Every finding on record at Renvilla Health Center

Based on interview and document review, the facility failed to ensure 1 of 5 sampled residents (R12) had completed tuberculosis (TB) testing upon admission.Findings include: R12's admission record identified that R12 had been admitted to the facility in March of 2026 for skilled nursing services. R12's 5/11/26, progress note identified an (an interferon-gramma (IGA) release assay test) aka a T-spot was drawn. There was no further documentation in the progress notes to identify if the test was delivered to the laboratory, or what the results of that test were. There was also no indication the facility had tested R12 upon admission to the facility in March 2026, versus a delated test in May 2026. Interview on 6/15/26 at 5:18 p.m., with director of nursing identified the facility had been completing audits related to missing some TB testing and they must have missed R12 during that audit process. She identified that R12 had blood drawn to complete a T-spot test for TB; however, the facility forgot to send a form along with the sample to the lab identifying who the blood sample was from and what was to be tested so it ended there. Her expectation would be that the facility would follow their policy, and all new resident admissions would be tested for TB as indicated. Review of the 1/21/25, Resident Tuberculosis Prevention and Control policy identified all new resident admissions to the facility would have a TB screening and testing completed within 72 of admission.

Based on interview and document review the facility failed to notify the physician of new wounds for 1 of 3 residents (R1) reviewed for pressure ulcers and impaired skin integrity. Findings include:R1's face sheet identified diagnoses of non-ST elevation myocardial infarction (heart attack from blockage of artery), chronic atrial fibrillation (heart flutter), cellulitis (bacterial infection) of left lower limb, type 2 diabetes, stage 5 chronic kidney disease dependent on renal dialysis, left below knee amputation, and cardiomyopathy (heart disease).R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 did not have cognitive impairment, no behaviors, but would reject evaluation or care four to six days. R1 required maximum to complete assistance with activities of daily living. R1 had one stage two pressure ulcer on admission (right lateral foot). R1's facility admission skin/wound assessment dated [DATE], identified fourteen wounds. One of the fourteen wounds assessed identified a blister to right dorsum 4th digit toe, not applicable to stage, present on admission. Measured 4.1 cm x 3.3 cm with depth, undermining, tunnelling marked as not applicable. Wound bed had granulation tissue but was unmarked how much of the wound was filled, no evidence of infection, moderate serous exudate, attached edges, surrounding tissue was excoriated and normal temperature, no edema, induration, or pain. Dressing was intact and non-adherent synthetic.R1's signed physician orders dated 10/7/25, identified wound care orders for four of the fourteen wounds identified on admission. These orders were for the wounds identified at the hospital and treated at the hospital and did not include orders for the right 4th toe.During a phone interview on 10/22/25 at 12:56 p.m., registered nurse (RN)-B stated he was the admission nurse for R1 when he came to the facility on [DATE]. R1 arrived at the facility from the hospital with wound care that was being done for a bunch of wounds. On admission, R1's toes on his right foot were covered in a dressing. RN-B removed the dressing and the toes were macerated with drainage around them and built up between the toes. The three middle toes, on the tops of them had drainage from those wounds, and a reddish color around the wounds. The dressing change for the toes was done on the same schedule as the heel dressing. RN-B could not recall what the order was for the toes but thought it was silver alginate and cover with gauze. RN-B stated he put the orders for R1 in the computer. RN-B did not notify the physician of the wounds.During an interview on 10/22/25 at 1:15 p.m., licensed practical nurse (LPN)-B stated during the night on 10/8/25, the kerlix wrapped around the toes had fallen off. There was no order in the medication administration record (MAR) for a dressing change, but she reapplied the wrap as they were.During a phone interview on 10/22/25 a 2:56 p.m., LPN-A stated on 10/11/25, R1's third and fourth toes were near black with a thick, white drainage coming from between the toes and the pinkie toe was gray. LPN-A was unable to separate the toes and cleaned the drainage as best as she could. LPN-A did not notify the physician of the wounds or the appearance of them as she assumed the physician was already aware of them. 10/16/25, LPN-A worked and stated she did not look at or do wound care on his toes as the physician had seen R1 and LPN-A thought the physician did the wound care on them.During a phone interview on 10/23/25 at 9:53 a.m., R1's primary care physician (PCP)-A stated she saw R1 on 10/16/25. PCP-A did not evaluate or look at R1's toes as they were wrapped and done by wound care. PCP-A did not recall receiving any information from the facility about wounds on R1 since his admission.During an interview on 10/24/25 at 9:47 a.m., Administrator stated it was an expectation that all areas on the body that have a dressing on them have a corresponding treatment plan in place and the physician notified. It is also an expectation that staff follow standing orders for new wound treatments, include the order in the resident MAR, notify physician, include interventions in care plan, and complete skin/wound assessment.The facility policy titled Skin Integrity dated 5/21/25, identified care center staff will notify the licensed nurse when a new skin integrity issue is observed. Licensed nurse will: assess the area and identify the cause, remove any source of pressure or trauma to the area, clean the area and provide treatment per House Standing Orders, complete a skin incident report in residents electronic health record, notify resident/responsible party, notify provider and request treatment orders, notify nurse manager/wound nurse, initiate a new tissue tolerance, initiate appropriate preventative measures based on the immediate root cause.

Based on interview and record review the facility failed to incorporate skin integrity interventions into care plans for 2 of 3 residents (R1, R2) who were reviewed for skin.Findings include: R1's face sheet identified diagnoses of non-ST elevation myocardial infarction (heart attack from blockage of artery), chronic atrial fibrillation (heart flutter), cellulitis (bacterial infection) of left lower limb, type 2 diabetes, stage 5 chronic kidney disease dependent on renal dialysis, left below knee amputation, cardiomyopathy (heart disease), sleep apnea, and hypertension.R1's admission Minimum Data Set (MDS) dated [DATE], identified no cognitive deficits, no behaviors, but would reject evaluation or care four to six days. R1 required maximum to complete assistance with activities of daily living. R1 had one stage two pressure ulcer on admission (right lateral foot). Care Area Assessment (CAA) triggered pressure ulcer, care planning decision dated 10/20/25.R1's facility admission skin/wound assessment dated [DATE], identified fourteen wounds.R1's care plan dated 10/8/25, identified R1 was on enhanced barrier precautions (EBP) related to pressure sores.Review of R1's care plan did not identify wounds, wound care, or interventions to prevent deterioration of skin integrity.R2R2's face sheet dated 10/22/25, identified diagnoses of non-pressure chronic ulcer of unspecified part of right lower leg, non-pressure chronic ulcer of unspecified part of left lower leg, varicose veins of left lower extremity with ulcer of unspecified site, stage 3 pressure ulcer of left heel, and localized edema.R2's admission MDS dated [DATE], identified R1 had some cognitive deficits, required assistance with activities of daily living, had pressure injuries and was at risk to develop pressure injuries.R2's care plan dated 10/22/25, identified impairment to skin integrity upon admission included venous stasis ulcers on bilateral lower extremities, pressure ulcer on left heel, pressure ulcer on right heel healed on 10/21/25. Interventions included air mattress, encourage good nutrition and hydration, float heels in bed, turn and reposition every 2.5 hours to prevent skin breakdown, treatment per provider orders, seen weekly by wound care nurse, weekly treatment documentation to include measurement of each area of skin breakdowns width, length, depth, type of tissue and exudate, and any other notable changes or observations.R2's Kardex for nursing assistants dated 10/22/25, identified enhanced barrier precautions (EBP), and air mattress on bed.R2's physician orders dated 9/30/25, identified an order for heel protectors to bilateral heels.R2's physician wound care orders dated 10/1/25, identified treatment recommendations of heel protectors to bilateral heels.R2's physician wound care orders dated 10/7/25, identified treatment recommendations of heel protectors to bilateral heels.R2's physician wound care orders dated 10/14/25, identified treatment recommendations of heel protectors to bilateral heels.R2's physician wound care orders dated 10/21/25, identified treatment recommendations of heel protectors to bilateral heels.R2's progress note dated 10/11/25, identified dressing was not intact to left heel and had moved completely away from the heel. Heel boots were not in place due to drainage and odor. Pillows were placed.During a phone interview on 10/23/25 at 2:29 p.m., RN-D stated the facility charting needs to improve. Management is working on care planning and getting a plan for improvement with them.During an interview on 10/24/25 at 9:47 a.m., administrator stated all interventions for prevention of skin breakdown, wound management, and wounds should be included in the care plan.The facility Person Centered Care Planning policy dated 12/18/23, identified each residents care plan will include measurable objectives and timeframes to meet a residents medical, nursing, mental, and psychosocial needs identified through the residents comprehensive assessment. The plan of care will describe: services that are to be furnished to attain or maintain the residents highest practicable wellbeing, management of risk factors and prevent avoidable declines in function

Based on interview and record review the facility failed to initiate, monitor, and notify the physician of wounds for 1 of 1 resident (R1) who was assessed on admission to have multiple wounds reviewed for impaired skin integrity.Findings include:R1's face sheet identified diagnoses of non-ST elevation myocardial infarction (heart attack from blockage of artery), chronic atrial fibrillation (heart flutter), cellulitis (bacterial infection) of left lower limb, type 2 diabetes, stage 5 chronic kidney disease dependent on renal dialysis, left below knee amputation, and cardiomyopathy (heart disease). R1's hospital Discharge summary dated [DATE], identified six skin issues on discharge but did not identify skin injury to right 4th toe. Wounds identified included: 1. Full thickness wound due to infection/edema of left residual limb2. Full thickness wound to right leg (edema)3. Right ear (unclear)4. Right arm/back/neck (trauma)5. Non-pressure open wounds due to perforating dermatitis of right anterior leg and left ear6. Partial thickness wound due to friction/shear of buttocks, pressure ulcer buttocksR1's admission Minimum Data Set (MDS) dated [DATE], identified no cognitive deficits, no behaviors, but would reject evaluation or care four to six days. R1 required maximum to complete assistance with activities of daily living. R1 had one stage two pressure ulcer on admission (right lateral foot). Care Area Assessment (CAA) triggered pressure ulcer, care planning decision dated 10/20/25.R1's skin and wound evaluation dated 10/7/25, identified blister to right dorsum 4th digit toe, not applicable to stage, present on admission. Measured 4.1 cm x 3.3 cm with depth, undermining, tunnelling marked as not applicable. Wound bed had granulation tissue but was unmarked how much of the wound was filled, no evidence of infection, moderate serous exudate, attached edges, surrounding tissue was excoriated and normal temperature, no edema, induration, or pain. Dressing was intact and non-adherent synthetic. Included in the admission skin/wound assessment were the following:1. Front right knee abrasion 1.4x1.8x1.3cm light exudate attached edges; dressing intact foam2. Blister right dorsum 4th digit toe 4.5x4.1x3.3cm granulation wound bed; moderate exudate serous, excoriated surrounding tissue; dressing intact non-adherent synthetic3. Right shin abrasion 2.2x2.4x1.3cm; granulation wound bed; foam dressing intact4. Stage 2 pressure ulcer right lateral foot 0.9x 1.4x0.9 no depth; wound bed is epithelial no dressing applied5. Left below knee amputation (BKA) site 9.6 x 4.2 x 3.0; wound bed granulation; light exudate serous; foam dressing intact6. Abrasion left BKA amputation site proximal no measurements; granulation wound bed, light exudate; foam dressing intact7. Abrasion patella 4.3x4.7x1.7; scab no drainage foam dressing intact8. Left antecubital space abrasion 1.1 x 1.5 x 1.0; scab; fragile skin at risk for breakdown; no dressing9. Left inner forearm bruise not measured10. Left antecubital space bruise 29.5x9.8x4.611. Right shoulder abrasion not measured no dressing12. Upper outer right arm abrasion not measured no dressing13. Right scapula abrasion not measured no dressing14. Sacrococcygeal open lesion 2.3x3.8x2.0; light serous exudate foam dressing intact Review of R1's signed physician orders dated 10/7/25, did not identify orders for wound care treatment to right 4th digit toe R1's care plan dated 10/8/25, identified R1 was on enhanced barrier precautions due to pressure sores. Review of R1's care plan did not identify specified wound locations, treatments, or interventions identified on the care plan R1's progress note dated 10/11/25 at 12:59 a.m., R1's toes were dark purple in appears and stuck to the kerlix and it took some time to remove the old dressing. At 1:55 p.m., identified R1 had purulent (thick, milky discharge, often signals infection) drainage coming from the right third, fourth, and fifth toes that was covered with telfa (nonadherent dressing) and kerlix (gauze bandage).R1's progress note dated 10/12/25 at 11:43 p.m., identified right foot redressed as it was draining outside of the dressing. The note did not identify what treatment was applied. R1's emergency room discharge date d 10/13/25, identified open wounds to left anterior toes with discoloration noted to the toes, positive dorsalis pedis (top of foot by big toe) pulse and able to move toes. X-ray of right foot showed extensive vascular calcifications (calcium salts in walls of blood vessels), no osteomyelitis (bone infection), skin ulceration noted along the plantar aspect deep to the calcaneus (bottom of foot to heel). discharged to facility with scheduled Tylenol for pain and recommendations for wound care. Iodosorb (iodine) gel 0.9% apply topically as needed for wound care to reduce germ load was listed as patient not taking and reported on 10/10/25 from an order on 10/7/25. R1's progress note dated 10/13/25 at 11:55 p.m., identified R1 returned from ED with new orders to change wound dressings daily and change small pads between right toes daily.R1's skin and wound evaluation dated 10/14/25, identified a blister to front right lateral lower leg that was acquired at facility. Wound measured 7.1 cm x 1.3 cm. The evaluation did not include any further characteristics of the wound such as appearance of wound bed, signs and symptoms of infection, presence of drainage, surrounding wound tissue, dressing/treatment provided. Notification made to medical doctor (MD).R1's physician visit note dated 10/16/25, identified review of emergency room visit which included X-ray of right foot showed extensive vascular calcifications, no osteomyelitis, skin ulceration noted along the plantar aspect deep to the calcaneus. discharged to facility with scheduled Tylenol for pain and recommendations for wound care. Facility notified via phone call regarding right foot wound on 10/14/25, and R1 began a 10-day course of Keflex (antibiotic) and an urgent general surgery referral was place and an appt made for 10/16/25. Per nursing staff, he has had a continued foot wound being wrapped by wound care at the facility. An addendum to the note at 3:50 p.m., included the facility notified that general surgery declined to see R1 due to his complex medical history and requested a higher level of care. A second wound care center was referred and also declined to care due to concern for necrosis of toes and recommended evaluation in the emergency room for potential interventions including intravenous (IV) antibiotics, drawing a lactic acid level, and potential transfer to higher level of care which would include vascular surgery interventions. R1 was informed that the risks of not being evaluated include worsening infection, spread of infection to the bone/bloodstream which could result in disability, stroke or death; necrosis, loss of toes and potential loss of his leg. R1 elected to be evaluated in the emergency room.R1's hospitalization record dated 10/23/25, identified medical doctor (MD)-A performed a transmetatarsal (removal of the toes to the five long bones connected to the ankle) amputation for wet gangrene (lack of blood flow) and peripheral vascular disease (PVD) (affects blood flow) of R1's right toes.During a phone interview on 10/23/25 at 8:28 a.m., hospital RN-E stated R1 came to the hospital and all five of the toes were bloody and black with drainage. RN-E took 25 pictures of wounds on R1's body and there were multiple wounds in each picture, a mixture of pressure and non-pressure skin injuries. R1 had bad blood supply to his toes. R1 had all five of his toes amputated at the hospital.During an interview on 10/21/25 at 12:20 p.m., nursing assistant (NA)-A stated R1 complained and refused cares a lot. R1 came to the facility with a lot of sores on his body. R1's toes were always wrapped.During an interview on 10/22/25 at 10:00 a.m., NA-B stated R1 always had a bandage on his right foot, and it covered his toes. On 10/11/25, NA-B gave R1 his bath and his toes were red, weepy, and looked sore.During a phone interview on 10/22/25 at 12:56 p.m., registered nurse (RN)-B stated he was the admission nurse for R1 when he came to the facility on [DATE]. R1 arrived at the facility from the hospital with wound care that was being done for a bunch of wounds. On admission, R1's toes on his right foot were covered in a dressing. RN-B removed the dressing and the toes were macerated with drainage around them and built up between the toes. The three middle toes, on the tops of them had drainage from those wounds, and a reddish color around the wounds. The dressing change for the toes was done on the same schedule as the heel dressing. RN-B could not recall what the order was for the toes but thought it was silver alginate and cover with gauze. RN-B stated he put the orders for R1 in the computer. RN-B did not notify the physician of the wounds. Wounds without specific wound care orders are observed and assessed weekly on bath day. If a wound was not marked as resolved the nurse should assess each wound on bath day and notify the physician if the wound looked better or worse. RN-B did not consider a blister a pressure ulcer.During a follow-up phone interview on 10/23/25 at 12:04 p.m., RN-B stated he changed R1's dressing on his toes on 10/13/25, 10/14/25, and 10/15/25. RN-B stated the wounds were bruise colored with clear drainage, kind of open, but did not seem as if they had deteriorated. There was no order for a dressing on the toes, it was just something we were doing until R1 was seen by the doctor. An order is not needed to treat everything.During an interview on 10/22/25 at 1:15 p.m., licensed practical nurse (LPN)-B stated during the night on 10/8/25, the kerlix wrapped around the toes had fallen off. There was no order in the medication administration record (MAR) for a dressing change, but she reapplied the wrap as they were. On 10/14/25, when R1 returned from the emergency room, LPN-B did not put the new orders for wound care in the MAR because she was not sure how to put orders for wounds in the MAR. Review of the skin assessments only shows the wounds were assessed on 10/7/25.During an interview on 10/21/25 at 2:35 p.m., RN-A stated R1's toe wounds were assessed and the skin and wound assessment updated on 10/14/25 by LPN-B. R1 went to the emergency room on [DATE] and returned. Care plan included turn and reposition, enhanced barrier precautions for wounds, standard pressure relieving mattress in bed.During a phone interview on 10/23/25 at 8:13 a.m., RN-C stated on 10/11/25, R1's toes were brownish/purple in color. RN-C was unsure how to know if a wound was worse. The orders would be followed from the MAR, if the wound looked different than what was last charted RN-C would relay the information to the next shift.During a phone interview on 10/22/25 a 2:56 p.m., LPN-A stated on 10/11/25 she removed the bandages on R1's toes for his bath. R1's third and fourth toes were near black with a thick, white drainage coming from between the toes and the pinkie toe was gray. LPN-A wore a mask when she did this because she had been told the wounds smelled foul, with the mask on she did not smell anything. LPN-A was unable to separate the toes and cleaned the drainage as best as she could. LPN-A did not notify the physician of the wounds or the appearance of them as she assumed the physician was already aware of them. 10/16/25, LPN-A worked and stated she did not look at or do wound care on his toes as the physician had seen R1 and LPN-A thought the physician did the wound care on them.During a phone interview on 10/23/25 at 9:53 a.m., R1's primary care physician (PCP)-A stated she saw R1 on 10/16/25. PCP-A did not evaluate or look at R1's toes as they were wrapped and done by wound care. PCP-A did not recall receiving any information from the facility about wounds on R1 since his admission.During an interview on 10/24/25 at 9:47 a.m., Administrator stated it was an expectation that all areas on the body that have a dressing on them have a corresponding treatment plan in place and the physician notified. It is also an expectation that staff follow standing orders for new wound treatments, include the order in the resident MAR, notify physician, include interventions in care plan, and complete skin/wound assessment.The facility policy titled Skin Integrity dated 5/21/25, identified care center staff will notify the licensed nurse when a new skin integrity issue is observed. Licensed nurse will: assess the area and identify the cause, remove any source of pressure or trauma to the area, clean the area and provide treatment per House Standing Orders, complete a skin incident report in residents electronic health record, notify resident/responsible party, notify provider and request treatment orders, notify nurse manager/wound nurse, initiate a new tissue tolerance, initiate appropriate preventative measures based on the immediate root cause.The facility House Standing Orders policy dated 10/10/23, identified Wound care:1.Cleanse all wounds with normal saline or wound cleanser.2.Treatment for open wound with skin flap: use sterile Q-tip to approximate the edges and apply steri-strips or clear dressing (e.g. Tegaderm absorbent). May cover with a secondary cover dressing PRN.3.Treatment for high friction areas, blisters and abrasions: Apply skin prep or transparent dressing to affected area, change every 3-5 days and PRN until healed, or Wound Nurse changes the treatment.4.Treatment for moisture associated skin with/without superficial open areas: Apply protective ointment to area.5.Treatment for open wound, shallow crater:a.With minimal drainage, apply generous layer of protective ointmentb.With light to moderate drainage, apply composite dressing, change every 3-5d and PRN. For fragile skin apply non-adhering foam dressing and secure with kerlix. Change every 3-5d and PRN.c.With heavier drainage, cover with calcium alginate & foam, secure with wrap or conforming bandage. Change qd and PRN.d.For suspected deep tissue injury (DTI), apply transparent dressing, protective booties, etc.6.Wound Nurse will be notified to conduct a root cause analysis (RCA) to determine wound type and recommend dressings. MD/NP will be notified.

Based on observation, interview, and record review the facility failed to identify and comprehensively assess a pressure ulcer for 1 of 3 residents (R3) reviewed for pressure ulcers. Findings include:R3's face sheet dated 10/22/25, identified diagnoses of fracture of lower end of right femur, type 2 diabetes.R3's admission Minimum Data Set (MDS) dated [DATE], identified no cognition issue, refused cares four to six days a week, substantial assistance with activities of daily living, always incontinent of bowel and bladder, and had no skin conditions.R3's care plan dated 7/10/25, identified impairment to skin integrity. Interventions included to encourage good nutrition and hydration to promote healthier skin, and skin treatments per provider, update as needed. Check all of body for breaks in skin and treat promptly.R3's Braden scale dated 7/30/25, identified a score of 15, which is at risk for skin impairment.R3's skin and wound evaluation dated 10/21/25, did not identify an open area to R3's coccyx.R3's progress note dated 10/21/25 at 7:53 p.m., identified R3 had a bed bath, see skin and wound note for details. During an observation and interview on 10/22/25 at 10:00 a.m., R3 was in bed and nursing assistants (NA)-A and NA-B were assisting R3 with dressing and pericares. While NA-B turned R3 on her left side R3 was observed to have an open spot on her coccyx with some fresh blood noted. R3 stated nurse knows about the spot, she was in here last night and did not think it was bad enough to need photos taken. NA-B applied barrier cream to coccyx. R3 did not want the nurse called to the room to look at the area as she was leaving for an appointment.During an observation and interview on 10/23/25 at 9:18 a.m., R3 was in bed. licensed practical nurse (LPN-A) stated she was not aware that R3 had a reddened area on her coccyx. R3 stated it is red, not opened. LPN-A informed R3 the area was open. LPN-A measured the area as 0.5 cm x 0.5 cm. LPN-A stated a wound should have a picture taken of it, and the wound covered with Vaseline then a bordered foam dressing applied. An order for a dressing change should be in the computer, and the wound should be assessed on bath days. NA's would look at the wound daily with peri cares. R3's progress note dated 10/23/25 at 10:15 a.m., identified LPN-A was alerted for a reddened spot on coccyx. Upon evaluation, there was a 0.5 centimeters (cm) by (x) 0.5 cm open area. No pain, not bleeding, no drainage. R3 requested to only treat with barrier cream and no bandage.During an interview on 10/23/25 at 2:57 p.m., NA-A stated R3's wound was there yesterday. NA-A indicated when it was reported to the nurse, the nurse was dismissive and walked awayDuring a phone interview on 10/23/25 at 3:18 p.m., registered nurse (RN)-D stated the facility has not had a lot of wounds, and they are working towards improvements with wound care. The expectation of floor nurses was to not stage wounds, notify director of nursing, and wound nurse of skin impairment and have one of them stage the wound for accuracy.During an interview on 10/24/25 at 9:47 a.m., Administrator stated management staff reviews all pressure sores in risk management weekly.The facility Skin Integrity policy dated 11/26/24, identified nursing staff will monitor residents skin integrity and address issues promptly while providing care and services consistent with professional standards of practice.

Based on observation, interview, and document review the facility failed to revise 1 of 1 resident's (R2) care plan when his nutritional status changed. R2's 9/8/25 admission Minimum Data Set assessment identified his cognition was severely impaired. He had diagnoses of malnutrition, encephalitis and encephalomyelitis (inflammations of the brain and spinal cord), meningitis (inflammation of protective layer around brain and spinal cord), type II diabetes, disorientation, and anxiety. He was dependent on staff for all activities of daily living and required total assist with meals. Observation on 9/15/25 at 11:59 a.m., in the dining room, R2 was seated in his wheelchair, he was slouched over with his eyes closed and appeared to be sleeping. He was approximately 2 feet from the dining room table where his meal was sitting. Staff approached him, woke him up, and moved him and his food to a different table to assist him with meal. Interview on 9/16/25 at 1:13 p.m., with nursing assistant (NA)-B identified they let R2 feed himself and when he stops eating and taps his fork on the table staff go over and prompt him. If he does not take any more bites, staff ask him if he is hungry and offer to help him. They were told a couple weeks ago they could start offering him food orally, so they have been doing that. We just kind of figured out that when he starts tapping on the table with his fork, he needs help finishing. If staff do not assist him with meal, he will not finish eating his food. Review of R2's 9/15/25 Speech Therapy Treatment Encounter Note identified recommendations for a soft and bite sized texture with added moisture, thin liquids, straws are okay. Complete assistance was needed by staff with all oral intakes. R2 was to sit up at 90 degrees for all eating and drinking and remain upright for 20-30 minutes after meal. Staff were to plan for 5-day trial with regular textures with meat cut into small pieces. Staff were educated on R2's diet trial. Review of R2's current, undated care plan identified he had an ADL self-care deficit, was dependent on staff for activities of daily living, and required a continuous feeding via G-tube. Staff were to change the feeding solution bag every 24 hours, discuss with family and care givers any concerns regarding the tube feeding, and elevate head at least 30 degrease. The care plan made no mention staff were to assist R2 with oral intake or that he was able to take food by mouth. Interview on 9/16/25 at 3:37 p.m., with the director of nursing identified she agreed with the above findings. Nursing should be using the communication from speech therapy to update the care plan. Nursing was notified of the diet change on 8/28/25 and the care plan should have been updated at that time to ensure staff understood how to provide the safest and most effective care to R2. Review of the facilities 12/18/23, Person Centered Care Planning policy identified the care plan would describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan will include the residents' dietary instructions, and services to be administered by the care center and personnel acting on the behalf of the care center. Care plans are to be updated on an ongoing basis as needed based on changes that occur between care conferences.

Based on observation, interview, and record review, the facility failed to prepare food under sanitary conditions, discard food that had been expired, ensure all foods were labeled and dated, and ensure the freezer door had been shit to prevent potential spoiling of food. This had the potential to affect all 39 residents. During observation and interview with cook-A and later joined by the dietary manager on [DATE] at 11:30 a.m., the following was observed during the initial tour of the kitchen: 1. Mrs. Gerry's Parmesan Pepper Corn Pasta Salad had been previously opened with an expiration date of [DATE]. 2. Mustard with a use by date of [DATE] 3. Bag of California Sun Dried Raisins, best before [DATE]. 4. Minced garlic in a squeeze bottle with no visible expiration date, bottle had a dark brown substance on the inside of the lid and around the opening and a black substance on the outside of the bottle. 5. A second bottle of minced garlic with a use by date printed on the bottom of [DATE] 6. A bottle of [NAME] Lynch Dressing with a use before [DATE] 7. A plastic container of strawberry smoothie mix with no expiration date and no open date. 8. Boursin Cheese with a use by date of [DATE]. 9. a zip lock bag of pepperoni with an expiration date of [DATE]. The following items were observed in the walk-in cooler with no date or label. 1. A Bowl containing a white creamy substance loosely wrapped with plastic Cook-A was unsure what the bowl contained; however, she thought it may be ranch dressing. 2. A plastic squeeze bottle with a solid white substance Cook-A was unsure what the bowl contained; however, she thought it may be sour cream 3. A plastic squeeze bottle, the contents had separated, an oily substance on top, a solid yellow substance in the middle, and a brown liquid on the bottom. 4. A glass jar with a screw top cap, the contents were a yellow creamy like consistency. The jar had no label and was not dated. 3. A partial head of lettuce loosely wrapped in plastic with one side exposed. The lettuce appeared brown and wilted. There was no label or date. 4. A zip lock bag containing lettuce with no label or date. 5. A plastic lidded container with a white solid block of unknown product, with no label or date. The walk-in freezer had copious amounts of frost build up on the first 2 shelving units closest to the door and did not contain an internal thermometer. The stove top had a piece of long hair and food particles, the front of the stove had dried brownish drip marks, the side of both stoves also had a brownish/yellow substance that had dried in a drip pattern. The wall behind the griddle had a yellow and brown substance that had dried. Interview [DATE] at 11:30 a.m., with Cook-A identified she was not certain of the contents of any of the unlabeled bottles but said most of the items were used for resident Happy Hour. She identified that the kitchen has had a lot of staff turnover and they have not had time to get their cleaning done or check for expired foods. Follow up interview on [DATE] at 8:20 a.m., with Cook-A identified when she came in for her shift on Friday morning on [DATE], the walk-in freezer door was open, the frost was much worse then it is now. She identified that she did not notify anyone that morning of the incident, she did not check the temperature of the freezer, and did not check to ensure the foods had not thawed. She had told the dietary manager later that day, however, nothing was ever directed to staff to check the food to ensure it had not thawed out overnight. Review of the [DATE] through [DATE], daily cleaning schedule sign off sheets provided by the dietary manager identified the following tasks: 1. Wipe up spills in oven. 2. Wash off stove tops. 3. Wipe out convection oven. 4. Wash out microwave. 5. Wipe off shelves below cook's station. 6. Wash can opener. 7. Wash food processor/Robot Coupe. 8. Clean and Sanitize work surfaces. 9. Scrub 3 compartment sink. 10. Clean and sanitize work counters. 11. Take out garbage. At the bottom of the sheet were notes to Make sure all tasks listed are completed before you leave your shift. All cooks watch for outdated foods and discard. None of the listed kitchen cleaning tasks had been signed off as completed for the following days: Week of [DATE], Monday, Tuesday, Wednesday, or Saturday. Week of [DATE], Sunday, Monday, Friday, or Saturday. Week of [DATE], Sunday, Tuesday, Wednesday, Thursday. Week of [DATE], Monday, Friday, or Saturday. Week of [DATE], Sunday, Monday, Tuesday, Wednesday, Thursday. Week of [DATE], Monday, Friday, or Saturday. Week of [DATE] Sunday, Monday, Tuesday, Wednesday, Thursday. Week of [DATE], Monday, Thursday, Friday, or Saturday. Week of [DATE], Sunday, Monday, Wednesday, Thursday. Week of [DATE], Monday, Friday, or Saturday. Week of [DATE], Sunday, Tuesday, Wednesday, Thursday. Week of [DATE], Monday, Wednesday, Friday, Saturday. Week of [DATE], Friday. Review of monthly cleaning schedule form January of 2024 through August of 2024, identified a task to wipe out walk in cooler. The task had not been signed off as completed on any of the months provided. Interview on [DATE] at 12:06 p.m., with the dietary manager identified she agrees with the above findings. Cooks are supposed to keep an eye expiration dates and should throw them away and order new if needed. We do not have any system to ensure staff are checking for expired foods, we discussed doing audits and competencies with staff, but we have never completed any. We wipe the cooler down monthly and once a year we pull the racks out and clean them. We have sign off sheets for cleaning the cooler, but I have not been checking them. The frost in the freezer was caused by the freezer door being left open over-night last week. Interview on [DATE] at 3:30 p.m., with the director of dietary services identified she had been in this position for about 15 months, she oversees 14 facilities for this corporation and most of her work is done remotely. She reviews weights monthly and assesses high risk residents like people on dialysis The dietary manager does most of the nutritional assessments on site. She had been at the facility in May and had done a tour of the kitchen, she had a conversation with the dietary manager about completing audits and competencies with staff but had not heard if she had completed them yet. Interview on [DATE] at 2:56 p.m., with the administrator identified she would expect the dietary manager would have a system in place to ensure staff were completing all kitchen duties including cleaning, removal of expired foods and appropriate labeling to prevent harm to residents. Review of the [DATE], Labeling of Foods/Grocies facility policy identified all foods need to have a label and date to indcate what is in the package and when it expires and when it was opened. The policy lacked any indication of what system the facility should use to ensure the policy is being followed. Review of the [DATE], Using Sanitary Practices to Prepare, Serve, and Store Food facility policy identified staff were to follow cleaning list to ensure all equipment is cleaned regularly, and employees will label, and date all opened food and items pulled out to be thawed. The policy lacked any indication what system (such as audits or competencies) should be used to ensure staff were following the policy.

Based on interview and document review the facility failed to implement 1 of 1 facility assessment protocol related to ensuring staff competencies were identified and completed respective to staff duties performed. The facility assessment protocol further failed to solicit input from staff, residents, representatives, or family members. Refer to F812 Findings include: Review of the 8/8/24, facility assessment identified changes which were highlighted in yellow that went into effect on 8/8/24. The changes included solicitation of feedback: questionnaire to resident/representative related to staffing, suggestion boxes throughout facility, annual notices to residents/representative prior to annual review, review during resident/family council meeting, departmental/all staff meetings. Accepting residents not on the assessment-add prior to admission. Competencies-knowledge and skills able to prove (demonstration) for hired staff, temporary staff, volunteers, and vendors. On the page identified as authorizations and resident profile listed persons assisting in completing assessment, including QAA/QAPI review and approval to include the administrator, director of nursing, SFHS regional director/governing body representative, medical director, and pharmacist. Highlighted in yellow was additional people including infection preventionist, licensed nurse, nursing assistant, resident/family council, and other. With identification that the facility assessment had been reviewed on 4/15/24 at QAA/QAPI and the next review would be October. The facility assessment further identified that staff competencies had been completed for licensed nurses, nursing assistants, dietary staff, and other staff. Review of a sample of staff competencies for licensed nurses, nursing assistants, and dietary staff identified the nursing staff had their competencies completed. The dietary staff sampled for competencies on sanitation and modified diets revealed that cook-A and cook-B had no competencies completed. Interview on 8/27/24 at 2:31 p.m., with dietary manager identified the dietary staff complete their training on educare. She stated competencies were only completed annually and she did not have any for the two staff requested. She reported the one staff went to part time and the other staff she would be completing soon. Interview on 8/27/24 at 4:31 p.m., with the administrator identified that the facility had not yet implemented input from residents or representatives as the regulation had just went into effect. She revealed that the facility had discussed the changes that went into effect during their leadership call with the corporate office. She reported that the facility would be adding residents, vendors, and staff input on next year's facility assessment. She confirmed that there had been no questionnaires sent out, no notices to residents/representatives had been sent, and the facility had not had a resident/family council yet to discuss the changes. She identified the area's highlighted in yellow on the facility assessment were the changes that the facility would be implementing by the next review.

Based on interview and document review the facility failed to have evidence of measurable goals and documentation of an analysis and evaluation of the data submitted to the QAPI committee to ensure areas identified had oversight for their perspective outcomes brought forth for 1 of 1 Quality Assurance Performance Improvement (QAPI) program. Findings include: Review of the 2/14/24, monthly QAPI meeting minutes identified the facility departments were submitting data to be reviewed by the committee. 2 examples of failure to document a measurable goal and/or analyze the data identified: 1) Quality improvement Incentive Program (QIIP) Bowel incontinence with toileting plan identified residents with bowel incontinence triggering would be reviewed for toileting habits and interviews with staff would be completed. The individualized toileting plans would be reviewed. The director of nursing (DON), assistant director of nursing (ADON) and the MDS coordinator would be assigned the review. Completion date was ongoing. Follow up area identified to assess toileting plan if effective and meeting goals. Information on QIIP by breakroom for all staff to review. There was no documentation of a measurable goal, no documentation to support the QAPI committee analyzed the data brought forward, how they were going to achieve their compliance, if further education was needed, or if the action plan required revision. 2) Performance-Based Incentive Payment Program (PIIP) identified task 2023 [NAME]-Employee Recruitment and Retention (UKG [NAME] Implementation) Reduce turnover by 2%, increase employee satisfaction, increase applications for open positions, fall grant, facility will continue to work on their fall reduction and prevention. Person assigned would be the HR/Grant Coordinator. Completion date identified as ongoing. Follow up education and communication was ongoing with any concerns noted with UKG. Next step was plans to be advanced scheduling. There was no documentation to support the QAPI committee had data to analyze brought forward, no action plan as how the facility would achieve their compliance, or if revisions were needed. Review of the 3/13/24, QAPI meeting minutes identified the facility departments were submitting data to be reviewed by the committee. 2 examples of failure to document a measurable goal and/or analyze the data identified: 1) Quality improvement Incentive Program (QIIP) Bowel incontinence with toileting plan identified residents with bowel incontinence triggering would be reviewed for toileting habits and interview staff. Individualized toileting plans would be reviewed. The director of nursing (DON), assistant director of nursing (ADON) and the MDS coordinator would be assigned the review. Completion date was ongoing. Follow up identified assess toileting plan if effective and meeting goals. Information on QIIP by breakroom for all staff to review. There was no change from last meeting and no documentation of a measurable goal, no documentation to support the QAPI committee analyzed the data brought forward, how they were going to achieve their compliance, if further education was needed, or if the action plan required revision. 2) Performance-Based Incentive Payment Program (PIIP) identified task 2023 [NAME]-Employee Recruitment and Retention (UKG [NAME] Implementation) Reduce turnover by 2%, increase employee satisfaction, increase applications for open positions, fall grant, facility will continue to work on their fall reduction and prevention. Person assigned HR/Grant Coordinator. Completion date identified as ongoing. Follow up education and communication were ongoing with any concerns noted with UKG. Next step was plans to be advanced scheduling. New this meeting was that in March 2024, performance reviews were now in the new UKG to start using. HR was to send managers information and training video. There was no documentation to support the QAPI committee had data to analyze brought forward, no action plan as how the facility would achieve their compliance, or if revisions were needed. Review of the 7/29/24, QAPI meeting minutes identified the facility departments were submitting data to be reviewed by the committee. 2 examples of failure to document a measurable goal and/or analyze the data identified: 1) Problem, April falls: 7 of 9 falls were on a weekend in April. Tasks identified will review staffing and activities. Person assigned was managers, completion date identified as ongoing. The follow up action plan included afternoon snack cart in dining room versus room to room. Get residents out of their room for afternoon snack/socialization. Review activity staffing hours on weekends. Monitor to see if continues as a trend or pattern. The problem had been identified at May meeting, with no documentation of a measurable goal, no documentation to support the QAPI committee analyzed any data brought forward, how they were going to achieve their compliance, if further education was needed, or if the action plan required revision. 2) Problem, dementia. Tasks included education with staff on how to handle residents with dementia. No person was assigned, completion date was ongoing, and there was no follow up or action plan identified. There was no documentation of a measurable goal, no documentation to support the QAPI committee analyzed any data brought forward, how they were going to achieve their compliance, if the action plan required revision. Interview on 8/27/24 at 2:45 p.m., with administrator identified the QAPI documentation was lacking but discussions had taken place about concerns identified. She agreed that there was a lack of measurable goals, and analysis of information brought forward during the meetings. Review of the 10/8/18, Quality Plan policy identified the administrator had the responsibility and was accountable to the Regional Director/VP/CEO and governance Board of Directors of QAPI and ensuring quality of care was delivered. The administrator was to provide staff support to the QAPI program and review recommendations made through that process. The administrator was to oversee each department actively participated in the program with objectives to problem identification, implementation of corrective action, and evaluation of the effectiveness of the program through ongoing monitoring and data collection.

Based on observation, interview and document review the facility failed to appropriately administer and accurately reconcile 1 of 1 resident's (R35) medication (lisinopril) (used for high blood pressure) when the order was changed and prior to administering any medication. Findings include: Observation, interview, and Medication Administration Record (MAR) review on 8/27/24 at 9:14 a.m., with trained medication aid (TMA)-A as she prepared to administer morning medications to R35 identified TMA-A removed R35's medication cards from the medication cart and placed them on top of the cart. She accessed the electronic medical record (EMR) which Displayed R35's current medication orders. TMA- A picked up a card, looked at the order on the screen, and popped the medication into a waiting medication cup. When TMA-A picked up the card containing the lisinopril she looked at the card, glanced at the screen, and prepared to place the lisinopril into the medication cup with the meds to be administered. TMA-A was asked what the order was for the lisinopril and looking at the EMR responded, the order listed 5 milligrams (mg) by mouth (PO) daily (QD). She was then asked what the medication label on the card containing lisinopril for R35 and responded it contained 10 mg tablets. Review of the printed Physician Order Review identified an order dated 6/24/24 for lisinopril 10 mg PO QD. The bubble packaged medication card had no label, or identification of a change in order, and had been stored in the cart with his other current medications. Interview on 8/27/24 at 9:19 a.m. with TMA-A reported she had been administering 10 mg of lisinopril to R35 QD and she had not been informed of a change in his dose. TMA-A confirmed she would have administered the 10 mg tablet to R35 if she had not been questioned. She reported the medication card should have been pulled from the cart, given to the charge nurse and the pharmacy contacted to provide the correct dose of medication. TMA-A reported this type of incident had occurred intermittently with other medications, she had informed the charge nurses, but the issues had not been clarified or acted upon. Interview on 8/27/24 at 9:23 a.m. with licensed practical nurse (LPN)-A (charge nurse) identified the order on the EMAR and the bubble packaged medication card did not match, and she was not aware of when the order had changed. LPN-A reported the procedure that staff were to follow was when a medication dose was changed, the medication card should have been pulled out of the medication cart, the pharmacy notified of the change and a card with the correct dose provided. She confirmed staff were supposed to be checking to ensure the orders and medication cards matched, but the old card should not have been left in the cart and it would have been possible for an error to occur. Interview on 8/27/24 at 9:53 a.m. with the director of nursing (DON) reported R35's lisinopril order had changed on 8/26/24 and the medication card should have been pulled from the cart, the pharmacy notified and a card with the correct dose provided. She reported staff were supposed to follow the checks for each medication administered, but the process had not been followed, and the order had been entered into the EMR, but the process was not completed when the card with the incorrect Lisinopril dose should have been removed from the cart, to avoid an error. The DON did provide a new Physician Order Review document which contained an order dated 8/26/24 with a start date of 8/26/24 for Lisinopril 5 mg PO QD. She confirmed the procedure for a medication order change had not been followed and R35 should have received 5 mg of Lisinopril on 8/26/24 instead of the 10 mg tablet. Review of the Nursing Policies and Procedures Transcribing MD/NP orders identified the nurse who received an orders was responsible to transcribe and follow the process for any orders received. Medication orders: 1. Were to be entered into the EMR. 2. The new medication or dose change was to be ordered from the pharmacy by either phone or fax. 3. Document the order and/or changes in the progress notes. 4. Make care plan changes if indicated. 5. Apply a label change sticker the medication card if appropriate.

Based on observation, interview, and document review, the facility failed to ensure an accurate labeling of three medication for two residents (R35 and R38), who had medication package labels and orders that did not match or give clear direction, to avoid the potential medication errors. Findings included: R35's current 8/26/24 physician order for lisinopril ( a blood pressure medication) listed 5 milligrams (mg) by mouth (PO) daily (QD). The medication card located with R35's active medications contained 10 mg tablets. The bubble packaged medication card had no label, or identification of a change in order, or dosage. R38's current Physician Order Summary contained a 6/18/24 order for Gabapentin ( used to treat neuropathic pain) oral capsule 100 mg, 3 capsules PO twice daily (BID) (7:00 a.m.-10:00 a.m. and 7:00 p.m. - 10:00 p.m.) and 100 mg PO QD (12:00 p.m.-2:30 p.m.). The current medication card contained 300 mg capsules and directed staff to administer one capsule PO BID. The card failed to contain any label or notation to draw attention to the dosage of the medication in the active card, and the orders. R35 also had a 8/13/24 order for Lidoderm External Patch 5% 1 patch QD on (7:00 a.m. - 11:00 a.m.) off at bedtime (HS). The current pharmacy package label directed to apply 1-3 patches to skin QD. Leave on for up to 12 hours in a 24 hour period. Interview on 8/27/24 at 9:19 a.m. with trained medication aid (TMA)-A confirmed the order listed in the electronic medical record (EMR) listed Lisinopril 5 mg PO QD, and the current medication card contained 10 mg tablets with directions to administer 1 tablet PO QD. She reported she had been administering the 10 mg daily and confirmed she had not been notified of a change in the dosage. TMA-A reported when an order was changed the process was to pull the card and request a new card from pharmacy. She reported she would not have attempted to break the 10 mg tablet, but would have waited for a new correct dose medication to be sent from the pharmacy. She identified she would have administered the 10 mg tablet, as that was the dose R35 had been receiving. Interview on 8/27/24 at 9:23 a.m. with licensed practical nurse (LPN)-A (charge nurse), confirmed R35's active Lisinopril medication card contained 10 mg tablets and the order had been changed in the EMR, but she was not aware of a change in dosage. LPN-A reported the order change should have been communicated, the card pulled from the medication cart, and a new card requested from the pharmacy. She identified the process for medication changes, had not been followed and could have resulted in a medication error. Interview on 8/27/24 at 9:53 a.m. with the director of nursing (DON) reported R35's Lisinopril order had changed on 8/26/24 to Lisinopril 5 mg PO QD and the medication card should have been pulled from the cart, the pharmacy notified and a card with the correct dose provided. The change in order should have also been communicated during shirt report to avoid a potential error. Review of the Nursing Policies and Procedures Transcribing MD/NP orders identified the nurse who received an orders was responsible to transcribe and follow the process for any orders received. Medication orders: 1. Were to be entered into the EMR. 2. The new medication or dose change was to be ordered from the pharmacy by either phone or fax. 3. Document the order and/or changes in the progress notes. 4. Make care plan changes if indicated. 5. Apply a label change sticker the medication card if appropriate.

Based on observation and interview the facility failed to ensure hair nets were accessible prior to entry for visitors and staff for 1 of 1 kitchenette. The facility also failed to ensure 1 of 1 walk-in freezer, 1 of 1 walk-in refridgerator, 2 of 2 stand alone refrigerators temperatures were consistently monitored and 1 of 2 stand alone refrigerator outside of the kitchen and 1 of 1 walk-in refrigerator was kept clean and free of food-like debris. In addition, the facility also failed to ensure food was not stored on the floor in 1 of 1 dry food storage area, scoops were not stored in 1 of 2 bulk containers, and 1 of 1 dishwasher temperature was consistently monitored. Findings include: Observation, interview, and document review on 9/5/23 at 10:00 a.m., with the certified dietary manager (CDM) on initial tour identified a log was hung outside of both the walk-in freezer and the walk-in refrigerator. On those logs were 2 documented temperatures (both within normal range). 3 of the 5 days had no temperatures logged. The CDM revealed that had been a known concern of getting staff to log the temperatures daily as required. Inside the walk-in refrigerator there was a spill of pink juice-like substance just below the box marked chicken, located on the bottom shelf approximately the size of a pie plate. The floor inside the walk-in refrigerator was observed to be sticky while walking on it. The CDM stated the cook should have cleaned up any spills immediately. Observation of the dry storage area identified a box of potatoes was sitting on the floor next to the storage rack. The CDM picked the box up and carried it into the walk-in refrigerator. She agreed food was not to be stored on the floor. The bulk flour container was noted to have the scoop stored in the container sitting in the flour. The CDM removed the scoop stated staff were aware they were not to leave scoops food items. In the washing machine room was a hot temperature washing machine. Staff were to log temperatures during each wash cycle. The log had 1 temperature noted for the month of September. Observation on 9/5/23 at 11:35 a.m., of the refrigerator on the Centennial wing found a temperature log hanging on the outside of the refrigerator with 4 of the 5 days documented. Inside the refrigerator there was observed to be a red juice-like substance spilled on the bottom and the sides of the refrigerator wall. There were no hairnets accessible at the Centennial kitchenette serving area. There was a yellow sign hanging on the paper towel holder above the sink to notify staff to Make sure to wear your hairnet. When asked, staff were unable to locate or recall where hairnets were stored. Observation on 9/6/23 at 11:00 a.m., of the South nurses station refrigerator identified a temperature log outside of the refrigerator. Only 1 documented temperature was recorded for month of September. Further review of the July, August, and September 2023, temperature logs for the walk-in freezer identified: 8 out of 31 days in July,no temperatures documented as having been monitored. 8 out of 31 days in August had no temperatures documented as having been monitored, and 2 out of 5 days in September had no temperatures documented as having been monitored. Further review of the July, August, and September 2023, temperature logs for the walk-in refrigerator identified: 8 out of 31 days in July had no temperatures documented as having been monitored. 8 out of 31 days in August had no temperatures documented as having been monitored, and 2 out of 5 days in September had no temperatures documented as having been monitored. Review of the July, August, and September 2023, temperature log for Centennial wing refrigerator identified 17 out of 31 days in July had no temperatures documented as having been monitored, 2 out of 31 days in August had no temperature documented as having been monitored, and 1 out of 5 days in September had no temperature documented as having been monitored. Review of the July, August, and September 2023, temperature log for South nurses station refrigerator identified 4 out of 31 days in July had no temperatures documented as having been monitored, 11 out of 31 days in August had no temperature documented as having been monitored, and 3 out of 6 days in September had no temperature documented as having been monitored. Further review of July, August, and September 2023, temperature log for the dishwasher identified: 1/31 morning shift and 31/31 PM shift in July had no temperatures documented as having been monitored, 1/31 morning shift and 31/31 PM shifts in August had no temperature documented as having been monitored, and 4/5 morning shifts and 5/5 PM shifts in September had no temperature documented as having been monitored. Review of 8/27/23 through 9/2/23, Daily Cleaning/Duty Sheet identified staff were to wipe out the refrigerator in Centennial serving area and record refrigerator and freezer temperatures. There was no mention of a cleaning task in the kitchen area. Interview on 9/6/23 at 4:36 p.m., with the registered dietician identified she would expect dietary staff would maintain a sanitary department, keeping the refrigerators clean, not leave scoops in bulk stock foods, ensure there was no food stored on the floor, log temperatures in all refrigerators and freezers daily, and log dishwasher temperature to ensure appropriate monitoring occurred with each wash. There was to be a cleaning schedule for routine cleaning, but staff were expected to maintain sanitation should a spill occur. Review of undated, Hair Covering policy identified all exposed hair, such as facial and hair on staff's head, was to be covered in order to prevent hair from contaminating food or clean dishes. There was no mention hairnets should be accessible at the entrances of the kitchen or the kitchenette serving areas.

Based on observation, interview and document review the facility failed to appropriately clean and disinfect 1 of 2 Master Care Integrity Bath with Reservoir tubs per the manufacture's guidelines using a wet contact time of 10 minutes with an approved chemical. This had the potential to effect 41 of 41 residents who used the Master Care tubs. Findings include: Observation and interview on 9/6/23 at 10:36 a.m., with nursing assistant (NA)-A as she took the attached sprayer and rinsed the tub and chair surfaces with water and allowed to drain from the tub, She then closed the tub drain, turned on the jets, filled the tub to the intake value, turned on the disinfectant switch to allow the disinfectant/cleaner to flow into the tub, and used a scrub brush to scrub all interior surfaces of the tub and bath chair. NA-A turned off the jets and drained the solution from the tub. She again closed the drain, reached to the side of the Master Care jetted tub, turned the panel button for the attached manufacturer's disinfectant located beside the tub and using the attached sprayer, sprayed the tub and bath chair surfaces, she then took the scrub brush and scrubbed the tub and chair surfaces with disinfectant and removed the chair cushion to allow cleaning of the bottom surfaces. NA-A sprayed the disinfectant over the tub and chair and reported she would wait 10 minutes and then return to rinse the tub. The surface of the tub sides and upright chair surface was observed drying and were dry at 10:51 a.m., when NA-A reported she could now open the drain and rinse the tub and chair surfaces with water to get rid of the disinfectant that was on the surface, and it was ready for the next bath. NA-A reported staff were to clean the tub after each bath and a there was an additional cleaning and disinfecting process completed after the last bath was given. She referred to the cleaning and disinfecting instructions posted on the wall beside the tub which listed to let the disinfectant sit on the tub surfaces for at least 10 minutes. She reported she followed the directions to make sure the tub was clean and disinfected and was not aware of a need to keep the tub and chair surfaces wet for disinfection, only that it needed to be on the surface for 10 minutes. Interview on 9/6/23 at 11:00 a.m., with the infection preventionist (IP)/assistant director of nursing (ADON) reported staff had been reeducated on cleaning and disinfecting the Master Care tubs, after being cited last year, but she was not aware of the manufacture's label directions on the disinfectant solution that identified the required wet time of 1 to 10 minutes for disinfection depending on the organism. The ADON agreed that the disinfectant was not being used per the manufacture's guidelines. Interview on 9/6/23 at 11:45 a.m. with the director of nursing (DON) reported staff had received education on how to clean and disinfect the Master Care tub and review of the Master Care integrity Bath with reservoir System Operation procedures listed to open the drain and after standard contact time per label directions on disinfectant container, use the Shower Wand to rinse all areas that had contact with the disinfectant cleaner. She reported she was not aware of the need for surfaces to remain wet for 1 to 10 minutes as directed on the disinfectant label. Interview on 9/07/23 at 11:01 a.m., with the environmental services supervisor reported he had contacted the Master Care company about the brand of whirlpool disinfectant and cleaner being used in the facility. He reported they did not specify a specific brand of disinfectant to be use in the Master Care jetted tubs, but the label directions should be followed to ensure disinfection was completed. Review of the manufacturer's System Operation Procedures identified the Master Care Integrity Bath with Reservoir System disinfection was to be used according to the standard contact time on the label of the disinfectant container. The Classic Whirlpool Disinfectant and Cleaner label identified after using the whirlpool unit, staff were to drain and refill with fresh water to the level of covering the intake valve. Staff were to add 2 ounces of the disinfectant for each gallon of fresh water added. Staff were to then start the pump to circulate the solution and wash down the unit sides, seat of the chair, lift and any/all related equipment with a clean swab, brush, or sponge. Treated surfaces were to remain wet for 10 minutes. After the unit had been thoroughly cleaned, staff were to drain the solution from the unit and rinse any/all cleaned surfaces with fresh water.

Based on observation, interview and document review the facility failed to comprehensively assess, and create and implement interventions for ongoing undesired weight loss for 1 of 1 (R7) reviewed for significant weight loss. Findings include: R7's 9/6/23, resident face sheet identified R7 was admitted to the facility on [DATE]. R7 had the following diagnoses a history of left hip fracture, adjustment disorder with depressed mood, age-related osteoporosis, hypertension, amnesia, seizures, and dementia. R7's 8/8/23, significant Minimum Data Set (MDS) assessment identified R7 had severe cognitive deficit, was independent with eating after set up assistance. R7 had physical behaviors towards others, had behaviors that significantly affected her cares and impacted others. R7 took a daily antipsychotic medication and had no identified swallowing or chewing problems. R7's 7/10/23, Service Plan (care plan) identified R7 was independent with eating and should continue to be independent after set up assistance. The staff were to offer R7 foods and drinks per R7's preference. R7 will brush her own existing teeth with a soft brush in the morning and evening during cares. R7 had partials but did not wear them. Review of 7/27/23, certified dietary manager (CDM) 5 day nutritional assessment with the assessment reference date (ARD) of 7/17/23, the CDM identified R7's weight was 104 pounds, R7 had a regular diet and no supplements at the time. R7 was pleasantly confused. CDM identified R7 was as risk for weight loss and dehydration and would care planned R7 to increase fluid intake at meals, offer drinks after toileting program, and increase snacks and possible supplements. There was no mention of these interventions on the care plan. Review of 8/7/23, CDM Significant Change Nutritional Assessment identified R7's weight at 101 pounds. R7 remained on a regular diet and started supplement 2 ounces three times a day. R7 continued to be independent with eating after set up assistance, R7 was identified to be confused and combative at times. R7 was at risk for weight loss and dehydration, R7 slept through meals and refused meals. The assessment identified care plan changes included increase fluid intake at meals, offer drinks after toileting program, increase snacks and possible supplement. There was no change to the care plan interventions, and no mention of these intervention on the care plan. Review of R7's weights since admission on 7/10/23: 7/10/23-103.9 pounds (lbs) 7/11/23-102.8 lbs. 7/12/23-103.8 lbs. 7/19/23-104 lbs. 7/25/23-101.6 lbs. 8/25/23-96.6 lbs. 8/25/23-89.2 lbs. 8/31/23-90.8 lbs. 8/31/23-90.8 lbs. Between 7/10/23 and 8/31/23, R7 had a 12.61% weight loss, with no interventions implemented. Observation on 9/6/23 at 8:33 a.m., of R7 in dining room sitting at table eating her breakfast independently. She then starts to leave wheeling herself away from the table, she had a couple bites of scrabbled eggs left, and some sausage. There was a medication staff at medication cart about 4 feet from her and a staff person charting off to the side of the dining area however, no staff attempted to stop her to encourage her to finish her breakfast. Interview on 9/6/23 at 8:51 a.m., with cook (C)-A identified she normally gave R7 small portions because if she gave her to much on her plate in the morning she would not eat as R7 seemed to get overwhelmed. So if she gave her small portions she would eat everything on her plate and not leave the table. She also reported R7 normally would not come out for lunch or eat lunch. She stated they brought her out for lunch yesterday but she would not eat anything she just sat there. Observation 9/6/23 at 11:53 a.m., R7 was sleeping in her room in her recliner, others are all in the dining area seated at the table for lunch. At 12:21 p.m., R7 continues to be in her room sleeping in her recliner during noon meal. At 12:40 p.m., R7 was seated at the table in dining room not eating, there was no staff encouraging her to eat. Interview on 9/6/23 at 1:52 p.m., with CDM identified when there was a new admission she would completed an assessment within 5 days. The Dietician then would review the admission assessment, and she would complete the annually, and significant changes assessment or assess a resident upon request. The CDM revealed that the dietician had not reviewed R7 yet related to being ill the last time she was scheduled to come to the facility and she had to work remotely. She reported that R7 had been admitted to the facility under weight and the family had reported to her that R7 did not like to drink supplements. She reported she had started the dietary assessment and nutritional risk assessment for R7 in the electronic medical record with the review date of 7/17/23, however she had not completed either of them and they both still showed in progress, she stated she did assess R7 though and just made a progress note. She monitored weights weekly and was aware R7 had been loosing weight. She stated she had been monitoring R7's intake about every other day reporting that R7 did well with drinking her fluids so she had dietary give her vanilla ensure in her milk when she ate breakfast but did not have that documented anywhere. She confirmed she had not started R7 on any type of supplement, she stated the doctor had not even referred R7 to the dietician at all. When asked if she had contacted the dietician about R7's weight loss she reported she had contacted her 2 days ago and had no record of that as she had just called the dietician. There was no indication the kitchen staff were fortifying her food for extra caloric intake. Interview on 9/6/23 on 4:36 p.m., with dietician identified she was unaware of R7's weight loss and had not been notified of R7's weight loss. She identified she would expect to be notified any time a resident was loosing weight either by a phone call or email as she could make a recommendation to the facility or she could contact the provider with a recommendation. She reported she does admission assessments, and annual assessment when she comes to the facility for her visits. For issues that arise between those times that need addressing sooner she was contacted and could complete an assessment remotely if she has access. She agreed that R7's weight loss was significant and the provider should be updated and interventions put into place. Interview on 9/7/23 at 8:25 a.m., with trained medication aide (TMA)-A identified R7 ate independently and normally ate a good breakfast but did not eat lunch unless she ate her dessert. TMA-A revealed R7 did not get any supplements that she was aware of and staff did not do anything for her to get her to eat as she eats independently when she wants to eat. Interview on 9/7/23 at 9:18 a.m., with registered nurse(RN)-B identified nursing does weights on bath days, then dietary reviews those weights. Staff can see other weights when they enter the weight into the computer system and if they note a change they should be reporting that to the charge nurse. If a resident was noted to be having a weight loss nursing would notify the provider as well as talk with the dietary manager to see what else we could be doing to help prevent additional weight loss. She was unaware that R7 had a significant weight loss. Interview on 9/7/23 at 10:26 a.m., with director of nursing identified that nursing completes weights weekly, dietary should monitoring weights weekly, and if a resident was loosing weight an assessment should have been completed to find out the root cause of the weight loss and implement interventions to prevent further weight loss. Review of 1/18/21, Weight Monitoring Program policy identified a significant weight loss was of 5% or more in 30 days or 10% in 189 days. The staff were to monitor for weights to maintain or improve a residents overall health. Staff would weight residents weekly, weights would be tracked and assessed once entered into the electronic health record. Residents with weight loss or risk of weight loss should be discussed at interdisciplinary team (IDT) and identify interventions. The registered dietician would be notified of all new admission, hospital returns with identified changes in conditions that may affect weight so interventions could be implements. The provider would be contacted for any significant weight changes and care plans should reflect interventions implemented.

Based on interview and document review the facility failed to perform a root cause analysis and appropriately monitor/supervise 2 of 3 residents (R29 and R30) who had a history of repeated falls. This resulted in both R29 and R30 sustaining serious injury due to falls. Findings include: R29 Review of the 5/21/22 at 7:15 a.m., facility incident report identified R29 had been assisted with her activities of daily living (ADLS) and was seated in her wheelchair (w/c), while an unidentified nursing assistant (NA) cleaned up the bathroom. Without warning R29 stood up from her w/c to put on her sweater, lost her balance and fell hitting her right side against her w/c and a flower stand. As she was falling R29 struck the right side of her head against the window ledge which resulted in a 2.5-centimeter (cm) laceration to the right posterior area of her head. R29 also obtained a large hematoma to her right gluteal (buttock) area and a first rib fracture. R29 was receiving scheduled doses of [MEDICATION(S)] (blood thinner) and was transferred to the emergency department (ED) via ambulance for assessment and required staples for closure of her head laceration. Following treatmen,t R29 was determined stable for outpatient management and discharge instructions were provided for transfer back to the facility. The report failed to identify review for root cause analysis of the cause of R29's fall, if existing interventions were appropriate, or if further interventins and/or supervision was require. Review of the 5/30/22 at 3:50 p.m., facility incident report identified R29 had been transferred onto the toilet by NA-E, had requested to sit on the toilet for a while, and was told by NA-E to turn on her call light when she was ready to get off the toilet. R29 was heard calling out and discovered lying on the floor between the bathroom and her room. R29 was noted to have deformity of her right ankle and was complaining of right ankle, hip, and knee pain. R29 denied attempting to self-transfer and stated she had slid off the toilet. Her walker was tipped and resting beneath her right thigh and due to her position and complaints of pain Emergency Medical Services (EMS) were called and R29 was transferred to the ED for evaluation. ED assessment identified R29 had a trimalleolar (leg sections that form the ankle joint and help to move foot and ankle) ankle fracture pattern with lateral dislocation of the ankle. R29 was transferred to a Regional medical center for surgical evaluation and treatment. The report failed to identify review for root cause analysis of the cause of R29's fall, if existing interventions were appropriate, or if further interventins and/or supervision was require. R29's, 7/5/22, Quarterly Minimum Data Set (MDS) identified her cognition was intact and that she required extensive assistance with activities of daily living, (ADLS). R29 had experienced 2 falls since her previous assessment, one which had required scalp staples and the second resulted in an ankle fracture that had required surgical intervention. R29 had diagnoses of fracture and other trauma, [CONDITION(S)], high blood pressure, and diabetes. R29's undated, current care plan identified she was only to be walking with therapy and required a 1-2 person assist with ADLs including transfers, mobility, and repositioning, and was identified at risk for falls or injury related to (R/T) cognitive deficits. R29 received anticoagulants and was at risk for bleeding/bruising. In addition, R29 was receiving a scheduled diuretic, but there was no mention of a toileting plan due to an increased need for urination. Pain management was per order and restorative ambulation was on hold due to her ankle fracture. Interventions listed reminders to use her call light and staff were to ask if she needed anything before leaving the area. The Interdisciplinary team (IDT) review was identified to assess safety for use of an electric recliner chair, but there was no mention of the need for increased supervision due to her history of self-transfer to the bathroom. Interview on 7/22/22 at 3:30 p.m., with NA-D reported R29 had a history of self-transferring when she wanted to use the bathroom, but since her most recent fall she had used her call light and requested assistance. NA-D identified R29 was considered a high fall risk and required extensive assistance from one staff for transfers to maintain standing balance. NA-D reported since her fall with ankle fracture R29 had been using a bedside commode and was transferred with a gait belt due to weight restriction of her right ankle. On 5/30/22, R29 was discovered by NA-D in the process of self-transferring from her recliner to the toilet in the bathroom, and left R29 without supervision which resulted in a fall with fracture following use of the toilet. NA-Dwas unaware of needing to provide any increased supervision. Interview on 7/25/22 at 11:08 a.m., with R29 reported she had diabetes and numbness in her feet along with poor circulation and she thought that had possibly been why she had fallen. R29 reported she had fallen on 5/30/21 because she had been on the toilet for 1/2 hour, her call light was on, and she had fallen off the toilet. R29 stated she had broken her ankle but did not remember if she had any other injuries. R29 stated she did not remember any previous falls. Interview on 7/25/22 at 11:15 a.m., with trained medication aide (TMA)-A reported R29 had been better at using her call light since her fall and ankle fracture, but the reason she had fallen was she attempted to self-transfer from the toilet and fell . TMA-A reported staff frequently had to remind R29 to use her call light and wait for assistance, but but R29 was known to self-transfer herself and had done so more often prior to her most recent fall. R30 Review of the 7/2/22, facility incident report identified at at 2:00 p.m. that day, laundry staff (LS)-A was in the room next door when she heard a thud went to check and discovered R30 lying on the floor. LS-A immediately notified RN-B who responded and assessed R30. The report identified R30's w/c that had been in front of her recliner prior to her fall had been moved away. When questioned R30 reported she was trying to get up and fell , but was not able to state what she had wanted to do. R30 was noted to have been incontinent of BM and was observed attempting to get up by herself as she demanded staff to help her get up. No complaints of pain or deformity were noted and she was assisted by staff into her w/c and then transferred with a stand lift to her bed. When in the standing lift R30 began complaining of pain in her right inner hip and groin, and the decision was made to transfer to the ED for evaluation and treatment. The report identified prior to the fall she had been toileted, had eaten lunch and after eating had requested to return to her room to rest. R30 was taken back to her room and transferred into her recliner. The report identified R30 had been more active on 7/2/22 and had been found attempting to get up several times, and once was discovered in another resident's room. The root cause was listed as a self-transfer, and the IDT note identified R30 had interventions in place. There was no review or determination documented if the 30 minute checks had been identified as adequate supervision with R30's repeated attempts to self-transfer. R30's 4/30/22, Significant Change MDS identified R30 had severe cognitive impairment and she required extensive assistance of two staff persons for personal care and one staff for mobility. R30 required assist with transfers and was only able to stabilize with assistance and the use of a walker and/or w/c. R30 had diagnoses of non-traumatic [CONDITION(S)], dementia, and hypertension. R30 had one fall without injury since the previous assessment. R30's undated care plan identified she was at risk for falls due to her cognitive deficits and lack of safety awareness and required assistance with mobility and transfers. Staff provided frequent room checks as they were passing by, but there was no specific time frame or documentation of checks being completed R30's walker and w/c were placed within reach due to R30's history of self-transfers and to assist with stability when she attempted to self-transfer. Her bed sheets were loosely tucked to avoid R30 becoming tangled in them, a night light was kept on, a non-skid rug was beside her bed, the bed was kept locked, and she was checked frequently by staff. Review of the 7/2/22 at 3:31 p.m., ED, CT (Computed Tomography) scan per radiology identified R30 had a mildly displaced comminuted (producing multiple bone splinters) right acetabular (ball and socket) fracture and mild displaced fractures of the right superior and inferior pelvic area. A hematoma (bruise) was noted along the right pelvis sidewall. Consultation with an orthopedic surgeon identified surgical intervention was not necessary. R30 was discharged back to the facility with non-weight bearing status as much as possible, toe-touch with transfers and to follow up with orthopedics in 1 week. Interview on 7/21/22 at 10:10 a.m., with NA-C identified R30 was to be checked and/or changed every (Q) 2 hours (H) and was a total assist with the Hoyer lift for transfers. She required the assistance of 1-2 staff for personal cares. NA-C reported R30 was at risk for falls and safety checks were completed Q15-30 minutes. NA-C reported R30's walker and w/c are positioned close to either her bed or recliner and they make certain the brakes are on. NA-C identified even with that R30 will at times release the breaks and move the w/c or walker and then attempt to self-transfer. NA-C identified the frequency of checks increased following her fall, but she had been working that day and the care plan was being followed and staff checked on her as they passed by her room. NA-C identified that following a resident fall the staff on duty have a huddle to discuss what happened and to determine the possible cause. NA-C reported there was no documentation of safety checks, but all staff looked in on residents as they went about their duties. Interview on 7/22/22 at 9:44 a.m., with TMA-A identified she was working passing medications on the date of R30's fall and R30 had been brought to the dining room about 11:00 a.m. through 11:30 a.m., and at 10:45 a.m., she had assisted NA-C to toilet her and then assist her back into her recliner. TMA- A reported R30 had appeared anxious when she was in the dining room as she was repeatedly moving away from the table. TMA- A identified R30 had received her scheduled Tylenol at 9:15 a.m. and did not appear to have discomfort. R30 ate her lunch, and repeatedly moved away from the table, and when asked if wanted to return to her room, replied yes, but would not allow staff to take her to her room. R30 continued to move about in her w/c and about 12:20 p.m., TMA-A and RN-C toileted R30 and transferred her to her recliner. TMA-A reported R30 was covered with a blanket, her call light was within reach, and she had turned her head, closed her eyes, and appeared to be resting. TMA-A was not certain what time R30 was last visualized after being transferred to her recliner, but she had passed by her room while passing medications and R30 was sleeping. TMA-A reported she did not remember the time she saw R30 sleeping in her chair or if anyone had checked on her again prior to her fall. Interview on 7/22/22 at 12:44 p.m., with RN-B identified she had been working on 7/2/22 when R30 fell and was notified by LS-A who was in the room beside R30's and heard a thud, went to investigate, and discovered R30 on the floor. RN-B reported prior to her fall R30 had been sitting in her recliner with the w/c positioned beside the recliner. RN-B reported she knew R30 was sleeping because she had made a round and observed her but was not certain of the actual time. RN-B reported R30 had been toileted prior to lunch and after lunch had been transferred to her recliner, but she was uncertain when staff had last checked on her. RN-B identified R30 had been more active prior to the fall, but she was at times, had a short attention span. RN-B reported R30's usual pattern was to rest in her recliner after lunch and she had seen her sleeping in her recliner. RN-B reported she had made notifications according to policy, and fax notification to the primary provider. R30 had been voicing complaints of pain when she was transferred from the w/c to bed and the decision was made to transfer her to the ED for evaluation. RN-B reported she was aware of the reporting requirements to the SA and an incident should be reported to SA within 2 hours if it is abuse or neglect, but she thought if the care plan had been followed and there was no abuse and no neglect it did not need to be reported to the SA. Interview on 7/25/22 at 11:24 a.m., with the assistant director of nursing (ADON) identified R29 was alert, oriented, and was aware of her risk of falling, but chose not to use her call light and transfer unassisted. The ADON identified a significant injury as a fracture, or displacement and if a resident had to be sent to the ED and required surgery, staples, or sutures that would also be considered a significant injury. The ADON reported she would not have reported R29's or R30's falls with injury to the State Agency (SA) due to the care plan being followed. She reported she was under the impression had not been followed then it would be a reportable incident. Interview on 7/25/22 at 11:44 a.m., with the Director of Nursing (DON) reported she defined a significant or major injury as a fracture and if the care plan had not been followed then it would need to be reported to the SA. The DON reported she did not consider a laceration that required sutures or staples as needing to be reported to the SA. The DON identified neither R29 or R30's falls with injury had been reported to the SA due to the care plan being followed and with R29 she was able to state what had happened. The DON stated the facility was following their policy for reporting falls at the time of occurrence and she would expect the facility to follow their policy and the SA requirements for reporting an incident. Review of the 1/8/18 policy Accident/Incident identified all incidents were to be evaluated and examined to ensure the cause was determined and interventions were developed to prevent reoccurrences. Trends or patterns were to be identified that had to parenthetical to contribute to incidents or accidents. Interdisciplinary (IDT) assessment follow up was to occur within 48-72 hours and interventions evaluated for effectiveness. If interventions are not effective, the IDT will develop and implement new interventions with monitoring and documentation of the effectiveness.

Based on interview and document review the facility failed to report to residents, representatives, and families suspected or confirmed COVID-19 within 12 hours of the occurrence of a single confirmed COVID-19 infection or of three or more residents or staff with new onset of respiratory symptoms that occurred within 72 of each other. This had the potential to affect all 35 residents and thier families. Findings include: Review of staff positive COVID-19 results identified 2 staff tested positive during the month of May and 9 staff tested positive during the month of June. Review of resident positive COVID-19 results identified no residents tested positive during the month of May and 9 residents tested positive during the month of June. Review of facility notification to families identified there were no family notifications sent out in May and there were only 4 notifications sent out in June, confirming that families had not been updated following a single occurrence of confirmed COVID-19 and at times there had been up to 5 days of individual positive cases one each day with notification not going out until day 5 with the update of the new cases. Interview on 7/25/22 at 9:20 a.m., with the assistant director of nursing (ADON) also the infection control nurse identified that the administrator was responsible for communication with family's on new COVID-19 cases. Interview on 7/25/22 at 12:39 p.m., with administrator identified she sent out weekly updates on COVID-19. She identified when there was a COVID-19 positive case she sent out a notices as soon as possible. She then revealed at the weekly COVID update call they were told they had 24 hours to update families and it was staff and they had not been in the building for 72 hours prior to testing they did not need to report that as there would have been no risk to residents. The administrator revealed some of the COVID-19 positive results happened over the weekend and she did not report until Monday and that was 'her bad that she had missed the weekend ones. Review of the 7/13/20, Communication with Residents, Families, and Staff policy identified the facility was to use an automated service to notify families and residents when a confirmed case of COVID-19 had been identified. There was no mention the facility ensured notification was to be sent by 5 p.m. the next calendar day following a confirmed infection of COVID-19.

Based on interview and document review, the facility failed to notify the county (designated State mental health authority) when for 1 of 3 residents (R4) reviewed, who had a changes in mental health and/or had new-onset mental illness diagnoses. Findings include: R4's face sheet printed on 7/22/22, identified admitted in November 2019, with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's diagnosis list identified that upon admission R4 had no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/25/21, R4 was diagnosed with dementia without behavioral disturbance, then on 12/27/21, R4 was diagnosed with delusional disorders and hallucinations. R4's medical recorded lacked information that the county had been notified of the new diagnoses. R4's 11/7/19, Initial Pre-Admission Screening (PASRR) Results identified R4 lived in their own home or apartment, including assisted living. R4 had a 3 day stay in hospital with discharge to long term care facility on 11/9/19. Screening identified R4 did not meet the criteria for mental illness (MI). R4's 2/28/22, quarterly Minimum Data Set (MDS) assessment identified the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 had severe cognitive impairments, with inattention that fluctuates, behaviors not directed at others 1 to 3 days during the assessment period. R4's 5/2/22, Significant Change MDS did not identify any behaviors or inattention. Review of R4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's 5/18/22, care plan identified R4 received treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 7/20/22 at 3:20 p.m., with social service designee (SSD) revealed she had never had to update the county to come and complete a level II screening for services since she started here about a year ago. She revealed she did not think she had any training on PASARR since she had worked here and have just learned things as they have come up. Interview on 7/22/22 at 9:15 a.m. with registered nurse (RN)-A who is the MDS coordinator identified that R4 Risperdone order was on 1/28/22 for new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A revealed she was unaware that the county needed to be updated with new mental disorder diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 7/22/22 at 9:30 a.m., with the director of nursing revealed she was unaware that an level II screening needed to be completed after a resident received an new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She identified the facility normally did not have this many residents on antipsychotic medication so it most likely did not trigger to look at the PASRR. Review of 3/7/22 Pre-Admission Screening (PASRR) policy identified that a pre-admission screening was to be completed by appropriate assessor to determine the need for nursing facility care center level of care and complete activities related to serous mental illness. When mental illness was identified, an additional screening, referred as PASRR Level II screening was required. The level II screening determines whether a person has a serious mental illness which may require needed mental heath services offered in the nursing facility or in the community. Level II screeners have 9 work days from the referral to the county to complete the level II screening.

Based on observation, interview and document review the facility failed to appropriately clean and disinfect 1 of 1 whirlpool tub per the manufacture's guidelines using a wet contact time of 10 minutes with an approved chemical. Finding include: Observation and interview on 7/21/22 at 9:39 a.m., with nursing assistant (NA)-C who turned button for the attached manufacturer's disinfectant located beside the tub (MasterCare). NA-C sprayed the tub down with the disinfectant but failed to appropriately scrub the tub with brush to remove any debris or particles that may be on the walls of the tub. NA-C stated staff were to clean the tub after each use and then a couple times a week housekeeping also cleans the tub with Clorox bleach or another cleaner. NA-C further revealed that staff only need to spray the disinfectant on the tub and then leave it. NA-C indicated she did not have to scrub the tub, ensure a wet contact time of 10 minutes or rinse the chemical from the tub. We just leave it sit. Observation, interview, and manufacturer's instruction label review on 7/21/22 at 12:21 p.m. with assistant director of nursing (ADON)/ infection preventionist identified she reviewed the MasterCare Bath Aire System Disinfectant label that is used to fill the disinfectant hose on tub. The MasterCare disinfectant identified directions for use to disinfection of hard non-porous surfaces in whirlpool units after using the whirlpool unit. Staff were to drain and refill with fresh water to the level of covering the intake valve. Staff were to add 2 ounces of MasterCare bath Aire system disinfectant for each gallon of fresh water added. Staff were to then start the pump to circulate the solution and wash down the the unit sides, seat of the chair, lift and any/all related equipment with a clean swab, brush or sponge. Treated surfaces were to remain wet for 10 minutes. After the unit had been thoroughly cleaned, staff were to drain the solution from the unit and rinse any/all cleaned surfaces with fresh water. The ADON agreed that the disinfectant was not being used per the manufacture's guidelines. The ADON confirmed there were no instructions located in the tub room for staff to follow. She confirmed her expectation was manufacture instructions were to be followed. Interview on 7/21/22 at 2:01 p.m., with NA-E who identified staff used a spray bottle of cleaner to spray the tub. They got this cleaner from housekeeping. NA-E looked in locked cupboard for the spray bottle but the product was not there that she normally used. She then stated We spray the tub after use and leave it on for a little bit, then rinse it off. She revealed we do not use the hose thing on the side of the tub. NA-E stated the spray bottle contained a cleaner named Comet or something. She then went outside the tub room and told housekeeper (H)-B the tub was missing the spray bottle to clean the tub. H-B returned with a bottle of Comet All Purpose Cleaner. Interview on 7/21/22 at 2:08 p.m., with H-B identified that housekeeping sometimes used the comet cleaner with added bleach to clean the tub or the floor and made a copy of the Comet cleaner instructions. The bottle was Comet cleaner with bleach 3-30. Further interview on 7/12/22 at 2:12 p.m., with ADON identified she was unaware some staff were using a common household cleaner named Comet on the tub. She was unsure why housekeeping was supplying that product to use when the tub manufacturer did not recommend that cleaner. She revealed she had now posted clear instructions on the wall in tub rooms on how to clean and disinfect the tubs after use according to manufacturer's guidelines. Review of MasterCare tub manufacture's instruction for cleaning and disinfection the tub identified to spray areas thoroughly scrub, disinfect, and rinse the appropriate disinfectant from the tub after a standard wet contact time of 10 minutes. Review of the bottled, Comet cleaner label identified it was ready to use and for use on a toilet to flush toilet, spray entire area and let stand for 10 minutes and flush again. There was no directions for use in bathtubs. The product also stated if it came in contact with skin, rinse with plenty of water. Get medical attention if irritation develops and persists. The cleaner contained sulfuric acid monododecyl [NAME] sodium salt (cleaning surfactant used to remove dirt and grime) and sodium hypochlorite (bleach).

Based on interview and documentation review the facility failed to report allegation of potential physical abuse to the State Agency within 2 hours for 1 of 1 (R1) residents who alleged physical abuse from staff. Findings include: Review of the 7/23/20 at 12:08 p.m., State Agency (SA) report identified R1 reported during the night shift at 7/23/20 at 5:00 a.m., a dark-skinned bigger statured female nursing assistant (NA)-C came into her room and was rough with her. R1 reported that she quivered when she comes in. R1 identified she put her call light on as she needed to use the bathroom and was incontinent of urine. NA-C came into her room and shut off her call light. R1 told her she was wet. NA-C uncovered her to check and told R1 she was not wet and left the room. R1's 7/28/20, face sheet identified she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R1's 6/16/20, quarterly Minimum Data Set (MDS) identified R1 had moderate cognitive impairment. R1 required one to two staff for bed mobility, transfers, and toileting and was frequently incontinent of her bladder. R1's 7/28/20, care plan identified she required one to two staff for bed mobility. R1 received anti-psychotic medication daily for hallucinations and delusional disorder. Facility and family would meet with R1 as needed to address concerns. Staff were to monitor R1's mood and response to her medication. Staff were to offer support and listen to her concerns. R1's behaviors included she believed her husband was cheating on her, would cry, heard voices and would think it was her husband. R1 would dwell on someone cutting her legs off. Staff were to validate her feelings, provide 1:1 visits, and offer reassurance. R1 was able to express her needs verbally. R1 was at risk for bladder incontinence related to poor cognition and impaired mobility and used an incontinent product. R1 had chronic pain in both knees. Staff were to monitor for signs and symptoms of pain such as grimacing, moaning, or guarding and report to medical doctor as needed. Staff were to offer and attempt position changes and provide rest periods. Interview on 7/27/20 at 1:49 p.m., with R1 identified she had hip surgery and every time NA-C put a brief on her she would push on R1's side to turn her over and she did not seem to care. R1 identified when NA-C pushed on the hip that she had surgery on it felt rough and it would hurt. R1 identified when she was turned side to side by NA-C she was afraid that something would happen to her hip like the pin coming out. NA-C always looked grumpy when she helped her. R1 identified that NA-C has not helped her since she told someone about her and she now feels safer. Additional interview on 7/28/20 at 8:28 a.m., R1 identified her concern was that the night staff was supposed to check to see if she was wet, which they did check her but the staff was grumpy and told her she was not wet. R1 identified that this girl has not worked with her since she reported her. Interview on 7/27/20 at 2:33 p.m., with family member (FM) identified R1 has made a comment before that this one staff is rough when she moves her around in bed to change her incontinent product. FM identified R1 had identified she is not limber when she wakes in the night to turn and staff basically push her onto her side. FM identified R1 likes everyone else at the facility and likes the facility except for this one night staff person. FM identified she spoke to the social worker and activity staff about her mom's concern. FM identified she has not been updated on what the facility found out or what has been done. FM identified she was concerned if the staff found out that her mom said something the staff would take it out on her mom. Interview of 7/27/20 at 2:51 p.m., with licensed social worker (LSW) identified she was informed of R1 concern by the assistant director of nursing (ADON) the morning of 7/23/20 and spoke to R1 around 9:30 a.m. LSW identified that R1 identified a dark skinned bigger girl was rough with her. LSW identified she asked R1 what the staff did that was rough. R1 reported to her NA-C came into her room and shut off her light, uncovered her and told her she was not wet and left the room. LSW identified that R1 does often have delusional thoughts such as thinking her husband is here but not coming into to see her. R1 often thought he was having an affair with others here. LSW interviewed other residents NA-C assisted and the staff R1 initially reported this to in the morning. LSW identified she is usually the one who makes the SA reports but the director of nursing or administrator also make reports. LSW was unaware if the assistant director of nursing (ADON) was able to make SA reports. LSW identified the SA report was not filed until 12:08 p.m. that same day. Approximately 6.5 hours later. LSW thought immediate reporting was for egregious incidents, but after reviewing facility policy, confirmed the potential abuse should of been reported immediately within the two hour time-frame. Interview on 7/27/20 at 3:00 p.m., with ADON identified facility staff had notified her of R1's accusations on 7/23/20. R1 told NA-A and NA-B during morning cares that the night staff was rough with her. ADON identified she went to talk to R1 soon after. R1 told the ADON the girl was rough with her on the night shift. R1 makes accusations about her husband cheating on her and R1 has delusions and hallucinations. The ADON reported the allegation to the LSW who began an investigation. ADON identified that the LSW was responsible to make the report to the SA when she was onsite. Interview on 7/27/20 at 3:11 p.m., with the director of nursing (DON) identified she was made aware of R1 concern first thing in the morning on 7/23/20. The ADON and LSW talked about the incident and reporting. DON identified she then completed interviews with staff and determined no concerns were identified so NA-C was not suspended and returned to work that night. R1 had hallucinations and delusions and after her interviews, she did not feel there had been abuse. R1 seemed upset she was not changed when she felt she was wet. DON identified if a resident made an allegation of potential abuse, or was rough with them, staff were to be suspended pending an investigation. Staff were to file a Vulnerable Adult report and complete an investigation. Reporting of allegations was to occur within an hour or so. Interview on 7/28/20 at 8:42 a.m., with NA-C identified the DON had called her and asked her questions about cares with R1. NA-C identified that during the night of 7/22/20 into 7/23/20 she had checked on R1 two times once around 12:00 midnight R1 was wet and then again on last round and R1 was dry. NA-C identified during last rounds she told R1 what she was doing, raised her bed and checked her brief, NA-C identified if the line on the brief is yellow it means not wet and R1's line was yellow, so she did not remove her brief she lowered the bed and left the room. NA-C identified she asked the staff working in room next door if she had already changed R1 as she is usually wet each time you check her but that staff said no. NA-C identified she has worked with R1 since that day and R1 has never said anything to her during cares that she is rough. NA-C identified R1 has never asked her to slow down during cares or anything, the only thing R1 had ever told her is that she wants me to tell her if I am going to change her brief. NA-C identified R1 has always been fine when she has assisted her. Interview on 7/28/20 at 8:55 a.m., with licensed practical nurse (LPN)-A identified she worked the night of 7/22/20 into 7/23/20. LPN-A was unaware R1 had reported concerns with staff that night. LPN-A identified nothing unusual occurred during the night and staff assisted R1 as usual. LPN-A later became aware of R1's complaint when she was interviewed the next day. LPN-A had no concerns with NA-C or any other staff related to potential abuse. Interview on 7/28/20 at 9:08 a.m., with NA-A identified R1 reported to her around 7:00 a.m. on 7/23/20, while during cares the night before, R1 had put the light on to tell night staff she was wet and the night staff told her she was not wet. R1 reported the night staff was rough with her but did not identify which staff member it was. NA-A told the ADON. The ADON then spoke to R1 about the allegation. The LSW also interviewed herself that morning. Review of 2/19/18, Maltreatment Prohibition Policy identified the definition of physical abuse occurred when an individual was injured hit, slapped, kicked, pinched, bitten, pushed, scratched, or burned. A resident complaining of staff treating them roughly was potential physical abuse and required a investigation. Staff were to report all allegations made involving suspected or known abuse immediately, as soon as possible, but no later than two hours after the allegation.

Based on interview and document review, the facility failed to update the care plan for 1 of 1 residents (R1) who did not want a specific staff person to assist her. Findings include: Review of the 7/23/20 at 12:08 p.m., State Agency (SA) report identified R1 reported during the night shift at 7/23/20 at 5:00 a.m., a dark-skinned bigger statured female nursing assistant (NA)-C came into her room and was rough with her. R1 reported that she quivered when she comes in. R1 identified she put her call light on as she needed to use the bathroom and was incontinent of urine. NA-C came into her room and shut off her call light. R1 told her she was wet. NA-C uncovered her to check and told R1 she was not wet and left the room. R1's 7/28/20, face sheet identified she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R1's 6/16/20, quarterly Minimum Data Set (MDS) identified R1 had moderate cognitive impairment. R1 required one to two staff for bed mobility, transfers, and toileting and was frequently incontinent of her bladder. R1's 7/28/20, care plan identified she required one to two staff for bed mobility. R1 received anti-psychotic medication daily for hallucinations and delusional disorder. Facility and family would meet with R1 as needed to address concerns. Staff were to monitor R1's mood and response to her medication. Staff were to offer support and listen to her concerns. R1's behaviors included she believed her husband was cheating on her, would cry, heard voices and would think it was her husband. R1 would dwell on someone cutting her legs off. Staff were to validate her feelings, provide 1:1 visits, and offer reassurance. R1 was able to express her needs verbally. R1 was at risk for bladder incontinence related to poor cognition and impaired mobility and used an incontinent product. R1 had chronic pain in both knees. Staff were to monitor for signs and symptoms of pain such as grimacing, moaning, or guarding and report to medical doctor as needed. Staff were to offer and attempt position changes and provide rest periods. No additional interventions had been updated after allegations of abuse had been made. Interview on 7/27/20 at 1:49 p.m., with R1 identified she had hip surgery and every time NA-C put a brief on her she would push on R1's side to turn her over and she did not seem to care. R1 identified when NA-C pushed on the hip that she had surgery on it felt rough and it would hurt. R1 identified when she was turned side to side by NA-C she was afraid that something would happen to her hip like the pin coming out. NA-C always looked grumpy when she helped her. R1 identified that NA-C has not helped her since she told someone about her and she now feels safer. Additional interview on 7/28/20 at 8:28 a.m., R1 identified her concern was that the night staff was supposed to check to see if she was wet, which they did check her but the staff was grumpy and told her she was not wet. R1 identified that this girl has not worked with her since she reported her. Interview on 7/27/20 at 2:33 p.m., with family member (FM) identified R1 has made a comment before that this one staff is rough when she moves her around in bed to change her incontinent product. FM identified R1 had identified she is not limber when she wakes in the night to turn and staff basically push her onto her side. FM identified R1 likes everyone else at the facility and likes the facility except for this one night staff person. FM identified she spoke to the social worker and activity staff about her mom's concern. FM identified she has not been updated on what the facility found out or what has been done. FM identified she was concerned if the staff found out that her mom said something the staff would take it out on her mom. Interview on 7/28/20 at 10:26 a.m., with DON confirmed no changes had been made to R1's care plan as it already addressed behaviors at the time of the incident. The DON was made aware of R1's concern first thing in the morning on 7/23/20. The ADON and LSW talked about the incident. The DON completed interviews with staff and determined no concerns were identified so NA-C was not suspended and returned to work that night. R1 had hallucinations and delusions and after her interviews, she did not feel there had been abuse. R1 seemed upset she was not changed when she felt she was wet. DON was updating R1's care plan to include two staff to assist her with cares at night to ensure she felt safe. Review of the 10/10/14, Care Plan policy identified staff were to identify resident needs, problems or concerns. The care plan was to include approaches to meet the identified goals including care and services that must be provided to meet those goals. Staff were to update the care plan on an ongoing basis as needs occurred. Review of 2/19/18, St. Maltreatment Prohibition Policy identified staff were to initiate immediate interventions to prevent any further occurrences or potential or suspect abuse. The interdisciplinary team would evaluate the current interventions and implement additional further intervention as needed.