Every finding on record at Stonebridge Desoto

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent during medication administration. There were 27 opportunities for error and three medication administration errors, resulting in an error rate of 11.11%, which affected two residents (Residents #16 and #26) out of 11 sampled residents. The facility census was 49.The facility did not provide a policy regarding priming insulin pens prior to administration. Review of the insulin aspart (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) FlexPen (insulin in a pen-type device) instructions, revised, June 2023, showed:- Attach the needle;- Prime the pen by turning the dose knob to two units;- Hold the pen with the needle pointing up;- Tap the cartridge holder gently to collect air bubbles at the top;- Push the dose knob in until it stops, and zero is seen in the dose window, count to five slowly, the insulin will be visible at the tip of the needle;- Select the dose;- Give the injection after selecting the area and cleaning the site with an alcohol swab.Review of the insulin lispro (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Pen injector (insulin in a pen-type device) manufacturer's guidelines for administration, revised 07/2023, showed:- Prime the pen before each injection;-Attach the needle;- Priming Directions of Insulin Pen: turn the dose knob to select two units; hold the pen with the needle pointing up; tap the cartridge holder gently to collect air bubbles at the top; push the dose knob in and continue holding the pen with the needle pointing up; push the dose knob in until it stops, and zero is seen in the dose window; hold the dose knob in and count to five slowly; check for insulin at the tip of the needle; if insulin wasn't present, repeat the priming steps one to three, no more than four times; if insulin still not present, change the needle, and repeat the priming steps;- Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly;- If the pen isn't primed before each injection, the patient may get too much or too little insulin.1. Review of Resident #26's medical record showed:- admitted on [DATE];- Diagnosis of Type 2 Diabetes Mellitus (T2DM, abnormal blood sugar);- An order for NovoLOG (insulin medication to lower blood sugar) FlexPen ReliOn Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart). Inject 10 units subcutaneously (under the skin) before meals related to T2DM. Hold for blood sugar below 150. Order dated 01/01/26;- An order for NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart). Inject as per sliding scale if 111 - 140 = 2 units,141 - 180 = 4 units,181 - 220 = 6 units, 221 - 260 = 8 units, 261 - 300 = 10 units, 301 - 350 = 12 units, 351 - 400 = 14 units, subcutaneously before meals and at bedtime for T2DM. Call the doctor if two consecutive blood sugars are over 400. Order dated 08/06/25.Observation on 06/23/26 at 12:24 P.M. showed Certified Medical Technician (CMT) A attached the needle to the NovoLOG insulin pen, selected and administered eight sliding scale units and 10 scheduled units for Resident #26 without first priming the insulin pen.Failure to prime an insulin pen before each injection may result in administration of too much or too little insulin because air remaining in the cartridge or needle may affect the delivered dose. 2. Review of Resident #16's medical record showed:- admitted on [DATE];- Diagnosis of T2DM;- An order for Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro). Inject as per sliding scale if 0 - 180 = 0, 181 - 200 = 2 units, 201 - 250 = 4 units, 251 - 300 = 6 units, 301 - 350 = 8 units, 351 - 400 = 10 units 401 or greater 12units, subcutaneously with meals related to T2DM. Order dated 04/18/26.Observation on 06/23/26 at 1:38 P.M. showed CMT A attached the needle to the insulin lispro pen and administered four units for Resident #16 without first priming the insulin pen.Failure to prime an insulin pen before each injection may result in administration of too much or too little insulin because air remaining in the cartridge or needle may affect the delivered dose. During an interview on 06/23/26 at 1:45 P.M., CMT A said he/she should dial the insulin pens to two units after cleaning the hub, attach the needle to the insulin pen, and then dial the ordered amount of insulin to be administered to the resident.During an interview on 06/25/26 at 11:55 A.M., CMT B said he/she should dial the insulin pen to two units after attaching the needle to prime the insulin pen and then dial the ordered amount of insulin ordered to be administered to the resident.During an interview on 06/26/26 at 9:40 A.M. the Director of Nursing (DON) said the insulin pens should be primed by two units of insulin after the needle was attached to the insulin pen. He/She would expect staff to prime insulin pens after the needle was attached.During an interview on 06/26/26 at 1:45 P.M., the DON and Administrator would expect the medication error rate to be less than five percent.

Based on interview and record review, the facility failed to follow physician orders for daily weights for one resident (Resident #10) out of three sampled residents. The facility census was 49. Review of the facility policy titled, Policy and Procedure Physician Orders, revised 01/04/23, showed:- Clear and complete orders will be transcribed to the appropriate administration record of either the Medication Administration Record (MAR) or the Treatment Administration Record (TAR);- New orders will be reviewed at least weekly by the Interdisciplinary Team as a part of routine clinical review;- A monthly review of physician orders will be completed to assure appropriateness, accuracy, and completeness. 1. Review of Resident #10's medical record showed:- admitted on [DATE];- Diagnoses of chronic diastolic heart failure and chronic kidney disease;- An order for daily weight every day shift related to chronic diastolic heart failure. Order start date 03/18/26 and end date 04/09/26;- An order to weigh daily related to heart failure. Report greater than three pounds gained to doctor. Order dated 04/17/26;-An order for torsemide (medication to pull excess fluid from body) oral tablet 10 milligrams (mg). Give three tablets by mouth two times a day related to heart failure. Order dated 05/28/26. Review of weights from March to June 24, 2026 showed:- March weights missed on 03/20/26, 03/21/26, 03/25/26, 03/26/26, and 03/30/26 for a total of five out of 13 opportunities missed;- April weights missed on 04/04/26, 04/19/26, 04/21/26, 04/22/26, 04/23/26, 04/24/26, 04/25/26, 04/26/26, 04/27/26, 04/28/26, 04/29/26, and 04/30/26 for a total of 12 out of 20 opportunities missed;- May weights missed on 05/01/26, 05/02/26, 05/03/26, 05/05/26, 05/07/26, 05/09/26, 05/10/26, 05/12/26, 05/13/26, 05/17/26, 05/18/26, 05/20/26, 05/21/26, 05/22/26, 05/23/26, 05/25/26, 05/26/26, 05/27/26, 05/30/26, 05/31/26 for a total of 20 out of 31 opportunities missed;- June weights missed on 06/01/26, 06/04/26, 06/05/26, 06/06/26, 06/08/26, 06/09/26, 06/10/26, 06/11/26, 06/12/26, 06/13/26, 06/14/26, 06/15/26, 06/17/26, 06/18/26, 06/19/26, 06/21/26, 06/23/26, 06/24/26 for a total of 18 out of 24 opportunities missed.During an interview on 06/26/26 at 10:36 A.M., Nurse Aide (NA) C and Certified Nurse Aide (CNA) D said they would get weights that the nurse would tell them to get. The nurse would hand us a piece of paper with who needed weighed that day and then after getting the weights, then would give the results to the nurse to chart. Dialysis residents got weighed before and after they got back from dialysis.During an interview on 06/26/26 at 10:45 A.M., Registered Nurse (RN) E said the nurse aides or nurse weighed the resident. Typically the nurse aides did the weights and the nurse would document. The nurse would know who needed weighed by checking the resident's orders or if the resident was a new admission. The nurse would write down who needed weighed and give it to the nurse aides to get and once completed, the nurse would document the weight in the computer system under the weights/vitals tab or on the TAR. He/She would look at the weights/vitals tab for the most accurate spot for looking up past weights.During an interview on 06/26/26 at 1:45 P.M., the Director of Nursing (DON) said that the night nurse would complete the daily weights and if not done then the day shift would complete it. Both the nurse aide and the nurse could document the weight which would be documented under the weights/vitals tab. Weights should be done as ordered.

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan (the minimum healthcare information necessary to properly care for the immediate needs of a resident) for three residents (Residents #22, #43, and #55) out of four sampled residents. The facility census was 49. The facility did not provide a policy regarding Baseline Care Plans. 1. Review of Resident #22's medical record showed: - admission date of 06/01/26; - Diagnoses of chronic obstructive pulmonary disease (COPD, lung disease making it hard to breathe), diabetes mellitus (a chronic condition that affects the way the body processes glucose), heart failure (heart not pumping blood as it should), obstructive sleep apnea (OSA, airway obstruction making it harder to breathe), chronic leg wounds, anxiety (feelings of worry, anxiety, or fear strong enough to interfere with one's daily activities), and atrial fibrillation (abnormal heart beat); - No documentation of a baseline care plan; - The facility failed to complete a baseline care plan within 48 hours of admission. 2. Review of Resident #43's medical record showed: - admission date of 12/18/25; - Diagnoses of diabetes mellitus, osteomyelitis (a serious bone infection), necrotizing fasciitis (an infection that kills the body's soft tissue), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), generalized anxiety disorder, and intermittent explosive disorder (repeated, sudden bouts of impulsive, aggressive, violent behavior); - A baseline care plan, dated 02/25/26; - The facility failed to complete a baseline care plan within 48 hours of admission. 3. Review of Resident #55's medical record showed: - admission date of 06/05/26; - Diagnoses of type two diabetes mellitus, myocardial infarction (MI – heart attack), atrial fibrillation (A-fib, abnormal heart rhythm), congestive heart failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), COPD, acute kidney failure (sudden and rapid loss of your kidneys' ability to filter waste from your blood), chronic kidney disease (gradual loss of kidney function), and anxiety disorder; - No documentation of a baseline care plan; - The facility failed to complete a baseline care plan within 48 hours of admission. During an interview on 06/26/26 at 1:45 P.M., the Director of Nursing (DON) and Administrator said they would expect the admitting nurse to complete the baseline care plan. The baseline care plan should be completed within 24 hours.

Based on interview and record review, the facility failed to implement physician orders for pre- and post-dialysis assessments and pre- and post-dialysis weights and failed to develop a comprehensive care plan that addressed the resident's dialysis needs for one resident (Resident #55) out of one sampled resident receiving dialysis. The facility census was 49.Review of the facility policy titled, Care of a Resident with End-Stage Renal Disease, dated September 2019, showed:- Staff caring for the resident with End-Stage Renal Disease (ESRD - the final stage of chronic kidney disease that requires a regular course of dialysis or a kidney transplant), including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents;- Education and training of staff includes the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis and the care of grafts and fistulas;- The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Review of Resident #55's medical record showed:- Diagnoses of acute kidney failure and chronic kidney disease;- Physician orders, dated 06/06/26, directed hemodialysis three times weekly;- Physician orders dated 06/09/26 directed pre- and post-dialysis assessments and pre- and post-dialysis weights every Tuesday, Thursday, and Saturday. Review of pre and post dialysis assessments showed:- On 06/09/26, no pre or post dialysis assessments were completed;- On 06/11/26, no pre or post dialysis assessments were completed;- On 06/13/26, no pre or post dialysis assessments were completed;- On 06/20/26, no post dialysis assessment was completed;- On 06/23/26, no pre or post dialysis assessments were completed;- On 06/25/26, no post dialysis assessment was completed;- The facility failed to complete 10 of 14 physician-ordered pre- and post-dialysis assessments. Review of the resident's weights showed:- On 06/09/26, the resident was not weighed before dialysis;- On 06/11/26, the resident was not weighed before or after dialysis;- On 06/16/26, the resident was not weighed before or after dialysis;- On 06/23/26, the resident was not weighed before dialysis;- On 06/25/26, the resident was not weighed after dialysis;- The facility failed to obtain seven of 14 physician-ordered pre- and post-dialysis weights. Review of the resident's care plan, initiated 06/25/26, showed:- Obtain vital signs and weights per protocol and report significant changes in pules, respirations and blood pressure immediately, initiated 06/25/26;- Monitor, document, and report to physician any bleeding, hemorrhage (rapid or uncontrolled loss of blood from damaged blood vessels), redness, swelling, warmth or drainage to access site;- The care plan did not address the physician-ordered pre- and post-dialysis assessments or pre- and post-dialysis weights. During an interview on 07/01/26 at 3:52 P.M., Licensed Practical Nurse (LPN) F said a pre-dialysis assessment and post-dialysis assessment were completed for residents on dialysis. The assessment included vital signs, weights, and assessment of the fistula or port. During an interview on 06/26/26 at 1:45 P.M., the Director of Nursing (DON) and Administrator said nursing should complete assessments, including weights, before residents left for dialysis and after they returned.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the dietary department during the storage and preparation of food, increasing the potential for cross-contamination and food-borne illness. This deficient practice had the potential to affect all residents who received meals prepared by the facility. The facility census was 49.Review of the facility's policy titled, Sanitization, dated October 2008, showed:- Kitchens, kitchen areas, and dining areas would be kept clean and free of litter and debris;- Utensils, counters, shelves, and equipment would be maintained in good repair and kept free of breaks, corrosion, open seams, cracks, and chipped surfaces that could interfere with proper cleaning;- Kitchen and dining room surfaces not in direct contact with food would be cleaned routinely to prevent the accumulation of dirt and grime; The Dietary Manager (DM) was responsible for scheduling routine cleaning of the kitchen and dining areas.Review of the facility's Daily Cleaning Schedule for May and June 2026 showed the kitchen and dining room floors were scheduled to be swept and mopped daily. The pantry was not included on the daily cleaning schedule.Observation of the kitchen on 06/23/26 at 9:58 A.M., 06/25/26 at 10:15 A.M., and 06/25/26 at 1:31 P.M. showed:- Food debris floated in dark, opaque fryer oil, and heavy accumulations of crumbs on the fryer ledge;- A puddle of standing water measuring approximately two feet by four feet between the dishwasher and sink, with an empty cart parked in the water;- The pantry floor contained scattered debris and a visible dull film with shoe prints near the doorway; - A storage rack had a bent right front leg/wheel, causing the rack to lean.Observation of the kitchen on 06/25/26 at 10:15 A.M. showed:- A puddle of standing water measuring approximately two feet by seven feet while staff were washing dishes;- The pantry floor contained scattered debris, a dull film, shoe prints, and a discarded hair net near the doorway.- Observation of the kitchen on 06/25/26 at 1:31 P.M. showed a dented can of cream of mushroom soup in food storage for resident use.During an interview on 06/26/26 at 10:19 A.M., the DM said the pantry was swept and mopped daily. The DM said the fryer was scheduled to be cleaned twice each week and was due to be cleaned that day. The DM said the standing water resulted from a drainage problem and the facility was waiting for contractor bids to repair it.During an interview on 06/26/26 at 10:24 A.M., the Administrator said the facility was waiting on a second contractor bid to replace the grease trap.During an interview on 06/26/26 at 1:45 P.M., the Administrator said she expected the kitchen to be maintained in a clean, sanitary condition, kept in good repair, and safe for food preparation.

Based on interview and record review, the facility failed to provide written notice of transfer to the resident and/or the resident's representative that included all required transfer information, including bed-hold information for six residents (Residents #3, #10, #16, #34, #36 and #40) out of six sampled residents who were transferred to the hospital. The facility census was 49. Review of the facility's policy titled, Bed Holds, dated March 2022, showed: The facility would inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of the bed-hold policy; Upon admission and when a resident transferred for hospitalization or therapeutic leave, the facility would provide written information regarding the bed-hold policy to the resident or representative in a format they could understand; When emergency transfers were necessary, the facility would provide the resident or representative with written information concerning the bed-hold policy within 24 hours of the transfer. Review of the facility's policy titled, Transfer or Discharge Notice, dated November 2017, showed: The resident and/or representative would receive written notice that included the reason and date for the transfer or discharge and the location to which the resident was transferred or discharged . 1. Review of Resident #3's medical record showed: - Transferred to the hospital on [DATE] and returned on 01/09/26; - Transferred to the hospital on [DATE] and returned on 02/17/26; - No documentation the resident's representative received written notice of either transfer; - No documentation the resident or representative received written information regarding the bed-hold policy for either hospitalization. 2. Review of Resident #10's medical record showed: - Transferred to the hospital on [DATE] and returned on 04/15/26; - No documentation the resident or the resident's representative received written notice of the transfer; - No documentation the resident or the resident's representative received written information regarding the facility's bed-hold policy. 3. Review of Resident #16's medical record showed: - Transferred to the hospital on [DATE] and returned the same day; - No documentation the resident or the resident's representative received written notice of the transfer. 4. Review of Resident #34's medical record showed: - Transferred to the hospital on [DATE] and returned on 06/03/26; - Bed-hold form, dated 05/29/26; - No documentation the bed-hold information was provided to the resident or the resident's representative. 5. Review of Resident #36's medical record showed: - Transferred to the hospital on [DATE] and returned on 04/21/26; - Transferred to the hospital on [DATE] and returned on 05/19/26. - Bed-hold forms, dated 04/13/26 and 05/16/26; No documentation the bed-hold information was provided to the resident or the resident's representative. Review of Resident #40's medical record showed: Transferred to the hospital on [DATE] and returned on 04/07/26; No transfer notice or bed-hold documentation was completed for the hospitalization. During an interview on 06/26/26 at 10:45 A.M., Registered Nurse (RN) E said the nurse completed the transfer assessment in the computer, printed the paperwork, and sent it with Emergency Medical Services (EMS). RN E said nurses did not review written transfer paperwork with residents and verbally notified family members by telephone but did not provide written notification. RN E said residents did not sign transfer paperwork. During an interview on 06/26/26 at 10:45 A.M., the Social Services Designee said he/she sent transfer notices to the State Ombudsman but did not send written transfer notices or bed-hold information to residents' responsible parties. During an interview on 06/26/26 at 1:45 P.M., the Director of Nursing and Administrator said nurses were responsible for completing transfer paperwork, gathering the face sheet and physician orders, completing the transfer assessment, and sending the paperwork with the resident.

Based on interview and record review, the facility failed to complete comprehensive Minimum Data Set (MDS, a federally mandated assessment completed by the facility) assessments within the required timeframes for two residents (Residents #22 and #55) out of 13 sampled residents. The facility census was 49. Review of the facility's policy titled MDS–Staff Responsibilities, dated October 2017, showed: - Members of the interdisciplinary team (IDT) would complete assigned sections of the MDS and corresponding Care Area Assessments (CAAs) within the timeframes established by the Resident Assessment Instrument (RAI) Manual; - The MDS Coordinator would schedule admission, quarterly, and annual MDS assessments; - The MDS Department would immediately notify the Administrator of issues affecting timely completion of MDS assessments. 1. Review of Resident #22's medical record showed: - admitted to the facility on [DATE]; - A comprehensive admission MDS assessment with an Assessment Reference Date (ARD) due by 06/14/26; - No completed Care Area Assessments (CAAs); - No completed comprehensive admission MDS assessment within the required timeframe. 2. Review of Resident #55's medical record showed: - admitted to the facility on [DATE]; - A Medicare Five-Day MDS assessment due by 06/13/26; - A comprehensive admission MDS assessment with an ARD due by 06/18/26; - No completed Care Area Assessments (CAAs); - No completed comprehensive admission MDS assessment within the required timeframe. During an interview on 06/26/26 at 1:24 P.M., the MDS Coordinator said Medicare Five-Day assessments and admission comprehensive MDS assessments should be completed within the required timeframe. The MDS Coordinator acknowledged some assessments were overdue. During an interview on 06/26/26 at 1:45 P.M., the Director of Nursing (DON) and Administrator said they expected MDS assessments to be completed within the required timeframes.

Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #1) out of three sampled residents when staff failed to place a fall mat next to the resident's bed as directed by the care plan. The resident fell out of bed onto the floor resulting in injury. The facility census was 52. The administration was notified on 07/24/25 of the Past Non-Compliance which occurred on 07/18/25. On 07/18/25, upon notification, the facility administration started an investigation and notified the Department of Health and Senior Services of the fall which resulted in a fracture. The non-compliance was corrected on 07/18/25, as the facility in-serviced all staff on the facility's policy and procedures on Falls and Fall Risk, Managing, High Fall Risk Patient Interventions, and on the Abuse and Neglect Policy. Review of the facility policy titled, Falls and Fall Risk, Managing, revised on December 2019, showed:The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once);In conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis (a disease that weakens the bones), as applicable) to try to minimize serious consequences of falling. Review of Resident #1's medical record showed:admission date of 11/27/24;Diagnoses of Alzheimer's disease (a brain condition that gradually affects memory, thinking, and behavior, leading to difficulties in daily tasks), bipolar disorder (episodes of mood swings, from depressive lows to manic highs), chronic kidney disease stage 4 (kidneys are severely damaged and can only filter a small amount of waste), osteopenia (brittle bones), and adult failure to thrive (condition characterized by significant weight loss, decreased appetite, and reduced physical activity). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff), dated 05/23/25, showed:Cognition moderately impaired with inattention, disorganized thinking, poor decision making; Had one to three falls. Review of the Resident's Care Plan, last revised on 06/06/25, showed:A bolstered low air loss mattress (a type of low air loss mattress that incorporates raised side perimeters to provide additional safety and support);Ensure bed in the low position;A fall mat next to the bed. Review of the resident's Fall Assessments showed:On 06/25/25, a history of falls in last the last three months with one - two falls and a moderate fall risk;On 07/01/25, a history of falls in the last three months with three or more falls and a high fall risk;On 07/17/25, a history of falls in the last three with three more falls and a high fall risk;On 07/18/25, a history of falls in the last three months with three more falls and a high fall risk. Review of the resident's Progress Notes, dated 07/01/25 - 07/18/25, showed:A fall note on 07/01/25 at 6:00 P.M., the resident was on a fall mat in front of the bed. The resident climbed out of the bed before staff help. Upon entering the room, the resident sat on the fall mat in front of the bed on his/her knees. No apparent injuries;A fall note on 07/17/25 at 4:29 A.M., the resident was on the floor mat at the bedside with his/her head facing the foot of the bed and his/her feet faced the head of bed. No apparent injuries;A fall note on 07/18/25 at 4:00 P.M., the resident was found next to the bed bleeding from an active head laceration. A large hematoma noted to left side of the head. The resident was yelling out for help to his/her leg. The resident screamed out when the nurse palpated his/her left hip and left leg. Pressure was applied to the head wound to control the bleeding. Hospice, the resident's family, and the physician were notified of the fall with an injury. Resident was sent to the emergency room (ER) for evaluation. He/She was admitted to the hospital for surgical intervention. The resident's family declined surgery and instead chose conservative treatment. Review of the resident's X-ray Report, dated 07/18/25, showed:An intertrochanteric left hip fracture with varus angulation (a break in the upper part of the left thigh bone, near the hip, with the broken pieces angled inward towards the body). During an interview on 07/24/25 at 11:30 A.M., Nurse Assistant (NA) #C said he/she was one of the aides assigned to Resident #1 on 07/18/25. NA C said he/she got complacent. NA C and another staff went in the resident's room, transferred the resident with a Hoyer lift (a mechanical lift), removed the Hoyer sling, changed the resident, covered him/her up with a blanket, put the call light in reach, lowered the bed, and left the room. NA C went to tell the nurse the resident had cramping stomach pain. NA C went across the hall to help another resident when he/she heard Resident #1 call out for help and that he/she was in pain. NA C looked over and saw the resident's leg on the floor. NA C called for help and went to the resident's room to wait for the nurse to get there. During an interview on 07/24/25 at 1:00 P.M., the Administrator and the Director of Nursing (DON) said they would expect staff to replace all safety devices, such as a fall mat, prior to leaving the resident's room after performing care. During a phone interview on 07/28/25, at 11:05 A.M., the Medical Director said he/she knew Resident #1 had osteopenia (a condition characterized by lower-than-normal bond density) and brittle bones, he/she couldn't give a definitive answer whether the fall mat could or would have prevented the resident's fracture. He/She had other patients with osteopenia who sustained fractures with a fall mat in place. Complaint #2566337

Based on observation, interview, and record review, the facility failed to ensure a physician's order for bilevel positive airway pressure (BIPAP - a noninvasive ventilation device that helps people breathe by delivering pressurized air into the airways) included settings. This affected one resident (Resident #32) out of one sampled resident. The facility's census was 46. Review of the facility's policy titled, CPAP/BiPAP Support, dated March 2015, showed: - Review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure for the machine. Review of Resident #32's medical record showed: - admitted [DATE]; - Diagnoses of chronic obstructive pulmonary disease (COPD - a group of lung diseases that causes restricted airflow and breathing problems), obstructive sleep apnea (a sleep disorder that occurs when the upper airway becomes blocked during sleep), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), diastolic heart failure (a condition where the heart muscle becomes stiff and cannot relax properly between heartbeats), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of the resident's Physician's Order Sheet (POS), dated 03/13/25, showed: - An order for trilogy (a device that delivers both invasive and non-invasive ventilation modes) on at bedtime and off in the morning with four liters (L) per minute of oxygen (O2) bled in, dated 07/15/24; - No order for BiPAP settings. During an interview on 03/12/25 at 11:45 A.M., the resident said he/she uses BiPAP at night and needs some assistance with reaching the mask and machine. Observation on 03/13/25 at 11:35 A.M. showed the resident turned on the machine and started BiPAP. During an interview on 03/13/25 at 11:35 A.M., Licensed Practical Nurse (LPN) A said he/she does not know what the settings are for the resident's BiPAP. During an interview on 03/13/25 at 8:45 P.M., the Director of Nursing (DON) and the Administrator both said they would expect the settings for BiPAP to be listed in the order.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility's census was 46. Review of the facility's policy titled, Sanitization, dated October 2008, showed: - The food service area shall be maintained in a clean and sanitary manner; - All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects; - All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, and cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair; - If a sink is used for washing utensils, cooking equipment, or dishes, and also used to wash produce or thaw food, it will be cleaned between uses with an approved cleaning and sanitizing agent; - High-Temperature Dishwashing machines must be operated using wash temperatures between 150 and 165 degrees Fahrenheit (F) for at least 45 seconds and rinse temperatures between 165 and 180 degrees F for at least 12 seconds; - Food Service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. 1. Observations on 03/10/25 at 10:49 A.M. of the kitchen showed: - Dirt and debris on the floor under the main food prep table; - Dirt, grime and old food debris along the top of the dishwasher; - Floors dingy and sticky; - Numerous dirty and dingy ceiling tiles; - The deep fryer grease dark brown with left over food residue; - Grease down the sides of the fryer and on the floor below the fryer; - One ten ounce (oz) dented can of crushed pineapple; - One four pound (lb) dented can of chunk light tuna in water. 2. Observation on 03/13/25 at 10:57 A.M. of the kitchen showed: - The deep fryer grease dark brown with left over food residue; - Grease down the sides of the fryer and on the floor below the fryer; - No thermometer inside the walk in refrigerator or freezer; - Stove top with old food debris on it; - Two frying pans on the shelf above the stove with black buildup on the bottoms. 3. Observation on 03/13/25 at 11:45 A.M. of the upstairs kitchen serving area showed: - Food crumbs, dirt and debris over the entire floor; - The warming station covered with food debris; - The plate storage rack with dried food debris and dried liquid spills down all sides of it; - One container of cereal not dated; - The toaster with crumbs on it and on the counter below; - The walls, cabinet doors, blinds, and windows covered in dirt, grime, spilled liquid run marks, and dried food. Review of the cleaning schedule for the upstairs kitchen, starting on 03/09/25, showed: - Cleaning was completed on 03/09/25, 03/10/25, and 03/11/25; - No documentation that cleaning had been completed on 03/12/25 or 03/13/25. Review of temperature logs for the upstairs kitchen refrigerator showed: - Temperatures logged from 10/16/24 to 10/24/24 and from 01/01/25 to 01/21/25; - No temperatures logged for the month of February 2025; - No temperatures logged for the month of March 2025. No record of temperature logs for the upstairs kitchen freezer. Review of food temperature logs showed: - Food temperatures logged for 03/11/25 and 03/12/25; - No food temperatures recorded prior to 03/11/25. 4. Observation on 03/13/25 at 2:15 P.M. of the kitchen showed Dietary Aide K prepped hamburger patties without wearing a hair restraint. Review of temperature log for high temperature dish machine from 12/01/24 through 03/13/25 showed: - On 01/15/25, day shift recorded a rinse temperature of 140 degrees F; - On 01/22/25, day shift recorded a rinse temperature of 130 degrees F; - On 01/22/25, evening shift recorded a rinse temperature of 160 degrees F; - On 01/23/25, day shift recorded a rinse temperature of 160 degrees F; - On 01/24/25, day shift recorded a wash temperature of 130 degrees F; - On 01/26/25, day shift recorded a wash temperature of 145 degrees F and a rinse temperature of 160 degrees F; - On 01/26/25, evening shift recorded a rinse temperature of 163 degrees F; - On 01/27/25, day shift recorded a wash temperature of 142 degrees F and a rinse temperature of 143 degrees F; - On 01/27/25, evening shift recorded a rinse temperature of 151 degrees F; - On 01/28/25, day shift recorded a rinse temperature of 150 degrees F; - On 01/29/25, day shift recorded a rinse temperature of 150 degrees F; - On 01/31/25, day shift recorded a wash temperature of 147 degrees F; - On 01/31/25, evening shift recorded a wash temperature of 148 degrees F; - On 02/03/25, day shift recorded a rinse temperature of 150 degrees F; - On 02/03/25, evening shift recorded a rinse temperature of 154 degrees F; - On 02/04/25, evening shift recorded a wash temperature of 148 degrees F; - On 02/05/25, day shift recorded a wash temperature of 130 degrees F; - On 02/06/25, evening shift recorded a wash temperature of 148 degrees F and a rinse temperature of 160 degrees F; - On 02/07/25, day shift recorded a rinse temperature of 155 degrees F; - On 02/07/25, evening shift recorded a rinse temperature of 156 degrees F; - On 02/08/25, day shift recorded a rinse temperature of 155 degrees F; - On 02/08/25, evening shift recorded a rinse temperature of 161 degrees F; - On 02/09/25, day shift recorded a rinse temperature of 163 degrees F; - On 02/09/25, evening shift recorded a wash temperature of 148 degrees F and a rinse temperature of 160 degrees F; - On 02/10/25, day shift recorded a wash temperature of 130 degrees F; - On 02/10/25, evening shift recorded a wash temperature of 149 degrees F; - On 02/11/25, day shift recorded a wash temperature of 148 degrees F; - On 02/11/25, evening shift recorded a wash temperature of 130 degrees F; - On 02/12/25, day shift recorded a wash temperature of 130 degrees F; - On 02/12/25, evening shift recorded a wash temperature of 136 degrees F; - On 02/15/25, day shift recorded a wash temperature of 148 degrees F; - On 02/16/25, evening shift recorded a wash temperature of 132 degrees F; - On 02/17/25, day shift recorded a wash temperature of 130 degrees F and a rinse temperature of 110 degrees F; - On 02/17/25, evening shift recorded a wash temperature of 130 degrees F; - On 02/18/25, day shift recorded a wash temperature of 130 degrees F and a rinse temperature of 110 degrees F; - On 02/18/25, evening shift recorded a wash temperature of 130 degrees F and a rinse temperature of 140 degrees F; - On 02/19/25, day shift recorded a rinse temperature of 158 degrees F; - On 02/19/25, evening shift recorded a wash temperature of 138 degrees F and a rinse temperature of 157 degrees F; - On 02/20/25, evening shift recorded a wash temperature of 140 degrees F and a rinse temperature of 158 degrees F; - On 02/23/25, day shift recorded a wash temperature of 130 degrees F; - On 02/23/25, evening shift recorded a wash temperature of 130 degrees F; - On 02/24/25, day shift recorded a wash temperature of 140 degrees F; - On 02/24/25, evening shift recorded a wash temperature of 140 degrees F; - On 02/25/25, day shift recorded a wash temperature of 135 degrees F; - On 02/25/25, evening shift recorded a wash temperature of 145 degrees F; - On 02/26/25, day shift recorded a wash temperature of 135 degrees F; - On 02/26/25, evening shift recorded a wash temperature of 140 degrees F; - On 02/27/25, day shift recorded a wash temperature of 137 degrees F; - On 02/27/25, evening shift recorded a wash temperature of 145 degrees F; - On 02/28/25, day shift recorded a wash temperature of 138 degrees F; - On 02/28/25, evening shift recorded a wash temperature of 145 degrees F; - On 03/01/25, day shift recorded a wash temperature of 130 degrees F; - On 03/01/25, evening shift recorded a wash temperature of 140 degrees F; - On 03/02/25, day shift recorded a wash temperature of 145 degrees F; - On 03/03/25, day shift recorded a wash temperature of 136 degrees F; - On 03/04/25, day shift recorded a wash temperature of 140 degrees F; - On 03/05/25, day shift recorded a wash temperature of 136 degrees F; - On 03/05/25, evening shift recorded a wash temperature of 140 degrees F; - On 03/06/25, evening shift recorded a wash temperature of 145 degrees F; - On 03/07/25, evening shift recorded a wash temperature of 140 degrees F; - On 03/08/25, evening shift recorded a wash temperature of 140 degrees F; - On 03/09/25, evening shift recorded a wash temperature of 140 degrees F. During an interview on 03/13/25 at 12:00 P.M., the Dietary Manager (DM) said the floors needed to be rewaxed and they were looking for a company who could do that for them. The DM was unaware of the type of dishwasher in the kitchen. During an interview on 03/13/25 at 8:45 P.M., the Administrator said she would expect the kitchen to be free from dirt, debris and grime.

Based on observation, interview, and record review, facility staff failed to maintain appropriate infection control practices by not following enhanced barrier precautions (EBP) for one resident (Resident #20) out of three sampled residents and by not performing proper hand hygiene and glove changing techniques during incontinent care, transfer, and wound care for three residents (Resident #20, #22 and #23) out of 16 sampled residents. The facility's census was 46. Review of the facility's policy titled Enhanced Barrier Precautions, last updated 04/04/24, showed: - All staff receive training on enhanced barrier precautions upon hire and at least annually and expected to comply with all designated precautions; - All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions; - The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education; - High-contact resident care activities include dressing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and wound care; - Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until the wound heals. Review of the facility's policy titled, Wound Care, revised September 2018, showed: - The purpose of this procedure is to provide guidelines for the care of wounds to promote healing; - Verify that there is a physician's order for this procedure; - Review the resident's care plan to assess for any special needs of the resident; - Assemble the equipment and supplies as needed; - Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field; - Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier; - Put on gloves. Loosen tape and remove dressing, discard dressing appropriately, wash and dry hands thoroughly; - Put on gloves. Gowns will only be necessary if soiling your skin or clothing, masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely; - Wear sterile gloves when physically touching the wound or holding a moist surface over the wound; - Place one gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water; - Remove dry gauze. Apply treatments as indicated; - Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time and date and apply dressing; - Remove the disposable items and discard appropriately, remove gloves and discard; - Wash and dry hands thoroughly. Review of the facility's policy titled, Hand Hygiene, dated May 2021, showed: - The use of gloves does not replace hand hygiene; - If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the facility's policy titled, Negative Pressure Wound Therapy, dated February 2014, showed: - Identify and size wound to be treated; - Wash hands and apply gloves; - Clean wound according to facility protocol, or as ordered; - Remove gloves; - Wash hands and apply new gloves; - Cut sponge dressing to size; - Create barrier dressing to protect healthy skin as needed: - Estimate the size of barrier dressing that will need to be cut. There should be at least a 1-inch barrier around the margins of the wound; - Cut the dressing with clean scissors; - Apply skin prep to the peri-wound skin; - Apply barrier dressing over the top of the wound; - Carefully trim a hole in the dressing to expose the wound and allow insertion of the sponge/gauze dressing; - Alternatively, the drape may be cut and placed in strips surrounding the wound and leaving the wound cavity open; - Apply secondary layer of barrier adhesive (drape); - Apply adhesive pad with tubing to the wound; - Assemble pump and disposable canister; - Connect device (canister) tubing to wound tubing, turn to lock into place; - Unclamp both sides of tubing; - Turn on pump, initiate negative pressure setting on pump as ordered. 1. Review of Resident #20's medical record showed: - An order to cleanse wound with wound cleanser, apply folded alginate calcium (an absorbent material used for dressing), collagen powder (a substance used to promote wound healing), skin prep peri wound and apply superabsorbent gelling fiber with silicone border and faced (a cover dressing with silicone) every day shift and as needed for stage three (full-thickness skin loss, exposing fat tissue) pressure wound, dated 03/10/25. Review of the resident's Plan of Care, last revised 10/10/24, showed: - Requires Enhanced Barrier Precautions (EBP) related to wound. Observation on 03/10/25 at 11:35 A.M. of the resident's mechanical lift transfer showed: - Signage for EBP on the resident's door; - Personal Protective Equipment outside the room door; - Without donning gloves and gown, Certified Nurse Aide (CNA) B and CNA C entered the room; - CNA C moved the mechanical lift over the resident, attached the sling straps to the lift on the resident's right side while touching the right side of the bed with his/her clothes; - CNA B attached the sling straps to the left side of the mechanical lift, touching the bed with his/her clothes; - CNA B and CNA C transferred the resident from the bed to the wheelchair using the mechanical lift; - CNA B brushed the resident's hair; - CNA C made the resident's bed; - CNA B and CNA C performed hand hygiene and left the room. Observation on 03/12/25 at 9:10 A.M. of the resident's incontinent care showed: - Without donning gowns, CNA B and CNA D entered the room; - CNA B and CNA D donned gloves without performing hand hygiene; - CNA B wet wash cloths; - CNA B and CNA D positioned the resident onto his/her left side, touching the bed with their clothes; - CNA B and CNA D removed the mechanical lift sling from under the resident; - CNA B wiped the resident's front peri area with a wet cloth; - CNA D reached into CNA B's pocket and obtained a roll of trash bags, removed a bag, laid the roll onto the bed, and opened the trash bag; - CNA B placed the dirty cloth into the trash bag; - CNA D positioned the resident onto his/her left side; - CNA B wiped the resident's buttocks with a clean, wet, cloth; - Without performing hand hygiene, CNA B changed gloves; - CNA B placed a clean brief on the resident; - CNA B and CNA D repositioned the resident in the bed, placed blanket and call light; - CNA B and CNA D removed gloves and performed hand hygiene; - CNA B placed the roll of trash bags back into his/her pocket; - CNA B and D left the room. During an interview on 03/12/25 at 10:15 A.M., CNA B said he/she knows who requires EBP by the sign on the door, should have worn a gown and gloves during care of the resident who required EBP and should have not placed the roll of trash bags back into his/her pocket after the roll was laid on the resident's bed. During an interview on 03/12/25 at 11:15 A.M., CNA D said he/she should have worn a gown during the care of the resident who required EBP. Observation on 03/12/25 at 9:45 A.M. of the resident's wound care, showed: - Licensed Practical Nurse (LPN) A donned a gown, gathered a cover dressing, opened gauze and opened calcium alginate from the treatment cart with his/her bare hands, contaminating dressing supplies; - LPN A placed contaminated gauze and calcium alginate in hand, placed the cover dressing, opened gauze, opened calcium alginate, bottle of wound cleanser, bottle of liquid vitamin E, and tube of collagen powder onto a newspaper on the resident's bedside table, without using a barrier; - LPN A washed hands and donned gloves; - LPN A positioned the resident on his/her left side; - LPN A removed gloves and donned new gloves without performing hand hygiene; - LPN A applied calcium alginate to cover dressing, applied collagen powder to the calcium alginate, laid the dressing on the bed pad, without using a barrier; - LPN A cleansed wound with contaminated gauze and dermal wound cleanser; - LPN A changed gloves, did not perform hand hygiene; - LPN A applied skin prep to peri wound; - LPN A applied dressing to wound; - LPN A changes gloves, did not perform hand hygiene; - LPN A applied vitamin E to the resident's upper arms; - LPN A removed gloves, did not perform hand hygiene, positioned resident's blanket and call light; - LPN A placed wound cleanser, bottle of vitamin E, tube of collagen powder on top of treatment cart, contaminating cart, performed hand hygiene with hand sanitizer, and then placed the supplies into the treatment cart drawer, contaminating other supplies. During an interview on 03/12/25 at 9:58 A.M., LPN A said he/she should have worn clean gloves when gathering supplies, used a barrier, should have sanitized the multi-use supplies before placing them back in the cart, and should have at least used hand sanitizer with each glove change. 2. Review of Resident #22's Physician's Order Sheet showed: - An order for right inner shin dressing change, apply two Xeroform (a non-adherent gauze that minimizes pain during dressing changes and promotes healing) and cover with dressing to be changed once daily and as needed for stage three pressure wound (a full-thickness skin loss where fat is visible), dated 02/24/25. Observation of Resident #22's wound care on 03/13/25 at 8:55 A.M. showed: - Resident's dressing already removed; - Registered Nurse (RN) I entered the resident's room with supplies in hand; - Without a barrier, RN I laid supplies on the resident's bedside table; - Without performing hand hygiene, RN I donned gloves; - RN I picked up supplies and walked to the resident sitting in his/her wheelchair; - RN I squatted down in front of the resident, took saturated gauze out of cup and wiped wound and surrounding skin; - Without establishing a clean field, RN I set dressing supplies on the overbed table; - RN I removed gloves and threw the gloves and gauze into the waste can; - Without performing hand hygiene, RN I donned new gloves; - RN I removed Xeroform from package; - RN I opened Mepilex (self-adherent, soft silicone bordered foam dressing that is used to protect wounds from infection and further damage) while holding Xeroform between fingers; - RN I placed the Xeroform on the center of the Mepilex and placed it over the wound; - RN I removed gloves, disposed of trash in waste can; - Without performing hand hygiene, RN I left the resident's room. During an interview on 03/19/2025 at 10:52 A.M., RN I said hand hygiene should be performed upon entry to the resident's room, between glove changes, and when exiting the room. RN I said he/she only uses a barrier for supplies when it is a sterile procedure. He/She said the overbed table is to be wiped with a disinfectant prior to putting supplies on the table. 3. Review of Resident #23's Physician's Order Sheet, dated 03/20/25, showed: - An order for wound vac to right foot: clean wound and surrounding skin with wound cleanser and pat dry, apply skin prep (a protective wipes or liquid film-forming dressing to create a barrier between the skin and adhesives, tapes, or films) and drape (transparent material that creates a seal while acting as a barrier to external contaminants) to peri wound (the area of skin surrounding a wound) to prevent foam from touching healthy skin, apply black foam to wound bed and secure with drape, bridge foam to non-weight bearing surface if needed and apply vac at negative pressure 125mmHG continuous suction, change every Tuesday, Thursday, and Saturday, dated 03/07/25. Observation on 03/10/25 at 4:05 P.M. of the resident's wound care showed: - Registered Nurse (RN) S said he/she had already wiped down the bedside table. Without placing a barrier on the table, RN S placed the dressing supplies on the table; - RN J donned gown, sanitized hands, and donned gloves; - RN J opened dressings and cut drape into strips; - RN J opened the sterile packing; - RN J removed gloves and placed into trash, sanitized hands, and donned new gloves; - RN J clamped tubing, removed dressing and wound vac from the resident's right foot; - The skin around the wound red and macerated (a condition where the skin becomes soft, soggy, and breaks down due to prolonged exposure to moisture); - RN J removed gloves and placed in trash; - Without performing hand hygiene, RN J donned new gloves; - RN J discarded old wound vac dressing and canister into trash; - RN J removed gloves and placed in trash; - Without performing hand hygiene, RN J donned new gloves; - RN J cleansed the wound with a wet gauze, removed gloves and placed gloves and gauze in trash; - Without performing hand hygiene, RN J donned new gloves; - RN J cleansed the wound with a wet gauze, removed gloves and placed gloves and gauze in trash; - RN J sanitized hands and donned new gloves; - RN J cleansed the wound with a wet gauze, removed gloves and placed gloves and gauze in trash; - RN J sanitized hands and donned new gloves; - RN J failed to apply skin prep and drape to peri wound; - RN J measured wound, cut black foam to fit wound bed, and placed black foam onto wound bed; - Without covering foam with drape, RN J applied wound vac [NAME] pad (a specialized tubing that is placed on top of the sponge and is connected to the device) to top of black foam; - RN J removed gloves and placed in trash; - RN J sanitized hands; - The [NAME] pad and black foam started separating from the wound; - Without donning gloves, RN J placed finger onto the dressing to hold in place; - RN J donned gloves; - The open end of [NAME] pad tubing fell on to the floor. RN J picked up the tubing and laid it across the resident's legs; - RN J applied drape cut into strips over the [NAME] Pad and around black foam; - RN J removed gloves and placed in trash; - RN J sanitized hands and donned new gloves; - RN J wiped off the end of the open wound vac tubing that fell on the floor with wound cleaning solution and gauze; - RN J connected [NAME] pad tubing to canister tubing, plugged wound vac device into the wall and turned it on. During an interview on 03/10/25 at 4:55 P.M., RN J said he/she cleaned the tubing that fell on the floor because there were no more wound vac supplies and that is the only option he/she had. RN J said he/she should have applied skin prep and allowed it to dry before applying the dressing. During an interview on 03/13/25 at 08:45 A.M., RN I said Resident #23 had wound vac supplies in his/her room all week. During an interview on 03/13/25 at 8:45 P.M., the Administrator and Director of Nursing (DON) both said they would expect the dressing to be changed if the open tubing fell on to the floor. During an interview on 03/13/25 at 8:50 P.M., the Administrator and the DON said they expect staff to wear a gown and gloves during high contact activities for residents who require EBP, to perform hand hygiene prior to donning gloves, use a barrier for wound care supplies, and to sanitize multi use supplies after use. 49879 49999

Based on observation, interview, and record review, the facility failed to provide access to survey results. This had the potential to affect all residents. The facility census is 46. Review of the facility's policy titled, Examination of Survey Results, dated April 2007, showed: - A copy of the most recent standard survey along with state approved plans of correction of noted deficiencies, is maintained in a three-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room. Observations from 03/10/25 through 03/13/25 showed: - On 03/10/25 at 11:35 A.M., no survey binder was found at the nurses' station or activities room; - On 03/13/25 at 2:15 P.M., no survey binder was found at the nurses' station or activities room. During an interview on 03/13/25 at 10:10 A.M., Resident #25 said he/she was not aware the survey results could be read or where to find them. During an interview on 03/13/25 at 10:10 A.M., Resident #4 said he/she did not know where to find the survey results. During an interview on 03/13/25 at 10:10 A.M., Resident #35 said he/she did not know where to find the survey results. During an interview on 03/13/25 at 8:45 P.M., the Administrator said she would expect the survey results to be available for the residents to read without asking.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices affected all residents. The facility census was 46. Review of the facility's Food Receiving and Storage policy, revised July 2014, showed: - Foods shall be received and stored in a manner that complies with safe food handling practices; - All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 1. Observation on 02/06/24 at 10:46 A.M. of the reach-in cooler showed: - One large container of Ott's Famous dressing with no opened date and no expiration date; - One large container of ranch dressing, labeled as Italian dressing, with no opened date and no expiration date; - One large container of maraschino cherries with no opened date. 2. Observation on 02/06/24 at 10:50 A.M. of a shipment of hamburger buns showed: - A large box containing individual packages of hamburger buns with a received date of 02/05/24 and a baked on date of 11/25/23; - Dietary Manager unable to find best by dates on any of the individual hamburger bun packages. 3. Observation on 02/06/24 at 10:55 A.M. of the dry storage area showed three packs of hot dog buns sitting on a shelf with dates of 11/25/23 on the packages and one package with visible mold. During an interview on 02/06/24 at 11:00 A.M., the Dietary Manager (DM) said staff are supposed to label items when they are opened and dispose of items three days past the best by date. Staff dates the boxes of bread and buns when they come in and monitor the quality. Buns and bread should have a best by date. The DM was unsure if the numbers stamped on the packages of hamburger buns contain best by dates. There shouldn't be any moldy food in the kitchen. During an interview on 02/09/24 at 5:30 P.M., the Administrator said she would expect food to be properly labeled and stored and to have no moldy food in dry storage.

Based on observation, interview, and record review, the facility staff failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase their ROM and/or prevent a further decrease in their ROM. The facility staff failed to perform restorative services as ordered for two residents (Resident #3 and #11) out of two sampled residents. The facility census was 46. Review of the facility's Restorative Nursing Services Policy Statement, dated July 2017, showed: - Residents will receive restorative nursing care as needed to help promote optimal safety and independence; - Restorative goals and objectives are individualized and resident centered and are outlined in the resident's plan of care; - The resident or representative will be included in determining goals and the plan of care. 1. Review of Resident #3's medical record showed: - admitted [DATE]; - Diagnoses of contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that cause the joints to shorten and become very stiff) of unspecified joint, osteoarthritis (a joint disease, in which the tissues in the joint break down over time), contracture right wrist, contracture right hand, muscle weakness, stroke, and dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 01/24/24, showed: - Severely impaired cognition; - Dependent with activities of daily living (ADLs) and self care; - Impairment to both upper and lower extremities; - Restorative Nursing Program for passive (when an outside force, such as another person, causes movement of a joint) range of motion. Review of the resident's care plan, dated 12/05/23, showed: - Dependent on staff for turning and repositioning; - Contractures of the right hand and right wrist; - Limited ROM of arms and legs. Review of the resident's Physician's Order Sheet (POS), dated February 2024, showed an order for Restorative Nursing Services to be provided daily, seven days a week, dated 09/10/23. Review of the resident's restorative nursing documentation, dated 09/12/23 through 02/09/24, showed: - Restorative therapy for range of motion for upper extremities; - A total of 121 out of 151 missed opportunities for restorative therapy. Observations of the resident on 02/06/24 at 12:47 P.M., 02/07/24 at 8:49 A.M., and 02/07/24 at 1:01 P.M. showed contractures of the right hand and wrist. 2. Review of Resident #11's medical record showed: - admitted [DATE]; - Diagnoses of Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), osteoarthritis of knee, and visual loss-both eyes. Review of the resident's POS, dated February 2024, showed an order, dated 09/10/23, for restorative therapy seven days per week to include active (movement of a joint provided entirely by the individual performing the exercise) ROM and passive ROM exercises to right and left upper extremities and right and left lower extremities. Review of the documentation survey report, dated September 2023 through February 2024, showed a total of 96 out of 152 missed opportunities for restorative therapy. During an interview on 02/09/24 at 11:33 A.M., Certified Nursing Assistant (CNA) I said he/she works one-two days a week, does restorative therapy, helps the aides, and documents restorative therapy in the electronic medical record. There was a Monday through Friday restorative nursing aide that quit about two weeks ago. During an interview on 02/09/2024 at 5:30 P.M., the Administrator and Director of Nursing said they would expect a resident with an order for restorative therapy to receive restorative therapy per the order.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer when one resident (Resident #44) out of one sampled resident transferred to the hospital. The facility's census was 46. 1. Review of Resident #44's medical record showed: - Resident transferred to the hospital for medical evaluation on 01/31/24 and readmitted to the facility on [DATE]; - No documentation of written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on 01/31/24. During an interview on 02/09/24 at 12:15 P.M., the Administrator said she would expect the resident and/or the resident's representative to receive a transfer notification in writing when a resident is transferred to the hospital. The facility did not provide a policy regarding transfers.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of the facility's bed hold policy when one resident (Resident #44) out of one sampled resident transferred to the hospital. The facility's census was 46. Review of the facility's policy, Bed Hold Notice Prior to Transfer, revised October 2017, showed: - In the event of a resident transfer to the hospital or the resident goes on therapeutic leave, the facility will provide written information to the resident and/or the resident representative regarding the bed hold; - The notice will be provided prior to leave, if possible. In the event the notice is not provided prior to leave due to unforeseen circumstances, the notice will be provided within the requirements for such notice; - Attempts at delivery of the bed hold notice will be documented; - The following information will be given to the resident and/or resident's representative: the duration of the state bed hold, if any, during which the resident is permitted to return and resume residence in the nursing facility; the reserve bed payment policy in the state plan, if any; and the facility policy regarding bed hold periods to include permitting the residents to return. Review of the facility's policy, Bed Holds, dated March 2022, showed the facility shall inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of the bed hold policy. 1. Review of Resident #44's medical record showed: - Resident transferred to the hospital for medical evaluation on 01/31/24 and readmitted to the facility on [DATE]; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. During an interview on 02/09/24 at 12:15 P.M., the Administrator said she would expect the resident and/or the resident's representative to receive their bed hold policy in writing when a resident is transferred to the hospital.

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS, a federally mandated assessment completed by the facility) assessment for two residents (Resident #11 and Resident #26) out of 12 sampled residents. The facility census was 46. Review of the facility's Certifying Accuracy of the Resident Assessment Policy showed: - All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment; - Any individual who willfully and knowingly certifies (or causes another individual to certify) a material and false statement in a resident assessment is subject to disciplinary action and such incident must be promptly reported to the Administrator. 1. Review of Resident #11's medical record showed: - admitted [DATE]; - Diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), visual loss-both eyes, and dysphagia (difficulty swallowing); - Monthly Summary, dated 02/07/2024, showed vision-blind, daily incontinence of bowel and bladder, contracture of hand-not specified, and therapy-none. During an interview on 02/08/2024 at 3:45 P.M., Registered Nurse (RN) J said that Resident #11 is totally blind and dependent on staff for care. Review of the resident's quarterly MDS, dated [DATE], showed Vision, moderately impaired. 2. Review of the facility's policy titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, dated September 2012, showed the threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss=[usual weight - actual weight] / [usual weight] x 100): a. 1 month - 5% weight loss is significant; greater than 5% is severe; b. 3 month - 7.5% weight loss is significant; greater than 7.5% is severe; c. 6 month - 10% weight loss is significant; greater than 10% is severe. Review of Resident #26's medical record showed: - A quarterly MDS, dated [DATE], with a weight of 193 pounds; - A comprehensive annual MDS assessment, dated 12/05/23, with a weight of 177 pounds; - A severe weight loss of 8.29% from 09/04/23 to 12/05/23 not identified on the MDS. During an interview on 02/09/24 at 9:20 A.M., the MDS/Care Plan Coordinator said care plans are updated quarterly and as needed, often daily, said MDS assessments and care plans should reflect current care/needs of residents. During an interview on 02/09/24 at 5:30 P.M., the Administrator and Director of Nursing (DON) said they would expect the MDS to reflect a significant weight loss.

Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan to meet the individual needs for one resident (Resident #11) out of 12 sampled residents. The facility census was 46. Review of the facility's Life Enrichment Policy Program Policy, dated October 2017, showed: - Each resident's interests and needs will be assessed on a routine basis. Included in this assessment will be Minimum Data Set (MDS - a mandatory assessment completed by the facility) and Care Plan; - Activities will be designed with the intent to enhance the resident's sense of well being; promote or enhance emotional health; promote self esteem, dignity, pleasure, comfort, education, creativity, success and independence; - Space and equipment necessary are provided to ensure the resident's care plan is followed; - Life Enrichment Assessments, Participation reviews, and Life Enrichment Care plans will be completed on admission, quarterly, at the time a resident experiences significant change, and if the Life Enrichment Director notes an inherent trend or change in a resident's participation in activities; - The Life Enrichment Director is responsible for accurate and timely care plans and assessments of the resident needs, participation and preference. Review of Resident #11's medical record showed: - admitted [DATE]; - Diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), visual loss-both eyes, depression (an illness that negatively affects how you feel, the way you think and how you act), slurred speech, dysphagia (difficulty swallowing); - A comprehensive care plan, with a target goal date of 03/04/24, showed no activities care planned. During an interview on 02/07/24 at 1:30 P.M., the resident said he/she doesn't know what kind of activities he/she can do because he/she is blind, but he/she enjoys music. During an interview on 02/09/24 at 9:20 A.M., the MDS/Care Plan Coordinator said care plans are updated quarterly and as needed, often daily. He/She said the MDS assessments and care plans should reflect the current care needs of residents. During an interview on 02/09/24 at 5:30 P.M., the Administrator and Director of Nursing said they would expect a resident with sensory impairments to be able to participate in activities and for that to be reflected on the care plan.

Based on observation, interview, and record review, the facility failed to update and revise a comprehensive care plan to meet the individual needs for one resident (Resident #11) out of 12 sampled residents. The facility census was 46. Review of the facility's Comprehensive Care Plans Policy, dated September 2022, showed: - It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; - The care planning process will include an assessment of the resident's strengths and needs; - The comprehensive care plan will be reviewed and revised by the interdisciplinary team (a group of professionals from different disciplines that know the resident's needs) after each comprehensive (no more than 366 days from prior comprehensive assessment) and quarterly (no more than 92 days from prior quarterly or comprehensive assessment); MDS (Minimum Data Set assessment-a mandatory assessment required by the facility); - The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Review of Resident #11's medical record showed: - admitted [DATE]; - Diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), visual loss-both eyes, and dysphagia (difficulty swallowing); - Physician's Order Sheet (POS), dated 02/09/24, showed an order for a regular diet, mechanical soft texture, regular liquids consistency, may have pleasure foods, built-up spoon and fork, red foam cup with lid and straw, prefers a clothing protector, fortified foods twice a day, health shake with meals for nutrition. Review of the resident's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Eating: substantial/maximal assistance, loss of liquids/solids from mouth when eating/drinking, coughing or choking during meals; - Toileting: dependent, substantial/maximal assistance for toilet transfers. Observations of the resident showed: - On 02/06/24 at 12:45 P.M., resident in dining room being fed by staff, and dependent on staff to propel his/her high back wheelchair; - On 02/07/24 at 1:00 P.M., resident in dining room being fed by staff, and dependent on staff to propel his/her high back wheelchair. During an interview on 02/08/24 at 3:45 P.M., Registered Nurse (RN) J said the resident is totally blind and is dependent on staff for care. Review of the resident's care plan, target goal date of 03/04/24, showed: - The resident prefers to eat in his/her room at times, provide set up assist, serve diet as ordered, able to feed self. Staff to use verbal cues for encouragement to attend meals in dining room for stimulation and socialization, assist with meal preparation, but encourage to be as independent as possible, notify physician and representative (if applicable) of any sudden changes related to nutritional care and/or status; - Will maintain status and continue to use toilet to promote decreased incontinent episodes, toileting assist-provide transfer/hygiene assist per staff as needed, require assist of one with a gait belt for toilet transfers, adjust provision of ADL's (activities of daily living-daily self care activities) to compensate for resident's changing abilities, incontinent of bowel and bladder at times and dependent on staff for incontinent care; - Resident uses the rail on the wall and his/her feet to propel wheelchair. No indications of acute eye problems through the review date. Monitor/document to MD the following signs and symptoms of acute eye problems, sudden visual loss. During an interview on 02/09/24 at 5:30 P.M., the Administrator and Director of Nursing said they would expect a resident's care plan to reflect the current status of the resident and be updated with changes.

Based on observation, interview, and record review, the facility failed to provide resident care for activities of daily living (ADLs) when residents did not receive scheduled showers and preferences were not acknowledged for three residents (Resident #10, #30, and #46) out of 12 sampled residents. The facility census was 46. The facility's policy did not address shower frequency. 1. Review of Resident #10's medical record showed: - admitted [DATE]; - Diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities, causing significant impairment in daily life), mild cognitive impairment, lack of coordination, unsteadiness on feet, weakness, high blood pressure, and heart failure. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility), dated 01/18/24, showed: - Moderately impaired cognition; - Moderate assistance for upper body dressing and personal hygiene; - Dependent assistance for lower body dressing and toileting; - Maximal assistance for shower/bath. Review of the resident's comprehensive care plan, dated 12/19/23, showed: - Resident requires assistance with activities of daily living; - Staff to assist with showers twice weekly per schedule. Review of the facility's shower schedule showed the resident was scheduled for showers on Tuesdays and Fridays. Review of the resident's shower sheets from 11/01/23 through 01/31/24 showed 11 out of 27 opportunities for showers missed. During an interview on 02/06/24 at 12:53 P.M., the resident said he/she could not remember when he/she last received a shower, but needs one. Observation on 02/06/23 at 12:54 P.M. showed the resident lay in bed with a brown substance under his/her fingernails. 2. Review of Resident #30's medical record showed: - admitted [DATE]; - Diagnoses of stroke and muscle wasting (thinning of muscle mass). Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Maximal assistance of staff for lower body dressing; - Moderate assistance for personal hygiene and toileting; - Moderate assistance for shower/bath. Review of the resident's comprehensive care plan, dated 08/26/23, showed: - Assist resident with dressing/grooming; - Assist of one staff with showers twice weekly per schedule. Review of the facility's shower schedule showed the resident was scheduled for showers on Sundays and Wednesdays. Review of the resident's shower sheets from 01/01/24 through 02/09/24 showed six missed showers out of 11 opportunities. During an interview on 02/06/24 at 12:28 P.M., the resident said he/she cannot remember the last shower he/she had, and that he/she doesn't get them often enough. 3. Review of Resident #46's medical record showed: - admitted [DATE]; - Diagnoses of spinal stenosis (narrowing of the spinal column that causes pressure on the spinal cord), major depressive disorder, weakness, general anxiety disorder, heart failure, high blood pressure, stroke, and difficulty walking. Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Supervisory/Touching assistance for upper body dressing; - Maximal assistance for lower body dressing and shower/bath; - Moderate assistance for personal hygiene; - Maximal assistance for shower/bath. Review of the resident's comprehensive care plan, dated 12/18/23, showed: - Resident requires assistance with activities of daily living; - Showers/bathing was not addressed. Review of the facility's shower schedule showed the resident was scheduled for showers on Mondays and Thursdays. Review of the resident's shower sheets from 11/01/23 through 01/31/24, showed 13 out of 27 opportunities for showers missed. During an interview on 02/06/24 at 10:25 A.M., the resident said he/she prefers bed baths, often goes 10 days without one, has went as long as two weeks without one, prefers to be clean shaven with a mustache, fingernails are too long and dirty because staff will not assist with it. He/She has asked staff about nail care during a bed bath and is just ignored. Observation on 02/06/24 at 10:26 A.M. showed the resident lay in bed with one-eighth to one-quarter inch long facial hair and a brown substance under the nails on the left hand. During an interview on 02/09/24 at 2:40 P.M., Certified Nurse Assistance (CNA) B said showers are scheduled on the run sheets. He/She is able to get showers done as scheduled and can't recall a time that he/she hasn't been able to give the scheduled showers. During an interview on 02/09/24 at 2:45 P.M., the Assistant Director of Nursing (ADON) said they give showers per the schedule on the run sheet. They try to accommodate residents' showers whether they want them day or night. They will add someone to the next day's schedule if they refuse. They gave a new training on 02/07/24 and now nurses are to be notified if a resident refuses and nurses will chart that refusal. During an interview on 02/09/24 at 5:30 P.M., the Administrator and Director of Nursing said they would expect residents to have showers twice a week per the shower schedule. 47678