Every finding on record at River Valley Skilled Nursing and Therapy

Based on record review and interview, the facility failed to notify the physician of severe weight loss defined as greater than 5% in 30 days, greater than 7.5% in 90 days, and greater than 10% in 180 days for 1 (#7) of 2 sampled residents reviewed for significant weight loss.The administrator identified two residents had significant weight loss within 90 days. Findings: A policy titled Weight List, dated 10/21/09, read in part, The resident's physician should be notified of any significant weight changes. An admission assessment for Resident #7, dated 02/22/26, showed the resident was admitted to the facility on [DATE] with diagnoses which included a left hip fracture and parkinsonism. The assessment showed Resident #7 weighed 193 pounds. A nutrition progress note for Resident #7, dated 03/12/26, showed the resident was seen by the dietician and was found to have had significant weight loss. The progress note stated to alert the physician of significant weight loss. An undated weight log for Resident #7 showed on 03/16/26 the resident weighed 157.6 pounds. Resident #7 had an 18.34% weight loss from admission. A review of Resident #7's health chart showed no notifications to the physician regarding significant weight loss between 02/16/26 and 03/16/26. On 03/18/26 at 10:07 a.m., CMA #1 stated the certified nurse aides or CMAs obtained resident weights. They stated they overlooked the weight loss for Resident #7 and did not report it to the charge nurse. On 03/18/26 at 10:12 a.m., the DON stated they monitored resident weights monthly and reported gain or loss to the physician. The DON reviewed Resident #7's weight log and stated the physician had not been notified of their significant weight loss.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed to address reoccurring pneumonia for 1 (#4) of 14 sampled resident's reviewed for care plans.The administrator identified 55 residents resided in the facility.Findings:A physician's order for Resident #4, dated 08/01/25, showed the resident was on Levaquin (fluoroquinolone antibiotic), two times a day for seven days for pneumonia. A physician order for Resident #4, dated 12/29/25, showed the resident was on Doxycycline (tetracycline antibiotic), two times a day for pneumonia. A physician's order for Resident #4, dated 03/12/26, showed the resident was on Doxycycline for a lower respiratory tract infection for seven days. A review of Resident #4's health record and revised care plan did not show any interventions for preventing or treating recurring pneumonia.On 03/18/26 at 11:25 a.m., the DON stated resident did not come out of their room. The DON stated the interventions for treating pneumonia for Resident #4 were per physician's orders. They stated there were no interventions to prevent recurring pneumonia.On 03/18/26 at 1:18 p.m., the MDS coordinator stated there was no care plan for prevention or treatment of Resident #4's pneumonia. They stated active and recurring pneumonia should have been included in the care plan.

Based on observation, record review, and interview, the facility failed to ensure infection control precautions were used during indwelling catheter care for 1 (#1) of 3 sampled residents reviewed for infection control practicesThe administrator identified eight residents had indwelling catheters requiring infection control precautions during care. Findings:On 03/18/26 at 1:33 p.m., LPN #1 was observed to don a gown and gloves and place the front of incontinent brief flat on the bed between Resident #1's legs. LPN #1 was observed to begin performing indwelling catheter care for Resident #1. LPN #1 was observed to secure the tabs on the incontinent brief once it was back in place while wearing the same soiled gloves. LPN #1 was observed to adjust the bed covers on Resident #1 and returned the overbed table beside the bed without removing their gloves. LPN #1 was observed to pick up Resident #1's water pitcher and place it within their reach on the table, still wearing the same gloves used to provide indwelling catheter care. LPN #1 was observed to not change gloves during catheter care.A facility document titled Catheter Care Guideline, dated 03/2025, read in part, Our facility is committed to providing proper catheter care in accordance with current professional standards of practice. And to ensure care aligns with safe effective management of urinary catheters and reduce risk of infection and promote resident comfort and dignity. An admitting physician order for Resident #1, dated 01/2026, showed the resident was admitted to facility on 01/02/26 with diagnoses which included urinary retention, benign prostate hyperplasia, and stage 2 pressure ulcer of sacral region. A 5-day MDS assessment for Resident #1, dated 01/04/26, showed the resident had a brief interview for mental status score of 15 indicating intact cognition. The assessment showed Resident #1 required assistance with bowel incontinence and indwelling catheter care. A care plan for Resident #1, initiated 01/04/26, showed the resident had an indwelling catheter and required enhanced barrier precautions.On 03/18/26 at 1:39 p.m., LPN #1 stated they felt like everything was done correctly while performing catheter care on Resident #1. On 03/19/26 at 10:00 a.m., the DON stated there was no skills check sheet to evaluate correct procedures for catheter care. The DON verified LPN #1 should have changed gloves.

Based on observation and interview, the facility failed to ensure utensils were not used from raw, uncooked food to ready to eat food. The CDM identified 49 residents received services from the kitchen. Findings: On 12/17/24 at 10:56 a.m., [NAME] #1 was observed using tongs to put raw, frozen chicken fried beef patties into the fryer. They were observed using the same tongs to remove the cooked chicken fried beef patties from the fryer basket. On 12/17/24 at 12:33 p.m., [NAME] #1 was asked for examples of cross contamination. They stated using the same utensils without washing between food items. [NAME] #1 stated they did use the same utensils for raw, uncooked meat and cooked, ready to eat meat. 51897

Based on observation, record review, and interview, the facility failed to ensure menus were followed for pureed diets for one of one meal service observed. Cook #1 identified three residents who had diet orders for pureed meals. Findings: The menu extension, dated 12/17/24, documented the noon pureed meal was to have chicken fried beef steak and bread of the day. On 12/17/24 at 10:36 a.m., [NAME] #1 was observed placing four chicken fried steak patties into the blender. They blended four chicken fried steaks and added one piece of bread. On 12/17/24 at 11:26 a.m., Resident #50 was observed to be served the pureed meat and bread mixture. On 12/17/24 at 12:30 p.m., [NAME] #1 stated they pureed four chicken fried steak patties with one piece of bread. They stated they should have used two pieces. On 12/17/24 at 12:35 p.m., the CDM stated four pieces of bread should have blended with the chicken fried steak patties.

Based on record review, observation, and interview the facility failed to ensure food was served at a palatable temperature for five (#20, 44, 56, 12 and #54) of six residents reviewed for meal services. The dietary manager identified 66 residents received meals from the kitchen. Findings: On 09/26/22 at 2:39 p.m., Resident #20 stated the food was cold by the time they received it. On 09/26/22 at 2:48 p.m., Resident #44 stated the food wasn't hot a lot of the times they received it. On 09/26/22 at 2:57 p.m., Resident #12 stated the food was always cold. On 09/27/22 at 7:27 a.m., the DA #1 was observed to temp the food on the steam table. The ground meat, pureed meat, pureed eggs were observed to be below 135 degrees Fahrenheit. These foods were observed on the left side of the steam table. DA #1 stated they have been having problems with the warmer on the left side of the table. DA #1 was observed to take food and place them in the oven. On 09/27/22 at 7:48 a.m., DA #1 was observed to place malt-o-meal on the left side of the steam table. DA #1 was observed to take temperatures of the food one time during meal service. On 09/27/22 at 8:47 a.m., a test tray was requested and the food was temped. The sausage temperature was 110 degree Fahrenheit, and the malt-o-meal was 97 degrees Fahrenheit. The sausage and malt-o-meal tasted cold. On 09/27/22 at 9:31 a.m., Resident #54 stated the food was always cold. On 09/29/22 at 10:32 a.m., the DM was asked how staff ensured food temperature was served at a palatable temperature. They stated they took temperatures of food at each meal before and during meal service at different times. The DM was asked what was an acceptable temperature of food. They stated it should be at least 135 degrees Fahrenheit and above. On 09/28/22 at 09:30 a.m., Resident #56's breakfast tray was observed still covered sitting on the OTB table. The resident was asked why hadn't they eaten breakfast. Resident #54 stated, By the time it gets to me it's so cold.

Based on record review, observation and interview the facility failed to ensure menus were followed for one (#41) of 13 sampled residents reviewed for dining. The dietary manager identified 66 residents received meals from the kitchen. Findings: The diet spreadsheet, dated Spring/Summer 2022, documented breakfast on 09/27/22 consisted of 3/4 cup of hot or cold cereal of choice, and one biscuit. Resident #41 had diagnoses which included [CONDITION(S)], and type 2 diabetes mellitus. A quarterly assessment, dated 08/19/22, documented Resident #41 had severe cognitive impairment with daily decision making, and was independent with eating, and required set up assistance. Resident #41's care plan, reviewed 08/22/22, read in parts, .[Resident] has impaired cognitive function .[Resident] need supervision/assistance with all decision making .staff will assess that my needs are met and will assist me accordingly .[Resident] has potential nutritional problem or wt. to fluctuate r/t DM and [CONDITION(S)] .Provide, serve regular Regular diet as ordered .staff to assist with menu to choose what [resident] wishes to eat at mealtimes . On 09/27/22 at 7:51 a.m., Resident #41 was observed to be served 1/2 piece of toast, a scoop of scrambled eggs, and one sausage patty. On 09/29/22 at 10:32 a.m., the DM was asked how they ensured menus were followed. The DM stated they looked at them. They were asked how staff ensured items and portion size on the menu were provided. The DM stated they watched and provided training to the staff. On 09/29/22 at 10:50 a.m., the meal ticket for Resident #41 and observation of breakfast served on 09/27/22 was reviewed with the DM. They stated, I don't know why [they] got half a piece of toast.

Based on record review, observation, and interview, the facility failed to ensure food was distributed in a sanitary manner for five (#19, 42, 11, 34 and #44) of six residents observed for food services. The dietary manager identified 66 resident received food from the kitchen. Findings: On 09/27/22 at 7:58 a.m., DA #1 was observed to open a biscuit with food tongs and their left hand. The biscuit was served to Resident #19. On 09/27/22 at 8:10 a.m., DA #1 was observed to touch their face mask with both hands, then opened a biscuit with food tongs and their left hand. The biscuit was served to Resident #42. On 09/27/22 at 8:18 a.m., DA #1 was observed to open two biscuits with food tongs and their left hand. The biscuits were served to Resident #11 and #34. On 09/27/22 at 8:21 a.m., DA #1 was observed to open a biscuit with food tongs and their left hand. The biscuit was served to Resident #44. On 09/29/22 at 10:32 a.m., the DM was asked when staff were to touch food with their bare hands. They stated, Never.

Based on record review, observation, and interview, the facility failed to ensure residents' food preferences were available for two (#15 and #214) of six residents reviewed for food preferences. The dietary manager identified 66 residents received food from the kitchen. Findings: The diet spreadsheet, dated Spring/Summer 2022, documented breakfast consisted of Egg of Choice. 1. Resident #15 had diagnoses which included, [CONDITION(S)], [CONDITION(S)], and other depressive disorders. A five day assessment, dated 07/21/22, documented Resident #15 was cognitively intact, and did not exhibit any inattention, disorganized thinking or altered level of consciousness. A physician order, dated 07/20/22, read in part, .Regular diet Regular Texture, Regular-Thin liquids consistency . On 09/27/22 at 8:09 a.m., Resident #15 was observed in the dining room and had just finished breakfast. Resident #15, stated, they were supposed to give me eggs over easy, but I couldn't get them. Resident #15 was asked how long had they not been able to get over easy eggs. Resident #15 stated, Quite a while. Resident #15 showed this surveyor a Meal Ticket, dated 09/27/22 that documented Resident #15's order as .2 f. eggs, Toast/Gravy Bacon oatmeal B-sugar . Resident #15 stated, I asked for 4 pieces of bacon, and got two. 2. Resident #214 was admitted with diagnoses which included, unspecified protein-calorie malnutrition, Non-[CONDITION(S)] and diastolic heart failure. A significant change in status assessment, dated 09/02/22, documented Resident #214 was cognitively intact. A physician order, dated 09/01/22, read in part, .Regular diet Regular texture, Regular-Thin liquids consistency . On 09/26/22 at 3:28 p.m., Resident #41 complained of not getting food as ordered especially for breakfast. The resident was asked if there are choices for meals. Resident #41 stated a staff member comes in and tells you what is on the menu. Resident has been keeping handwritten copies of meal order slips turned in. Resident #41 stated they ordered, two sausage patties or five sausage links, four slices of bread and two over easy eggs. Resident #41 has been keeping order slips from his tray and showed this surveyor where they had ordered two over easy eggs and the slip documented 2 f eggs. The resident stated they did not receive over easy eggs, and the bread was untoasted and did not have any butter. On 09/27/22 at 8:46 a.m., the DM stated they didn't have hard shell eggs. The DM stated, I must have not ordered them. They were asked when they ran out of the eggs. DA #1 and Cook #1 stated they didn't have eggs last Friday, 09/23/22. On 09/29/22 at 10:32 a.m., the DM was asked how staff ensured residents were served what they ordered. They stated staff would write on the meal ticket what the residents wanted and dietary staff would follow the meal tickets. The DM was asked how they ensured food items on the menu were available. They stated they ordered it. The DM stated they have been told, now, they can FedEx items.

Based on record review, observations and interview, the facility failed to provide toileting/incontinent care for dependent residents in a timely manner. This affected two (#41, and #55) of five sampled residents reviewed for adl care. The Resident Census and Condition of Residents report, dated 09/26/22, documented two residents were dependent and 46 residents required assistance for toileting, and 66 residents resided in the facility. Findings: 1. Resident #55 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 03/05/21, read in parts, .skin integrity .keep the resident's skin clean and dry .[incontinent] of bowel and bladder needs assist with toileting .disposable briefs at his requesst [sic]. Change prn .[encourage] .to be up on toilet, assist needed .requires max assist with adls . A quarterly assessment, dated 08/25/22, documented Resident #55 had severe cognitive impairment for daily decision making, required extensive assistance of two staff for all transfers, required extensive assistance of one staff for dressing and toileting, was frequently incontinent of urine and always incontinent of bowel. The Documentation Survey Report, dated 09/27/22 documented Resident #55 required total assistance of one staff for toileting on the day and night shifts, and required extensive assistance of one staff on the evening shift. On 09/27/22 at 3:35 p.m., Resident #55 was observed to be assisted/wheeled from the resident's room to the dining room by CMA #1. Resident #55 wore light gray sweat pants and a lift/transfer sheet under the resident. The light gray pants appeared to be saturate, darker in color from just below the waist to near the resident's knees, and across the fullness of the lower torso/lap area. The CMA stopped momentarily to adjust the straps of the lift/transfer sheet from the wheels of the wheelchair, then continued down the hall to the main dining room. Resident #55 was provided a cup of coffee and a glass of milk. Resident #55 remained in the dining room. No attempts were made to encourage the resident to be changed into dry clothing or toileted. At 4:19 p.m., Resident #55 wheeled/mobiled himself to his room. At 4:27 p.m., multiple nursing staff were observed to be on the hall near Resident #55's room and answering call lights. Staff did not enter the room of Resident #55. At 4:40 p.m., an unidentified female staff was observed to approach Resident #55's room, turn the overhead light on/off in the resident room but did not enter or verbally interact with Resident #55. At 4:41 p.m., Resident #55 propelled himself into the room doorway with feet positioned into the hall. Resident #55 remained seated in the doorway, observing staff in the hallway. At 4:43 p.m., Resident #55 propelled into the hallway, and asked a male staff what time was it. Resident #55 and the unidentified male staff discussed it was time to eat. Resident #55 began to propel down the hallway, toward the main dining area. Resident #55 remained in the same light gray pants which appeared saturated with the darker areas from just below the waist, to near the knees, and across the lap. Staff did not attempt to encourage resident to change clothing or offer to be toileting. At 4:50 p.m., Resident #55 arrived to the dining room to the same place setting previously established with coffee and milk. At 4:58 p.m., multiple staff were observed standing in a line at the steam table area, located next to Resident #55's table. Staff did not identify the need for Resident #55 to be assisted into dry clothing or toileted. At 5:19 p.m., Resident #55 was served a meal tray. Staff provided set-up assistance for the meal to ensure eating utensils, condiments and fluids were available. No attempts were made to encourage Resident #55 to change into dry clothing or toileted prior to the meal service. Resident #55 continued to wear saturated pants as he began to eat the evening meal that was provided to him. From 3:35 p.m., to 5:19 p.m., Resident #55 was not observed to be offered/encouraged toileting/incontinent care, or change their clothes. On 09/29/22 at 1:45 p.m., LPN #1 was asked how often dependent residents should be offered toileting and/or incontinent care. The LPN stated every two hours. LPN #1 was asked what was expected of staff if a resident was incontinent between the routine toileting/incontinent care. LPN #1 stated the staff should provide care at the time. LPN #1 was asked how it would be determined what was too long for a resident to not be toileted/incontinent care provided if the resident was known to have had an incontinent event. LPN #1 stated, No more than 30 minutes. On 09/29/22 at 1:50 p.m., CNA #1 was asked how often residents should be checked for the need of incontinent care. CNA #1 stated at least 4 times per shift. CNA #1 was asked what instructions were provided for residents that have been observed to be wet/incontinent of urine. CNA #1 stated the resident should be changed right away. On 09/29/22 at 3:52 p.m., the administrator and DON were asked what the facility policy was regarding direction on the timeliness of incontinent care. The DON stated there was not a policy but it was expected of staff to provide toileting/incontinent care every two hours and as needed. The administrator and DON were asked if a dependent resident presented as having an incontinent event and was obviously wet, when should the staff offer/attempt to provide care. They stated the staff should attempt care at the time a resident requests and/or the staff identified the resident to be wet. The administrator and DON were informed of the observations of Resident #55 on 09/27/22. They were asked if staff should have identified the resident had been incontinent, offered to change and/or toilet prior to being served the evening meal. The administrator and DON stated the staff should have identified the resident's needs and provided assistance, not walk away. 2. Resident #41 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 08/19/22, documented Resident #41 had severe cognitive impairment for daily decision making, and required extensive assistance with toileting, transfers, dressing, bed mobility, and personal hygiene. Resident #41's care plan, reviewed 08/22/22, read in parts, .[Resident] has impaired cognitive function .[Resident] need supervision/assistance with all decision making .staff will assess that my needs are met and will assist me accordingly .I have urinary/bowel incontinence .my B&B incontinence fluctuates r/t cognition .Ensure clothing is dry and odor free .I have bowel incontinence staff to assist with toileting frequently .[ Resident's] incontinence depends on .cognition and if [resident] remembers to ask to be toileting . On 09/26/22 at 1:18 p.m., Resident #41 was observed sitting in a wheelchair in the hallway just outside the resident's room. Resident #41's pants were observed to have an outline on the lap/groin area. On 09/26/22 at 1:54 p.m., Resident #41 was observed still sitting in the hallway. Outline in lap/groin area still observed. On 09/29/22 at 7:30 a.m., Resident #41 was observed sitting at the dining room table drinking coffee. On 09/29/22 at 9:25 a.m., Resident #41 was oberved sitting at the dining room table. An outline on left side of lap/groin area was observed on the residents sweat pants. At 9:53 am the DON was asked to observe Resident #41. The DON stated, [Resident #41] needs to be changed.

Based on record review, observations and interview, the facility failed to ensure residents were treated with dignity and respect with the provision of timely incontinent care and addressing a resident by a preferred name. This affected two (#42 and #55) of two sampled residents reviewed for dignity and respect. The Resident Census and Condition of Residents report, dated 09/26/22, documented 66 residents resided in the facility. Findings: 1. Resident #55 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 03/05/21, read in parts, .skin integrity .keep the resident's skin clean and dry .[incontinent] of bowel and bladder needs assist with toileting .disposable briefs at his requesst [sic]. Change prn .[encourage] .to be up on toilet, assist needed .requires max assist with adls . A quarterly assessment, dated 08/25/22, documented Resident #55 had severe cognitive impairment for daily decision making, required extensive assistance of two staff for all transfers, required extensive assistance of one staff for dressing and toileting, was frequently incontinent of urine and always incontinent of bowel. The Documentation Survey Report, dated 09/27/22 documented Resident #55 required total assistance of one staff for toileting on the day and night shifts, and required extensive assistance of one staff on the evening shift. On 09/27/22 at 3:35 p.m., Resident #55 was observed to be assisted/wheeled from the resident's room to the dining room by CMA #1. Resident #55 wore light gray sweat pants and a lift/transfer sheet under the resident. The light gray pants appeared to be saturated, darker in color from just below the waist to near the resident's knees, and across the fullness of the lower torso/lap area. The CMA stopped momentarily to adjust the straps of the lift/transfer sheet from the wheels of the wheelchair, then continued down the hall to the main dining room. Resident #55 was provided a cup of coffee and a glass of milk. Resident #55 remained in the dining room. No attempts were made to encourage the resident to be changed into dry clothing or toileted. At 4:19 p.m., Resident #55 wheeled/mobiled himself to his room. At 4:27 p.m., multiple nursing staff were observed to be on the hall near Resident #55's room and answering call lights. Staff did not enter the room of Resident #55 to check and provide care. At 4:40 p.m., an unidentified female staff was observed to approach Resident #55's room, turn the overhead light on/off in the resident room but did not enter or verbally interact with Resident #55. At 4:41 p.m., Resident #55 propelled himself into the room doorway with feet positioned into the hall. Resident #55 remained seated in the doorway, observing staff in the hallway. The resident continued to be in his saturarted clothes. At 4:43 p.m., Resident #55 propelled into the hallway, and asked a male staff what time was it. Resident #55 and the unidentified male staff discussed it was time to eat. Resident #55 began to propel down the hallway, toward the main dining area. Resident #55 remained in the same light gray pants which appeared saturated with the darker areas from just below the waist, to near the knees, and across the lap. Staff did not attempt to encourage resident to change clothing or offer to be toileted. At 4:50 p.m., Resident #55 arrived to the dining room to the same place setting previously established with coffee and milk. At 4:58 p.m., multiple staff were observed standing in a line at the steam table area, located next to Resident #55's table. Staff did not identify the need for Resident #55 to be assisted into dry clothing or toileted. At 5:19 p.m., Resident #55 was served a meal tray. Staff provided set-up assistance for the meal to ensure eating utensils, condiments and fluids were available. No attempts were made to encourage Resident #55 to change into dry clothing or toileted prior to the meal service. Resident #55 continued to wear saturated pants as he began to eat the evening meal that was provided to him. From 3:35 p.m., to 5:19 p.m., staff were not observed to offer or encourage toileting/incontinent care, or change Resident #55's clothing. On 09/29/22 at 3:52 p.m., the administrator and DON were asked what the facility's policy was regarding direction on the timeliness of incontinent care. The DON stated there was not a policy but it was expected of staff to provide toileting/incontinent care every two hours and as needed. The administrator and DON were informed of the observations of Resident #55 on 09/27/22. They were asked if staff should have identified the resident had been incontinent, offered to change and/or toilet prior to being served the evening meal. The administrator and DON stated the resident should have been changed. They were asked if they felt this was a dignity concern for the Resident #55 to not be provided the proper toileting/incontinent care prior to being served. They shook their heads yes. 2. Resident #42 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 08/24/22, documented Resident #42 was cognitively intact, and had a name preference. On 09/27/22 at 10:44 a.m., Resident #42 was asked if they smoked. They stated, I had a big beard couple three weeks ago .went outside .wind was blowing .lit cigarette the wind changed, the cigarette flared and caught my beard on fire. Resident #42 was asked how the fire was put out, they stated, There was another guy out there .patted it out for me. I burned my thumb, chin and ears. Resident #42 stated, All the girls call me shish-k-[NAME] or Bobecue .It's not funny . At 12:26 p.m., Resident #42 was asked if they had reported staff had been calling them names. They stated, no. At 12:30 p.m., the Administrator was notified regarding the allegation staff had been calling Resident #42 Shish-k-[NAME] and [NAME]-b-que. The administrator stated, that was verbal abuse and an investigation would be started.

Based on record review and interviews, the facility failed to re-assess a resident's elevated temperature for one (#13) of 14 sampled residents reviewed for changes in condition. The Administrator identified 56 residents resided in the facility. Findings: Resident #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physicians order, dated 04/27/18, documented the resident to be administered acetaminophen 500 milligrams every 4 hours as needed for fever, pain or headache. A care plan, dated 03/17/20, read in parts, .at risk for s/s COVID-19 .Assess resident for cough, fever .Follow facility protocol for COVID-19 screening/precautions . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Covid Test as needed for pandemic precautions . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .COVID-19 .Symptom Monitoring. Assess resident for Cough, Fever .CALL PHYSICIAN AND RULE OUT INFLUENZA . The Weights and Vitals Summary report documented the resident had an elevated temperature of 102 degrees Fahrenheit on 11/02/20 at 2:04 a.m., at 2:08 a.m., and at 3:55 a.m. The Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . The record documented the resident had denied pain. A progress note, dated 11/03/20 at 3:47 p.m., read in parts, .Daughter .called concerned about mom not sounding well over the phone and wanted her checked out. Daughter was told Resident has not had a fever yesterday or today. Resident did c/o of body aches pain scale 8/10, prn Tylenol given .Staff stated resident is not standing well and required two person assist A progress note, dated 11/03/20 at 6:08 p.m., read in parts, .Staff observed resident on room floor lying .Able to move all extremities without difficulty .Resident states she fell asleep in wheelchair and fell forward out of wheelchair . A progress note, dated 11/03/20 at 8:48 p.m., read in parts, .Staff called out for help .something is wrong with resident .eyes open .was not responding to verbal stimuli .Sent to E.R A progress note, dated 11/10/20 at 8:35 p.m., read in parts, .Late entry .ER nurse reported on 11/03/20 resident tested positive for Covid . On 11/15/21 at 3:00 p.m., in the presence of the administrator, and DON, the IP nurse was asked what was the date of the first positive COVID case in building that heightened awareness to increase monitoring residents for s/s of COVID. IP stated the first positive case was a staff member that tested positive on 08/03/20. The DON was asked if Res #13 had been re-assessed and/or tested for COVID when she presented with an elevated temperature of 102 degrees Fahrenheit on 11/03/20. The DON reviewed the medical record for Res #13, and stated the resident had not been re-assessed or tested for COVID and should have been.

Based on record review and interviews, the facility failed to notify family of a resident's change of condition for one (#13) of 14 sampled residents reviewed for notification of change. The Administrator identified 56 residents resided in the facility. Findings: Resident #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 01/11/21, documented Res #13 required [CONDITION(S)] due to renal failure and would receive [CONDITION(S)] on Monday, Wednesday, and Friday. Staff were to monitor AVF in the right arm for s/s trauma and/or infection. A progress note, dated 03/18/21 at 12:30 p.m., read in parts, .Clarification: Resident returned to facility from outpatient surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] The clinical record did not document the resident's family had been notified Res #13 was to have/or had a surgical procedure. A quarterly assessment, dated 08/26/21, documented Res #13 was cognitively intact for daily decision making, had clear speech, and received [CONDITION(S)]. On 11/15/21 at 3:00 p.m., in the presence of IP nurse and the administrator, the DON was asked, if the family had been notified Res #13 was to have an outpatient procedure on 3/11/21. After review of the records, the DON stated the family had not been notified and should have been.

Based on observation and staff interview, it was determined the facility failed to have an effective pest control program. The facility identified 62 residents received services from the kitchen. Findings: On 05/29/19 at 8:52 a.m., a tour of the kitchen was conducted. The following observations were made: ~ there was a cockroach crawling on the floor under the Glenco four door reach-in cooler, ~ there was a live cockroach on the floor in front of the Kenmore one door reach-in freezer, ~ there were multiple dead roaches on the floor on a sticky trap behind the reach-in cold hold units and ~ there was a dead moth in one of the steam table wells located on the steam table. On 05/30/19 at 8:50 a.m., a tour of the kitchen was conducted. The following observations were made: ~ there was a cockroach crawling on the outside area of the dish machine and ~ there was dead cockroach on the shelf below the microwave. On 05/31/19 at 10:05 a.m., a tour of the kitchen was conducted. The following observations were made: ~ there were three cockroaches crawling on the floor near the dish machine, ~ there were two cockroaches on the floor under the dish machine. One was crawling on the floor and the other one was on its back, ~ there were two cockroaches crawling on the wall under the dish machine and ~ three dead cockroaches were on the floor by the maintenance closet across from the dish machine. At 11:47 a.m., the certified dietary manager was asked how staff ensured the kitchen was free of pests. She stated they cleaned and had scheduled pest control services. She was made aware of the above observations. She acknowledged the findings.

Based on observation and staff interview, it was determined the facility failed to ensure: ~ food products were monitored and discarded at designated times and ~ food service equipment, the floor and the walls were kept clean. The facility identified 62 residents received services from the kitchen. Findings: On 05/29/19 at 8:52 a.m., a tour of the kitchen was conducted. There was a one gallon size zip lock bag of coleslaw, dated 05/17/19, in the True two door reach-in cooler. On 05/30/19 at 8:50 a.m., a tour of the kitchen and dining room was conducted. The following observations were made: ~ there was a gray and black residue inside of the dish machine, ~ there was black and brown residue on the outside area of the dish machine and on the floor and the wall behind/below the dish machine, ~ there was green and black residue inside of the ice shoot, white and brown residue on the water nozzle and black residue on the drain area of the ice machine/water dispenser in the dining room. On 05/31/19 at 10:05 a.m., a tour of the kitchen was conducted. There was a one gallon size zip lock bag of coleslaw, dated 05/17/19, was in True two door reach-in cooler. At 11:47 a.m., the certified dietary manager (CDM) was asked how staff ensured food service equipment, the floor and the walls were kept clean. She stated they had a cleaning schedule on what needed to be cleaned. She was asked what was the policy for date marking food products. She stated non-hazardous foods were not to be kept more than seven days. She stated meat was to be held no more than 24 hours unless it was frozen. The CDM was made aware of the above observations. She acknowledged the findings.

Based on observation, record review and staff interview, it was determined the facility failed to ensure menus were followed for residents who received a pureed diet. The facility identified three residents who received a pureed diet. Findings: On 05/31/19 at 10:20 a.m., the pureed food preparation for the lunch meal service was observed. The diet spreadsheet for the kitchen staff documented the residents who received a pureed diet were to have received a #20 scoop (1-2 ounces) of pureed bread of choice. Dietary cook #1 was not observed to prepare a pureed bread item. At 11:20 a.m., the lunch meal service was observed. There was no pureed bread item served. At 11:47 a.m., the certified dietary manager was asked if the menu indicated residents who received a pureed diet were to have received bread. She stated they were. She was made aware of the above observation and asked if the menu was followed. She stated it wasn't if pureed bread was not served.

Based on observation and staff interview, it was determined the facility failed to ensure medications where properly stored in the director of nursing's (DON) office. The Resident Census and Conditions of Residents report, dated 05/29/19, documented 62 residents resided in the facility. Findings: On 05/31/19 at 10:41 a.m., a clear plastic bag containing multiple residents' medications was observed to be sitting on the bottom shelf of a cabinet inside the DON's North office door. The DON was in her office at the time. At 10:45 a.m., the DON was made aware of the observation and asked what the policy was for medication storage. She stated medications were to be under lock and key.

Based on record review and staff interviews, it was determined the facility failed to follow physicians' orders for finger stick blood sugar (FSBS) monitoring for two (#25 and #164) of four sampled residents whose clinical records were reviewed for insulin administration. The facility identified 13 residents who had orders for insulin with a sliding scale. Findings: 1. Resident #25 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] Solution 100 UNIT/ML (milliliter) (Insulin [MEDICATION NAME]) Inject as per sliding scale: if 101 - 124 = 0; 125 - 149 = 2; 150 - 174 = 4; 175 - 199 = 6; 200 - 224 = 8; 225 - 249 = 10; 250 - 274 = 12; 275 - 299 = 14; 300 - 324 = 16; 325 - 999 = 18 then recheck in 1 hr (hour) and notify PCP (primary care physician) if remains > (greater than) 325, subcutaneously before meals and at bedtime . The (MONTH) 2019 injections/insulin/FSBS administration record documented on 04/04/19 at 8:00 p.m. the resident's FSBS was 365 and 18 units of insulin was administered. There was no documentation the resident's FSBS was rechecked in one hour. On 06/03/19 at 1:23 p.m., the regional nurse consultant was shown the resident's physician's orders [REDACTED]. She was asked to locate documentation the resident's FSBS was rechecked in one hour. She stated she didn't see where it had been rechecked. 2. Resident #164 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Insulin [MEDICATION NAME] Solution 100 UNIT/ML Inject as per sliding scale: if 0 - 40 = 0 Transport to hospital; 41 - 60 = 0 If alert give 4oz (ounce) juice, repeat FSBS in 15min (minutes), if not alert call EMS (emergency medical services); 61 - 120 = 0; 121 - 150 = 2 units; 151 - 180 = 4 uints (sic); 181 - 220 = 6 units; 221 - 250 = 8 units; 251 - 300 = 10 units; 301 - 350 = 12 units Recheck FSBS q (every) 30min & (and) redose per ss (sliding scale) till less than 300. ; 351 - 400 = 14 units call PCP, subcutaneously before meals and at bedtime . The (MONTH) 2019 injections/insulin/FSBS administration record documented the following: ~ on 05/01/19 at 6:00 a.m., the resident's FSBS was 321 and 12 units of insulin was administered. There was no documentation the FSBS was rechecked q 30 min and redosed per ss until less than 300, ~ on 05/02/19 at 6:00 a.m., the resident's FSBS was 352 and 14 units of insulin was administered. There was no documentation the PCP was called, ~ on 05/03/19 at 6:00 a.m., the resident's FSBS was 400 and 14 units of insulin was administered. There was no documentation the PCP was called. At 8:00 p.m., the resident's FSBS was 347 and 12 units of insulin was administered. There was no documentation the FSBS was rechecked q 30 min and redosed per ss until less than 300 and ~ on 05/04/19 at 6:00 a.m., the resident's FSBS was 389 and 14 units of insulin was administered. There was no documentation the PCP was called. On 05/31/19 at 9:14 a.m., the director of nursing (DON) and regional nurse consultant were shown the resident's physician's orders [REDACTED]. They were asked to locate where the FSBSs were rechecked and the PCP was called. At 10:18 a.m., the DON stated they couldn't locate any documentation the resident's FSBSs had been rechecked and PCP was called.

Based on record review and staff interview, it was determined the facility failed to provide bathing for a dependent resident for one (#213) of one sampled resident reviewed for bathing. The Resident Census and Conditions of Residents report, dated 05/29/19, documented 62 residents resided in the facility. Findings: Resident #213 had [DIAGNOSES REDACTED]. An admission assessment, dated 11/16/18, documented the resident required total assistance of one staff for bathing. A care plan, dated 11/18/18, documented, .Focus .(Resident) has an ADL (activity of daily living) Self Care Performance Deficit r/t (related to) post hip surgery .Intervention .shower days are mon (Monday), wed (Wednesday), and fri (Friday) 6-2 . A bathing record, dated 11/09/18 through 11/24/18, documented the resident did not receive a bath on 11/09/18, 11/12/18 or on 11/16/18 as scheduled. It documented the resident refused on 11/21 and 11/23/18. On 05/31/19 at 9:16 a.m., licensed practical nurse #1 was asked how frequently residents were bathed. She stated three times weekly and as needed. She was shown the resident's bathing record and asked to identify when he had been bathed. She stated he was bathed on 11/14 and 11/19/18. She was asked if the resident had been bathed as scheduled. She stated not the first five days.

Based on record review and staff interview, it was determined the facility failed to obtain a physician's order for laboratory (lab) services for one (#165) of five sampled residents reviewed for lab services. The Resident Census and Conditions of Residents report, dated 07/09/18, documented 65 residents. Findings: Resident #165's clinical record contained lab results for a comprehensive metabolic panel and a complete blood count dated 06/25/18 . There were no physician's orders located for the labs. On 07/10/18 at 4:06 p.m., the director of nursing (DON) was asked to locate the orders for the above labs. At 4:23 p.m., the DON stated she didn't have an order to collect the labs. She stated she collected baseline labs when the resident was admitted and didn't write the order.