Every finding on record at Riverside

Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 13 resident (R6) reviewed for hospice. R6 was receiving hospice services, and the facility failed to obtain hospice documentation. Evidenced by: The facility policy titled Hospice Plan of Care, dated 7/1/96, with last review date of 1/2026, states, in part: Purpose: Hospice Staff and the nursing home staff will establish one individualized Plan of Care for the Hospice resident/family in the nursing home setting. The Plan of Care will be developed by both staff - Hospice and nursing home. Procedure:. 1. Nursing home resident becomes Hospice. a. Hospice will meet with family and resident for admission assessment and collaborate with nursing home staff. R6 was admitted to the facility on [DATE] with diagnoses that include, in part: Acute kidney failure, Type 2 diabetes mellitus, and Chronic Obstructive Pulmonary Disease. R6's most recent MDS (Minimum Date Set) dated 12/29/25 states that R6 has a BIMS (Brief Interview of Mental Status) of 4 out of 15, indicating that R6 has severe cognitive impairment. The MDS also indicates that R6 is dependent on staff for toileting and transfers, requires substantial/maximal assistance for lower body dressing, and partial/moderate assistance for upper body dressing, personal hygiene, and rolling in bed. R6 is a bilateral lower extremity amputee. R6 was admitted to hospice services on 12/22/25 with primary hospice diagnosis of metastatic cholangiocarcinoma (cancer that has spread to other parts of the body). R6's hospice admission note indicated that an [Hospice Name] binder was provided to the facility. On 1/14/26 at 3:39 PM, Surveyor asked to review R6's hospice binder that was kept at the nurse's station. Surveyor observed that R6's hospice binder was empty. R6's Comprehensive Care Plan states, in part: Problem: I am enrolled in [Hospice Name ] as of 12/22/25.Goal: Both Hospice and Riverside staff will provide collaborative, necessary care to meet the needs of the resident.Interventions: Work collaboratively in developing the resident's plan of care. Discontinue facility standing orders. Inform Hospice of any condition change or need that the resident has. Keep the resident as comfortable as possible. Update responsible party and MD as needed.Start Date: 12/22/25. Edited on: 1/2/26. On 1/14/26 at 3:31 PM, Surveyor interviewed LPN J (Licensed Practical Nurse) and asked about R6's hospice services. LPN J stated that when the hospice nurse comes to the facility, they will talk to the charge nurse and will also stop to talk to the floor nurse to see how R6 is doing that particular day. LPN J stated that she will reach out to the hospice on call with any changes or medication needs. Surveyor asked LPN J where the hospice care plan was included in R6's medical record. LPN J stated that a paper copy was kept in a binder at the nurse's station/HUC (Health Unit Coordinator) desk. On 1/14/26 at 3:35 PM, Surveyor interviewed CNA K (Certified Nursing Assistant) about R6's hospice services. CNA K stated that the facility CNAs do one shower a week and the hospice aide will come in and do the other shower. Surveyor asked CNA K where she would locate R6's hospice care plan in the medical record. CNA K stated that there were hospice binders at the nurse's station. On 1/14/26 at 3:39 PM, Surveyor interviewed HUC L (Health Unit Coordinator) about R6's hospice services. HUC C stated that she typically scans the hospice notes and care plan into the resident's electronic medical record. Surveyor asked HUC L to show where these documents were kept in the electronic medical record. HUC L accessed R6's chart and indicated where the electronic notes should be but noted that R6 did not have any hospice notes in his electronic medical record. Surveyor asked to see R6's hospice binder. HUC L retrieved R6's hospice binder, but upon opening the binder observed that there was nothing in the binder. HUC L stated that she could call hospice if she needed any records. On 1/14/26 at 3:39 PM, Surveyor interviewed LPN/Charge Nurse H about R6's hospice services. Surveyor asked Charge Nurse H about R6's hospice binder being empty and lack of hospice documentation in R6's electronic medical record. Charge Nurse H showed Surveyor a paper copy of R6's physician order to admit to hospice and stated that she didn't know if hospice would give them any documentation unless they were making any changes. On 1/14/26 at 4:16 PM, Surveyor interviewed DON B (Director of Nursing) about R6's hospice services. Surveyor asked DON B who was responsible for communicating with hospice and obtaining hospice documentation. DON B stated that the charge nurses do that. Surveyor asked DON B how staff would access the hospice care plan and documentation. DON B indicated that there were hospice binders for each hospice patient at the nurse's station. Surveyor asked DON B if the hospice care plan was included in the resident medical record. DON B stated that the HUCs would scan them into the resident's electronic medical record. Surveyor shared with DON B the observations that were made with Charge Nurse H and HUC L, and that R6's hospice binder was empty and there was no hospice documentation in his electronic medical record. DON B stated this information should be a part of R6's medical record and she would reach out to hospice to make sure they were getting that information to the facility. On 1/15/26 at 11:13 AM, Surveyor interviewed Hospice RN M (Registered Nurse). Hospice RN M stated that he had seen R6 3-4 times and that he likes to fax all his notes to the facility after he sees his patient. Hospice RN M stated that he was notified on 1/14/26 that the facility was not receiving the hospice documentation from them. Hospice RN M stated that he was not sure what happened but that it was some kind of miscommunication. Hospice RN M stated that the care plan, visit notes, and IDT (Interdisciplinary Team) meetings should all be part of R6's medical record, and that going forward the plan was to fax them to the facility weekly.

Based on observation, interview, and record review, the facility did not ensure that all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. This affected 2 of 3 medication carts.Surveyor observed R2's latanoprost eye drops on the medication cart with no open date during medication storage task.Surveyor observed R47's brimonidine eye drops on the medication cart with no open date during medication storage task.Evidenced by:The facility policy entitled Medication Administration, dated 1/2026, states, in part: . Purpose: The following guidelines have been established for the staff to assure the safe administration of all medications, without jeopardizing the health and safety of all residents.Procedure: Medication therapy at Riverside is administered only in accordance with written orders of the resident's attending physician or designee, consulting physicians or Riverside's Medical Director. Telephone orders may be obtained from these physicians by licensed nursing staff only.8. The expiration/beyond the use date on the medication label must be checked prior to administration. When opening a multi-dose container, the date opened shall be recorded on the container. Example 1:R2 admitted to the facility on [DATE] and has diagnoses that includes primary open-angle glaucoma (a chronic eye disease damaging the optic nerve, often due to slow clogging of the eye's drainage canals, leading to increased eye pressure and gradual painless peripheral vision loss).R2's Quarterly Minimum Data Set Assessment, dated [DATE], shows R2 has a Brief Interview of Mental Status score of 15 indicating R2 is cognitively intact.R2's Physician Orders, dated [DATE], states, in part: . Start Date: [DATE] End Date: Open Ended. latanoprost drops, 0.005%; amount: 1 drop in both eyes, ophthalmic (eye). Special instructions: Place one drop in both eyes at bedtime. For: primary open-angle glaucoma. At Bedtime; bedtime. R2's EMAR (electronic medication administration record) for month of [DATE] shows R2 received latanoprost eye drops [DATE]-[DATE]. Order on EMAR reads: latanoprost drops; 0.005%; amount to administer: 1 drop in both eyes; ophthalmic (eye). Frequency: at bedtime. Special Instructions: Place 1 drop in both eyes at bedtime for: primary open-angle glaucoma.On [DATE], at 9:51AM, Surveyor observed R2's Latanoprost 0.0005% eye drops opened and undated during the medication storage observation with CMA C (certified medication aide). The manufacturer's expiration date on the bottle was [DATE]. At this time Surveyor asked CMA C what the facility process is for dating eye drops. CMA C indicated the process is upon opening a new bottle of eye drops, date the bottle. Surveyor asked CMA C what the expiration date of R2's latanoprost eye drops was, CMA C indicated there is no open date, so it is unknown. CMA C indicated the eye drops would be good for 42 days after opening. Surveyor asked CMA C what she'll do with the latanoprost bottle. CMA C indicated remove from cart and reorder the latanoprost eye drops from pharmacy.Example 2:R47 admitted to the facility on [DATE] and has diagnoses that include nonexudate age-related macular degeneration (right eye) (characterized by gradual central vision loss due to retinal deterioration), exudative age-related macular degeneration (left eye) (severe form where abnormal, leaky blood vessels grow under the retina, releasing fluid and blood, causing rapid central vision loss) and primary open-angle glaucoma (slow painless damage to the optic nerve, leading to gradual irreversible peripheral vision loss). R47's Quarterly Minimum Data Set Assessment, dated [DATE], shows R47 has a Brief Interview of Mental Status score of 00 indicating R47 has severe cognitive impairment. R47's Physician Orders dated [DATE] states in part: . Start Date: [DATE]. End Date: Open Ended. Alphagen P (brimonidine) drops; 0.1%. Amt (amount): 1 drop; ophthalmic (eye). Special Instructions: Place 1 drop into right eye twice daily. Dx (diagnosis): Macular degeneration. Separate drops by 5 minutes. Twice a day; morning, evening.R47's EMAR (electronic medication administration record) for month of [DATE] shows R47 received brimonidine eye drops [DATE]-[DATE]. Order on EMAR reads: Alphagan P (brimonide) drops; 0.1%; Amount to administer: 1 drop; ophthalmic (eye). Frequency: Twice a day. Special Instructions: Place 1 drop into right eye twice daily. Dx: Macular degeneration. Separate drops by 5 minutes. Start/End Date: [DATE]- open ended. On [DATE] at 10:31 AM, Surveyor observed R47's Brimonidine tartrate 0.1% eye drops opened and undated during the medication storage observation with CMA N (certified medication aide). The manufacturer's expiration date on the bottle was 12/26. The bottle did not have an open date marked on the bottle. At this time Surveyor asked CMA N what the facility process is for dating eye drops. CMA N indicated the process is upon opening a new bottle of eye drops, date the bottle with an open date. Surveyor asked CMA N what the expiration date is of R47's eye drops. CMA N indicated it is expired now without knowing the open date. CMA N indicated the eye drops would be good for 42 days after opening. Surveyor asked CMA N what she will do with the brimonidine bottle. CMA N indicated remove from cart and reorder the brimonidine eye drops from pharmacy.On [DATE] at 3:00 PM, Surveyor interviewed DON B (Director of Nursing) and asked what the facility process is for dating eye drops. DON B indicated when a new bottle is opened, the nurse is to date the bottle with the open date to determine the expiration date. DON B indicated Natural Tears, and such go by manufacturer's expiration date. Latanoprost is good for 28 days after opening. DON B indicated she would need to check to be sure. Surveyor informed DON B of observation of R2's latanoprost eye drops with no open date. DON B indicated she would expect an open date to be on the bottle. Surveyor informed DON B on the observation of R47's brimonidine eye drops on the medication cart with no open date. DON B indicated they should have had an open date on the bottle. DON B indicated the undated bottles should not be on the medication cart in circulation for use without an open date.

Based on interview and record review, the facility did not recognize, evaluate and address the nutritional and hydration needs of 1 of 3 Residents (R50) to reduce the risk of continued weight loss. R50 did not have appropriate interventions put into place to prevent continued weight loss. R50 had an unintentional weight loss of 8.4 pounds/5.77% over 1 month, indicating a severe weight loss. This is evidenced by: Facility policy titled, Identification of Residents at Nutritional Risk, undated, states in part, Policy: Nutrition risk is determined by the presence of characteristics that are associated with an increased likelihood of poor nutritional status. This includes various non-acute or chronic diseases and conditions, unintended weight change, inadequate or inappropriate food/fluid intake, dependence, disability. Procedure: A. Special nutritional needs will be identified by the following criteria: 1. Weight status; unplanned loss or gain a. >5% WT (weight) change in 30 days. 2. Oral/nutrition intake; food: a. Leaves 25% or more at most meals. Facility policy titled, Immediate Temporary Interventions for Unintended Significant Weight Loss, dated 2017, states in part, Policy: Individuals with unintended significant/severe weight loss will receive immediate nutrition interventions to prevent further weight loss, stabilize weight, and/or assist to regain weight as appropriate. Procedure: 1. Facility staff will request temporary nutrition interventions as appropriate for significant/severe weight loss. The individual should be interviewed for preference of intervention. 2. These temporary interventions may include: a. Oral nutritional supplements one to three times a day, between meals or with medication passes. B. Other interventions such as extra milk, pudding, yogurt, milkshakes, fortified foods, or extra portions as appropriate. 5. The registered dietitian (RD) or designee will review all significant/severe weight losses monthly or more often as needed and assess nutritional status. At that time, the temporary intervention may be changed as needed. 6. The RD or designee will determine a monitoring system to evaluate the success of the interventions initiated (i.e. weekly weights, food/fluid intake studies, etc.). R50's original admission date to the facility was 3/1/18 with most recent admission to the facility being 3/11/24. R50 has diagnoses that include, in part: Hemiplegia and hemiparesis following cerebral infarction affecting right dominate side- R (right) sided weakness, Congestive heart failure, Chronic kidney disease stage 3, Type 2 diabetes mellitus, Vitamin D deficiency, Other specified disorders of bone density and structure, Osteopenia (lower than normal bone density, Aphasia (impaired ability to speak) following cerebral infarction (stroke), Vascular cognitive impairment, Other reduced mobility. R50's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/7/25 indicates that R50 has a Brief Interview for Mental Status (BIMS) of 3 out of 15, indicating that R50 has a severe cognitive impairment. K0100 indicates that R50 did not have a swallowing disorder. Section GG of the MDS indicates R50 requires set up and/or clean up assistance with eating. R50s Comprehensive Care Plan, states, in part:Problem: Nutrition strength: No nutrition dx (diagnosis) with good appetite and stable weights.Goal: Maintain weight within 145-155# (pound) range.Interventions: Approach: 1. Serve LCS (Low Calorie Sweetener) diet. 2. Offer PM and HS (bedtime) snacks and as I request. 3. Provide Vitamin C, Ca (calcium), B12 and Florajen as ordered. 4. Notify dietary if weight goes below 145#. 5. I am able to eat independently after set up but need a deep divided plate now to help maintain my independence.6. Honor my food preferences.7. Discourage extra snacking per daughter's request.Start Date: 3/12/18. Last Reviewed: 11/5/25. R50's Physician Orders state, in part: --DIET: LCS. Encourage Low sugar/Carb options at breakfast due to significant blood sugar elevation at lunch. Start Date: 7/31/22. No end date.--Weight 2x/week on M/F (Monday/Friday). Update MD if >3# in a week anytime or SOB (shortness of breath), edema (swelling), etc. Notify dietary if weight is out of goal range of 150-165 . Start Date: 9/17/24. No end date. R50's weights were documented as follows:12/12/25: 145.6 lbs. (pounds)12/15/25: 145.6 lbs.12/19/25: 145.4 lbs.12/22/25: 143.2 lbs. (Note: the electronic health system flagged this weight)12/26/25: 140.6 lbs. (Note: this is almost a 5 lbs weight loss in one week. It is greater than the 3 lbs. per week parameter and is below the 145 lbs. threshold. Physician orders and care plan state MD should be notified. The electronic health system flagged this weight)12/29/25: 141.9 lbs. (Note: the electronic health system flagged this weight)1/2/26: 140.0 lbs. (Note: the electronic health system flagged this weight)1/5/26: 138.0 lbs. (Note: the electronic health system flagged this weight)1/9/26: 138.8 lbs. (Note: the electronic health system flagged this weight)1/12/26: 137.2 lbs. (Note: the electronic health system flagged this weight) (Note: Despite the electronic health system flagging on 12/22/25 that R50 went below the 145-155 lbs. goal range indicated on R50's care plan, below the 150-165 lbs. goal range indicated in R50's physician orders, and R50 sustaining a greater than 3 lbs. weight loss in one week, there is no indication that R50's weight was rechecked for accuracy, the physician and Registered Dietician (RD) were not notified, nor was R50's care plan updated with any new interventions. R50's 's unintentional weight loss continued to a severe weight loss of greater than 5%). R50's documented meal intakes from 12/12/25 to 1/14/26 indicate the following:Refused or marked as none for intake = 11 times1-25% = 43 times26 - 50% = 25 times51 - 75% = 13 times76 - 100% - 7 times (Note: R50 consumed less than 25% of most meals. Additionally, R50 had a greater than 5% unplanned weight loss in one month. Both indicators of someone who is nutritionally at risk). A Progress Note in R50's chart completed on 12/26/25 states, in part: This DON (Director of Nursing) spoke with.POA (Power of Attorney) at 1420.informed since 12/19/25 [Resident Name]'s weight is down 5 pounds - did not eat this AM and has been in bed today so far. DR P (Doctor) notified and ordered chest x-ray with no acute findings. Informed of influenza in building and [Resident Name] declines swab - so not sure what she may have at this time. Discussed Tamiflu prophylaxis with [POA] and she was in agreement. (Note: Despite the progress note indicating that the physician was notified on 12/26/25 of R50 having possible influenza, there is no indication that R50's recent unintentional weight loss was discussed. Nor is there any indication that the physician or the registered dietician was notified on 12/22/25 when R50's weight loss first triggered in the electronic health system). On 1/13/26 at 9:39 AM, Surveyor observed R50 eating breakfast on a tray in her room. Surveyor observed that R50 had only eaten a few bites of her breakfast. R50 declined to be interviewed by Surveyor. On 1/14/26 at 9:08 AM, Surveyor interviewed CNA F (Certified Nursing Assistant) about R50's unintentional weight loss. CNA F stated R50 eats in her room most of the time and that R50 can feed herself with staff set up. CNA F indicated that R50 will often pick at her food and will sometimes refuse meals, depending on her mood. CNA F stated that she was unsure if R50 had lost any weight, and that R50 did not receive any nutritional supplements. CNA F indicated that it is the CNA's responsibility to take the resident's weight on bath days and to note the weight on a sheet on a clipboard that the nurse then enters the weight into the electronic health record. CNA F stated that she would let the nurse on duty know if any resident had changes to their weight or meal intakes. CNA F indicated that she had not notified the nurse of any weight loss for R50. On 1/14/26 at 9:18 AM, Surveyor interviewed LPN G (Licensed Practical Nurse) about R50's unintentional weight loss. LPN G indicated that R50 does not eat much most of the time and will refuse an entire meal on rare occasions. LPN G stated that R50 does not always want the food on the tray and will just consume the liquids. LPN G stated that she thought R50 had lost a few pounds recently, but that her weight was coming back up. Surveyor asked LPN G if R50 had any weight loss parameters. LPN G indicated that R50's order was to notify the physician of a 3 lbs. weight loss in a week, and that her goal weight is 150-165 lbs. Surveyor asked LPN G if she had notified the physician of R50's recent unintentional weight loss. LPN G stated that the charge nurse sees the red flags in the system and then they are the ones to notify the doctor. LPN G indicated that she had never notified the physician or the charge nurse about R50's recent weight loss. On 1/14/26 at 9:40 AM, Surveyor interviewed LPN/Charge Nurse H about R50's recent unintentional weight loss. Charge Nurse H stated that the staff will alert her and then she reviews and compares the weights for the past month. Charge Nurse H stated that she would send the PA (Physician's Assistant) a note letting her know of the weight change and ask if she had any recommendations such as starting the resident on a nutritional supplement. Charge Nurse H also stated that she would have a chat with the resident, based on intake, to find out why they are eating less. Surveyor asked Charge Nurse H if this process had been followed for R50's recent unintentional weight loss. Charge Nurse H stated that R50's POA had been notified and that she didn't want R50 on any supplements. Charge Nurse H stated that they were encouraging R50 to eat and offering her more snacks. (Note: No snacks had been charted for R50). On 1/14/26 at 2:06 PM, Surveyor interviewed RD I (Registered Dietician) who stated that she was familiar with R50. Surveyor asked RD I if she was aware of R50's recent unintentional weight loss. RD I stated that R50's significant weight loss was news to her. RD I stated she had not been notified of R50's recent unintentional weight loss, and she would expect staff to notify her so that she could monitor the weight loss and follow up with recommendations. RD I indicated that either the nursing staff or the dietary manager should notify her of resident weight loss so that she could see the resident and evaluate what needed to be done to mitigate further weight loss. RD I indicated that, according to R50's chart, R50's recent unintentional weight loss could be attributed to a respiratory infection she had, however it did not appear that R50's meal intakes were affected. RD I stated that she is at the facility every Friday and she would have expected to be notified of R50's unintentional weight loss so that she could start some supplements or troubleshoot how to get more calories in R50's diet. On 1/14/26 at 3:00 PM, Surveyor interviewed DON B (Director of Nursing) about R50's recent unintentional weight loss. Surveyor asked DON B if R50 was at risk for impaired nutritional status. DON B indicated that R50 had been having some weight loss recently, and that a care conference was scheduled with R50's POA to determine her goals of care. Surveyor asked DON B if R50's recent unintended weight loss of 5.77% in one month would be considered severe. DON B stated yes, she would consider that severe weight loss. DON B indicated that RD I is in the building every Friday and residents with weight concerns are discussed. Surveyor asked DON B if the registered dietician should have been notified about R50's severe unintentional weight loss. DON B stated yes, she would have expected staff to notify the registered dietician of R50's severe weight loss. Despite R50's severe unintentional weight loss, the facility failed to obtain reweights to ensure accuracy, failed to evaluate her care plan and implement interventions to prevent further decline. The facility failed to recognize R50's severe weight loss as a significant change in condition, and the RD was not notified, which led to further weight loss.

Based on interview and record review, the facility did not immediately notify and consult with the resident's physician when a change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 25 sampled residents (R94). R94 was sent to the ED (Emergency Department) with a change in condition. The facility did not consult with PA E (Physician Assistant) or any provider regarding R94's abnormal lab results. As evidenced by The facility policy, Change of Condition Notification, updated 1/2026, documents, in part, as follows: Purpose: Notification of a provider and family/POA (Power of Attorney) of changes in a resident's condition or health status.Procedure for Provider NotificationBetween the hours of 8:00 AM to 5:00 PM, 7 days a week, attending provider or on-call provider is to be notified of all condition or health status changes.Between the hours of 5:00 PM - 8:00 AM the attending on-call provider should be notified of any change in condition, health status or incident that (list is not inclusive-examples only):b. Abnormal lab values for the residentvii. Unusual bleedingxiii. Significant change in mental psychosocial status R94 was admitted to the facility on [DATE] with diagnoses including, but not limited to: colitis (inflammation of the large intestine), hypomagnesemia (low magnesium), anemia (blood lacks health red blood cells reducing oxygen delivery), DM type 2 (diabetes mellitus type 2), CKD (chronic kidney disease) Stage 3b, and debility. R94's admission Minimum Data Set (MDS) dated [DATE] indicates R94 has a Brief Interview of Mental Status (BIMS) of a 11 out of 15, which indicates he is moderately cognitively impaired. R94 is his own decision maker prior to being hospitalized on [DATE]. On 10/19/25 at 12:16 PM, R94's Progress Notes document as follows: Bowel Status: This writer (a Registered Nurse) noted resident was having multiple dark tarry stools. A sample was obtained for hemoccult testing with a positive test result noted. VSS (Vital Signs Stable). Charge RN notified. On 10/19/25 at 12:20 PM, a second RN (Registered Nurse) documented the following: Resident noted to have dark brown/back tarry stools this AM. Hemoccult obtained, result = positive. Resident is pleasant, cooperative, alert, and orientated per baseline. VS (Vital Signs) = WNL (within normal limits) for resident. No changes in ROM or ADL function. Charge nurse updated and Event in place. On 10/19/25 at 1:04 PM, the Charge RN (Charge Registered Nurse) documented as follows: This writer updated the physician due to dark/tarry appearing stools, medications, diagnosis' and positive hemoccult test. Provider also aware of follow up scope scheduled for the 30th of this month. New order obtained for CBC (Complete Blood Count) and BMP (Basic Metabolic Panel) now. On 10/19/25 at 1:43 PM, R94's Progress Notes document as follows: Labs: Labs drawn from Right AC (antecubital), resident tolerated well. Labs spinning to be sent to hospital on [DATE] an order was added for Assessments - Description: Clinical Charting - Monitor for s/sx (signs/symptoms) of bleeding, GI (gastrointestinal upset), and full set of VS (vital signs) Q (every) shift x 72 hours. Document in Progress Note and attach to event. Order Date: 10/19 - 10/22/25. It is important to note R94's vital signs remained stable prior to being hospitalization on 10/21.25. On 10/19/25 at 2:30 PM, R94's Progress Notes document as follows: Respiratory status: Lung sounds clear. Intermittent cough noted. No sputum. On 10/19/25 at 3:28 PM, R94's Progress Notes document as follows: Stools: Resident noted to have 4 total loose stools on Am, 1 incontinent along with 3 continents. One medium soft incontinence stool. Resident had no GI complaints such as bloating, discomfort, or cramping. Resident no current or recent ATB use. Dx (diagnosis) of colitis. Nursing continues to monitor with labs pending at hospital, waiting for result to review with on call provider. On 10/20/25 at 8:26 AM, R94's Progress Notes document as follows: RESPIRATORY: Resident denies any SOB (shortness of breath), cough is minimal this morning and lung sounds remain clear bilaterally, resident is afebrile, will continue to monitor. On 10/20/25 at 8:30 AM, R94's Progress Notes document as follows: GI/Bleeding: Resident denies any GI upset including, N/V (nausea/vomiting), indigestion, or stomach cramps. Resident was incontinent of a medium soft stool, dark brown to black in color. VSS (vital signs stable), will continue to monitor. On 10/20/25 at 8:42 AM, the hospital faxed R94's test results to the facility. The tests results include, in part, as follows:Hemoglobin 8.5 (Reference Range 13.2-16.6 g/dL)Hematocrit 26.9 (Reference Range 38.3-48.6)Erythrocytes 3.07 (Reference Range 4.35-5.65)RBC (red blood cell) Distrib (Distribution) Width 17.9 (11.8-14.5)Leukocytes 9.8 (Reference Range 3.4-9.6) Neutrophils 7.75 (Reference Range 1.56-6.45)Sodium 130 (Reference Range 135-145) Chloride 130 (Reference Range 98-107) On 10/20/25 at 8:44 AM, a Charge RN (Registered nurse) sent the following email to PA E (Physician Assistant). R94 had some dark, tarry stools over the weekend. The physician was notified and gave orders for labs to be drawn. Both (staff first name) and Charge RN are having a hard time logging in the hospital records to see results. Can you look into him (R94) and tell me what the results are and if you have any new orders regarding them. On 10/20/25 at 9:05 AM, R94's Progress Notes document as follows: Lab results: Resident's labs came back within normal limits except the following: Hgb 8.5(L), Hct 26.9(L), Erythrocytes 3.07(L), RBC Distrib Width 17.9(H), Leukocytes 9.8(H), Neutrophils 7.75(H), Sodium 130(L), and Chloride 96(L). PA E (Physician Assistant) notified via email. It is important to note, the facility did not consult with the provider regarding R94's test results. On 10/20/25 at 1:47 PM, R94's Progress Notes document as follows: MULTIPLE LOOSE STOOLS: Residents continue to have multiple, incontinent stools today x5, hemoccult positive this shift, resident denies any cramping, distention, or abdominal pain. Appetite has been fair, consuming 50-75% of today's meals. Resident does have a scope scheduled for 10/30/2025, charge nurse to be notified. 10/20/25 8:54 PM RESPIRATORY STATUS: Resident has a dry cough present on this shift when trying to lay down. PRN cough drops requested and administered. Lungs diminished in all fields. Vitals within parameters. On room air and stable this shift. On 10/20/25 at 8:56 PM, R94's Progress Notes document as follows: BLEEDING: Scant black tarry stool during cares. Offers no complaints of upset stomach or other GI (gastrointestinal) issues on this shift. On 10/21/25 at 4:38 AM, R94's Progress Notes document as follows: BLEEDING/GI (gastrointestinal): No stools to observe this shift. No complaints of GI upset. Sleeping well throughout this shift. On 10/21/25 at 10:21 AM, R94's Progress Notes document as follows: GI (Gastrointestinal): Resident denies any pain or discomfort to abdomen, no N/V (nausea/vomiting), however, resident did request 2 Tums due to slight indigestion which brought resident effective relief. Resident did have 1, continent, BM this morning, which was a large, loose, greenish brown stool, abdomen does feel a bit firm and distended, will continue to monitor. On 10/21/25 at 2:07 PM, R94's Progress Notes document as follows: R94's family member called to speak with this hall nurse, states she talked to R94 on the phone and he appeared confused. Assessed resident who had his light on to use the restroom, appeared alert and orientated calling me by name and denying any pain or discomfort. R94 asked this RN (Registered Nurse) when the provider was going to see him, informed him that it will be sometimes this afternoon. Resident did refuse lunch today, stated, I am just not hungry now, offered snack and a drink, R94 accepted, will continue to monitor. On 10/21/25 at 4:03 PM, R94's Progress Notes document as follows: PA E (Physician Assistant) update: PA E in house and reviewed labs. PA E gave the following order:1) Please send to ED (emergency department) NOW. dx: increased weakness with known GI bleed and Anemia, decreased Na+ and decreased Magnesium. On 1/15/26 at 12:45 PM, Surveyor left a message for PA E (Physician Assistant) requesting a return phone call. PA E has not returned Surveyor's phone call. It is important to note, the facility has no documentation that the provider was consulted regarding R94's abnormal lab results. On 1/15/25 at 1:00 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor discussed chain of events and lab results not reported to the provider timely. Surveyor asked DON B, how soon should staff have reported R94's labs to the provider. DON B stated, staff should have reported the labs to the provider immediately. DON B stated, staff should have notified the provider via phone to avoid the delay. DON B stated this is important due to a possible GI (gastrointestinal) bleed. DON B stated this delay in notifying the provider is unacceptable. Surveyor asked DON B, what standard of practice does the facility follow for change in condition such as this. DON B stated, she is unsure if there is a specific standard of practice however, staff should learn in nursing school that these results black stools indicate a GI bleed as well as low HCT (hematocrit) and HGB (hemoglobin) need to be reported immediately. DON B stated sodium that is outside of parameters should also be reported to the provider immediately.

Based on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 25 sampled residents (R49).R49 was observed to have a cup of medications left on her bedside table for her to take independently. R49 does not have an assessment for self-administration of medications indicating that she is safe to administer medications independently.Evidenced by:The facility policy titled, Self-Administration of Medication states, in part, Facility, in conjunction with the interdisciplinary care team, should assess and determine with respect to each resident whether self-administration of medications is safe and appropriate .to ensure safe and appropriate self administration, facility should educate residents to ensure that resident is able to: a) state the name, dose, strength, frequency, time, and purpose for use of his/her medications; b) understand the possible side effects of his/her medications and the he/she should notify facility staff if he/she experiences any such side effects; c) correctly administer, inject or apply his/her medications .Facility should obtain a physician order for self-administration .Facility should document in the resident's care plan whether the resident or facility staff is responsible for the storage of the resident's medications .Facility should document the self-administration of medications in the resident's care plan.R49 was admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set), includes a BIMS (Brief Interview for Mental Status) score of 15, indicating R49 is cognitively intact.It should be noted that R49 had a previous stay at the facility in which she discharged on 12/9/25 with a Return Not Anticipated noted on her discharge MDS. This was a planned discharge to another facility.During this previous stay, R49 was assessed on 3/25/25 to self-administer certain medications.On 1/15/2026 at 8:29 AM, Surveyor observed R49 in her room lying in her bed with the head of the bed elevated. R49's bedside table was over her bed. Observed on the table was a small medication cup with a red pill in it along with another small medication cup with a small spoon and what appeared to be yogurt or pudding. When asked what the red pill was, R49 stated, That is my senna. They just leave it for me. R49 stated that she gets intermittent constipation and diarrhea and is not always sure she wants to take it so they leave the pill for her and she takes it depending on how she feels. On 1/15/26, Surveyor interviewed LPN O (Licensed Practical Nurse) who stated that, in the past, R49 would get certain medications left at her bedside for self-administration, but that was for a previous stay. LPN O indicated that she (R49) used to have an order to self-administer certain medications but then discharged and since coming back, no longer had an order so she (LPN O) would not leave her any medications to self-administer, nor should any other nurse. Of note, R49's care plan does not indicate that she can self-administer medications, nor does she have any physician's orders indicating that she can self-administer medications. On 1/14/2026 at 3:10 PM, Surveyor interviewed DON B (Director of Nursing) who stated that R49 does not currently have a self-administration of medications assessment or order, but had one during a previous stay and that she was only gone from the facility a short time. When asked if R49 should had orders for self administration of medications and been reassessed and care planned again given the new admission, DON B stated, Yes.

Based on interviews and record reviews, the facility failed to protect a resident's right to be free from physical abuse. The facility did not protect residents (R) from physical abuse by a staff member or protect the resident immediately after the abuse occurred. This affected 1 of 4 residents (R1) reviewed for abuse. On 01/06/25, Certified Nursing Assistant (CNA) D witnessed CNA C strike R1 across the face. CNA D left CNA C alone with R1 to report the incident to nursing staff. R1 was left alone with CNA C for approximately 15 minutes. This left R1 at risk for further physical abuse from CNA C. The facility's failure to protect vulnerable residents from physical abuse created a finding of immediate jeopardy that began on 01/06/25. Surveyor notified the Nursing Home Administrator (NHA) and Director of Nursing (DON) of the immediate jeopardy on 01/14/25 at 2:55 p.m. The immediate jeopardy was removed 01/07/25 and corrected on 01/10/25. Based on this determination, this citation is being cited as past noncompliance. Findings include: Facility policy and procedure titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, last reviewed on 01/08/25, states in part, .It is the policy of Riverside that the resident(s) will be protected from the alleged offenders(s). Procedure: Immediately upon receiving a report of alleged abuse, the Administrator, and or designee will coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable individual are of utmost priority. Safety, security and support of the resident, their roommate, if applicable and other residents with the potential to be affected will be provided. The facility will take necessary steps to protect residents from possible subsequent incidents of misconduct or injury. This should include as appropriate: 1. Procedures must be in place to provide the resident with a safe, protected environment during the investigation: A. The alleged perpetrator may immediately be removed for the resident's protection. Employees accused of alleged abuse may be immediately removed from the facility and will remain removed pending the results of a thorough investigation . Record review identified R1 was admitted to the facility on [DATE] with diagnoses including, in part, Alzheimer's disease with late onset, depression, dementia with other behavioral disturbance, anxiety disorder, and cognitive communication deficit. R1's medical record identified R1 was not able to complete a Brief Interview for Mental Status assessment, which indicated R1 had severe cognitive impairment. The Resident Profile identified R1 had a history of physical and verbal agitation with cares. Special instructions: Approaches: 1:1, redirect, reapproach, PRNs [as needed medications], retired nurse-talk about nursing. Triggers: Pain and ADL [activities of daily living] care. Surveyor reviewed the facility incident investigation file and identified a statement provided by CNA D. CNA D stated on the night of 01/06/25, CNA D entered the 200-dementia unit to deliver supplies and see what time CNA C wanted a break. CNA D stated from the doorway of R1's room she observed CNA C was changing R1's brief. CNA D witnessed CNA C strike R1 in the face with an open backhand. R1 responded by putting her hands to her face. CNA D turned and began walking out of the unit to inform the nurse of the incident. At that time CNA C was left alone with R1. The incident investigation file identified Registered Nurse (RN) E was informed of the incident at 11:15 PM by CNA D. RN E then placed calls to NHA A and DON B. RN E was not able to reach either NHA A or DON B and left messages for them. RN E then called the police to report the incident at 11:19 PM. The incident investigation file identified RN E went to the 600 unit to request help from another staff member before entering the 200 unit. When RN E entered the 200 unit, CNA C was assisting R1 in the bathroom. The investigation file indicated RN E asked CNA C if he hit R1 and CNA C confirmed he had hit R1 as a reflex. A witness statement from CNA F noted sometime between 11:15 PM to 11:30 PM, RN E informed CNA F what had occurred on the 200 unit and requested assistance. When the police arrived, CNA F went to the 200 unit and informed RN E. RN E requested CNA F stay with CNA C while RN E spoke with the police. The police report identified the officer arrived at the facility at 11:36 PM. The police report identified the officer interviewed CNA D, who witnessed the abuse, in a common area of the building, then went to R1's room with RN E. The officer observed redness around R1's lips and two cuts on the top and bottom lip on the right side. The cuts were still bleeding. The officer then interviewed CNA C in a common area near R1's room. During the interview CNA C informed the officer CNA C did hit R1 in the face. When the officer asked CNA C to clarify what he meant, CNA C raised his right arm and open right hand upwards mimicking his action towards R1. CNA C stated he was frustrated with R1 because she was in the way while he was changing her. CNA C was arrested and removed from the building by the officer. On 01/14/25 at 1:10 PM, Surveyor attempted a telephone interview of CNA D who witnessed the incident. Surveyor left a voicemail message requesting a call back. No call back has been received at the time of this writing. On 01/15/25 at 8:05 AM, Surveyor conducted a telephone interview with RN E. RN E stated on the night of 01/06/25, CNA D approached her at the nursing station outside of the 200 unit at approximately 11:15 PM. CNA D appeared very upset and informed RN E she had just witnessed CNA C hit R1 in the face. RN E immediately attempted to call both NHA A and DON B and left messages for both, and then called the police department to report the incident. RN E then went to the 600 unit to request help from CNA F. RN E then entered the 200 unit and found CNA C assisting R1 on the toilet in her room. RN E stated she was unsure of the time, but estimated it was not more than 10 minutes between the time she was informed of the incident and when she entered the unit. RN E stated CNA C was not left alone on the unit or with residents after the time she entered the unit. RN E stated when the police arrived, CNA F came to the unit to inform her. RN E requested CNA F stay with CNA C on the 200 unit while she spoke to the police. On 01/15/25 at 8:56 AM, Surveyor conducted a telephone interview with CNA F. CNA F stated on the night of 01/06/25, he was assigned to work on the 600 unit. CNA F was not sure of the time, but sometime after 11:00 PM, RN E informed him of the incident on the 200 unit. RN E asked CNA F to come to the 200 unit to let her know when the police arrived. CNA F stated when the police arrived, CNA F entered the 200 unit to inform RN E. CNA F stated when he entered the unit, CNA C was in the resident's bathroom with R1, and RN E was not in the resident's room. RN E asked CNA F to stay with CNA C while RN E spoke with the police. CNA F stated he then assisted CNA C to finish assisting R1 with cares and got her back in bed. CNA F stated CNA C was never left alone with residents after he entered the unit. It is of note RN E was informed that CNA C hit R1 in the face at 11:15 PM and CNA C was still alone with R1 in her bathroom when CNA F entered the unit at 11:36 PM when the police arrived. After CNA C was removed from the facility, CNA F and another CNA were instructed to begin immediate skin assessments of all residents to check for signs of abuse for all residents on the 200 unit. DON B and assistant arrived in the building at approximately 1:00 AM on 01/07/25 and started immediate education for all staff in the building on the need to immediately protect residents from suspected abuse. The facility's failure to protect vulnerable residents from physical abuse created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed on 01/07/25 when staff was educated on the need to immediately protect residents from suspected abuse. The immediate jeopardy was corrected on 01/10/25 after the facility completed the following: Educated all staff on immediate protection of residents Educated on the abuse policy Interviewed all staff and residents about any concerns with abuse Completed skin assessments on all residents and any unknown injuries to assess for any signs of abuse Assessed non-interviewable residents for any psychosocial outcomes Completed dementia training on how to deal with aggressive behaviors Completed caregiver stress education, and signs of caregiver burnout Completed abuse drill scenarios to determine how staff should respond if witnessing abuse Based on this determination, the citation is issued as past noncompliance.

Based on observation, interview and record review, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. Staff touched ready to eat foods with contaminated gloves when preparing and serving toast to two residents (R66 and R57). Staff carried uncovered food trays in the hallway for R62, R393, R43, R20, R42, R392 and R73. Findings include: Example 1 Facility policy and procedure entitled, Bare Hand Contact with Food and Use of Plastic Gloves, stated in part, .3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 4. Hands are to be washed when entering the kitchen and before putting on the single-use gloves (before beginning to work with food) 6. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed . On 08/27/24 at 6:49 AM, Surveyor observed Certified Nursing Assistant (CNA) O preparing and serving breakfast from the kitchenette on the 200 unit. Surveyor observed CNA O put on gloves and take a piece of bread out of the bag and place it in the toaster. CNA O did not wash hands or use hand sanitizer before putting on the gloves. Surveyor observed CNA O fill two glasses with juice and touched multiple items, cupboard doors, and surfaces in the kitchenette with the same gloves on. CNA O then took the toast out of the toaster with the same gloves on, opened a drawer and took out a knife, buttered the toast, cut it in half, and served it to R66. CNA O then took another piece of bread and placed it in the toaster with the same gloves on that had touched multiple surfaces in the kitchenette and dining area. Surveyor observed CNA O take off the contaminated gloves, wash hands, and put on clean gloves before taking the toast out of toaster. CNA O buttered the toast and served it to R57. On 08/27/24 at 1:48 PM, Surveyor interviewed Culinary Services Manager (CSM) D and described the observation of breakfast service by CNA O on the 200 unit. Surveyor asked CSM D if CNA O was following safe food handling during the observation of preparing and serving toast. CSM D stated, no, staff was supposed to change gloves anytime they touch a potentially contaminated surface, or use a tongs before touching a ready to eat food. 49353 Example 2 On 08/27/24 at 11:43 AM, Surveyor observed certified food service cart located at the beginning of resident 500 hallway, between rooms [ROOM NUMBERS]. Surveyor observed CNA C deliver the hot lunch meal trays to residents eating in their rooms in the 500 unit. Surveyor observed CNA C remove hot meal trays from food service cart, remove the covers from main course plate and remove the covers on the cold drinks that included milk and juice. Surveyor observed CNA C carry the uncovered food trays down the hallway, past multiple rooms and people, and delivered the trays to R62, R393, R43, R20, R42, R392 and R73.

Based on observation, interview and record review, the facility did not ensure that 4 of 6 residents (R) reviewed for pressure injuries (PI) (R58, R89, R9, and R28) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs. R58 was admitted with multiple PIs and was at risk for PI development. R58 developed an unstageable PI. The facility did not reposition R58 for several hours. R89 was at risk for PI development. The facility failed to evaluate the effectiveness of current interventions R89 had in place. The facility did not reposition R89 for several hours and did not off-load heels and coccyx. R9 and R28 have existing PIs. R9 and R28 were not repositioned to promote healing of existing PIs or prevent pressure injuries from developing. Findings include: Example 1 R58 was admitted to facility on 01/30/24 with diagnoses which included in part: hypertension, hyponatremia, pressure injury to the right ankle stage 3, unstageable pressure injury to the right heel, stage 2 pressure injury to the sacral region, and bullous pemphigoid. R58's Minimum Data Set (MDS) assessment, dated 01/31/24, identified R58 scored 15 during a Brief Interview for Mental Status (BIMS), indicating cognition intact. MDS identified R58 required total dependent assistance of two people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and for transfers. MDS also indicated that R58 was determined to be at risk for PIs. Surveyor reviewed R58's Braden skin risk assessment completed on 01/30/24 scored 15 at risk for pressure injury. Surveyor reviewed R58's admission skin assessment completed on 01/30/24 indicating R58 had a PI to foot stage 3, left heel unstageable PI, stage 3 PI to the right lateral bunion scabbed over at present time. Surveyor reviewed Activities of Daily Living (ADL) CNA Kardex sheet: -Minimize time sitting in wheelchair to less than 2 hours at a time during meals. -Lay resident down after lunch. -Transfer Hoyer with 2 assists. -The resident is totally dependent on staff for bed mobility and repositioning and turning in bed 1-2 person assist. -Staff is to assist with turning and repositioning. Surveyor reviewed R58's IMPAIRED SKIN Care Plan: -Skin will remain intact initiated on 01/30/24, revised on 06/24/24. -CNA to observe skin during AM/HS cares report changes to nurse initiated on 01/30/24. -Pressure redistribution cushion in chair initiated on 01/30/24. -Pressure redistribution mattress initiated on 01/30/24. -Nurse to complete a systematic skin inspection on assigned bath day. Complete weekly skin assessment observation and wound management, including measurements, when appropriate initiated on 01/30/24. -Assess and record the condition of the skin surrounding the pressure ulcer initiated on 01/30/2024. -Assess the pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization weekly initiated 01/30/2024. -Conduct a systematic skin inspection weekly. Report any signs of further skin breakdown initiated 01/30/2024. -Keep clean and dry as possible. Minimize skin exposure to moisture initiated 01/30/2024. -Keep linens clean, dry, and wrinkle free initiated 01/30/2024. -Observe and report signs of osteomyelitis (pain, redness, swelling in affected joint, muscle spasms in affected joint, chills, fever (rapid elevation), diaphoresis, tachycardia, restlessness, irritability) initiated 01/30/2024. -Observe and report signs of sepsis (fever, lassitude or malaise, change in mental status, tachycardia, hypotension, anorexia, nausea, vomiting, diarrhea, headache, lymph node tenderness/enlargement). initiated 01/30/2024. -Podiatry and wound care appointments as scheduled initiated 01/30/2024. -Treatment: see TAR for specifics initiated 01/30/2024. -Turn and reposition routinely per protocol initiated 01/30/2024 and reviewed/revised on 06/26/24. Surveyor reviewed weekly skin assessments and noted: -On 06/20/24 a new skin event initiated and indicated pressure ulcer discovered in house acquired stage 1 pressure injury to the right ischium. Right ischium had area of non-blanchable erythema measuring 2x1.5cm with surrounding skin blanchable red measuring 5x4cm. Interventions being used or put into place indicates: *Skin will remain intact initiated on 01/30/24, revised on 06/24/24. *Turn and reposition routinely per protocol initiated 01/30/2024 and reviewed/revised on 06/26/24. *Pressure relieving gel pad on commode initiated on 06/24/24. -On 06/26/24 wound zoom documentation indicates: Right posterior iliac crest Superficial wound measuring 3.4cmx4,4cmx0.10cm. Surveyor's interview with Director of Nursing on 9/9/24 indicates on 6/20/24, the wound nurse noted a red area with a small area that was non-blanchable. Due to its indurated nature, it was monitored closely as it was not easily classifiable due to it possibly being a blister from bullous pemphigoid. In addition, it was found R58's daughter had brought in his previous custom-made ish-dish seat cushion R58 used prior to admission. It was sitting in his recliner at the time of the assessment. R58's daughter brought this when she took him to last wound appointment. The wound nurse immediately took this cushion away and placed the roho cushion to be used. R58's daughter was educated and took it home with her. This ish-dish is hard and would cause pressure on the ischium. On 6/24/24, R58 was admitted to the hospital with possible sepsis related to his chronic UTI. Resident has a suprapubic catheter and history of cancer. The hospital did not note the PI area during his hospital stay and it was not addressed while he was admitted there. R58 returned on 6/26/24 with a declined wound status of right hip. Upon the admission skin assessment, R58 was also found to have a new pressure injury to buttocks, suspicious of DTI. In-house provider saw the resident on 6/27/24 for follow-up. Resident was also experiencing possible extremity cellulitis and another exacerbation of bullous pemphigoid due to illness: Given patient's known bolus pemphigoid it was thought this may be related to a new flare up due to the stress of the acute illness. R58 was seen again by in-house physician on 7/2/24 to follow up on the bullous pemphigoid exacerbation and cellulitis. R58 was started on an antibiotic and Lasix for edema at that time. The wound appears to be intact but continued to be monitored as area of concern. Physician orders in part: On 06/26/24: ADL - Toileting: Suprapubic Catheter, Cont/Incont Bowels, Hoyer A x 2 to commode, 100% non-weight bearing to right lower extremity. Special Instructions: Encourage less than 15 minutes on commode. On 06/26/2024: Check (SpanAm Alternating) air mattress is properly inflated every shift. Special Instructions: Firmness setting to resident's comfort level Three Times A Day. On 06/26/2024: Barrier skin prep to L medial heel discoloration BID. Twice A Day. On 06/26/24: Check (ROHO) cushion placement and proper inflation every shift. Three Times A Day. -On 07/03/24 weekly skin assessment missed. -On 07/03/24 wound zoom documentation indicates: Right posterior iliac crest (ischium) wound measuring 3.6cmx4.0cmx0.00cm. Thick discolored well adhered callous. -On 07/10/24 wound zoom documentation indicates: Right posterior ischium PI unstageable measuring 3.4cmx3.2cmx0.00cm. -On 07/17/24 wound zoom documentation indicates: Right posterior iliac crest wound 3.4cmx3.7cmx0.20cm, Black well adhered leathery necrotic tissue covering majority of open area. **Physician orders: On 07/22/2024: Repositioning 2 hours. Every Shift. On 07/24/24 weekly skin assessment completed. On 07/31/24 weekly skin assessment completed. **Physician orders: On 08/02/24: BLE Rooke boots off at AM, on at HS. Twice A Day. On 08/02/24: Document any refusal of repositioning, sitting on commode, or up in wheelchair every shift. Special Instructions: Patient should be allowed time tilting side to side in bed between meals. Minimize time sitting in wheelchair to less than 2 hours at a time during meals. On 08/06/24: ADL - Skin: Rooke Boots to BLE at HS only, SpanAM Alt. Mat, Roho, Enc Repos Q 2 hours (REPO SHEET), Aquaphor L leg/foot & R leg daily. Physician visit note on 7/11/24 indicates that R58 was out for an appointment with his wife for several hours and was sitting on a hard surface cushion that R58's wife had provided during this outing. On 7/12/24, the facility completed a risk benefit agreement with R58 regarding limiting the time on the commode and educated on the risks of developing a PI, if R58 chose to sit longer on the commode. The facility added a gel cushion to the commode to prevent pressure. Physician note on 8/2/24 in part, It is reasonable to think that this was a bulllous pemphigoid blister that worsened due to resident's choice to sit on commode . Physician orders: On 08/15/24: Try to spend time up in chair limited to 1-2 hours at a time, encourage to lay down in bed between meals twice a day. -On 08/21/24 wound zoom documentation indicates unstageable PI to the posterior right ischial 2.7cmx2.9x0.20cm, no tunneling, no undermining. On 08/26/2024: Treatment to Right ischium: Special Instructions: Offload ischium frequently. Use cushion in recliner or similar cushion. Every Shift - PRN Observations were made of resident not being repositioned for 2.5 hours on 08/26/24. On 08/26/24 at 11:01 AM, Surveyor observed R58 sitting in wheelchair, Hoyer sling underneath, and R58 watching TV. On 08/26/24 at 12:33 PM, Surveyor observed R58 sitting in wheelchair, Hoyer sling underneath and R58 watching TV. On 08/26/24 at 1:37 PM, Surveyor observed Registered Nurse (RN) T lay R58 down into bed to complete wound dressing changes. Surveyor reviewed repositioning schedule from 08/26/24 that did not have documentation of R58 refusing to be repositioned. On 08/26/24, documentation indicates R58 stayed sitting in wheelchair from 8:00AM-2:00PM. Observations were made of resident not being repositioned or toileted for 5 hours on 08/27/24. On 08/27/24 at 7:51 AM, Surveyor observed staff place R58 on commode. On 08/27/24 at 8:18 AM, Surveyor observed staff transfer R58 off R58's commode. Staff observed R58 sitting on commode for 27 minutes and staff did not follow R58's care plan. On 08/27/24 at 10:27 AM, Surveyor observed R58 sitting in wheelchair with Hoyer sling underneath R58. Surveyor did not observe R58 repositioned or offered repositioning. On 08/27/24 at 12:22 PM, Surveyor observed R58 still in wheelchair with Hoyer sling underneath R58. Surveyor did not observe R58 repositioned or offered repositioning. R58 sitting in room visiting with family. On 08/27/24 at 12:48 PM, Surveyor observed R58's daughter ask Certified Nursing Assistant (CNA) M if CNA M could transfer R58 to recliner as R58 was requesting to be repositioned off bottom. On 08/27/24 at 1:26 PM, Surveyor observed R58's daughter come out to hallway and scan for staff. Surveyor heard R58's daughter state to R58 that when staff get a chance staff will lay R58 down soon. On 08/27/24 at 1:28 PM, Surveyor observed CNA M enter R58's room and ask R58 if everything was ok. R58 requested to be placed in recliner. CNA M and a student CNA transferred R58 via Hoyer into recliner. On 08/27/24 at 1:38 PM, Surveyor interviewed R58's daughter and asked if R58's daughter had any concerns with R58's repositioning. R58's daughter indicated that she believes the staff try to get to R58 when they have time. R58's daughter indicated she understands there is an issue with a pressure injury on R58's bottom. R58's daughter indicated that R58 wants to relieve pressure off R58's bottom but doesn't always get the help right away but that facility staff do their best. On 08/27/24 at 2:05 PM, Surveyor interviewed CNA M and asked if R58 was repositioned anytime in the day other than before placing R58 into recliner. CNA M indicated that R58 has been in wheelchair all day because R58 refuses sometimes and R58 had a visitor little before lunch time. Surveyor reviewed repositioning schedule from 08/27/24 that did not have documentation of R58 refusing to be repositioned. On 08/27/24 from 6:00 AM until 2:00 PM there was no documentation of refusing or repositioning of R58. On 08/28/24 at 7:58 AM, Surveyor interviewed CNA C and asked how the repositioning schedule charting worked for R58. CNA C indicated that if it is care planned that staff reposition residents every so often then CNAs chart on the repositioning schedule and then it gets scanned in every so often into the EHR. CNA C indicated that R58's repositioning schedule was to reposition every 1-2 hours, and up for maximum of 1-2 hours in chair. CNA C indicated that CNA C documents when R58 is repositioned on the sheet. On 08/28/24 at 9:21 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectation was for repositioning R58. DON B indicated that all residents should be repositioned every two hours. Surveyor asked DON B if DON B has a repositioning policy in place. DON B indicated the facility does not have a repositioning policy, but that expectation is for staff to follow standards of practice and reposition every 2 hours. DON B indicated that R58 sometimes refuses but that when this occurs staff should document the refusal in the Electronic Health Record (EHR). Surveyor indicated to DON B that upon review of the repositioning schedule and Surveyor's observations, Surveyor found missing documentation on repositioning or refusals for R58. Surveyor indicated to DON B that Surveyor observed R58 sitting in wheelchair for up to 5 hours without being off loaded off R58's bilateral ischiums and coccyx. Surveyor asked DON B if R58's PI on the right ischium could have been avoidable. DON B indicated that originally facility thought the PI on the right ischium was from sitting on commode for long periods of time. The facility initiated limited time on the commode to 15 minutes, but R58 is his own person and insists on sitting longer at times. A risk benefit education has been done with R58. DON B indicated that staff should have offered; if R58 refused, then staff are to document this. DON B indicated the facility implemented a gel cushion for the commode as well and increased the repositioning frequency. DON B indicated that staff are still to offer or reposition every 1-2 hours with R58 while R58 is up in wheelchair, recliner or lying in bed. On 08/28/24 at 2:05 PM, Surveyor interviewed DON B and Nursing Home Administrator (NHA) A and asked if there was any other information to provide with observations of no repositioning for R58 and evidence of off-loading during Surveyor's observations from 08/26/24 and 08/27/24. DON B indicated that at this time there was no other information to provide. Example 2 R89 was admitted to facility on 08/01/24 with diagnoses which included in part: acute respiratory failure with hypoxia, right heart failure, hypertension, and acute kidney failure. R89's Minimum Data Set (MDS) assessment, dated 08/07/24, identified R89 scored 15 during a Brief Interview for Mental Status (BIMS), indicating cognition intact. MDS identified R89 required total dependent assistance of two people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and for transfers. MDS also indicated that R89 was determined to be at risk for PIs. Surveyor reviewed physician orders: -Check ROHO cushion placement and proper inflation every shift. -Check Span AM air mattress is properly inflated every shift. Special instructions pump to resident's firmness preference. -Encourage to float heels. -Encourage to turn and reposition every two-four hour with care. Surveyor reviewed R89's Braden skin risk assessment completed on 08/01/24 scored 13 at moderate risk for pressure injury. Surveyor reviewed R89's admission skin assessment completed on 08/01/24 indicating R89 had gluteal crease and buttocks with incontinence associated dermatitis with fungal involvement. Surveyor reviewed Activities of Daily Living (ADL) CNA Kardex sheet: -Roho cushion. -Encourage to float heels. -Encourage to turn and reposition every two-four hour with care. -Bed mobility assists of two. Surveyor reviewed R58's IMPAIRED SKIN Care Plan: -Skin will remain intact initiated on 08/01/24. -CNA to observe skin during AM/HS cares report changes to nurse initiated on 08/01/24. -Pressure redistribution cushion in chair initiated on 08/01/24. -Pressure redistribution mattress initiated on 08/01/24. -Nurse to complete a systematic skin inspection on assigned bath day. Complete weekly skin assessment observation and wound management, including measurements, when appropriate initiated on 08/01/24. Observations were made of R89 not being repositioned for 4 hours on 08/27/24. On 08/27/24 at 7:29 AM, Surveyor observed R89 lying in bed supine at a 45-degree angle directly on the coccyx and R89's heels directly on the bed. R89 was sleeping soundly in bed. Surveyor did not observe staff offer or reposition R89. On 08/27/24 at 9:25 AM, Surveyor observed R89 lying in bed supine at a 45-degree angle directly on the coccyx and R89's heels directly on the bed. R89 had just finished eating breakfast. Surveyor did not observe staff offer or reposition R89. On 08/27/24 10:27 AM, Surveyor observed R89 lying in bed supine at a 45-degree angle directly on the coccyx and R89's heels directly on the bed. LPN S entered to give morning medications. Surveyor did not observe staff offer or reposition R89. On 08/27/24 at 11:29 AM, Surveyor observed LPN S and Hospice nurse roll R89 to the right side and perform peri cares. LPN S noted that the slit on R89's coccyx/sacrum area was a new slightly opened area. Surveyor observed the bilateral coccyx area had redness and superficial breakdown. LPN S applied [NAME] and capisopom as ordered and repositioned R89 back to R89's back. Surveyor observed R89 placed back on back and heels directly on R89's bed. On 08/27/24 at 11:35 AM, Surveyor interviewed LPN S and asked LPN S what process LPN S follows for proceeding with a new finding of skin breakdown for R89. LPN S indicated that LPN S would review orders and progress notes to see if the current treatments being completed presently covers the skin breakdown observed to R89's sacrum/coccyx area. LPN S indicated two weeks ago when he was assessing R89's bottom that the breakdown was not there. LPN S indicated that LPN S will be checking the EHR for skin breakdown changes and report to charge wound nurse as soon as possible and begin standing orders and daily assessments. Surveyor asked what LPN S's expectation for repositioning R89 is. LPN S indicated that R89 should be repositioned off the coccyx area every 2 hours and heels floated. LPN S indicated that LPN S did not reposition R89 off R89's bottom and did not elevate R89's heels at this time as LPN S is unsure the last time R89 was repositioned. On 08/28/24 at 1:36 PM, Surveyor interviewed DON B and asked about expectation for alternating mattress. DON B indicated that the alternating mattress is based on resident's comfort for pressure levels and there is no set parameters or expectations of use. Surveyor asked DON B if R89 had weekly skin assessments completed since admission on 08/01/24 as Surveyor could only find 08/01/24, 08/09/24, and 08/24/24. Weekly skin assessment was not completed for 08/15/24. DON B indicated that the weekly assessment on 08/15/24 was missed. Surveyor asked DON B when the facility noted a suspected DTI on the left inner heel area and why this was not assessed again on the weekly skin assessments since admission. DON B indicated that there has been a staffing crisis and turnover and that the further assessment of the suspicious DTI on left inner heel has been missed. Surveyor asked DON B what interventions other than redistribution mattress on bed and cushion in chair was in place to prevent further breakdown for R89. DON B indicated that is expectation that R89 be repositioned every 2 hours as the standards of practice. On 08/28/24 at 2:05 PM, Surveyor interviewed DON B and Nursing Home Administrator (NHA) A and asked if there was any other information to provide with observations of no repositioning for R89. DON B indicated at this time there was no other information to provide. 46694 Example 3 R9 was admitted on [DATE] from an acute care hospital stay with the following diagnoses, in part, pressure ulcer of right lower back, Kyphosis (is a condition where your spine curves outward more than it should). R9's Braden risk assessment score of 11.0 which indicated R9 was at risk for development of a pressure injury. R9's admission baseline care plan identified R9 had a stage 3 PI to left mid back with interventions in place to reposition every 2-4 hours, a ROHO cushion for R9's buttocks and a waffle cushion for R9's back. R9's admission Minimum Data Set (MDS) assessment, dated 06/03/24, identified R9 was at risk for development of a pressure injury and had a stage 3 pressure injury. On 08/26/24, Surveyor observed R9 sitting in R9's Broda chair from 9:54 AM until 2:01 PM without being repositioned. On 08/27/24, R9 was brought out to the hallway at 9:35 AM where R9 ate breakfast. At 11:48 AM, R9's lunch tray was brought, and no repositioning was offered. On 08/28/24, Surveyor observed R9 from 9:28 AM until 11:20 AM. Resident was not repositioned during that time. At 11:30 a.m., R9's significant other came, and they went to the dining room. On 08/28/24, Surveyor reviewed wound zoom notes for R9. Wound changes on 06/12/24 the mid back PI measured 1.6cm X 1.1cm and on 06/19/24 the same wound measured 2.4cm X 1.9cm with an increase of 2.2cm. Surveyor asked Assistant Director of Nursing (ADON) L for an explanation for this increase in surface area. ADON L informed Surveyor that R9 required an iron infusion on 06/17/24 which R9 had to sit in a standard wheelchair instead of the broda chair for an extended amount of time. Example 4 R28 was admitted on [DATE] with diagnoses, in part, Lewy Body dementia (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function), obesity and Parkinsonism. R28's Braden risk assessment score of 14 dated 07/20/24 indicated R28 had a moderate risk for development of a pressure injury. R28's Minimum Data Set (MDS) assessment, dated 07/26/24, identified R28 was at risk for development of a pressure injury and had no unhealed pressure injuries. R28's medical chart, dated 08/04/24 at 4:24 PM, states in part, Writer observed what appears to be a deep tissue injury (DTI) on left buttock measuring 1cm X 1cm. R28's care plan states in part, Possible DTI to left buttock discovered 8/04/24 at 14:00 Discoloration- Non-blanchable purple area to left buttock 1 X 3cm No blood loss wound edges not applicable .Immediate measures taken cleansed area, topical ointment, other- reposition side/side. On 08/27/24, Surveyor observed R28 from 8:15 AM until 12:44 PM; resident remained on the right side in bed no offloading observed with SPAN air mattress on level 3 alternating. On 08/28/24 at 2:08 PM, Surveyor interviewed RN J about the start of R28's DTI. On 08/04/24, R28 was willing to go in bed as opposed to the recliner. Chamosyn was ordered to R28's skin with cares and instituted documentation of refusals of repositioning. On 08/05/24, labs drawn indicated mild dehydration from poor oral intake. This was just prior to R28's UTI. R28's mobility decreased. The SPAN air mattress was instituted on 08/09/24. R28 has documented repositioning refusals on 08/09/24, 08/10/24 and 08/14/24. 49353

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During the 4-day survey Surveyors had multiple observations of staff not following the Centers for Disease Control (CDC) guidance for Personal Protective Equipment (PPE) use during a COVID-19 outbreak. This had the potential to affect all 18 residents residing on the dementia unit. Surveyor observed staff not performing hand hygiene after changing soiled gloves during cares for R64. Findings include: According to CDC Infection Control Guidance: SARS-CoV-2 [COVID-19] last updated 06/24/24, in reference to use of masks or respirators, .If they are used during the care of patient for which a NIOSH Approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH Approved particulate respirators with N95 filters or higher during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions), they should be removed and discarded after the patient care encounter and a new one should be donned . The CDC guidance also includes, .Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) worn during all patient care encounters . On 08/26/24 at 9:32 AM, Surveyor entered the 200-dementia unit. Surveyor noted a sign on the outside door to the unit that stated COVID outbreak. N95 masks required for staff and visitors. On 08/26/24 at 9:40 AM, Surveyor interviewed Licensed Practical Nurse (LPN) S who stated there were four residents who tested positive for COVID-19 over the weekend, and one more resident was found to be positive this AM. LPN S stated due to the residents having dementia and wandering, they are unable to keep all of the positive residents quarantined to their rooms. LPN S stated it was also difficult to get those confused residents to comply with wearing a mask, so they were having all staff wear N95 respirators on the unit and trying to assist the residents with frequent hand hygiene. On 08/26/24 at 10:30 AM, Surveyor observed signs outside R64's door stating droplet and contact precautions. Surveyor observed R64 wandering around the hall and dining area touching multiple surfaces. Surveyor observed R64 had a runny nose and was frequently wiping nose with hands. Record review identified R64 had a diagnosis of Alzheimer's disease and had tested positive for COVID-19. On 08/26/24 from 9:30 AM to 12:45 PM, Surveyor had multiple observations of LPN S and Certified Nursing Assistant (CNA) O and CNA U donning and doffing PPE for rooms that were identified as droplet and contact precautions due to COVID-19. Surveyor observed staff wearing a surgical mask over the N95 before entering the droplet precautions rooms. Then when they left the room, they would remove the surgical mask and put a new surgical mask over the N95 without changing the N95. On 08/26/24 at 1:29 PM, Surveyor observed R47 walking down the hallway with walker independently. R47 was not wearing a mask. R47 was pleasantly confused. Record review identified R47 had a diagnosis of vascular dementia and tested positive for COVID-19 on 08/24/24. The record stated R47 was placed on enhanced droplet precautions. On 08/26/24 at 1:35 PM, Surveyor interviewed LPN S and asked what the facility policy was for N95 use in droplet precaution rooms. LPN S stated they were not sure if this was following facility policy, but LPN S was using the surgical mask to cover the N95 to save it or keep it clean. LPN S stated they did not change the N95 when leaving the droplet precaution rooms, just the surgical mask over top. Surveyor asked LPN S if they had a shortage of N95 masks, or were in a contingency plan for PPE due to shortages. LPN S did not think there was a shortage of N95 masks. On 08/27/24 at 6:24 AM, Surveyor observed CNA R exit R47's room. Surveyor noted there was a sign outside the door that said droplet plus contact precautions. Surveyor observed CNA R had a surgical mask on over N95 respirator and goggles on when exiting the room. CNA R removed the goggles and placed in the top drawer of the PPE cart outside the door. CNA R did not wipe off the goggle with a sanitizer wipe before placing them in the drawer. CNA R did not change the surgical mask or N95 after leaving the room. On 08/27/24 at 7:04 AM, Surveyor observed CNA R and CNA O prepare to enter R64's room to provide morning cares for R64. Surveyor observed both CNAs use hand sanitizer and put on a gown and gloves outside the door. CNA O already had an N95 mask on and no surgical mask over the N95. CNA R had an N95 mask with a surgical mask over the N95. Neither CNA put on goggles or eye protection before entering the room. CNA O assisted R64 to wash face and upper body while CNA R assisted with feet and legs. CNA R removed gloves and gown and used hand sanitizer before leaving the room to get more supplies. CNA R returned to the room with a gown, gloves, N95, and goggles on. CNA R did not have a surgical mask over the N95 when re-entering the room. After finishing R64's upper body, CNA O removed the gloves, and put on clean gloves. Surveyor noted CNA O did not wash hands or use hand sanitizer before putting on clean gloves. CNA O washed and dried R64's bottom and removed the old incontinent brief and threw it away. CNA O applied barrier cream to R64's bottom, removed gloves, and put on clean gloves without washing hands or using hand sanitizer. CNA O put a clean brief on R64, and CNA O and CNA R assisted R64 to dress and transfer to a wheelchair. CNA O removed gloves and washed hands in bathroom. CNA O came out with a brush and assisted R64 to brush hair with no gloves on. CNA O returned to bathroom, washed hands, and applied clean gloves. CNA O applied powder to right side of R64's neck. CNA O assisted R64 to the bathroom in wheelchair, removed gloves and put on clean gloves without using hand sanitizer between. CNA O assisted R64 to brush teeth. CNA R removed gown and gloves, used hand sanitizer, and left the room. CNA R did not remove the goggles or N95 before leaving the room. CNA R returned to the room with gown and gloves, an N95 with surgical mask over the N95, and goggles on. CNA R handed a plastic cup to CNA O who helped R64 rinse mouth. Both CNAs removed gowns and gloves and washed hands. CNA O put a gait belt around R64 and assisted her to stand. CNA R removed the surgical mask over N95, left the same N95 and goggles on, and assisted R64 to walk to the dining room. CNA R did not use hand sanitizer when leaving the room. CNA O removed the N95 in the room, carried trash and linen bags to hampers in the hall. CNA O used hand sanitizer and put on a new N95 mask and walked to dining room. Surveyor observed CNA R wearing an N95 and goggles assisting residents in the dining room. On 08/27/24 at 7:38 AM, Surveyor observed Food Service Aide (FSA) N enter the unit wearing a surgical mask with plastic eye shield on the mask. FSA N stated they could not find an N95, and asked the CNA O if it was okay to wear that mask to check the kitchenette. CNA O stated it was their risk. Surveyor observed FSA N walk past multiple residents in the hallway and dining room to get to and from the kitchenette. On 08/27/24 at 8:07 AM, Surveyor observed CNA O use hand sanitizer and put on a gown and gloves. CNA O put a surgical mask over the N95 CNA O was already wearing and prepared to enter room [ROOM NUMBER]. Surveyor noted a sign outside the room that stated droplet plus contact precautions. Surveyor asked CNA O which resident in the room was on precautions. CNA O stated it was R13 who was on precautions due to COVID-19. CNA M stated they were going to assist R13 go to the bathroom and get washed up and dressed for the day. CNA O did not put goggles on before entering room. On 08/27/24 at 9:05 AM, Surveyor observed LPN P administer medications to R13. Surveyor noted a droplet plus contact precautions sign outside the door to R13's room. LPN P used hand sanitizer and donned a gown, gloves, goggles, and surgical mask over the N95 that LPN P was already wearing. After administering the medications, LPN P removed the gown, gloves, and surgical mask in the room and exited the room with the same N95 on. Surveyor interviewed LPN P who stated they were instructed to keep their N95 on at all times and put a surgical mask over the N95 when going in droplet precaution rooms. LPN P stated they remove the surgical mask when exiting the room and keep the same N95 on. On 08/27/24 at 9:36 AM, Surveyor interviewed Registered Nurse (RN) E who is the facility's infection preventionist. Surveyor explained multiple observations of staff inconsistently using goggles when entering droplet precaution rooms and staff not sanitizing the goggles after leaving those rooms. RN E stated everyone should be wearing goggles when entering droplet precaution rooms. RN E stated the multi-use goggles should be sanitized after use. RN E stated they have the surgical masks with the plastic eye protection attached, and they would prefer staff use those over their N95 instead of the multi-use goggles. Surveyor asked RN E what guidance they were following for N95 use in their COVID-19 unit. RN E stated they follow CDC guidance for N95 use. Surveyor asked if it was CDC guidance to wear a surgical mask over the N95 and not change the N95. RN E stated because the unit was a closed dementia unit and they were unable to keep all of the COVID-19 positive residents quarantined in their rooms, they were having the staff keep their N95s on and using a surgical mask over to decrease their risk with removing the N95s multiple times. Surveyor clarified that they were not doing this due to a supply issue and were not specifically following CDC guidance. RN E stated this was correct, they had modified the guidance and have staff wear the surgical masks over the N95 to reduce the frequency of changing the N95s on the outbreak unit. RN E stated all staff should remove the N95 when leaving the unit. Surveyor explained the observations of CNAs removing and putting on clean gloves during morning cares for R64 without performing hand hygiene between glove changes. RN E stated that was not following the facility policy. RN E stated staff should perform hand hygiene after every time they remove contaminated gloves. On 08/27/24 at 2:45 PM, Surveyor observed R47 propel self in wheelchair down the hall from room to sitting area at the end of the 200 hall. R47 was not wearing a mask. Surveyor observed R47 coughing and wiping nose with the back of hand. On 08/28/24 at 8:41 AM, Surveyor observed FSA Q exit the 400 unit with a rolling metal cart with beverages on it. FSA Q removed the surgical face mask they were wearing and put on an N95. FSA Q did not use hand sanitizer before or after doing the mask change. FSA Q carried the surgical mask that had been removed in one hand and pushed the metal cart into the 200 unit. At 8:45 AM, FSA Q exited the 200 unit with the rolling cart. FSA Q was still holding a surgical mask in one hand. FSA Q removed the N95 and placed it on the rolling cart. FSA Q put the surgical mask on that they were holding in one hand. FSA Q took the N95 from the cart and threw it away in the trash. FSA Q pushed the rolling metal cart down the hall. FSA Q did not use hand sanitizer before or after any of the mask changes observed. FSA Q did not wipe the metal cart with a sanitizer wipe placing the used N95 on the cart during mask change. On 08/28/24 at 9:16 AM, Surveyor observed FSA Q exit the 400 unit with a surgical mask on. FSA Q walked to PPE bin outside 200 unit, took out N95 mask and put it on over the surgical mask they were already wearing. FSA Q did not use hand sanitizer. FSA Q entered the 200 unit. At 9:24 AM, FSA Q exited the 200 unit and removed the N95 mask and threw it in the trash. The surgical mask that FSA Q was wearing under the N95 came off at the same time. FSA Q put that same surgical mask back on and then used hand sanitizer. Surveyor asked if FSA Q had received training on PPE use and hand hygiene. FSA Q stated yes they were trained, but it was a long time ago. 43352 Example 2 R25 was admitted to the facility on [DATE] and has diagnoses that include, methicillin-resistant staphylococcus aureus (MRSA), acute respiratory failure, dysphagia, and anxiety disorder. There is a sign on the outside of R25's door that reads contact precautions. The facility's policy titled, Infection Surveillance & Outbreak Prevention, with an updated date of 07/23/24 reads in part, Contact precautions mandatory PPE includes gown and gloves. On 08/28/24 at 12:58 PM, Surveyor observed CNA G come out of R25's room with a lift and was wiping it down with a sanitizing wipe. Surveyor observed CNA G come out of R25's room wearing no PPE. After wiping down lift Surveyor observed CNA G go back into R25's room with only gloves on. CNA G had a sanitizing wipe and was observed wiping down R25's chair remote. CNA G then removed their gloves, picked up some washcloths from R25's room with bare hands, and CNA G pushed the scale chair out of the room along with holding the washcloths. CNA G walked down to the beginning of the hall and into the kitchenette area to get R25 something to drink. CNA G returned to R25's room with a drink, entered the room and did not put on any PPE. CNA G then exited R25's room. Surveyor interviewed CNA G and asked who CNA G used the scale chair for. CNA G indicated for R25. Surveyor asked CNA G if they did anything with the chair before they brought it into the hallway. CNA G indicated they wiped it down. Surveyor then asked CNA G how they know if a resident is on precautions. CNA G indicated there are bins on the outside of the room and during shift report they are updated. Surveyor asked CNA G if they have had any recent training on infection control. CNA G indicated a couple of months ago. Surveyor asked CNA G if they knew the difference between enhanced barrier precautions and contact precautions. CNA G indicated that contact precautions was if you are coming into contact with someone. On 08/28/24 at about 1:11 PM, Surveyor interviewed CNA F and asked how they know if someone was on precautions. CNA F indicated there is a sign on the outside of the door that tells you what kind of precautions. Surveyor asked CNA F if a resident is on contact precautions and you are bringing them a glass of water would you have to put on PPE. CNA F indicated any contact at all they would put on PPE. Surveyor asked CNA F if they have had any recent infection control training. CNA F indicated they get yearly training through Relias and about 2 months ago they went through a CNA boot camp that covered things like infection control, the different types of precautions and what to wear. On 08/28/24 at 3:19 PM, Surveyor interviewed RN E, who is also the infection preventionist and repeated the above observation of CNA G and asked if CNA G used appropriate PPE. RN E indicated no.

Based on observation, interview and record review, the facility did not maintain confidentiality of resident medical record information for 12 of 12 sampled and supplemental residents reviewed. Surveyor observed resident (R79, R142, R83, R33, R45, R54, R15, R20, R73 and R39) dietary information on index cards in plastic upright holders on tables in the [NAME] dining room. The resident information was easily read by the Surveyor when passing by the tables in the dining room. During the three-day survey, Surveyors had three observations of computer screens left open and unattended on medication carts with resident (R) identifiable information visible. (R23, R1.) This is evidenced by: Example 1 Surveyor requested and reviewed the facility policy titled HIPPA Privacy Rule dated December 2019. The policy in part reads: ~Employees only have the right to see and read residents' confidential/health information on a need to know basis in order to perform their duties. ~Medical charts and confidential/health information should not be left unattended or where it is easily readable by unauthorized persons. ~Remember: Confidentiality is everyone's job, share information responsibly, Be aware of your surroundings . On 08/07/23 at 1:13 PM, Surveyor observed lunch in the [NAME] dining room. Surveyor observed R79 and R142 being assisted with their meal. In front of R79 and R142 Surveyor observed a plastic standing tray with an index card. The card could easily be read by the Surveyor while passing R79 and R142's table. The card noted the following information: R79: Name, Room number, Diet: General and beverages of cranberry and black tea for lunch and Dinner. As well as a note dated 8/06/23 with a diet order of 3 day trial pureed. R142: Name, Room number, Diet: General and beverages of water and coffee at lunch and dinner. Surveyor noted there were 8 other ticket holders on tables with resident dietary information, some of which were written in large black letters. Again the information was easily read as Surveyor passed the dining room tables. The information included the following: R83: Name, room number, Diet: General, 2000 cc fluid restriction, skim milk. R33: Name, room number, Diet: Mech soft with grd mt, nectar thick liquids, gravy and sauce, gry weighted utensils, plate guard, covered cups. In large black letters: Take frequent drinks, take small bites. R45: Name, room number, Diet: Mech soft with chopped meat/low k+ (potassium). Avoid foods high in K+ (potassium), beverage choices: water, skim milk and coffee for lunch and dinner large whole sandwich for dinner. R54: Name, room number, Diet: General, lunch: 2 chocolate milk and dinner: 2 chocolate milk and whole sandwich. R15: Name, room number, Diet: LCS (low concentrated sweets), Low K (potassium). Lunch: cranberry juice with low sugar sub and coffee, Dinner: Lettuce salad for dessert, cranberry juice with sugar sub. decaf coffee. R20: Name, room number, Diet: General, plate guard, ice water, covered cups, skim milk. R73: Name, room number, Diet: LCS (low concentrated sweets) 2000 fluid restriction, NSS (non sugar sweetener), Lunch: Large, small dessert, ice water. Dinner: Large whole sandwich, ice water. R39: Name, room number, Diet: Mech soft with grd mt, honey thick liquids. Plate guard. Lunch and Dinner: strawberry kiwi. On 8/07/23 at 1:26 PM, Surveyor noted resident lunch was over, the tables in the [NAME] dining room have been covered with clean tablecloths and tray ticket holders with the same dietary tickets are on the tables. Surveyor observed staff in and out of the dining room collecting dirty linens and cleaning the dining room. On 8/08/23 at 10:17 AM, Surveyor observed Dietary Aide (DA) G setting the same card holders with the dietary cards at the tables with the resident dietary information. Surveyor spoke with DA G about the resident dietary information. DA G indicated she has been on staff almost 5 years and it is part of her daily routine to set tables. Further expressing she generally sets up the dining room, including the resident dietary tickets at 10:15 am for lunch and 2:45 pm for supper. Surveyor asked DA G what information is on the resident dietary tickets. DA G explained the tickets in the upright holders say what kind of diet each resident is on such as pureed, what to drink at each meal and if liquids are thickened, allergies, and adaptive wear needed. All information is resident specific and placed where residents usually sit. The Dietary Manager or Cook fills out tickets. On 08/08/23 at 10:28 AM, Surveyor spoke with the Food Service Director (FSD) H who has been at the facility for [AGE] years. FSD H indicated it has always been the facility process to fill out dietary tickets with resident diet, preferences, resident name, room number and allergies. The cook or manager fills out the cards and the dietary aides may add resident preferences. The dietary tickets are placed in a holder on tables in front of residents when tables are set by the dietary aides. Surveyor asked FSD H if the resident information is private and if the information should be available for others to see. FSD H indicated the information is resident private information and should only be seen by those staff, such as certified nursing assistants, who need to know the information. Surveyor asked if the current process protects resident private health care information. FSD H responded, Probably not. It is the facility policy that resident information should be kept private, only staff who need to know the information should have access. On 8/08/23 at 1:29 PM, Surveyor spoke with Director of Nursing (DON) B about the observation. DON B expressed there was a past issue, before her time when staff were not following diet orders. DON B expressed she understands the diet information should be private but also wants to ensure resident safety with eating. DON B indicated she understands the privacy concern and believes there are ways to inform staff of dietary needs of residents that is more private than the large cards in the stands at the tables. 40181 Example 2 Facility policy entitled, HIPAA Privacy Rule dated December 2019, stated in part: .Medical charts and confidential/health information should not be left unattended where it is easily readable by unauthorized persons . On 08/08/23 at 7:32 AM, Surveyor observed the medication cart on the 400 unit unattended in the hallway. The computer screen was open with R23's Medication Administration Record (MAR) visible to anyone who walked by the cart. At 7:40 AM, Nurse Tech (NT) F returned to the medication cart and began preparing medications to administer to another resident. On 08/08/23 at 8:17 AM, Surveyor interviewed NT F about leaving the medication cart unattended with resident information visible on the computer screen on the cart. NT F stated they usually close the laptop so a resident's MAR was not visible. NT F stated earlier there was a resident trying to get up and NT F rushed to make sure the resident did not fall. NT F stated they accidentally left the MAR visible at that time. On 08/09/23 at 9:55 AM, Surveyor interviewed Director of Nursing (DON) B about observations of medication cart left unattended with MAR screen open and resident information visible. DON B stated that was not acceptable and the nursing staff was taught the computer screen must be closed or minimized so that resident information was not visible when the cart was left unattended. 43352 Example 3 On 08/07/23 at 9:58 AM, Surveyor observed Licensed Practical Nurse (LPN) C go into R1's room and left resident info up on computer screen. Anyone who walked by in the hallway could see R1's medication information. 40590 Example 4 On 08/08/23 at 8:05 AM, Surveyor arrived on memory care unit and observed medication cart sitting in hall by dining area. NT F was observed in the dining area away from the medication cart. Medication cart was unlocked, computer screen was open with resident information exposed and medication cart keys were left sitting on top of it. The resident information on the computer screen was visible to anyone walking past the medication cart. There was a resident who is ambulatory that was sitting in a chair next to where the unlocked medication cart was parked.

Based on observation, interview and record review, staff did not perform hand hygiene when warranted during cares for 3 (R79, R58, R67) of 7 residents observed for cares. Certified Nursing Assistants (CNA) I and J did not perform hand hygiene when warranted during R79's morning cares. CNA D did not perform hand hygiene before putting on gloves to empty a catheter for R67. This is evidenced by: Surveyor requested and received the facility policy titled Standard Precautions with most recent date of 4/26/23. The policy in part reads: Purpose: Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection and are to be used to care for all residents regardless of diagnosis or presumed infection status. Hand Hygiene: Employees must wash their hands for at least 20 seconds .under the following conditions: ~After contact with resident mucous membranes and body fluids or excretions. ~After handling soiled or used linens . ~After removing gloves. Example 1 On 8/08/23 at 8:06 AM, Surveyor observed CNA I and CNA J assist R79 with her morning cares. CNA I and J performed hand hygiene and placed needed supplies on R79's bedside table. CNA I and J donned gloves. CNA I rolled R79 slightly in bed and washed her face. CNA J removed pillows from under R79's legs and obtained a clean brief from cabinet in R79's room. CNA J lowered R79's gown and washed and dried under R79's arms. CNA I removed her gloves and donned clean gloves. CNA J removed his gloves, went into the bathroom, performed hand hygiene and obtained bags. CNA I applied lotion to R79's arms. CNA I removed her gloves and donned clean gloves. CNA I did not perform hand hygiene. CNA I obtained the clean brief from the bedside table as CNA J checked R79's brief for incontinence. CNA J removed R79's brief and informed Surveyor the brief was a little wet. CNA J performed perineal care, rolled R79 in bed and removed his gloves. CNA J donned clean gloves without first performing hand hygiene. CNA J rolled R79 in bed and washed and dried R79's backside. CNA J again removed his gloves and donned clean gloves without performing hand hygiene. CNA J applied barrier cream to R79's backside. CNA J rolled R79 in bed and applied R79's clean brief and clean gown. Both CNA I and J removed their gloves and assisted with positioning R79 with pillows in bed. CNA J and I performed hand hygiene. Following the observation, Surveyor spoke with CNA I and J about hand hygiene with glove change and when going from a dirty task to a clean task. CNA I and J expressed hand hygiene should be done to prevent the spread of germs and for infection control. On 8/08/23 at 1:32 PM, Surveyor spoke with Director of Nursing (DON) B about the observation. DON B expressed she would expect staff to doff gloves, perform hand hygiene and don clean gloves when going from dirty to clean task during resident cares. 43352 Example 2 On 08/08/23 at 1:28 PM, Surveyor observed CNA D empty R67's catheter. CNA D put on gloves; no hand hygiene was performed. CNA D put a barrier down on the floor, opened catheter port, drained urine in a graduate, wiped port with alcohol swab, closed catheter port, measured urine, dumped in toilet, got water from clean graduate, rinsed out dirty one, then removed gloves. CNA D washed hands with soap and water. Surveyor asked CNA D what do you do before you put on gloves. CNA D said, Sanitize my hands. I forgot to do that. 46694 Example 3 CNA Q and CNA E did not perform hand hygiene before putting on gloves to provide cares to R58. CNA Q touched her own hair without hand hygiene after providing toileting cares to R58. On 08/08/23 at 8:44 AM, Surveyor observed CNA Q enter R58's room and put on gloves without using Alcohol Based Hand Rub (ABHR). R58 was taken to bathroom via E-Z stand lift. R58's clothes were removed to shower. During shower, CNA Q washed R58's buttocks with a new washcloth and then went to wash residents' hair without hand hygiene and new gloves. R58 was observed as taken back to her bathroom; the lift was used to put R58 on the toilet. R58 told CNA Q that she was not sitting right on the toilet. CNA E entered the room. CNA Q asked CNA E for assistance to help put R58 on the toilet right. CNA E put on gloves without using ABHR. Resident was lifted and lowered back on the toilet right. CNA Q removed gloves, used ABHR and left room.

Based on interview and record review, the facility did not ensure each residents' drug regimen was free of unnecessary medications for 1 (R23) of 3 sampled residents reviewed for unnecessary medications related to monitoring of prophylactic antibiotic use. R23 has been on a prophylactic antibiotic for an excessive duration without adequate assessments/monitoring for continued use. This is evidenced by: R23 was admitted to the facility on [DATE] and has diagnoses that include, in part: Alzheimer's disease, dementia and history of recurrent urinary tract infections (UTI). On 08/08/23, at 10:00 AM, Surveyor reviewed R23's Electronic Health Record (EHR). Review of EHR shows R23 has a physician's order for cephalexin capsule 250 mg with instructions to give 250 mg (1 capsule) daily for prophylaxis related to prevention of UTI with start date of 05/27/21. Review of nurses' notes in EHR shows that facility nurses are not documenting or monitoring R23's ordered antibiotic. Review of care plan for R23 shows that there is no care plan for the implementation, monitoring or evaluation of R23's prophylactic antibiotic. Review of infection control line list shows that R23 is not on the facility's line list for surveillance and/or antibiotic stewardship. On 08/08/23 at 11:50 AM, Surveyor requested supporting documentation for the prolonged use of R23's prophylactic antibiotic. On 08/08/23 at 2:19 PM, Surveyor interviewed Director of Nursing (DON) B about the prophylactic antibiotic use. DON B stated that their previous infection preventionist, who left employment 4 weeks ago, had removed resident from the infection control line list and it is unknown why. DON B states that they usually do a checklist for prophylactic antibiotics so that it does not get missed on the line list, care plan and documentation for monitoring. DON B states that R23 is not on the line list and does not have a care plan for the prophylactic antibiotic. DON B states that there is no supporting documentation for the monitoring of the effectiveness or appropriateness of the antibiotic.

Based on observation and interview, the facility did not ensure all drugs and biologicals were stored in locked compartments and did not ensure only authorized personnel had access to the keys. This occurred for 1 of 6 medication carts observed. During the three-day survey, observations were made of medication carts left unlocked with the keys on top of the cart when unattended and out of view of staff. One observation was made of resident medications left on top of the medication cart when the cart was unattended and out of view of staff. Findings include: Example 1 On 08/08/23 at 7:32 AM, Surveyor observed a medication cart on the 400 unit unattended in the hallway. The cart was unlocked, and the nurse keys were on top of the cart. There was a tube of Diclofenac gel and a bottle of refresh artificial tears labeled with a resident's name sitting on top of the unattended cart. At 7:40 AM, Surveyor observed Nurse Tech (NT) F return to the medication cart and place the medications back in a drawer on the cart. NT F began preparing medications for another resident. On 08/08/23 at 8:17 AM, Surveyor interviewed NT F about leaving the medication cart unlocked with keys and resident medications on top when the cart was left unattended. NT F stated they usually place all medications in the drawers, lock the cart and take the keys with them when leaving the cart unattended. NT F stated earlier there was a resident trying to get up and NT F rushed to make sure the resident did not fall. NT F stated they accidentally left the medication cart unlocked with medications and keys on top at that time. On 08/09/23 at 9:55 AM, Surveyor interviewed Director of Nursing (DON) B about observations of the medication carts left unlocked with resident medications and nurse's keys on top when the cart was left unattended in resident care areas. DON B stated that was not acceptable. DON B stated the staff was taught they should always lock the cart when leaving it and never leave medications or keys on the cart when the cart was unattended. DON B stated they did not think they had a policy and procedure that stated this, but it was standard nursing practice to lock medication carts when unattended. 40590 Example 2 On 08/08/23 at 8:05 AM, Surveyor arrived on memory care unit and observed medication cart sitting in hall by dining area. NT F was observed in the dining area away from the medication cart. Medication cart was unlocked and medication cart keys were left sitting on top of it. Medications were not secured in a locked compartment, when NT F walked away.

Based on observation and interview the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has a potential to affect all 100 (R) residents who reside in the facility. Surveyor observed 4 expired half gallons of buttermilk during initial tour of kitchen. Surveyor observed a cart of uncovered leftovers in the walk-in freezer. Surveyor observed a tray of 10 ice cream dishes uncovered. Surveyor observed 4 trays of applesauce dishes uncovered. Surveyor observed 2 pans of leftovers incorrectly dated. Surveyor observed a garbage container that was full and uncovered. Surveyor observed staff serving dessert dishes by placing their thumbs inside of the dishes with no gloves on and plate guards being attached to plates with bare hands with no hand hygiene. Surveyor observed 6 expired mighty shakes in the freezer on the 400-unit. Surveyor observed freezer door shelves dirty and with crumbs. Surveyor observed undated opened gallons of fat free milk, whole milk, low fat chocolate milk, and half and half cream in the refrigerator on the 400-unit. Surveyor observed 3 expired boxes of cranberry juice in the refrigerator on the 400-unit. Surveyor observed in the refrigerator on the 200-unit undated opened gallons of whole milk and low-fat chocolate milk and a box of cranberry juice expired. Surveyor observed under the microwave glass plate built up rust on the 200 unit. Surveyor observed on the [NAME] Servery undated opened gallons of fat free milk and whole milk. This is evidenced by: The facility policy, entitled Food Storage, dated 2017, states, in part: Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and by methods designed to prevent contamination or cross contamination. Procedure: .7) .c. Food should be dated as it is placed on the shelves if required by state regulation .13) Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 7 days or discarded as per the 2013 Federal Food Code . 14) Refrigerated food storage: .f. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. g. All foods should be stored to allow air circulation .15) Frozen Foods: a. All freezer units will be kept clean and in good working condition at all times .c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe dates or discarded . The facility policy, entitled, Food Safety and Sanitation, dated 2017, states, in part: Policy: All local, state, and federal standards and regulations will be followed to assure a safe and sanitary department of food and nutrition services. Procedures: .d. Employees will wash their hands just before they start to work in the kitchen and .touching .surfaces or items with potential for contamination .4) Food Storage .a. Stored foods is handled to prevent contamination and growth of pathogenic organisms .Food is protected from contamination (dust .) .All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered, and dated when stored . The facility policy, entitled, Food Safety- Director of Food and Nutrition Services, dated 2017, states, in part: . Responsibility .3. Proper waste disposal methods will be used .5. Employees will follow sanitary practices and good personal hygiene at all times . The facility policy, entitled, Employee Sanitary Practices, dated 2017, states, in part: . 10. a. Have clean hands .c. Pick dishes up by their rims . The facility policy, entitled, Hand Washing, dated 2017, states, in part: Policy: Employees will wash their hands as frequently as needed throughout the day using proper hand washing procedures .Procedure: Clean hands and exposed portions of arms (or surrogate prosthetic devices) immediately before engaging in food preparation .j. After engaging in other activities that . The facility policy, entitled, Waste Disposal, dated 2017, states, in part: Policy: Garbage will be disposed of and as needed throughout the day and at the end of each day. Procedure: 1. Prior to disposal, all waste shall be kept in a leak-proof, non-absorbent, fireproof container that are kept covered when not in use . On [DATE], at 11:30 AM, Surveyor did walk through in the kitchen with CS (Cook/Supervisor) E. Surveyor observed 3 unopened half gallons of cultured buttermilk with expiration dates of [DATE] and 1 opened half gallon of cultured buttermilk with an expiration date of [DATE]. CS E indicated all 4 buttermilks were expired and set them aside. On [DATE], at 11:30 AM, during kitchen walk through with CS E, Surveyor observed a metal cart with uncovered leftovers of 17 burgers, a small pan of jojo fries and a pan of mashed potatoes set in the freezer just inside door. Surveyor asked CS E if the leftovers should be covered, and CS E indicated they cool food per Serv Safe. On [DATE], at 11:30 AM, during kitchen walk through with CS E, Surveyor observed an uncovered tray of 10 ice cream dishes in the freezer by the tray line. Surveyor asked CS E if the tray should be covered, and CS E indicated yes. On [DATE], at 11:30 AM, during kitchen walk through with CS E, Surveyor observed 5 trays which consisted of 35 applesauce dishes with saran wrap covering the top tray and then draped down the front of all five trays in the refrigerator by the tray line. Surveyor asked CS E if all five trays should be covered, and CS E indicated no since the saran wrap was draped down the front of the trays. On [DATE], at 11:30 AM, during kitchen walk through with CS E, Surveyor observed in the walk-in refrigerator 2 pans of leftovers. One pan consisted of turkey and gravy labeled with a date of [DATE]. The second pan consisted of mashed potatoes and boiled potatoes with a date of [DATE]. CS E indicated leftovers are marked with the date they are put in the refrigerator and are good for 5 days. CS E indicated the date marked must have been done in error. On [DATE], at 11:30 AM, during kitchen walk through with CS E, Surveyor observed an uncovered small garbage container that was full sitting under the counter at the end of the three-compartment sink. Surveyor observed a large mixer and small mixer on a table close to garbage where splatter from garbage could contaminate. On [DATE], at 07:45 AM, Surveyor observed 2 strawberry mighty shakes with use by dates of [DATE], 4 vanilla mighty shakes with use by dates of [DATE], and the five door shelves in the 400-unit freezer with a dried brown substance and crumbs on. Surveyor asked CS D if the mighty shakes were expired, and CS D indicated yes and disposed them in the garbage. Surveyor asked CS D if the five shelves on the freezer door were clean, and CS D indicated they were dirty and needed to be cleaned. Surveyor observed in the 400-unit refrigerator an opened gallon of fat free milk with no open date, an opened gallon of whole milk with no open date, and an opened gallon of low-fat chocolate milk with no open date. Surveyor observed a Half and Half opened with no open date and 3 boxes of cranberry juice with expiration dates of [DATE] and [DATE]. Surveyor asked CS D if the three boxes of cranberry juice was expired and CS D indicated yes, all three boxes were expired. Surveyor asked CS D how one would know if the milks were expired, and CS D indicated when the milks are opened they are to be dated to expire 7 days out from opening. CS D indicated the milks were not dated so should be considered expired. On [DATE], at 08:00 AM, Surveyor observed in the 200-unit refrigerator an opened gallon of whole milk and an opened gallon low-fat chocolate milk that had no open dates. Surveyor observed a box of cranberry juice with an expiration date of [DATE]. Surveyor asked LPN (Licensed Practical Nurse) H if the cranberry juice was expired, and LPN H indicated yes. Surveyor asked LPN H when does the whole milk and low-fat chocolate milk expire and LPN H indicated LPN H was not sure but would find out. LPN H came back and indicated if there is no open date the expiration date would be the best by date on the jugs otherwise 7 days from opening the milk. Surveyor asked LPN H when the 2 gallons of milk expire and LPN H indicated she would go by the best by date. Surveyor asked LPN H who was responsible for dating the milk once opened. LPN H indicated dietary stamps the date on the milks but if nursing opens the milk nursing puts the open date on it. On [DATE], at 08:15 AM, Surveyor observed an opened gallon of fat free milk and an opened gallon of whole milk with no open dates in the refrigerator in the [NAME] Servery. Surveyor asked DA F ( Dietary Aide) what the expiration dates are for the whole milk and fat free milk. DA F indicated 7 days from today because DA F just opened them that morning. Surveyor asked DA F how one would know when it expires by looking at the undated milks and DA F indicated DA F is supposed to date them when opened but DA F had not that morning. On [DATE], at 10:31 AM, Surveyor observed CS D put her ungloved right hand in her pants pocket and retrieve a black marker and then used the marker to cross off an item on her list, then put the marker back into pants pocket. Surveyor observed CS D continue to serve food by grabbing plates and putting plate guards on and grabbing dessert dishes with thumb inside of dishes. Surveyor observed DA (Dietary Aide) F moving food carts around then grabbing dessert dishes with thumbs inside the dishes with no gloves on. Surveyor observed no hand hygiene being performed by CS D or DA F. On [DATE], at 09:08 AM, Surveyor interviewed DM (Dietary Manager) C. Surveyor asked DM C asked who is responsible for dating the milks on the units when opened and DM C indicated nursing should be dating the milks when opening. Surveyor informed DM C of undated opened milks on the units and asked if the milks would be considered expired. DM C said the milks would be considered expired with no dates marked when opened. Surveyor informed DM C of expired mighty shakes, cranberry juices, half and half and milks. DM C indicated she would be sure they were removed off the units and disposed of. Surveyor informed DM C of the freezer with a dried brown substance and crumbs on the five door shelves and DM C indicated yes they are considered dirty. DM C indicated there is a sign on each refrigerator on the units to wipe out spills. DM C indicated the expectation is nursing and dietary use a team effort and work together on cleanliness of units. Surveyor informed DM C of the 4 expired buttermilks in refrigerator observed on walk through. DM C indicated the expired milks should have been caught and pulled since deliveries come every Tuesday and Thursday. DM C indicated the expired buttermilks should not have been on the shelf in circulation. Surveyor informed DM C of the 5 trays of applesauce dishes with the top tray covered with saran wrap and the other four having the saran wrap draped down the front of the trays. DM C indicated each tray should have been covered. Surveyor informed DM C of the tray of ice cream dishes in the freezer and DM C indicated the tray should be covered. Surveyor asked DM C what the expectation of handling dishes with food is on the tray line without gloves. DM C indicated staff should be grabbing dishes underneath, otherwise gloves should be on if unable to handle from underneath the dish. Surveyor informed DM C of the 2 pans of leftovers with date of [DATE] and DM C indicated leftovers should have the date they were put in the refrigerator not [DATE] since it is only [DATE]. Surveyor asked DM C if cooling food in the freezer should be covered, and DM C indicated they follow Serv Safe. Surveyor asked DM C with the cart being right inside the door could dust or contaminated particles spread onto leftovers. DM C indicated yes, being that close to door with traffic going in and out of freezer. Surveyor informed DM C of the uncovered garbage container under the three compartment sink that was full and the rust under the microwaves glass plate on the 200 unit.

Based on interview and record review, the facility did not ensure that every resident was treated with dignity and respect when providing activities of daily living for 3 of 6 residents (R1, R3, R6) reviewed. Staff report CNA E (Certified Nursing Assistant) holding R1's baby doll by the hand or the feet and tossing/throwing R1's baby doll across the room. R1 believes this baby doll is alive and real. Staff report R3 being angry and CNA E holding her hands towards R3 in fists asking him if he wants to fight and laughing at his reaction. Staff report CNA E startled R6 by hiding behind chairs and jumping out while making loud noises on more than one occasion and laughing at R3's reaction. Staff report CNA E using foul language in front of residents, using her personal cellphone during work hours, and being rude, in a hurry, and rough while assisting residents on the facility's dementia unit. This is evidenced by: Facility policy, entitled Personal Telephone Calls, Cellular Phones, and Other Electronic Devices, undated, includes, in part: Cellular phones and other electronic devices are not allowed in resident areas without prior approval by your supervisor . No photos, videos, or audio recordings may be taken in work areas except for authorized work purposes and only when directed by administration. Unless an employee has been approved to carry a cell phone or other device in resident areas by the administration of (the facility), they must be kept out of resident areas. Cell phones and devices may be kept in your locker or car, or other supervisor approved areas. If an employee wishes to use his/her personal call phone or other electronic device during break or lunchtime, that is allowable, but must not be done in a resident area. Personal phone calls can be made or received during work breaks only and may not be made in resident areas. Emergency phone calls may be received at the facility number, and you will be contacted and informed of the call . Example 1 R1 was admitted to the facility on [DATE] with diagnoses, including Alzheimer's disease and Vascular dementia without behavior disturbance. Her most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 1/10/22 indicates R1 is rarely/never understood and sometimes understands others. On 2/28/22, HR Director I (Human Resource Director) wrote the following statement after LPN H (Licensed Practical Nurse) came into her office to report some concerns, statement includes, in part: LPN H arrived at my door requesting to shut the door. Writer invited her in. LPN H proceeded to share . CNA E's behavior on the unit is horrible . R1 carries a look alike baby, and she believes it is a real baby. She reports CNA E thinks it is funny to pick up the baby and throw it in the air and let it drop. LPN H gave an impression of R1's startled and worried response. LPN H reports CNA E then laughs in R1's face. LPN H states that she has told CNA E to stop many times . On 3/22/22 at 2:56 PM during an interview, HR Director I indicated she took a concern down from LPN H and reported it to NHA A (Nursing Home Administrator) and DON B (Director of Nursing) on 2/28/22. HR Director I indicated LPN H came into her office on 2/28/22 with concerns regarding CNA E and the way she treats staff and residents. These concerns included: CNA E throwing R1's baby doll up in the air and letting it drop on the floor, CNA E running behind residents and scaring them on purpose because it is funny, CNA E having conversations of getting pregnant/being drunk/abortions while providing resident care, CNA E using the f word in front of and at residents, and CNA E not following the care plan. Facility's Investigation, started 2/28/22, includes the following interviews, in part: LPN H: CNA E is not fit to work with dementia residents . CNA E throwing R1's baby doll up in the air and letting it drop on the floor . NT C (Nurse Tech): I have seen CNA E toss R1's baby into a recliner but never chuck it at the ground . RN D (Registered Nurse): I've seen (CNA E) take R1's doll by the hand or foot, yes this startled R1 . On 3/22/22 at 10:30 AM during an interview, CNA E indicated she used to work with R1 until LPN H made a complaint against her. CNA E indicated R1 usually has a baby doll or a stuffed animal on her lap and she thinks the baby is a real baby at times. CNA E indicated she has picked the baby up by the foot, hand/arm, and has tossed the baby across the room into an easy chair. CNA E indicated there was one-time R1 was upset with her when she took R1's baby from her and tossed it towards an easy chair to get ready for dinner. CNA E demonstrated the reaction of R1 when the baby was tossed by letting out a loud distressed sigh and throwing her hands in the air. Surveyor asked CNA E if she had dementia training and CNA E indicated she has and considers herself to be one of the better ones in the home. On 3/22/22 at 11:00 AM, Surveyor observed R1 sitting in her wheelchair holding a stuffed animal. R1 was smiling and interacting with her stuffed animal. People passing commented on the animal being cute and R1 responded with a smile and moved the animal to view it and talk to it. On 3/22/22 at 11:25 AM during an interview, SSA L (Social Services Assist) indicated R1 used to work as a Registered Nurse and now whenever SSA L sees R1 she is holding a baby doll or a stuffed animal. SSA L indicated R1 thinks her baby is real. On 3/22/22 at 11:30 AM during an interview, DON B indicated R1 loves her doll and thinks that it is a real baby. On 3/22/22 at 11:40 AM during an interview, SW K (Social Worker) stated, (R1) normally has her doll or a stuffed animal on her lap. That's her baby doll. She thinks it is real. On 3/22/22 at 11:45 AM during an interview, CNA F indicated R1 usually carries a doll or a stuffed animal with her. CNA F indicated she has witnessed CNA E toss R1's doll but not intentionally to upset R1 but because she was getting it out of the way so R1 could eat. CNA F indicated this upset R1. On 3/22/22 at 2:02 PM during an interview, CNA G indicated R1 always has a doll or a stuffed animal on her lap. CNA G also indicated CNA E does not hold R1's baby like a real baby and this makes R1 upset and worried. On 3/22/22 at 2:27 PM during an interview, LPN H indicated CNA E upsets residents on purpose and gets amusement out of the resident's reactions in distress or anger. LPN H indicated on 2/18/22 R1 was holding a baby doll in the multipurpose room which she believes is her real baby. CNA E snatched the baby out of R1's grip without a warning and threw it in the air and the baby landed on the floor. CNA E then faced R1 and laughed in her face. LPN H indicated this incident caused R1 to panic. R1 gasped, reached her arms out, and said aloud, Oh God. On 3/22/22 at 2:56 PM during an interview, HR Director I indicated she took a concern down from LPN H and reported it to NHA A and DON B on 2/28/22. HR Director indicated LPN H came into her office on 2/28/22 with concerns regarding CNA E and the way she treats staff and residents. These concerns included: CNA E throwing R1's baby doll up in the air and letting it drop on the floor, CNA E running behind residents and scaring them on purpose because it is funny, CNA E having conversations of getting pregnant/being drunk/abortions while providing resident care, CNA E using the f word in front of and at residents, and CNA E not following the care plan. On 3/22/22 at 3:44 PM during an interview, DON B indicated the facility investigated this incident and did not think it was a malicious act. DON B indicated holding R1's doll by the foot or hand or throwing or tossing R1's baby doll is not treating R1 with respect and/or dignity. Example 2 R2 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . His most recent MDS with ARD of 1/17/22 indicates R2's cognition is mildly impaired with a BIMS (Brief Interview for Mental Status) score of 10 out of 15. On 2/28/22, HR Director I received a written statement from CNA G. This statement included, in part: (CNA E's) antics with residents has brought up their anxiety levels on more than one occasion. Asking an angry resident if they want to fight while putting up her fists and moving around them to the point of agitation for the resident. On 3/22/22 at 2:02 PM during an interview, CNA G indicated CNA E is immature and is not a good fit for the dementia care unit. CNA G indicated CNA E yanks residents by the arms without notice and rushes them causing confusion, anger, and distress. CNA G has witnessed CNA E put her fists up and stand in a fighting stance while saying to R2, Come on. Do you want to fight? CNA G indicated this caused R2 to continue being agitated. On 3/22/22 at 2:27 PM during an interview, LPN H indicated CNA E antagonizes residents on purpose, especially R2 and then laughs at his reaction. LPN H indicated she has witnessed CNA E ask R2 if he wants to fight while he is already upset. LPN H indicated CNA E thinks she is funny, and this just makes R2 more upset and confused. On 3/22/22 at 5:30 PM during an interview, DON B indicated CNA E holding two fists up and asking R2 if he wants to fight when he is already angry is not treating R2 with dignity and respect. Example 3 R6 was admitted to the facility on [DATE] with diagnoses, including dementia, peripheral vascular disease, bilateral sensorineural hearing loss, myalgia, [CONDITION(S)], left lower quadrant pain, pain, and weakness. On 2/28/22, HR Director wrote the following statement after LPN H came into her office to report some concerns, statement includes, in part: . LPN H arrived at my door requesting to shut the door. Writer invited her in. LPN H proceeded to share . CNA E's behavior on the unit is horrible . She runs behind residents and scares them. LPN H feels this is purposeful, that she thinks it is funny. Facility's Investigation, started 2/28/22, includes the following interviews, in part: LPN H: . CNA E running behind residents and scaring them on purpose because it is funny . CNA E having conversations of getting pregnant/being drunk/abortions while providing resident care, CNA E using the f word in front of and at residents, and CNA E not following the care plan. CNA G: . (CNA E's) antics with residents has brought up their anxiety levels on more than one occasion. Sneaking up on residents whom she knows are sensitive to noise and sudden movements and giving them a jolt by jumping up and making loud noise and then laughing at the resident's reaction as if it is funny. Playful is one thing. Disruptive is another. On 3/22/22 at 2:02 PM during an interview, CNA G indicated CNA E is immature and is not a good fit for the dementia care unit. CNA G indicated she has witnessed CNA G hide behind chairs and jump out at R6. CNA G stated R6 is audio sensitive and CNA E knows this. CNA G stated, (CNA E) startles (R6) on purpose and laughs at her reactions. I believe in dignity too. These residents deserve to be treated with dignity. On 3/22/22 at 2:27 PM during an interview, LPN H indicated she has witnessed CNA E jump out and make loud noises to startle R6. LPN H indicated she has reported her concerns to management with no follow up. LPN H indicated R6 looks to be in distress when CNA E startles her and CNA E can be seen laughing and mocking R6. On 3/22/22 at 5:30 PM during an interview, DON B indicated CNA E hiding behind chairs and jumping out while making louds sounds is not treating R6 with dignity and respect. Example 4 Facility's Investigation, started 2/28/22, includes the following interviews, in part: CNA E: When I was forced to work alone, I had to do a 2 assist (transfer) by myself . (R1) has gotten upset with me tossing the baby into the chair while I was unaware, she was watching . I understand I need to watch what I say, language wise RN D: Sometimes she will sit in the recliners or residents' wheelchairs and put her feet up by the residents near the windows in the recliners. They (residents) seem offended at first but laugh it off. I just tell her to knock it off and so do the residents . I do think her louder nature, swearing, and mannerisms get some of the people worked up. They do seem calmer when she isn't working down there . CNA G: How I am treated can be addressed by me, however when it comes to the residents, this is where I draw the line . CNA E has done a 2-assist resident by herself . foul language is abundant . I'm not going to get f-ing (resident name). She's getting on my f-ing nerves. Then arguing with nurse after making that comment quite loud with residents around and continuing to f-bomb . NT C: I have heard CNA E swear in conversations with staff around residents, but I have never heard her swear directly at a resident . RN J: As a nurse working with CNA E, I have noticed . talking about a resident having a large incontinent bowel movement within family's earshot . She does have her (personal) phone out at times . On 3/22/22 at 11:45 AM during an interview, CNA F indicated she has observed CNA F swear in front of the residents and be on her personal phone while working with residents on the unit. On 3/22/22 at 2:02 PM during an interview, CNA G indicated CNA E is immature and is not a good fit for the dementia care unit. CNA G indicated CNA E is immature and is not a good fit for the dementia care unit. CNA G indicated CNA E yanks residents by the arms without notice and rushes them causing confusion, anger, and distress. CNA G indicated CNA E is constantly on her cell phone in the presence of residents and discusses what bars she has been to and is going to be at later in the night. CNA G stated, I believe in dignity too. These residents deserve to be treated with dignity. On 3/22/22 at 2:27 PM during an interview, LPN H indicated CNA E swears in front of residents, sneaks up on them or hides on them and jumps out to startle them, laughs at them in distress, is rude to them, and is on her phone while working with residents. On 3/22/22 at 5:30 PM during an interview, DON B indicated CNA E swearing at or in front of residents is not treating them with dignity and respect. DON B indicated CNA E using her personal cellphone for personal conversations and social media is not treating residents with dignity and respect. DON B indicated CNA E moving a resident's body without notice is not treating them with dignity and respect. DON B indicated discussing residents dying or having bowel movements in front of other residents is not treating residents with dignity and respect. DON B indicated it is her expectation that all staff treat all residents residing in the home with dignity and respect. On 3/3/22, the facility provided CNA E with the following education however did not provide education to other staff education included: Personal cellphone use: Cell phones and devices may be kept in your locker or car, or other supervisor approved areas. If an employee desires to use his/her personal cell phone or other electronic devices during break or lunchtime, that is allowable, but not in resident areas. Unless an employee was approved to carry a cellphone or other device in resident areas by the administration . they must be kept out of resident areas . Professionalism: make a good first impression .avoid gossip . communication is key . understand your work environment . be personable yet professional . Things to remember when coming to the workplace: Swearing, cursing, or cussing whatever you call it has no place in most workplaces. Refrain from using foul language, particularly if those who you might offend are present. Don't be a grump . Don't gossip . Try to stay positive . CNA E was provided Dementia education including Positive Physical Approach: Approach from in front of/ahead of them . slowly respectfully . Positive approach gets a positive response . call them by the name they prefer . make sure they see you before touching them . Dos and Don'ts: No one wants to hug a cactus . For fabulous communication Do: soften up, be kind, be gentle, reassure your partner, be empathetic and compassionate, try to see other person's perspective, point out what you hear your spouse saying . Say I understand why you feel that way . take responsibility when you can, focus 1 issue at a time, try to find a solution . ask for what you need to feel better, take breaks and stop when you feel like you are losing self-control .

Based on interview and record review, the facility did not ensure a resident who has cognitive impairment or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (R1) reviewed for behavioral interventions. R1 has cognitive impairment with aggressive behaviors, R1 was held down by nursing staff when he became agitated. At the time of the incident the facility did not ensure R1's plan of care included resident centered care plan approaches and interventions when R1 displayed behaviors. The facility did not assure facility staff were given the behavioral and dementia training necessary to prevent future restrictive interventions from being deployed. Findings include R1 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His most recent MDS (Minimum Data Set), dated 7/19/21, shows a BIMS (Brief Interview for Mental Status) score of 6, indicating R1 is severely cognitively impaired. On 8/22/21, a facility nurse reported that CNA C (Certified Nursing Assistant) had noted before leaving the building from her shift at approximately 2:00 AM she had held the hands of R1 during an episode of agitation. Facility administration conducted an investigation, interviewed residents and staff, and monitored R1 for any lingering distress. According to CNA C's statement, R1 woke up at 11:45 PM (8/21/21) and began making sexual comments. The staff got R1 up in his wheelchair and a short time later he became agitated, began hallucinating and continued making sexual comments. At one point, CNA C moved R1 to the nurse's station and noticed R1 trying to stand up. CNA C's statement read: It is at this point that R1's safety became a danger .I asked R1 to please hold my hands. I was trying to divert his attention and prevent him from trying to stand. He agreed to this request .at this time I decided the safest option for both him and I was to wait patiently for another person to come and to hold his hands with no force so that I could prevent him from standing and/or falling but also prevent the possibility of him touching me inappropriately. The resident asked me to let go and I refused out of safety concerns. I explained to him I would let go as soon as the person who was on her way arrived. As one can imagine, this agitated R1 furthermore and he began to kick my shins, squeeze my hands, spit in my face, and make uncomfortable eye contact. No other staff observed CNA holding R1's hands. On 9/22/21 at 11:55 PM, Surveyor interviewed CNA C via phone. CNA C confirmed her statement and described how she was holding down R1's hands. CNA C stated she had brought R1 to the nurse's station in his wheelchair and locked the wheels so he could not move. She stood to the side of the wheelchair and held R1's hands down on his lap so he could not lift them and could not get up. CNA C could not elaborate how long she did this but was trying to prevent R1 from falling. On 9/22/21 at 12:20 PM, Surveyor interviewed SW D (Social Worker). SW D, who provided dementia and behavioral training to staff twice per month. SW D stated she had provided a 1 to 1 training with CNA C after the 8/22/21 incident. SW D stated she has never and will never teach staff to put hands on residents or restrain them in any way, including locking their wheelchairs as this can agitate residents even more and can create more of a fall risk to residents. SW D stated she had provided training to some other staff on R1's care plan, interventions for his sexual comments as well as interventions for his physical aggressiveness, but not specifically for touching residents or restraining them by holding them down or locking wheelchairs. The facility provided additional education to 15 nursing staff. The facility employs 126 nursing staff. When asked why only 15 staff had been given training on behavioral interventions for residents with dementia-like behaviors, SW D stated those 15 staff work on R1's hall. When asked if there were residents on other wings in the facility with compromised cognition or that display dementia-like behaviors, SW D stated those types of behaviors and severely cognitively impaired residents were located in all areas of the nursing facility. The facility was aware a R1, a resident with dementia-like behaviors, had been held down and restrained by nursing staff. R1's care plan at the time of incident did not include resident centered approaches and interventions when R1 displayed these behaviors. The facility did not assure facility staff were given the behavioral and dementia training necessary to prevent future restrictive interventions from being deployed.

Based on record review and staff interview, the facility did not ensure the environment for 1 (Resident 1) of 3 sampled residents was free of accident hazards (created by receiving liquids that were the wrong consistency) and received supervision to prevent a choking accident. Resident (R) 1 had difficulty swallowing and had a physician order for nectar-thick liquid consistency in attempt to prevent aspiration (breathing foreign objects such as food into the airway when swallowing). R1 had been seen by Speech Therapy (ST) who also recommended R1 have supervision with meal intake. R1 was given orange juice that was not thickened with breakfast and was then left unsupervised. R1 was overheard coughing and when staff entered the room, R1 had consumed approximately 90 cubic centimeters (cc's) of 180 cc orange juice that was not thickened and also was observed to have had an emesis of a yellow substance. R1 rapidly declined in condition, the physician was notified and supplemental oxygen and an antibiotic was ordered. R1 continued to decline in condition and expired at the facility the same evening at approximately 10:25 PM. The facility's failure to ensure R1 received the approprite diet and supervision during meals created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. The DON B (Director of Nursing) was informed of the IJ finding on [DATE] at 12:00 PM. On [DATE], the facility recognized the deficient practice by the facility nursing staff and took steps to correct the deficient practice and ensure compliance at the time of the complaint survey. Based upon this determination, the IJ was removed and corrected on [DATE]. Findings include: According to the electronic Facesheet, R1 was admitted to the facility with diagnoses of Alzheimer's Disease and Respiratory Failure with [CONDITION(S)] (absence of enough oxygen in the tissues to sustain bodily function). The ST -Therapist progress and Discharge Summary dated [DATE] indicated R1 was seen by ST from [DATE] through [DATE] related to functional deficits in expressive language, auditory comprehension and swallowing. The discharge summary indicated ST discharge plans and instructions were R1 would continue diet of mechanical soft textures with ground meat and nectar-thick liquid with supervision during meals. The facility updated the plan of care on [DATE] for Nutritional Status. The following approach was listed in the plan of care: ~ Per Speech Language Pathologist (SLP)- Nectar thick liquids due to increased coughing with thin liquids and weak cough reflex. The Progress Notes dated [DATE] documented at 2:44 PM, by a Registered Nurse Aspiration: During breakfast the kitchen sent down his tray with one cup of thin liquid orange juice. The Certified Nursing Assistant (CNA) did not notice this and set him up to eat in his room. I came into his room after I heard him coughing and noticed he had a small amount of yellow emesis (vomiting). I saw he had 1 cup of thin liquids about half gone. I took the cup and breakfast away at first. I had a CNA clean him up and I took a set of vitals: Blood Pressure (BP): ,d+[DATE], Pulse (P): 115 regular, Respirations (R): 24, Temperature (T): 97.7 degrees and Oxygen saturation was 94%. Lung sounds were clear bilaterally and his rhythm was regular. He was responsive and had no complaints of pain. Charge nurse was notified. During lunch time he was given a couple bites of food and was pocketing them. He showed no signs of wanting to eat and was less responsive. Around 12:30 PM, he was not responding as much and began having periods of apnea (temporary cessation of breathing). A full set of vitals were taken. BP ,d+[DATE], T 97.5 degrees, P 105, R 28 and oxygen saturations varied between 85% - 92% depending on his respirations. Charge nurse was notified. The Progress Notes dated [DATE] documented at 3:01 PM indicated the physician was notified due to possible aspiration, emesis and subsequent status decline. This nurse and physician updated the Power of Attorney for Healthcare (POA-HC) to the situation. No plans for hospitalization at this time and to continue comfort focused care. Antibiotics and supplemental oxygen therapy ordered. The Progress Notes dated [DATE] edited at 7:51 PM due to more data available, indicated Coughing Episode: Heard resident coughing harshly. Upon entering the room, resident continued to cough harshly. He was able to talk in between coughing. No debris noted in mouth and oral cavity was moist. Nothing noted at the back of the throat. Lung sounds clear .Resident continued to cough and this did slow and then coughing stopped. Vitals at the time of coughing was BP ,d+[DATE], P 114, R 24, T 98.7 degrees and oxygen saturation was 96% on room air. As he slowed in his coughing his R (respirations) were 20 and oxygen saturations were 96% and pulse was 98. Resident is sitting in his broda chair watching a fishing show on TV. No coughing noted. Call placed to on call physician at 7:10 PM in regards to coughing, nothing noted in oral cavity or throat and no redness noted. Updated to original vitals, recheck and another recheck No new orders. The Progress Notes dated [DATE] documented at 11:15 PM. Status of PM Shift: Was given report and was told by charge nurse the on call physician had ordered oxygen for R1. This was started at 2:22 PM. A full set of vitals taken at that time. BP ,d+[DATE], P 118, R 40, T 97.8 degrees and oxygen saturation was 93%. R1 was unresponsive, would occasionally open his eyes but did not focus. Family arrived at the facility at 2:00 PM and stayed with R1 until 5:00 PM. R1 was not given any food, drink or his regular oral medications as he was not awake to swallow. Was called to his room at 3:50 PM, as he had another emesis when being rolled during cares. He was given his first [MEDICATION(S)] at 6:39 PM, vitals at that time were normal. Checked at 8:44 PM, his respirations had increased to 42 and shallow, breathing through his mouth, was not getting benefits of oxygen by nasal cannula. Oxygen saturations were 58%. Asked charge nurse what parameters were on the oxygen order, written up to 2 liters. Given doses of [MEDICATION(S)] and [MEDICATION(S)] at 9:00 PM Checked at 10:00 PM, without fever, P 81, oxygen saturations was 78% on 2 liters of oxygen, R 36. He stopped breathing and was pronounced deceased at 10:25 PM. As CNAs were performing postmortem cares, he had a rather large emesis of fluid, bile colored with brown streaks. On [DATE] at 8:25 AM, the Surveyor conducted a telephone interview with Dietary Aide (DA) A. DA A verified she was the staff person that prepared R1's breakfast tray on [DATE]. DA A indicated she would have had to place the thickened juice for R1 on another resident's tray and placed the non-thickened juice on R1's breakfast tray. On [DATE] at 9:15 AM, the Surveyor interviewed CNA B. CNA B verified she was the staff person that delivered the tray to R1 on [DATE]. CNA B stated the breakfast tray came down to the unit and CNA B was aware that R1 required supervision with meals. CNA B indicated she had started to assist R1 when she heard a call light turn on and she went to the doorway to see whose light was on. CNA B stated it was a resident that was on 15 minute checks and was frequently trying to self transfer that morning. She could not see any staff in the area and did not wish the resident to fall, so CNA B responded to the call light and left R1 unsupervised. CNA B indicated she was away from R1 for approximately 15 minutes when the RN came in by her and stated he needed to see her when she was finished with the resident. CNA B stated when she reported to the RN, she was told that R1 had consumed non thickened orange juice and had an emesis and probably aspirated. CNA B indicated she had never noticed the consistency of the orange juice on R1's tray. The facility's failure to ensure R1 received the appropriate diet and staff supervision during meals created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. DON B (Director of Nursing) was informed of the IJ finding on [DATE] at 12:00 PM. On [DATE], the facility recognized the deficient practice by the facility nursing staff and took steps to correct the deficient practice and ensure compliance at the time of the complaint survey. Based upon this determination, the IJ was removed and corrected on [DATE] as evidenced below. The faciity developed a performance improvement plan and root cause analysis. The facility met with residents to assess if any they had any concerns regarding meals or staff, and no concerns were identified. Nursing and dietary staff began an audit review of all resident care plans, CNA care plans, diet cards and the dietary sheets to ensure all matched. The facility updated the breakfast menu slips with color coding to make it easier for staff to identify diet types. An education program was initiated to ensure staff were aware of the new process and to ensre the understanding of the expectations and process for residents who are receiving thickened liquids. Education videos were implemented with the requirement of completing a post test. The [MEDICATION(S)] Maneuver training was completed. Speech Therapist provided training regarding swallowing and dysphagia (difficulty in swallowing) along with mixing thickened liquids. Audits are being completed to ensure compliance. On [DATE], the Surveyor reviewed the facility's documentation regarding the incident. After the incident occured, the faciity developed a performance improvement plan and root cause analysis. The facility also met with residents to assess if any they had any concerns regarding meals or staff, and no concerns were identified. Nursing and dietary staff began an audit review of all resident care plans, CNA care plans, diet cards and the dietary sheets to ensure all matched. The facility creasted some new processes for completing breakfast slips so there is a double check system in place. The facility updated the breakfast menu slips with color coding to make it easier for staff to identify diet types. An education program was initiated to ensure staff were aware of the new process and to ensre the understanding of the expectations and process for residents who are receiving thickened liquids. Education videos were implemented with the requirement of completing a post test. The [MEDICATION(S)] Maneuver training was completed and the Speech Therapist provided training regarding swallowing and dysphagia (difficulty in swallowing) along with mixing thickened liquids. The facility also were completing audits to ensure compliance. On [DATE] at 11:45 AM, the Surveyor interviewed Director of Nursing (DON) C. DON C verified the above interventions, and indicated the new meal ticket and red flag processes were implemented for all meals. DON C provided documentation regarding training. On [DATE] at 8:25 AM, the Surveyor conducted a telephone interview with Dietary Aide (DA) A. DA A verified the facility had changed meal processes and developed a color coded ticket that is placed on meal trays that state which diet is ordered, to include the kind of thickened liquids, and specifically for the breakfast meal, the type of food that was ordered as residents indicate what they would like for breakfast. DA A stated dietary staff needs to review each meal tray before leaving the kitchen and sign the ticket that the tray was reviewed for the proper therapeutic diet. DA A indicated there is also a place on the meal ticket that nursing has to sign before delivering the tray to the resident that they also reviewed the meal tray for proper diet. On [DATE] at 9:15 AM, the Surveyor interviewed CNA B. CNA B stated the facility has changed processes for meals and reiterated the color coded meal tickets and that staff that delivered trays also had to sign the ticket indicating the tray was reviewed and the diet was correct. CNA B indicated the signed tickets are kept at the nurses station and someone else reviews the tickets to ensure the new process is being followed. CNA B stated the facility also implemented a red flag system that is on a meal ticket which signifies that the resident requires supervision and the tray can not be delivered unless a qualified staff person is present and assisting the resident. CNA B indicated audits were completed daily by the charge nurse to ensure therapeutic diets were given to residents as ordered. On [DATE], a sample of residents during 2 meals were observed and the residents received the proper therapeutic diet along with thickened liquids.

Based on observation, interview, and record review, the facility did not sanitize and store items used to prepare and serve food in accordance with professional standards for food service safety, which has the potential to affect 102 of 102 residents residing in the facility. The following were observed during the survey: - Water temperatures of the facility's high temperature dishwasher's final rinse cycle exceeded safe levels, reducing its ability to provide sufficient sanitization to surfaces - Open refrigerated items were not properly labeled in the main kitchen and kitchenettes throughout the facility - Dented food cans were observed being stored in dry food storage This is evidenced by: The facility policy titled, Cleaning Dishes/Dish Machine, from 2017 Becky Dorner & Associates Policy and Procedure Manual states, All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. It also states, Note: Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation. Thermal strips may be used as verification that the temperature is adequately hot, but cannot verify actual temperatures. The facility policy titled, Dish Machine Temperature Log, also from 2017 Becky Dorner & Associates Policy and Procedure Manual states, Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Within the procedure, it indicates the following: 1. Staff will monitor dish machine temperatures throughout the dishwashing process. 2. Staff will record dish machine temperatures for the wash and rinse cycles at each meal. a. The director of food and nutrition services will spot check this log to assure temperatures are appropriate and staff is correctly monitoring dish machine temperatures. 3. Staff will be trained to report any problem with the dish machine to the director of food and nutrition services as soon as they occur. 4. The director of food and nutrition services will promptly assess any dish machine problems and take action immediately to assure proper sanitation of dishes. According to the 2017 Food and Drug Administration (FDA) Food Code, a nationally recognized professional standard of practice for food safety, when the sanitizing rinse temperature exceeds 194 degrees Fahrenheit, the water becomes volatile and begins to vaporize, reducing its ability to provide sufficient sanitization to utensil surfaces. On [DATE], at 9:37 AM, Surveyor observed Dietary Aide/Cook Assistant E and Dietary Aide/Cook Assistant F with the dishwashing process. Surveyor observed outside gauge of dishwashing machine temperatures and final rinse gauge increase to 201 degrees Fahrenheit. At 9:39 AM, Surveyor spoke with Dietary Aide/Cook Assistant F and observed process of running an internal thermal strip through the dish machine. Surveyor asked Dietary Aide/Cook Assistant F if she was aware of what the final rinse temperature reading had been running during this time, and she stated, It always gets to 190 or over, but indicated the cooks were the ones who kept track of temperatures. On [DATE], at 10:01 AM, Supervisor spoke to Cook Supervisor D regarding the temperature recording of the dishwasher and made observation of the [DATE] temperature log. Cook Supervisor D indicated that she hadn't written the reading for the morning check down yet today, but that she usually records the two readings she takes (breakfast and noon meal dishwashing) after lunch. Surveyor and Cook Supervisor D observed two dishwashing cycles together and the final rinse time for each read 199 on the gauge. Surveyor asked Cook Supervisor D about the temperature reading above 194 and she replied, I know there is a way to turn it down. Surveyor asked what her plan to do was now, knowing the rinse temperature is noted to be higher than 194, and she stated, I will put in a maintenance slip. Surveyor observed the facility's Hot Water Mechanical Dish Machine Monitoring Chart log and noted all wash cycle temperatures for [DATE] for all meals recorded as 160 and all rinse water temperatures for all meals recorded as 190 (69 recordings of each at the time). On [DATE], at 1:17 PM, Surveyor observed dishwashing cycle with Dietary Aide/Cook Assistant F, who confirmed with Surveyor a final rinse cycle temperature reading of 203. Surveyor spoke with Director of Food Service C who indicated she and maintenance were made aware of the dishwasher rinse cycle temperatures being too high. Surveyor asked Director of Food Service C if the dishwasher should have been used again for the lunch meal, knowing the temperature of the final rinse was running too hot during breakfast dishes, and she indicated she didn't know what the staff was thinking. Surveyor asked Director of Food Service C when she personally found out the final rinse of the dishwasher was running too hot, and she stated, I think I found out around 11:30, after the lunch tray line. Director of Food Service C stated Cook Supervisor D put in a maintenance slip. On [DATE], at 1:36 PM, Surveyor spoke with Maintenance Director G, who stated he was informed of the dishwasher final rinse running too hot this morning sometime after breakfast. Director of Food Service C informed Maintenance Director G that it needed to run under 194 degrees on the final rinse and it needed to be ready by supper, and if she needed to call the company that services the machine, she would. On [DATE], at 1:51 PM, Surveyor asked Director of Food Service C about the facility's dish supply/inventory and what the facility did as a back up to using the dishwasher. Director of Food Service C indicated that the facility does use the same dishes at each meal and although they do not use many larger dinner plates at breakfast, there would have been several items such as juice cups, small plates, and utensils that were used for both breakfast and lunch today. Director of Food Service C also indicated the facility has a cold/chemical wash process they can switch to, as well as about four days or so worth of disposable items. Director of Food Service C indicated the facility could run dishes through the chemical wash system or use disposable items for tonight's meal and the dishwashing machine was being worked on at this time. On [DATE], at 2:03 PM, Director of Food Service C provided Surveyor with requested copies of the Hot Water Mechanical Dish Machine Monitoring Chart. Surveyor asked if the facility did any routine maintenance on the dishwasher. Director of Food Service C indicated she didn't believe so, but that the company that services the dishwasher is here often enough for various things they are usually checking it when they are at the facility. The facility routinely does a weekly thorough cleaning and de-lime, along with a daily cleaning/hose down of the machine and check of the catch bin. Surveyor requested documentation of the last time the dishwasher was serviced by the company they use, and Director of Food Service C provided a service report dated [DATE], which notes, Adc-66 dishwasher was not temping on the gauge in front. I check the wash tank temperature gauge and it wasn't working. I changed out the old gauge with a new won (sic) and now reading 160 degrees for the wash tank. The machine is working fine. On [DATE], at 3:34 PM, Surveyor spoke with Director of Food Service C and asked if the cold/chemical wash system should have been initiated as soon as the dishwasher temps were observed by kitchen staff and reported to maintenance and herself as the supervisor. Director of Food Service C stated, Well, if you look at the temp log, you wouldn't know it was out of range. Surveyor agreed and stated, True, but (Cook Supervisor D) and I observed the temperature at 10:01 AM to be 199 and she charted that the temperature at 10:15 AM was 190. Do you know why she recorded it to be 190 and not 199? Director of Food Service C stated, I don't. I know she was frazzled today and had a lot to do. We did redo all the dishes. Director of Food Service C acknowledged the facility policies were not followed as written. On [DATE], at 7:43 AM, Surveyor spoke with Cook Supervisor D regarding the observations made together the previous day. Surveyor asked Cook Supervisor D why the Hot Water Mechanical Dish Machine Monitoring Chart temperature recording was documented as a rinse temperature of 190 degrees at 10:15 when our observation at 10:01 AM was a temperature of 199 degrees. Cook Supervisor D indicated she had a temporary mental lapse. Surveyor asked Cook Supervisor D if her routine was to monitor dishwasher temperatures throughout the cycle or just at one time. Cook Supervisor D stated, I check it twice - once in the morning and once later in the shift when they are doing the lunch dishes. Cook Supervisor D verified again that she only checks temperatures twice during her entire shift, but indicated she supposed someone else could glance at it as they walk by. Surveyor also noted on the Hot Water Mechanical Dish Machine Monitoring Chart, the lunch time temperature for the previous day was covered with white-out and 198 written in place, as well as a note under the corrective action that (the servicing company) came to fix. On [DATE], at 9:47 AM, Surveyor observed Cook Supervisor D run three cycles of the dishwasher, all with final rinse temperatures ranging from ,[DATE] degrees Fahrenheit. Surveyor observed a newly placed bright green sign above the dishwasher regarding what the dishwashing temperatures should be and to update the cook or Director of Food Service C if out of range. On [DATE], at approximately 2:35 PM, NHA A indicated he did not understand why the kitchen staff failed to immediately switch over to the cold water/chemical wash system when the dishwasher rinse cycle was found to be out of range and that he would have expected them to do so. Example 2 The facility policy titled, Labeling/Dating Food/Beverage Items in Coolers, Servery and Kitchenettes, dated [DATE] states, It is the policy of (the facility) to ensure all food & beverage is safe for resident consumption. The policy reads, in part . 1. Kitchen coolers: Cooks will manually date all food and beverage items in the kitchen coolers that do not have a manufacturer expiration date stamped on the item, with the exception of fresh fruit & veggies. 2. Cooks will be responsible for discarding all expired food & beverage from the kitchen coolers according to manufacturer's dates. 3. Any food or beverage in coolers dated by dietary will be discarded within 5 days . According to the 2017 FDA Food Code, refrigerated, ready to eat (RTE), Time/Temperature Controlled for Safety (TCS) food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of seven days. The day of preparation shall be counted as Day 1. Refrigerated, RTE/TCS food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed or discarded. If the manufacturer's use-by date is based on food safety, it may not be offered in a retail establishment beyond that date. If RTE, PHF (Potentially Hazardous Food)/TCS foods are frozen after preparation or opening, only the time stored under refrigeration will be counted as part of the 7 total days until consumed, sold, or discarded. On [DATE], at 10:33 AM, Surveyor made initial observations of the kitchen along with Cook Supervisor D. Surveyor observed an opened gallon jug of whole milk in what the facility refers to as the reach in cooler with no open date indicated anywhere. Surveyor asked Cook Supervisor D what the facility policy was on opened milk and she stated, We just go by the use by date. This particular gallon of whole milk stamped manufacturer's date read [DATE]. Surveyor also observed two open containers of half and half on the shelf without any indication of when they were opened. One half and half container did not have a printed manufacturer's date printed anywhere on it, while the other was printed with a date of [DATE] near the top of the carton. On [DATE], at 10:53 AM, Surveyor spoke with Director of Food Service C regarding opened containers of milk and half and half in the reach in cooler. Director of Food Service C stated they go by the printed use by date. Surveyor and Director of Food Service C observed the open containers of half and half and Director of Food Service C could not locate a use by date on one either, stating, I'll ask if that was opened today, but I've never seen a non-dated carton like that before. It probably should have been noticed and pulled prior to opening and using. On [DATE], at 9:06 AM, Surveyor observed the [DATE] unit refrigerator which contained open containers of 8 thickened juices, a half-gallon of lactose free milk, one container of chocolate milk, and one gallon of white milk all with non-expired manufacture dates, but no opened dates or date to indicate when to discard product after being opened for seven days were noted. On [DATE], at 10:08 AM, Surveyor observed 200 unit refrigerator and found the following items with no indication of an open or discard by date, but not expired manufacture dates: One gallon of whole milk, one half-gallon of chocolate milk, one half-gallon of half and half, one container of Med Pass. On [DATE], at 10:19 AM, Surveyor observed 400 unit refrigerator and found the following items with no indication of an open or discard by date, but not expired manufacture dates: Two gallons of white milk, one half-gallon of chocolate milk, one Fiber Basics juice. On [DATE], at 10:28, Surveyor observed Dorset Lounge refrigerator adjacent to the 600 unit and nurses station and found the following items with no indication of an open or discard by date, but not expired manufacture dates: One gallon of white milk, one half gallon of chocolate milk, five thickened liquid juice containers. On [DATE], at 10:19 AM, Surveyor spoke with CNA I (Certified Nursing Assistant) regarding opened items in the 400 unit refrigerator. CNA I stated, The kitchen (staff) checks the fridge each morning, we (staff working on the 400 unit) make out a supply list each morning and then they come down and check it out, too. On [DATE], at 1:32 PM, Surveyor spoke with Director of Food Service C to ask how the facility knows that milk or other items that have a stamped manufacturer's date is still good if they don't have a date marked to indicate when they have been opened or when they should be discarded. Director of Food Service C said the facility's policy is that, anything without a manufacture date should have a date put on it by whoever opens it, but anything with a manufacture date, we use until it is gone or discard it by the expiration date. On [DATE], at approximately 2:35 PM, Surveyor discussed with NHA A observations of opened refrigerated items and no facility process for knowing how long they have been open. Surveyor reviewed the 2017 FDA Food Code guidance that indicates once opened, RTE/PHF/TCS foods must be used or discarded after seven total days. NHA A voiced understanding that by only using a manufacturer's date, items could reach the seven total open days before the manufacturer's date, at which point they should be discarded. Example 3 The facility policy titled, Accepting Food Deliveries, from 2017 Becky Dorner & Associates Policy and Procedure Manual states the policy is that, Food deliveries will be accepted into the facility on ly by the following procedure, in part, . 2. d. Do not allow delivery people to inventory and restock items without supervision. 3. Staff will refuse to accept delivery of any foods not safe for consumption. An additional handwritten note dated [DATE] with Director of Food Service's initials is written in following this step, which reads, All dented cans noticed upon delivery will be returned immediately. All dented cans noticed after delivery will be set aside and returned for a refund/credit. On [DATE], at 10:47 AM during the initial observation of the kitchen, Surveyor observed dry storage room with Director of Food Service C. Surveyor observed two dented blueberry pie filling cans and one lemon pie filling can sitting on shelves with non-dented items. Director of Food Service C stated these would have been delivered on Friday ([DATE]) and should have been pulled by whomever put away the delivery. On follow up trips to the kitchen, six additional dented cans were observed on the return counter, along with the initial three pie fillings.

The facility did not establish and maintain an infection prevention and control program, conduct an annual review of its IPCP (Infection Prevention and Control Program) or update their infection control program for 4 (R23, R20, R67 and R75) of 25 sampled residents and 6 (R300, R35, R301, R39, R22 and R11) of 10 supplemental residents. The facility is not utilizing their SOP (Standard of Practice), McGeer Criteria to identify if signs and symptoms meet criteria of infection for (R23, R20, R67, R300, R35, R301, R39, R22 and R11). R75 was admitted with a urinary tract infection R75 and receiving antibiotic therapy. R75 was not listed on the line list as a community acquired infection. The facility line lists did not include organisms or colony counts. The facility has four Policies and Procedures that have not been reviewed annually. This is evidenced by: The Facility's Infection Control Surveillance Policy and Procedure, dated 11/13/19 documents, in part: .The data collected is used to monitor trends in infections and pathogens, including detecting outbreaks .The Facility used the McGeer surveillance tool to track infection events .Procedure: Outcome Measures .2. All staff will recognize and intervene when classic and non-specific signs and symptoms of infection are present .9. The infection control nurse is responsible for systematically collecting, analyzing, interpreting, and disseminating the data . Infection Control data was reviewed from December 2020 through March 23, 2021. In December, 4 of 11 infections (R23, R300, R20 and R35) did not include proper signs and symptoms indicating the residents meet infection control criteria according to, the facility's SOP, McGeer criteria. In January, there were 2 of 15 infections (R301 and R67) did not have signs and symptoms indicating an infection according to McGeer criteria. In February, 1 of 10 infections (R39) did not have signs and symptoms indicating an infection according to McGeer criteria and 1 resident's infection (R75) was not included on the line list at all. In March, there were 2 of 8 infections (R22 and R11) did not have signs and symptoms indicating an infection according to McGeer criteria. For the 10 of 44 total infections reviewed during this time frame, the Facility did follow their SOP, McGeer criteria, to determine if signs and symptoms meet infection control criteria. This lead to inaccurate data and surveillance of infections. The Facility's line list from December 2020 through March 23, 2021 did not include organism(s) or colony count(s). The Facility's four policies that had not been reviewed annually were: Pneumococcal dated 2/16, Influenza dated 5/13, Legionnaire's dated 2/20 and Infection Control Surveillance dated 11/13/19. On 3/23/21 at 9:51 AM, Surveyor interviewed RN/ICP H (Registered Nurse/Infection Control Preventionist) and DON B (Director of Nursing). Surveyor asked RN/ICP H what SOP the Facility uses for infection surveillance, DON B replied McGeer's. Surveyor asked RN/ICP H how he determines if an infection meets McGeer's criteria, RN/ICP H stated I know what McGeer's is but I haven't really had training on it. Surveyor asked RN/ICP H how often the Infection Control Policies and Procedures are reviewed, RN/ICP H said at least yearly. Surveyor asked RN/ICP H if there would be documentation other than the date on the Policy/Procedure of review date, DON B said no, most everything has been COVID this past year, so we may have missed a few. Surveyor asked RN/ICP H how the Facility ensures new admissions who come in on antibiotics are receiving the correct antibiotic if their lab or diagnostic test results are pending yet or not included, RN/ICP H said we try to get them. Surveyor asked RN/ICP H who is responsible to obtain the results and review them, RN/ICP H stated I am. Surveyor asked DON B if there was anything to add in relation to infection control, DON B stated with COVID, we lost sight of a few areas but we will get back on top of this.

The Facility did not establish an infection prevention and control program (IPCP) that must include an antibiotic stewardship program including antibiotic use protocols and a system to monitor antibiotic use for 4 of 25 sampled residents (R23, R20, R67 and R75) and 10 supplemental residents (R300, R35, R301, R39, R22, R11, R4, R302, R94 and R54). R23, R300, R20, R35, R301, R67, R39, R22, R11 and R4 did not meet McGeer's criteria according to the S/Sx (signs and symptoms) listed on the line list. R75 was admitted with an UTI. R75 was not included on the line list at all upon admission and UA (urinalysis) C/S (culture and sensitivity) was not in medical record. R4 and R54's C/S did not exceed 100,000 colonies, which does not meet McGeer's Criteria to treat as an infection. R302's UA was negative, indicating there was no infection present in urine. R94 did not have a C/S completed, which does not meet McGeer's Criteria to treat as an infection. This is evidenced by: The Facility's Antibiotic Stewardship Policy and Procedure dated 2/24/21, documents in part: .Procedure: 1) Whenever clinically indicated, use of the McGeer Criteria will be utilized to assist in the determination need for antimicrobial usage and surveillance .4) Reassessment of empiric antibiotics after 2-3 days for appropriateness and necessity, factoring in results of diagnostic tests, laboratory reports and/or changes in the clinical status of the resident .Develop and maintain a system to monitor antibiotic use, which includes reviewing antibiotics prescribed to residents upon their admission or transfer to the facility . McGeer Criteria for Long Term Care Surveillance Definitions for Infections Updated 2012, documents the following in part: . Urinary Tract Infections (UTI's): For Urinary Tract Infections without a catheter the new definitions differ substantially from the original guidelines. The definitions take into account the low probability of UTI in residents without catheters if symptoms are not present as well as they now take into account the need for a urine culture for microbiologic confirmation .New Criteria for UTI without a Catheter: (Both criteria 1 and 2 must be present), Criteria 1- At least one of the following sign or symptom criteria: a. Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate; b. Fever or leukocytosis (See Constitutional Criteria Table) and at least one of the following localizing urinary tract subcriteria: i. Acute costovertebral angle pain or tenderness, ii. Suprapubic pain, iii. Gross hematuria, iv. New or marked increase in incontinence, v. New or marked increase in urgency, vi. New or marked increase in frequency; c. In the absence of fever or leukocystosis, then 2 or more of the following subcriteria: i. Suprapubic pain, ii. Gross hematuria, iii. New or marked increase in incontinence, iv. New or marked increase in urgency, v. New or marked increase in frequency; Criteria 2- a. At least 105 cfu/mL (colony-forming unit per milliliter) of, no more than 2 species of microorganisms in a voided urine sample, b. At least 102 cfu/mL of any number of organisms in a specimen collected by in-and-out catheter .UTI in resident WITH catheter (if symptoms begin within 48 hours after discontinuing a catheter, count it as related to catheter), Both criteria must be present: At least 1 of the following subcriteria: Fever, rigors, or new-onset [MEDICAL CONDITION], with no alternate site of infection; Either acute change in mental status or acute functional decline, with no alternate site of infection; New-onset suprapubic pain or costovertebral angle pain or tenderness; Purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate AND Must have: Urinary catheter specimen culture with at least 105 cfu/mL of any organism(s) . [MEDICAL CONDITION]/soft tissue/wound: At least 1 criteria must be present: Pus present at a wound, skin, or soft tissue site; New or increasing presence of at least 4 of the following subcriteria: Heat at the affected site, Redness at the affected site, Swelling at the affected site, Tenderness of pain at the affected site, Serous drainage at the affected site; One (1) Constitutional Criteria .Table 2: Definitions for Constitutional Criteria in Residents of Long-Term Care Facilities (LTCFs): Fever- 1. Single oral temperature >100°F OR 2. Repeated oral temperatures >99°F OR 3. Single temperature >2°F over baseline from any site (oral, tympanic, axillary); Leukocytosis- 1. [DIAGNOSES REDACTED]ia (>14,000 leukocytes/mm3) (millimeter) OR 2. Left shift (>6% bands or =1,500 bands/mm3); Acute change in mental status from baseline- All criteria must be present: 1. Acute onset (Evidence of acute change in resident's mental status from baseline), 2. Fluctuating course (Behavior fluctuating: e.g., coming and going or changing in severity during the assessment), 3. Inattention (Resident has difficulty focusing attention: e.g., unable to keep track of discussion or easily distracted), 4. Either disorganized thinking or altered level of consciousness a. Disorganized thinking (Resident's thinking is incoherent: e.g., rambling conversation, unclear flow of ideas, unpredictable switches in subject) OR b. Altered level of consciousness (Resident's level of consciousness is described as different from baseline: e.g., hyper-alert, sleepy, drowsy, difficult to arouse, non-responsive); Acute functional decline- 1. A new 3-point increase in total activities of daily living (ADL) score (range, 0-28) from baseline, based on the following 7 ADL items, each scored from 0 (independent) to 4 (total dependence), Bed mobility, Transfer, Locomotion within LTCF, Dressing, Toilet use, Personal hygiene, Eating. In the month of December 2020, the following 5 residents had the following concerns: R23 had the following S/Sx listed on the line list pain, burning, foul odor, cloudy urine. This does not meet McGeer's Criteria for UTI but R23 was treated with [MEDICATION NAME]. R300 had the following S/Sx listed on the line list weakness, burning. This does not meet McGeer's Criteria for UTI but R300 was treated with [MEDICATION NAME]. R20 had the following S/Sx listed on the line list hematuria. This does not meet McGeer's Criteria for UTI but R20 was treated with [MEDICATION NAME]. R35 had the following S/Sx listed on the line list frequency, confusion. This does not meet McGeer's Criteria for UTI but R35 was treated with Bactrim DS. R4 had the following S/Sx listed on the line list increased incontinence, frequency, urgency and R4's UA C/S only grew out 10,000-49,000 cfu/ml Escherichia coli. This does not meet McGeer's Criteria for UTI but R4 was treated with [MEDICATION NAME]. There was no evidence that the facility followed up with the Physician regarding UA C/S results. In the month of January 2021, the following 4 residents had the following concerns: R301 had the following S/Sx listed on the line list redness, pain, inflammation. This does not meet McGeer's Criteria for Skin/Wound but R301 was treated with [MEDICATION NAME]. R67 had no S/Sx listed on the line list. This does not meet McGeer's Criteria for Skin/Wound R67 was treated with an antibiotic. R302's UA was negative indicating there was no infection present in her urine. This does not meet McGeer's Criteria for UTI, but she was treated with SXT-TMP. There was no evidence that the facility followed up with the Physician regarding UA results. R94 had no UA C/S completed. This does not meet McGeer's Criteria for UTI but R94 was treated with [MEDICATION NAME]. In the month of February 2021, the following 2 residents had the following concerns: R39 had the following S/Sx listed on the line list confusion. This does not meet McGeer's Criteria for UTI but R39 was treated with [MEDICATION NAME]. R75 was not on the line list at all, R75 admitted on [DATE] on [MEDICATION NAME] for UTI, and there was no evidence that the facility had R75's UA C/S prior to Surveyor requesting it. In the month of March 2021, the following 3 residents had the following concerns: R22 had the following S/Sx listed on the line list increased confusion. This does not meet McGeer's Criteria for UTI but R22 was treated with SXT-TMP which was later changed to [MEDICATION NAME] based off of the UA C/S. R54 had the following S/Sx listed on the line list urgency and frequency and R54's UA C/S only grew out 50,000-99,000 Escherichia coli. This does not meet McGeer's Criteria for UTI but R54 was treated with [MEDICATION NAME]. There was no evidence that the facility followed up with the Physician regarding UA C/S results. R11 had the following S/Sx listed on the line list inflammation. This does not meet the McGeer's Criteria for Skin/Wound but R11 was treated with [MEDICATION NAME]. On 3/23/21 at 9:51 AM, Surveyor interviewed RN/ICP H (Registered Nurse/Infection Control Preventionist) and DON B (Director of Nursing). Surveyor asked RN/ICP H what SOP the Facility uses for infection surveillance, DON B replied McGeer's. Surveyor asked RN/ICP H how he determines if an infection meets McGeer's criteria, RN/ICP H stated I know what McGeer's is but I haven't really had training on it. Surveyor asked RN/ICP H how the Facility ensures that new admissions who come in on antibiotics are receiving the correct antibiotic if their lab or diagnostic test results are pending yet or not included, RN/ICP H said we try to get them. Surveyor asked RN/ICP H whose responsibility is it to obtain the results and review them, RN/ICP H stated mine. Surveyor asked RN/ICP H if a UA is negative, what should occur; RN/ICP H said the Physician should be called to stop antibiotic if already started. Surveyor asked RN/ICP H if the UA C/S comes back and the colony count is less than 100,000, what should occur; RN/ICP H stated I need to be better versed in the McGeer's Criteria, but I'd say call the Physician. Surveyor asked DON B if there was anything to add in relation to infection control, DON B stated with COVID, we lost sight of a few areas but we will get back on top of this. These 14 residents did not meet McGeer's Criteria of an infection but were treated with antibiotics anyway. Unnecessarily being treated with antibiotics could lead to development of antibiotic-resistant organisms. The intent of Antibiotic Stewardship is to develop and implement protocols to optimize the treatment of [REDACTED].

Based on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance to prevent avoidable accidents for 1 of 5 sampled residents (R1). R1 was to receive a pureed diet (foods that are blended until smooth and drinkable) and was to be supervised while eating. CNA C (Certified Nursing Assistant) provided R1 a breakfast sandwich that was not pureed and did not stay with R1 to supervise him while he was eating, resulting in R1 choking on the breakfast sandwich and expiring as a result. The facility's failure to follow diet orders and supervise a resident per the resident's plan of care created a finding of Immediate Jeopardy (IJ) that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the IJ on [DATE] at 2:12 PM. The IJ was removed on [DATE] and corrected on [DATE]. This is being cited as past noncompliance. This is evidenced by: According to http://www.emedicinehealth.com/choking/article_em.htm, Choking is a blockage of the upper airway by food or other objects, which prevents a person from breathing effectively. Choking can cause a simple coughing fit, but complete blockage of the airway may lead to death. Choking is a true medical emergency that requires fast, appropriate action by anyone available. Emergency medical teams may not arrive in time to save a choking person's life. .When someone is choking with a completely blocked airway, no oxygen can enter the lungs. The brain is extremely sensitive to this lack of oxygen and begins to die within four to six minutes. It is during this time that first aid must take place. Irreversible brain death occurs in as little as 10 minutes. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's Admission MDS (Minimum Data Set), dated [DATE], indicates R1's BIMS (Brief Interview of Mental Status) is 11 out of 15, which indicates R1 has moderate cognitive impairment. Section K indicates R1 does not have a swallowing disorder and weighs 244 pounds. R1's Quarterly MDS, dated [DATE], indicates the following: R1's BIMS was not assessed. Section G indicates that R1 needs one person physical assist and supervision with eating. Section K indicates that R1 was on a mechanically altered diet (requires change in texture of food or liquids such as pureed food, thickened liquids). Section K also indicates R1 does not have any swallowing disorders and weighs 235 pounds. R1's Nutritional Status Care Plan, edited on [DATE], states, in part: [DATE] Remind (R1) of safe swallow guidelines per SLP (Speech language Pathologist) as written in orders and remind (R1) to slow down, take more drinks and swallow food before taking more bitesXXX[DATE] I am able to eat independently but need supervision/cues to slow down in the dining room d/t (due to) aspiration precautionsXXX[DATE] Therapy Order: Patient has been downgraded to pureed textures d/t high choking risk and unsafe swallowing behaviors despite verbal cues . R1's Physician Orders, signed on [DATE], states, in part: [DATE] - open ended - Diet: Pureed textures. Special instructions: easy to chew, thin liquids. [DATE] - open ended - Feeding precautions: patient alert, positioned fully upright for all oral intake, staff to supervise meals. Assist w/ (with) feeding PRN (as needed), Liquids: single sips ok from edge of cup or straw, Food: ,[DATE] spoon/fork-fuls, alternate intake of food and fluids, Medications whole w/ water or puree. Discontinue oral intake if concern for aspiration arises. Three times a day . R1's Speech Therapy Daily Treatment Note, dated [DATE], indicates: Patient seen in dining room. Patient was alert and pleasant. Dietary staff member provided patient with verbal instructions to eat meal slowly, as it was very hot. SLP (Speech Language Pathologist) also provided patient instructions to eat slowly, take small bites, and take drinks after every ,[DATE] bites. Patient did not listen to education and continued to eat at a very fast pace. SLP asked patient if he wants to upgrade diet. Patient reported no, he wants to continue with pureed textures. At this time, SLP does not feel patient would be safe upgrading diet as he has not demonstrated ability to improve swallow safety, even with mechanical soft trial. (R1) would be at higher choking risk if he was upgraded. R1's Speech Therapy Daily Treatment Note, dated [DATE], indicates: Patient in dining room. Patient was alert and pleasant. SLP recommends patient continue on current diet of pureed textures and thin liquid as he was not able to apply what he had learned from ST (Speech Therapy) and improve safe swallow behaviors with or without cues. R1's Walking Care Plan, on [DATE], states, in part: Pureed/Aspiration Precautions. (Aspiration Precaution), under Positioning Equipment, R1 is indicated in capital letters as Pureed Diet. Under the section PT (Physical Therapy) /OT (Occupational Therapy)/Speech orders, R1 is indicated as in upright position, position for all oral intake with extended supervision as tolerated. Miscellaneous section indicates Aspiration precautions: supervise meals per ST, must be in an upright position . On [DATE] at 10:24 AM, Surveyor interviewed CNA C via phone regarding an incident involving R1 on [DATE]. CNA C indicated that R1 slept in that day and was gotten up around 9 AM. CNA C indicated they had stopped serving breakfast already, so he asked R1 what he wanted for breakfast. CNA C indicated that R1 replied that he wanted a breakfast sandwich; therefore, CNA C went to get a breakfast sandwich for R1. CNA C indicated he did not check the care plan prior and gave R1 the breakfast sandwich in his room. CNA C indicated he left R1 unattended in his room for approximately 5 to 6 minutes and when he came back, R1 was slumped over and drooling. CNA C indicated he tried to get a response from R1 and did assist the nurses with the [MEDICATION NAME]. CNA C indicated that breakfast is continental breakfast and whatever is left is placed into the fridge. CNA C indicated the breakfast sandwich was taken from the fridge and heated up, then taken down to R1. CNA C indicated that he received education from DON B. CNA C indicated you're to check for diets on the Walking Care Plan and it's highlighted in pink. CNA C indicated that R1 was supposed to be supervised during meals and that R1 normally eats in the dining room. CNA C's Witness Statement, dated [DATE], states, in part: I went to get (R1) up and ready for the day. I don't know what time it exactly was, but it was just after when breakfast ends. His brief was soaked through his sheets on his bed so I removed them and went to get new sheets. After I got (R1) ready, I moved out to the hall because he likes to move around on his own. When I was doing that, a lady that may have been a housekeeping or cleaning worker informed me that breakfast had ended and that I should get him something to eat. I asked (R1) what he wanted and he told me chocolate milk and eggs. I asked him how many eggs and he said 2. I went to the kitchen to grab those two things and only grabbed chocolate milk since there were no eggs. I brought back the choc. (chocolate) milk and asked if he wanted anything instead, I offered a breakfast sandwich and he said yes. I went to the kitchen to get a breakfast sandwich and heated it up in the microwave for the recommended time. I did not check his care plan to see what type of diet he was on. He was on a pureed diet. I gave him the sandwich and went to use the restroom. After I got out of the restroom, I went to go make his bed and found him slumped over, drooling with food stuck in his mouth and down his shirt. I tried calling his name and shaking him to see if he would respond. He didn't. I called for (RN E) to come to (R1's) room immediately and she couldn't get him to respond either. she told me to get the charge nurse and I got (RN D) . They had me do the [MEDICATION NAME] because I had the longest arms. we were able to get a little of the food out but not much. Another nurse was using her finger to scoop out the food from his mouth. She was getting big chunks but could still feel good (SIC) down his esophagus. She also said he was biting her finger. He started to turn blue so they got a suction machine but it wasn't very helpful. They turned him on his back and started hitting his back to help him try to get him to cough it out. He didn't cough and I believe he didn't have a pulse during that time either. Another nurse told me that I could step outside and gather myself (staff name) informed me (R1) had passed. R1's Nurses Note, dated [DATE] at 1:44 PM, states: Death: at about 0940 (9:40 AM) CNA came to me at the nurse's cart and asked this Writer to come into the resident's room. Upon entering the room with the CNA the resident was found in his wheelchair and slouched over his tray table. He appeared cyanotic (bluish in color) at the time of entering the room. CNA then states I think he is choking. His eyes were closed, mouth was open and there was phlegm coming from his mouth. There was an empty plate with pieces of thick chewed food present. There were pieces of chewed food on his chest. At this time the Writer was unsure if the resident had emesis or was choking on food. The resident's head was slouched to his chest. His lips appeared cyanotic. This Writer attempted to arouse resident by yelling his name. He remained unresponsive to voice. I called for further assistance from the charge nurse and other nurses. This Writer also attempted to give sternal rubs to resident while holding his upper body back in the wheelchair. The resident gave two shallow breaths but remained unresponsive. Radial and carotid pulses we (SIC) checked at this time and no pulses were able to be palpated. Two other nurses entered the room. One nurse attempted the [MEDICATION NAME] on the resident while in the chair but the resident was slouched over in the chair and she was unable to get her arms around the resident. This Writer and staff were unable to assist the resident to the floor as he was a very large, tall, and heavy man. The staff nurses then helped assist the resident in bed with a medi lift (full body lift) as we were afraid he was going to fall out of the chair. At this time the Writer was able to sweep large chunks of food out of the residents mouth. [MEDICATION NAME] maneuver was attempted on resident once in bed. Another staff member was then directed to attempt the [MEDICATION NAME] as they had longer arms. Oxygen 10L (10 Liters) face mask was placed on resident. Ambu-bag with oxygen was then applied in between suctioning of mouth until EMT (Emergency Medical Technician) arrived. Attempted to get multiple sets of vitals unsuccessfully. Once EMT arrived, they continued suctioning and oxygen with ambu bag without success. EMT instructed team to stop intervention and time of death was determined to be 1010 (10:10 AM). R1's Nurses Note, dated [DATE] at 3:50 PM, states, in part: Death: Around 0940 approximately. Writer was called in to resident's room where other staff were present. Resident was up in wheelchair, unresponsive to staff, (see RN (Registered Nurse) note). This Writer then went out to check code status (DNR (Do Not Resuscitate), called POA (Power of Attorney), and called the on-call provider; called provider to get order due to DNR status and unsure of residents unresponsiveness cause at that time whether choking, emesis or another cause. Order from on-call provider, (Physician name), to send resident in by emergent ambulance with lights and sirens, family was ok with this. Ambulance arrived, EMT's (Emergency Medical Technician) asked for resident POST (Physician order [REDACTED]. EMT's worked on resident for a short time before calling (Hospital name) ER (emergency room ). Per EMT they were instructed to not bring him in if there was no pulse. Time of death called at 1010 called by (Physician Name). This Writer called and updated family of death, once here resident's daughter asked Did he choke. Called and updated (DON B) of the death; she updated Administrator and Social Worker .Called and updated Medical Examiner, . signed by RN D. On [DATE], Surveyor requested EMT report from NHA A, which was obtained on [DATE]. EMT report indicates they were dispatched at 9:54 AM on [DATE] and arrived to the facility on [DATE] at 10:01 AM. EMT Narrative states, in part: Dispatched . for a male patient chocking and unresponsive. Arrived on scene . patient was laying on a bed. His head was at a 45 degree angle. Staff on scene stated that the patient had been eating a sandwich. They found him in his room choking. They stated that they attempted to get the sandwich out of the patient airway. RN stated that the patient was unresponsive for about 15 minutes prior to EMS (Emergency Medical Services) arrival.patients airway was manually opened. Staff stated that there was no trauma. Patient did not have a pulse . Noted that the patient was in asystole ([MEDICAL CONDITION]) rhythm . A Mcgil forceps and laryngeal scope was used along with suction to clear the patient airway. Pieces of sandwich was removed from the patients airway.Patient remained unresponsive and in an asystole rhythm.(Physician) stated that resuscitation efforts can stop . On [DATE] at 8:56 AM, Surveyor interviewed DM K (Dietary Manager) regarding the incident for R1. DM K indicated that breakfast had already been served, due to continental breakfast is from 7 AM to 9 AM. R1 did not come down to breakfast as he usually does. DM K indicated that once breakfast is over, the CNAs are to get breakfast for residents. CNAs must have came down to the servery and got the breakfast themselves and took it down to (R1's) room. DM K indicated R1 was pureed diet with aspiration precautions and R1 needed staff supervision due to impulsiveness and this is why R1 was on a pureed diet. On [DATE] at 9:00 AM, Surveyor interviewed NHA A regarding R1. NHA A indicated that CNA C did not check R1's care plan and that he should have checked R1's diet prior to providing food to R1. NHA A indicated that R1 was a pureed diet and received a breakfast sandwich. NHA A indicated that the facility is doing audits, questioning staff on care plan items, brought in a CPR instructor for a mock [MEDICATION NAME] maneuver, online training updated, and updated their policy. NHA A indicated they did an investigation regarding the incident involving R1 on [DATE]. The failure to follow diet orders and failure to supervise a resident per resident's plan of care, created a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE], when it had completed the following: 1. Printed list of residents with special diet for each hallway and had staff sign off that they reviewed the list. 2. Held debriefing with staff involved in the incident. 3. Provided read & sign education to all nurses and CNAs certified in basic life support. They had to read Choking relief for adults, children and infants from the American Heart Association basic life support manual. 4. Updated CNA competency orientation training sheet so it's very evident to discuss to educate on special diets and location on the walking care plan. 5. Updated CPR policy, adding choking event. 6. Food Service Director created cheat sheets on different foods that can be served for each type of diet. 7. Collaborated with Medical Director regarding incident. 8. Collaborated with Regional Field Office Supervisor. 9. Audited all residents Diet Order, Tray Card, Plan of Care and Walking Plan of Care to ensure they match. 10. Relias education and exam provided to staff on special high risk diets, speech pathology handouts on General Swallow Precautions and Dysphagia Diet Levels. Instruction on where to find out a resident's diet. Review of Physician Orders, care plan, CNA Walking Care Plan and Diet Cards. Location and content of new Diet Cheat Sheets on each side of the building. Updated Basic Life Support/CPR policy review. 11. Developed audit forms for care plans and diets. 12. Coaching/Disciplinary Warning notice given to CNA C. 13. Verified all nurses have current CPR training. 14. Mock [MEDICATION NAME] Maneuver Training from Director of Emergency Education at Mayo Training Center. 15. Coaching/Disciplinary warning notice given to RN D. 16. Audit 7 charts weekly for 4 weeks to ensure the Diet Card matches Physician Order, Plan of Care and Walking Plan of Care. 17. Audit 7 staff weekly for 4 weeks to ensure staff are carrying their Walking Care Plan and they are competent on reading and using the care plan. 18. Need for continued audits will be determined after four weeks according to compliance. 19. Bring audits to QAPI (Quality Assurance and Performance Improvement) team at bi-monthly meetings and determine if further action is necessary.

Based on interview, record review and policy review, the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the resident wishes and plan of care for 1 of 1 sampled residents (Resident #22) as it relates to receiving CPR (Cardiopulmonary Resuscitation). This has the potential to affect any of the 17 residents currently residing in the facility who have requested to be full code. Resident #22 was her own person and made her own decisions. Resident #22 signed a document on [DATE] indicating that Resident #22 is to be a Full Code for Cardiopulmonary Resuscitation. On [DATE], Resident #22 was found cold with no breath sounds and no heart rhythm. No one initiated CPR and no one called 911 as directed by the facility policy and the resident's code status. The failure to provide the care needed by Resident #22 negated Resident 22's only chance for survival. This created a finding of Immediate Jeopardy situation that began on [DATE]. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy at 1:23 p.m. on [DATE]. Immediate Jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of E (potential for harm that is not Immediate Jeopardy/pattern) as the facility fully implements its CPR policies and as evidenced by the following: 2. Resident #11 had an open area to her coccyx and the facility did not provide a comprehensive assessment, did not document the wound, did not update the care plan and did not notify the physician. 3. Resident #5 had a decline in bowel function, without a bowel assessment being completed to determine interventions to maintain or restore bowel function. As evidenced by: The facility policy states, It is the policy of Bethany Riverside that our staff will initiate and perform cardiopulmonary resuscitation (CPR) on residents who receive CPR if they suffer a cardiopulmonary arrest at our facility, either a witnessed arrest or unwitnessed arrest. Facility staff will also call the emergency medical technicians (EMT's) immediately after a witnessed or unwitnessed cardiopulmonary arrest has occurred on a resident who has chosen to receive CPR. The facility procedure includes.1. Bethany Riverside will have staff certified in CPR on duty every shift. These individuals must provide CPR for any resident who becomes pulseless or non-breathing unless: a. The resident has a do not resuscitate (DNR) order b. The resident has obvious signs of clinic death (e.g. rigor mortis, dependent lividity, (pooling of blood that occurs after death and may look blue, purple or black and is similar to bruising), decapitation, transection or decomposition, or, c. The initialization of CPR could cause injury or peril to the rescuer. A review of Resident #22's record was completed on [DATE]. According to the record, Resident #22 was her own person and made her own decisions. Resident 22 signed a Power of Attorney for Healthcare document on [DATE] indicating that Resident #22 is to be a Full Code for Cardiopulmonary Resuscitation. This document was found in the front of the resident's medical record. Resident #22's medical record contained additional documentation she was a full code in the following locations: -on the face sheet in her medical record -in the internal medicine progress notes faxed to the facility on the date of admission ([DATE]) -on the physician orders dated [DATE] -in the admission nurses' notes on [DATE] The nurse charting by Registered Nurse (RN) A on [DATE] at 5:03 a.m. states, Death: called to room at 0445 (4:45 a.m.) by CNA (Certified Nursing Assistant). (Resident #22)had no respirations, no heartbeat. Listed as full code but is already cold to the touch. Time of death 0445 by (physician's name). Called sister (first name identified) who is on her way in to say good bye to (Resident #22). On [DATE] at 10:00 a.m., Surveyor interviewed RN A who verified she was aware Resident #22 was a full code. RN A stated the code status was identified on the front of Resident #22's medical record. RN A stated CNA FF yelled for her to come to Resident #22's room and upon arrival in the room RN A found Resident #22 cold and without a pulse or respirations. RN A stated she did not perform CPR or notify the emergency medical technicians (EMTs) as Resident #22 was cold and had no pulse or respirations when she assessed her. Surveyor asked RN A to describe the assessment she completed. RN A stated to Surveyor the assessment she completed was self-explanatory in her nurses' notes. RN A stated she has always been told during her employment at Bethany Riverside you do not perform CPR on a resident who is cold even if a resident is a full code. RN A could not identify who had informed her of this. RN A stated she has never performed CPR on any resident who was found cold even if the resident was a full code. RN A stated she did not see any purpose in doing CPR if the resident was cold. RN A stated it would be cruel and inhumane to perform CPR on a resident who was clearly gone. RN A stated upon Resident #22's sister arriving at the facility she had informed the sister that no CPR was performed as Resident #22 was cold when she was assessed. RN A stated she was CPR certified. RN A stated she did not know if the facility had a written policy and procedure for CPR as she had never seen one. RN A stated she did not recall being trained in the facility's CPR policy and procedure and stated she received no training after the CPR policy and procedure was updated in [DATE]. RN A stated she was unaware of CPR masks being placed in the rooms of residents who were full codes. RN A stated she was the charge nurse on the night shift on [DATE]. On [DATE] at 8:20 a.m., Surveyor interviewed the Director of Nurses (DON) and requested any additional information related to CPR not being provided to Resident #22 on [DATE]. The DON stated no investigation had been completed related to Resident #22's death. The DON stated, You don't do CPR on a resident who is a No Code. The DON asked why any investigation would need to have been completed when Resident #22 was a No Code. The DON stated nurses would not initiate CPR if a resident was cold to touch when found. Surveyor informed the DON Resident #22's medical record identified in five locations she was a full code. The DON stated he was not aware Resident #22 had been a full code. On [DATE] at 8:55 a.m., Surveyors and interviewed the DON. The DON stated Resident #22 was cold to touch when RN A entered the room. The DON stated the facility had no policy and procedure on how staff would know if a resident was full code. The DON stated the Medication Administration Record [REDACTED]. The DON verified no education had been provided related to the facility's CPR policy and procedure after Resident #22's death. The DON stated he had provided training to staff after the CPR policy and procedure was updated on [DATE] during the Nursing Leadership Agenda meeting. The DON stated this meeting is attended by the administrative nurses. The DON stated a lot of the nurses, recreation staff and CNAs employed by the facility are CPR certified. On [DATE] at 12:10 p.m., Administrative Assistant EE provided Surveyor with a copy of the Nursing Leadership Agenda dated [DATE]rd. The copy contained a section: CPR Policy Review. No additional information was documented. The DON attached a typed attendance sheet dated [DATE]. The DON documented, I am unable to locate a sign in sheet; Routine attendees are as follows: The names of nine licensed staff were identified. The routine attendees identified by the DON were: the infection control/staff development nurse, one RN case manager, two RN coordinators and four charge RNs. RN A's name was not included on the attendance sheet. No additional information was provided related to training of additional staff on the CPR policy and procedure updated on [DATE]. On [DATE] at 1:23 p.m., Surveyor met with the Administrator to discuss Resident #22 not being provided CPR on [DATE]. The Administrator verified RN A did not follow the facility's CPR policy and procedure for Resident #22 who had requested to be a full code. According to the American Heart Association's Chain of Survival, the chances for survival decrease ,[DATE]% for each minute that CPR is delayed following a sudden [MEDICAL CONDITION]. Brain damage can occur within ,[DATE] minutes. After 10 minutes of delay, few attempts at resuscitation succeed. <http://www.chainofsurvival.com/cos/Timing_detail.asp> The failure to provide CPR created a finding of Immediate Jeopardy. Although it is not certain that CPR would have been effective in reviving this resident, the failure to honor her wishes and to provide the care she wanted denied her the only opportunity she had for living. Immediate action was needed to try to revive her and this was not forthcoming. The facility removed the Immediate Jeopardy on [DATE] by reviewing their policy and educating all licensed and therapy staff regarding the protocol. The facility clarified the identification of code status, CPR Certification requirements and held an inservice with staff. The deficient practice continues at scope/severity level E (potential for harm that is not immediate jeopardy/pattern) as evidenced by: 2. On [DATE] at 1:25 p.m., Surveyor reviewed the medical record for Resident #11 and noted the following: - Minimum Data Set (MDS), dated [DATE], stated Resident #11 had two stage II pressure ulcers to the coccyx region which were currently healed. MDS indicated no open area to the coccyx region of Resident #11. - Comprehensive Nursing Care Plan, received [DATE], did not indicate an open area to the coccyx of Resident #11. - CNA care plan, received [DATE], did not indicate an open area to the coccyx of Resident #11. - Current physician orders did not indicate a treatment for [REDACTED]. On [DATE] at 8:55 a.m., Surveyor observed CNA M and CNA P provide personal cares to Resident #11. Surveyor observed the CNAs use a mechanical lift to place the resident on the commode. When Resident #11 stated she was finished going to the bathroom, the CNAs raised the resident up into the air to provide pericare. CNA P stated Resident #11 had a small open area near the rectum and then applied an ointment to the open area. Surveyor observed a small superficial open area to the right of the rectum. Surveyor asked the CNAs how long Resident #11 had this open area and both stated Resident #11 had had this open area for a while and it was not a new area. CNA M stated Resident #11's coccyx was typically red from sitting so long in her chair and this was normal for her. On [DATE] at 9:05 a.m., Surveyor interviewed RN O about the observation above and interview with CNAs M and P about Resident #11's coccyx region. Surveyor asked RN O if he was aware of Resident #11 having an open area near her rectum and RN O stated, No. RN O stated if there was an open area on the resident there would be a blue skin sheet in the treatment book. RN O looked in the treatment book and noted no blue skin sheet for Resident #11 identifying an open area near the rectum. RN O stated it was the expectation that CNAs tell the nursing staff of all skin conditions. On [DATE] at 9:07 a.m., Surveyor interviewed RN L in regard to the open area to Resident #11's coccyx region. RN L stated she was only aware of an open area to Resident #11's left heel and not to the rectal area. On [DATE], Surveyor requested a copy of all assessments, interventions and physician notifications in regard to the open area near the rectal area of Resident #11. On [DATE] at 9:15 a.m., Surveyor interviewed RN Manager (RNM) I in regard to the above noted observations. RNM I stated nursing staff should have assessed the open area, filled out a blue sheet, updated the care plan and notified the physician. RNM I was unable to provide documentation that the area was assessed, the care plan was updated, the physician was notified and interventions were implemented. On [DATE] at 7:14 a.m., Surveyor received a copy of a comprehensive nursing assessment to the open area near the rectum on Resident #11. The assessment stated Resident #11 had an open area that measured 0.75 cm (centimeters) in diameter to the right side of the rectum and appears to be pink and macerated. 3. On [DATE], Surveyor reviewed Resident #5's medical record. Resident #5's comprehensive care plan does not address that the resident is incontinent of bowel. The CNA assignment sheet has no information for bowel incontinence. Surveyor reviewed Resident #5's significant change in status MDS, dated [DATE], Bowel Continence coded Resident #5 being continent. The MDS, dated [DATE], documents Bowel Continence coded Resident #5 being frequently incontinent (two or more episodes of bowel incontinence but at least one continent bowel movement) within the last five days of the completion of the MDS. Surveyor interviewed the MDS nurse, RN W. Surveyor asked how the data was collected to determine the resident was frequently incontinent of bowel. RN W printed off the vitals report, dated ,[DATE] to [DATE]. This documented Resident #5 had two incontinent bowel movements. Surveyor asked for the current documentation of Resident #5's bowel continence. RN W stated, We do not track continent or incontinent all the time, only during an MDS look back time period. Surveyor asked if a bowel assessment was completed when RN W was aware of a decline. RN W stated, No, I did not do an assessment since this was a therapy triggered MDS. On [DATE], the facility provided Surveyor with Resident #5's most recent bowel assessment; it was completed [DATE], prior to the decline in bowel function. On [DATE] at 10:00 a.m., Surveyor shared the above information with the Director of Nursing.