Every finding on record at Pecan Bayou Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to implement its policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 3 of 8 (Resident #23, Resident #25 and Resident #62) residents reviewed for food and nutrition services. The facility failed to ensure that Resident #23 and Resident #25's personal refrigerator had a temperature log during the month of August 2025. The facility failed to ensure that Resident #62's personal refrigerator had temperature log completed from 08/19/2025 thru 08/26/2025. These failures could place residents at risk for foodborne illnesses. The findings were: During an observation on 08/26/2025 at 9:55 AM, revealed Resident #23' s personal refrigerator's temperature log was last dated 08/18/2025. Resident #23's refrigerator contained drinks. During an observation on 08/26/2025 at 10:37 AM, revealed Resident #62' s personal refrigerator did not have temperature log on the refrigerator. Resident #62's refrigerator contained drinks. During an observation on 08/27/2025 at 10:00 AM, revealed Resident #25' s personal refrigerator did not have temperature log on the refrigerator. Resident #25's refrigerator contained drinks. During an interview on 08/27/2025 at 10:17 AM the ADMN stated her expectation was refrigerators should have had thermometers in them and a temperature log on the refrigerator. The ADMN stated the department managers were assigned rooms to make daily rounds and during their daily rounds they were supposed to check and log the temperatures of the refrigerator. The ADMN stated residents could have received food that had spoiled. The ADMN stated what led to failure was miscommunication between staff. The ADMN stated she did not have a policy for refrigerator temperatures being checked and logged. During an interview on 08/27/2025 at 2:02 PM the ADON stated Resident #62 was one of the residents' rooms she was assigned to check daily. The ADON stated she was supposed to check the temperature of the refrigerator and log the temperature. The ADON stated she did not know why there was not a log on Resident #62's refrigerator. The ADON stated what led to failure was oversight on her part. The ADON stated the negative affect on residents could have been resident could have received food that was spoiled or items out of date. During an interview on 08/27/2025 at 2:25 PM Medical Records A stated she was assigned five rooms she was responsible to check daily and Resident #23 was one of her rooms. Medical Records A stated each refrigerator was supposed to have a thermometer and a log. Medical Records A stated residents could have had spoiled food in their refrigerator. Medical Records A stated what led to failure was oversight on her part.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: The facility's kitchen staff failed to practice proper hand hygiene during meal preparations. The facility failed to ensure kitchen staff handled ready to serve food with proper technique. The facility failed to ensure kitchen staff disposed of serving utensils when they became soiled. These failures placed residents at risk for food borne illness and cross-contamination. Findings included:During an observation on 08/25/2025 12:45 PM to 1:00 PM revealed [NAME] B used her gloved hand, that had touched plates and serving utensils and picked up rolls with the same gloved hand. [NAME] B left the food service line to grab a stack of plate warmers from another part of kitchen. [NAME] B changed her gloves but failed to wash her hands. [NAME] B dropped the tongs for the cooked chicken into the pan that contained chicken and continued to use the soiled tongs. [NAME] B continued to use her gloved hand, that touched the chicken, to pick up rolls. During an interview on 08/25/2025 at 1:15 PM the DDM stated her expectation was when staff changed gloves, they should have washed their hands. The DDM stated when a serving utensil was dropped into the food, the utensil should have been changed out for a new one. The DDM stated staff should have picked up rolls with tongs and not her gloved hand that was touching other food utensils. The DDM stated residents could have been affected by being exposed to cross contamination. The DDM stated the DM was responsible to ensure staff followed policies and procedures in the kitchen. The DDM stated staff nerves led to the failures that occurred. During an interview on 08/25/2025 at 1:45 PM [NAME] B stated she had only worked at the facility for 2 to 3 months and continued to learn as she went. [NAME] B stated she should have washed her hands when she changed her gloves and should have used tongs to pick up bread instead of her gloved hand that was touching everything else. [NAME] B stated residents could have been affected by cross contamination. [NAME] B stated what led to failure was being in a hurry and being nervous. During an interview on 08/25/2025 at 2:30 PM the DM stated her expectation was staff should have washed their hands when they changed gloves. The DM stated staff should have changed serving utensils when the utensils were dropped into food containers. The DM stated staff should have used the tongs to pick up rolls instead of using their gloved hand (that was being used to serve food). The DM stated she was responsible to ensure staff followed the policy and procedures. The DM stated residents could have gotten sick due to exposure to cross contamination. The DM stated what led to failure was staff was nervous. Record review of facility provided policy titled, Food: Preparation dated 2/2025 revealed: All staff will practice proper hand washing techniques and glove use. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use.Record review of facility provided policy titled, Food Handling during meal service without a date, revealed: The appropriate use of items such as gloves, tongs, deli paper, and spatulas is essential in minimizing the risk of food borne illness. Gloved hands are considered a food contact surface that can get contaminated or soiled. Disposable gloves are a single use item and should be discarded between and after each use. When serving food on the line, all food items should be handled by their designated utensil to minimize the risk of cross contamination.

Based on interviews and record review, the facility failed to immediately consult with the physician of a significant change in the resident's physical, mental, psychosocial status; or a need to alter treatment significantly for 1 (Resident #63) of 4 residents reviewed for physician notification. The facility failed to notify the physician of change of condition which led to Resident #63 going into respiratory and cardiac arrest and was pronounced dead after transfer to the hospital on [DATE]. An Immediate Jeopardy was identified on [DATE] at 2:40 pm. The IJ template was provided to the facility on [DATE] at 2:40 pm. While the IJ was removed on [DATE] at 3:18 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. This failure placed residents at risk for not receiving emergency care and further life-saving treatments as desired, that could lead to serious illness, hospitalization , and/or death. Findings Include: Review of Resident #63's electronic face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: fractured femur, breast cancer, and muscle weakness. Further review of the electronic face sheet revealed discharged [DATE] to acute care hospital. Review of Resident #63's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 15 which indicated no impaired cognition. Section I Active Diagnosis revealed Resident #63 had cancer and high blood pressure. Further review revealed no cardio or respiratory diagnosis. Review of Resident #63's care plan, initiated [DATE], revealed: Focus: Resident has a code status of Full Code/CPR. Goal: Resident wishes to be a Full Code/CPR will be honored. Interventions: If resident arrest CPR will be performed, 911/EMS called, MD/RP informed. Further review of care plan revealed no evidence of respiratory or cardiac issues and no evidence of the use of oxygen. Review of Resident #63's electronic physicians orders from [DATE] to [DATE], revealed no evidence of any oxygen orders. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 9:00 pm, signed by LVN A, revealed: resident c/o feeling weak, pain to extremities, VS 97.8, 64, 20, ,d+[DATE], SPO2 81%@ RA, applied O2 @ 2lpm/NC, SPO2 up to 94%, respirations unlabored, administered PRN APAP#3 (Tylenol #3), resident drank approximately 240cc of H20, resident then vomited, VS remain 97.7,71, 20, ,d+[DATE], SpO2 93%@2lpm/NC. Review of Resident #63's electronic record from [DATE]-[DATE], revealed no evidence of any respiratory or lung assessments completed. Further review of Resident #63's record revealed no evidence of physician notification or change or condition. Review of Resident #63's electronic nurse's progress notes from [DATE] to [DATE] revealed no evidence of follow up assessments or monitoring after oxygen was administered. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 05:00 am, signed by LVN A, revealed: resident has had no further Nausea/vomiting this shift, continues to c/o pain to BLE, VS remain stable, SpO2 ,d+[DATE]%@2lpm/NC, has drank approximately ,d+[DATE]cc of fluids this shift, alert, oriented, able to make needs known. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 07:30 am, signed by RN B, revealed: CNA came to nurse stating resident not responding-this nurse entered room resident not breathing-not responding to verbal or tactile stimulation-RN call for help CPR initiated and LVN called 911- 7:35 ems arrived, and CPR continued - MD/[family member] notified-8am ems departed with resident cpr still in progress. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 10:43 am, signed by RN B revealed: Hospital notified states resident expired. Review of Resident #63's hospital clinical record dated [DATE], revealed: 8:21 am CPR was continued on arrival to emergency room without any change. 8:32 am expired due to cardiac and respiratory arrest During an interview on [DATE] at 3:30 pm, the DON stated the physician, and the family should have been notified on [DATE] at 9:00 pm when Resident #63 had a change of condition requiring oxygen placement. She stated a change of condition assessment should have been completed. The DON stated Residents #63 should have been monitored closely throughout the night. She stated she did not feel that it was a significant enough change for her to have been notified. The DON stated she felt that the nurse had probably notified the doctor and just forgot to document it. She stated it was probably just a hectic night and the nurse forgot to document her assessments and any further monitoring throughout the night. The DON stated CNA F no longer worked at the facility. During an interview on [DATE] at 4:00 pm, the Physician stated she was notified on [DATE] that Resident #63 had coded and was sent to the emergency room . She stated she was not notified the night before of the resident change in condition and requiring oxygen. The physician stated she expected to be notified of any change of condition and that any resident who previously did not require oxygen and then does was considered a significant change in condition. She said she would have sent Resident #63 to the emergency room or at least started treatment on the night of ,d+[DATE] had she been notified because she had already discussed this with Resident #63 and the resident wanted aggressive treatment. The Physician stated it was a delay in care and she could have been treated 10 hours earlier possibly preventing the code and the death. During an interview on [DATE] at 4:45 PM, LVN A stated Resident #63 had a low blood pressure and low oxygen saturation on ,d+[DATE] at 9:00 pm. She stated she applied oxygen, and that Resident #63 had a prn oxygen order. She stated she texted the physician but did not get a reply, but she was not concerned because she did not feel that anything was wrong with Resident #63. She stated she did not perform a lung assessment because the resident did not seem distressed. She stated she did not consider it a change in condition and did not complete a change in condition assessment. She stated she and her CNA did check on the resident throughout the night, but she just forgot to document it. During an interview on [DATE] at 5:02 PM, RN B stated she was notified of nurse aides that Resident #63 was found unresponsive at the time of shift change. During an interview on [DATE] at 5:04 PM, CNA H stated she walked into Resident #63's room, found resident non-responsive, and notified RN B immediately. She stated this occurred at shift change. During an interview on [DATE] at 1:56 PM, the ADMN stated her expectation was to call the physician with any change of condition. She stated if a residents oxygen level decreased and staff was having to address that, staff should have contacted the physician and the DON, but only if the resident needed orders outside of resident's parameter orders. Attempted interview on [DATE] at 11:09 AM with CNA F who worked on the night of [DATE] and she did not answer. During an interview on [DATE] at 01:00 PM, CNA G stated she worked the night of [DATE] and was aware of Resident #63's episode at 9:00 pm. She stated she notified LVN A that the resident was having difficulty breathing and the nurse applied oxygen to the resident. She stated she was not in charge of care for that resident and was unaware of her status the rest of the night. She stated CNAs did not document every 2 hours. She stated they complete once a shift documentation. CNA stated there was no way to prove that residents were rounded on every 2 hours. Record review of the policy titled, Change in a Resident's Condition or Status, last revised [DATE] read in part: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly .2. A significant change of condition is a major decline or improvement in the resident's statue that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provide, including information prompted by the Interact SBAR Communication Form. Record review of the policy titled, Oxygen Administration, last revised [DATE] read in part: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident .Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis; 2. Signs or symptoms of hypoxia; .4. Vital signs; 5. Lung sounds .Procedure .13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated . This was determined to be an Immediate Jeopardy on [DATE] at 2:40 PM. The ADMIN was notified. The ADMIN was provided with the IJ template on [DATE] at 2:40 PM. The following Plan of Removal was submitted by the facility was accepted on [DATE]at 1:06 PM: Impact Statement: On [DATE] an abbreviated survey was initiated. On [DATE] the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to identify and provide treatment and care to resident #1. How were other residents at risk to be affected by this deficient practice identified? The facility DON and nurse management team completed an audit to address potential change of conditions on all residents using the ,d+[DATE]-hour report on [DATE]. All residents had the potential to be affected by this deficient practice, no other residents were identified as being affected. What corrective actions have been implemented for the identified resident? Resident #1 no longer resides in the building as of [DATE]. What corrective actions were taken? 1. The following actions were initiated immediately on [DATE] a. On [DATE] an audit was completed by the DON and/or designee to identify all residents who were at risk for having a change in condition in last 30days related to their disease process including reviewing all Oxygen orders in last 30days. No residents were identified to be affected. DON and ADON were educated on [DATE] by CSD (Clinical Service Director) on identification of change of condition, e-interact stop and watch tool, and notification to physician when changes of condition are observed in residents. Change in condition will be reported/monitored with the Stop and Watch tool and SBAR. When a change in condition has been identified it will be placed on the shift-to-shift charge nurse report and also reported in the morning clinical meeting by the charge nurse. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. b. On [DATE] an in-service was initiated for all Licensed Nurses, on change of condition, notifying the physician of changes. All staff who are unable to attend will be required to complete training before their next scheduled shift. Inservice was completed on [DATE] and will be monitored and review for effectiveness by DON During QAPI. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. c. On [DATE] an in-service was initiated for all staff by the DON and/or designee on the importance of completing stop and watch forms when there are changes of condition noticed in residents. All nursing staff unable to attend will be required to complete training before their next scheduled shift. Inservice was completed on [DATE] and will be monitored and review for effectiveness by DON During QAPI. 2. How will the system be monitored to ensure compliance? d. The ADON, DON and/or designee will review the facilities ,d+[DATE]-hour summary report in PCC 5 days per week in the morning clinical meeting starting on [DATE] for 4 weeks and then ongoing to identify any resident who has had a change in condition or has symptoms that may trigger an acute decline requiring medical attention. Licensed and trained nursing staff will ensure the physician has been notified and interventions implemented. Any identified concerns will be addressed immediately, and additional training will be provided as needed. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. e. The DON and Nurse Manager will review all stop and watch forms completed by all staff in morning meetings to help identify observed changes in condition and to ensure the physician has been notified. Starting on [DATE] and will be ongoing. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. f. The weekend supervisor and/or designee was in-serviced on [DATE] by DON on how to review the ,d+[DATE]-hour report from PCC and the stop and watch tools on Saturdays and Sundays to ensure that any residents with a change in condition are identified. Nursing staff will contact the physician and ensure appropriate orders and interventions are in place. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. g. Newly hired staff, agency, and PRN staff will be trained on the stop and watch tools, changes in condition, verification of orders, notification to physician during orientation by the DON or designee. Staff unable to come to receive training will be required to completed training before their next scheduled shift. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring of the facility's Plan of Removal through interviews and record reviews from [DATE] at 1:06 pm through [DATE] at 3:00 pm revealed: During an interview on [DATE] at 01:51 PM, the DON stated she ran 24-hour report and ran an order listing report that would encompass all new orders. She stated looked at all residents' vital signs including weight and nurses' documentation to identify residents who were at risk. She stated that any change of condition including administering O2, staff would have to contact MD with changes and then anything that was not normal had to be documented as MD notified. The DON stated if there was not an answer from doctor then they would continue to try to contact and if they could not get ahold of the physician then nurses will contact DON or ADMN to notify the Medical Director. She stated the Medical Directors had been notified of POR and the Medical Directors have been notified that if staff were unable to reach attending, then she would be notified. The DON stated changes in condition would be discussed in morning meeting and be documented on a 24-hour report with VS, falls, and new orders in the clinical meeting and everything from previous day would be reviewed. The DON stated she would monitor that the in-services were effective by looking at the dashboard on PCC to see if alerts have been cleared out. She stated she would monitor that physicians were being notified by monitoring nurses notes to verify that change in condition was followed up on. The DON stated she had remote access to PCC. She stated the weekend supervisor would be the DON and ADON every weekend and that one of them would look at the reports and monitor/review ,d+[DATE]-hour report from PCC. During random interviews via phone on [DATE] at 1:15 PM, revealed 2 Licensed Nurse and 1 Registered Nurse who worked the 12-hour night shift had been educated regarding change of condition and notifying the physician of changes. During random interviews on [DATE] at 2:15 PM, revealed 1 Licensed Nurse and 1 Registered Nurse who worked the 12-hour day shift had been educated regarding change of condition and notifying the physician of changes. Review of written in-service initiated on [DATE] about Change of Condition - Administering O2 - Contacting MD & RP's with changes - Stop n watch - Monitoring after the change of condition - documentation ensure change is on 24 hour report - care planning - monitor nurse alerts require monitoring & documentation. Notify the MD - call - if no answer the nurse will notify DON and/or Administrator and the Medical Director will be notified - Must be documented in the Medical Record. Verified all nurses' signatures on in-service. During random interviews via phone on [DATE] at 1:15 PM, revealed 3 CNAs, who worked the 12-hour night shift had been educated regarding the importance of completing stop and watch forms when there are changes of condition noticed in residents. During random interviews on [DATE] at 2:15 PM revealed 2 CNAs, who worked the 12-hour night shift had been educated regarding the importance of completing stop and watch forms when there are changes of condition noticed in residents. Review of written in-service initiated on [DATE] with CNAs titled Change of condition- Stop N Watch, with 27 signatures. Review on [DATE] at 01:51 PM, revealed QAPI Signature page with: ADMN and MD signatures on [DATE] and DON, ADON, Payroll, BOM, Housekeeping, Maintenance Director, Medical Records, Nutrition Services, Rehab Services Director, Social Service, and Activity Director signatures on [DATE]. The ADMIN was informed that the Immediate Jeopardy was removed on [DATE] at 3:18 PM. The facility remained out of compliance at a scope of isolated with no actual harm, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems that were put into place.

Based on interview, and record review the facility failed to ensure a resident received the necessary treatment and services, consistent with professional standards of practice for 1 of 4 residents (Resident #63) reviewed for hospitalization s. LVN A failed to recognize Resident #63 was having a change in condition when her oxygen saturation was low, she required supplemental oxygen, she vomited, and complained of pain, and no additional assessments of her condition were provided including follow-up assessments of her vital signs. The facility failed to provide basic quality of care to prevent Resident #63 from going into respiratory and cardiac arrest. The resident was pronounced dead after transfer to the hospital on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:40 PM. While the IJ was removed on [DATE] at 3:18 PM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. This failure placed residents at risk for not receiving emergency care and further life-saving treatments as desired, that could lead to serious illness, hospitalization , and/or death. Findings Include: Review of Resident #63's electronic face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: fractured femur, breast cancer, and muscle weakness. Further review of electronic face sheet revealed discharged [DATE] to acute care hospital. Review of Resident #63's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 15 which indicated no impaired cognition. Section I Active Diagnosis revealed Resident #63 had cancer and high blood pressure. Further review revealed no cardio or respiratory diagnosis. Review of Resident #63's care plan, initiated [DATE], revealed: Focus: Resident has a code status of Full Code/CPR. Goal: Resident wishes to be a Full Code/CPR will be honored. Interventions: If resident arrest CPR will be performed, 911/EMS called, MD/RP informed. Further review of care plan revealed no evidence of respiratory or cardiac issues and no evidence of the use of oxygen. Review of Resident #63's electronic physicians orders from [DATE] to [DATE], revealed no evidence of any oxygen orders. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 9:00 pm, signed by LVN A, revealed: resident c/o feeling weak, pain to extremities, VS 97.8, 64, 20, ,d+[DATE], SPO2 81%@ RA, applied O2 @ 2lpm/NC, SPO2 up to 94%, respirations unlabored, administered PRN APAP#3 (Tylenol #3), resident drank approximately 240cc of H20, resident then vomited, VS remain 97.7,71, 20, ,d+[DATE], SpO2 93%@2lpm/NC. Review of Resident #63's electronic record from [DATE]-[DATE], revealed no evidence of any respiratory or lung assessments completed. Further review of Resident #63's record revealed no evidence of physician notification or change or condition. Review of Resident #63's electronic nurse's progress notes from [DATE] to [DATE] revealed no evidence of follow up assessments or monitoring after oxygen was administered. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 05:00 am, signed by LVN A, revealed: resident has had no further Nausea/vomiting this shift, continues to c/o pain to BLE, VS remain stable, SpO2 ,d+[DATE]%@2lpm/NC, has drank approximately ,d+[DATE]cc of fluids this shift, alert, oriented, able to make needs known. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 07:30 am, signed by RN B, revealed: CNA came to nurse stating resident not responding-this nurse entered room resident not breathing-not responding to verbal or tactile stimulation-RN call for help CPR initiated and LVN called 911- 7:35 ems arrived, and CPR continued - MD/[family member] notified-8am ems departed with resident cpr still in progress. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 10:43, signed by RN B revealed: Hospital notified states resident expired. Review of Resident #63's hospital clinical record dated [DATE], revealed: 8:21 am CPR was continued on arrival to emergency room without any change. 8:32 am expired due to cardiac and respiratory arrest During an interview on [DATE] at 3:30 pm, the DON stated the physician, and the family should have been notified on [DATE] at 21:00 when Resident #63 had a change of condition requiring oxygen placement. She stated a change of condition assessment should have been completed. DON stated Residents #63 should have been monitored closely throughout the night. She stated she did not feel that it was a significant enough change for her to have been notified. DON stated she felt that the nurse had probably notified the doctor and just forgot to document it. She stated it was probably just a hectic night and the nurse forgot to document her assessments and any further monitoring throughout the night. DON stated CNA F no longer worked at the facility. During an interview on [DATE] at 4:00 pm, the Physician stated she was notified on [DATE] that Resident #63 had coded and was sent to the emergency room . She stated she was not notified the night before of the resident change in condition and requiring oxygen. The physician stated she expected to be notified of any change of condition and that any resident who previously did not require oxygen and then does is considered a significant change in condition. She said she would have sent Resident #63 to the emergency room or at least started treatment on the night of ,d+[DATE] had she been notified because she had already discussed this with Resident #63 and the resident wanted aggressive treatment. Physician stated it was a delay in care and she could have been treated 10 hours earlier possibly preventing the code and the death. During an interview on [DATE] at 4:45 PM, LVN A stated Resident #63 had a low blood pressure and low oxygen saturation on ,d+[DATE] at 9:00 pm. She stated she applied oxygen, and that Resident #63 had a prn oxygen order. She stated she texted the physician but did not get a reply, but she was not concerned because she did not feel that anything was wrong with Resident #63. She stated she did not perform a lung assessment because the resident did not seem distressed. She stated she did not consider it a change in condition and did not complete a change in condition assessment. She stated she and her CNA did check on the resident throughout the night, but she just forgot to document it. During an interview on [DATE] at 5:02 PM, RN B stated she was notified of nurse aides that Resident #63 was found unresponsive at the time of shift change. During an interview on [DATE] at 5:04 PM, CNA H stated she walked into Resident #63's room, found resident non-responsive, and notified RN B immediately. She stated this occurred at shift change. During an interview on [DATE] at 1:56 PM, the ADMN stated her expectation was to call the physician with any change of condition. She stated if a residents oxygen level decreased and staff was having to address that, staff should have contacted the physician and the DON, but only if the resident needed orders outside of resident's parameter orders. Attempted interview on [DATE] at 11:09 AM with CNA F who worked on the night of [DATE] and she did not answer. During an interview on [DATE] at 01:00 PM, CNA G stated she worked the night of [DATE] and was aware of Resident #63's episode at 9:00 pm. She stated she notified the nurse that the resident was having difficulty breathing and the nurse applied oxygen to the resident. She stated she was not in charge of care for that resident and was unaware of her status the rest of the night. She stated CNAs did not document every 2 hours. She stated they complete once a shift documentation. CNA stated there is no way to prove that residents were rounded on every 2 hours. Record review of policy titled, Change in a Resident's Condition or Status, last revised [DATE] read in part: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly .2. A significant change of condition is a major decline or improvement in the resident's statue that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provide, including information prompted by the Interact SBAR Communication Form. Record review of policy titled, Oxygen Administration, last revised [DATE] read in part: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident .Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis; 2. Signs or symptoms of hypoxia; .4. Vital signs; 5. Lung sounds .Procedure .13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated . This was determined to be an Immediate Jeopardy on [DATE] at 2:40 PM. The ADMIN was notified. The ADMIN was provided with the IJ template on [DATE] at 2:40 PM. The following Plan of Removal was submitted by the facility was accepted on [DATE] at 1:06 PM: Impact Statement: On [DATE] an abbreviated survey was initiated. On [DATE] the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to identify and provide treatment and care to resident #1. How were other residents at risk to be affected by this deficient practice identified? The facility DON and nurse management team completed an audit to address potential change of conditions on all residents using the ,d+[DATE]-hour report on [DATE]. All residents had the potential to be affected by this deficient practice, no other residents were identified as being affected. What corrective actions have been implemented for the identified resident? Resident #1 no longer resides in the building as of [DATE]. What corrective actions were taken? 3. The following actions were initiated immediately on [DATE] h. On [DATE] an audit was completed by the DON and/or designee to identify all residents who were at risk for having a change in condition in last 30days related to their disease process including reviewing all Oxygen orders in last 30days. No residents were identified to be affected. DON and ADON were educated on [DATE] by CSD (Clinical Service Director) on identification of change of condition, e-interact stop and watch tool, and notification to physician when changes of condition are observed in residents. Change in condition will be reported/monitored with the Stop and Watch tool and SBAR. When a change in condition has been identified it will be placed on the shift-to-shift charge nurse report and also reported in the morning clinical meeting by the charge nurse. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. i. On [DATE] an in-service was initiated for all Licensed Nurses, on change of condition, notifying the physician of changes. All staff who are unable to attend will be required to complete training before their next scheduled shift. Inservice was completed on [DATE] and will be monitored and review for effectiveness by DON During QAPI. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. j. On [DATE] an in-service was initiated for all staff by the DON and/or designee on the importance of completing stop and watch forms when there are changes of condition noticed in residents. All nursing staff unable to attend will be required to complete training before their next scheduled shift. Inservice was completed on [DATE] and will be monitored and review for effectiveness by DON During QAPI. 4. How will the system be monitored to ensure compliance? k. The ADON, DON and/or designee will review the facilities ,d+[DATE]-hour summary report in PCC 5 days per week in the morning clinical meeting starting on [DATE] for 4 weeks and then ongoing to identify any resident who has had a change in condition or has symptoms that may trigger an acute decline requiring medical attention. Licensed and trained nursing staff will ensure the physician has been notified and interventions implemented. Any identified concerns will be addressed immediately, and additional training will be provided as needed. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. l. The DON and Nurse Manager will review all stop and watch forms completed by all staff in morning meetings to help identify observed changes in condition and to ensure the physician has been notified. Starting on [DATE] and will be ongoing. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. m. The weekend supervisor and/or designee was in-serviced on [DATE] by DON on how to review the ,d+[DATE]-hour report from PCC and the stop and watch tools on Saturdays and Sundays to ensure that any residents with a change in condition are identified. Nursing staff will contact the physician and ensure appropriate orders and interventions are in place. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. n. Newly hired staff, agency, and PRN staff will be trained on the stop and watch tools, changes in condition, verification of orders, notification to physician during orientation by the DON or designee. Staff unable to come to receive training will be required to completed training before their next scheduled shift. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring of the facility's Plan of Removal through interviews and record reviews from [DATE]at 1:06 pm through [DATE] at 3:00 pm revealed: During an interview on [DATE] at 01:51 PM, DON stated she ran 24-hour report and ran an order listing report that would encompass all new orders. She stated looked at all residents' vital signs including weight and nurses' documentation to identify residents who were at risk. She stated that any change of condition including administering O2, staff would have to contact MD with changes and then anything that was not normal had to be documented as MD notified. DON stated if there was not an answer from doctor then they would continue to try to contact and if they could not get ahold of the physician then nurses will contact DON or ADMN to notify Medical Director. She stated the Medical Directors had been notified of POR and the Medical Directors have been notified that if staff were unable to reach attending, then she would be notified. DON stated changes in condition would be discussed in morning meeting and be documented on a 24-hour report with VS, falls, and new orders in the clinical meeting and everything from previous day would be reviewed. DON stated she would monitor that the in-services were effective by looking at the dashboard on PCC to see if alerts have been cleared out. She stated she would monitor that physicians are being notified by monitoring nurses notes to verify that change in condition was followed up on. DON stated she had remote access to PCC. She stated the weekend supervisor would be the DON and ADON every weekend and that one of them would look at the reports and monitor/review ,d+[DATE]-hour report from PCC. During random interviews via phone on [DATE] at 1:15 PM, revealed 2 Licensed Nurse and 1 Registered Nurse who worked the 12-hour night shift had been educated regarding change of condition and notifying the physician of changes. During random interviews on [DATE] at 2:15 PM, revealed 1 Licensed Nurse and 1 Registered Nurse who worked the 12-hour day shift had been educated regarding change of condition and notifying the physician of changes. Review of written in-service initiated on [DATE] about Change of Condition - Administering O2 - Contacting MD & RP's with changes - Stop n watch - Monitoring after the change of condition - documentation ensure change is on 24 hour report - care planning - monitor nurse alerts require monitoring & documentation. Notify the MD - call - if no answer the nurse will notify DON and/or Administrator and the Medical Director will be notified - Must be documented in the Medical Record. Verified nurses' signatures on in-service. During random interviews via phone on [DATE] at 1:15 PM, revealed 3 CNAs, the importance of completing stop and watch forms when there are changes of condition noticed in residents. During random interviews on [DATE] at 2:15 PM revealed 2 CNAs, the importance of completing stop and watch forms when there are changes of condition noticed in residents. Review of written in-service initiated on [DATE] with CNAs titled Change of condition- Stop N Watch, with 27 signatures. Review on [DATE] at 01:51 PM, revealed QAPI Signature page with: ADMN and MD signatures on [DATE] and DON, ADON, Payroll, BOM, Housekeeping, Maintenance Director, Medical Records, Nutrition Services, Rehab Services Director, Social Service, and Activity Director signatures on [DATE]. The ADMIN was informed that the Immediate Jeopardy was removed on [DATE] at 3:18 PM. The facility remained out of compliance at a scope of isolated with no actual harm, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems that were put into place.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in freezer and dry storage. The facility failed to ensure all food was not past expiration date. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on [DATE] between 9:45 AM and 10:10 AM of the kitchen revealed: Refrigerator #1 1. One unopened container of sour cream with a best by date of [DATE]. Dry Storage 1. One package of breadcrumbs with open date of [DATE] sitting in a see through bag that was unsealed, and food exposed to air. Freezer 1. Two packages of cake that were sealed and out of original package with no item description or date. During an interview on [DATE] at 10:07 AM, the DM stated items stored outside of the original container should be labeled with item description and date on it. She stated the item in freezer was angel food cake. She stated items in the dry storage should be sealed. The DM stated she expected for items in refrigerator to not be expired. She stated she monitors that food was stored properly. She did not know why there was expired goods, unlabeled goods and open to air goods being stored. She stated that improper storing of food could cause residents to become sick. During an interview on [DATE] at 5:03 PM, the ADMN stated she expected food to be stored out of original containers to be labeled and dated. She stated all expired goods should be discarded and all food items to be sealed. She stated facility contracts dietary staff and the DM along with other contracted agency staff monitor that food was stored correctly. The ADMN stated she and other cooperate staff also monitor that food was stored correctly. She did not know why items were stored incorrectly. She stated the DM does check food items and had been diligent in checking dates during the DM's rounds. She stated if food was not stored properly, it had potential to have a negative impact on the residents. She did not state what that negative impact would be but stated that residents should not eat spoiled food. She stated that every resident did eat out of the dining room unless outside food was brought into facility by that resident's family members. Record review of the facility policy titled, Food Storage: Cold Foods dated ,d+[DATE] revealed: All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Record review of the facility policy titled, Food Storage: Dry Goods dated ,d+[DATE] revealed: The Dining Services Director or designee regularly inspects the dry storage area to ensure it is well lit, well ventilated and not subject to sewage or wastewater back flow or contamination by condensation, leakage, rodents or vermin. All packaged and canned food items will be kept clean, dry, and properly sealed. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed [DATE] revealed: ,d+[DATE].11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement. (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD. (3) An accurate declaration of the net quantity of contents. (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observation, interview, and record review the facility failed to review and revise resident's comprehensive care plancs by the interdiscplianry team after each assessment 3 (Residents #13, #22 and #33) of 16 residents reviewed for comprehensive care plans. The interdisciplinary team failed to review and revise the plan of care for Residents #13, #22 and #33. These failures could affect residents by placing them at risk for not having their individual needs met. Findings included: Resident #13 Record review of Resident #13's Face sheet dated 07/24/2024 revealed an [AGE] year-old female, with an initial admitted to the facility on [DATE]. Resident #13 had a diagnoses of obstructive sleep apnea and anxiety. Record review of Resident #13's Physician orders dated 05/13/2024 revealed: O2 sats every shift and as needed. O2 at 2-4 liter/minute via nasal cannula. Record review of Resident #13's MDS dated [DATE], Section C under Cognitive Patterns revealed a BIMS score of 00 (severely impaired). Record review of Resident #13's Care Plan with the last review dated 07/18/2024 revealed, no evidence of Oxygen use via nasal cannula. During an observation on 07/23/2024 at 8:42 AM, Resident #13 had Oxygen on via nasal cannula. Resident #22 Record review of Resident #22's Face sheet dated 07/24/2024 revealed an [AGE] year-old male, with an initial admitted to the facility on [DATE]. Resident #22 had a diagnoses of muscle weakness, person injured in collision between other specified motor vehicle, displaced fracture of olecranon process without intraarticular extension of left ulna (elbow fracture) and unsteadiness on feet. Record review of Resident #22's Physician orders dated 07/24/2024 revealed: WBAT to LLE with fx boot and WBAT to LUE with a start date of 07/08/2024. Record review of Resident #22's MDS dated [DATE] Section C under Cognitive Patterns revealed a BIMS score of 14 (cognitively intact). Record review of Resident #22's Care Plan initiated 06/11/2024 revealed there were no splints or braces Care Planned. During on observation and interview on 07/23/24 at 04:24 PM, Resident #22 had a back brace and left ankle boot on. The resident stated he only wore his brace and boot when he was out of bed. Resident #33 Record review of Resident #33's Face sheet dated 07/24/2024 revealed a [AGE] year-old female, with an initial admitted to the facility on [DATE] and a most recent admitted [DATE]. Resident #33 had a diagnoses of acute and chronic respiratory failure and congestive heart failure. Record review of Resident #33's Physician orders dated 07/24/2024 revealed: O2 at 2 liters/minute via nasal cannula continuously with a start date of 05/18/2023. Record review of Resident #33's MDS dated , 06/13/2024 Section C under Cognitive Patterns revealed a BIMS score of 15 (cognitively intact). Record review of Resident #33's Care Plan date initiated 11/06/2019 and a revision date of 12/20/2023 revealed: Focus-The resident has altered respiratory status/difficulty breathing r/t heart failure. Goal- the resident will maintain normal breathing pattern as evidenced by normal skin color, and regular respiratory rate/pattern through the review date. Interventions O2 saturation every shift, apply as needed O2 if > (greater) or = (equal) to 90 % (percent) every shift. During an observation on 07/22/2024 at 4:02 PM, Resident #33 was wearing O2 via nasal cannula. During an interview on 07/25/24 at 8:30 AM the DON stated, if there were an order for O2 and braces, they should have been care planned as well as being measurable. She stated Resident #33's Care Plan was not person centered or measurable and was a typo and could be corrected. The DON stated the DON, MDS, and ADON was in charge of monitoring the care plans although the ADON and the MDS were new to the facility. She stated there was no negative impact or outcome for residents not having the O2 in their care plan as well as the braces. The DON stated the residents were still getting the proper care they needed and was only the paperwork that was not correct. She stated she would have to look at each case to if there were a failure, but if it were late at night, the failure would have been the residents nurse that failed to update the care plan. The DON stated her expectations were for all care plans to be updated when needed. During an interview 07/25/24 at 10:38 AM, the previous facility MDS Coordinator stated If there were an order for O2 or braces it should have been care planned as well have been resident centered. During an interview on 07/25/24 at 11:23 AM, LVN-E stated the nurses looked at care plans in the EMR and if it needed to be updated, they could have done that. She stated they then would have always notified the DON for any and all changes they made. During an interview on 07/25/24 at 3:14 PM LVN-D stated she still worked on resident care plans and felt it was still her responsibility to keep them up to date. She stated she had been out of the facility for two weeks and could log into the resident EMR from her home, but she had been too busy to do so. LVN-D stated if she were still full time at the facility, the protocols and policies were to review the MDS's and then updated the care plans as needed or with significant change. LVN-D stated staff had morning meetings as well and if there were any changes voiced, the care plans would need to be reviewed and updated. During an interview on 07/25/24 at 3:39 PM the MDS Corporate Consultant stated the care plans were to be reviewed quarterly and updated as needed. She stated if there were an order for O2 and/or braces, those orders should have been care planned. The MDS Corporate Consultant stated the staff as a whole should have monitored the residents care plans. She stated she felt there was no negative impact for residents if not care planned as the nurses went by the resident orders and not the care plans. She stated she had no idea what the failure might have been. The MDS Corporate Consultants expectations were that the care plans should be reviewed upon admission, quarterly and as needed. Review of facility Policy titled Care Plans, Comprehensive Person-Centered dated December 2016 revealed: Policy: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is develop and implemented for each resident. Policy Interpretation and Implementation: 8. the comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; e. Include the resident's stated goals upon admission and desired outcomes; . 13. Care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview and record review the facility failed to adequately provide a communication system that would relay a call directly to staff or a centralized staff work are for 1(Resident #20) of 16 residents reviewed for resident call system. The facility failed to provide a working communication system, that was easily at reach, that would allow Resident #20 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living. The findings included: Record review of Resident #20's face sheet dated 07/23/2024 revealed [AGE] year-old female admitted on [DATE] with original admitted [DATE] with the following diagnoses: cerebral infarction (stroke), peripheral vascular disease (decreased blood flow to lower extremities), acquired absence of left leg above knee (left leg above the knee amputation), muscle weakness, abnormalities of gait and mobility, and aphasia following cerebral infarction (difficulty speaking following stroke). Record review of Resident #20's quarterly MDS dated [DATE] revealed Section C- Cognitive Patterns Resident #20 had a BIMS score of 05 (meaning severe cognitive impairment); Section GG-Functional Abilities and Goals revealed- Resident #20 used wheelchair for mobility and was dependent on staff for bed mobility and bed to chair transfer. Record review of Resident #20's care plan dated 06/26/2024 revealed Focus: Resident #20 is at risk for falls related to confusion, poor communication/comprehension, and unaware of safety needs with date initiated 10/19/2018; Goal: The resident will not sustain serious injury through the review date with date initiated 10/19/2018; Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .The resident needs a safe environment with even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light with date initiated 10/19/2018. During an observation on 07/22/2024 at 03:57 PM, Resident #20's room did not have call light plugged into wall on her side of the room closest to window. During an observation on 07/23/2024 at 11:34 AM, Resident #20 was lying in bed with no call light plugged into wall or in reach of her bed. She did not answer any questions. During an observation on 07/23/2024 at 3:12 PM, Resident #20's room had call light plugged into wall and attached to her bed. Attempted phone interview on 7/23/2024 at 11:42 AM with Resident #20's responsible party who did not answer phone call. During an interview on 07/23/2024 at 3:25 PM, the Maintenance Director stated he was informed by RN C on 07/23/2024 around lunch time that Resident #20 did not have call light on her side of room. He stated he went to Resident #20's room right away and plugged in a call light. He stated he was not sure why Resident #20's side of her room did not have access to call light prior. He stated he was responsible for performing call light checks. During an interview on 07/23/2024 at 3:27 PM, RN C stated she was told by a CNA that Resident #20 did not have a call light in her room around lunch time. She could not remember who told her, but she reported to Maintenance Director at that time. She did not know why Resident #20 did not have call light on her side of the room. During an interview on 07/23/2024 at 3:30 PM, the DON stated she expected for all residents to have a call light. She did not know why Resident #20 did not have a call light on her side of the room. She stated there were no negative outcome to because she would not use call light anyway. She stated that CNAs check on Resident #20 frequently and she felt her needs were met. She did not know who monitored that call lights were in residents' rooms. During an interview on 07/23/2024 at 5:10 PM, the ADMN stated she expected for all residents to have call light in every resident's room and in reach of every resident. She stated Resident #20 would not use call light, but call light should be present on her side of the room. She stated everyone working in the building was responsible for ensuring call lights were available in all rooms and working. She stated the facility was already in-servicing staff and managers on her expectations. She did not know why Resident #20 did not have access to call light on her side of the room during observations on 7/22/2024 and 7/23/2024. During a follow up interview on 07/24/2024 at 10:29 AM, the ADMN stated Resident #20 had no incidents or falls since 2019 and did not feel she was negatively impacted from not having call light available on her side of room. Record review of the facility policy titled Answering the Call Light dated March 2012 revealed Be sure that the call light is plugged in at all times. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Some residents may not be able to use their call light. Be sure you check these residents frequently. Report all defective call lights to the Nurse Supervisor promptly.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of 1 of 16 resident (Resident #118) reviewed for expired medications. The B Hall medication cart contained Promethazine cream with an expiration date of 06/28/2024 for Resident #118 who did not have an order for the medication. This failure could place residents at risk of exposure to medications and/or biologicals that are expired and/or contaminated. Findings include: Review of the electronic face sheet for Resident #118 revealed an admitted [DATE]. Resident was a [AGE] year-old female with diagnoses of dementia, high blood pressure, and overactive bladder. Review of the electronic physician's orders for Resident #118 revealed no orders for Promethazine cream. During on observation on 07/22/2024 at 09:25 AM of the B Hall medication cart Further observation revealed Promethazine cream with an expiration date of 06/28/2024 for Resident #118. During an interview on 07/22/24 at 01:33 PM, RN-C stated expired or discontinued medications should be removed from the medication cart immediately. She stated it was the medications nurse's responsibility to check the medication cart daily and prior to giving medications for expiration dates. During an interview on 07/23/24 at 10:00 AM, the DON stated all expired and discontinued medications should have been removed from the medication carts immediately. The DON stated it was the nurse's responsibility to check medications and carts routinely for expired medications. She stated it was ultimately her responsibility to ensure this is done. During an interview on 07/24/24 at 10:35 AM, the Administrator stated the issue with the expired medications was related to resident being in the facility for respite care and hospice services and providing their own medications. She stated the nurses should have checked expiration dates prior to accepting the medications and placing them in the medication cart. Review of the policy titled, Storage of Medications, last revised April 2007 read in part: Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 1, Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received .2. The nursing staff shall be responsible for maintain medication storage .3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions for 1 of 3 medication carts (Hall B medication cart) reviewed for medication labeling and storage. The B Hall medication cart contained two Fiasp flex pen insulins for Resident #116 with no pharmacy label. The B Hall medication cart contained one Novolin R flex pen insulin for Resident #23 with no pharmacy label. These failures could place residents at risk of receiving the wrong medications. Findings Included: Review of the electronic face sheet for Resident #116 revealed an admitted [DATE]. Resident was an [AGE] year-old female with a diagnosis of diabetes, dementia, and irregular heartrate. Review of the electronic physician's orders for Resident #116 revealed orders for Fiasp Injection Solution 100 UNIT/ML Inject as per sliding scale: if 0 - 70 Notify MD and start hypoglycemic protocol; 71 - 200 = 0; 201 - 250 = 3 units; 251 - 300 = 5 units; 301 - 360 = 7 units; 361 - 499 = 8 units; 500 - 600 = 8 units Notify MD, subcutaneously. Review of the electronic face sheet for Resident #23 revealed an admitted [DATE]. Resident was a [AGE] year-old female with a diagnosis of diabetes, depression, and seizures. Review of the electronic physician's orders for Resident #23 revealed orders for NovoLIN R FlexPen Injection Solution Pen-injector 100 UNIT/ML Inject as per sliding scale: if 121 - 150 = 2 units if 0-70=0 Follow hypoglycemic protocol, notify MD; 151 - 200 = 3 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units 400+ give 10 units Notify MD, subcutaneously before meals. During on observation on 07/22/2024 at 09:25 AM of the B Hall medication cart, two Fiasp flex pen insulins for Resident #116 had no pharmacy label and one Novolin R flex pen insulin for Resident #23 had no pharmacy label. During an interview on 07/22/24 at 01:33 PM, RN-C stated the unlabeled insulin pens were residents home medications and that both residents were there just for 5 days on respite care and wanted to use their own medications. During an interview on 07/23/24 at 10:00 AM, the DON stated the unlabeled insulins had been an issue the facility has been working on. She stated the pharmacy won't label any medication that they did not fill. She stated that when residents want to use their own medications, they must let them. The DON stated that per policy all prescription medications must be properly labeled by a pharmacy. The DON stated it was the nurse's responsibility to check medications and carts routinely for miss labeled medications. She stated it was ultimately her responsibility to ensure this is done. During an interview on 07/24/24 at 10:35 AM, the Administrator stated the issue with the unlabeled medications was related to resident being in the facility for respite care and hospice services and providing their own medications. She stated the nurses should have checked to ensur all medications were properly labeled prior to accepting the medications and placing them in the medication cart. Review of the policy titled, Storage of Medications, last revised April 2007 read in part: Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 1, Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received .2. The nursing staff shall be responsible for maintain medication storage .3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: The facility's kitchen staff failed to wear hair nets during meal preparations. The facility's kitchen staff failed to store food properly. The facility's kitchen staff failed to control the temperature of food while dispensing food portions for individual residents. These failures placed residents at risk for food borne illness and cross-contamination. Findings included: During observation on 04/11/2022 at 10:10 AM, three sheet pans that included frozen green beans, frozen Brussel sprouts and hamburger meat patties were on the prep table, uncovered, left to thaw. In an interview on 04/11/2022 at 10:12, DM-A stated, they let thaw a little in the refrigerator then move to prep table to continue thawing. They have been out approximately 20 minutes. During observation 04/11/22 at 10:18 AM, the dry food storage room revealed: 1. One open bag of potato chips with no in date or open date. During observation 04/11/22 at 10:31 AM, there was a pan with pizza dough placed on the warming table to thaw. During observation on 04/11/2022 at 10:36 AM, Refrigerator #1 revealed: 1. 2 cups of milk and 3 cups of juice with no label, date, or use by date. 2. 1 bowl of cubed ham with no label, date, or use by date. 3. 1 bowl of sliced tomatoes with no label, date or use by date. 4. 1 bowl of sliced onions with no use by date. 5. 2 bowls of premade salad with no label, date, or use by date. 6. 1 bowl of cooked bacon with no label or use by date. During observation 04/11/2022 at 10:39 AM Refrigerator #2 revealed: 1. 1 clear plastic container labeled Tomato soup dated 4/8 and had no use by dated of 4/21. 2. 1 clear sealed plastic bag containing Hard boiled eggs, with open date 4/8, and had no use by date. 3. 1 clear sealed plastic bag containing labeled turkey salad, with open date 4/9 and had no use by date. 4. 1 clear sealed plastic bag containing turkey loaf, with open date 4/9 and had no use by date. 5. 1 clear plastic container labeled vanilla pudding with open date of 4/8 and had no use by date. 6. 1 clear plastic container labeled butter rice, dated 4/8 with use by date of 4/21. 7. 1 clear plastic container labeled green beans, dated 4/9 and had no use by date. 8. 1 clear plastic container labeled [NAME] sausage, dated 4/4, with use by date of 4/12. 9. 1 clear plastic container labeled Grape jelly, dated 3/30 and had no use by date. 10. 1 clear plastic container labeled Ranch dressing dated 4/9 and had no use by date. 11. 2 pints of buttermilk with no in date. 12. 14 gallons of 2% milk with no in date. 13. 28 gallons of whole milk with no in date. During observation 04/11/2022, 11:04 AM there were 2 uncovered sheet pans of garlic bread on prep table. In an interview on 04/11/2022 at 11:10 AM, DM-A and DM-B, both stated the policy for thawing food is to take out of freezer the night before and place into refrigerator, if it's not thawed, they place in the sink with running water. They also stated all the food out on prep table should be covered. They stated it is both of their job as DM's to make sure this is done correctly and the expectations are for all staff to be responsible for preparing safe food for the residents. They also stated the failures are where the staff are not practicing with what they learned previously in their in-services. They stated, when storing food in the refrigerators, all food should have open and use by dates, it depends on what it is, and sometimes is 3 days or 7 days. Milk should have an in date, but stated they go by the expiration date that is on the container, and the pudding goes fast, so there is no need to put a use by date. During observation 04/11/2022 at 12:05 PM, DM-A is wearing only a cap and no hairnet with uncontained hair while in kitchen prep area. In an interview 04/11/2022 at 12:06 PM with DM-A, he stated he can wear a cap without a hairnet if all his hair is covered. DM-B stated at her building it is mandatory to wear hairnets, but at this facility she finds the staff does not. She also stated the expectations are for the staff to always wear hairnets, the failure is the staff should be utilizing what they are provided and are not. The DM's are responsible for ensuring staff are following procedures. During observation and interview 04/11/2022 at 12:13 PM Maintenance entered through the back door with no hairnet. He stated he knows hairnets are mandatory in the kitchen, but he was only going slightly into the kitchen and back out. During observation on 04/11/2022 at 12:11 PM, All food on warming table was uncovered while staff prepared other food. During observation on 04/11/2022 at 12:42 PM, two sheet pans of cooked pizza on stovetop instead of warming table with one sheet pan of uncooked and uncovered pizza dough on stovetop thawing and rising before preparation In an interview 04/11/2022 at 12:45 PM, DM-A stated the pizza is on the stovetop to keep warm before serving and the pizza dough will rise faster. During observation on 04/11/2022 at 12:50 PM, on the warming table, temperatures of food revealed: 1. Green beans 120 degrees Fahrenheit (F) with second temperature at 170 degrees F. 2. Ravioli 120 degrees F with second temperature at 170 degrees F. 3. Puree ravioli 100 degrees F with second temperature at 157 degrees F. 4. Puree green beans 110 degrees F with second temperature at 169 degrees F. 5. Hamburger patties 108 degrees F with second temperature at 165 degrees F. In an interview 04/11/2022 at 1:19 PM, DM-B stated the protocol for serving food on the warming table was, food should not be placed on the warming table no earlier than 30 minutes before serving and should be covered. Their expectations are for the food to go out to residents no later than assigned times, with palatable and hot food without having to reheat to regulation temperatures, and not be served at 1:30 PM as it was today, instead of the assigned time of 12:00 PM She also stated the failure was due to not keeping the food covered on the warming table to maintain heat. She also stated she was not sure why the food was not covered at this time. DM-A stated he had no answer as to why the food was not covered. In an interview on 04/13/22 at 03:12 PM, ADMIN stated, refrigerated foods need to be covered, labeled, and dated and products coming in should have the in date on all products, including Milk, and should have open and use by dates. She also stated, thawing food should not be thawed on the prep table and should be left to thaw in the refrigerator. Anything that is left out on a pan should be covered, including the warming table. On the warming table the temperatures should be taken before serving, if not correct temp, should rewarm with a temperature above 165 degrees. Her expectations are for staff to follow the policy and procedures, if there are any questions, to ask their manager and the failures tend to be not following policy and procedures of what they are in-service on. The Admin also stated she was responsible as well as the contracted company for making sure staff are following guidelines and procedures. Record review of facility policy Staff Attire, HCSG Policy 024, with a revised date of 09/2017, the policy statement is as follows: All employees wear approved attire for the performance of their duties. Procedures: 1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. Record review of facility policy Food Preparation, with revision date of 09/2017, the policy statement is as follows: All foods are prepared in accordance with the FDA Food Code. Procedures: 5. The Cook(s) thaws frozen items that requires defrosting prior to preparation using one of the following methods: a. Thawing in the refrigerator b. Thawing in a microwave oven, then transferring immediately to conventional cooking equipment. c. Completely submerging the item under cold water (at a temperature of 70 degrees) d. Cooking directly from the frozen state, when directed. 9. The Cook(s) will prepare all cooked food items in a fashion that permits rapid heating to appropriate minimum internal temperature. 11. When hot pureed, ground, or diced food drop into the danger zone (below 135 degrees), the mechanically altered food must be reheated to 165 degrees for 15 seconds if holding for hot service. 12. When reheating, foods will be rapidly heated to 165 degrees for 15 seconds. 13. All foods will be held at appropriate temperatures, greater than 135 degrees F (or as state regulation requires) for hot holding, and less than 41 degrees for cold food holding. 17. All TCS foods that are to be held for more than 24 hours at a temperature of 41 degrees or less, will be labeled and dated with a prepared date (day 1) and use by date (day 7). Record review of facility policy Food Storage: Cold Food, with revision date of 04/2018, the policy statement is as follows: All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures: 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on interview and record review, the facility failed to develop a Baseline Care Plan within 48 hours of a resident's admission for 5 of 5 (Resident #55, Resident #206, Resident #205, Resident #207, Resident #255) residents reviewed for baseline care plan completion. 1. The facility failed to complete baseline care plan within the required 48-hour timeframe for Resident #55 who was admitted to facility on 01/08/2022 2. The facility failed to compete baseline care plan within the required 48-hour timeframe for Resident #206 who was admitted to the facility on [DATE]. 3. The facility failed to complete baseline care plan within the requited 48-hour timeframe for Resident #205 who was admitted to the facility on [DATE]. 4. The facility failed to compete baseline care plan within the required 48-hour timeframe for Resident #207 who was admitted to the facility on [DATE]. 5. The facility failed to complete baseline care plan within the required 48-hour timeframe for Resident # 255 who was admitted on [DATE]. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. Findings include: Review of Resident # 55's electronic Face Sheet on 04/12/2022 resident was [AGE] year-old male admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of MDS dated [DATE], no BIMS score was recorded. Per review of Resident #55's EMR on 04/12/2022 no baseline care plan available. Review of Resident #206's electronic Face Sheet on 04/11/2022 resident was [AGE] year-old male admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review on 04/13/2022 of EMR, no MDS available for review. No BIMS score available for review. Per review of Resident #206 EMR on 04/11/2022 no baseline care paln available. Review of Resident #205's electronic Face Sheet on 04/12/2022 resident was [AGE] year-old female admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review on 04/13/2022 of resident EMR on 04/13/2022 no MDS available for review. No BIMS score available for review. Per review of Resident #205 EMR on 04/12/2022 no baseline care plan available. Per review of Resident #207 electronic Face Sheet on 04/12/2022 resident was [AGE] year-old male admitted on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident's EMR on dated 04/06/2022 no BIMS score recorded. Per review of Resident # 207 EMR on 04/12/2022 no baseline care plan available. Per review of Resident #255 electronic Face Sheet on 04/13/2022 resident was a [AGE] year-old female admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of resident's EMR on 04/13/2022 no MDS available for review. No BIMS score available for review. Per review of Resident #255 EMR on 04/13/2022 no baseline care plan available. Per interview with DON on 04/12/22 03:56 PM she said the new admits would have an interim plan of care. She said per guidelines she looked at it does not have to have the diagnosis. If a resident came in and needed [CONDITION(S)] it would be in the orders, same as if they have a [CONDITION(S)] and weight bearing status, but not in interim care plan. I would not consider it a baseline care plan. The aides document on POC (Plan of Care)and they only document the care that they have given. Let me go check on the computer for the steps that they take. Per interview on 04/13/22 10:01 AM with Corporate Clinical Consultant, she said the Interim plan of care- yes, the interim is baseline care plan. The nurse can add to the baseline from the comprehensive. The aides can look at the interim or comprehensive care plan. Then if it needs more problems in the first couple of weeks it will be modified. ADLs would not be in there; wound care will go in comprehensive care plan., The Aides do not have access to the interim plan of care. They do not have access to any care plan until comprehensive care plan is completed. The aides can only look at the tasks that DON has triggered. Per interview with DON on 04/13/2022 at 08:52 AM she said the admit nurse does the Interim Plan of Care during the admission of a new resident. A section under tasks is where the plan of care for CNAs in initiated. The Admit nurse may or may not be an LVN. She said she would expect the Interim Plan of Care be completed in 48 hours of admission of new resident. Not having a baseline care plan could result the resident not getting the right care. She said she did not know why the care plans are not being done within 48 hours of admission. As DON she said she was responsible for training and ensuring they are done. Per review of Facility's policy dated (Revised December 2016) titled: Care Plans-Baseline A baseline care plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Policy interpretation and Implementation 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] b. Physician orders c. Dietary orders d. Therapy Services e. Social services f. PASARR recommendation, if applicable 3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. 4. The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a. The initial foals of the resident b. A summary of the resident's medications and dietary instructions c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. An updated information based on the details of the comprehensive care plan as necessary.

Based on interviews, observations, and record reviews, the facility failed to ensure that residents who require [CONDITION(S)], receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #255) reviewed for [CONDITION(S)]. Resident #255 had no orders for maintenance of [CONDITION(S)] care needs. Resident #255 interim plan of care did not address [CONDITION(S)] care needs. Resident #255 nursing progress notes did not mention any care regarding observations or maintenance of [CONDITION(S)]. These failures place residents at risk of receiving the necessary care and treatment including medical and nursing care and services regarding [CONDITION(S)]. Findings included: Record review of Resident #255 electronic Face sheet dated 04/12/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #255 Interim Plan of Care dated 04/07/22 did not address [CONDITION(S)] care needs. Record review of Resident #255 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #255 Weekly Skin assessment dated [DATE] revealed a skin area of Left iliac crest Ostomy. Record review of Resident #255 Nursing Progress Notes dated 04/06/22 through 04/13/22 revealed no documentation regarding resident [CONDITION(S)]. During an interview on 04/13/22 at 10:30AM with RN A, she said the admission nurse is responsible for putting orders in for the resident. She said the orders are based off the hospital discharge orders and/or physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Checking the appearance of the stoma when changing the wafer. RN A said the changing of the wafer for the stoma/colotomy would fall to the responsibility of the treatment nurse, but the resident's nurse had access to the stoma supplies and could change the resident [CONDITION(S)] wafer and pouch if needed. RN A reviewed Resident #255 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said after a resident was admitted the ADON would double check the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON would do the reconciliation of the physician orders, but RN A did not know if there was a specific time frame to reconcile the physician orders. During an interview on 04/13/22 at 10:45AM with the ADON, she said, the admitting nurse was responsible for getting all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON said the timeframe for admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview/observation on 04/13/22 at 3:20PM with Resident #255, [CONDITION(S)] bag on left lower abdomen. Resident had just finished eating her saved lunch after returning from [CONDITION(S)]. Resident #255 [CONDITION(S)] bag had small amount of stool in the bag, the ostomy wafer was clean, noted that small amount of hard brown stool was protruding from lower side of wafer. Resident said she thought the facility changed the wafer and ostomy bag at least 1 time in the past week, but she said she could not remember what day it was. During an interview on 04/13/22 at 3:55PM with CNA A, she said the aides do not touch resident colostomies. She said only the nurses check, change, empty the resident colostomies. She said Resident #255 came into the facility last week with a [CONDITION(S)]. Record review of facility policy labeled [CONDITION(S)]/[CONDITION(S)] Care revised October 2010 revealed: Review the resident's care plan to assess for any special needs of the resident .Cleanse skin with appropriate skin cleansing preparation. When evaluating the condition of the resident's skin, note the following: Breaks in the skin. Excoriation. Signs of infection (heat, swelling, pain, redness, purulent exudate, etc.) Documentation The following information should be recorded in the resident's medical record: The date and time the [CONDITION(S)]/[CONDITION(S)] care was provided . Any breaks in resident's skin, signs of infection (purulent discharge, pain, redness, swelling, temperature), or excoriation of skin.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents who require [CONDITION(S)] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 (Resident #255) reviewed for [CONDITION(S)]. Resident #255 did not have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #255 interim plan of care did not address [CONDITION(S)] care needs. These findings place residents at risk of receiving care and services for the provision of hemodialysis. Findings included: Record review of Resident #255 electronic Face sheet dated 04/12/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #255 Interim Plan of Care dated 04/07/22 did not address [CONDITION(S)] care needs. Record review of Resident #255 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #255 Weekly Skin assessment dated [DATE] did not address resident [CONDITION(S)] access site. Record review of Resident #255 Nursing Progress notes 04/08/22 through 04/11/22 included mention of resident [CONDITION(S)] shunt/fistula to LUE. During an interview on 04/13/22 at 10:30AM with RN A, she said the admission nurse is responsible for putting orders in for the resident. She said the orders are based off of the hospital discharge orders and/or physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the orders would also include monitoring of the fistula site before and after [CONDITION(S)]. RN A reviewed Resident #255 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said after a resident was admitted the ADON would double check the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON would do the reconciliation of the physician orders, but RN A did not know if there was a specific time frame to reconcile the physician orders. During an interview on 04/13/22 at 10:45AM with the ADON , she said, the admitting nurse was responsible for getting all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON said the timeframe for admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview/observation on 04/13/22 at 3:20PM with Resident #255, dressing on left upper forearm. Resident had just finished eating her saved lunch after returning from [CONDITION(S)]. She had been going to [CONDITION(S)] in the late morning and she took a green folder with her to and from [CONDITION(S)]. She said she goes to [CONDITION(S)] on Monday, Wednesday, and Friday. During an interview on 04/13/22 at 3:55PM with CNA A, she said Resident #255 came into the facility last week with [CONDITION(S)]. Record review of facility policy labeled End-Stage [CONDITION(S)], Care of a Resident with revised September 2010 revealed: Residents with end-stage [CONDITION(S)] ([CONDITION(S)]) will be cared for according to currently recognized standards of care . Staff caring for residents with [CONDITION(S)], including residents receiving [CONDITION(S)] care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes, specifically: The nature and clinical management of [CONDITION(S)] (including infection prevention and nutritional needs); The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis; Signs and symptoms of worsening condition and/or complications of [CONDITION(S)]; How to recognize and intervene in medical emergencies such as hemorrhages and septic infections; How to recognize and manage equipment failure or complications .; Timing and administration of medications, particularly those before and after [CONDITION(S)]; The care of grafts and fistulas; and The handling of waste

Based on observations, interviews, and record reviews, the facility failed to complete admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #255 did not have admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #255 did not have admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures place residents at risk of maintaining functional abilities. Findings included: Record review of Resident #255 electronic Face sheet dated 04/12/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #255 Interim Plan of Care dated 04/07/22 did not address [CONDITION(S)] care needs or [CONDITION(S)] care needs. Record review of Resident #255 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #255 Weekly Skin assessment dated [DATE] revealed a skin area of Left iliac crest Ostomy. Record review of Resident #255 Nursing Progress Notes dated 04/06/22 through 04/13/22 revealed no documentation regarding resident [CONDITION(S)]. Progress notes 04/08/22 through 04/11/22 included mention of resident [CONDITION(S)] shunt/fistula to LUE . During an interview on 04/13/22 at 10:30AM with RN A, she said the admission nurse is responsible for putting orders in for the resident. She said the orders are based off the hospital discharge orders and/or physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the orders would also include monitoring of the fistula site before and after [CONDITION(S)]. RN A said if a resident had a [CONDITION(S)], they would have orders for checking the ostomy daily, changing the wafer and ostomy bag either weekly or every 3 days. Checking the appearance of the stoma when changing the wafer. RN A said the changing of the wafer for the stoma/colotomy would fall to the responsibility of the treatment nurse, but the resident's nurse had access to the stoma supplies and could change the resident [CONDITION(S)] wafer and pouch if needed. RN A reviewed Resident #255 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said after a resident was admitted the ADON would double check the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON would do the reconciliation of the physician orders, but RN A did not know if there was a specific time frame to reconcile the physician orders. During an interview on 04/13/22 at 10:45AM with the ADON, she said the admitting nurse was responsible for getting all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON said the timeframe for admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview/observation on 04/13/22 at 3:20PM with Resident #255, dressing on left upper forearm, [CONDITION(S)] bag on left lower abdomen. Resident had just finished eating her saved lunch after returning from [CONDITION(S)]. She said she had been going to [CONDITION(S)] in the late morning and she took a green folder with her to and from [CONDITION(S)]. She said she goes to [CONDITION(S)] on Monday, Wednesday, and Friday. Resident #255 [CONDITION(S)] bag had small amount of stool in the bag, the ostomy wafer was clean, noted that small amount of hard brown stool was protruding from lower side of wafer. Resident said she thought the facility changed the wafer and ostomy bag at least 1 time in the past week, but she said she could not remember what day it was. During an interview on 04/13/22 at 3:55PM with CNA A, she said the aides do not touch resident colostomies. She said only the nurses check, change, empty the resident colostomies. She said Resident #255 came into the facility last week with [CONDITION(S)] and a [CONDITION(S)]. Record review of facility policy labeled Admission Assessment and Follow Up: Role of the Nurse revised September 2012 revealed: Reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to established procedures. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of facility policy labeled [CONDITION(S)]/[CONDITION(S)] Care revised October 2010 revealed: Review the resident's care plan to assess for any special needs of the resident .Cleanse skin with appropriate skin cleansing preparation. When evaluating the condition of the resident's skin, note the following: Breaks in the skin. Excoriation. Signs of infection (heat, swelling, pain, redness, purulent exudate, etc) Documentation The following information should be recorded in the resident's medical record: The date and time the [CONDITION(S)]/[CONDITION(S)] care was provided . Any breaks in resident's skin, signs of infection (purulent discharge, pain, redness, swelling, temperature), or excoriation of skin. Record review of facility policy labeled End-Stage [CONDITION(S)], Care of a Resident with revised September 2010 revealed: Residents with end-stage [CONDITION(S)] ([CONDITION(S)]) will be cared for according to currently recognized standards of care . Staff caring for residents with [CONDITION(S)], including residents receiving [CONDITION(S)] care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes, specifically: The nature and clinical management of [CONDITION(S)] (including infection prevention and nutritional needs); The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis; Signs and symptoms of worsening condition and/or complications of [CONDITION(S)]; How to recognize and intervene in medical emergencies such as hemorrhages and septic infections; How to recognize and manage equipment failure or complications .; Timing and administration of medications, particularly those before and after [CONDITION(S)]; The care of grafts and fistulas; and The handling of waste

Based on observation, interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services as evidenced by uncertified dietary manager for one of one kitchen. This failure could place residents at risk for food borne illness due to food being prepared by unqualified staff. The findings include: Observation on 9/9/19 at 8:45 revealed no Certified Dietary Manager certificate was posted in the facility. Record review of the personnel files revealed the dietary manager was originally hired by the facility on 11/1/15. He became the Dining Services Director on 4/23/18. No Certification was in his file. In an interview on 9/9/19 at 8:50 am the dietary manager said he was not certified and the contract company responsible for food service staff was 'trying to arrange for a testing session though it may be 3 months'. In an interview on 9/9/19 at 3:49pm with the Administrator, she said the kitchen is contracted with another company. Concerning the certification of the dietary manager she said, 'I thought that was all taken care of.' In an interview on 9/11/19 at 10:30am with the Administrator, she said she had been in touch with 'Corporate' about the contract company for the dietary department. She was told a test date for the dietary manager had not been finalized. In an interview on 9/11/19 at 11:00am with the dietary manager he said there is a dietician on contract but she is not full-time. Record review of the contract company's undated job description, printed on 9/11/19, for Dining Services Director states, 'A facility that employs a qualified dietician, less than full-time, requires a full-time Director of Dining Services who is certified.'

Based on observation, interview and record review, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection for 4 of 4 residents ( #1, #2, #8, #9) and 6 (CNAs C, D, E, and F) of 6 CNAs observed for infection control procedures. a) CNA A did not perform hand hygiene and/or change gloves between dirty and clean tasks for Resident #1 and Resident #9. b) CNA A and CNA B did not perform hand hygiene prior to providing care to Resident #9. c) CNA C and CNA D did not perform hand hygiene or change gloves between dirty and clean tasks for Resident #8. d) CNA E and CNA F did not perform hand hygiene or/and change gloves between dirty and clean tasks for Resident #2 These failures could affect the 66 residents who required assistance with ADLs by placing them at risk for cross-contamination and the spread of infection. Findings included: Resident #1 Review of Resident #1's undated Face Sheet indicated he was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] indicated he was always incontinent of bowel and bladder. During observation on 08/07/17 at 10:50 AM CNA A and CNA B pushed the Hoyer lift into Resident #1's room. They washed their hands and donned gloves. They tucked the front of the wet brief between the resident's legs. CNA A cleaned the perineum. The CNAs turned the resident onto his left side. CNA A cleaned the buttocks of a small amount of feces. CNA A's long, unrestrained hair was brushing across Resident #1's bottom sheet when she was bent over performing incontinent care. CNA A picked up a clean brief and placed it on Resident #1 without first changing gloves. CNA A got a pair of pants from the resident's closet wearing the same gloves. The CNAs moved the Hoyer lift, sling and wheelchair to the bedside. They put the pants on the resident and placed the sling underneath him. They transferred him to his wheelchair. CNA A removed her gloves and brushed her hands through her hair. She took a shirt from the closet and put it on the resident. Resident #2 Record review of Resident #2's undated Face Sheet indicated Resident #2 was [AGE] years-old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #2's 5-Day Scheduled Minimum Data Set (MDS) Assessment, dated 5/19/17, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 2 indicating impaired cognition. Resident #2 required extensive assistance from 1-2 staff for activities of daily living (ADLs) and required setup assistance with meals. The MDS also indicated an active [DIAGNOSES REDACTED]. During an observation on 8/8/17 at 10:41 a.m. CNA E and F donned personal protective equipment (PPE) due to the Resident #2 being on droplet and contact precautions for MRSA. The CNAs had supplies they would be requiring in a plastic bag prior to entering Resident #2's room. CNA E and F entered Resident #2's room to provide incontinence care. CNA E and F washed their hands in the residents bathroom sink and put on clean gloves. Resident #2 had voided both bowel and bladder. CNA E cleaned the resident's perineal area using wipes that she disposed of after one wipe. CNA E then removed her soiled gloves and then without washing her hands reached underneath her protective gown and into her scrub pants pocket and pulled out hand sanitizer and applied the sanitizer to her hands, CNA E then returned the hand sanitizer to her scrub pants pocket and donned a new pair of gloves. CNA E then wiped the bed while the resident was rolled to one side of the bed by CNA F. After CNA E disposed of the wipe, CNA E grabbed the clean linen and rolled the clean linen onto the bed while removing the dirty linen by rolling the clean linen to where the dirty linen had been rolled away. CNA E then grabbed a tube of protective barrier cream and applied it to Resident #2 while the resident was rolled on his side without removing and washing her hands and donning a new pair of gloves. During this time CNA F assisted with rolling the dirty linen up and placed it in a yellow linen bag and placed it in the appropriate container in the room. She then returned without washing her hands and changing gloves. CNA F then assisted in unrolling the clean linen and assisted with making the rest of the bed. CNA F then removed her gloves and reached into her scrub pants pocket that was underneath her protective gown without washing her hands and retrieved her hand sanitizer, after she applied it to her hands she returned the hand sanitizer to her pocket and donned a new pair of gloves. CNA E with the assistance of CNA F who was still wearing the same gloves assisted with positioning Resident #2 higher in bed for comfort with the use of the extra sheets that were positioned underneath the resident. Prior to leaving Resident #2's room the CNAs removed their PPE and washed their hands. During an interview with the DON on 8/9/17 at 1:40 p.m., she said her expectations were that staff clean their hands in between gloves. After removing dirty gloves and prior to donning clean gloves. The DON said staff should not be touching clean items with dirty gloves. During an interview with CNA E on 8/9/17 at 1:50 p.m. she said proper hand washing would be cleaning hands between gloves after removing dirty gloves and before donning clean gloves. CNA E said she should not have touched clean areas with dirty gloves or after removing dirty gloves prior to cleansing hands. Resident ID #8 Record review of resident ID #8's Admission Face Sheet, not dated, documented she was a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of resident ID #8's Quarterly MDS Assessment, dated 07/19/2017, documented the following: she required extensive assistance of 1 person for bed mobility, transfers, personal hygiene and toileting. She required extensive assistance with two person assist for dressing and total dependence for bathing. She is always incontinent of bladder and frequently incontinent of bowel. Record review of resident ID #8's Physician order [REDACTED]. 03/22/2017 - telephone order: may collect urinalysis due to lower abdominal pain/confusion; 03/23/2017 - urinalysis and culture; 03/24/2017 - Bactrim DS (this medication is a combination of two antibiotics: [MEDICATION NAME] and [MEDICATION NAME]. It is used to treat a wide variety of bacterial infections (such as middle ear, urine, respiratory, and intestinal infections) one tablet by mouth twice a day for 7 day for urinary tract infection; 05/15/2017 - [MEDICATION NAME] 100mg. (is an antibiotic used to treat bladder infections) one tablet by mouth twice a day for 10 days; 06/25/2017 - telephone order: [MEDICATION NAME] 100mg. (is an antibiotic used to treat bladder infections) one tablet by mouth three times a day for 6 days for E.coli/urinary tract infection The urinary tract is the most common site of E coli (Escherichia coli) infection, and of all uncomplicated UTIs (urinary tract infection) are caused by E coli infection; 06/27/2017 - discontinue [MEDICATION NAME] 100mg. Start [MEDICATION NAME] 50 mg. one tablet by mouth twice a day for 10 days for [DIAGNOSES REDACTED].>07/22/2017 - may collect urinalysis and culture if indicated; 07/24/2017 -[MEDICATION NAME]. (used to treat urinary tract infections) one tablet by mouth twice a day for 7 days; 07/25/2017 - [MEDICATION NAME]. one tablet by mouth twice a day for 7 days and start [MEDICATION NAME] 500mg. (treatment of [REDACTED]. In an observation on 08/08/2017 at 3:15 PM, CNA C and D washed their hands, donned gloves and positioned a gait belt around resident ID #8's waist. CNA C and D assisted resident ID #8 to stand and placed her on the toilet. CNA C placed a bag of supplies in the sink and took a package of wipes out of the bag and placed it on the back of the toilet. CNA D removed the soiled brief from the resident but did not remove her soiled gloves. CNA C pulled a wipe from the package and properly cleaned resident ID #8's peri-area. Resident ID #8 had a bowel movement and CNA C pulled a wipe from the package and began to clean the resident's buttocks. CNA C reached into the wipe package several times to clean resident ID #8's buttocks. CNA C did not remove her soiled gloves or perform hand hygiene. CNA C reached in the bag and got a clean brief and positioned the brief between resident ID #8's legs. CNA C and D attached the tabs of the brief and assisted resident ID #8 to stand. CNA C and D pulled the brief and the resident's pants up and assisted the resident into the wheelchair. CNA D patted resident ID #8's hand and CNA C pushed the wheelchair to the resident's bedside. CNA C and D then removed their soiled gloves and washed their hands. In an interview on 08/08/2017 at 3:30 PM, CNA D stated she should have removed her soiled gloves after she removed the soiled brief and she should have performed hand hygiene before donning clean gloves. She stated she should not have touched resident ID #8's clothing or her hand until she performed hand hygiene. In an interview on 08/08/2017 at 3:40 PM, CNA C stated she should have removed her soiled gloves after cleaning resident ID #8, perform hand hygiene and donned clean gloves prior to touching resident ID #8's clothing. She stated the wipes belonged to resident ID #8 and she should have taken several out of the package prior to cleaning the resident. Resident #9 Review of Resident #9's undated Face Sheet indicated he was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #9's MDS assessment dated [DATE] indicated he was always incontinent of bowel and bladder. During observation on 08/07/17 at 11:30 AM CNA A and CNA B pushed the Hoyer lift into Resident #9's room. Both donned gloves but did not first wash their hands. They tucked the front of the wet brief between the resident's legs. CNA A cleaned the perineum. The CNAs turned the resident onto his left side. CNA A cleaned the buttocks/anus. CNA A picked up a clean brief and placed it on Resident #9 without first changing gloves. In an interview on 08/09/2017 at 6:40 AM, the DON stated the CNA should gather supplies and pull several wipes from the package prior to cleaning the resident and to never place supplies on the residents' bed or toilet. She stated she expects the CNA to wash their hands, don gloves, and clean the resident's peri-area and buttocks. She stated she expects the CNA to perform hand hygiene in between glove changes and change their gloves from dirty and prior to touching clean items. In an interview on 08/09/2018 at 7:15 AM, the ADON stated she tries to schedule CNAs to work a specific hall for continuity of care but the CNA can work any hall if needed. She stated the night shift CNAs are not scheduled for a specific hall. Record review of the facility's Tracking and Trending log, during June 2017 documented there were 6 residents with urinary tract infections and during July 2017 there were 10 residents with urinary tract infections. Record review of the facility's policy and procedure titled Perineal Care, revised date October 2010, documented the following (in part): The purposes of this procedure are to provide cleanliness and comfort t the resident, to prevent infections and skin irritation and to observe the residents' skin condition. Gather supplies; identify self and explain what you are going to do; wash hands and put on gloves; place wipes package on clean bedside table; Female - cleans labia with one hand and cleanse the area with downward strokes using a new wipe with each stroke; clean rectal area with clean wipe by wiping from front to back; place soiled items in a plastic bag; change gloves using proper technique and disposal; place a clean incontinent pad or brief on resident; Remove gloves and wash hands. Record Review of the Infection Control Policy undated provided by the DON indicated the following: All employees are required to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Form CMS 672, Resident Census and Conditions of Residents, completed and signed and dated by the DON on 8/7/17, indicated a census of 66 residents.

Based on observation, interview, and record review, the facility failed to ensure 6 of 6 CNAs (CNAs A, B, C, D, E, and F) observed demonstrated competency in techniques to care for 4 of 4 residents (Residents #1, 2, 8, and 9) observed for incontinent care. a) CNA A did not perform hand hygiene and/or change gloves between dirty and clean tasks for Resident #1 and Resident #9. b) CNA A and CNA B did not perform hand hygiene prior to providing care to Resident #9. c) CNA C and CNA D did not perform hand hygiene or change gloves between dirty and clean tasks for Resident #8. d) CNA E and CNA F did not perform hand hygiene or/and change gloves between dirty and clean tasks for Resident #2. This failure affected 4 residents and could affect the other 62 residents by causing the spread of infection and a decline in the residents' health and well being. Findings included: Resident #1 Review of Resident #1's Face Sheet indicated he was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] indicated he was always incontinent of bowel and bladder. During observation on 08/07/17 at 10:50 AM CNA A and CNA B pushed the Hoyer lift into Resident #1's room. The washed their hands and donned gloves. They tucked the front of the wet brief between the resident's legs. CNA A cleaned the perineum. The CNAs turned the resident onto his left side. CNA A cleaned the buttocks of a small amount of feces. CNA A's long, unrestrained hair was brushing across Resident #1's bottom sheet when she was bent over performing incontinent care. CNA A picked up a clean brief and placed it on Resident #1 without first changing gloves. CNA A got a pair of pants from the resident's closet wearing the same gloves. The CNAs moved the Hoyer lift, sling and wheelchair to the bedside. They put the pants on the resident and placed the sling underneath him. They transferred him to his wheelchair. CNA A removed her gloves and brushed her hands through her hair. She took a shirt from the closet and put it on the resident. Resident #2 Record review of Resident #2's Face Sheet indicated Resident #2 was [AGE] years-old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #2's 5-Day Scheduled Minimum Data Set (MDS) Assessment, dated 5/19/17, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 2 indicating impaired cognition. Resident #2 required extensive assistance from 1-2 staff for activities of daily living (ADLs) and required setup assistance with meals. The MDS also indicated an active [DIAGNOSES REDACTED]. During an observation on 8/8/17 at 10:41 a.m. CNA E and F donned personal protective equipment (PPE) due to the Resident #2 being on droplet and contact precautions [MEDICAL CONDITION]. The CNAs had supplies they would be requiring in a plastic bag prior to entering Resident #2's room. CNA E and F entered Resident #2's room to provide incontinence care. CNA E and F washed their hands in the residents bathroom sink and put on clean gloves. Resident #2 had voided both bowel and bladder. CNA E cleaned the resident's perineal area using wipes that she disposed of after one wipe. CNA E then removed her soiled gloves and then without washing her hands reached underneath her protective gown and into her scrub pants pocket and pulled out hand sanitizer and applied the sanitizer to her hands, CNA E then returned the hand sanitizer to her scrub pants pocket and donned a new pair of gloves. CNA E then wiped the bed while the resident was rolled to one side of the bed by CNA F. After CNA E disposed of the wipe, CNA E grabbed the clean linen and rolled the clean linen onto the bed while removing the dirty linen by rolling the clean linen to where the dirty linen had been rolled away. CNA E then grabbed a tube of protective barrier cream and applied it to Resident #2 while the resident was rolled on his side without removing and washing her hands and donning a new pair of gloves. During this time CNA F assisted with rolling the dirty linen up and placed it in a yellow linen bag and placed it in the appropriate container in the room. She then returned without washing her hands and changing gloves. CNA F then assisted in unrolling the clean linen and assisted with making the rest of the bed. CNA F then removed her gloves and reached into her scrub pants pocket that was underneath her protective gown without washing her hands and retrieved her hand sanitizer, after she applied it to her hands she returned the hand sanitizer to her pocket and donned a new pair of gloves. CNA E with the assistance of CNA F who was still wearing the same gloves assisted with positioning Resident #2 higher in bed for comfort with the use of the extra sheets that were positioned underneath the resident. Prior to leaving Resident #2's room the CNAs removed their PPE and washed their hands. During an interview with the DON on 8/9/17 at 1:40 p.m., she said her expectations were that staff clean their hands in between gloves. After removing dirty gloves and prior to donning clean gloves. The DON said staff should not be touching clean items with dirty gloves. During an interview with CNA E on 8/9/17 at 1:50 p.m. she said proper hand washing would be cleaning hands between gloves after removing dirty gloves and before donning clean gloves. CNA E said she should not have touched clean areas with dirty gloves or after removing dirty gloves prior to cleansing hands. Resident #8 Record review of resident ID #8's Admission Face Sheet, not dated, documented she was a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of resident ID #8's Quarterly MDS Assessment, dated 07/19/2017, documented the following: she required extensive assistance of 1 person for bed mobility, transfers, personal hygiene and toileting. She required extensive assistance with two person assist for dressing and total dependence for bathing. She was always incontinent of bladder and frequently incontinent of bowel. Record review of resident ID #8's Physician order [REDACTED]. 03/22/2017 - telephone order: may collect urinalysis due to lower abdominal pain/confusion; 03/23/2017 - urinalysis and culture; 03/24/2017 - Bactrim DS (this medication is a combination of two antibiotics: [MEDICATION NAME] and [MEDICATION NAME]. It is used to treat a wide variety of bacterial infections (such a urine infections) one tablet by mouth twice a day for 7 day for urinary tract infection; 05/15/2017 - [MEDICATION NAME] 100mg. (is an antibiotic used to treat bladder infections) one tablet by mouth twice a day for 10 days; 06/25/2017 - telephone order: [MEDICATION NAME] 100mg. (is an antibiotic used to treat bladder infections) one tablet by mouth three times a day for 6 days for E.coli/urinary tract infection The urinary tract is the most common site of E coli (Escherichia coli) infection, and of all uncomplicated UTIs (urinary tract infection) are caused by E coli infection; 06/27/2017 - discontinue [MEDICATION NAME] 100mg. Start [MEDICATION NAME] 50 mg. one tablet by mouth twice a day for 10 days for [DIAGNOSES REDACTED].>07/22/2017 - may collect urinalysis and culture if indicated; 07/24/2017 -[MEDICATION NAME]. (used to treat urinary tract infections) one tablet by mouth twice a day for 7 days; 07/25/2017 - [MEDICATION NAME]. one tablet by mouth twice a day for 7 days and start [MEDICATION NAME] 500mg. (treatment of [REDACTED]. In an observation on 08/08/2017 at 3:15 PM, CNA C and D washed their hands, donned gloves and positioned a gait belt around resident ID #8's waist. CNA C and D assisted resident ID #8 to stand and placed her on the toilet. CNA C placed a bag of supplies in the sink and took a package of wipes out of the bag and placed it on the back of the toilet. CNA D removed the soiled brief from the resident but did not remove her soiled gloves. CNA C pulled a wipe from the package and properly cleaned resident ID #8's peri-area. Resident ID #8 had a bowel movement and CNA C pulled a wipe from the package and began to clean the resident's buttocks. CNA C reached into the wipe package several times to clean resident ID #8's buttocks. CNA C did not remove her soiled gloves or perform hand hygiene. CNA C reached in the bag and got a clean brief and positioned the brief between resident ID #8's legs. CNA C and D attached the tabs of the brief and assisted resident ID #8 to stand. CNA C and D pulled the brief and the resident's pants up and assisted the resident into the wheelchair. CNA D patted resident ID #8's hand and CNA C pushed the wheelchair to the resident's bedside. CNA C and D then removed their soiled gloves and washed their hands. In an interview on 08/08/2017 at 3:30 PM, CNA D stated she should have removed her soiled gloves after she removed the soiled brief and she should have performed hand hygiene before donning clean gloves. She stated she should not have touched resident ID #8's clothing or her hand until she performed hand hygiene. In an interview on 08/08/2017 at 3:40 PM, CNA C stated she should have removed her soiled gloves after cleaning resident ID #8, perform hand hygiene and donned clean gloves prior to touching resident ID #8's clothing. She stated the wipes belonged to resident ID #8 and she should have taken several out of the package prior to cleaning the resident. In an interview on 08/09/2017 at 6:40 AM, the DON stated the CNA should gather supplies and pull several wipes from the package prior to cleaning the resident and to never place supplies on the residents' bed or toilet. She stated she expects the CNA to wash their hands, don gloves, and clean the resident's peri-area and buttocks. She stated she expects the CNA to perform hand hygiene in between glove changes and change their gloves from dirty and prior to touching clean items. In an interview on 08/09/2018 at 7:15 AM, the ADON stated she tries to schedule CNAs to work a specific hall for continuity of care but the CNAs can work any hall if needed. She stated the night shift CNAs are not scheduled for a specific hall. Resident #9 Review of Resident #9's Face Sheet indicated he was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #9's MDS assessment dated [DATE] indicated he was always incontinent of bowel and bladder. During observation on 08/07/17 at 11:30 AM CNA A and CNA B pushed the Hoyer lift into Resident #9's room. Both donned gloves but did not first wash their hands. They tucked the front of the wet brief between the resident's legs. CNA A cleaned the perineum. The CNAs turned the resident onto his left side. CNA A cleaned the buttocks/anus. CNA A picked up a clean brief and placed it on Resident #9 without first changing gloves. Record review of the facility's policy and procedure titled Perineal Care, revised date October 2010, documented the following (in part): The purposes of this procedure are to provide cleanliness and comfort t the resident, to prevent infections and skin irritation and to observe the residents' skin condition. Gather supplies; identify self and explain what you are going to do; wash hands and put on gloves; place wipes package on clean bedside table; Female - cleans labia with one hand and cleanse the area with downward [MEDICAL CONDITION] using a new wipe with each stroke; clean rectal area with clean wipe by wiping from front to back; place soiled items in a plastic bag; change gloves using proper technique and disposal; place a clean incontinent pad or brief on resident; Remove gloves and wash hands. Record review of the facility's Tracking and Trending log, during June 2017 documented there were 6 residents with urinary tract infections and during July 2017 there were 10 residents with urinary tract infections. Record Review of the Infection Control Policy undated provided by the DON indicated the following: All employees are required to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Review of CMS Form 672, Resident Census and Condition of Residents, dated 08/07/17, listed a census of 66.

Based on observation, interview and record review, the facility failed to ensure that one of one kitchens were maintained in a safe, clean and sanitary condition for the storage, preparation and serving of food. The facility failed to ensure food stored in the refrigerator and walk-in cooler was labeled and dated. This failure could affect the 63 residents who received meals from the facility kitchen that could place them at risk for the potential of food contamination, food-borne illnesses and infection. The findings included: Observation and interview during initial tour on 7/25/16 between 2:20 and 2:40 pm revealed the following: In the walk-in cooler: a gallon size zip top style bag of shredded red cabbage dated 7/8/16, not labeled for contents In the refrigerator: Zip top style bag of cinnamon rolls, dated, was not labeled for contents. The DM said the bag contained cinnamon rolls. Zip top style bag of cooked sausage, dated, was not labeled for contents. The DM said the bag contained sausage. Zip top style bag of scrambled eggs, dated, was not labeled for contents. The DM said the bag contained scrambled eggs. In an interview on 7/25/16 at 2:30pm, DM stated he would label the red cabbage, cinnamon rolls, sausage, and scrambled eggs as to the contents of each bag as well as check for any other unlabeled items. Observation on 7/25/16 between 5:05 and 5:30 pm of the walk-in cooler revealed: Gallon size zip top style bag containing what appeared to be grated parmesan cheese, dated 7/13/16, not labeled for contents Gallon size zip top style bag containing an open bag of mozzarella cheese, outer bag was not dated Gallon size zip top style bag containing green salad mix, dated 7/23/16, was not labeled for contents Gallon size zip top style bag containing shredded iceberg lettuce, dated 7/21/16, was not labeled for content. The previously observed gallon size zip top style bag of shredded red cabbage dated 7/8/16, remained unlabeled. In an interview on 7/28/16 at 9:08 am, DM stated his expectation was when a package is opened, it gets dated and if the original packaging was not used to store any remaining product; all replacement packaging should be labeled and dated. On 7/28/16 at 1:15pm, the facility's food storage policy was requested from DM. At 2:30 pm he provided a copy labeled as page 53 from the Texas Food Establishment Rules §228.66 (a)(1)(G) with an asterisk marked at (b) Food storage containers, identified with common name of food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. In an interview on 7/26/16 at 10:51 am DM stated 63 residents eat food prepared from the kitchen.

Based on observation, interview and record review, the facility failed to promote care in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality for 2 of 18 residents (Resident # 14, 18) reviewed for dignity. A. Staff standing over residents while assisting them to eat. B. Staff referred to residents as feeders. These failures could affect 6 residents who require assistance or are dependent on staff for eating by placing them at risk for decreased quality of life and loss of self-esteem. Findings include: Review of the undated face sheet revealed Resident #14 was a [AGE] year old male whose latest return to the facility was on 11/14/14 with an original admission date of [DATE]. Resident #14 ' s current [DIAGNOSES REDACTED]. Review of Resident #14's quarterly Minimum (MDS) data set [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 9. A score rating 8-12 indicates moderately impaired. Assessment of Resident 14's Activities of Daily Living (ADL's) for eating revealed a score indicating the need for extensive assistance of two + persons. Observation on 7/26/16 at 1:00 pm in the facility's main dining room, revealed CNA D standing over Resident #14 while feeding him. In an interview on 7/27/16 at 9:00 am, CNA D commented they had a feeder on the hall of resident rooms she was assigned to and she assists with feeders in the facility's main dining room. When asked about standing to feed residents, CNA D stated the facility does not have any rules about standing or sitting to feed residents. Review of the undated face sheet revealed Resident #18 was an [AGE] year old male whose latest return to the facility was on 12/08/14 with an original admission date of [DATE]. Resident #18's current [DIAGNOSES REDACTED]. Observation on 7/26/16 at 1:15 pm in the facility's main dining room, revealed CNA E standing over Resident #18 while feeding him. In an interview on 7/27/16 at 6:00 pm, information was provided to DON about observations of staff standing to feed residents. No verbal response was given. During an interview with DON on 07/28/16 at 9:21 a.m. while discussing residents who need assistance in the dining room, she said the facility had several feeders and that if a resident needed more than minimal assistance the facility would make them a feeder . In an interview with RN consultant on 07/28/16 at 1:23 p.m. she stated that the use of the term feeders was not an appropriate term and was discouraged by the corporation. On 7/28/16 at 1:15 pm request was made for the facility's policy and procedure for feeding residents. Administrator was unable to provide one. Review of the facility's policy and procedure, undated, titled Quality of Life Policy CFR 483.15 received from Administrator on 7/28/16 revealed: The facility will care for residents in a manner and environment that promotes maintenance or enhancement of each resident's quality of life, including dignity and respect with full recognition of his/her individuality. In an interview on 7/28/16 at 3:00 pm, DON stated there were 6 residents in the facility that required staff assistance or are dependent on staff for eating.

Based on observation, interview and record reviewed, the facility failed to provide services according to the written Plan of Care for 1 of 15 residents (Resident #2) reviewed for accuracy of care plans by not providing the resident with supervision during meal times. This failure could affect 6 residents in the facility who require assistance with meals by not providing individualized levels of supervision which could result in an adverse event causing a decline in the resident ' s health status. Findings include: Record review of Resident #2 ' s face sheet dated 10/23/15 revealed that she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2 ' s Quarterly MDS 3.0 (Minimum Data Set) dated 6/8/16 revealed Hearing, Speech, Vision that the resident ' s vision was moderately impaired in that her vision was limited to the degree that she could not see newspaper print but could identify objects. Cognitive Patterns, the BIMS (Brief Interview for Mental Status) was not completed because the resident was rarely/ never understood. Staff assessment of the resident ' s mental status indicated that the resident had short-term and long-term memory problems. Her cognitive ability to make daily decisions was moderately impaired in that her decisions were poor and she required cuing and supervision for decision making. Functional Status, revealed that the resident required the limited assistance of one person to physically assist her with eating. Record review of ADL (Activities of Daily Living) Plan of Care with date range of 2/16/16 to present reveals that Resident #2 required setup the setup help of one person, verbal cueing to eat, and supervision with limited assistance for eating. Record review of Plan of Care dated initiated on 2/16/16 and most recently updated on 6/22/16 reveals that Resident #2 was at risk for weight loss as evidenced by dementia and leaves 25% or more of food uneaten. A comment under Problems/ Needs stated Add Ice Cream and a sandwich without vegetables to lunch and supper. A goal was set for Resident #2 eating 75% to 100% of meals in the next 90 days. Interventions included assessing the resident for food preferences, monitoring dietary intake, serving food of preference, and CNA assisting Resident #2 with meals and encouraging her to finish all meals. Record review of Care Plan summaries dated 10/15/15, 12/23/15, and 6/23/16 revealed Resident #2 required assistance with ADL. Review of care plan summary dated 5/19/16 revealed that Resident #2 was receiving Occupational Therapy services and needed encouragement to participate in ADL. Record review of Annual Nutrition Assessment completed by Dietician dated 7/20/16 reveals that Resident #2 required supervision with eating and has chewing problems. Record review of Communication Form dated 2/2/16 revealed a written message that stated Make Res assist with all meals . Record review of Nurse ' s Notes for Resident #2 revealed the following: 3/21/16: Required extensive assistance with feeding 3/2/16: Resident independent with set-up for feeding 4/4/16: Resident independent with stand by assistance for feeding 4/12/16: Resident required limited contact-guard assistance for feeding 4/25/16: Resident requires limited contact-guard assistance for feeding. Verbal cues after set-up. 5/23/16: Resident is independent to extensive assist with feeding. Needs cues and breaks. 6/1/16: Resident is independent to extensive assist with feeding 6/6/16: Resident is inconsistently independent with eating can require extensive assistance. Record review of Occupational Therapy (OT) progress notes signed 6/8/16 revealed that Resident #2 required stand by assistance for ADL Self-Care and Self-Feeding when their services were initiated on 3/15/16. The anticipated level of Self-Care and Self-Feeding at the end of therapy was that Resident #2 would require supervision only for these skills but was still requiring stand by assist when discharged from services on 6/8/16. OT progress notes on 6/1/16 reveal that Resident # 2 was able to perform self-feeding and required max (maximum) assistance and encouragement to consume her food. She picked up pieces of food with her hand and put some in her mouth. Patient was offered a spoon but would not pick it up. Patient was offered food on the spoon and she opened her mouth and ate it. Patient would not initiate, continue or complete task on her own, and required cues, extra time, and encouragement to consume 50% of the meal . Progress notes on 6/8/16 revealed that Resident #2 required moderate to maximum cues and redirection to initiate, continue and complete tasks and required set up and initially stand by assistance with self-feeding and then was eventually able to complete the task. OT recommended continued training in self-care/ ADL ' s to improve safety for task performance. In a family interview on 7/26/16 at 5:25 PM Resident #2 ' s son stated that he didn't feel like the staff were checking on his mother frequently enough. He stated that Resident #2 will eat what is put on her plate and was frequently served food that she was not supposed to have because it hurts her stomach. Mixed peas and carrots were observed on the resident ' s plate. Her son stated that she shouldn ' t eat the peas and because of her poor vision couldn ' t see well enough to separate the peas from the carrots. He stated that he is present at dinner most days but does not feel that Resident #2 is assisted when he is not there. Observation during meal service on 7/26/16 from 12:30 to 12:40PM in resident room revealed Resident #2 to be sitting up in bed with an over the bed table and tray in front of her. The plate cover had been removed and placed in her recliner. Resident #2 was served ground chicken with brown gravy, mashed red potatoes, roll, green bean casserole, and banana pudding. The silverware was still wrapped in a napkin beside the plate on the tray. Resident #2 was eating with her fingers. Her glasses were on the over the bed table next to the tray. At 12:35 Resident #2 found the silverware on her tray, unwrapped it, and began to feed herself. She had a spoon in her left hand and a fork in her right hand. Resident #2 ' s eyes were closed during most of the observation. Some bites had food on the fork or spoon and some bites had no food on the fork or spoon. When asked if she could see what she was eating she answered mmm mmm which surveyor could not determine to be a yes or no. Resident was unable to answer any additional questions with understandable words or in a way that made sense. Observation from 12:43 PM to 1:10 PM on 7/26/16 revealed no staff entering or leaving Resident #2 ' s room. Tray was picked up at 1:10 PM by Certified Nurse Aide (CNA) A. Resident #2 had eaten about half of her roll, only bites of chicken and mashed potatoes, none of the green bean casserole and 100% of banana pudding. Resident #2 was not observed drinking tea or water during the meal and a visibly significant change in the volume of fluid in either cup was not noted. In an interview on 7/26/16 at 1:10 PM with CNA A he stated that did not assist Resident #2 with eating and did not leave the tray longer or encourage Resident #2 to eat more because she said she was done. He said he usually does not check on her because she feeds herself. Observation from 12:35 PM to 12:40 PMon 7/27/16 revealed Resident #2 to be awake and alert and sitting up in her recliner. Tray delivered at 12:38 PM and staff left the room after removing the plate cover. No additional assistance was provided with the meal. Resident was served chopped steak fingers, cream corn, mashed potatoes, roll, and an apple pie. Resident was eating steak fingers and mashed potatoes with her hands. Surveyor left room and remained within line of sight of Resident #2 ' s room from 12:40 PM to 1:00 PM. Surveyor checked on progress of meal at 12:45 and noted that Resident #2 had used spoon to eat her corn but was still using her hands to eat chopped meat and potatoes. Entered room and checked progress of meal at 12:50 PM, 12:55 PM, and 1:00 PM. At 1:00 PM observed that Resident #2 had eaten 100% of her meat and corn, 95% of potatoes and pie, and half of roll. CNA entered room at 1:02 PM to pick up tray. Observation of supper on 7/25/16 at 5:25 PM revealed that Resident #2 was served a grilled sandwich, which was the entrée, but no ice cream. Lunch on 7/26/16 at 12:30 PM revealed that Resident #2 was served ice cream but no sandwich, and lunch on 7/27/16 at 12:35 revealed that Resident #2 was not served ice cream or a sandwich. In an interview on 7/28/16 at 9:40 AM the DON stated that during meal times the treatment nurse was assigned to monitor the dining room and charge nurses and CNA should be monitoring the residents who eat in their rooms. She stated that if a resident needed assistance in their room they would be made a feeder . She stated We ' re in the halls all the time. The DON stated that it was her expectation was that staff should encourage the residents to eat more and leave the tray longer if needed. She stated that Resident #2 didn ' t always need help and some days she gets agitated if they are in there too much . When asked about what her expectation is for a resident whose care plan indicated that they need assistance and supervision with meals the DON stated I would expect to see someone helping her and stated again that they are always in and out. In an interview on 7/28/16 at 1:10 PM CNA B stated that she workd day shift and usually workd on Hall B where Resident #2 resides. She said that she sets up Resident #2 ' s tray and sometimes will stay a little longer to wake her up but does not stay for the entire meal because she mostly feeds herself . CNA B said she knows what is on a resident ' s care plan by using the kiosk system for CNA documentation or from verbal updates by the charge nurse. She said she didn ' t think Resident #2 ' s care plan indicated that she needed to stay with the resident or assist her with meals during meals. In an interview on 7/28/16 at 2:55 PM CNA C stated that she workd 3:00 PM to 11:00 PM and was typically assigned to Hall B where Resident #2 resided. She stated that Resident #2 only required assistance with setting up her tray and she does not stay with her throughout the meal because she delivered other hall trays. She stated sometimes she had to try to keep Resident #2 awake.She stated that if Resident #2 ' s son was present he will feed her. She stated that care plan information was found on the kiosk system used by CNA for documentation and she didn ' t know if Resident #2 ' s care plan indicated that she should stay with the resident or provide assistance while she ate. Record review of facility policy titled Comprehensive Resident Plan of Care revealed the following: A comprehensive care plan is developed for each resident using the results of the comprehensive assessment. Each resident's care plan shall include measurable objectives and timetables to meet all resident needs identified in the comprehensive assessment. All items or services ordered to be provided or withheld shall be included in each resident's plan of care. The comprehensive care plan describes services furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Residents' right to refuse care and treatment shall also be included in the comprehensive care plan. .Comprehensive care plans are prepared by an interdisciplinary team. The interdisciplinary team includes: 1. The resident's attending physician; 2. A registered nurse with responsibility for the resident; 3. Other appropriate staff in disciplines as determined by the resident's needs; and 4. The resident, the resident's family, resident's legal representative to the extent practical. .Care plans are revised as necessary to address the current needs of each resident. .In accordance with each resident's plan of care, all services provided or arranged by the facility meet professional standards of quality and are provided by qualified persons. The care plan will be made available to all direct care staff. The facility did not have a policy related to feeding residents who required assistance. According to a list provided by the DON on 7/28/16 at 3:00 PM there were 6 residents in the facility who required assistance wtih meals.