Every finding on record at Pocahontas Healthcare and Rehabilitation Center

Based on record review, interview, and facility document review, the facility failed to ensure that nursing staff responded appropriately to an unwitnessed fall, specifically failing to notify the appropriate parties and initiate neurological checks for an unwitnessed fall for one (Resident #1) of three residents reviewed for falls. Following the incident and prior to the surveyors entry into the facility, the facility terminated LPN #1 and initiated and completed a corrective action plan, thus these findings indicate past non-compliance. The findings include: A review of the admission Record indicated that Resident #1 was admitted [DATE] with diagnoses that included hypertensive encephalopathy (brain dysfunction) and hypertensive emergency. A review of the admission Minimum Data Set with an Assessment Reference Date of 02/14/2025 revealed Resident #1 had a Brief Interview for Mental Status score of 8, which indicated moderate cognitive impairment. The MDS also indicated Resident #1 required partial or moderate assistance with toilet transfer, with the helper doing less than half the effort. Resident #1 had a fall in the last month, had a fall within the last two to six months, and a fracture related fall within the last six months. A review of the Care Plan, initiated on 02/13/2025, indicated that Resident #1 required weight-bearing assistance with activities of daily living due to weakness, that Resident #1 was at risk for falls, and had an actual unwitnessed fall on 02/20/2025, with the goal that Resident #1 will not sustain serious injury through the review date. A review of the Fall Risk Assessment, dated 02/20/2025 at 12:22 PM, indicated that Resident #1 scored a 13, which indicated a high risk for falls. A review of the Order Summary for Resident #1 revealed an order, dated 02/13/2025, for an anti-platelet medication to be administered one time daily. A review of the OLTC (Office of Long-Term Care) Witness Statement, dated 02/20/2025 at 6:43 PM and provided by LPN #5, indicated Certified Nursing Assistant (CNA) #2 had placed Resident #1 on the toilet. Resident #1 pulled the call light, which indicated they were finished. While CNA #2 was walking toward the room, she heard the resident fall. LPN #5 entered the room and found Resident #1, without their walker, on their right side lying with their right arm under their head. Resident #1 stated that their back was sore, and that the resident did not recall hitting their head. No injury was observed [Resident #1 ' s] body. [Resident #1] stated they wanted up. [Resident #1] was assisted out of the floor and sat on their bed. A neurologic check was completed by the nurse before getting the resident out of floor and a body assessment was completed. Vitals were taken and blood pressure was high. LPN #1 took the resident ' s blood pressure several times and on both arms. We did not leave the room until the blood pressure had returned to normal. Resident #1was asked why they did not wait on staff for assistance nor use their walker to leave the restroom and [Resident #1] stated, I did not think I needed it. Resident #1 asked for pain medication and received a dose. The resident was assisted to bed and only complained of a back ache. A review of a progress note, created on 02/20/2025 at 04:18 AM, indicated that Resident #1 was in the restroom. Resident #1 attempted to get up by themselves with their walker and had an unwitnessed fall. CNA #2 was walking down the hall towards Resident #1 ' s room for call light notification and heard Resident #1 fall. Resident #1 was found lying on their right side with arms extended toward the bed. A review of a progress note, created on 2/20/2025 at 2:30 PM, indicated LPN #4 was called to the resident's room at 7:30 AM due to an elevated blood pressure of 235/110. Resident #1 was notably weak and unable to sit up on their own and repeatedly stated I'm sick. Registered Nurse (RN) #6 was in the facility and was notified of the situation. At 8:00 AM, Resident #1 was reassessed by this nurse (LPN #4). Blood pressure was 225/100, pulse was 49. The resident was not responsive to verbal or physical stimuli. This nurse notified the MD in person. The MD assessed the resident at this time and ordered resident to be transferred to the emergency room for evaluation. Resident #1 was transported by ambulance to the hospital. A review of a progress note, created on 02/20/2025 at 9:24 AM, indicated that LPN #4 was notified of Resident #1's high blood pressure. Upon assessment by LPN #4, Resident #1 was lethargic and stated, I'm sick. Blood Pressure was 240/110. The MD was notified and ordered to transfer to the emergency room for evaluation. Upon transfer, Resident #1 was unresponsive to stimuli. A review of the [area hospital] Imaging Services indicated that there were new areas of bleeding on both sides of the brain, just under the outer covering (called subdural hematomas). The bleed on the left side was larger, about 1.8 centimeters wide, while the bleed on the right side was smaller, about 0.5 centimeters wide. Because of the pressure from the bleeding, the brain had been pushed about 1.9 centimeters from its normal center position, toward the right side. The grooves on the surface of the brain (called sulci) were being squeezed, more so on the left. A fluid-filled space near the base of the brain (called the suprasellar cistern) was also partially squeezed. There were no new broken bones in the skull. A review of the [area hospital] Hospitalist History and Physical, updated on 02/20/2025 at 12:35 PM, indicated Resident #1 presented to the emergency department from the nursing home for altered mental status. According to notes, Resident #1 had several falls recently and was admitted to the nursing home for rehab after being hospitalized from 02/8 to 02/12 for weakness and falls. Resident #1 had a fall last night in the nursing home. CT (Computed Tomography) of head revealed new areas of bleeding on both sides of the brain. The family had opted for comfort care. A review of the [areal hospital] Hospitalist History and Physical revealed a physician note, completed on 02/20/2025 at 12:35 PM, indicated Resident #1 was admitted from the nursing home after a fall last night, and found to have large left-sided and small right-sided bleeding around the brain. Resident #1 was ultimately admitted for comfort care. Family was aware that the expectation was [Resident #1] passing from this. A review of the Death Certificate indicated that Resident #1 was pronounced dead on 02/21/2025 at 4:58 PM, immediate cause subdural hematoma with an underlying cause fall, manner of death was accidental with the approximate date of injury occurring on 02/19/2025 at 2:57 AM. During an interview on 06/17/2025 at 6:00 PM, CNA #2 stated they knew Resident #1 personally. CNA #2 took the resident to the bathroom on the day of the incident, and asked Resident #1 if they wanted privacy or wanted the CNA to wait. CNA #2 stated Resident #1 asked for privacy, was given the pull cord, and instructed on usage. CNA #2 then took another resident to bathroom, then waited at the nurse's station for one of them to pull the light. CNA #2 stated they heard someone fall, and told LPN #5, I bet that was [Resident #1]. CNA#2 stated Resident #1 reported head pain when the resident was being helped up from the floor and put back into bed. CNA #2 stated that Resident #1 complained even more about a headache after being put into bed. CNA #2 stated Resident #1 told them about it every 30 minutes after that. CNA #2 notified LPN #1 about that each time. CNA #2 stated the process during a fall included CNAs were supposed to alert the nurse and do what they told them to do, but neurological checks were not initiated for Resident #1. CNA #2 stated, I got the initial vital signs, including manual blood pressure, but [ LPN #1] did not ask me to get any more vital signs. CNA #2 stated that LPN #1 told her that Resident #1 had high blood pressure normally. During an interview on 06/18/2025 at 8:50 AM, LPN #4 stated that he assessed Resident #1 about 7:30 AM, and Resident #1, who was usually talkative and happy go lucky, was not their normal baseline. LPN #4 stated Resident #1 was really lethargic and complained about being sick. LPN #4 stated that they went to RN #6, who gave instruction to administer an updraft treatment (medication administered in an aerosolized form). LPN #4 went back to assess Resident #1 after the updraft; Resident #1 was not responding to stimulus. LPN #4 stated that they told the MD face to face of what was going on and received the order to send Resident #1 out to the emergency department. During an interview on 06/18/2025 at 9:02 AM, LPN #1 stated that at the time of the incident, there were two nurses and two aides in the building. LPN #1 reported helping CNA #7 with a resident on 600 hall, when LPN #5 came down and stated that she needed help, that Resident #1 had fallen, but that everything was fine. LPN #1 stated when they entered the room, Resident #1 was sitting on the side of the bed and had abnormally high blood pressure. LPN #1 stated they thought it was false, went to check it again, checked it on the other arm where it was also elevated. LPN #1 stated that CNA #2 went to get a manual blood pressure cuff, and it was not elevated when we checked it manually. LPN #1 stated that one of the aides reported Resident #1 needed something for pain, and LPN #5 provided pain medication. LPN #1 reported filling out an incident report. LPN #1 stated that the process for an unwitnessed fall was to check vital signs, to write down information on a piece of paper with a check list, but there was nobody in the chart to notify as Resident #1 was listed as their own POA (power of attorney). LPN #1 stated, We were told not to call the doctor unless injured and added it to the communication book. LPN #1 stated that they did not start neuro checks, to my knowledge, [Resident #1] did not hit (the resident ' s) head. LPN #1 stated they did not know if Resident #1 hit their head, stating, I never saw Resident #1 in the floor or anything. LPN #1 stated that they had contacted the medical director to notify them before for other stuff, but Resident #1 did not have a change in condition, so they did not contact. LPN #1 stated that they were terminated for violation of policies according to the Director of Nursing. During an interview on 06/18/2025 at 10:55 AM, Medication Assistant Certified (MAC) #3 reported being the permanent CNA on 200 hall. MAC #3 stated that during report they were told that Resident #1 had fallen. MAC #3 stated that Resident #1 was sitting on the side of the bed, dry heaving, drooling, and snot coming out of nose. MAC #3 stated vital signs were abnormal, they went to get the nurse, the nurse assessed the resident and re-checked blood pressure. MAC #3 stated that LPN #4 notified the registered nurse and the Director of Nursing (DON), who made the decision to send Resident #1 out to the emergency room. During an interview on 06/20/2025 at 8:40 AM, the MD reported they had just arrived at the facility when it was reported that Resident #1 was having trouble breathing. The MD stated that at the time we were dealing with COVID and the Flu in the building, so they ordered Resident #1 to be tested for those diseases. The MD stated that was the first time it was reported to them that Resident #1 had a change of condition or had fallen. The MD stated then they were told Resident #1 was unresponsive and the MD went to assess the resident. The MD stated, I cannot remember the vital signs, but I know just a few minutes later we sent [Resident #1] to the hospital. During an interview on 06/20/2025 at 10:00 AM, the Administrator stated that the process for falls was that we investigate to find out if there was anybody who witnessed it, we interview the resident themself, and if there was an injury we send them to the emergency room. The Administrator stated that staff automatically do neuro checks on everybody. We changed that to where we do it on everyone now. The Administrator stated the process for change in condition was to immediately start investigating it and contact the doctor. The Administrator stated, When I came in that morning, I was told [Resident #1] had fallen, at that time [Resident #1] was having issues. The Administrator stated the MD was in the room with Resident #1. The facility started investigating the fall, then immediately started a reportable to the state agency, when we discovered the nurse did not notify the doctor and did not initiate neuro checks. The Administrator stated that LPN #1 was terminated. During an interview on 06/20/2025 at 9:00 AM, the DON stated the process for when a resident falls was that a CNA stays with the resident, does not move the resident, a nurse performs an assessment, initial vitals were taken, the resident was moved if needed, staff immediately initiate fall interventions, notify appropriate parties, and follow MD orders. The DON stated that for unwitnessed falls, staff were to initiate neuro checks, every time an unwitnessed fall occurs. The DON stated that the process for a change in condition was to immediately assess the resident and notify the doctor and family. The DON stated that they consider a change of condition to include mental status change and abnormal vital signs. The DON stated that they brought LPN #1 in for questioning about the fall, and that LPN #1 was suspended for not following proper protocols, not notifying the physician, and for not initiating neuro checks after an unwitnessed fall. The DON stated that LPN #1 was then terminated for violating policies. A review of the facility policy Notification of Change indicates that the nursing facility will inform the resident/elder and consult with the physician when a significant change occurs. The nursing facility will also notify the resident/elder's legal representative or a designated contact person when a significant change occurs. A review of the facility guidelines Fall Guidelines indicates that Neuro checks (neurological checks) initiated for all head injuries for 72 hours, Documentation General Guidelines 6. Physician and legal representative notification. A review of the facility training Incident Reports on 02/3/2025 was signed by LPN #1 and indicated staff verbalized understanding on the following I wanted to remind everyone that for all incident reports, you need to conduct neuro checks unless the incident was witnessed and you can confirm there was no head impact. Following the incident, and prior to the surveyors entry into the facility, the facility terminated LPN #1 and initiated a corrective action plan, which included: 1. Auditing all resident profiles to ensure contact information is available for notification, completed 02/20/2025. 2. Audit all resident Kardex's to ensure ADL tasks are visible, completed 02/20/2025. 3. In-service MDS Coordinator to input ADL tasks to Kardex next working day after admission, completed 02/20/2025. 4. Initiate in-service to all Nurse staff on completion of admission Nursing Evaluation Form with specific focus on Functional Abilities and Baseline Care Plan sections, completed 02/23/2025. 5. Review all unwitnessed falls for the last three months to ensure neuro checks were completed. Change in Condition Assessment to be completed on all residents who did not receive neuro checks per audit, completed 02/21/2025. 6. Initiate in-service for all Nurse staff that neuro checks must be completed on all unwitnessed falls, completed 02/23/2025. 7. Initiate in-service for all Nurses staff on immediate notification to provider and family via direct communication, completed 02/23/2025. 8. Initiate in-service for all direct care staff that residents who are assessed as high risk for falls should not be left unattended in the bathroom, completed on 02/23/2025. 9. Review all resident Kardex's to ensure residents who are high risk for falls is noted on the Kardex, completed 02/22/2025. 10. All falls will be reviewed by nurse management daily to ensure I&A is completed correctly and neuro checks are initiated as appropriate, ongoing. 11. Initiate -in-service to all Nurse staff on completing I&A, completed 02/23/2025. 12. Initiate in-service to all Nurse staff on performing an assessment with a change in condition, documenting that assessment, and notifying provider and responsible party of change, completed 02/23/2025. 13. Run Form Scoring Report for admission nursing evaluation, fall risk score, fall risk assessment, weekly and place in a binder reference, ongoing. 14. All monitoring forms related to this action plan will be reviewed by Administrator and any negative findings will be addressed immediately and included in Q&A process, ongoing. 15. Nurse Management will monitor for changes in condition and follow up through Clinical Start up, review of 24 hour/ 72 hour reports, and walking rounds, ongoing.

Based on observation, interviews, and facility policy review, it was determined that the facility failed to ensure a portable oxygen cylinder was secured to prevent an accident or injury. The findings include: A review of the facility's undated policy titled Accident Hazards prevention indicated The environment will be free from an accident hazards as is possible .An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents . A review of the facility's undated policy titled Handling of oxygen and flammable gas, indicated Oxygen cylinders will be stored in a designated ventilated area and stored in a safe manner to prevent cylinder from fall over. During an observation on 12/31/2024 at 2:04 PM, an unsecured portable oxygen cylinder was standing in front of the nursing station with residents and staff present. Two nurses were sitting behind the nursing station documenting. Three staff members were standing on the opposite side of the nursing station. Two residents were in the day area adjacent to the nursing station. During an interview on 12/31/2024 at 2:05 PM, Licensed Practical Nurse [LPN] 3 confirmed a portable oxygen tank should not be left unsecured due to a possibility of causing injuries if the tank fell over. During an interview on 12/31/2024 at 2:07 PM, LPN #2 confirmed an oxygen tank should be secured to prevent an accident or explosion. During an interview on 12/31/24 at 2:10PM, the Director of Nursing (DON) confirmed a portable oxygen tank should be secured to prevent an accident.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to promote the dignity of a resident who was observed with staff shaving in the dining room for 1 (Resident #6) 1 residents reviewed for dignity. The findings include: A review of the facility's undated policy titled resident rights and responsibility indicated The nursing facility protects and promotes the rights of each Resident/Elder admitted in order to provide a dignified existence, self-determination and communication with and access to persons and services inside and outside the nursing facility. A review of the facility's undated policy titled accident hazard prevention indicated .The facility is responsible for providing care to residents in a manner that helps promote quality of life. This includes respecting residents' rights to privacy, dignity and self-determination, and their right to make choices about significant aspects of their life in the facility. A review of the Admission Record indicated the facility admitted Resident #6 with diagnoses that included vascular dementia (a condition that affects thinking, memory and behavior due to poor blood flow to brain), unspecified psychosis (a set of symptoms that indicate a loss of contact with reality), and Alzheimer's disease. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/19/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident had severe cognitive impairment. A review of Resident #6's care plan, initiated on 09/17/2024, revealed the resident ' s usual performance was weight bearing assist with ADLs (activities of daily living). Interventions included personal hygiene: set up or clean up assistance. (Helper sets up or cleans up: resident completed task. Helper assists only prior to activity or following activity: combing hair, shaving, makeup, washing/drying face and hands. During an observation on 12/30/2024 at 11:44 AM, Certified Nursing Assistant (CNA) #1 was shaving Resident #6 in the dining room with two male residents and one female resident present. During a concurrent observation and interview, on 12/30/2024 at 11:47 AM, while shaving Resident #6, CNA #1 confirmed shaving male residents in the dining room because it was easier to do and continue to watch other residents. CNA #1 confirmed that shaving was not performed during meal services. During an interview on 01/01/2025 at 11:58 AM, the Director of Nursing (DON) confirmed shaving should be completed in resident rooms and not in the dining room due to dignity concerns.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure infection prevention and control practices were implemented to prevent the development of communicable diseases and infections as evidenced by failure to wear personal protective equipment (PPE) in a contact isolation room for 1 (Resident #7) of 1 resident reviewed for infection control. The findings include: A review of the facility's undated policy titled Transmission based precautions categories, indicated Contact precaution: a. Personal protective equipment: Gloves and gown. B. Wear PPE [personal protective equipment] for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. C. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens. A review of the admission record indicated the facility admitted Resident #7 with diagnosis that included extended spectrum beta lactamase resistance (an enzyme that some bacteria produce to break down antibiotics). The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2024, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. A review of Resident #7's Care plan, revised on 10/30/2024, revealed the risk for multi-drug resistance organism (MDRO) Interventions included educating resident/family/staff on enhanced barrier precautions and answer questions, ensure isolation signage is posted. A review of physician orders revealed Resident #7 is on contact isolation for extended-spectrum beta lactamase (ESBL) in urine. During an observation on 12/30/2024 at 12:41 PM, Resident #7 had a contact isolation sign on door and PPE outside room. During an observation on 12/31/24 at 8:42 AM, Certified Nursing Assistant (CNA) #1 was in Resident #7 ' s room changing the resident ' s clothes and only wearing a mask and gloves. During a concurrent observation and interview, on 12/31/2024 at 8:44 AM, CNA #1 confirmed Resident #7 was on contact isolation and CNA #1 was only wearing a mask and gloves while changing the resident's clothes. During an interview on 12/31/2024 at 8:50 AM, Licensed Practical Nurse (LPN) #2 confirmed Resident #7 was on contact isolation due to ESBL and mask, gown, and gloves were required to provide personal care. During an interview, on 12/31/2024 at 8:57AM, the Consultant confirmed mask, gown, and gloves were required to provide personal care in a contact isolation room.

Based on observations, record review and interviews, the facility failed to ensure cross contamination during lunch service did not occur for one of one kitchen. The findings are: On 08/20/2024 at 12:05 PM, the surveyor observed Dietary Aide #6 take a stack of plates to put inside the lunch cart for 100 Hall. Dietary Aide #6 had their hand on top of the stack as they slid it on a tray inside the cart. On 08/20/2024 at 12:08 PM, the surveyor observed Dietary Aide #6 touch the inside of a divided plate intended to serve the puree diet for the 100 Hall. On 08/20/2024 at 12:09 PM, Surveyor observed Dietary Aide #6 picked up a bowl, put their finger inside of the bowl where food would rest and serve gravy for 100 Hall. On 08/20/2024 at 12:15 PM, Surveyor observed Dietary Aide #6 removing the aluminum foil off the regular meatloaf, when a piece fell on to the steam table pan. Dietary Aide #6 then reached in with bare hands to grab the piece of aluminum foil touching the regular meatloaf. On 08/21/2024 at 3:00 PM, during an interview the Dietary Manager confirmed they are not supposed to touch food contact areas while serving. Stated they use a suction cup to lift the plates, and you go at the base for the bowls, The Dietary Manager stated staff were not to touch the inside of plates, bowls and other dishes due to cross contamination On 08/21/2024 at 3:20 PM, during an interview Dietary Aide #6 stated staff were not to touch the inside of plates or bowls due to cross contamination. A review of the facility procedure titled, Serve Safe Manager. revealed that Service staff should use these guidelines when serving food; hold dishes by the bottom or edge, hold glasses by the middle, bottom or stem, Do not touch the food-contact areas of dishes or glassware.

Based on record review and interview the facility failed to provide an environment that promoted the maintenance or enhancement of the resident's quality of life, denying self-determination, and adequate communication for 1 (Resident #29) of 1 resident reviewed for resident rights. The findings are: On 08/19/24 at 11:01 AM, the surveyor attempted to interview Resident #29. Resident #29 spoke a few words in English but responded to the majority of the surveyor's inquiries by smiling and nodding their head. Review of the Care Plan dated 6/17/2024 revealed Resident #29 has an impaired cognitive function related to a language barrier. The intervention was to observe/report as needed any changes in cognitive function. Noted food preferences were not listed. On 8/21/2024 at 9:30 AM, Certified Nursing Assistant (CNA) #1 was asked to identify Resident #29's native language. CNA #1 was unsure. CNA #1 stated the resident can understand some things and understands how to use his/her call light, but there are some language barriers. CNA #1 states she points to things to determine what the resident might need. When asked about resident's meal intake, CNA #1 stated Resident #29 doesn't eat that much. I do try to remind [his/her] yogurt is on the tray because it's something the resident will eat. When asked why the resident doesn't consume more from his/her meal trays, CNA #1 stated the resident doesn't like the food, and prefers things family brings in. CNA #1 stated the resident's family brings food in about once a week on average. The surveyor asked how staff knows which snacks the resident prefers, and CNA #1 stated she wasn't aware of any lists but knows Resident #29 will eat yogurt. On 8/21/2024 at 2:30 PM, Resident #29's family member stated, I'm not satisfied with the care provided. When prompted to expand on her dissatisfaction, the family member described the facility does not make a lot of effort to eliminate the communication barrier, stating the resident speaks and understands only a limited amount of English. The family member stated a picture board would help and has been successful in other places such as the hospital. In addition, the family member complained about the food they offer the resident and is unsure if they have tried to get Resident #29's preferences for food, but even if they have asked (the resident) she doubts the resident fully understood enough to participate or communicate his/her preferences appropriately. The family member stated, [Resident #29] won't ask for help on repositioning or to be changed unless certain people are working, and if he/she doesn't ask, they won't ask him/her]. She says they ignore her if she doesn't ask them for something. On 8/21/2024 at 1:30 PM, interviewed with MDS Coordinator was asked review the care plan for Resident #29 dated 6/17/2024. During this review, the MDS Coordinator stated the care plan lacks appropriate interventions to eliminate the communication barrier and does not educate or guide staff to provide sufficient care to the resident. The MDS Coordinator stated maybe a picture board and the use of a language app could help bridge communication of staff and resident. She also agreed the family should be heavily involved to ensure the resident's needs and preferences are clearly understood. The MDS Coordinator voiced that the existing care plan is lacking, and staff needs to have a clear plan to follow if the facility is to deliver adequate care to the resident, especially with cultural differences and language barriers. On 8/21/2024 at 3:45 PM, the Administrator stated the resident could understand some English. The Surveyor asked how the Administrator differentiated between what Resident #29 could and could not understand. The Administer stated Resident #29 might nod or answer. The surveyor asked if the Administrator had spoken to the daughter regarding preferences, or the resident's fluency in English. She answered not that she is aware of. The Nurse Consultant stated, I've looked at the care plan, it's minimal. You (the Administrator) need to call the daughter and schedule something with her before she calls you. The Nurse Consultant advised the Director of Nursing (DON) to get to work immediately on improving Resident #29's care plan and preferences. On 8/22/2024 at 9:00 AM, the Dietary Manager confirmed there wasn't a preference list that is appropriately completed with likes and dislikes for staff to review. She stated the resident's granddaughter was consulted a long time ago, but nothing recent, and there needed to be more interventions to improve the resident's quality of life than has been provided up to this point.

Based on observation, record review, and interview, the facility failed to ensure a safe, clean, homelike environment was provided for the 100-hall secured unit. On 08/19/2024 at 11:28 AM, the surveyor observed in room [ROOM NUMBER], on side B, the wall was scratched with paint removed exposing bare drywall. The baseboard by the bathroom was coming away from the wall and was warped, and right above the baseboard paint was peeling back. In the shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER], to the right and behind the toilet the baseboard was coming away from the wall and warped. In the right-hand corner, the paint was peeling, and the drywall was crumbling. On the baseboard right behind the toilet is what appears to be a black substance, and the surveyor noted the bathroom had a musty, stagnant odor. On 08/19/2024 at 11:34 AM, Surveyor noted in room [ROOM NUMBER] the baseboard next the bed on side B had indentions in the wall with the paint peeling and bare drywall exposed. On 08/21/2024 at 10:03 AM, during environmental rounds, Maintenance stated in the bathroom between 103 and 105 the toilet had been reported for leaking, but they checked the left side not the right side of the toilet. Maintenance stated he had flushed the toilet and noted no issues with it leaking out of the left side. Maintenance then stated, the right-hand corner has been wet a lot it's starting to mold and needs torn out immediately .Looked like water damage from a leak on the right side. In room [ROOM NUMBER], Maintenance stated the bed against the wall needs mudding and painted it's from the bed against the wall. Maintenance then stated the baseboard next to the bathroom, could have been ran into but it also looked like water damage from the bathroom. On room [ROOM NUMBER]'s baseboard and the affected wall, Maintenance stated it has been ran into a lot and needs to be patched and painted. Maintenance stated he had a maintenance log, but most of the time it is through verbal channels he finds out what may need to be fixed throughout the building. On 08/21/2024 at 1:00 PM, during an interview the Director of Nursing (DON) stated it is important to report environmental issues to Maintenance to ensure that safety hazards can be taken care of. A review of the facility policy Accident Hazards Prevention states that The environment will be free from accident hazards, as is possible.

Based on observations, record review, and interview, the facility failed to a smoking apron was utilized for 1 (Resident #20) of 1 sampled resident. The findings are: A review of the Order Summary revealed Resident #20 had diagnoses of cognitive communication deficit, dementia, and chronic obstructive pulmonary disorder. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/07/2024 revealed Resident #20 scored a 13 (cognitively intact) on the Brief Interview for Mental Status (BIMS). A review of the Care Plan reveals Approaches/Tasks: Resident #20 requires a smoking apron while smoking. A review of the Smoking Safety Screen completed on 05/31/2024, reveals that Resident #20 required adaptive equipment in the form of a smoking apron. On 08/21/2024 at 11:30 AM, the surveyor observed Resident #20 going outside off the end of the 100-Hall secured unit with Certified Nursing Assistant (CNA) #2 to smoke. The surveyor observed Resident #20 was not wearing a smoking apron. On 08/21/2024 at 11:45 AM, during an interview CNA #2 stated they did not know Resident #20 was supposed to use a smoking apron. CNA #2 then stated without a smoking apron Resident #20 could have dropped his/her cigarette and burned themselves. On 08/21/2024 at 1:00 PM, during an interview the Director of Nursing (DON) stated the smoking apron is to prevent a resident from burning themselves while smoking. A review of an undated facility titled, Smoking, revealed that all residents that wish to smoke will have a smoking assessment completed upon admission and change in condition to determine safety equipment that is needed. A review of the facility policy Accident Hazards Prevention states that The environment will be free from accident hazards, as is possible.

Based on observation, record review, and interview, it was determined the facility failed to ensure refrigerated narcotics were stored in a permanently affixed storage box to ensure no misappropriation of resident medications affecting all 51 residents in the facility. The findings are: On 8/20/2024 at 9:30 AM, during an observation of the medication storage area inside the medication refrigerator, observed a small (approximately 4x 6), clear, medication box with a red temporary cable tie lock. The box contained a controlled medication (lorazepam) and was not secured inside the refrigerator. On 8/20/2024 at 11:45 AM, during an interview Licensed Practical Nurse #7 was asked why it is important to secure the box inside the refrigerator and stated, Because of the size, it would be very easy to remove the box with the medication. On 8/20/2024 at 11:45 AM, during an interview the Administrator confirmed the controlled medication box should be affixed inside the refrigerator. Reviewed the facility's undated policy (received on 8/20/24 PM from Administrator) on Pharmaceutical Services Under the section labeled Storage of drugs, the policy states: The separately locked and permanently affixed compartment are provided for storage of controlled drugs.

Based on observations, record review, and interview, the facility failed to ensure mechanical soft diets and puree diets were in the proper form for 2 of 2 observed meals provided by the facility kitchen. The findings are: On 08/19/2024 at 12:00 PM, the surveyor observed lunch service on the 100-hall unit, it is done in family style where the Certified Nursing Assistants (CNA) serve lunch for the residents according to the Dietary Manager. CNA #5 began serving the residents, the surveyor observed both regular and mechanical soft diets were getting diced ham and beans. Surveyor observed Resident #40 was spitting out the ham and laying it on a napkin. A review of the menu card revealed Resident #40's diet was Mechanical Soft, thin liquids, Supercal/High kcal. Surveyor observed Resident #39 was spitting ham out and putting it on the table. A review of the menu card revealed that Resident #39's diet was Mechanical Soft, regular diet, thin liquids. On 08/19/2024 at 12:15 PM, Resident #36's family member stated this is not an unusual occurrence they get food they cannot chew often. Resident #40's family member stated Resident #40 will not be able to chew the ham but might eat the beans. On 08/19/2024 at 12:20 PM, during interview CNA #5 confirmed that diced ham is not part of a mechanical soft diet and residents could choke on diced ham. On 08/20/2024 at 12:08 PM, Surveyor observed Dietary Aide #6 plate the food for the puree for 100-hall, Dietary Aide #6 scooped the puree roll, which was observed to be sticking to the utensil and was hard to get onto the plate. The cream of corn was observed to be thin and watery. The surveyor observed the puree meatloaf was sticking to the utensil and was hard to get onto the plate. On 08/20/2024 at 12:20 PM, the surveyor observed CNA #4 taking the pureed tray down the hall to the Resident #3's room on the unit. Surveyor asked CNA #4 to describe the pureed tray, CNA #4 stated the roll looked like a thick slice of bread, the meat loaf is thicker than normal, and the corn is watery. The surveyor asked CNA #4 to spoon a small amount of each out, the pureed roll stayed on the spoon until the CNA #4 thumped it to put it back on the plate, the cream of corn ran out of the spoon quickly, and the pureed meatloaf stayed in a spoon shaped hunk after it came off the utensil. The surveyor observed mashed potatoes were not added onto the plate for a starch. Resident #3 stated, I am not eating this. On 08/20/2024 at 12:30 PM, the surveyor observed in the dining area the mechanical soft diets only had mashed potatoes and meatloaf with gravy. The regular diet residents were eating ham and beans as the alternative instead of meatloaf. CNA #3 stated they did not receive regular meat loaf or cream of corn for the mechanical soft diets on the secure unit. Upon hearing what the CNA stated about the missing food items, Resident #40's family member stated, It was not surprising for them to forget something. On 08/20/2024 at 12:35 PM, the Dietary Manager brought back the regular meatloaf and cream of corn for the mechanical soft diets on the secure unit CNA #3, then served cream of corn to the mechanical soft diet residents and offered meat loaf to the regular diet residents on the unit. On 08/21/2024 at 3:00 PM, during an interview the Dietary Manager stated, They have always done diced ham for the ham and beans. Dietary Manager then stated that it should probably not be served like that and instead ran through the food processor to be ground up. The Dietary Manager stated the pureed roll and meatloaf was sticky mashed potato consistency, and that the cream of corn was of the same consistency as well for the puree diet. The Dietary Manager then stated that when it went on the serving line it did look a bit thicker. The Dietary Manager stated it's important to serve food in the proper form cause the residents have difficulty swallowing and chewing so the residents have special diets. On 08/21/2024 at 3:20 PM, during interview Dietary Aide #6 reported noticing the puree when it came out of the food processor was pudding like consistency but when serving it seemed to have thickened or thinned, like it did not keep the original consistency. A review of the Diet Spread Sheet reveals for Week 4, Day 22, for the Mechanical Soft Lunch residents were to be served ground ham and beans. A review of the Dietary and Nutrition Care Manual reveals for Dysphagia Puree Diet that all foods must be the consistency of moist mashed potatoes or pudding. A review of the Dietary and Nutrition Care Manual reveals that for Dysphagia Advanced or Mechanical Soft Diets foods that are difficult to chew are chopped, ground, shredded, or altered to make them easier to chew and swallow.

Based on record review, observations, and interviews, the facility failed to ensure infection control measures, including hand hygiene, were implemented during incontinent care for 1 (Resident #5) of 1 sampled resident to prevent potential infection and or the spread of infections. The findings are: 1. Review of a procedure guide titled, PERI-CARE PROCEDURE, updated 04/29/2024 and provided by the Director of Nursing on 08/20/2024, indicated, Pat dry using clean, dry wash cloth, remove gloves, place in trash bag, put on clean gloves, apply sin barrier as needed. A review of an Admission Record indicated the facility admitted Resident #5 with a diagnosis of congestive heart failure (CHF) that included emphysema. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident was severely impaired for their daily decision making. Review of Resident #5's Care Plan, revised on 10/11/2023, revealed the resident had an activities of daily living (ADL) self-care deficit and was at risk for impaired skin integrity related to their incontinence. Interventions included provide incontinent as needed and clean perineal area with each incontinence episode. On 08/21/24 09:59 AM, Certified Nursing Assistant (CNA) #1 was observed performing incontinent care on Resident #5. CNA #1 cleaned her hands and put on gloves prior to performing care, but she did not change her gloves or wash her hands after performing care and before picking up and applying the barrier cream. On 08/21/2024 CNA #1 was interviewed and asked when she should have changed her gloves. She stated she should have changed them before she picked up the barrier cream and applied it to prevent contamination and/or infection control. On 08/21/2024 12:30 PM, the Infection Preventionist (IP) was interviewed and asked if the CNA should have changed gloves prior to picking up the barrier cream. The IP said the CNA should have changed her gloves. On 08/21/204 1:00 PM, the Director of Nursing (DON) was interviewed and asked if the CNA should have changed gloves prior to picking up the barrier cream, and the DON said the CNA should have changed her gloves to prevent contamination.

Based on observation, interviews, record review and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for 1 (Resident #29) of 1 resident reviewed for MDS accuracy. The findings are: Upon record review, the Admission MDS with an Assessment Reference Date of 6/25/2024, in section A1110, noted that English is the resident's preferred language, and no interpreter is needed. On 8/19/2024 at 11:01 AM, the surveyor attempted to interview Resident #29. The resident spoke a few words in English, but most of the surveyor's inquiries were answered with head nodding and smiling. On 8/21/2024 at 9:30 AM, CNA #1 was asked what language the resident spoke, CNA #1 was unsure of the resident's native language. CNA #1 stated the resident can understand some things and understands how to use his/her call light, but there are some language barriers. The CNA stated she points to things to determine what the resident might need. On 8/21/2024 at 2:30 PM, the resident's family member stated, I'm not satisfied with the care provided. When prompted to expand on her dissatisfaction, the family member described how the facility does not make a lot of effort to eliminate the communication barrier, stating the resident speaks and understands only a limited amount of English. On 8/21/2024 at 1:30 PM, the MDS Coordinator was asked to review the MDS dated [DATE]. During this review, the MDS Coordinator was asked to specifically look at the section A at preferred language. The MDS Coordinator confirmed that the entry stating English was Resident #29's preferred language was incorrect, and it should have listed residents actual preferred language which is Marshallese.

Based on interview, record review, and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to reflect the residents needs and preferences, and to properly assess a resident's fluency in English, to obtain all preferences to provide a diet consisting of resident's preferences, and to provide communication assistant devices, which affected the resident's physical, mental, and psychosocial well-being for 1 (Resident #29) of 1 resident reviewed for care plans. The findings are: On 08/19/2024 at 11:01 AM, the surveyor attempted to interview Resident #29, but realized some of the responses were not appropriate to the questions. It was noticed mostly with the open-ended questions such as, how long does it take staff to respond to the call light, where Resident #29 responded with a smile while nodding yes. Resident #29 spoke a few words in English, but most inquires were responded to with head nodding. The care plan dated 6/17/2024 stated Resident #29 has an impaired cognitive function related to language barrier. The intervention was to observe/report as needed any changes in cognitive function Resident has: a communication problem related to language barrier. The intervention is: to report to nurse changes in ability to communicate, Possible factors which cause/make worse/make better any communication problems. On 8/21/2024 at 9:30 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #1 regarding Resident #29's care and communication. When asked to identify the resident's native language, CNA #1 was unsure. CNA #1 stated the resident can understand some things and understands how to use his/her call light, but there are some language barriers. The CNA states she points to things to determine what the resident might need. When asked about resident's meal intake, the CNA stated he/she doesn't eat that much, and that she tries to remind him/her that yogurt is on the tray because it's something the resident will eat. When asked why the resident doesn't consume more from his/her meal trays, CNA #1 stated the resident doesn't like the food, and prefers things family brings in. CNA #1 stated the resident's family brings food in about once a week on average. Surveyor asked about how staff knows which snacks the resident prefers, CNA #1 stated she wasn't aware of any lists but knows he/she will eat yogurt. On 8/21/2024 at 2:30 PM, interviewed Resident #29's family member regarding the resident's care. The family member stated, I'm not satisfied with the care provided. When prompted to expand on her dissatisfaction, the family member described the facility does not make a lot of effort to improve the communication barrier, stating the resident speaks and understands only a limited amount of English. The family member stated a picture board would help and has been successful in other places such as the hospital. In addition, the family member complained about the food they offer the resident. She is unsure if they have tried to get Resident #29's preferences for food, but even if they have asked him/her (the resident), she doubts the resident fully understood enough to participate or communicate his/her preferences appropriately. The daughter states, [Resident #29] won't ask for help on repositioning or to be changed unless certain people are working, and if [he/she] doesn't ask, they won't ask [him/her]. [He/She] says they ignore [him/her] if [he/she] doesn't ask them for something. On 8/21/2024 at 1:30 PM, the MDS(Minimum Data Set) Coordinator was asked to review the care plan for Resident #29 dated 6/17/2024. During this review, the MDS Coordinator stated she sees where the care plan could be better. The MDS Coordinator stated the care plan lacks appropriate interventions to improve communication with Resident #29 and does not educate or guide staff to provide sufficient care to the resident. The MDS Coordinator stated that maybe a picture board and the use of a language application could help bridge communication of staff and resident. She also agreed the family should be heavily involved to ensure the resident's needs and preferences are clearly understood. The MDS Coordinator expressed understanding that the existing care plan is lacking, and that staff needs to have a clear plan to follow if the facility is to deliver adequate care to the resident, especially with cultural differences and language barriers. On 8/21/2024 at 3:45 PM, the surveyor interviewed the Administrator regarding a food preference list she completed with Resident #29, as well as the resident's overall care plan. The Administrator stated the resident could understand some English. The surveyor asked, How do you know what [he/she] understands and what [he/she] doesn't? The Administrator stated the resident might nod or answer. The RN Consultant confirmed the care plan was minimal and recommended the Director of Nursing reach out to schedule a meeting with the family.

Based on observation, interview and record review, the facility failed to ensure food items stored in the freezer were dated to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; dented cans were removed from stock, and the dishwashing machine temperature reached the necessary, recommended minimum temperature specified by the manufacturer's instructions to destroy food borne illnesses for the residents who received meals from 1 of 1 kitchen and detergent levels in the low temperature dishwasher were consistently monitored to ensure there was detergent going through. This failed practice had the potential to affect 38 residents who received meals from the kitchen according to a list provided by the Administrator on 09/14/23 at 9:04 AM. The findings are: 1. On 09/13/23 at 11:50 AM, in the Freezer #1 were 3 bags of chicken, the bags were not dated. The Surveyor asked the Dietary Manager about the 3 bags of undated chicken observed in the freezer. The Dietary Manager stated that the chicken was received on 09/04/23 and the Dietary Manager put the box in the freezer and dated the box, but the bags in the box were not dated. The Dietary Manger stated that one of the dietary staff must have emptied the box and put the three bags in the freezer and the bags were not dated. 2. On 09/11/23 at 11:38 AM, in the Pantry there was 6.5 pound can of corn and a 6.5 pound can of peaches with dents in the rims of the cans. a. On 09/13/23 at 11:50 AM, the Dietary Manager confirmed she was responsible for checking the dates on food items, and cans for dents. 3. On 09/13/23 at 11:15 AM, observed during a wash cycle of the dishwasher, the temperature reached 130 degrees Fahrenheit, and the rinse cycle reached 140 degrees Fahrenheit. a. DE #1 confirmed the dishwasher was a low temperature dishwasher. The Surveyor asked DE #1 to test the concentration of the cleaning solution in the dishwasher. DE #1 inserted a test strip into the dishwasher and compared the strip to the color chart on the bottle, which indicated a concentration of less than 25 parts per million. DE #1 immediately went to the container that dispensed cleaning solution into the dishwasher and stated it was empty. DE #1 changed the solution, and a second attempt indicated a concentration of 100 parts per million. DE #1 stated, It used to have an alarm that would tell me when it was empty but that hasn't been working for a while. b. The Surveyor asked the Dietary Manager if they were aware the low temperature dishwasher was being used without cleaning solution while washing dishes used to serve residents. The Dietary Supervisor stated, No, the machine has an alarm to notify us when it runs out of cleaner. c. A facility policy titled, Diet, Sanitation, and Menu provided by the Administrator on 09/14/2023 at 9:04 AM documented, Policy.The nursing facility will store, prepare, distribute and serve food under sanitary conditions . Dishwashing Machine In the event Facility utilizes a dishwashing machine, Facility shall act in accordance with the manufacturer's instruction. d. The Dishwasher Manufacture Procedures provided by the Dietary Manager on 09/14/23 at 9:55 AM documented, .Replace detergent capsule when out of product alarm for detergent is on. Put a new rinse additive block when out of product for rinse additive for rinse additive is on. Replace empty sanitizer container, if needed .

Based on observation, record review and interview, the facility failed to ensure a Physician's Order was obtained prior to administering a Trilogy unit for 1 (Resident #5) of 1 sampled resident and Physician Orders were obtained prior to administering oxygen for 1 (Resident #21) of 1 sampled resident and Physician Orders were followed for 2 (Residents #1 and #5) of 4 (Resident #1, #5, #11 and #37) sampled residents. The findings are: 1. On 09/11/23 at 11:00 AM, Resident #1 was lying in bed receiving oxygen at 1 liter per minute by nasal cannula. a. On 09/12/23 at 8:52 AM, Resident #1 was lying in bed receiving oxygen at 1 liter per minute by nasal cannula. b. On 09/12/23 at 2:48 PM, Resident #1's oxygen tubing was lying on the bed wrapped in dirty linen. c. A Physicians Order dated 07/25/23 noted Resident #1 was to receive oxygen at 2 liters per minute via nasal cannula as needed. d. A Care Plan with a revision date of 08/14/23 did not address oxygen therapy. e. On 09/12/23 at 2:55 PM, the Surveyor asked Certified Nursing Assistant (CNA) # to check the flow meter on Resident #1's oxygen concentrator. CNA #1 stated, It's at a one. The Surveyor asked if the tubing should be lying on dirty linen. CNA #1 stated, No. CNA #1 picked up the tubing from the linens and dropped it on the floor, picked it up then laid it back on the dirty linens. The Surveyor asked where the tubing should be stored when not in use. CNA #1 stated, In a bag. f. On 09/12/23 at 3:10 PM, the Surveyor asked the Assistant Director of Nursing (ADON) to check Resident #1's flow rate on the oxygen concentrator. The ADON stated, It's at one. The ADON picked up the oxygen tubing and stated, It should be in a closed bag. g. On 09/13/23 at 1:00 PM, the Surveyor asked the Administrator to explain the purpose of a flow rate on oxygen administration. The Administrator stated, It needs to be at the resident prescribed level. 2. Resident #21 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). a. On 09/11/23 at 3:15 PM, Resident #21 was sitting in a recliner with oxygen at 4 liters per minute by nasal cannula. b. On 09/12/23 at 9:16 AM, Resident #21 was lying in bed with oxygen at 4 liters per minute by nasal cannula. c. A review of Resident #21's Physician Orders failed to reveal an order for oxygen therapy. d. On 09/13/23 at 3:20 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 who was responsible for making sure orders were put in the computer. LPN #1 stated, The nurses. e. On 09/13/23 at 3:26 PM, the Surveyor asked Registered Nurse (RN) #1 who was responsible for making sure an order gets put in the computer. RN #1 stated, Nurses. g. On 09/12/23 at 4:21 PM, the Nurse Consultant stated, We do not have an oxygen policy. 47916 3. On 09/11/23 at 1:26 PM, Resident #5's oxygen concentrator was set on 3 liters per minute and a Trilogy unit was at the bedside with the mask behind the unit not in sealed bag or container. Resident #5 said, I am on three liters nasal cannula. I do not blow off my Carbon Dioxide like I am supposed to. I wear the Trilogy at night. a. On 09/11/23 at 2:33 PM, Resident #5 was lying in bed with oxygen at 3 liters per minute by nasal cannula. A Trilogy unit was at the bedside, the mask was draped over the Trilogy unit not in a sealed bag or container. b. On 09/13/23 at 8:48 AM, Resident #5 was lying in bed with oxygen at 3 liters per minute by nasal cannula. Resident #5 said, If they gave me another storage bag, I probably would not use it, because I never used a storage bag at home either. c. A review of Resident #5 Physician Orders failed to reveal an order for Trilogy. d. On 09/13/23 at 9:50 AM, the Administrator confirmed Resident #5 wears a Trilogy at night and is on oxygen. e. On 09/13/23 at 1:02 PM, Registered Nurse (RN) #1 verified there was an oxygen order for two liters per minute by nasal cannula and confirmed the oxygen concentrator is was set on three liters per minute.

Based on interview and record review, the facility failed to ensure resident funds were refunded within 30 days after the resident was discharged /expired and had a remaining balance in the facilities resident trust fund account for 1 (Resident #140) of sampled resident per a list provided by the Administrator on [DATE] on 8:45 AM. The findings are: 1. Resident #140's closed record noted the resident expired on [DATE]. 2. The Trust Transaction History for [DATE] to [DATE] documented, Resident #140 had a closing balance of $675.82. 3. On [DATE] at 11:17 AM, the Surveyor asked the Business Office Manager (BOM) to identify the date Resident #140 had expired. The BOM verified Resident #140 expired on [DATE]. The Surveyor asked what the timeline was for the facility to convey remaining funds in the trust accounts to the resident's family upon expiration. The BOM stated, Thirty days, but we try to do it in two weeks. The Surveyor asked if an attempt had been made to contact Resident #140's representative to arrange the return of remaining funds. The BOM stated, No. 4. The Resident Trust Manual 2016 provided by the Administrator on [DATE] at 9:55 AM documented, Page 17 .Responsibilities of the Facility .f) Facility will convey funds upon the death of a resident within 30 days . Page 20 .Treatment of deceased Resident Personal Trust Fund In the event of the death of a resident, the facility administrator shall within 30 days of the resident's death provide an accounting and shall return all refunds and funds held in trust .

Based on observation, interview, and record review, the facility failed to ensure the walls in 2 (rooms [ROOM NUMBERS]) resident rooms were not damaged and cracked floor tiles were replaced on the 300 Hall. The findings are: 1. On 09/13/23 at 11:41 AM, observed an 11.5 inch by 2.5 inch cracked tile in the floor of the 300 Hall. 2. On 09/14/23 at 8:27 AM, Resident room [ROOM NUMBER] had a 10 inch by 82 inch damaged area to the wall extending past the length of the resident ' s bed. The area had been partially repaired with white spackling and had a rough appearance and contrasted with the surrounding wall. 3. On 09/13/23 at 1:02 PM, the Surveyor accompanied Register Nurse (RN) #1 to Resident room [ROOM NUMBER]. RN #1 identified three visible scrapes measuring 26 inches, 19.5 inches, and 13.5 inches, located to the far left wall from the door. 4. On 09/13/2023 at 3:37 PM, the Surveyor pointed out to the Maintenance Supervisor the cracked floor tile on the 300 Hall, and the scratches on the wall in Resident room [ROOM NUMBER]. The Maintenance Supervisor stated, I do not have a purchase order or anything for the tile or the wall, but I am adding these issues to my list for repairs., and further stated, I have some extra tiles. I will go through and find one to fix that. 6. A facility policy titled, Housekeeping and Maintenance, provided by the Administrator on 09/14/23 at 9:04 AM documented, .Floors will be maintained in a clean and safe condition .The nursing facility provides maintenance services to assure maintenance of the physical plant .

Based on observation, interview, and record review, the facility failed to ensure the Comprehensive Care Plan addressed the use of a Trilogy unit (a ventilator that provides respiratory support) for 1 (Resident #5) of 1 sampled resident. The findings are: 1. On 09/11/23 at 1:26 PM, observed a Trilogy unit at Resident #5's bedside. Resident #5 stated, I wear the Trilogy at night. 2. On 09/11/23 at 1:45 PM, Resident #5's Comprehensive Care Plan with a revision date of 09/08/23 did not address care and interventions for the use of the Trilogy. 3. On 09/13/23 at 11:30 AM, the Minimum Data Set (MDS) Nurse confirmed Resident #5's Trilogy unit was not on the care plan. 4. A Comprehensive Care Plan policy provided by the Administrator on 09/14/23 at 9:04 AM stated, .It is the Guidance of this facility is to develop and implement a comprehensive person-centered care plan for each resident . Guidance Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care . 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment . The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 46868

Based on observation, interview and record review, the facility failed to ensure nebulizer treatments were administered as ordered for 1 (Resident #15) of 2 (Resident #15 and #21) sampled residents. The findings are: 1. On 09/11/23 at 11:14 AM, Resident #15 was lying in bed. A nebulizer machine was on the bedside table. There was a clear liquid in the nebulizer chamber with crystalized sediment around the top of the clear liquid. a. On 09/11/23 at 2:30 PM, Resident #15 was lying in bed. A nebulizer machine was on the bedside table with approximately 2 millimeters of clear liquid in the nebulizer chamber. The liquid had a slight odor. b. On 09/12/23 at 2:55 PM, observed a nebulizer machine sitting on Resident #15 ' s bedside table with approximately 1.5 millimeters of clear liquid in the nebulizer chamber, the liquid had a slight odor. The Surveyor asked Resident #15 if she used the Nebulizer. Resident #15 stated, Yes, three times a day. c. A Physicians Order dated 04/09/23 noted Resident #15 was to receive a nebulizer treatment three times a day. d. The September 2023 Medication Administration Record noted the nebulizer treatment was documented as given three times per day, with no missed treatments noted. e. On 09/12/23 at 3:00 PM, the Surveyor asked the Assistant Director of Nursing (ADON) to observe Resident #15 ' s nebulizer chamber and describe what she saw. The ADON stated, That's her albuterol., f. On 09/12/23 at 3:23 PM, during a phone interview the Director of Nursing (DON) stated the ADON administered the treatment, and I turned it off. The Surveyor asked if she was aware that there was medication left in the chamber. The DON stated that it might be water where she rinsed it out. The Surveyor asked if water was typically left in the chamber. The DON stated, No. g. On 09/13/23 at 1:00 PM, the Surveyor asked the Administrator to explain the nebulizer process. The Administrator stated, You put the medication in the container then when there is no more liquid, you rinse out the reservoir. The Surveyor asked if there should be medication left in the reservoir. The Administrator stated No, because the patient would not get the complete dose required.

Based on observation, interview, and record review, the facility failed to ensure thickened water was provided at the bedside for 1 (Resident #6) of 1 sampled resident and tray cards were followed for likes and dislikes, substitutions were offered, food tray was set up with all foods opened. The findings are: 1. On 09/11/23 at 1:30 PM, Resident #6 had no fluids at the bedside. a. On 09/12/23 at 9:29 AM, Resident #6 had no fluids at the bedside. b. On 09/12/23 at 1:20 PM, Resident #6 had no fluids in her room. c. On 09/12/23 at 3:00 PM, the Surveyor asked Certified Nursing Assistant (CNA) #4 if there were any residents that do not get fluids at the bedside. CNA #4 said, There is a resident that gets nutrition by peg (percutaneous endoscopic gastrostomy) tube. Everyone else gets fluids. d. On 09/13/23 at 8:50 AM, Resident #6 had no fluids or at the bedside. e. The Care Plan with a revision date of 08/16/21 noted Resident #6 staff were to encourage hydration to minimize risk of constipation. f. On 09/13/23 at 12:30 PM, observed the Speech Therapist feeding Resident #6. The Surveyor asked the Speech Therapist if she feeds Resident #6 every day, and if the resident could have thickened water at the bedside in a two-handle cup. The Speech Therapist said, No. I just noticed she has been having a little trouble, so I have been trying things to see what works best. I may even recommend they give her sips from the side of a cup in her room. I am not sure what she is drinking from, but she should have thickened liquids in her room. g. On 09/13/23 at 12:47 PM, the Surveyor asked CNA #5 if there was a reason Resident #6 has not had thickened liquids in her room. CNA #5 said, She should have a cooler with thickened liquids in her room. The coolers are cleaned on Monday, Wednesday, and Fridays. They may have taken the cooler out of her room, and not returned it when she returned to the facility. She is an assist, so I usually offer her something when I am in the room, but I have been off. h. On 09/13/23 at 3:15 AM, the Surveyor asked the Assistant Director of Nursing (ADON) if Resident #6 could have thickened water at the bedside, and if it was appropriate that she has not had water. The ADON said, That is not appropriate, and she should have fluids at the bedside. Everyone is responsible for making sure residents have water at the bedside. She is at risk of dehydration if she is not offered fluids. i. The Nurse Consultant said, We do not have a hydration policy. 46868 2. On 09/13/23 at 12:25 PM, Resident #15 was eating lunch in her room. There was pork sausage on the meal tray. Her butter was not opened. Resident #15 ' s tray card documented pork as a dislike. Resident #15 stated, No one has offered me an alternate. a. A Physicians Order dated 08/18/22 noted Resident #15 was to receive a Regular textured meal, with thin consistency fluids, Super Calorie diet. b. A Care Plan with a revision date of 01/10/23 noted Resident #15 had a potential for nutritional deficits and the facility was to obtain her food preferences, like and dislikes, offer substitutes for foods not eaten. c. On 09/13/23 at 1:00 PM, the Administrator confirmed the staff should have opened the butter and offered an alternative to the resident. d. On 09/13/23 at 3:40 PM, the Surveyor asked the Dietary Manager (DM) who was responsible for ensuring a resident is fed an adequate nutritional diet and make sure that all food/liquids are opened. The DM stated, As far as feeding, its nursing. Preparing is dietary.