was also observed with long, and jagged fingernails. The fingernails were noted with black substance under the nails. V11 said she will have a CNA to cut R33's nails. The care plan dated 3/19/2022 showed that R33 has an ADL (Activities of Daily Living) self-care performance deficit related to activity intolerance, impaired balance, and weakness. The care plan showed that R33 currently requires assistance with ADLs. 35267 6. On 9/5/23 at 1:31 PM during Resident Council group meeting, the following residents expressed concerns regarding not receiving ADL (Activities of Daily Living) assistance in a timely manner: - R33 stated getting timely care was a problem at the facility and she has waited hours for ADL care. R33 stated days prior she sat an hour in bowel movement and waited for staff to answer her call light to assist her in toileting. - R31 stated the CNAs (Certified Nursing Assistants) will pass her room while her call light was on because they were not specifically assigned to her. - R84 stated when she needs help with ADLs, staff sometimes come in her room, turn off her call light, and but do not provide assistance. R84 stated she has waited 30-45 minutes for ADL care and sometimes 50 minutes in the middle of the night. - R88 stated she has waited an hour or more on the toilet waiting for staff to assist her. R88 stated she recently felt trapped in the bathroom for over and hour waiting for staff to answer her call light to assist her with toileting. R88 stated she was banging on the door to try to get staff attention. - R51 stated she has waited almost an hour for ADL assistance MDS (Minimum Data Sheet), dated 7/19/23, shows R31 was cognitively intact, was frequently incontinent of bowel, required total assistance of staff for transfers and toileting, and required the extensive assistance of staff for bed mobility, dressing and hygiene. MDS, dated [DATE], shows R33 was cognitively intact, was always incontinent of bowel and bladder, and required extensive assistance for bed mobility, transfers, dressing and personal hygiene. The MDS shows R33 was totally dependent on staff for toilet use. MDS, dated [DATE], shows R84 was cognitively intact, was occasionally incontinent of bowel/bladder, and required extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. MDS, dated [DATE], shows R88 was cognitively intact, was occasionally incontinent of bowel/bladder, and required extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. MDS, dated [DATE], shows R51 was cognitively intact, was occasionally incontinent of bowel/bladder, and required extensive assistance for bed mobility, transfers, dressing, toileting use, and personal hygiene. Review of facility Resident Council Meeting minutes showed the following: 5/25/23 - CNA's take a long time to answer their call lights. 3/23/23 - Other CNAs are answering other CNAs lights, but they do not help. 2/23/23 - CNAs don't answer call lights overnight in a timely manner. 12/29/23 - CNAs take a long time to answer lights, when they do they turn the light off and say they will be back and never do. 10/27/22 Overnight CNAs don't do their rounds. When they do, they only ask one roommate by the door and not the roommate by the window.

Based on observation, interview and record review, the facility failed to implement physician order regarding the use of compression stockings and compression wrap to treat and manage edema. This applies to four of four residents (R1, R70, R80 and R102) reviewed for edema in the sample of 24. The findings include: 1. On 9/05/23 at 10:53 AM, R1 was observed in the dining room. R1 was sitting in her wheelchair. R1 was wearing a pair of pants and lower legs were visible. R1 was wearing a pair of socks and shoes. R1 was noted with edema to the lower legs/ankles. R1 was not wearing compression stocking. V11 (Unit Charge Nurse) was present during this observation. The Nurses Shift Report dated 9/5/203 shows that R1 was supposed to wear a pair of compression stocking during the day. The compression stockings were to be applied in the morning and removed at night. Review of the POS (Physician Order Sheet) for the month of 9/2023 shows a physician order for R1 to apply the compression stocking in the morning and to take it off at night. The current care plan initiated on 9/23/2021 showed that R1 has impaired circulation related to edema. The goal was for R1 to be free from signs and symptoms of complications of poor circulation. The interventions included but not limited to administer physician orders, elevate legs as needed, and apply elastic stockings (compression stockings) to BLE (bilateral lower extremities) one time a day for BLE edema. Apply in the AM and remove at bedtime. The EMR (Electronic Medical record) shows that R1, a [AGE] year-old with diagnoses of disorder of muscle. congestive heart failure, asthma, respiratory diseases. morbid obesity, depressive disorder, and localized edema. The MDS (Minimum Data Set) dated 8/4/2023 showed that R1 was cognitively intact with BIMS score of 13/15 (Brief Interview Mental Status). R1 required assistance from staff for mobility, transfer, hygiene, and dressing. 2. On 9/05/23 at 10:01 AM, R70 was observed lying in bed. R70 was observed with swollen right hand, forearm, upper arm all the way towards the under arm. There was no compression wrap to R70's right arm. V11 was present during this observation. The Nurses Shift Report dated 9/5/203 shows that R70 was supposed to have ace wrap (compression elastic wrap) to the right hand, starting from the palm to the elbow. The care plan 7/1/2023 showed that R70 has an ADL self-care performance deficit related to ADL needs, due to cerebral infarction with right hemiplegia, impaired mobility and balance and morbid obesity. The care plan intervention included but not limited to Ace wrap on the right hand, starting from the palm to the elbow in the morning and remove in the evening. Refer to POS/MAR (Physician Order Sheet/Medication Administration Record) for current orders. Please leave her fingers out and elevate afterwards. Apply per MD orders and monitor skin condition for changes, elevate right arm when in bed. The EMR showed that R70, a [AGE] year-old with diagnoses that included but not limited to cerebral infarction, peripheral neuropathy, congestive heart failure, and morbid obesity, The MDS dated [DATE] showed that R70's cognition was severely impaired. R70 also required extensive to total assistance for mobility, transfer, dressing and hygiene. On 9/6/2023 at 4:03 PM, V11 said that R70 has chronic swelling on the right arm and must have the ace wrap/compression wrap as ordered by the physician. 3. On 9/05/2023 at 10:30 AM, R80 was observed in the dining room. R80 was sitting in her wheelchair. R80 was noted wearing a pair of socks and shoes. R80 was observed with swollen lower legs and ankles. R80 was not wearing compression stockings. R80 said I guess they (staff) forgot to put it (compression stockings) on. V11 was present during this observation. The Nurses Shift Report dated 9/5/203 shows that R80 was supposed to wear the compression stockings on during the day, apply in the morning and remove at night. The EMR showed R80's diagnoses that included but not limited to osteoarthritis, peripheral vascular disease, morbid obesity, diabetes mellitus, atherosclerosis of arteries of extremities, and localized edema. The current care plan that was initiated on 8/9/2021 showed that R80 has impaired circulation related to edema to the lower extremities. The goal for plan of care was for R80 to be free from signs and symptoms of complications of poor circulation. The care plan included interventions such as to elevate legs when resting and to apply compression stockings/TED Hose per orders. The POS for the month of 9/2023 shows a physician order for the compression stocking on during the day, apply in AM and remove at night. On 9/07/23 at 11:00 AM, V11 (Charge Nurse) said R80 must use the compression stockings for the edema to the lower extremities. V11 said the edema was related to R80's medical condition. 4. On 9/05/2023 at 11:11 AM, R102 was in the dining room R102 was sitting in her wheelchair. R102 was noted wearing a pair of socks and shoes. R102 was observed with swollen lower legs and ankles. R102 was not wearing compression stockings. V11 was present during this observation. The Nurses Shift Report dated 9/5/203 shows that R102 was supposed to wear the compression stockings on during the day, apply in the morning and remove at night. The POS for the month of 9/2023 shows a physician order 5/9/2023 for compression stockings to be applied to the BLE. It also showed to apply the compression stockings in the morning and remove at night. The EMR shows R102's diagnoses that included but limited to osteoarthritis, peripheral neuropathy, osteoporosis, and cerebral infarction. The physician progress notes dated 6/5/2023 showed that R102 was admitted to the facility on [DATE] after recent hospitalization for left hip ORIF (open reduction internal fixation). The notes also showed that the A/P (Assessment and Plan) included to continue compression stockings as ordered to treat and manage edema to the BLE. On 9/07/23 at 11:00 AM, V11 said R102 must use the compression stockings for BLE edema due to medical condition.

Based on interview and record review, the facility failed to ensure 2 staff were present during resident care to prevent resident injury for 2 residents (R9 and R77), and failed to ensure 2 staff were present for a resident transfer for 1 resident (R46). This failure resulted in R77 rolling out of bed, sustaining subdural hematomas requiring emergency care and hospitalization . This applies to 3 of 25 residents (R9, R77, R46) reviewed for safety/supervision in the sample of 25. The findings include: R77's Facility assessment dated [DATE], 5/23/22, and 8/22/22 showed R77 being [AGE] years old, being cognitively intact, and needing two-person assistance with bed mobility, transfers, dressing, toileting, and bathing. The facility's Final Incident Report dated 5/10/22 showed On 5/3/22 .resident was turned on her side by CNA staff during incontinence care, Resident rolled over and fell on the floor .paramedics arrived and transported resident to ER for evaluation. On 10/18/22 at 8:35 AM, R77 was noted to have multiple contractures of both arms and hands. R77 was unable to self-turn in bed. R77 stated, A few months ago I had to go to the hospital. One of the CNAs was cleaning me up by herself. She turned me on my side to clean my backside, and I rolled off the bed away from her. I hit my wheelchair on the way down, and basically landed on my face. On 10/18/22 at 2:35 PM, V21 (R77 Daughter) stated the facility contacted me when mom fell . They told me [R77] was receiving peri-care by one staff member, and she rolled off the bed. At the hospital they said [R77] had some blood between her skull and brain from the fall. R77's Hospital Records dated 5/3/22 showed R77 admitted to the hospital. R77's head CT scan results showed two acute subdural hematomas. On 10/18/22 at 2:00 PM, V18 (Therapy Director) stated, she has assisted with turning R77 in the past. Due to her contractures, and inability to move herself, she needs to have two people turn her with care. On 10/18/22 at 11:35 AM, V2 (Director of Nursing/DON) stated if a resident is designated as a two-person assist, there should be two staff members providing the care. R77 should not be turned with only one person for care. The facility's Activities of Daily Living (ADL) Policy revised 3/27/21 showed .Each ADL should be provided at the level of assistance that promotes the highest practicable level of function for the resident, while ensuring the needs and desired goals of the resident are met safely. R9's face sheet shows she has diagnoses including [CONDITION(S)] and [CONDITION(S)] following a cerebral infarction. R9's 7/22/22 facility assessment shows her cognition is mildly impaired, and she requires extensive 2-person staff assistance with bed mobility and turning from side to side. R9's Activity of Daily Living (ADL) care plan, revised on 8/11/21, shows R9 has limited mobility due to left sided [CONDITION(S)] and [CONDITION(S)], and requires extensive 2 staff assist with her bed mobility. R9's fall risk care plan revised on 10/18/22 shows she is at risk for falls and has a history of falls. On 10/17/22 at 9:56 AM, R9 said she was rolled out of bed by a Certified Nursing Assistant (CNA) who had come in the room alone to turn and change her. R9 said the CNA was turning her alone and she rolled right out of bed hit her face on the floor and had to go to the emergency room . On 10/17/22 at 9:59 AM, V9 (Certified Nursing Assistant/CNA) said R9 does require 2 CNAs to turn and re-position her. A fall incident report dated 9/4/22 at 5:20 AM, shows that a CNA identified as (V13) was turning R9 and she suddenly moved and fell out of bed landing on the floor on her right side. The fall incident report shows that R9 was taken to the hospital and had no apparent injury A nursing progress note dated 9/4/22 at 11:39 AM, shows R9 returned from the hospital with no apparent injury and states, educated CNAs to have 2 persons assist when providing care. On 10/18/22 at 1:36 PM, V8 (Unit Manager) said there is (Trade name) storage/file system in the computer that staff can look at to see how resident transfers or how many staff are needed to turn or lift a resident. On 10/18/22 at 2:09 PM, V13 said he was the CNA in the room changing R9 alone when she suddenly rolled out of bed. V13 said he had not worked with R9 that much and he did not realize she needed 2 staff to turn and re-position her. V13 said he was not familiar with a (Trade name) storage/file system in the computer to look for how many staff are needed to turn or transfer a resident. 3.) R46's face sheet shows he has diagnoses including [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting his left side. R46's 8/10/22 facility assessment shows his cognition is intact and he requires extensive 2-person staff assistance for transfers and toileting. R46's active fall prevention care plan, revised on 2/17/21, shows R46 is a fall risk. R46's active ADL care plan, revised on 5/14/21, shows he requires extensive 2 person staff assistance with transfers and toileting. On 10/17/22 at 9:16 AM, V7 (Certified Nursing Assistant/CNA) took R46 into the bathroom to toilet him. She was the only CNA present, and she had R46 grab the bar and stand up and transferred R46 onto the toilet alone. V7 said that R46 is a 1-person transfer and she gets the information communicated to her from the nurse how each resident transfers. On 10/18/22 at 1:36 PM, V8 (Unit Manager) initially said that R46 was a 1 person staff transfer and went to check the (Trade name) storage/file system in the computer. V8 returned and said it was her mistake but R46 does require 2 staff to transfer him. V8 showed this surveyor R46's (Trade name) storage/file system that indicates he requires 2 staff for transfers and toileting.

Based on interview and record review, the facility failed to identify and inform the physician of a resident's decreased intake and urinary output. This failure resulted in a change of mental status and the resident being hospitalized in the intensive care unit with severe dehydration and malnutrition. This applies to 1 of 3 residents (R1) reviewed for dehydration and malnutrition in a total sample of 13 residents. The findings include: According to the Electronic Health Record (EHR) R1 had [DIAGNOSES REDACTED]. R1 was admitted to the facility on [DATE]. The admission Minimum Data Set ((MDS) dated [DATE] showed R1 needed extensive assistance of one person for bed mobility, transfers, dressing, eating, toilet use, and hygiene. R1 had impaired range of motion of one lower extremity and used a walker and a wheelchair. R1 was always incontinent of bowel and bladder. R1 was five feet six inches tall and weighed 110 pounds. The MDS showed R1's cognition was severely impaired. The MDS did not show any swallowing disorder. The MDS care area assessment (CAA) showed R1 was at risk for dehydration and nutrition deficiency. The CAA showed R1 had a body mass index (BMI) of 17.75, below ideal body weight. A baseline care plan dated 01/13/2021 showed R1 may need assistance with eating and drinking with interventions including spending a lot or the entire time with R1 during meals. Hospital Records dated 01/11/2021 just prior to R1's admission to the facility showed the following laboratory blood work: White Blood Cells count (WBC) 5.4 (normal WBC is 4-11); Sodium 138 milliequivalents (mEq) (normal Sodium levels are 133-144 mEq); Potassium 3.6 mEq (normal Potassium levels are 3.4-5.1 mEq); Chloride 106 mEq (normal Chloride levels are 98-107 mEq); Blood Urea Nitrogen (BUN) 18.6 milligrams per deciliter (mg/dL) (normal BUN is 7 to 25 mg/dL); Creatinine 0.59 mg/dL (normal Creatinine 0.6 to 1.2 mg/dL); and Glomerular Filtration Rate (GFR) 155 milliliters per minute (ml/min) (normal GFR greater than 60 ml/min). An Emergency Department Physician Report dated 01/30/2021 at 4:17 PM showed on arrival the paramedics had difficulty obtaining intravenous access for R1 and an intraosseous line was placed in the left tibia. R1 was admitted to the hospital with [REDACTED]. Hospital Laboratory blood work dated 01/30/2021 at 5:27 PM showed: White Blood Cells count (WBC) 14.8 (normal WBC is 4-11); Sodium 177 milliequivalents (mEq) (normal Sodium levels are 133-144 mEq); Potassium 5.4 mEq (normal Potassium levels are 3.4-5.1 mEq); Chloride 135 mEq (normal Chloride levels are 98-107 mEq); Blood Urea Nitrogen (BUN) 219 milligrams per deciliter (mg/dL) (normal BUN is 7 to 25 mg/dL); Creatinine 6.66 mg/dL (normal Creatinine 0.6 to 1.2 mg/dL); and Estimated Glomerular Filtration Rate (GFR) 9 milliliters per minute (ml/min) (normal GFR greater than 60 ml/min). On 02/11/2021 at 12:12 PM, V6 (agency Certified Nursing Assistant/CNA) said she worked double shifts (16 hours) each day with R1 on 01/27/2021, 01/28/2021, and 01/29/2021. V6 said R1 liked some sweet stuff to be mixed with his food but he wouldn't eat the food, he would just suck the yogurt off the food. V6 was told by an unknown CNA to make sure R1 ate his yogurt because he didn't eat much. V6 didn't report anything to the nurse since she assumed they knew. On Friday 01/29/2021 V6 said R1 hardly had any urine output during the 16 hours shift she had worked. V6 stated she reported to V8 (Licensed Practical Nurse/LPN) about R1 not urinating very much during the shifts. On 02/11/2021 at 1:51 PM, V7 (agency CNA) said it was the first time she had cared for R1 on 01/30/2021 on the day shift. R1 absolutely needed 100 % assistance for eating. V7 said he was R1 was not alert and oriented or would not respond to his name at all. V7 stated, As far as I know that's how he was. The nurse (V8) had asked V7 if R1 ate anything and V7 stated he did not. When V7 tried to feed R1, he would let the food and liquids just drain out of his mouth. R1 did not try chewing or swallowing. V7 said R1 did not void or have a bowel movement during the day shift on 01/30/2021 and V7 notified V8 (LPN). On 02/11/2021 at 2:58 PM, V8 (LPN) said she was told by the night shift nurse during morning report on 01/30/2021, R1 had not really urinated during the night shift. V8 said she tried to encourage fluids during morning medication pass. V8 said R1 only took about 100 ml of water before he started spitting it out. V8 also had attempted to give R1 the med pass supplement but he drank a little bit and spit it out. V8 instructed V7 (CNA) to watch R1 for his intake and urinating. V8 was informed by V7 that R1 hadn't eaten anything. V8 attempted to feed R1 lunch around 12:30 PM or 1:00 PM, after V7 had attempted to feed him, but he had refused to eat for her as well. V8 said she had not called the physician until after 2:30 PM when she found he wasn't responding to his name and his oxygen saturation levels were in the 80's. V8 said she was told to send R1 to the hospital for evaluation and called 911. On 02/17/2021 at 12:58 PM, V2 (Director of Nursing/DON) said R1 always needed a staff member present for feeding. V2 said R1 was a messy eater and would grab the food and put it in his mouth quickly. V2 said the staff needed to encourage R1 to take liquids as well. V2 stated R1's decreased meal intake and decreased urine output was not brought to her attention, but it should have been. The meal intake record provided by the facility showed R1's meal intake between 01/19/2021 and 01/30/2021. Only 23 out of 35 possible meals (65.7 percent) were documented. R1's documented meal intake during this time period was: 3 of the 23 meals R1 ate 76 to 100 percent; 7 of the 23 meals R1 ate 51 to 75 percent; 4 of the 23 meals R1 ate 26 to 50 percent; and 9 of the 23 meals R1 ate 0 to 25 percent. The seven meals on 01/28/2021, 01/29/2021, and 01/30/2021 were documented R1 took zero to 25 percent of the meal. On 02/17/2021 at 3:07 PM, V2 (DON) said after checking with V6 (CNA) about R1's food intake between 01/28/2021 and 01/29/2021, V6 said R1 ate only 10 to 15 percent of his meals on 01/28/2021 and 01/29/2021. On 02/16/2021 at 5:10 PM, V11 (agency RN) said she worked Friday night shift 01/29/2021 to 01/30/2021 as a CNA because the facility was short one Certified Nursing Assistant. V11 said R1 did not have any urine output for her during the shift, even after encouraging fluids. V11 said she asked V18 (RN) to check R1's incontinence brief when she was busy with another resident. On 02/18/2021 at 8:56 AM, V18 (Registered Nurse/RN) said she worked the night shift on Friday 01/29/2021 into Saturday 01/30/2021 morning. V18 said, during report, the evening shift nurse had said (R1) hadn't had much of a urine output and to watch him. V18 denied anyone mentioning anything about (R1's) eating They would only mention it if he wasn't eating and it wasn't mentioned. V18 said she assisted changing R1's incontinence brief midway through the shift for a small to moderate amount of urine. V18 said, during morning report on 01/30/2021, she told the day shift nurse both verbally and written on the 24 hour report sheet, to watch R1's urine output since it was decreased since the day prior. On 02/16/2021 at 9:39 AM, V13 (RN) said Definitely the CNAs should be telling me if a resident doesn't eat much for a meal so we can monitor and watch them. On 02/16/2021 at 3:01 PM, V12 (Registered Dietitian/RD) said she did R1's admission nutritional assessment. V12 said R1 was eating adequately prior to admission and there wasn't any recent bloodwork laboratory results while at the facility. V12 said R1's food intake had varied mostly between 26 and 75 percent which meant he was not meeting 100 percent of his needs. V12 said he had a low BMI, weighed only 112 pounds and was 66 inches tall he would need extra calories from a supplement. V12 determined his calorie intake to be 30-35 calories per kilogram for a total of 1500-1750 calories per day and a fluid intake 30 ml/kg for a total of 1500 ml/day. When asked how does the facility ensure a resident was receiving adequate food and fluids, V12 said she would look at the resident's intake record, and in the case of R1, would speak with the nurse managers since R1 was non-verbal. V12 would also look at the weekly weight records. V12 said if a resident was not eating or drinking, the staff should call the doctor. V12 said she was only in the facility one day per week and if a resident needed fluids intravenously, she would not have anything to do with that. On 02/11/2021 at 4:22 PM, V8 (MD Hospital ICU Intensivist) said he was getting reports from the nursing home that didn't correlate with the clinical signs of what we were seeing. V8 said Someone doesn't go from eating one day to being dehydrated that severely the next. On exam, V8 stated it did not look like (R1) was getting any nutrition. On 02/17/2021 at 1:54 PM, V17 (Medical Doctor/MD) said he had not seen previous medical records but felt R1 may have had nutritional deficiencies prior to being admitted to the facility. V17 said Seeing his output had diminished and he was admitted (to the hospital) with severe dehydration, shows me they were not successful in improving his nutrition. V17 stated It certainly didn't look good that the facility had not called the physician when his intake and output had decreased for three days. On 02/17/2021 at 9:32 AM, V9 (Attending MD) said he was not aware or notified R1 was not eating or drinking or had little urine output. V9 said if he had been notified he probably would have acted sooner and done some blood work. V9 would have ordered a basic metabolic panel (BMP), complete blood Count (CBC), urinalysis and a urine culture and sensitivity to determine R1's hydration status and come up with a plan. If R1 had a decrease in intake and a decrease in output Certain protocols would call for notification and V9's expectation would have been a call or some kind of notification from the facility, which did not happen. The facility's Standards and Guidelines Change of Condition policy dated 11/01/2016 included to observe resident during routine care to identify significant changes in physical or mental conditions, orientation, change in vital signs, weights, etc. Contact the primary physician to update him/her to the change in condition.

Based on Observation, Interview and Record review the facility failed to ensure residents fall interventions were implemented. This resulted in (R1) sustaining a facial fracture and a burst [MEDICAL CONDITION] vertebrae. This applies to 2 of 3 residents (R1 and R2) reviewed for falls in the sample of 11. The findings include; R1's Face sheet shows resident is a [AGE] year old male with the following Diagnoses: [REDACTED]. R1's MDS (Minimum Data Set) assessment dated (MONTH) 9, (YEAR) shows R1's cognitive status is moderately impaired. The MDS shows R1 requires extensive assistance for dressing, bed mobility, toilet use, and hygiene. R1 is totally dependent on (2) staff members for transferring resident with mechanical lift. R1's Care plan dated (MONTH) 18, (YEAR) shows R1 has a history of falls and is at risk for falls related to decreased balance and inadequate safety awareness. R1's fall investigation report dated (MONTH) 9, (YEAR), faxed to IDPH, shows R1 at 10:12 AM was in front of the nurse's station. Per witness ,V9's (Insurance Case Manager) statement shows R1 was noticed sitting in his wheelchair by nurse's station and then she noticed resident was leaning forward, falling from chair and then hit his head on the ground. On (MONTH) 13, (YEAR) at 3:02 PM, V3 LPN (Licensed Practical Nurse) stated she was not R1's nurse on (MONTH) 5, (YEAR). V3 stated she was sitting at the nurse's station but was unable to visually see R1. V3 stated R1was a high fall risk. V3 stated all of the facility fall risk residents,on this unit, need to be visually monitored by all staff. V3 stated all fall risk residents on this wing are lined up at the nurse's station by the desk. V3 stated fall risk residents are kept in view and the facility always tries to have a staff member at the nurse's station desk. V3 stated an insurance case manager yelled; He is going to fall and we all ran towards R1. On (MONTH) 13, (YEAR) at 11:00 AM, V1 (Administrator) stated R1 was at the nurse's station. R1 was trying to pick something off the floor and visitor tried to stop him. R1 was leaning over the wheelchair and he fell forward, hitting his head. V1 stated, according to the neurosurgeon at the hospital, he could not perform surgery so the family decided to remove R1 from life support and provide comfort care. R1 died the next day on (MONTH) 6, (YEAR). V1 stated R1's personal safety alarms were removed and in place of them, the staff were to keep a visual eye on him. On (MONTH) 13, (YEAR) at 12:00 PM, V2 DON (Director of Nursing) stated R1 had a low bed, his bed against the wall, mattress on the floor and a skid resistant pad for his wheelchair seat. V2 stated as far as she knows, R1's previous falls all happened in his room. V2 stated one of R1's interventions were to try to keep R1 in the dining room so staff could see him. V2 stated the facility no longer uses personal safety alarms at this time. V2 stated R1 was brought to the front of the nurse's station at approximately 10:00 AM. V2 stated she was notified R1 was on the floor and he was provided first aid, 911 was called and he was immobilized. V2 stated she was not sure if R1 was in staff's view. On (MONTH) 13, (YEAR) at 3:22 PM, V4 LPN (Licensed Practical Nurse) stated R1 was reaching for something but she could not understand what he was trying to say. V4 stated she did see R1's eye glass case on the floor after the fall. V4 stated the nurses and CNAs (Certified Nursing Assistants) are supposed to watch the fall risk patients but do not have enough time or staff to do it. V4 stated; We cannot always be around the nurse's station, we have to pass meds. V4 stated; We had a meeting and I ,with another nurse, spoke up that we needed more staff and the same response was given that 'we are working on it. V4 stated on (MONTH) 5, (YEAR), at the time R1 fell , she was sitting behind the nurse's station desk and did not see R1 fall until she ran around the nurse's station and he was already on the floor. V4 stated an insurance case manager was visiting and yelled that a resident was falling and I jumped up and ran towards R1. V4 stated usually the fall risk residents are behind the nurse's station desk, V 4 said I do not know why he was left in front of the nurse's station. V4 stated R1 usually lays down. V4 stated once after R1 fell we had him at the nurse's station because he was trying to get up from his wheelchair. On (MONTH) 14, (YEAR) at 9:50 AM, V5 (Coroner) stated he spoke with the ER staff at the hospital regarding R1. V5 stated V11 (ICU Physician) documented R1's cause of death is related to the fall and [MEDICAL CONDITION]. The tentative death of R1 is fall related and in addition, hypercapnia. V5 stated the coroner's case is still open until all medical records are received. On (MONTH) 14, (YEAR) at 10:10 AM, V6 (R1's wife) stated R1 broke his neck and nose. V6 stated he died related to the fall and it was a terrible situation. V6 stated R1 fell multiple times times. V6 stated ;it was very concerning to me. V6 stated R1 should have not fallen like he did. V6 stated she felt the facility should have put something in or on his chair or do something that would prevent him from falling. V6 stated she was married to R1 for over 32 ,[DATE] years and he will be truly missed. On (MONTH) 14, (YEAR) at 11:00 AM, V7 RN (Registered Nurse) stated on (MONTH) 5, (YEAR) at 9:40 AM she was getting her folder from the 400 hall wing office for a meeting. V7 stated and she saw R1 at a table in the dining room asleep with a tray on his lap and a bowl of cereal, spoon and fork on his leg. V7 stated she tapped R1's shoulder and asked if a CNA (Certified Nursing Assistant) could change him . When V7 and R1 reached the nurses station, all CNAs and nurses were at the nurses station for morning meeting. V7 stated she told R1's CNA that he spilled cereal on his lap and needed to be changed. V7 stated she put R1 by the outer part of the nurse's station where the aide could see R1. V7 stated she was not sure if R1's CNA changed his clothes. V7 stated R1 fell at the spot she put him. V7 stated ,most of the time, if a resident is a fall risk they have to be in staff's view at the nurse's station where staff are present. V7 stated the reason she did not place R1 behind the nurses station is because all the staff where behind the desk. V7 stated if R1 is confused, a staff member will sit with him and chart. V7 stated we remind staff in the am meetings who are frequent fallers and who need to go to bed to prevent falls. V7 stated there is no specific time frame implemented on checking fall risk patients. V7 stated the facility did away with alarms and thought alarms were more convenient for the staff. Alarms would not stop resident from falling. V7 stated the staff should check on the residents physically. V7 stated the facility looks at the falls based on how the resident falls and then implement interventions. R1's Hospital records were reviewed and showed V11 (Neurosurgeon) explained to V6 (R1's wife) that R1 was not a reasonable candidate for his neck fracture. In addition, R1's cause of death was [MEDICAL CONDITION] due to airway compromise, due to a burst [MEDICAL CONDITION] vertebrae which was the result of an accidental fall. A burst fracture is a descriptive term for an injury to the spine in which the vertebral body is severely compressed. Burst fractures typically occur from severe trauma such as a fall. 2. R2's face sheet showed resident with the following Diagnoses: [REDACTED]. On (MONTH) 13, (YEAR) at 9:45 AM, R2 was at the nurse's station behind the desk sleeping in his wheelchair. V3 LPN (Licensed Practical Nurse) stated R2 was sitting behind the nursing station desk because he was a fall risk. R2 was noticed with his wheelchair brakes on and his body was pushed up against the desk. V3 stated she had to go to the bathroom. No staff were at the nurse's station or in the dining room to view R2 for 18 minutes consecutively. R2 woke up and started to push back on his wheelchair that was locked. V3 returned from the bathroom and was told R2 was pushing himself back in his wheelchair trying to move away from the desk. V3 stated staff should have been at the desk to monitor him. R2's Fall Risk Care Plan dated (MONTH) 2, (YEAR) to present shows resident is alert to person and place with episodes of confusion; exhibits poor safety awareness and unsafe attempts to transfer self without assistance and last known fall was on (MONTH) 1, (YEAR). R2's interventions are as follows: to be monitored frequently and keep within sight of staff and to monitor frequently and anticipate his needs. On (MONTH) 13, (YEAR) at 10:30 AM, V2 DON (Director of Nursing) was told R2 was left at the nurse's station behind the desk with no one at the nurse's station or in the dining room from 10:02AM to 10:20 AM. In addition, V2 was told R2 was trying to stand but his wheelchair brakes were locked. V2 stated R2 is positioned at the nurse's station so that staff would be able to see him to prevent him from standing and falling. On (MONTH) 13, (YEAR) at 2:00 PM, V1 (Administrator) stated R2 is positioned in the nurses station, behind the desk, because he was a high fall risk. V1 stated R2 should not have been left alone at the nurse's station and not in sight of a staff member. V1 stated R2 should monitored and should be kept within sight of staff members. On (MONTH) 13, (YEAR) at 11:00 AM, V1 stated R2 has a history of falls and tries to get up and down all the time . Staff walk with R2, do activities, 1:1, and R2 is placed behind the nurse's station to keep him with someone. V1 stated R2 has not fallen recently since these interventions mentioned above. The Facility's Incidents/Accidents Policy and Procedure Revised (MONTH) (YEAR) shows: The facility will take every precaution to prevent the occurrence of accidents .An incident may defined as, but is not limited to falls, resident injuries of known or unknown origin, or any occurrence of an unusual nature that requires investigation.