Every finding on record at St Johns Nursing Center

Based on observations and interviews, the facility failed to provide food to residents in a safe and sanitary method. This had the potential to affect 154 residents. The findings included:A tour of the kitchen was conducted on 03/03/26 at 8:50 AM, accompanied by the Kitchen Supervisor upon entering the kitchen. At approximately 9:30 AM, the Kitchen Manager joined the surveyor and the Kitchen Supervisor. At approximately 10:30 AM, the Director of Food and Nutrition Services joined the surveyor, the Kitchen Supervisor, and the Kitchen Manager, on the tour of the kitchen. The following was observed: a. Upon entering the kitchen, a tall gray garbage bin close to the Vulcan stove had an open lid. The staff quickly closed the lid. Regulations mandate that the garbage should be maintained with a closed lid. During a later observation of the garbage bin with an open lid, the Director of Food and Nutrition Services was asked if the lid was left open for convenience. It was observed that there was no garbage bin close to the hand-washing area. The Director of Food and Nutrition Services said that they didn't leave it open for convenience. He said that the lid should have been closed. b. Two red buckets of solution were identified as sanitizing solution. The first bucket (bucket #1) was located close to the shelf of bananas. The Kitchen Supervisor was asked to test the concentration of the solution with a test strip. The tip of the strip remained yellow. That was the same color as the tips of the strips were when they were in the plastic vial, unused. The Director of Food and Nutrition services was asked to test a red bucket (bucket #2) of solution that was near the pot washing station. After he held the strip in the solution for approximately 10 seconds, the tip of the strip remained yellow. The test strips should have turned a green-blue color to indicate the concentration of quaternary ammonium (sanitizer). The yellow color indicated that there was no sanitizer added to the water in the bucket. The Kitchen Supervisor and the Director of Food and Nutrition Services agreed with this finding. c. The plastic bin that housed the bananas had small round beige pieces of debris on the bottom. There was also a small piece of white paper, and brown/black debris on its' surface. A piece of hair was on the plastic close to the bananas. The Kitchen Supervisor agreed with this finding. d. In the pot washing room, a garbage bin was located very close to the mixer. The mixer should be maintained in a clean area away from garbage. The Kitchen Supervisor agreed with this finding. e. Three Air Conditioning vents located above the tray line had caked on dark gray matter on the vent. The dark gray substance extended to the area surrounding the vents on the ceiling. The Kitchen Supervisor agreed with this finding. f. Ricotta cheese in the walk-in refrigerator was expired. The manufacturer's expiration date was 02/01/26. Clusters of dark black-green spots were on the exterior, top portion of the plastic container. The Kitchen Supervisor agreed with this finding. g. The walk-in refrigerator had a 12-pound container of chocolate frosting on a shelf. The frosting was expired. The expiration date was 01/31/26. The plastic container of chocolate frosting was open. A thick green substance was on the exterior of the container along the deep grooves of the container. Clusters of the green matter was observed. The Kitchen Supervisor agreed with this finding. h. The walk-in refrigerator had a plastic container filled with pureed pumpkin. The label listed the date it was prepared was 02/04/26. The use-by date written on the label was 02/11/26. [NAME] spherical matter with spore-like projections was visible on the top layer of the pumpkin. The Kitchen Supervisor agreed with this finding. i. The walk-in refrigerator had a plastic container with a piece of beef with no date on it. The Kitchen Manager said that it must have been left-over. He did not know how long it was in the refrigerator. j. The juice machine had a build-up of pink and yellow-orange stuck-on residue. The Director of Food and Nutrition Services agreed with this finding. k. The Vulcan tilt skillet handle and oven temperature knob had thick yellow-brown residue in all of the gloves and depressions. [NAME] particles were on the surface of the skillet. The Kitchen Supervisor agreed with this finding. l. The grille, located to the right of the tilt skillet, had yellow and yellow-brown remnants of food on the cooking surface, the metal borders of the grille, and the backsplash border behind the grill. The cook was asked when the last time the grille was used. She said yesterday. The Kitchen Supervisor agreed with this finding. m. Remnants of food, (yellow, beige, black, and red), were on the surface of the counter in between the counter and the grille. The Kitchen Supervisor agreed with this finding. n. The Vulcan oven had dried on yellow-brown liquid on the metal ledge that was seen when the door was opened. The interior of the oven door was covered with brown residue. The floor of the interior of the oven had a build-up of black residue. The Director of Food and Nutrition Services was asked how often the ovens were cleaned. He said they were cleaned weekly and then they are cleaned more often for incidents of spills. He said that the spill should have been cleaned. o. The cans stored in the dry goods storage room had white granules on top of them. One of the cans of evaporated milk was dented. Dented cans should be separated away from cans that are used in cooking. The Kitchen Supervisor agreed with this finding. p. The floor of the dry goods storage room had stuck on brown-black residue. q. Tube shaped pasta was on the floor in the corner surrounding a wheel that supported the shelving fixture. r. The shelf fixture had evidence of spillage. Yellow-brown stuck-on residue was on the shelves. Dried-on drippings were observed. The Kitchen Supervisor agreed with this finding. s. Two plastic containers of ice cream toppings were expired. The expiration date on the handwritten label was 10/20/25. The container of the beige, crunchy-looking topping, was opened. The Director of Food and Nutrition Services agreed that they should have been thrown out. t. The Turbo-Air reach in refrigerator had a case of Mighty shakes that were not frozen. The box had the words Keep Frozen printed on it. It was dated 01/31/26. When asked how long the Mighty shakes were in the refrigerator, the Director of Food and Nutrition, and the Kitchen Supervisor did not know how long it was there. During an interview with the Kitchen Supervisor on 03/03/26 at 5:00 PM, he said that the box of Mighty shakes was thrown out. They knew it shouldn't have been in the refrigerator. u. The muffin pans had rust colored debris, and white residue. Food particles were on the muffin pans. The Kitchen Supervisor agreed with this finding. v. The slicing machine had a dead roach on it. The slicer was on a shelf with other frying pans. A bottle of disinfectant spray was next to the slicer. Cleaning products should be stored away from foods and cooking apparatus. The Kitchen Supervisor agreed with this finding. w. The Rubbermaid containers of sugar, lentils, and dried peas located under the counter in the cooking area were sticky to the touch. The supervisor washed hands after touching the handle of the bins. Yellow and brown residue was on the exterior of the containers. x. The exterior top of the Vevor rolling toaster had a dried-on spill of a dark brown greasy substance. The Director of Food and Nutrition Services agreed with this finding. y. The Amana microwave had a build-up of yellow-brown residue on the interior of the door, and on its' upper interior surface. The Director of Food and Nutrition Services agreed with this finding. z. A plastic bag of personal instant coffee was on the lower shelf of the food production area. The Kitchen Supervisor agreed with this finding.

Based on record review and interview, the facility failed to follow the facility policy of documenting identified changes in the sacral skin condition for 1 of 1 sampled resident reviewed for pressure ulcers, Resident #1.The findings included:Review of facility's policy, titled, Wound Prevention, Skin Observation, with an effective date of 10/19/05, and a revision date of 11/21/17, documented that 'the nurse would evaluate and document identified changes in the weekly skin check section of the electronic medical record.' Record review documented Resident #1 was admitted to the facility on [DATE] after a surgical operation of the right knee. The resident had history of Vancomycin induced Acute Kidney Injury, Atrial Fibrillation and Hypertension. The resident was discharged to a hospital on [DATE]. Review of the admission Minimum Data Set (MDS) assessment, dated 02/02/26, documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating he had good cognitive function.Section M revealed a presence of one Stage I pressure ulcer or injury. Review of nursing progress notes, dated 01/27 26 at 9:35 PM and on 01/28/26 at 10:11 AM, documented Resident #1 had redness and/or sacral rashes with no signs and symptoms of infection noted. The notes added that the sacral rashes were present on admission. After 01/28/26, there were no further nursing progress notes about the redness or sacral rashes. The daily general skin assessment documented the skin was warm and dry, with several documentations regarding the right knee surgical site skin conditions on these dates: 02/09/26, 02/03/26, 02/02/26, 01/28/26, and 01/27/26. In an interview conducted with Staff A, Certified Nursing Assistant (CNA) on 02/12/26 at approximately 11:13 AM, she was asked their process of admitting new resident. She responded they help the resident in the room and perform skin assessment with the nurses. Staff A stated the nurses document all the findings, and they both agreed that if there are skin conditions they must be reported to the doctor. She stated she continually performs skin assessments when she performs daily care to the resident and then reports to the nurse if there are new skin conditions observed or if the former skin condition is worsening. In an interview conducted with Staff B, Registered Nurse, on 02/12/26 at 12:43 PM, when she was asked her admission process, she responded that she and the assigned CNA perform the head-to-toe assessment to ensure all skin areas are assessed. She takes notes of any redness, or open skin areas, notifies the doctor and documents all her findings in the progress notes. Staff B added that the staff performed weekly skin assessment for Resident #1 to makes sure the redness in the sacral area was improving. She stated she remembered applying cream to that area. When she was asked if she monitored and measured the sacral redness / rashes after the initial admission assessment, she responded, no. She stated she did not monitor or measure the area because the wound care nurse does the monitoring and measuring. Staff B stated the wound care nurse documented all the skin conditions for the resident after the staff nurses make the skin referral. In an interview conducted with Staff D, Wound Care Nurse on 02/12/26 at approximately 11:26 AM when asked if she assessed and monitored the sacral area with redness/rashes for Resident #1, she responded that she saw it on admission, a cream was ordered by the physician, and the nurses applied the cream daily as ordered. Staff D stated, the resident was in a 'turning every 2 hours program', but no, she did not monitor the sacral area, and only monitored and documented updates regarding Resident #1's right knee surgical area. She stated she thought the staff nurses were monitoring and documenting the sacral area redness and rashes.In continuing interviews with the nurses, they stated that skin conditions are documented upon admission, and weekly thereafter, but when they were asked to provide the documentation for Resident #1, they stated they did not document the weekly skin assessment of the sacral area. They stated they thought the Wound Care Nurse is responsible for the weekly documentation of the sacral area for Resident #1. Review of Resident #1's nursing care plan revealed the sacral area would show evidence of healing by 02/13/26. The interventions revealed to monitor, measure and document wound status on a weekly basis until healed. Additional record reviews revealed no documentation in the nursing progress notes regarding monitoring, measuring, and documenting the wound status on a weekly basis. In an interview conducted with the Assistant Director of Nursing (ADON) at approximately 4:30 PM, when informed that staff nurses thought that only the Wound Care Nurse was documenting, measuring and monitoring Resident #1's sacral area, she responded that all staff nurses received Health Stream (the facility's online continuing education flatform) training regarding documentation of pressure ulcers. She did not understand why the facility nurses were not documenting according to the training and their policy.

Based on observations, interviews, and record review, the facility failed to treat residents in a dignified manner for 3 of 3 sampled residents during mealtime observations, Resident #140, Resident #75, and Resident #100; and failed to provide grooming for 1 of 1 sampled resident, Resident #139. The findings included: 1. In an observation conducted on 01/13/25 at 12:22 PM, Staff H, Certified Nursing Assistant (CNA), was passing the lunch tray on the 2nd floor South unit. She turned to another staff member on the unit and said, She is a feeder. A few minutes later, at 12:27 PM, Staff I, CNA, asked another staff member, How many feeders do we have? 2. Continued observation on the 2nd floor South unit at 12:30 PM revealed Staff I stated to another staff member, She is a feeder as well. She then turned to the surveyor and said, I need to wait with some of the trays in the meal cart because I need to finish feeding the other residents. 3. In an observation conducted on 01/13/25 at 12:22 PM, Resident #140's roommate ate her lunch while Resident #140 waited. At 12:40 PM, Resident #140's roommate finished her lunch meal while Resident #140 was still waiting on her lunch tray. At 12:50 PM, no lunch tray was noted for Resident #140. At 12:55 PM, about 35 minutes later, the lunch tray was brought to Resident #140. 4. Record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses of Weakness, Anemia, Failure to Thrive, Sacral Wound, Iron Deficiency and Dementia. The admission 5-day Minimum Data Set (MDS) assessment dated [DATE] documented Resident #75 has a Brief Interview Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Section GG for eating showed that Resident #75 needed partial to moderate assistance during eating. In an observation conducted on 01/13/25 at 5:02 PM, Staff B, Certified Nursing Assistant, was standing over Resident #75 while feeding him the dinner meal. A continued observation at 5:45 PM showed Staff C, sister, standing over Resident #75 while feeding him the dinner meal. In an interview conducted on 01/16/25 at 7:45 AM, Staff J, Certified Nursing Assistant, stated that when assisting a resident during mealtimes, she needs to sit down at eye level while feeding the resident. She further said that she uses the word Feeder only when she talks to other staff members. In an interview conducted on 01/16/25 at 11:00 AM with the Administrator, she was informed of the above findings. 50370 5. Record review documented Resident # 100 was admitted on [DATE] with diagnoses including Unspecified Dementia, Diabetes Mellitus, Gastroesophageal Reflux Disease, Hypertension, Benign Prostatic Hypertrophy, and Unspecified Psychosis. Review of quarterly Minimum Data Set (MDS), section C, dated 11/02/24, revealed a Brief Interview for Mental Status Score (BIMS) of 03 indicating severe mental impairment. Review of physician orders dated 01/01/25 revealed an order for regular dietary restrictions, and a radiology test for peg (percutaneous endoscopic gastrostomy) tube placement on 01/02/25. Review of dietary notes dated 01/01/25 revealed Resident #100's primary source of nutrition and hydration is from the PEG tube, but receives meals by mouth of the following: dysphagia mechanical, soft liquids, no added salt (NAS), and concentrated sweets (NCS) diet restrictions remain in place. Further review of the Certified Nursing Assistant's (CNA's) notes revealed the resident consumes zero to 25 % of pleasure meals. During a hallway dinner observation on 01/13/25 at 5:20 PM, Staff M, CNA, was going in and out of residents' rooms and was heard calling a resident a feeder. When asked when Resident #100 was going to eat his meal, since the dinner tray had been sitting in front of the resident for 10 minutes, Staff M, CNA stated. He is a feeder; someone has to feed him.

Based on observations, interview and record review, the facility failed to ensure the residents' call devices were in reach for 3 of 33 sampled residents reviewed for call light accessibility, Residents #85, #153 and #51. The findings included: Review of the facility's policy, titled, Call Bells-Lights, effective date 08/12/19 and reviewed date 10/16/24, included the following: Call bells will be available to facilitate care and to enhance safety for all residents. Procedure: 1.Staff will ensure that call buttons are within the reach of the resident at all times. 1. Record review for Resident #85 revealed the resident was admitted to the facility on [DATE] with the diagnoses that included Gastrointestinal Hemorrhage, Dementia, Hypertension, History of Falling, and Diabetes Mellitus. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 had a Brief Interview for Mental Status (BIMS) score of 05, indicating severe cognitive impairment. Review of Section GG of the same MDS revealed Resident #85 had no upper extremity impairment and was dependent on staff for his activities of daily living (ADLs), including personal hygiene. During the initial observational tour of the facility's 3rd floor conducted on 01/13/25 at 11:11 AM, Resident #85 was observed in his room, in bed. Further observation revealed Resident #85's call light cord was wrapped around the bed rail and the call light button was dangling and not within the resident's reach. Resident #85 was asked if he could reach for the call light. It was observed that Resident #85 was unable to reach and just shrugged his shoulders. Photographic Evidence Obtained. An interview was conducted on 01/16/25 at 10:36 AM with Staff CC, third floor Nurse Manager, who stated she has worked at the facility for 8 years. She stated the nursing staff is aware to clip the resident's call light on the bed to make sure it is accessible for the resident. Staff CC confirmed that staff are not to wrap the call light cord around the bedside rail. At this time, a side-by-side observation was conducted with Staff CC of Resident 85's room. She confirmed Resident #85's call light was wrapped around the bedside rail and the push button was dangling out of reach of Resident #85. 2. Record review for Resident #153 revealed the resident was admitted to the facility on [DATE] with the diagnoses that included Sequelae of Cerebral Infarction, Atherosclerotic Heart Disease, Chronic Obstructive Pulmonary Disease (COPD), and Type 2 Diabetes Mellitus. Review of Section C of the MDS assessment dated [DATE] revealed Resident #153 had a BIMS score of 11, indicating moderate cognitive impairment. Section GG revealed that Resident #153 had upper extremity impairment on one side and required substantial assistance for ADLs. During the initial observational tour of the facility's 3rd floor conducted on 01/13/25 at 11:15 AM, Resident #153 was observed in bed. Further observation revealed Resident #153's call light cord was wrapped around the bed rail with the call button dangling off the bed and not within the resident's reach, Resident #153 was asked if he could reach the call light button, and he stated no. When asked how often his call light button is unreachable, Resident #153 stated often. Photographic Evidence Obtained. On 01/15/25 at 9:35 AM, an observation was conducted on the facility's 3rd floor and noted Resident #153 in his bed. Again, Resident #153's call light cord was observed wrapped around the bedrail and not accessible to Resident #153. 3. Record review for Resident #51 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Sepsis, Urinary Tract Infection, Clonic Hemifacial Spasm, and Acute Kidney Failure. Review of Section C of the MDS assessment dated [DATE] revealed Resident #51 had a BIMS of 08, indicating moderate cognitive impairment. Review of Section GG of the same MDS assessment revealed Resident #51 had upper extremity impairment on one side and requires substantial assistance for some of his ADLs including toileting hygiene. On 01/15/25 at 10:11 AM, an observation was conducted on the facility's 3rd floor and noted Resident #51 sitting in his bed. Further observation revealed Resident #51's call light cord was wrapped around the bed rail and dangling from the bed and was not within the resident's reach. Resident #51 stated he can never find the call light. He stated if he needs something he uses his cell phone to contact his daughter because the call light button is not around. Photographic Evidence Obtained. An interview was conducted on 01/16/25 at 9:27 AM with Staff W, LPN, who stated she has worked for the facility for 4 1/2 years. She stated any staff member can respond to the call lights. Staff W stated the call light cord has a clip that can be used to securely attach the call light button to the sheet or pillow to be within reach and accessible for the resident. An interview was conducted on 01/16/25 at 10:26 AM with Staff AA, Certified Nursing Assistant (CNA), who stated he has worked at the facility for 2 years. He stated call lights are answered as soon as possible, and residents' call light button should be available to the resident to contact someone for help. An interview was conducted on 01/16/25 at 10:32 AM with Staff BB, CNA, who stated she has been working at the facility for [AGE] years. She stated the call light button is to be within reach of the resident and depending on the resident's strong side (left or right). An interview was conducted on 01/16/25 at 10:36 AM with Staff CC, third floor Nurse Manager, who stated she has worked at the facility for 8 years. She stated the nursing staff is aware to clip the resident's call light on the bed to make sure it is accessible for the resident. Staff CC confirmed that staff are not to wrap the call light cord around the bedside rail. An interview wasmconducted on 01/16/25 at 11:09 AM with the Director of Nursing (DON) who was informed of the call lights wrapped around the bedside rails.

Based on interviews and records review, the facility failed to honor 1 of 22 sampled residents, Resident #130's rights for self-determination, as evidenced by the facility's infringement on Resident #130's right to refuse and discontinue nursing home care services. The findings included: On 01/13/25 at 11:44 AM, Resident #130 stated he was asked in the month of October 2024 to come to the nursing home while his assisted living facility's (ALF) apartment was being renovated. He said that they told him that he would return to the ALF in two months. Yet, he has not heard from anyone, he does not know what is going on, and it has been three months. The resident stated they have ignored all his concerns. Resident #130's electronic record documented the following diagnoses: Chronic systolic heart failure; Hypertensive Heart disease; Bacteremia; Hyperlipidemia; presence of Cardiac Pace Maker; Glaucoma bilateral unspecified and gait abnormalities. On the Brief Interview of Mental Status (BIMS) Resident #130 obtained a score of 15/15. That BIMS score is indicative of someone whose cognitive abilities were intact. An interview was conducted with the Social Services Director (SSD) on 01/14/25 at 03:08 PM to obtain clarification on the cause of Resident #130 being at a nursing home. The SSD stated that Resident #130 would be returning to the ALF tentatively, on Monday, the 20th of January 2025. However, the SSD could not provide the rationale for the resident's admission to the Nursing Home. She said, she did not know why this resident was admitted to the facility. The SSD said, they were processing Resident 130's Medicaid application and he would return to the ALF soon. On 01/14/25 at 03:25 PM, Employee JJ, a Social Worker (SW) informed that Resident #130 was at the facility because of financial reason. Employee JJ said usually when Residents of the ALF, which is owned or operated by the same organization, have their Medicaid cases pending, they transfer them to this nursing home, while the process is ongoing. Employee JJ said she received correspondence from the Business Office Manager (BOM), and the SW from the ALF informing her that Resident #130 was eligible for Medicaid and that he could now go back to his previous residence in the ALF. The SW also said that she did not have any documentation to support the legitimacy of Resident #130 being admitted to the nursing home, other than perhaps the agreement that Resident #130 had signed to be admitted to the nursing home. Employee KK, a Resident Navigator, informed on 01/14/25 at 03:43 PM, her role at the nursing home was to tour the nursing home with prospective residents, before and after their admission to the facility. Employee KK also assigned rooms to the residents, and ensured residents signed the admission packet. Employee KK said that she gave Resident #130 a tour of this facility prior to his admission. Employee KK said Resident #130 was transferred to the nursing home because there was some kind of billing issue at the ALF. He came here to wait for his Medicaid approval before he could return to the ALF. Employee KK further stated that she gets a few residents from the ALF who ended up in the nursing home when their funds run out over there in the ALF. She said that Resident #130 agreed to be admitted to the nursing home. Review of the Admission Packet showed Resident #130 was admitted to the facility on [DATE]. He signed the document as presented. The Resident Navigator said that Resident #130 came to the facility by himself since Resident #130 does not have a power of attorney (POA). On 01/14/25 at 04:11 PM, the Director of Nursing (DON) informed she has been working at this facility for three years. she said they have a centralized admission team who screen residents who are supposed to be admitted to this facility. However, she would occasionally screen resident, especially if the resident was going to be admitted for long-term care. She said she screened Resident #130 prior to his admission to the facility and he had gait disorder, memory loss, and history of falls. She said Resident #130 could no longer take care of himself at the ALF, so they transferred him to this facility. Review of the health assessment form (AHCA form 1823) provided by the DON and dated 5/24/2024 documented that Resident #130 did not require 24-hour nursing care. Review of the AHCA form 5000-3008 dated 9/19/2024 and completed by the Resident's Primary Care Physician confirmed that the resident did not require nursing facility placement services but needed Medicaid Waiver services. The DON said that she did not know that the physician had written that information. On 01/15/25 at10:19 AM, Resident #130 said, he never had any falls while in the ALF. The only physical problem he had was a subluxation of his spine many years ago before coming to the facility. Resident #130 said, they have not done anything for him in this nursing home but giving him his medications. He asked how much he would have to pay, for being at the nursing home? They told him they would take it from his account and they would leave some money for him in his account. He said since he was admitted to the nursing home, he never received any mails. Resident #130 said he was paying 1000.00 dollars at the ALF. Every time he wanted to go back to the ALF, they told him he could not go, he needed permission to do so although most of his belongings were left at the ALF. He felt deprived of his rights to handle his personal affairs. Resident #130 said at the ALF, all he had to do was sign out and he could go about his business. But, at the nursing home, he could not do anything. He said that he has been complaining about going back to the ALF for a long time. On 01/15/25 at 10:53 AM, the Physical Therapist (PT) Director said that Resident #130 did not receive any rehabilitation services. He said that he was not familiar with the resident's name. The PT Director said that Resident #130 was only screened for long term care on 11/13/2024. The patient showed no indication that he needed rehabilitation services, said the PT Director. The Business Office Manager (BOM) said on 01/15/25 at10:59 am, that Resident #130 would soon be going back to the ALF. The BOM said that Resident #130's Medicaid application for long-term care was approved. She said she did not open an account for Resident #130's stay in the nursing home because they knew Resident #130 was supposed to go back to the ALF. The BOM said Resident # 130 had a patient liability for the month of October 2024 in the amount of $11423.00 dollars and $1175.00 dollars for the months of November and December 2024. The BOM said they did not expect the Medicaid application to take that long that is why Resident #130 ended up staying so long at the facility. On 01/15/25 at 3:40 PM, the Administrator said that they had obtained other medical assessment/evidence verifying that Resident #130 needed nursing home care services. The Administrator provided a hospital transfer form which was signed by the nursing home Medical Director on 10/4/2024. The Administrator also attested to the fact that Resident #130 had been complaining about his stay at the nursing home. The Administrator acknowledged that Resident #130 wanted to go back to the ALF since he came to the nursing home. The Administrator declared that she was also the assisted living facility's (ALF) Administrator where Resident #130 came from. The Administrator said that the rent increased in the ALF and Resident #130 could not afford the rate increase, when he was transferred to the Nursing Home. However, upon Surveyor intervention, the Administrator decided to send Resident #130 back to the ALF on the same day. She said that she would immediately arrange the transfer of Resident #130 back to the ALF. On 1/16/2025, it was observed that Resident #130 was relocated back to the assisted living facility as he desired.

Based on observation, records review, and interview, the facility failed to provide assistance with Activites of Daily Living (ADLs) for 1 of 22 sampled residents, Resident#139, related to removal of facial hair. The findings included: Review of Resident #139's facesheet and section A of the Minimum Data Set (MDS) assessement documented the resident's admitted to the facility to be 06/08/23.Review of on the Brief Interview for Mental Status (BIMS) for Resiident #139 noted a score of 3 of 15 indicating severe cognitive impairment. Section GG of the MDS. titled Functional Abilities and goals. documented the resident required total assistance for most ADLs. Review of the resident's ADL care plan (CP) dated 02/12/24 documented the resident has self-care deficits as evidenced by her decreased balance and endurance, safety awareness strength, and required maximum assistance with upper body dressing, total assistance with lower body dressing, total assistance with toilet transfer, total assistance with toileting hygiene, due to functional decline related to ADL dysfunction muscle weakness status post (s/p) cerebrovascular aneurysm (CVA). On 01/13/25 at 12:35 PM, Resident #139 was observed with overgrown facial hair under her chin. The resident answered basic questions but could not provide any feedback regarding her personal care needs. In an interview conducted with Staff II, Certified Nursing Assistant (CNA), on 01/13/25 at 1:01 PM, right after exiting Resident #139's room, Staff II said that she has been working at the facility for 2 years. Staff II said she had ten residents assigned to her to assist with activities of daily living (ADLs), of whom Resident #139 was one. Staff II stated Resident #139 had a colostomy bag and could not perform any personal care. Staff II said that she gave Resident #139 a bed bath in the morning and assisted her with oral hygiene care, confirming that she had noticed the resident's overgrown facial hair but took no action. On 01/16/25 at 2:21 PM, a follow-up observation revealed that after a couple of days, Resident #139 was nicely groomed, and the overgrown facial hair was removed. Resident #139 could not say when on that day or the night before she was shaved, nor who might have done it. During an interview with the fourth floor Unit Manager, Staff T, on 01/16/25 at 2:24 PM, he said that he did not know who shaved Resident #139. His interviews with the staff who worked the mornings of 01/15/25 and 01/16/25 provided no definitive answers as to who might have shaved the resident. Until the time of the exit meeting with the facility on 01/16/25 at 5:45 PM, no answer was provided as to who might have shaved the resident between the days of 01/13/25 and 01/16/25.

Based on observations, interviews and record reviews, the facility failed to follow Physician orders for urinary care for 1 of 1 sampled resident, Resident # 152, reviewed for urinary care. The findings included: Review of a document, titled, Foley Catheter Care, with policy # 2032, and reviewed on 08/22/22, revealed catheter care will be provided to all residents with indwelling catheters at least daily. An additional statement revealed the purpose of catheter care is to prevent possible urinary tract infections from bacteria spreading from the perineal area and external catheter into the bladder. Record review documented Resident #152 was admitted on [DATE] with diagnoses that included Atrial Fibrillation, Heart Failure, Benign Prostatic Hypertrophy, Chronic Urinary Retention, Diabetes Mellitus, Thyroid Disorder, Malnutrition, Sacral Wounds, and Asthma. Review of the Minimum Data Set (MDS) assessment, Section C, dated 01/05/25, revealed a Brief Interview for Mental Status (BIMS) score of 10 of 15 indicating moderate cognition impairment. Review of the physician orders dated 12/13/24 revealed: to provide Foley [Inventor's name of a urinary tubing] catheter care for Obstructive Uropathy every shift. Review of the nursing care plan dated 01/10/25 revealed a problem of increased risk for infection related to indwelling catheter due to Obstructive Uropathy. The interventions included to monitor urine for sediment, cloudiness, odor or blood, and to notify MD promptly when changes occur. Record review of the nurses notes dated 01/13/25 at 11:33 AM revealed Staff Q, Licensed Practical nurse (LPN), documented the following: resident poor appetite, assistance with meals, and fluids encouraged. In bed, head of bed (HOB) elevated, weakness and decline. Family aware, will continue to monitor. There was no documentation regarding Foley catheter care for Obstructive Uropathy. Review of the nurses notes dated 01/13/25 at 11: 44 PM revealed another LPN documented the resident in no acute distress, alert to self, and surrounding, assistance with meals, appetite remains poor, per orem fluids encouraged, will continue to monitor. There was no documentation regarding providing Foley catheter care for Obstructive Uropathy. Review of the nurses notes dated 01/14/25 at 10:48 PM revealed the type of Infection: Urinary Tract Infection (UTI), Vital signs: Pulse = 66/min, Temperature = 97.4, blood pressure = 118/68, respiration = regular. There were no notes regarding the color of urine, the urinary tubing, and the urinary bag. An observation on 01/13/25 at 10:25 AM revealed Resident #152's urinary tubing had a reddish tinged color with whitish sediments, and the urinary drainage bag did not have a privacy cover. An observation on 01/14/25 at 11:25 AM revealed the urinary bag had no privacy covering, and the urine was reddish tinged, both in the tubing and the urinary drainage bag. An additional observation on 01/14/25 at 5:20 PM revealed the urine in the urinary drainage bag and tubing was dark red tinged to dark brown in color, and no privacy bag covering was noted over the urinary bag. Observation on 01/15/25 at 1:24 PM revealed the urine had brownish color inside the urinary drainage bag, and it was covered with blue privacy bag. An observation on 01/16/25 at 9:45 AM revealed a red-orange colored urine in urinary bag, and it was covered with a blue privacy bag. In an interview with Staff Q, LPN, on 01/15/25 at 8:58 AM, when asked if she observed a red colored urinary tubing or urine on resident's urinary catheter, she responded she would document it. She stated she would make sure the Foley catheter was still attached to resident; if resident is male, she would check the penis, the Foley anchor, date, tag and any changes she observed on the urinary tubing, urinary bag and urinary anchor. She added that she would observe for mucus and bleeding. When asked regarding bleeding, she stated she would contact the resident's doctor and notify her or him immediately, would talk to Certified Nursing Assistants (CNAs) and ask them if they notice bleeding or red coloration in urinary tubing and urinary bag. She added that she would document in nurses notes including the date and time red colored urine was observed. She added that she would also document when MD (Medical Doctor) was notified, the orders received from MD, laboratory orders which she would put in the laboratory order book, the date and time she talked with MD, and pass on all information during report to the next shift.

Based on observations, interviews, and record review, the facility failed to identify weight loss and provide nutritional interventions in a timely manner for 2 of 8 sampled residents reviewed for nutrition, Resident #7, and Resident #140. The findings included: Review of the facility's policy titled Nutrition Assessment and Monitoring, revised on 09/08/24, revealed the following: A systematic approach will be used to optimize a resident's nutritional status. The process includes identifying and assessing each Resident's nutritional status and risk factors, evaluating/analyzing the assessment information, developing and consistently implementing the effectiveness, monitoring pertinent approaches and interventions, and revising them as necessary. Review of the facility's policy titled Resident Weights reviewed on 10/16/24 showed the following: The Weight Team will be responsible for weighing Residents and entering weight into the EMR. Weight Fluctuations shall be re-weighed and then reported to the Nurse/Dietitian/Diet Tech if there is a +/- 5-pound change in weight. Appropriate Documentation shall be entered into the Resident's Medical Record, and proper interventions shall be implemented. Residents shall be weighed within 24 hours of admission and re-admission; they will be re-weighed again within 24 hours. AII admissions and re-admissions are to be weighed for four consecutive weeks after admission. Significant weight deviations of +/- 5 pounds shall be re-weighed within 24 hours and then shall be notified to the Nurse Manager/Dietitian/Diet Tech via Resident weight loss form. The Nurse Manager/Dietitian/Diet Tech shall notify the Physician/ARNP/Physician Assistant in a timely manner. AIl Resident weight gains or losses shall be properly documented in the EMR. Proper interventions shall be put into place and monitored. All weight deviations are to be brought up at NIPS/Care Plan Meetings and discussed with the Interdisciplinary team. 1. Record review showed that Resident #75 was admitted to the facility on [DATE] with diagnoses to include Weakness, Anemia, Failure to Thrive, Sacral Wound, Iron Deficiency and Dementia. The admission 5-day Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #75 has a Brief Interview Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Section GG for eating showed that Resident #75 needed partial to moderate assistance during eating. Review of the weight log for Resident #75 showed the following: On 01/08/24, a weight of 155.6 pounds. On 11/14/24, a weight of 164 pounds. On 11/22/24, a weight of 156.4 pounds. On 12/08/24, a weight of 144.3 pounds. On 01/08/25, a weight of 136.3 pounds. This showed a significant weight loss of 7.7% from 11/22/24 to 12/08/24 and a significant weight loss of 5.5% from 12/08/24 to 01/08/25. In an interview conducted on 01/13/25 at 4:40 PM, Resident #75 stated that he has a good appetite and that he eats enough. When asked if he was aware that he lost weight he stated, it's because he does not eat much. When asked if he would like nutritional supplements, he said yes. An interview was conducted on 01/13/25 at 5:02 PM, with Staff B, Certified Nursing Assistant (CNA), who stated that Resident #75 usually eats 100% of his meals. In an observation conducted on 01/14/25 at 8:23 AM, Resident #75 consumed 100% of his breakfast meal. A bottle of Glucerna (nutritional supplement), which had been provided the night before, was 100% consumed. In this observation, Resident #75 said that he ate 100% of his breakfast meal and has a good appetite. He further stated he likes the Glucerna supplements and drinks them all when provided. An interview was conducted on 01/14/25 at 8:30 AM with Staff L, Licensed Practical Nurse (LPN), who stated Resident #75 gets his nutritional supplements twice a day: at 10:00 AM and at 9:00 PM. The supplements are provided by the Nurse assigned to the resident. They are brought into the pantry on the floor from the Dietary department. The Initial Nutrition Assessment was completed on 11/16/24, 9 days after Resident #75 was admitted . The assessment showed the following: Resident was at high nutritional risk secondary to stage 3-4 pressure ulcers. Resident #75 has increased nutritional needs with interventions added for Pro T Gold (protein supplement), vitamin C, and Zinc. The protein supplements were ordered on 01/14/24 and added 7 days after Resident #75 was admitted . The next follow-up nutritional progress note was dated 12/31/24, about three weeks after the significant weight loss of 7.7% was identified on 12/08/24. This note revealed the following: The Resident was eating 100% of his meals with a 7.3% (clinically significant) weight loss in one month. The goals were to provide Glucerna (nutritional supplements) twice a day and to monitor weekly weights for three weeks. Further review of the nutritional progress notes did not show that a follow-up progress note was completed on Resident #75, identifying the significant weight loss of 5.5% from 12/08/24 to 01/08/25. Record review of the hospital records dated 11/5/24 revealed Resident #75 had a 6 centimeters gastric mass highly concerning for malignancy. The hospital nutritional note dated 11/02/24 showed Resident #75 was 145 pounds. An interview was conducted on 01/14/25 at 3:56 PM with Staff D, Consultant Dietitian, who stated she started working in the facility on 12/16/24. They have 5 to 7 days to complete an initial nutrition assessment but are told to complete them within 5 days. If a resident has a weight loss, the nursing staff would also let her know if it is between the resident's quarterly assessments. A monthly weight report is run, and that is done monthly. They are in the process of initiating a new weight policy that could overlap nursing and nutrition. Staff D stated she runs the weekly weights report weekly and attends the weekly Weights and Wounds meetings. The last Consultant Dietitian left around December 5th, and the Regional Clinical Manager covered the period between December 5th and December 16th. She would try to address any significant weight loss on the same day, and for any discrepancies in weight, she would ask for a reweight. Staff D was aware that Resident #75 had a significant weight change of 5.5%, and she was in the process of writing a follow-up note to address the weight loss. An interview was conducted on 01/14/25 at 5:13 PM with the Director of Nursing who stated the Consultant Dietitian attends the Wounds and Weights meeting weekly. In these meetings Staff D would be notified of any weight changes. The Restorative Certified Nursing Assistants oversees weighting the residents, and they would notify the Unit Manager, Director of Nursing or the Assistant Director of Nursing of any changes. In an observation conducted on 07/15/25 at 7:22 AM, Staff E, Restorative Certified Nursing Assistant, used a Hoyer Lift to take the weight of Resident #75. The Hoyer lift scale showed a weight of 141.4. In this observation, Staff E said she gets a list of the weekly weights and the monthly weights that are needed to be taken from Staff D. For any significant weight changes, she would inform the Unit Manager. In an interview conducted on 01/15/35 at 10:50 AM with Resident #75's Primary Physician, he stated Resident #75 has a tumor in his stomach, and at one point, Hospice services were considered and was denied by the family. Resident #75 has severe osteomyelitis and a sacrum wound. According to the Primary Physician, Resident #75's weight loss is unavoidable, and his weight was around 145 pounds in the hospital. 2. Record review revealed Resident #140 was admitted on [DATE] with diagnoses to inlcude Dysphagia and Dementia. The Quarterly MDS assessment dated [DATE] showed that Resident #140 has a BIMS score of 01, indicating severe cognitive impairment. Section GG for eating showed that Resident #140 needed substantial to maximum assistance. Review of Resident #140 ' s weight record showed the following: 04/12/24: 105 pounds. 05/13/24: 106 pounds. 06/11/24: 108.3 pounds. 07/11/24: 109.6 pounds. 08/12/24: 103.8 pounds. 08/13/24: 102.4 pounds. 08/19/24: 104.4 pounds. 08/26/24: 100 pounds. 10/1/24: 103.7 pounds. 11/12/24: 102 pounds. 12/08/24: 90.8 pounds. This showed a severe weight loss of 10.9% from 11/12/24 to 12/8/24. A follow-up nutritional note dated 12/27/24 was completed by Staff D, addressing the severe weight loss, which was about 3 weeks later. In this note, Staff D stated Resident #140 was eating 26% of the last 12 meals recorded and met less than 75% of her estimated calorie needs. She was receiving superfoods with all meals and was also receiving Glucerna (nutritional supplements) 3 times a day. Resident #140 has a stage 3 sacral wound and was on Protein supplements as well. In this note, Staff D recommended decreasing the Glucerna to twice a day and adding Magic cup (nutritional supplement) at supper time. In an observation conducted on 01/13/25 at 5:10 PM, Resident #140 was eating her dinner meal with Staff F, Activities, at the bedside. She stated Resident #140 eats between 75% and 80% of her meals and that she likes to drink a lot. The meal ticket did not have a Magic cup listed, and the dinner meal did not have any nutritional supplements on the tray. In an observation conducted on 01/14/25 at 8:34 AM, Resident #140 was in her room with the breakfast tray. Staff G, Unit Secretary, was in the room helping Resident #140 with her breakfast meal. Staff G stated Resident #140 eats between 25% and 75%, depending on what she gets. Resident #140 likes to drink and gets a nutritional supplement twice a day. If you open the supplement bottles for the resident, she will drink them. According to Staff G, if Resident #140 does not eat her meals, they make sure that she drinks the supplements to compensate for the incomplete meals. In an observation conducted on 01/14/25 at 12:24 PM, Resident #140 was in the room waiting on her lunch tray. A bottle on Glucerna date 01/14/25 at 10:00 AM was noted unopened and untouched at the bed side. In an observation conducted on 01/15/25 at 8:15 AM, Resident #140 was in the room. A bottle of Glucerna, dated 01/14/25 at 2:00 PM, was noted unopened and untouched at the bedside. In an observation conducted on 01/15/25 at 9:04 AM, Staff F sat near Resident #140, assisting her with the breakfast meal. The surveyor asked if she would try to give Resident #140 a Glucerna supplement. A new bottle of Glucerna was brought from the kitchen and was given to Staff F. Staff F brought the Glucerna bottle to Resident #140's mouth and held the bottle for the resident to drink. Resident #140 was observed drinking the Glucerna, and Staff F said, She loves drinking, as she proceeded to hold the Glucerna supplement for Resident #140. In an interview conducted on 01/16/25 at 8:57 AM, Staff D stated that in her note on 12/27/24, she recommended decreasing the Glucerna supplements from 3 times a day to 2 times a day because she was told that Resident #140 was only drinking two cans a day. She added a Magic Cup nutritional supplement to the dinner tray, which comes from the kitchen on the tray. The Magic Cup was added to Resident #140's dinner meal tickets. Review of Resident #140's meal tickets from 12/29/24 to 01/13/25 did not show that a Magic Cup supplement was added to the dinner meals. In an interview conducted on 01/16/25 at 9:30 AM with Staff D, she acknowledged that the Magic Cup supplements were never added to the meal tickets for Resident #140.

Based on observations, interviews and record reviews, the facility failed to follow physicians orders for fluid restriction for 1 of 1 sampled resident, Resident #42, reviewed for Dialysis. The findings included: Review of the policy document provided, titled Dialysis Residents, with a policy #2008, and reviewed on 10/16/24, revealed the purpose is to ensure that all needs / services of residents on dialysis are met while at the Facility. Recor review revealed Resident #42 was admitted on [DATE] with diagnoses including End Stage Renal Disease on Dialysis, Anxiety Disorder, Anemia, and Hypertension. Review of quarterly Minimum Data Set (MDS) assessment, Section C, dated 12/11/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Review of physician orders dated 09/11/24 revealed to monitor intake every shift as per fluid overload prevention protocol: 24-hour fluid restriction in milliliters (ml). 1200 ml (nursing 480 ml and dietary 720 ml). The order documented: 120 ml fluid restriction for night shift, 120 ml fluid restriction for evening shift, and 240 ml fluid restriction during the day shift. Review of a document, titled Week at a glance customized for resident #42, and provided by Staff HH, Regional Dietician, on 01/15/25 at 4:30 PM, revealed 780 milliliters (ml) daily average fluid provided by the Dietary Department on resident's meals. At this time, Staff HH stated she added the value in mls opposite the fluid served on breakfast, lunch and dinner. Review of the Certified Nursing Assistant (CNA) intake records dated 01/06/25 to 01/16/25 revealed several dates when Resident #42 received more than the 480 ml fluid from nursing, except on 01/07/25 (220 ml); on 01/09/25 (100 ml), and on 01/13/25 (360 ml). The amount of fluid nurses provided were documented as follows: 610 ml on 01/08/25, 880 ml on 01/09/25, 630 ml on 01/11/25, 420 ml on 01/12/25, 360 ml on 01/13/25, 960 ml on 01/14/25, and 840 ml on 01/15/25. Review of the Medication Administration Records (MARs) dated 01/01/25 to 01/14/25 revealed 2 times for the night shifts, fluid intake documentaion with the exception on 01/11/25 when a 120 ml being documented. In an observation on 01/13/25 at 2:00 PM, Resident #42 had a pitcher filled with water on a meal table (bedside) next to the right side of her bed. When asked if staff told her about the fluid amount she is allowed to drink, she stated I do not drink that much. An observation on 01/14/25 at 4:20 PM, revealed Resident #42 was seen with a pitcher of water and a styrofoam cup on the meal table on the right side of her bed. In an interview with Staff GG, Certified Nursing Assistant (CNA), on 01/16/25 at 1:58 PM, when asked regarding the care of the resident with fluid restriction, she stated, to put the resident head high, to give little water to resident, and to inform the nurse on how much fluid resident consumed. In an interview with Staff HH on 01/16/25 at 1:27 PM, she stated Resident #42 has a fluid restriction order of 1200 ml daily, where dietary provides 840 milliliters (ml), and nurses provide 360 ml daily. When asked how much the actual daily resident fluid consumption was and if data were recorded, she responded the Nutrition department provided the fluids on the meal tray, but the nurses document the total amount consumed. She added that fluid restriction in served meals are provided by the Nutrition department, but they do not keep records of daily resident's fluid consumption.

Based on review of policy and procedure, interview, observation and record review, the facility failed to address social services responsibilities regarding missing personal items and clothing for 1 of 1 sampled resident, Resident #223. The findings included: Review of undated facility's licensed Social Worker job description on [DATE] at 11:17 AM provided by the Administrator documented, Summary & Objective: The Social Worker coordinates and provides medically related Social Services to attain or maintain the highest practicable, physical, mental, and psychosocial wellbeing of each resident . Essential Functions: Complete progress notes/assessments as required . Participates in daily management team meetings to discuss resident status, census changes, and resident complaints or concerns if applicable . Other Duties: Comply with all policies, local, state, and federal laws and regulations and Perform other duties as assigned . Review of the facility's policy and procedure, titled, Handling of Valuables, provided by the Administrator, reviewed [DATE], documented in the Policy Statement: The facility will ensure the safekeeping of resident's personal property by identification processes . Purpose: The facility will establish processes that will maintain and respect the resident's rights to retain and use personal possessions, . and appropriate clothing as space permits, . Identification of Personal Items: 1. On admission and on an ongoing basis, Nursing staff will document, on the inventory of Personal Effects Form that is part of the medical record, all personal items including but not limited to: Clothing . And, all other personal items . Missing Items: In the event that items logged onto the Inventory of Personal Effects form are missing, the resident/family will inform nursing of this situation. Nursing shall endeavor to locate the missing items. If the situation cannot be resolved to the resident's/family's satisfaction, a formal grievance may be filed, as per facility policy. Investigation 1. Anyone receiving a report of a missing item will inform the Charge Nurse. 2. The Charge Nurse will contact appropriate departments, i.e. Environmental Services, Food/Nutritional Services, Security, etc. 3. Departments will also search and investigate. 4. An unusual Occurrence/Incident Report will be completed by Nursing if the item is not located. Record review revealed Resident #223 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus, Anxiety Disorder, Pulmonary Embolism, Acute Lymphadenitis of lower limb, Hypertension, Cystitis, History of falling, Fracture of Sacrum with generalized muscle weakness. The documented Brief Interview of Mental Status (BIMs) score was indicative of moderately impaired, decisions poor, cues/supervision required. On [DATE] at 11:27 AM, a telephone interview was conducted with Resident #223's son, who stated that subsequent to the time that his Mother had a missed medical appointment at this facility, he said that he had spoken with one (1) of the staff in the facility who asked him to bring some clothes into the facility so that they could put them on his Mother when she gets her up. Resident #223's son stated that in the beginning, he took home a bag of dirty clothes to wash that the resident already had in the facility. The resident's son stated he remembers later signing-in some clothing that he had personally brought in, but he said that he did not sign out any clothing. Photographic Evidence Obtained. The son stated that Resident #223 also had some miscellaneous personal items to include: 1) approximately $30 in cash, kept in a wallet in the purse itself which could not later be located and when he checked for this money and mentioned it to the Nun and one of the nurses, it was not addressed and nothing was done, He stated no action was ever taken on it. 2) a handbag containing a gate card to the resident's condominium, which was present when Resident #223 was admitted to this facility and it remained there, but the gate card was missing from her gray pocketbook and disappeared. He also said that he had some pictures of the resident's clothing spread out on her couch at home, before he packed them, so they could be viewed clearly. There were also some pictures of personal items and clothing hanging inside of the facility's closet dated [DATE] which he reiterated were signed in, but he never signed any out. Resident #223's son explained to the surveyor the reason why the family had previously taken pictures of the resident's clothing, while still at her home, prior to bringing them into the facility, was due to the ongoing concerns that they had previously encountered regarding other missing items. Resident #223's son stated that he brought in a new set of clothes after this. Resident #223's son stated that he sent an e-mail on [DATE] to Staff V, Sister/Master of Social Work, regarding some of the above clothing and personal items and she acknowledged with a return e-mail response on the same day. Review was conducted of the e-mail dated and sent on Tuesday [DATE] at 2:22 PM from the Resident #223's son to Staff V. This email was forwarded to the surveyor on Wednesday [DATE] indicating, Hello, please find attached photos of pocketbook, gate card from ,d+[DATE] and the clothing hanging in the closet. Clothes are also laid out for your review. 1. The first photo is of the items spread out on her couch at home before I packed them so they could be viewed clearly. I took the time documenting this due to the other missing items we had encountered. 2. The second photo is the missing gate card that was in her gray pocketbook and disappeared. The bag and card are photographed on the rolling table in her room at St [NAME]. 3. The third photo is the clothes hanging in the closet/wardrobe that was in her room. I was asked to bring the clothes by Staff V . I also reported missing case from my Mother's wallet .I also forwarded Staff V's response to me acknowledging receipt of the below email . The response back to me on Tuesday [DATE] at 2:45 PM was: Received. Thanks; same day. On [DATE] at 12:45 PM, a telephone interview was conducted with Resident #223's daughter, regarding the resident's clothing and personal items. She stated that her Mother was transferred to the hospital and from there she went onto Hospice where she subsequently expired. She stated she was told by someone in the facility that they could not find her Mother's belongings, and this was before 30 days. She stated she spoke with the Administrator and was told they had thrown out the gate card. Resident #223's daughter said the resident's purse was missing some items to include some money and stamps. She said the facility told her to bring in some clothing for the resident to be able to wear for when she gets up, for therapy, etc., she spoke with Staff V but the belongings were never found. She also stated she spoke with the Director of Nursing (DON) who told her she was imagining this, even with pictures being provided. Resident #223's daughter stated none of the belongings were found and she suspected that they had lost the belongings. Resident #223's daughter stated the Administrator said she believes that the items were thrown away. The daughter stated there was no recourse provided to replace by the facility and the Administrator offered to call the Condo association, but she told the Administrator that this was not necessary. During an interview conducted on [DATE] at 12:21 PM with Staff V, regarding the resident's clothing and personal items, she stated that the Unit Manager had spoken to her following a conversation that she earlier had with Resident #223's family about bringing in some clothing for Resident #223 to wear, since she was usually always in a hospital gown, and did not have clothing for an upcoming medical appt. After this appointment, Staff V revealed the resident's son brought in some clothing and no other personal items were brought in, at that time for the resident. Staff V proceeded to show the surveyor some colored photos of the clothing items in Resident #223's closet that were brought in by the resident's son. Staff V presented a copy of both the Inventory List of Personal Effects forms dated [DATE] and of the Changes to Inventory form dated [DATE]. Staff V revealed she had received an e-mail(s) from Resident #223's family during the time frame of [DATE] until [DATE], regarding the resident's clothing and personal items. Staff V was able to locate the e-mail that was sent directly to her on [DATE] at 2:22 PM from the resident's son regarding the resident's clothing and other personal items. She indicated that she did recall previously speaking with the resident's daughter regarding the resident's clothing as well as e-mailing a response back to the resident's son. Staff V stated none of those items were ever found. During this interview, Staff V and the surveyor were joined by the Regional Director of Care Coordinator for the Social Work and Utilization Management Division. At this time, Staff V briefly explained the process/protocol of what to do when a resident has missing clothing and personal items as: when it is learned that a resident has missing clothing and/or personal items they would confirm if it is on the inventory form; they would check the resident's room and laundry, if the item could not be located; the facility would ask the family if they have a receipt or an estimated monetary value, it would go to the Administrator in the form of a grievance and she would make the determination of what happens from there; she would speak with the family, the floor/unit manager, the Social Worker, Unit Secretary, Business office to see if it is a credit card; and a grievance would be completed within a maximum of a one (1) week time-frame. Staff V stated she does not recall speaking with any of the family members after that time, and did recall documenting any further information regarding this in Resident #223's record. There was no documentation found to show that any other pertinent staff members had been informed or notified of these ongoing issues and concerns involving the clothing and personal items for Resident #223's in the record. There was no further documented efforts by the facility, per their protocol, to follow-up with locating Resident #223's clothing and other personal items or belongings, after Staff V's two (2) previous documented telephone conversations on [DATE] and [DATE]. A side-by-side record review was conducted with Staff V, of both Resident #223's Inventory of Personal Effects log dated [DATE], which listed all of the following items: one (1) cell phone and charger, one (1) small hand bag, an unidentified Identification (ID) and two (2) unspecified cards. Photographic Evidence Obtained of above; and of Resident #223's Changes to Inventory log dated atop as [DATE] at 2:15 PM, in which it was documented the resident had all of the following items listed: two (2) pair black and white pants, two (2) shirts black and red, three (3) pair underwear and one (1) black bra. Photographic Evidence Obtained. Both of the inventory forms ultimately had Resident #223's signature at the bottom of the page. There was also an incomplete section at the bottom of the Inventory of Personal Effects log, and on the Discharge section on the bottom of the Changes to Inventory log indicating, receipt of valuables from the facility in good condition, as listed on this form, was also incomplete, unsigned and undated by both the Resident/Relative and the facility employee. There was no clarity or documentation on either of the above forms to indicate or authenticate as to whether or not the signature of Resident #223's son on the two (2) forms were signed at the time of drop-off, or at the time of pick-up, of any of the resident's clothing or personal items. Record review of the Social Worker notes by Staff V, dated [DATE], [DATE], [DATE], in which it was noted that, .SW took a small black purse from the resident's handbag that contained two credit cards ([name] Visa card and [Name] Credit Union Card), one [name] medical card, Driver's License and two [name] cards and some papers. Stored in SW office. Will contact family to pick up Credit Cards . The writer spoke with resident's son regarding resident's wallet. He will arrange pick up with the writer. He reported that he visited and picked up resident's Iphone and signed inventory with a nurse Resident collected his Mother's purse that contained her ID, two credit cards. Further record review of the last two (2) SS notes by Staff V, dated [DATE] and [DATE], documented, Resident is still in the hospital Writer followed up with .resident's daughter who also mentioned that she will stop-by soon to pick up resident's belongings. Writer informed floor staff and business; there was no documentation reviewed to support this .SW contacted resident's family .resident's daughter .stating that she will come during the week to pick up resident's stuff. There was no evidence reviewed in the transfer nurses' progress notes dated [DATE] at 5:26 PM by Staff W, LPN, referencing the status of Resident #223's clothing nor personal items, upon discharge from the facility. An interview was conducted with the Director of Social Services [DATE] at 4:03 PM regarding the resident's clothing and personal items and she stated that, the last communication she had with Resident #223's family members was on [DATE] involving the issuance of the Notice of Non-Medicare Coverage (NONMC). The Director of Social Services revealed she had not had any communication with the family during the resident's facility stay regarding the resident's clothing or personal items, as documented in the record. The Director of Social Services indicated she was not notified of any concerns or issues with missing clothing items or personal property for this resident at any time during the facility stay, by her own staff or by any other facility staff members. The Director of Social Services explained that the overall policy for following up with missing personal items and clothing involves: informing the Director, completing a grievance pending an investigation of the missing items, and a resolution being reached. This was not done. The Director of Social Services stated there was no report made and no grievance completed for such. An interview was conducted on [DATE] at 5:16 PM with the Director Of Nursing (DON) regarding Resident #223's clothing and personal items, who revealed she was not notified or informed of any concerns or issues with any missing clothing items or personal property at any time during the facility stay by her own staff or by any other facility staff members. The DON stated the facility has three (3) locked storage areas on-site for the resident's personal items and clothing (stored at a minimum of 30 days) on each nursing floor, and in each nurses' station / units there is a key to the storage room kept in an un-locked nurses' station desk (which is accessible to any staff member on the nursing floor). The DON further revealed that these three (3) storage rooms can go unattended for months without being checked. Photographic Evidence Obtained. The DON reiterated the procedure for following up with missing clothing and personal items reports from the resident or their representative as: a grievance would be filed pending an investigation of the missing items, the facility would check the inventory log to see if the items missing are on the inventory list, if they are there they would look for the missing items, but if they could not be located, then 3) the facility would ask the family to see what can be done e.g. reimbursement, 4) the Business office would follow-up, and 5) a resolution is reached, and the family would receive their reimbursement, if applicable. She acknowledged that none of the above steps had been followed in this case. On [DATE] at 5:35 PM, an observation was conducted of one (1) of three (3) storage rooms on the second (2nd) floor for resident's clothing and personal items in which it was noted there were numerous different types of bagged items, wheelchairs, etc. packed into the locked room, located in the community shower room. The key to this room is was accessible to anyone entering the nurses' station; and all of the staff members are aware of this key location, per the DON. The DON stated there was no master Inventory List of the facility's residents' personal belongings and items, only individual paper lists which are kept in each resident's chart. On [DATE] at 6:14 PM during an interview conducted with the Administrator, she stated she was not notified or informed of any issues or concerns involving missing clothing or personal items by any of her facility staff, for Resident #223. The Administrator revealed she had no prior knowledge or any idea about anything regarding Resident #223 personal items and missing clothing until the day of the survey.

Based on observations, interviews and record review, the facility failed to secure dispensed medications which were left unattended on a medication cart, and dispensed medications left at the bedside for a resident during initial observational tour, for 1 of 164 resiudents observed, Resident #374; failed to secure a treatment cart while unattended during wound care observation; and failed to secure an unlocked medication cart review in the facility's third floor wing. The findings included: Review of the facility's policy, titled, Drug Procurement/Storage/Inspection, effective date 12/03/04, reviewed date 10/24/24, included the following: Policies and procedures are designed to ensure the safe and accurate dispensing of medications throughout the facility. Procedure: Medications are stored in a secure manner. Lockable medication carts are used to store unit-of-use medications in the resident medication dose system. These carts will be locked when not attended. Review of the facility's policy, titled, Bedside Medications, effective date 12/03/04, reviewed date 10/25/24, included the following: It is the policy of this facility that certain medications may be left at the bedside only on the specific order from the physician. Medications left at the bedside may be administered following the Self-Administration of Medications policy and procedure requirements. Procedure: Medications shall not be left at the bedside for self-administration, with the exception of the following which have been approved by the Interdisciplinary Team: Aerosols and/or bronchodilators used in the treatment of bronchospasms Antacids Eye drops Throat lozenges External preps for topical application All medications left at the bedside may only be administered following the Self-Administration of Medications policy and procedure requirements. If the tenets of that policy are not met, the medications may not be left at the resident's bedside for self-administration. Bedside medications must be kept in a locked cabinet or drawer. 1. During the initial tour conducted on 01/13/25 at 10:45 AM, Staff FF, Licensed Practical Nurse (LPN), was observed on the third floor administering medications. Staff FF was observed entering a resident's room with the vitals' machine. Further observation of the medication cart revealed two small medication cups left on top of the locked cart. One of the small medication cups contained a green/bluish liquid and the other cup contained a few hard substances mixed with apple sauce. Photographic Evidence Obtained. The surveyor observed a few staff members pass by the medication cart including the in-house pharmacist. Staff FF returned to the medication cart approximately 5 minutes later. At this time, Staff FF was asked about the two small cups. She confirmed the contents of the small medication cups were medications for a resident. She stated the resident did not want the medications and she was going to try to administer the medications to the resident later. Staff FF opened the medication cart and placed the two cups containing the dispensed medications in the top drawer of the medication cart. 2. Record review for Resident #374 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Displacement Intertrochanteric Fracture Femur, Traumatic Subdural Hemorrhage, History of Falling, Localized Osteoporosis, Hypomagnesemia, Hypertension, Hyperlipidemia, Neuralgia and Neuritis. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #374 had a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. Review of the Physician's Orders showed Resident #374 had orders dated 12/27/24 for Calcium Carb-Cholecalciferol 600mg -10mcg tablet by mouth daily for Vitamin Deficiency; for Docusate Sodium 100mg tablet by mouth twice a day for Constipation; for Gabapentin 300mg capsule by mouth twice a day for Neuropathic Pain; and for Magnesium Oxide 400 (240mg) mg by mouth daily for Hypomagnesemia. Review of Resident #374's January electronic Medication Administration Record (eMAR) revealed Resident #374 was scheduled to receive the above 4 medications and it was document by the nurse as administered at 9:00 AM. During an observation conducted on 01/13/25 at 11:25 AM of Resident #374, she was noted in her bed. Upon closer observation, there was a small medication cup with 4 unidentified pills on the over-bed-side table in front of Resident #374. Photographic Evidence Obtained. When asked what was in the small cup, Resident #374 stated they were her morning medications, and the nurse just left it for her to take. She also stated the nurse does this every so often. Review of Resident #374's form, titled, Evaluation for Self-Administration of Medications, dated 12/27/24, revealed the resident was not evaluated to self-administer her medications. An interview was conducted on 01/16/25 at 9:27 AM with Staff W, LPN, who stated she has worked for the facility for 4 1/2 years. She stated dispensed medications that are refused by the resident are to be discarded or wasted in the drug buster. Then she stated that if the resident decides to take the medications afterwards, the medications are again dispensed and administered. She confirmed that the nurses cannot hold on to dispensed medications in the medication cart to be administered later. In addition, Staff W stated a resident can self-administer medications if the resident was assessed and there's an order from the physician stating the resident can self-administer the medications. She acknowledged that medications should never be left at the bedside, and the resident should be monitored even if they can self-administer. During an interview conducted on 01/16/25 at 10:36 AM with Staff CC, third floor Nurse Manager, who stated she has worked at the facility for 8 years. She stated nurses are to dispense and right away administer the medications to residents. Staff CC added that if the resident refuses the dispensed medications, the nurse is to document in the resident's chart and then destroy or waste the medications. She stated for residents to self-administer their medications, the resident would be evaluated by the nurse to see if resident can read the labels on medication bottles and demonstrate that they are able to administer medications properly. Staff CC stated a locked box would be placed at the bedside for the medications, the nurses will assist with the locked box and must be present when the resident takes the medication. During an interview conducted on 01/16/25 at 10:56 AM with Staff DD, 2nd floor nurse manager, who stated she has worked at the facility for 4 months. She stated that upon admission, a resident is assessed for self-administration of medications. Staff DD presented the self-administration medication form for Resident #374 and confirmed that the resident had not been assessed to self-administer her medications. An interview conducted on 01/16/25 at 11:09 AM with the Director of Nursing (DON). She stated the nurse is to document when the resident refuses their medication, contact the physician and destroy or waste the refused medications. The DON acknowledged hearing of the dispensed medications that were left on top of the medication cart and left on the bedside for the resident to be self-administered. 3. Wound care observation, on the 2nd floor, was conducted on 01/16/25 at 9:36 AM with Staff EE, LPN and wound care nurse, who stated she has worked at the facility for [AGE] years. She gathered all the supplies and placed them on top of the treatment cart, then she stated she would wash her hands in the resident's room. Staff EE walked away to the room, leaving the treatment cart unlocked, unattended and the supplies on top of the cart. She returned to the treatment cart and donned a gown, picked up the supplies and entered the resident's room. Staff EE again left the treatment cart unlocked and unattended in the hallway. The surveyor observed unlicensed staff members, therapy staff and residents walking and in wheelchairs ambulating by the unlocked treatment cart. During the wound care procedure, Staff EE returned to the treatment cart to retrieve additional tape and realized the cart was unlocked, but continued to retrieve the tape and don on a clean gown and went back into the room, leaving the treatment cart unlocked and unattended again. Upon completing the wound care procedure, an interview was conducted with Staff EE, who acknowledged leaving the treatment cart unlocked and unattended. Observations of the treatment cart revealed the wound cart contained ointments/creams labeled with residents' names, scissors, and wound supplies. 38349 4. Review of the facility policy and procedure, titled, Drug Procurement / Storage / Inspection, provided by the Administrator, reviewed 10/25/24, documented in the Policy Statement: Responsibility for control of medications within this facility rests with the facility and the Pharmacy. Policies and procedures are designed to ensure the safe and accurate dispensing of medications throughout the facility. These policies will be approved by the designated facility committee (s) .Procedure: Storage: Medications are stored under proper conditions as stated by the medication manufacturer to assure stability of that medication. Medications are stored in a secure manner. Lockable medication carts are used to store unit-of-use medications in the resident medication dose system. These carts will be locked when not attended. During an observation on the South wing hallway conducted on 01/14/25 at 10:47 AM, it was observed that the South Wing Medication cart #33 had been left unlocked and unattended; accessible to residents, staff members and visitors. An interview was conducted with Staff X, Licensed Practical Nurse (LPN), regarding the South Wing Medication cart #33 having been left unattended and unlocked. Staff X acknowledged that it was, but should not have been. Interview was conducted on 01/14/25 at 4:27 PM with the Registered Nurse / Unit Manager (RN UM) 3rd floor, working in the facility for [AGE] years, regarding the South Wing Medication cart #33 being left unattended and unlocked, and she also acknowledged that the medication cart should not have been left unlocked and unattended. Interview conducted on 01/15/25 at 11 AM with the DON, regarding the South Wing Medication cart #33 having been unattended and unlocked. She further acknowledged that the South Wing Medication cart #33 should have been secured.

38349 Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure it honored the resident's food preferences during a lunch meal for 4 of 33 sampled residents observed, Resident #14, Resident# 151, and Resident #133. The findings included: Record review of the facility policy and procedure, titled, Nutritional Services Rounds, provided by the Administrator, reviewed 10/16/24, documented: Purpose: To determine resident's likes/dislikes and overall acceptance of meal service. Residents' cultural, religious and ethnic food preferences are honored when possible and when not contraindicated To identify any errors or deficiencies in the meal tray service. Policy: The Registered Dietician or Dietary Technician: Record as appropriate, nutrition information in the medical record on nutrition progress notes. 1. Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnosis to included Gastroesophageal Reflux Disease (GERD). The current Minimum Date Set (MDS) assessment documented a Brief Interview Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. On 12/19/24, the Physician's Order documented, Regular diet for Resident #14. Record review of the Resident #14's Dietary / Nutritional Care plan revised 12/29/23 indicated Interventions: Honor food preferences . On 01/13/25 at 1:29 PM, an observation was conducted of Resident #14's lunch meal of a mechanical soft diet of chicken chunks and rice. Photographic Evidence Obtained. At this time, the lunch meal ticket documented the resident was to have chopped chicken with rice, instead. An interview was conducted on 01/14/25 at 9:50 AM with Staff Y, Certified Nursing Assistant (CNA). According to the CNA, she said that the dietary knows this resident does love chicken. She acknowledged this should have been recorded on the resident's lunch meal ticket; but it was not. On 01/14/25 at 10:18 AM an interview was conducted with Staff Z, Licensed Practical Nurse (LPN). According to the nurse, she acknowledged the food recorded on the lunch meal ticket was not what the resident had actually been served for lunch. 2. Record review revealed Resident #151 was admitted to the facility on [DATE] with diagnoses that included Acute Systolic (Congestive) Heart, Atherosclerotic Heart Disease and Chronic Kidney Disease. The current MDS documented a Brief Interview Mental Status (BIM) score of 10, indicating (moderate impairment). On 07/25/24, the Physician's Order documented, Mechanical Soft diet with minced / moist meats and thin liquids. Record review of the Resident #151's Dietary / Nutritional Care plan initiated 07/31/24 indicated Interventions: Honor food preferences . On 01/13/25 at 1:33 PM, the resident's lunch meal ticket documented the resident was to receive an Italian Beef Sandwich with potato tots. An observation conducted of the Resident# 151's lunch meal for the Dysphagia Mechanical diet revealed the meal tray with mashed potatoes and gravy only. There was no meat, no bread and no potato tots according to the resident. Photographic Evidence Obtained. Interview on 01/13/25 at 1:36 PM with the resident was conducted who stated she did not have a sandwich but received only mashed potatoes and gravy with no meat, no bread. She said that it bothers her that they prepare basically the same type of meals everyday, but not what she especially likes or prefers. The resident added that she recalls telling staff, but nothing changes. On 01/14/25 at 9:50 AM, an interview was conducted with Staff Y, CNA, who acknowledged that the food recorded on the lunch meal ticket was not what the resident had actually been served for lunch. During an interview conducted on 01/14/25 at 10:18 AM with Staff Z, Nurse, she acknowledged that the food recorded on the lunch meal ticket was not what the resident had actually been served for lunch. 3. Record review revealed Resident #133 was admitted to the facility on [DATE] with diagnoses that included Metabolic Encephalopathy, Folate Deficiency, Anemia and Vitamin Deficiency. The current MDS documented [added] a Brief Interview Mental Status (BIMS) score of 14, indicating intact cognition. On 10/10/24, the Physician's Order documented, Regular diet with cut up meat/mechanical soft meats and thin liquids. Record review of the Resident #133's Dietary/Nutritional Care plan reviewed 12/23/24 indicated Interventions: .Honor food preferences. On 01/13/25 at 1:41 PM, the lunch meal ticket documented the resident was to have a peanut butter and jelly sandwich. An observation at this time was conducted of the Resident #133's lunch meal for the Regular diet, showed that he had received a beef sandwich with tater tots, fruit and soup. Photographic Evidence Obtained. On 01/13/25 at 1:45 PM, an interview was conducted with Resident #133 who was asked about his care and services. He voiced that everything was ok, but the food here is not good, no taste; and it is usually been that way. He stated he did eat some of the soup for lunch today and he took a few bites of the sandwich, but it bothered him because it was very dry and tough. He said he did not want to even ask the staff again for anything else since it might not be any better. On 01/14/25 at 9:50 AM, an interview was conducted with Staff Y, CNA, who acknowledged the food recorded on the lunch meal ticket was not what the resident had actually been served for lunch. On 01/14/25 at 10:18 AM, an interview was conducted with Staff Z, Nurse, who acknowledged the food recorded on the lunch meal ticket was not what the resident had actually been served for lunch. An interview was conducted with the Director Of Nursing (DON) on 01/15/25 at 3:59 PM who acknowledged there was an incorrect discrepancy between what the resident's lunch meal tray had on it and what was actually recorded on the lunch meal ticket.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food according to professional standards for food service safety and sanitary conditions and to prevent foodborne illnesses for 2 of 2 observations to the main kitchen. The findings included: In an initial tour of the central kitchen conducted on 01/13/25 at 9:00 AM, the following were noted: 1. The Food Service Director did not have a facial hair covering in the food production area. 2. A dirty used rag was noted in the food production counter that was not placed in a sanitation bucket. 3. One (1) light of 3 lights under the hood was not working. 4. A 16-ounce private plastic drinking cup was noted under the food production area. 5. A large bag of cooked pork in the walk-in refrigerator had a date of 01/04/25 with a used by date of 01/07/25. 6. A large metal container of [NAME] sauce in the walk-in refrigerator had a date of 01/07/25 with a used by date of 01/09/25. 7. A large metal container of Marinara sauce in the walk-in refrigerator had a date of 12/31/24 and a used-by date of 01/03/25. 8. A large metal container of cooked eggs in the walk-in refrigerator had a date of 01/7/25 and a used-by date of 01/09/25. 9. A large metal container of cream of broccoli soup noted in the walk-in refrigerator had a date of 01/01/25 with a used-by date of 02/03/25. In this observation, the Food Service Director was not sure as to why the used-by date for the soup was about one month later. 10. A large metal container with pieces of raw fish was noted with a date of 01/09/25 and a used-by date of 01/11/25. 11. A large metal container with pieces of raw chicken noted with date of 01/09/25 and a used by date of 01/12/25. 12. A review of the Diet Spreadsheet week 2, day 2, showed the following menu for the Regular diet: 3 ounces of pork and 2 ounces of salsa sauce. In an observation conducted on 01/15/25 at 11:35 AM in the main kitchen during the tray line, a large tray of pre-sliced pork pieces was noted. The Food Service Director plated a sliced pork for a Regular consistency diet meal ticket. The surveyor requested that the weight of the sliced pork with the salsa sauce be taken using a facility-calibrated scale. The sliced pork and the salsa sauce were noted to be 2-ounces in total and not the necessary 3 ounces as per the facility's menu. An interview was conducted on 01/15/25 at 11:40 AM with Staff K, Cook, who stated that he pre-slices the pork pieces for 4-ounces each.

Based on observations, interviews and record reviews, the facility failed to disinfect the vital signs machine between residents' usage for Residents #137, Resident #42 and Resident #428; and failed to follow droplet precaution protocol for residents' positive for Coronavirus Disease 2019 (COVID-19), for Resident #375. The findings included: Review of the facility document, titled, Guidelines for Isolation Precautions, policy #4022, dated 10/25/24, revealed standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infections in hospitals. Page 5 of the policy revealed droplet transmission is a form of contact transmission, where droplets are generated from the source person primarily during coughing, sneezing, talking, and during the performance of suctioning and bronchoscopy. Isolation precautions are designed to prevent transmission of microorganisms in healthcare facilities. Since agents and host factors are more difficult to control, interruption of the spread of infection is directed primarily at transmission. Further review of policy on page 6 revealed the fundamentals of isolation precautions with infection control measures such as hand hygiene per new Center for Disease Control and Prevention (CDC) guidelines and gloving; cleansing hands as promptly and thoroughly as possible, between resident contacts and after contact with blood, body fluids, secretions, excretions and equipment or articles contaminated by them, appropriate resident placement explaining resident with highly transmissible or epidemiologically important microorganism are placed in private room, and appropriate barriers like mask, impervious dressings are worn or used by the resident to reduce transmission of microorganisms to other residents, personnel and visitors, and to reduce contamination of the environment. Page 9 of the policy revealed resident care equipment and articles for noncritical equipment (equipment that touches intact skin) contaminated with blood, body fluids, secretions, or excretions is cleaned and disinfected after use. 1. a. Record review revealed Resident #137 was originally admitted on [DATE] and readmitted on [DATE] with the diagnoses that includrf Aftercare following Joint Replacement Surgery, Presence of Left Artificial Hip Joint, Pain Left Hip, and History of Falling. Review of Minimum Data Set (MDS) assessment, Section C, dated 01/02/25, revealed a Brief Interview for Mental Status (BIMS) score of 08 indicating moderately impaired cognition. b. Record review revealed Resident #424 was admitted on [DATE] with diagnoses that included Urinary Tract Infection, Urinary Retention, Anemia, Arthritis, Cerebral-Vascular Accident (CVA), Right Sided Weakness, Benign Prostatic Hypertrophy (BPH) with Chronic Foley (Inventor's name of a urinary catheter) catheter. Review of MDS Section C, dated 01/14/25 revealed a BIMS score of 03 indicating severe impaired cognition. Review of physician orders revealed the following orders: On 01/08/25 for Isolation Precautions, contact for positive urine culture Morganella and Pseudomonas. On 01/09/25, check placement of dressing, replace if soiled or dislodged per Medical Doctor (MD) daily. On 01/10/25, evaluate nonfunctioning right arm midline one time only 01/10/25; and IV protocols: change midline site dressing one time only within the first 24 hours after line insertion, clean site, allow air to dry and cover with transparent dressing. Review of Treatment Administration Record dated 01/09/25 revealed treatment for left dorsal foot 3x (times) a week and provide Foley care every shift with nurses signatures. Review of nurses notes dated 01/13/25 revealed urine clarity, and color was amber, with Foley (urinary) catheter of 20 French and no problems; and on 01/15/25 at 3:09 PM, urine amber with Foley catheter of 20 French with tubing seen on left groin. c. Record review revealed Resident #428 was admitted on [DATE] with diagnoses that included Acute Metabolic Encephalopathy, Dental Abscess, CVA, Hypertension (HTN), Cardiomyopathy, Diabetes Mellitus (DM), and Dementia. Review of the MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Review of physician orders dated 01/02/25 revealed an ordered mechanical soft diet, dysphagia treatment by speech therapy, and wound care consult. The physician orders dated 01/02/25 revealed: Cefdinir (antibiotic) 300 mg capsule by mouth every 12 hours for tooth abscess; and on 01/03/25 an order to avoid direct pressure to sacrum, turn left to right, with wedge pillow, and check dressing placement. During an observation on 01/14/25 at 4:24 PM, Staff O, Certified Nursing Assistant (CNA), left a room with an East labelled Hill-Rom 5-wheels, Spot vital signs machine. She was observed to not disinfect the machine or perform hand sanitizing after leaving the room. She went straight into Resident # 137's room. Upon entering, she was observed not to clean or disinfect the machine and/or sanitize her hands. Staff O put on gloves, touched resident's privacy curtains, applied blood pressure cuff to Resident #137, clipped the pulse oximeter to resident's right pointer finger, and placed the thermometer a few inches away from resident's forehead on 01/14/25 at 4:27 PM. While using her gloved hand, she wrote on her clipboard after taking a pen out of her pocket. Staff O removed the blood pressure cuff from resident's right arm, and with the same gloves used for resident, touched resident's phone, and meal table, and then removed both gloves. She performed ABHR (alcohol-based hand rub) on 01/14/25 at 4:29 PM but did not clean or disinfect the vital signs machine. The machine had a basket with 2 pressure (BP) cuffs with a long gray cord, a pulse oximeter clip with a white cord, and a thermometer with a white cord. On 01/14/25 at 4:30 PM, Staff O went to the next room and sanitized her hands. With the same vital signs machine that she had not disinfected, she then applied the BP cuff on the Resident# 428's left arm on 01/14/25 at 4:30 PM. She was observed touching her forehead with the same gloves she used to apply the resident's BP cuff. With the same set of gloves, she wrote on her clipboard on 01/14/25 at 4:30 PM. She stood next to the vital signs machine and her clipboard was touching the cord part of the BP cuff. She then touched her left ear using the same gloves, removed BP cuff from resident's arm, then removed her gloves, discarded them in trash, and sanitized her hands. Further observation revealed Resident #428's room had an EBP (Enhanced Barrier Precaution) sign on the door frame. Staff O, a CNA did not clean and disinfect the vital signs machine before and after leaving the EBP room. On 01/14/25 at 4:32 PM, observation revealed Staff O placed the vital signs machine in front of Resident# 424's room. The room had an EBP (Enhanced Barrier Precaution) sign posted. On 01/14/25 at 4:33 PM, Staff O donned a personal protective equipment (PPE) gown, put a mask over her other face mask. Staff O did not clean or disinfect the machine she used for Resident #137, Resident # 428 , and a random observed resident on 01/14/25 at 4:33 PM. Staff O put on gloves, then applied the bigger BP cuff (brown, and white in color) to the Resident # 424's arm. She took off the BP cuff shortly afterwards, put it back in the white basket of the Hill Rom machine. She then applied a bp cuff found on resident's meal table. She did not sanitize this resident's BP cuff before putting on resident's left upper arm on 01/14/25 at 04:37 PM. Staff O touched the left side of her eyeglasses, then touched resident's arm, BP cuff, and the bulb of sphygmomanometer with her left hand, and with her right hand touched Resident #424's arm again. She put the BP cuff on top of resident's table without disinfecting it. She took the resident's temperature by placing the thermometer a few inches away from resident's forehead, and with the same gloves she used on this resident touched her clipboard and pen. She continued and touched the resident's napkin on the meal table, then pushed the meal table closer to resident's bed with the same set of gloves. She wheeled the vital signs machine next to the bathroom, removed her PPE gown, performed handwashing in resident's bathroom, and left the room with the machine. She did not clean and disinfect the machine but placed and plugged it into an electrical outlet on 01/14/25 04:42 PM. She then walked away from the East labelled Hill-Rom machine. In an interview with Staff O on 01/14/25 at 4:44 PM, when asked regarding CNA's care of residents with EBP post, she stated staff must put on gown, mask, glove before caring for residents. When asked why staff must wear the mentioned items, she responded, To protect self. In an interview with the Administrator on 01/14/25 at 5 :10 PM, when asked regarding disinfection of the Hill-Rom machine, she stated the facility does not have any. When asked what disinfectant the facility uses for the Hill-Rom machine, she responded, Whatever the manufacturer recommends. 40153 2. Record review revealed Resident #375 was admitted to the facility on [DATE] with diagnoses that included Muscle Weakness, Hypertension, and type 2 Diabetes. Review of the Physician's order showed an order dated 01/10/25 for droplet, contact, for Coronavirus disease (COVID-19) positive. In an observation conducted on 01/13/24 at 10:30 AM and 11:09 AM, Resident #375 was noted in his room with a droplet isolation precaution sign noted on the door. Continued observation at 12:15 PM revealed Staff A, Certified Nursing Assistant (CNA), was noted taking the lunch tray to Resident #375's room without practicing hand sanitizing before entering the room. She entered the room with a surgical mask but no gown or gloves. Staff A touched the side table and adjusted Resident #375's items on the side table before setting down his meal tray. She then walked around the bed and used the bed remote to help Resident #375 elevate his body and head. During this entire observation, Staff A used her bare hands. An interview was conducted on 01/16/25 at 7:20 AM with Staff J, CNA, who stated when a resident is on droplet isolation, she needs to make sure that she puts on a gown, mask, and gloves before going into the droplet isolation room. She then pointed out the Personal Protective Equipment (PPE) cart that was noted outside the room.

Based on observations, interviews, and record review, the facility failed to identify and provide nutritional interventions in a timely manner to prevent avoidable, severe weight loss for 4 of 7 sampled residents reviewed for nutrition, Residents #138, #42, #363, and #137. The findings included: Review of the facility's policy, titled, Weight Management, dated March 2017, showed, in part, the following: The dietitian or authorized clinical designee, in conjunction with the facility interdisciplinary team (IDT), will monitor and evaluate resident weights for significant changes or other changes that may indicate changing nutritional status. Resident weights will be obtained per facility policy and recorded in the medical record. Each resident will be weighed monthly (every 30 days) or more frequently (weekly, daily) per physician's order, nursing, or dietitian recommendation. For new admissions, weekly weights for four weeks are recommended. A reweigh must be obtained within 48 hours (or per unit policy) if a weight change that meets the following criteria is noted: If the resident is over 100 pounds, loss or gain of 5 pounds if the resident is less than 100 pounds, loss or gain of 3 pounds. The dietitian and authorized designee will assist the clinical team with identifying significant weight changes and pertinent trends as needed based on the facility process. The percent of Body Weight Change Interval is 2% one week, 5% one month, 7.5% three months, and 10% six months. Nutrition reassessment and modifications to existing plan of care may indicate. The dietitian will reassess the nutritional needs and intake of the resident with a weight change. Appropriate recommendations will be documented in the medical record and Dietitian Communication Log. Review of the facility's policy, titled, Nutrition Assessment and Progress Notes, dated March 2017, showed, in part, the following: All residents will receive a comprehensive nutrition assessment by a registered dietitian or authorized designee. Evaluation and documentation of nutritional concerns are recorded in a timely manner in the medical record. The nutrition assessments are an in-depth evaluation of objective and subjective data related to an individual's food and nutrient intake, lifestyle, and medical history. The assessment is the first step to be completed using the Nutrition Care Process. Progress notes are completed for intermittent documentation as needed according to facility policy and with nutrition status or care changes. Review of the facility's policy, titled, Resident Weights, reviewed on 08/14/23, showed, in part, the following: The Weight Team will be responsible for weighing Residents and entering weight into the Electronic System. Weight fluctuations shall be re-weighed and then reported to the Nurse / Dietitian / Diet Tech if there is a +l - 5-pound change in weight. Appropriate documentation shall be entered into the Resident's Medical Record, and proper interventions shall be implemented. To accurately report and record weights for monitoring and documenting residents' weight variances. Residents shall be weighed within 24 hours of admission and re-admission. All admissions and re-admissions are to be weighed for four consecutive weeks after 4. All residents will be weighed monthly unless a more frequent schedule is required, as noted. Any resident that the Physician / Nurse Manager / Dietitian / Diet Tech judge needs to have their weight checked more frequently may be placed on a weekly weight schedule. Significant weight deviations of +/- 5 pounds shall be re-weighed within 24 hours and then shall be notified to the Nurse Manager / Dietitian / Diet Tech via Resident weight loss form. All Resident weight gains or losses shall be properly documented in the Electronic System. Proper interventions shall be put into place and monitored. Calibration of scales is to be done quarterly by a company that is under contract. 1. Record review revealed that Resident #138 was initially admitted to the facility on [DATE]. He was discharged on [DATE] and returned to the facility on [DATE]. Resident #138 was transferred to the hospital on 08/05/23 and returned to the facility on [DATE]. The hospital consultation report dated 08/12/23 revealed that Resident #138 is a [AGE] year-old with a history of Diabetes, Stroke, and Seizures. Resident #138 was diagnosed with aspiration pneumonia (food or liquid is breathed into the airways or lungs) and to provide tube feeding with goal for optimal caloric intake. Resident #138 is also non-verbal and has altered mental status. The physician's orders, dated 08/16/23 and discontinued on 08/18/23, showed the following tube feeding history: Nepro (tube feeding formulary) at 55 milliliters (ml) an hour for 12 hours, starting at 6:00 PM and off at 6:00 AM. This tube feeding order provided 1183 calories daily and 53 grams of protein daily. A new physician order was noted, which began on 08/18/23 and discontinued on 08/25/23, for Nepro 60 ml an hour for 15 hours starting at 7:00 PM and off at 10:00 AM. This order provided 1620 calories a day and 73 grams of protein daily. A new physician order, starting on 08/25/23 and stopped on 09/15/23, was noted for Nepro at 45 ml an hour for 18 hours, starting at 4:00 PM and stopping at 10:00 AM. This tube feeding provided 1485 calories and 66 grams of protein a day. On 09/15/23, a new physician order for tube feeding was noted for Nepro at 50 ml an hour for 20 hours starting at 2:00 PM and stopping at 10:00 AM, providing 1800 calories a day and 81 grams of protein a day. The pressure ulcer skin report dated 08/17/23 revealed that Resident #138 has a stage 4 pressure ulcer, exposing muscle and noted to the sacrum area. In an observation conducted on 09/18/23 at 7:58 AM, Resident #138 was observed in his bed with the tube feeding Nepro running at 50 ml an hour. Closer observation showed a tube feeding with Nepro, which started on 09/17/23 the day before at 2:00 PM. The tube feeding bottle was marked on the 300 ml level on the 1000 ml capacity bottle. The tube feeding, which started at 2:00 PM the day before, running at 50 ml an hour, should have been on the 100 ml mark on the 1000 ml capacity bottle. Continued observation conducted on 09/18/23 at 10:00 AM showed Resident #138 was noted in his bed with the tube feeding running at 50 ml an hour. Closer observation showed a tube feeding with Nepro, which started at 2:00 PM the day before. The tube feeding level was on the 200 ml mark on the 1000 ml capacity bottle. The tube feeding bottle, which started at 2 PM the day before and ran at 50 hours, should have been completed at this time. An observation conducted on 09/18/23 at 2:45 PM showed that a new tube feeding bag was started at 2:00 PM with Nepro at 50 ml an hour. The tube feeding was at the 1000 mark on the 1000 capacity bottle. In an interview conducted on 09/19/23 at 7:00 AM, Staff D, Registered Nurse (RN), stated Resident #138 is tolerating his tube feeding well with no issues. In another observation conducted on 09/19/23 at 9:00 AM, Resident #138 was noted in the bed with the tube feeding on hold. The tube feeding showed that it was the same tube feeding bottle that started the day before at 2:00 PM. The tube feeding was on the 450 level on the 1000 ml bottle. The tube feeding that started the day before at 2:00 PM should have been at around the 50 ml mark on the 1000 ml bottle. In an observation conducted on 09/20/23 at 7:00 AM, Resident #138 was noted in his bed with the tube feeding running at 50ml an hour. Closer observation showed that the tube feeding was started at 8:00 PM the night before, dated 09/19/23. The tube feeding was noted at the 1000 ml mark on the 1000 ml capacity bottle. The tube feeding that started the night before at 8:00 PM should have been around the 450 ml mark (550 ml should have been infused) at 7:00 AM the next day. An interview conducted on 09/20/23 at 7:10 AM with Staff E, Licensed Practical Nurse LPN), stated that the 3:00 PM to 11:00 PM nurse started the tube feeding and that it was started at 8:00 PM. She further noted that the tube feeding was running all night and that Resident #138 was tolerating the tube feeding well. An interview conducted on 09/20/23 at 12:20 PM with Staff H (Clinical Dietitian) and the Clinical Dietary Manager. They stated that weights are taken upon admission, once a week for four weeks, until they become monthly, and then they weigh them once a month. All residents on tube feedings are considered high-risk residents, and weights are taken monthly. The weights are taken by Restorative Certified Nursing Assistants, who oversee taking the weights on all residents. New admission weights are based on the census that is printed for the day and given to the staff responsible for obtaining weights. For the monthly weight, the Dietitian will write the list of residents who need a monthly weight and give it to the designated staff. Staff H will write the list of residents who need a weight on a piece of paper, which is later given back to her with the weights taken. Staff H reported that the Dietitian working for that day will input the weights into the electronic system. For all significant weight loss that is identified, they will be addressed with interventions within 24 hours. When asked if the type of scale used is also documented with the weights in the electronic system, they said no. According to the Clinical Dietary Manger, for all severe weight loss identified, they will do a complete nutritional assessment. They will review their weight history, diet, medication, and any supplements they are provided. They will also try and interview the residents to see if they like the supplements or update their food preferences for other food items. For weight loss, they reported that severe weight loss is any weight loss of 5% or more in one month, 7.5 % or more in 90 days, and 10% or more in 180 days. A reweigh will be done if they notice a 5% weight discrepancy, and they will ask the staff to take another weight to ensure the correct weights are taken. When asked about scale calibration, they were told it is done every three months on all Hoyer lift scales. When asked about the communication between the different dietitians in the facility, they said they share a folder that has the list of all residents who are due for the monthly weights or weekly weights. There is always ongoing communication between the different dietitians, and they find it effective. Rarely do they not put residents' weight into the electronic system the same day they are taken or the following day. The surveyor asked the Clinical Dietary Manager why it took three weeks for Staff I, the Clinical Dietitian, to increase the tube feeding rate to meet estimated needs, but she did not know. The Clinical Manager said that Resident #138 should have been followed up a few days later to address any further vomiting or intolerance to the tube feeding and, if not, to increase the tube feeding back to goal rate. In an observation conducted on 09/20/23 at 4:50 PM, Resident #138 was noted in bed with the tube feeding 'on hold'. Closer observation showed that the tube feeding was started on 09/20/23 at 3:00 PM with Nepro at 50 ml an hour. Closer observation showed that the tube feeding was still at the 1000 ml mark on the 1000 ml capacity bottle. An interview was conducted on 09/20/23 at 4:56 PM with Staff K, RN, who said that she was the one who placed the tube feeding 'on hold' because the resident was moved from the chair to his bed. Record review of the weights log showed the following: Readmission weight noted at 147.2 pounds on 08/18/23, two days after his readmission, and 137.8 pounds on 09/15/23. This showed a 6.8% severe weight loss in less than a month, from 147.2 pounds to 137.8 pounds. Record review of the dietary readmitted d 08/18/23 revealed that Resident #138's estimated caloric daily needs to be between 1700-2000 calories and 80 grams to 100 grams daily protein needs. The resident's Body Mass Index (BMI) was noted at 23.7, within the normal level. In this note, the clinical dietitian reported that Resident #138 was on a tube feeding regimen that provided 69% of the lower end of caloric needs and only 59% of the higher end of caloric needs. It further showed that it only offered 66% of the lower-end protein needs and 53% of the higher-end protein needs. It was then recommended to change the tube feeding regimen to Nepro at 60 ml an hour for 15 hours, providing 1620 calories and 73 grams of protein. The clinical dietitian further recommended providing protein supplements twice a day, which provided an extra 34 grams of protein. The tube feeding Nepro at 60 ml an hour for 15 hours met 100% of the estimated lower end of caloric needs and 88% of the higher end of estimated caloric needs. Record review of the dietary progress note dated 08/25/23 revealed the following: Resident #138 had an episode of emesis (vomiting) and was given Zofran medication. In this note, the clinical dietitian changed the tube feeding recommendations and adjusted the feedings for Nepro at 45 ml an hour running for 18 hours, providing 1458 calories a day and 66 grams of protein daily. This tube feeding order met 94% of the estimated lower end of caloric needs and 79% of the higher end. This tube feeding order was running from 08/25/23 and was only discontinued on 09/15/23, three weeks later. The dietary progress note dated 09/15/23 revealed the following: Resident #138 has a BMI score of 21, which dropped from 23.7 to 21.0. In this note, the clinical dietitian reassessed the calories needed between 1802 and 2080 daily. She increased the tube feeding Nepro from 45 ml to 50 ml an hour for 20 hours to provide 1800 calories a day and 81 grams of protein. This change provided 93% of the higher end of caloric need for Resident #138. The care plan, which was initiated on 09/15/23, showed that Resident #138 had a significant weight loss of 6.7% in 30 days with a stage 4 pressure ulcer. It was recommended to adjust the tube feeding to meet estimated needs. The goal noted for the nutrition and hydration to be meet the needs and not show a weight decrease of 5% or more in 30 days or a decrease of 10% or more in 180 days. The Minimum Data Set (MDS), 180 days, which was dated 09/15/23, showed that Resident #138 had a Brief Interview of Mental Status (BIMS) score of 00, indicating high cognitive impairment. In an observation conducted on 09/20/23 at 9:38 AM, Staff A and Staff B (Certified Nursing Assistants) were asked to take the weight of Resident #138. A Hoyer lift scale was used to take the weight of Resident #138. Continued observation showed that the current weight taken on Resident #138 was noted at 132.2 pounds. This showed an additional weight loss from 137.8 pounds on 09/15/23 to 132.2 pounds in 5 days-a total severe weight loss of 10.12% in about one month. In an interview conducted on 09/20/23 at 9:50 AM, Staff A and Staff B, they stated that they get a list of residents daily from the dietitians. The list lists all the residents whose weights must be taken for that specific day. When taking the weights, they will write on that piece of paper the scale type that was used each time for taking the weights. That list is later given back to the dietitians, who input the weights into the electronic system. A tour was conducted on 09/20/23 at 10:13 AM with Staff C, Materials Manager, which observed the following: The 3rd floor was observed with 3 Hoyer lifts, which showed that the last scale calibrating was on 05/15/2023 and the next due date for calibration was on 08/20/23. The 4th floor was observed with 3 Hoyer lifts that showed the previous scale calibrating was on 05/15/23, and the next due date was on 08/20/23. The 2nd floor showed 3 Hoyer lifts that showed that the last scale calibrating was on 05/15/23, and the next due date was 08/2023. In an interview with Staff C on 09/20/23 at 11:35 AM, he stated that one company comes once a year to ensure that the Hoyer lifts in the facility are in working condition. When asked when the last time the outside scale company came to calibrate the Hoyer lift, he did not know. When asked when the next due date for the scale calibration was, Staff C stated he didn't know. When the Surveyor pointed to the stickers noted on the Hoyer lifts regarding the calibration of the scales, he said, I think that another company comes to the facility every quarter to calibrate the scales and make sure that the scales are weighing property. When asked by the surveyor for copies of all visitation invoices in the last year, he said that he needed to contact the company for the visitation invoices. Record review of the scale preventative maintenance and calibration agreement effective 08/01/2021 revealed quarterly visitations by the scale company to ensure that the scales are maintained for accuracy and balance; and to inspect and test with certified test weights to confirm national standards. In a phone interview conducted on 09/21/23 at 8:50 AM with the scale calibration outside company's technician, he stated that he had previously been to this facility to calibrate their scales. He further said that it is essential to calibrate the scales every three months because this facility does not have a way to verify or to make sure that the scales are accurate and calibrating them verifies their accuracy. He further reported that the last calibration visit was on 05/15/23, and the following visit was due in August 2023. According to him, the facility will remind them that it is time to come in if they run behind. In an observation conducted on 09/21/23 at 10:00 AM, the tube feeding was noted in the room, with a bottle of Nepro, which was started the day before, on 09/20/23, at 3:00 PM. Further observation showed the tube feeding was on the 450 ml mark on the 1000 ml capacity bottle. A tube feeding that started at 3:00 PM and ended at 10:00 AM should have been on the 50 ml mark. In an interview with the Assistant Director of Nursing (ADON) on 09/21/23 at 10:10 AM, she was asked what the protocol was for hanging a new tube feeding bottle. The sticker on the tube feeding bottle will have the tube feeding formulary, the date, and the time that the tube feeding was started. The nurse documents tolerance for the tube feeding or if it was held for any reason in the nurse's note. When asked what is documented in the Medication Administration Record (MAR) regarding the tube feeding, she said that nursing staff put the time with initial, and if the tube feeding is held for any reason, they will put in the option of the hold, but there is nowhere in the MAR to put the time it was held. She further verified that the tube feeding order for Resident #138 was supposed to be started at 2:00 PM and stopped at 10 AM the next day. The ADON was also asked if the tube feeding was held for any reason and restarted again and if the nursing staff ran it past the stop time to compensate for the missing hours for Resident #138, but she did not know. In an interview conducted on 09/21/23 at 10:28 AM with Staff L, Licensed Practical Nurse, she stated that she stopped the tube feeding this morning at 10:00 AM and has kept the tube feeding bottle the same since it started yesterday. In an interview conducted on 09/21/23 at 10:40 AM, the facility's medical director stated that Resident #138 was his patient. The tube feeding was placed on hold yesterday for a few hours because of nausea and vomiting and was restarted a few hours later. He further said that Resident #138 has had issues with nausea and vomiting in the past, and the tube feeding needed to be stopped for a few hours. In an interview conducted on 09/21/23 at 10:45 AM, Staff M, Licensed Practical Nurse, stated that when a new bottle of tube feeding is hung, the date and time that the tube feeding was started is recorded on the bottle's sticker. If the tube feeding is not tolerated, she would stop the feeding, check the residuals, and call the doctor for further orders. That would all be documented in the nurses' notes. Staff M further said that there is a section in the MAR that says 'other'. In that section, you can comment on why the tube feeding was stopped or held for any reason. Staff M also reported that if tube feeding is stopped and then restarted again, it will be stopped at the time that the order says. She stated she would not continue running the tube feeding to compensate for the missed tube feeding. Record review of Resident #138's nursing progress notes since the readmission on 08/16/23 revealed the following: On 09/20/23, Resident #138 had an episode of vomiting, medication was given, and Resident #138 tolerated tube feeding well. On 08/25/23, a note showed that Resident #138 had two episodes of vomiting, and medication was given. A continued review of the progress notes did not show any other tube feeding intolerance notes from 08/16/23 to 09/21/23. Record review of the MAR for August 2023 and September 2023 showed that Resident #138 was given the tube feeding orders with no issues and was marked as administered. In an interview conducted on 09/21/23 at 12:46 PM, the Director of Nursing (DON) stated that the 'wound care and weights meeting' are conducted once a week, usually on Tuesdays. They discuss any significant weight loss and any interventions for that weight loss. The dietitians are always part of the weight meetings. The DON reported that the facility's dietitians who attend the meeting have the list of all residents who had significant weight loss. When the weight loss is identified, they are expected to intervene for the weight loss and follow those interventions in place. When asked if the residents who had a weight loss the week before were followed at the next meeting, she said yes. The wounds and weights weekly meetings report showed that from 07/05/23 to 09/12/23, the clinical dietitian only participated four times out of the 11 meetings. Only 2 out of the 11 meetings showed a list of the follow-up residents noted with weight loss. The other meetings did not have any additional notes. 2. Record review revealed that Resident #42 was initially admitted to the facility on [DATE] with diagnoses that included Anemia, Hypotension, Colitis, and Congestive Heart Failure. The Minimum Data Set (MDS) dated [DATE] showed that Resident #42 had a Brief Interview of Mental Status (BIMS) score of 14, indicating cognition was intact. In an interview conducted on 09/20/23 at 3:30 PM, Resident #42 reported that he lost a ton of weight, which was not intentional. He further said that he did not have a good appetite, but it is improving. He loves the nutritional supplements (Ensure Chocolate), but it is not always provided with a chocolate flavor. Review of the weight log for Resident #42 revealed the following: a weight of 200.7 pounds on 07/03/23, a weight of 192.2 pounds on 07/07/23 that was entered on 07/11/23, a weight of 170.2 pounds on 07/07/23 that was entered on 07/31/23, a weight of 162.4 pounds on 07/21/23, that was entered on 07/31/23, a weight of 153.3 pounds on 07/28/23 that was entered on 07/31/23, a weight of 157.7 pounds on 08/07/23 that was entered on 08/09/23. The first initial weight loss was noted from 07/03/23 at 200.7 pounds to 170.2 pounds on 07/07/23, which is a 15% weight loss in 7 days. The second weight loss was noted from 200.7 pounds on 07/03/23 to 162.4 pounds on 07/21/23, which was a 19% weight loss. The 3rd weight loss was noted from 07/03/23 at 200.7 pounds to 153.3 pounds on 07/28/23, which was 24% weight loss. All weight loss identified showed a severe weight loss in less than one month. Record review of the Dietary Note dated 07/03/23 revealed the following: Resident #42 was on a soft mechanical diet with a food intake of 50% to 75% intake of meals. He had an unstageable wound to the sacrum area. The Usual Body Weight was noted between 200 to 210 pounds, and Resident #42 had a food intake decline over the past three months due to loss of appetite. In this note, Staff I, Clinical Dietitian, recommended protein supplements twice daily to provide an additional 70 calories and 17 grams of protein each. Staff I estimated caloric needs between 1900 to 2300 and protein needs between 90 grams to 135 grams daily. Resident #42's BMI was noted at 28.8, which is in the overweight category. The nutrition progress note dated 07/11/23 showed that a weight loss of 4.3% was identified in one week and that it was a desirable weight loss. It was recommended to provide Ensure nutritional supplement twice a day to provide an additional 26 grams of protein and 700 calories. This was only entered into the system and provided on 07/31/23, which was three weeks later. The nutrition progress note dated 07/31/23 was when Staff I identified the severe weight loss of 24% in less than a month and did not address the prior severe weight loss that was identified on 07/21/23 with 19% weight loss. Stage 3 sacrum wound was noted as well, and Resident #42's BMI dropped to 22. On this note, it was recommended to provide Ensure Plus nutritional supplements three times a day and Magic cup nutritional supplements at supper. An observation was made of Resident #42's breakfast tray on 09/21/23 at 8:15 AM. Resident #42 had consumed 100% of the meal on his tray. The surveyor also observed two cartons of strawberry flavored Ensure nutritional supplement. Staff N, Certified Nursing Assistant, stated that one carton was from last night and one was from this morning. The surveyor observed that one carton had approximately 50% consumed, and the other had about 25% finished. In an interview conducted on 09/21/23 at 10:15 AM, Resident #42 stated that his height is 5 feet 10 inches. He further said that he gets the Ensure Plus supplements three times a day, but if it is not Chocolate flavor, he will not drink it. He further said that he sometimes gets the Magic Cup supplements (providing an extra 290 kcal and 9 grams of protein), but the chocolate flavor would be better. A weight observation was conducted on 09/21/23 at 8:23 AM for Resident #42, which showed a new weight of 164.4 pounds. That is a weight drop from 167.7 pounds on 09/07/23 to 164.4 pounds on 09/21/23. A review of the Kitchen dietary system showed an order for Ensure Plus and Magic cup for Resident #42 but did not show the specific flavor of Chocolate. The care plan dated 09/14/23 showed that Resident #42 is at risk for weight loss and dehydration and is on a soft mechanical diet texture. It further showed to assess weight per facility protocol and notify the doctor of any significant weight changes, and to provide diet and supplements as ordered by the doctor. An interview was conducted on 09/21/23 at 10:28 AM with Staff I (Clinical Dietitian), and the Clinical Dietary Manager regarding Resident #42's weight loss. Staff I stated that she requested for the resident to be weighed again and then assessed the resident after the weight was taken. She further stated because she is not at this facility daily, sometimes she does not address weight loss immediately. The Clinical Dietary Manager said that Resident #42 was provided with Liquid Protein for wound healing on 07/03/23. She further reported Resident #42 was kept on the liquid protein supplement and had Ensure supplements added for the weight loss noted on 07/11/23. She then said she did not believe the initial weights (200.7 pounds 07/03/23 and 192.2 pounds 07/11/23) were accurate and that those weights should have been struck from the record and not used for this percent weight loss. The surveyor asked her to calculate the percent weight loss based on the following three weights (170.2 pounds 07/07/23, 162.4 pounds 07/21/23, and 153.3 pounds 07/28/23). She calculated this percent weight loss is 9.9%. The surveyor asked if this is an appropriate amount of weight loss to occur over the course of 3 weeks. The Clinical Dietary Manager stated, I believe this resident was also on diuretics. The surveyor asked if it is normal for a resident on a diuretic to lose this amount of weight. She stated, no. Staff, I reported that she sometimes attends the weekly Wound and Weight meetings, which are also attended by the facility's Administrator and Director of Nursing. Staff I also said that they discuss the residents who have suffered weight loss in these meetings. When asked if they only state the residents who have had weight loss or if they explain specifically the amount of weight loss that has been had, she stated she discusses the amount of weight loss and the percentage. The Clinical Dietary Manager then said, We have known for a while that this building is at high risk for resident weight loss due to our staffing issues. 3. Resident #363 was admitted to the facility on [DATE] with diagnoses that included Diabetes, Hypertension, and frequent falls. Review of the Minimum Data Set (MDS) dated [DATE] showed that Resident #363 had a Brief Interview of Mental Status (BIMS) score of 13, indicating cognition is intact. Review of the weight log revealed the following: an admission weight of 115.8 pounds dated 08/30/23, a weight of 109.5 pounds on 09/07/23, and a weight of 106 pounds dated 09/14/23. This showed a severe weight loss of 8.5 percent in two weeks. In an observation conducted on 09/18/23 at 8:27 AM, Resident #363 was noted in her room with the breakfast tray. Closer observation showed that she had no staff in the room, and she ate about 20% of her breakfast meal. The meal ticket noted a Mechanical soft diet and no nutritional supplements on the tray. An observation conducted on 09/20/23 at 8:50 AM showed Resident #363 was asleep in bed. Closer observation showed two cans of Glucerna shakes 8 ounces were noted to be full and unopened. Closer observation showed that the nutritional supplements were dated 09/12/23 at 10:00 AM and 09/15/23 at 10:00 AM. In an interview conducted on 09/20/23 at 9:00 AM, Staff F, Certified Nursing Assistant, stated that Resident #363 eats about 90% of her meals and that she needs assistance with her meals. When asked about the Glucerna supplements, she said that she drinks some of it but not all. Review of the Medication Administration Record for the month of September 2023 showed that Resident #363 was given her Glucerna supplements twice a day and that she consumed 100% of the supplements. The dietary nutrition note dated 08/30/23 revealed that Resident #363 had a BMI of 22.8, which is within normal limits. Her meal intake is between 26 to 75% of her meals. On this note, the Clinical Dietitian recommended Glucerna nutritional supplement once a day and that she will monitor weights and intake. The dietary progress note dated 09/07/23 revealed that Resident #363 had a severe weight loss of 5.4% and that her intake of meals is between 25 and 50 percent. On this note, the Clinical Dietitian recommended increasing the Glucerna supplements to twice a day. Resident #363's BMI dropped to 21.4 at this time. Further review of the weight log showed that Resident #363 weight dropped from 109.9 pounds on 09/07/23 to 106 pounds on 09/14/23. The dietitians should have addressed this, and no other nutritional progress notes were completed after 09/07/23. Resident #363's BMI is now noted at 20.7. The care plan initiated on 08/30/23 revealed that Resident #363 was at risk for weight loss and dehydration related to frequent falls and past medical history. It further showed, to be nourished and hydrated as evidenced by not showing a decrease in 5% or more in weight in less than or equal to 30 days, weight decrease to 10% or more in less than or equal to 180 days, or by showing weight gain, and to offer fluids and meals daily and to assist with meals and fluids. In an interview conducted on 09/21/23 at 2:30 PM with the facility's Administrator, she was informed of the findings. 41837 4. Record review for Resident #137 revealed the resident was admitted to the facility on [DATE] with the following diagnoses that included: [TRUNCATED]

Based on observations, interviews, and record review, the facility failed to follow physicians' orders regarding tube feeding for 1 of 2 sampled residents, Resident #124. The findings included: Review of the facility's policy, titled, Enteral Nutrition Products, dated 08/22/22, showed in part the following: The facility supplies residents with enteral nutrition support as ordered by the Physician. It further showed that all enteral nutrition products must be labeled with the Resident's name, date it was prepared, product name, concentration, and volume. Resident #124 was admitted to the facility initially on 06/01/23 with diagnoses to include Hyperlipidemia, Dementia, and Left Hip Fracture. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #124 had a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of the diet order, dated 09/01/23, noted for tube feeding, Jevity 1.5 (tube feeding formulary) at 65 milliliters (ml) an hour times 15 hours to start at 6:00 PM and off at 9:00 AM. The weight log for Resident #124 showed the following: 90.6 pounds on 06/20/23, 88.3 pounds on 07/11/23, 83.2 pounds on 07/27/23, 84.6 pounds on 08/09/23, 81.3 pounds on 08/10/23, 82.1 pounds on 09/01/23, 85 pounds on 09/20/23, and 81 pounds on 09/21/23. That is a 10.5% weight loss in 3 months. In an observation conducted on 09/18/23 at 8:02 AM, Resident #124 was noted in her room with the tube feeding running at 65 ml an hour. Closer observation showed that it started the day before, on 09/17/23, at 6:00 PM. The tube feeding was noted at the 850 ml mark on the 1500 ml capacity bottle. The tube feeding running at 65 ml an hour should have been at the 600 ml mark out of the 1500 ml capacity bottle. In an observation conducted on 09/18/23 at 11:45 AM, Resident #124 was in her room with the tube feeding off. In an observation conducted on 09/18/23 at 2:50 PM, Resident #124 was in her room with the tube feeding off. In an observation conducted on 09/19/23 at 9:00 AM, Resident #124 was noted in her room with the tube feeding running at 65 ml an hour. Further observation showed that the tube feeding was started the day before, on 09/18/23, at 6:00 PM. The tube feeding was noted at the 1200 ml mark on the 1500 ml capacity bottle. The tube feeding, which started the day before, running at 65 ml an hour, should have been around the 500 mark out of a 1500 ml capacity bottle. In an observation conducted on 09/20/23 at 7:05 AM, Resident #124 was noted in bed with the tube feeding running at 65 ml an hour. Closer observation showed that the tube feeding started on 09/19/23 at 6:00 PM. The tube feeding was noted at the 1150 ml mark on the 1500 ml capacity bottle. The bottle that started at 6:00 PM the night before should have been at around the 655 ml mark on the 1500 ml capacity bottle. About 845 ml of formulary should have been infused during the night. An interview was conducted on 09/20/23 at 7:10 AM with Staff E, Licensed Practical Nurse/LPN. Staff E stated that Resident #124's tube feeding was infusing all night and was well tolerated with no issues. In an observation conducted on 09/21/23 at 10:32 AM, the resident's weight was taken as requested by the surveyor. The facility used a standing scale to take the weight of the Resident, who was fully clothed with her shoes on before going on the standing scale. The first reading showed 80 pounds, and the second weight reading showed 81 pounds. The staff did not subtract the weight of the shoes from the total number of 81 pounds. This new weight had a 4-pound discrepancy from yesterday's (09/20/23) weight. The dietary progress note dated 07/07/23 showed that the Clinical Dietitian recommended placing Resident on Jevity 1.5 at 45 ml an hour for 18 hours, providing 1215 calories and 52 grams of protein daily. This order was changed on 07/07/23 and discontinued on 07/12/23. The dietary progress note dated 07/27/23 showed that Resident #124 had 7% weight loss within the month and was receiving tube feeding Jevity 1.5 at 35 ml an hour for 18 hours, which was ordered from 07/12/23 to 07/27/23. This tube feeding order provided 945 calories a day and met 89% of the estimated lower end of caloric needs and 75% of the estimated higher end of caloric needs a day. On this note, the Clinical Dietitian recommended changing the tube feeding to a bolus feeding regimen with three cans of Jevity 1.5, providing 1065 calories and 45 grams of protein daily. Resident #124's estimated caloric needs was between 1051 and 1261 and protein needs between 43 grams and 56 grams. Resident #124 had a Body Mass Index (BMI) of 19.6 (normal limits) on admission and was dropped to 17.6, which is underweight. Record review of the dietary progress note dated 08/03/23 revealed that the tube feeding order was changed again to Jevity 1.5 at 65 ml an hour running for 13 hours, providing 1265 calories and 54 grams of protein daily. On 08/10/23, the tube feeding was changed again to Jevity 1.5 at 65 running for 14 hours, which provided 1365 calories and 58 grams of protein. Continued record review revealed that on a dietary note dated 09/01/23, the tube feeding was increased again with Jevity 1.5 at 65 ml an hour for 15 hours, providing 1460 calories and 62 grams of protein a day. The care plan dated 07/07/23 showed Resident #124 was at risk for weight loss and dehydration related to swallowing problems and dementia. It further showed the resident will be nourished and hydrated as evidenced by not showing a decrease in 5% or more in weight in less than or equal to 30 days, weight decrease to 10% or more in less than or equal to 180 days, or by showing weight gain. The Physician's orders revealed that Resident #124 was on a diet by mouth before 07/06/23 but was totally dependent on tube feeding as the only source of nutrition after 07/06/23. In an interview conducted on 09/21/23 at 12:42 PM with the Assistant Director of Nursing (ADON), she was asked what the protocol is if a resident has a weight loss on tube feeding and at what point she would be concerned. She said that they would contact the doctor, and if this continues throughout the week, and the doctor will contact the dietitian for any changes. The ADON said this is also the protocol for any residents on tube feeding that is not tolerated.

Based on observations, interviews, and record review, the facility failed to assist with Activities of Daily Living (ADLs) regarding assistance during dining for 1 of 1 sampled resident, Resident #73. The findings included: Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses that included Altered Mental Status and Heart Failure. The physician order dated 08/17/23 noted for a regular heart-healthy diet with thin liquids. The Minimum Data Set (MDS) assessment dated [DATE] showed Resident #73 has a Brief Interview of Mental Status (BIMS) score of 01, indicating severe cognitive impairment. Section G of this MDS showed that for eating, Resident #73 needed extensive assistance from one person with her meals. In an observation conducted on 09/18/23 at 7:54 AM, the breakfast tray was taken into Resident #73's room and placed at her bedside table. At 8:00 AM, staff took the tray from the room and placed it on the meal cart outside in the hallway. Continued observation showed Staff F, Certified Nursing Assistant (CNA), taking the tray from the meal cart and taking it into the room again. At 8:40 AM, the meal was still 100% untouched, with no assistance provided by staff. In an observation conducted on 09/18/23 at 12:27 PM, the lunch meal was taken into Resident #73's room. At 12:40 PM, the tray was untouched. Continued observation at 12:55 PM noted Resident #73 ate nothing on her lunch tray. In an observation conducted on 09/19/23 at 8:50 AM, Resident #73 was noted in bed with the breakfast tray on her bedside table. Closer observation showed that the tray was set up, and no staff were in the room assisting her with her breakfast tray. At 9:05 AM, Resident #73 was screaming, and the tray was still 100% untouched. In an interview conducted on 09/20/23 at 9:00 AM, Staff F stated that Resident #73 can eat independently and does not need assistance with her meals. In an interview conducted on 09/20/23 at 9:18 AM with Staff G, the MDS coordinator, he was asked what it meant to have extensive assistance with one person for eating. Staff G reported that 'the staff needs guiding and using muscles to help with the meals and that the staff is providing more support. This means that sometimes the patient is dependent on staff for eating.' He would 'expect the staff to stay in the room to assist with the patient.' The Nutritional assessment dated [DATE] revealed Resident #73's meal intake was an average of 45% from admission, and that is related to refusal. It further showed that Resident #73 received varying amounts of assistance with meals. The care plan initiated on 08/30/23 showed that Resident #73 required limited to mostly extensive assistance with her ADLs, due to her cognitive impairment and functional decline. It further revealed that Resident #73 was at risk for weight loss and dehydration, and to assist and feed meals and snacks as needed. In an interview conducted on 09/21/23 at 2:30 PM with the facility's Administrator, she was informed of the findings.

Based on observation, interviews, record and policy review, the facility failed to follow physician orders for discontinued medications for 1 of 3 sampled residents reviewed for medication storage on Floor 2 South wing medication cart, Resident #73. The findings included: The facility's policy, titled, Medications-Disposition, effective [DATE], revised [DATE] and reviewed [DATE] revealed, The nurse is responsible for the proper disposition of drugs no longer eligible for use, such as those that have expired, were stored improperly or were degraded and discontinued. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses that included Altered Mental Status and Heart Failure. The Minimum Data Set (MDS) dated [DATE] showed that Resident #73 has a Brief Interview of Mental Status (BIMS) score of 01, indicating severe cognitive impairment. On [DATE] at 11:13 AM, an observation of the medication cart on Floor 2 South wing was done with Staff L, Licensed practical nurse (LPN). During medication reconciliation with Staff L for Ultram (a pain medication) administration, it was revealed that Resident #73 no longer had a current order for Ultram. Review of the physician order for Ultram revealed it was ordered on [DATE] and discontinued on [DATE]. Review of the medication monitoring / control record revealed Ultram had been administered to the resident on [DATE] at 7:00 AM after the medication was discontinued. The medication was still in the medication cart. Review was conducted with the Charge nurse, Staff O (LPN), who concurred that the order for Ultram was discontinued on [DATE] and the medication was still in the cart, administered on [DATE] without a physician's order, and should not have been in the cart.

Based on observation and interview the facility failed to provide dining in a dignified manner as evidenced by using disposable utensils and serving bowls as observed during lunch meals. The findings included: On 05/23/22 at 12:45 PM, observations were conducted of the lunch meal tray delivery on the South and East halls on the 3rd floor. Staff were observed delivering the lunch trays to residents and assisting with set up of the meal. At 1:05 PM, Resident #10 in room [ROOM NUMBER] was observed eating her lunch meal using a silverware fork for the chopped meat however only a white plastic teaspoon was available to eat the soup and dessert which were served in Styrofoam bowls. Resident #10 was observed to be having difficulty using the plastic teaspoon to get the soup to her mouth. At 1:08 PM, Resident #84 in room [ROOM NUMBER] was observed being fed by Certified Nursing Assistant (CNA) Staff L. She was sitting in a chair next to his gerichair feeding him his puree meal with a white plastic teaspoon. This lunch tray also had Styrofoam bowls for the soup and dessert. At 1:10 PM, the resident in room [ROOM NUMBER] was being fed her puree meal by an aide using a white plastic teaspoon. Both puree diets observed were served with white plastic teaspoons. All random trays observed on the 3rd floor South and East wings had Styrofoam bowls used for the soup and dessert. On 05/24/22 at 12:50 PM, observation of the lunch meal in room [ROOM NUMBER] revealed both residents had white plastic teaspoons for their soup with the fork and knife being metal silverware. Lunch trays observed in rooms 321, 326, 327, 330 and 333 had white plastic teaspoons to use for their soup. At 12:52 PM, Resident #84 was observed being fed his puree lunch meal by CNA Staff L using a white plastic teaspoon. On 05/25/22 at 12:44 PM, the puree meal in room [ROOM NUMBER] was observed to have a white plastic teaspoon as the only utensil on the tray. At 12:45 PM, the resident in room [ROOM NUMBER] was observed to have a white plastic teaspoon to use for her soup and metal silverware fork for the lunch meal. At 12:46 PM, observation in room [ROOM NUMBER] revealed the resident in Bed A eating her puree diet with a white plastic teaspoon and the resident in Bed B using a small white plastic fork for the meal and a white plastic teaspoon for the soup. An inquiry was made if she liked using plastic utensils to which she stated 'No'. The resident was observed to be having difficulty piercing the cut up chicken pieces on her plate with the plastic fork. At 12:49 PM, Resident #10 in room [ROOM NUMBER] was observed in her room using a small white plastic fork for the meal and a white plastic teaspoon for her soup. She was observed to be having difficulty piercing the cut up chicken pieces on her plate with the small plastic fork and the rice kept falling off the plastic fork before she could get it to her mouth. At 12:51 PM, CNA Staff N was observed feeding Resident #84 in room [ROOM NUMBER]. She was feeding the resident his puree meal with a white plastic teaspoon. An inquiry was made to CNA Staff N why they are using plastic utensils to which she just shrugged her shoulders and had no response. At 12:53 PM, the resident's lunch tray in room [ROOM NUMBER] was observed to have a white plastic teaspoon for the soup and a metal silverware fork for the meal. An interview was conducted with CNA Staff K who was in the resident's room at the time, why they are using plastic utensils to which she stated that is what the kitchen sends on the trays. On 05/26/22 at approximately 9:20 AM, an interview was conducted with the Administrator and Director of Nursing inquiring about the reason for using plastic utensils to which the Administrator stated she was not aware of this practice and would find out why this was happening. On 05/26/22 at 10:46 AM, an interview was conducted with the Director of Food Services regarding the observations of residents having to use plastic teaspoons and forks for their lunch meals and the soup and dessert being served in Styrofoam bowls, to which she stated those residents must be in isolation. The Director of Food Services was advised these observations were conducted on the 3rd floor which does not have any isolation to which she then stated their silverware and 9 ounce bowls are is in short supply and she has placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she just pulled some spare silverware from storage today when she realized there were not enough. An inquiry was made why she just pulled the spares from storage today and when did she realize they were using plastic utensils and Styrofoam bowls, to which she stated the Administrator informed her about it this morning. The Director of Food Services could not state how long they have been using plastic utensils and Styrofoam bowls, further stating the tray line Supervisor should have informed her they were short. She stated they will be using the silverware from storage for meals moving forward until the order arrives.

Based on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to ensure that it maintained a safe, clean, comfortable, homelike environment for 7 of 7 resident rooms identified during the initial environmental tour (Room #402, Room #403, Room #405, Room #407, Room #409, Room #421 for Resident #50 and Room #423 for Resident #36.) The findings included: 1) During an observational room tour conducted on 05/23/22 at 9:32 AM, it was noted that Resident #50 was observed trying to clean the floor around her bed utilizing a paper towel on the end of her cane. Resident #50 in Room #421 was originally admitted to the facility on [DATE] with diagnoses which included Dementia, Hypertension, Diabetes,, [CONDITION(S)] and Hypertensive Heart and [CONDITION(S)]. She had a Brief Interview Mental Status (BIMS) score of 12 (moderately impaired). During a brief interview conducted on 05/23/22 at 9:36 AM with Resident #50 regarding her actions observed above, she stated the floor looked dirty to her and had not been cleaned in days, so that's why she was cleaning it. On 05/23/22 at 9:43 AM, it was noted that the baseboard at the entry of the resident #50's bedroom doorway was peeling, stained and in disrepair; the resident's bedside table was dirty, dingy, chipped and peeling on the edges. Also, there was a used, dirty wash rag towel noted to be in wash basin in the bathroom on top of the resident's toilet. (Photographic evidence obtained.) On 05/24/22 at 9:05 AM, it was still noted that the baseboard at the entry of the resident #50's bedroom doorway was peeling, stained and in disrepair; the resident's bedside table was dirty, dingy, chipped and peeling on the edges. Also, there was a used, dirty wash rag towel still noted to be in wash basin in the bathroom on top of the resident's toilet. On 05/24/22 at 2:31 PM, it was still noted that the baseboard at the entry of the resident #50's bedroom doorway was peeling, stained and in disrepair; the resident's bedside table was dirty, dingy, chipped and peeling on the edges. Also, there was a used, dirty wash rag towel still noted to be in the wash basin in the bathroom on top of the resident's toilet, as observed during a tour conducted of the fourth Floor with the Director of Maintenance and Director of Housekeeping. 2) During an observational room tour conducted on 05/23/22 at 9:34 AM, it was noted that in Resident #36's room #423 the red sharps/needle box on the wall was observed to be only attached on one side with a screw; the other side was not attached/not screwed in and hanging half-off the wall inside of the resident's room. (Photographic evidence obtained.) Resident #36 was originally admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)], [CONDITION(S)] affecting right dominant side and [CONDITION(S)], [CONDITION(S)], Hypertension, Diabetes, and Peripheral Vascular Disease. She had a Brief Interview Mental Status (BIMS) score of 11 (moderately impaired). On 05/24/22 at 10:34 AM, Resident #36's room red sharps/needle box on the wall was still noted to be only attached on one side with a screw; the other side was not attached/not screwed in and hanging half-off the wall inside of the resident's room. On 05/24/22 at 2:31 PM, Resident #36's room red sharps/needle box on the wall was still noted to be only attached on one side with a screw; the other side was not attached/not screwed in and hanging half-off the wall inside of the resident's room, as was observed during a tour conducted of the 4th Floor with the Director of Maintenance and with the Director of Housekeeping. The Director of Maintenance and the Director of Housekeeping both acknowledged the above environmental observations during the tour, and they both recognized that repairs and cleaning were needed for the items in Resident #50 and Resident #36's rooms. Review of facility policy and procedure for Environmental Services Cleaning Procedures Manual dated reviewed 2015 stated in part, 'The seven step cleaning process is designed to maintain the highest standards of Shine cleanliness .Prerequisites: Safety, Hand Hygiene, damp wiping, waste handling, routine floor car, restroom cleaning and Infection prevention and control and the use of disinfectant.' 3) On 05/23/22 at 9:22 AM, during a tour of the facility, the following issues were observed: A nightstand observed in room 402 was noted to be in disrepair. In room 403 there was a scraped wall; the paint on the bathroom door was peeling off with splinters exposed. In room 405 there was scraped paint on the southwest wall. There was a heavily rusted and corroded electric wire on the running base board. In room 409 there was a scraped wall. In room 407 B, the electric outlet cover was not secured on the wall, exposing live wires. On the North Wing of the 400 unit hallway, the electric outlet cover was not securely screwed on, with live wires exposed. An environmental tour was conducted with the Maintenance Director and Environmental Service Director on 05/24/22 at 2:11 PM during which all identified issues were reviewed. The Maintenance Director reported that he will address the concerns as soon as possible.

Based on record reviews and interviews the facility failed to ensure proper treatment of [REDACTED].#1) to promote healing as evidenced by (1) no indication the attending physician was notified that Resident #1's sacral ulcer showed multiple signs of infection, (2) documentation that Resident #1 was not turned every two hours as ordered for 3 8-hour shifts and (3) documentation that dressing changes were not performed as ordered. The findings include: Resident #1 was admitted to the facility on [DATE]. Her medical history included a recent femur (leg) fracture, stroke, and heart problems. Resident #1's admission orders [REDACTED]. During an interview with the Director of Nursing (DON) on 09/10/2015 at 02:25 pm, she reported Resident #1 had an unstageable sacral pressure wound upon admission as well as arterial leg ulcers. A review was conducted of Resident #1's Turn and Reposition Detail Report for the dates of 07/07/2015 to 08/03/2015. On 07/10/2015 at 02:47 pm the Certified Nursing Assistant (CNA) #1 documented the answer No to the question of whether the resident was turned and repositioned about every 2 hours on this shift. For the reason she did not turn Resident #1, she documented ambulatory. On 07/18/2015 at 06:06 am CNA #2 documented No to the question of whether the resident was turned and repositioned about every 2 hours on this shift. For the reason she did not turn Resident #1 she answered turns and/or repositions self independently. On 07/19/2015 at 06:08 am CNA #2 again answered no to the question of whether Resident #1 was turned and repositioned about every 2 hours on this shift and again gave the reason she did not turn Resident #1 as turns and/or repositions self independently. Resident #1's 14-Day Minimun Data Set (MDS) assessment with a target date of 07/20/2015 revealed she required the extensive assistance of 2 persons for bed mobility, toileting and hygiene, was completely dependent for bathing, and could not walk. Review of Resident #1's Pressure Ulcer Charting revealed on her initial assessment of 07/08/2015 her sacral wound measured 10 (length) x 12 (width) x 0.1 centimeters (depth) and was described as eschar and slough (dead tissue) with a moderate amount of serosanguinous drainage and no undermining or induration. The area around the wound was documented as normal, which did not indicate further deep tissue injury beyond the wound ' s borders. Resident #1's Pressure Ulcer Charting on 07/15/2015 revealed the sacral wound was smaller but deeper at 8.3 x 9.1 x 0.3 centimeters (cm). The tissue was described as 100% slough with a moderate amount of serosanguinous drainage and no undermining or induration. The area around the wound was documented as normal. The Outpatient Wound Clinic Documentation for Resident #1 dated 07/16/2015 was reviewed for the clinic's initial assessment of the unstageable sacral wound with dimensions listed as 8.3 x 9.1 cm and an estimated depth of 0.3 cm. The exudate was documented as thin, watery, and clear. The tissue was documented as 10% [MEDICATION NAME] tissue, 80% slough, and 10% granulation tissue. The area around the wound was described as normal with no [MEDICAL CONDITION] or induration. On 07/22/2015 Resident #1's Pressure Ulcer Charting revealed the sacral wound was 11 x 7 x 1.1 cm with 10% [MEDICATION NAME] tissue, 10% granulation tissue, 30% slough, and 40% necrotic eschar. The discharge from the wound was a moderate amount of serosanguinous liquid described as thin and pale red/pink. The wound was documented to have an induration of less than 2 cm around the wound and the area around the wound was described as bright red and/or blanches to the touch, but with no tunneling or undermining. The healing progress was described as improving and appears more clean. The Outpatient Wound Clinic Documentation was reviewed for 07/22/2015 and the assessment matched the facility nurse ' s. On 07/22/2015 an order was written to turn and reposition Resident #1 every 2 hours and to avoid direct pressure to the wound site. An order was written and dated 07/23/2015 to Cleanse and irrigate sacrum with triple ABT (antibiotic) solution (GPC). Apply triple antibiotic solution soaked gauze to wound, cover with ABD (a dressing) and secure with tape daily and PRN (as needed). All except the second parentheses were added for clarification. GPC refers to a type of antibiotic solution. The July 2015 Treatment Administration Record (TAR) for Resident #1 documents to Cleanse and irrigate sacrum with triple ABT solution (GPC). Cover with ABD and secure with tape daily and PRN with a start date of 07/23/2015. This treatment was documented to be completed daily until 07/31/2015. The dressing order in place from 07/23/2015 included to apply triple antibiotic solution to gauze and cover with an ABD pad. The wound care instructions actually written on the August 2015 Treatment Administration Record were not transcribed as written. The Outpatient Wound Clinic Documentation for 07/27/2015 was reviewed and revealed Resident #1's sacral ulcer was determined to be at Stage IV and measured 12.5 x 13 x 0.2 cm. The wound clinic note documented at that time there was a large amount of purulent drainage with odor that covered greater than 75% of the wound dressing. The wound was described as becoming larger and was debrided. After debridement the wound was measured at 12.5 x 13 x 4 cm with undermining from 12 to 5 o ' clock to a maximum length of 3 cm. The wound progress was described as worsening. The worsening wound with purulent odorous drainage was not documented by the facility nurses until 07/31/2015 although the Treatment Administration Record documented the sacral wound care was conducted daily in July 2015. There was no documentation that the nurses noticed or the attending physician was informed the wound exhibited signs of infection. On 07/31/2015 Resident #1's Pressure Ulcer Charting revealed the sacral wound was 12.5 x 13 x 0.2 cm. The tissue was described as 80% necrotic eschar, 10% slough, and 10% granulation. At that time there was undermining of the wound at 12 o ' clock to 5 o ' clock, with a maximum length of 3 cm under the surface edge of the wound. At that time heavy discharge was noted and described as heavy, purulent, thin or thick, opaque, tan/yellow, and with odor. The area around the wound was once again normal. The wound care was documented as no change although the healing progress was described as worsened Stage IV and becoming larger. An emergency room Physician Notes entry on 08/03/2015 at 12:48 (pm) documented a large, infected appearing decub (decubitus) ulcer on buttock. An emergency room Physician Notes entry on 08/03/2015 at 13:26 documented an open wound to sacrum with purulent drainage and Decubitus located on sacrum approximately 7.6 cm to 20 cm is Stage IV is draining moderate amount purulent serosanguinous. An emergency room Physician Notes entry on 08/03/2015 at 13:31 documented a large decub (decubitus) ulcer to sacrococcygeal region with greenish discharge. The emergency room Disposition Summary on 08/03/2015 documented preliminary [DIAGNOSES REDACTED].#1's condition as critical and a Respiratory Intensive Care Unit bed was requested. Parentheses are added for clarification. The article Wound and Pressure Ulcer Management posted by John Hopkins Medicine and accessed on 09/19/2015 at http://www.hopkinsmedicine.org/gec/series/wound_care.html documents the following: Extreme malodor, especially if accompanied by purulent exudates is suggestive of infection. [DIAGNOSES REDACTED] - Redness of surrounding tissue may be normal in the [MEDICAL CONDITION] stage of healing. However, if accompanied by an increase in temperature of tissue, exudates or pain may also be a sign of infection. Induration - Abnormal hardening of the tissue caused by consolidation of [MEDICAL CONDITION], this may be a sign of underlying infection. Evaluation of infection, Infection - Signs and Symptoms: Redness, warmth and induration of adjacent tissues, pain or tenderness, dysmorphic and/or friable granulation, unusual odor, purulent exudates, and systemic signs (fever, chills, sweats).

Based on record review and interview the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents, in accordance with their assessed need, as evidenced by one staff member transferring a resident who was assessed to require a 2 person assist, resulting in a fall and fracture during care (Resident # 141). The findings include: Resident #141 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nursing note dated 8/16/12 documents" resident lowered to the floor while being transferred by staff ". Resident complained of right leg pain and an x-ray revealed a hip fracture. The resident was sent to the hospital for further evaluation and subsequently required surgery to repair the fracture. Further review of the record revealed care plans for mobility deficits and impaired vision documenting the resident is total assist with transfers and wheelchair mobility. The resident's care plan was not specific as to the number of staff necessary for safe transfers During an interview on 9/19/12 at 10:30 AM with the unit manager and the certified nurse assistant (CNA) who was assigned to the resident at the time of the fall, the CNA stated she transferred the resident by herself and while the resident was standing behind the wheelchair she was attempting to dress her. The resident started going down so she assisted the resident to the floor. The aid also stated the resident had not been complaining of pain prior to the incident. A written statement from the resident's aide was provided as part of the incident report by the risk manager " I took the patient form her wheel chair to change her clothes " A review on 9/19/12 at 10:15 AM with the unit manager of the resident's most recent quarterly minimum data set (MDS) assessment dated [DATE] documents activities of daily living for bed mobility and transfer as the resident requires total dependence on staff with 2 person physical assist and for surface to surface transfers (bed to chair) 2 staff assist. The annual MDS dated [DATE] and the quarterly MDS dated [DATE] also document activities of daily living for bed mobility and transfer as the resident requires total dependence on staff with 2 person physical assist. Review of the Rehabilitative Therapy Screen completed 6/22/12 reveals under the level of assistance, that the resident requires total assist; and "sling mechanical lift" is noted under the comments section next to the category "transfers". Resident #141 is noted on the Rehab Screen to have range of motion limitations in the leg and foot. The screen also notes there is no change in function since the last review. During an interview on 9/19/12 at 2:00 PM with the risk manager and unit manager regarding the resident's transfers, the unit manager stated the MDS coordinator gets their information from the nursing staff which is based on the residents needs. The unit manager also stated if an aide is comfortable transferring a resident by themselves they just do it and would not ask for help. During the interview it was acknowledged that the MDS documents Resident #141 is totally dependent on staff and requires a 2 person physical assist while being transferred. Review of the record revealed the resident returned to the facility on [DATE] and is unable to continue therapy due to increased pain and a Foley catheter inserted for urinary complications post operative. A review of the ADL (activities of daily living) flow sheet for 8/16/12, the day of the fall, revealed the aide documented the transfer as limited assistance with one person physical assist resulting in the resident falling/going down and fracturing her hip during care. The facility failed to implement interventions. including adequate supervision, consistent with a resident's needs.