Every finding on record at The Grove Care and Wellness

Based on observation, interview and record review, the facility failed to ensure nursing services were provided in accordance with professional standards of practice and facility's policy and procedure, when a licensed nurse failed to verify G-tube (gastrostomy tube - a soft plastic tube inserted through the abdomen directly into the stomach, which provides a direct route for liquid nutrition, hydration, and medications when a person cannot eat or drink safely by mouth) placement and assess for gastric residual (the volume of fluid-comprising food, water, medication, and digestive secretions-remaining in the stomach of a patient receiving tube (enteral) feeding) prior to administering medications through the G-tube, for one of one resident (Resident 12) observed receiving medications through the G-tube.This failure placed the resident at risk for complications associated with administration through an improperly positioned enteral tube, including aspiration, ineffective medication delivery and injury.Findings: On July 8, 2026, at 4:05 p.m., a concurrent medication administration observation and interview was conducted with Licensed Vocational Nurse (LVN). The LVN was observed to administer Resident 12's carvedilol (medication to treat hypertension [high blood pressure]) through the G-tube. The LVN was observed not to check the G-tube placement and gastric residual prior to administering the medication. The LVN stated she forgot to check for placement and residual prior to administering Resident 12's medication via G-tube. The LVN further stated this step ensures that the tubing is in the right place and to prevent the resident from vomiting or aspirating.A review of Resident 12's admission Record, indicated Resident 12 was admitted to the facility on [DATE], with a diagnosis which included encounter for attention to gastrostomy.A review of Resident 12's electronic Medication Administration Record (eMar), dated July 1, 2026 - July 31, 2026, indicated, .Enteral Feed Order every shift Check Tube Placement/Patency before and after giving medications and starting feedings.On July 9, 2026, at 1:05 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that it is important to check for G-tube placement prior to administering medications via G-tube, to prevent serious complications and/or harm to the residents.A review of the facility's policy and procedures, titled, Medication Administration via Feeding Tube, dated January 2026, indicated, .ensure the medications administered via feeding tube are administered safely and accurately.check for correct placement of feeding tube prior to administration of medication.auscultate for placement and aspirate for residual.According to the web article titled, Chapter 15 Administration of Enteral Medications, published by the National Library of Medicine, indicated .Medication is administered via an enteral tube when the patient is unable to orally swallow medication.Prior to medication administration, verify the placement. Placement is initially verified immediately after the tube is placed with an -ray (radiographic procedure), and the nurse should verify these results. Additionally, bedside placement is verified by the nurse before every medication pass.One method includes aspirating tube contents with a 60-ml (milliliter - unit of measurement) syringe and observing the fluid.

Based on observation and interviews, the facility failed to ensure the food preferences were honored and provided, for one of 32 sampled residents (Resident 17), when the resident was served food listed in the food dislikes.This failure had the potential for Resident 17 to reduce their nutritional intake, which may have adversely impacted on their nutritional status and compromised their overall medical condition.Findings:On July 6, 2026, at 10:38 a.m., an interview was conducted with Resident 17. Resident 17 stated, he just tolerated the food and preferred better food quality, stating that they would serve him meal items that he does not like such as beef and broccoli.On July 6, 2026, at 12:40 p.m., a concurrent lunch meal observation and interview was conducted with Resident 17. Resident 17 was observed lying upright in bed with an uneaten lunch on the bedside table. The meal included four large slices of meatloaf, mashed potatoes, corn, and bread. Resident 17 stated he does not eat beef or corn and mentioned disliking beef, which is frequently served by the facility, leading to refusal of meals. Resident 17 indicated the food was not warm, contributing to not eating the meal today. The meal ticket on the lunch tray indicated meat should be cut into bite-sized pieces and noted the residents' dislike of beef. Resident 17's family at bedside stated they would provide preferred food from outside.On July 7, 2026, at 12:35 p.m. a lunch meal observation and interview was conducted with Resident 17. Resident 17 was observed lying upright in bed with an untouched lunch meal on the bedside table. He reported the chicken entree was cold again and said he would only eat the fruit. The chicken was observed touching mashed potatoes and zucchini, which he disliked, stating the mixed presentation was unappetizing along with the inadequate temperature. Family at bedside said they would bring in the food from outside which the resident preferred.A review of Resident 17's medical record indicated Resident 17 was admitted to the facility on [DATE], with a diagnosis which included, diabetes mellitus type two (a chronic condition where the body resists insulin or cannot produce enough of it to maintain normal blood glucose levels) and chronic kidney disease stage 4 (severe kidney damage).A review of Resident 17's HISTORY AND PHYSICAL, dated June 26, 2026, indicated Resident 17 had the capacity to understand and/ or make decisions.A review of the Nutrition Evaluation and Review, dated June 26, 2026, indicated, .preferences.dislikes.No beef, or pork, cheese.meal intake.25-75% .nutritional plan of care.has nutritional problem or potential nutritional problem r/t (related too) s/p (status post) acute hospitalization for chest pain, hyperkalemia (high potassium), DM (diabetes mellitus - abnormal blood sugar), and chronic disease.will maintain adequate nutritional status.A review of Resident 17's diet order, dated June 27, 2026, indicated, .NAS (no added salt) diet easy to chew.thin liquids.A review of the mini nutritional assessment dated , July 2, 2026, indicated, .Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing.moderate decrease in food intake is checked.A review of the Diet meal ticket dated July 6, 2026, indicated, .Diet order.easy to chew, no added salt.notes.cut meat into bite-sized pieces per resident.dislikes.beef, broccoli, asparagus, milk, pork, ice cream.A review of the recipe titled, Old Fashioned Meatloaf dated July 6, 2026, indicated, .ingredients.ground beef.milk.salt.may give low salt diet.EC (easy to chew).may give.confirm texture meets EC specifications.A review of the meal intake percentage from June 12, 2026, to July 7, 2026, indicated an average of 50% intake.On July 8, 2026, at 3:58 p.m. an interview and record review was conducted with the Dietary Manager (DM). The DM stated Resident 17 was identified by the Registered Dietitian (RD) as at moderate risk for decreased intake, with recommendations made accordingly. The DM noted that Resident 17's average intake from June to July 2026, ranged from 25-75%, and a lunch meal was served to the resident on July 6, 2026, meatloaf was prepared with beef. The DM stated beef was listed as a dislike for Resident 17. The DM acknowledged that Resident 17's food preferences and dislikes should be honored, and if meatloaf was served, an appropriate meal alternative should have been provided. The DM further stated that residents must be served meals respecting their preferences, at appropriate temperature, and staff should ensure those preferences were honored.On July 9, 2026, at 12:42 p.m. an interview and record review was conducted with the RD. The RD stated after visiting with Resident 17 on July 2, 2026, it was determined the resident was identified to have moderate risk for decreased intake. The RD indicated she provided recommendations for increased intake and improved nutritional status. The RD reviewed the resident preferences and indicated dislikes include beef. Upon reviewing the Monday July 6, 2026, meal schedule and meatloaf recipe, the RD noted the meatloaf contained beef, which Resident 17 dislikes. The RD emphasized that residents at moderate risk for decreased intake should have food preferences honored to encourage adequate nutrition. The RD stated Resident 17 should not have been served meatloaf and if refused a meal an alternative should have been offered. The RD stressed the importance of respecting resident preferences to support nutrition during recovery and to provide food that was palatable.A review of the facility's policy and procedure titled, Meal Service, dated 2023, indicated, .meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures.A review of the facility's policy and procedure titled, Resident Allergies, Preferences, and Substitutes, revised January 2026, indicated, .the facility will honor food preferences.individual nutritional needs to the fullest extent possible while ensuring nutritional adequacy.resident preferences shall be respected.residents who dislikes a menu item shall be offered an appropriate substitute of similar nutritional value from the food group whenever available.resident meal trays shall be checked by Dietary staff and verified by Nursing staff, as applicable, to ensure accuracy.

Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR) recommendation by the pharmacy consultant to evaluate the use of heparin (an injectable anticoagulant {blood thinner} used to prevent and treat blood clots in blood vessels, the heart and the lungs) was acted upon by the physician, for one of six residents reviewed (Resident 12) for the use of unnecessary medication. This failure has the potential to place Resident 12 at high risk for complications related to heparin use. Findings: On July 7, 2026, at 3:11 p.m., a concurrent review of Resident 12's record and a concurrent interview was conducted with the Director of Nursing (DON). The record review indicated the following - Resident 12's Face Sheet, indicated the resident was admitted to the facility on [DATE], with diagnoses including nontraumatic intracerebral hemorrhage (long term physical, cognitive and emotional deficits that persist after the initial bleeding).- The Physician's Order, dated June 13, 2026, indicated to give Heparin Sodium - Porcine (rapidly acting anticoagulant medication used to treat and prevent blood clots) solution, 5000 unit/ml (milliliter - unit of measurement). Inject 5000 unit subcutaneously (the administration of medication or fluids into the fatty tissue layer located directly between the skin and the muscle).- The document titled, Note to Attending Physician/Prescriber, written by the pharmacist, dated June 16, 2026, indicated, .resident is on heparin without a stop date - recommendation, please consider clarifying heparin adding a potential stop date or discontinuing the heparin if the condition warrants. - The electronic Medication Administration Record (eMAR), dated June 17, 2026 to July 7, 2026, indicated Resident 12 continued to receive the medication heparin as ordered by the physician on June 13, 2026. - The Progress Notes, written by the Nurse Practitioner (NP), dated June 18, 19, 22, 23, and 25, 2026, indicated the NP did not address the pharmacist's MRR on June 16, 2026.In a concurrent interview, the DON stated the following:- The pharmacist conducted the MRR for the residents on June 16, 2026, and she received the MRR report on June 17, 2026; - Resident 12 had a pharmacy recommendation to evaluate the use of heparin, by adding a potential stop date or discontinuing the medication if the condition warrants; - Resident 12's physician or NP did not document recommendations in response to the pharmacist's MRR about heparin use on June 16, 2026; and- Pharmacy MRR recommendations for Resident 12 should have been referred to and addressed by the physician within seven days.A review of the facility's policy and procedure titled, Medical (Drug) Regimen Review, dated January 2026, indicated, .It is the policy of this facility that the drug regimen of each resident will be reviewed at least once a month by a licensed pharmacist.The Pharmacist MRR . shall include the resident's name, the relevant drug, and the irregularity the pharmacist identified.MRR recommendations to physician.The report is provided by the Pharmacist or facility to the responsible physician, facility's medical director and the Director of Nursing within seven (7) working days of review .Communication and physician response will be documented in the clinical record, along with any orders or changes to medication regimen .The attending physician will document within 7 days in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is no change in the medication, the attending physician will document his or her rationale in the resident medical record .A copy of the record is kept by the facility until the physician has reviewed the irregularity in the resident's record.

Based on interview and record review, the facility failed to ensure a thorough investigation was conducted to address a grievance filed regarding care provided, for one of three residents reviewed (Resident A), when Resident A notified the facility staff that the Registered Nurse smelled alcohol while providing care to her.This failure resulted in Resident A's grievance not being investigated in a prompt manner and the resident was fearful of the RN caring for her. In addition, this failure had the potential for other residents' psychosocial well-being to be affected.Findings:On March 11, 2026, at 8:45 a.m., an unannounced visit was made to the facility regarding a facility reported incident.On March 11, 2026, at 12:40 p.m., a review of Resident A's medical record was conducted. Resident A was admitted to the facility on [DATE] with diagnoses which included osteomyelitis (bacterial infection of the bone causing swelling, fever, tissue damage), bacteremia (presence of bacteria in the blood in an immunocompromised individual), and MRSA (Methicillin-resistant Staphylococcus aureus - a type of bacteria that is resistant to several antibiotics).A review of Resident A's Change in Condition Evaluation, dated March 8, 2026, at 10:04 p.m., indicated; .false allegation towards staff and falsifying stories.resident having false accusations.On March 11, 2026, at 2:30 p.m., an interview was conducted with the Administrator (Admin). The Admin stated the following:-The Director of Nursing (DON) informed him about Resident A's concern regarding the Registered Nurse (RN), who was noticed to have an odor of alcohol while beginning her intravenous (IV- through the veins) line procedure;-The RN on the afternoon shift was working with Licensed Vocational Nurse (LVN) 1, who had called the DON on March 7, 2026, to inform the DON about Resident A's allegation on the RN. LVN 1 informed the DON that she did not smell alcohol on the RN, and then the DON spoke with the RN, who also denied drinking alcohol;-He spoke with the RN who had denied using alcohol, as well as LVN 1 verifying the RN did not smell alcohol;- The Admin stated he did not interview Resident A or other residents regarding the incident. The Admin stated he did interview other staff working with the RN the evening of the incident; and- The Admin stated he is the Grievance Officer for the facility, the protocol is if a resident files a grievance, an investigation is to be started. The Admin stated he is aware LVN 2 completed a change of condition form regarding Resident A. The Admin stated they should have followed their policy and procedure on addressing grievances.On March 11, 2026, at 2:55 p.m., an interview was conducted with LVN 2. LVN 2 stated she was receiving report on March 8, 2026, and the staff were discussing Resident A's allegation that the RN was smelling of alcohol. LVN 2 stated she notified the DON, the DON instructed her to do a change of condition form and write a care plan regarding the incident. LVN 2 stated she did not talk with the RN, nor did she speak with Resident A, she filled out the change of condition form and wrote what the DON told her to write about false allegations.On March 11, 2026, at 3:15 p.m., an interview was conducted with Resident A. Resident A stated there was a male nurse who came to her room to check on her IV line and gave her medicine. Resident A stated the RN had alcohol on his breath, and the RN acted arrogantly towards her. Resident A stated she told another employee about the alcohol smell on the RN. Resident A stated no one came to talk with her about the incident.A review of the facility's policy and procedure titled Grievances, dated April 2025, indicated, .establish a grievance process that allows the resident (s) a way to execute their right to voice concerns or grievances to the facility or other agency/entity without fear of discrimination or reprisal.the behavior of staff.make prompt efforts to resolve grievances that the resident may have.facility's grievance official is responsible for overseeing the grievance process and for receiving and tracking grievances.coordinating with state and federal agencies.reasonable expected time frame for completing review of the grievance.Grievance Official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident's right while the alleged violation is being investigated.responds to the individual expressing the concern within (3) three working days of the initial concern to acknowledge receipt and describe steps taken toward resolution.

Based on observation, interview, and record review, the facility failed to ensure transmission-based precautions (additional infection control measures used for patients with suspected or confirmed highly transmissible pathogens) were implemented according to the facility's policy and procedure, for two of three residents reviewed (Residents A and B).This failure had the potential for Residents A and B to be exposed to further infections.Findings:On March 11, 2026, at 8:45 a.m., an unannounced visit was conducted for the investigation of infection prevention and control.On March 11, 2026, at 9:20 a.m., an interview with the Infection Preventionist (IP) was conducted. The IP stated there are several residents on enhanced barrier precautions (EBP - Infection control measures used in nursing homes to minimize the spread of infections during high contact care-requiring staff to wear gowns and gloves) and a few residents on contact isolation (mandatory use of gloves and gowns upon room entry and removed before exiting the room) at this time in the facility.On March 11, 2026, at 12:15 p.m., a concurrent observation and interview were conducted with the Certified Nurse Assistant (CNA). The CNA entered Resident A and Resident B's room, which had the sign on door indicating, Contact Isolation. The CNA was observed applying gloves to deliver the meal tray to Resident A, removed her gloves, and grabbed another meal tray from another CNA in the hallway and delivered the meal tray to Resident B. The CNA was observed to have not put on a gown when she was serving Residents A and B's meal tray. The CNA was observed not to perform hand hygiene between caring for the two residents. The CNA came out of the room and stated only Resident A is on contact isolation. The CNA stated she should have worn gown and gloves when serving Resident A's meal tray and should have used hand hygiene (washing hand with soap and water or using an alcohol-based sanitizer) before taking Resident B's meal tray to her.On March 11, 2026, at 12:30 p.m., an interview was conducted with the IP. The IP stated the CNA should have followed proper infection prevention and control protocol, she should have worn gown and gloves when she helped Resident A, and performed hand hygiene before helping Resident B.On March 11, 2026, at 12:40 p.m., a review of Resident A's medical record was conducted. Resident A was admitted to the facility on [DATE] with diagnoses which included osteomyelitis (bacterial infection of the bone causing swelling, fever, tissue damage), bacteremia (presence of bacteria in the blood in an immunocompromised individual), and MRSA (Methicillin-resistant Staphylococcus aureus-a type of bacteria that is resistant to several antibiotics).A review of Resident A's Order Summary Report, included a physician's order, dated March 3, 2026, which indicated, TRANSMISSION BASED PRECAUTIONS CONTACT ISOLATION.On March 11, 2026, at 4 p.m., a review of Resident B's medical record was conducted. Resident B was admitted to the facility on [DATE], with diagnosis which included dementia (impaired ability to remember, think, or make decisions) and bipolar disorder (mental health condition characterized by extreme mood swings).A review of the facility's policy and procedure titled IPCP (Interprofessional Collaborative Practice) Standard and Transmission-Based Precautions, dated March 2025, indicated, .implement infection control measures to prevent the spread of communicable diseases.contact precautions.are used with a known infection that is spread by direct or indirect contact with the resident or the resident's environment.personal protective equipment (PPE): wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment.Don (put on) PPE before room entry doff (remove) before room exit; change before caring for another resident.A review of the policy and procedure titled Infection Prevention and Control Program, dated January 2026, indicated, .decrease the risk of infection to residents and personnel. Recognize infection control practices while providing care.ensure compliance with state and federal regulations related to infection control.prevent and control the spread of infection.investigate, control and prevent infections in the facility.hand hygiene and appropriate use of personal protective equipment (PPE-specialized clothing [gloves, gowns, masks, goggles] used to prevent the spread of infections).facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection.facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by acceptable professional practice.A review of the facility's undated policy and procedure titled Infection Prevention-Hand Hygiene, indicated, .all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.before and after direct contact with residents.after removing gloves.before and after entering isolation precaution settings.before and after assisting a resident with meals.the use of gloves does not replace hand washing/hand hygiene.gloves should be used.when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions.

Based on interview and record review, the facility failed to develop a plan of care (POC) with specific goals and objectives to address the injury, for one of four sampled residents (Resident 4) when Resident 4's rib fracture was identified. This failure had the potential for Resident 4 not to receive appropriate interventions tailored to her needs. Findings: On March 3, 2025, at 8:51 a.m., an unannounced visit to the facility was conducted to investigate a facility reported incident related to an injury of unknown origin concerns. On March 3, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included osteomyelitis (infection of the bone) and osteoporosis (bone disease prone to fracture). A review of Resident 4 ' s History and Physical, dated February 7, 2025, indicated Resident 4 was mentally incapable of understanding. A review of Resident 4's Order Summary Report, dated February 11, 2025, indicated, .Alendronate Oral Tablet 70 MG (milligrams-unit of measurement) .Give 1 tablet by mouth in the morning every Mon (Monday) for OSTEOPOROSIS . A review of Resident 4 ' s Change of Condition, dated February 18, 2025, indicated, .Acute fractures to Right ribs 8th and 9th costochondral junction [joint between ribs and cartilage (surface that protects bones)] . On March 3, 2025, at 10:20 a.m., a concurrent interview and record review of Resident 4's records were conducted with the Licensed Vocational Nurse (LVN). The LVN stated on February 17, 2025, Resident 4 complaint of flank pain and had a change of condition that was relayed to physicianto order an X-ray (bone image). The LVN stated on the same day, the night shift nurse received a report that Resident 4 obtain a rib fracture. The LVN stated, the licensed nurse on night duty Should have been created a care plan for fracture. The LVN further stated, if care plan was not developed, the nurses would not been guided for treatment and intervention to prevent possible further injury. There was no documented evidence a care plan was initiated to addressed Resident 4's rib fracture. On March 3, 2025, at 11 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated Resident 4 had rib fracture and licensed nurses did not initiate care plan. The DON stated she expected to all licensed nurses should have been created and developed care plan for fracture as soon as they identified Resident 4 ' s condition. The DON further stated care plan was a tool for communication to staff to addressed issues or problems. A review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Planning, dated February 2025, indicated, .It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment .to provide effective and person-centered care that meet professional standards of quality care .The resident ' s comprehensive plan of care will be reviewed and/or revised by the IDT .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food practices were provided, when: 1. Lettuce and stalks of celery were found in the walk-in refrigerator, open to air; 2. A small container of elbow macaroni was not dated or labeled; and 3. One tin container was placed on top of another tin container touching cut up watermelon. These failures had the potential to cause growth of harmful bacteria in food served to a medically compensated population. Findings: 1. On January 27, 2025, at 9:47 a.m., during the initial kitchen tour with the Dietary Manager (DM), small heads of lettuce and stalks of celery were found in unsealed plastic bags observed to be open to air stored in the walk-in refrigerator. On January 27, 2025, at 10:20 a.m., an interview was conducted with the Dietary Manager (DM). The DM stated the lettuce and celery were in the walk-in refrigerator exposed to air and should not be exposed to air. A review of the facility's policy and procedure titled Storing Produce, dated 2023, indicated, .When storing vegetables that should remain crisp, such as lettuce and other leafy greens, fresh herbs, celery, green peppers, broccoli, and asparagus, they will stay fresh longer if you place them in a sealed bag or container .keeping fresh vegetables tightly wrapped with as little air in the bag/container as possible will keep them fresh longer . 2. On January 27, 2025, at 10:34 a.m. an observation was conducted in the dry storage area where a small container of elbow macaroni was found undated and unlabeled. On January 27, 2025, at 10:36 a.m., an interview with the DM was conducted. The DM stated all the containers should be dated and labeled. A review of the policy and procedure titled Labeling and Dating of Foods, 2023, indicated, .All food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for either food safety or product rotation .the individual opening or preparing a food shall be responsible for date marking at the time of processing and/or storage .the use by date will incorporate the open date .the use by date signifies the date in which food must be consumed or discarded . 3. On January 29, 2025, at 10:15 a.m., during a follow up observation in the kitchen, the dietary aide was observed preparing fruit for lunch. The Dietary Aide (DA) was observed cutting watermelon and putting in a tin container. The DA was observed to stack another tin container with whole fruit inside on top of the tin container with watermelon and was touching the watermelon. On January 29. 2025, at 10:15 a.m., an interview was conducted with the DA. The DA stated one container fell inside the container with the watermelon. On January 29, 2025, at 10:19 a.m., an interview was conducted with the Certified Dietary Manager (CDM) who stated the watermelon was contaminated and needed to be discarded. A record review of the policy and procedure titled Food Preparation, 2023, indicated, .consider all raw product as contaminated .handle it with methods designed to reduce existing contamination or to prevent cross contamination to other products .keep raw and cooked foods separate .use separate cleaned and sanitized cutting boards, utensils, and knives when moving between working with raw and cooked foods .

Based on interview and record review, the facility failed to ensure, one of five residents reviewed for unnecessary medications (Resident 10), was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when Resident 10 was administered sertraline (brand name Zoloft, used to treat depression) without an appropriate indication and/or clinical justification for its use. This failure resulted in unnecessary medications for Resident 10, which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of sertraline that included but not limited to sexual dysfunction, diarrhea, nausea, and seizures. Finding: On january 29, 225, a review of Resident 10's clinical record indicated she was initially admitted to the facility on [DATE] and recently readmitted on [DATE] with diagnoses including major depressive disorder (depression). A review of Resident 10's medical record indicated she had received sertraline prescribed for depression on December 7, 2021 to November 5, 2024. A review of Resident 10's medical record included a physician's order, dated November 6, 2024, for sertraline 150 milligrams (mg - unit of measurement) by mouth one time a day for chronic pain. A review of Resident 10's medical record indicated a current physician's order dated January 23, 2025 for sertraline 150 mg by mouth one time a day every Monday, Wednesday, Friday, Sunday for chronic pain and one time a day every Tuesday, Thursday, Saturday for chronic pain. On January 29, 2025 at 4:07 p.m., during a concurrent interview and record review with the Director of Nursing (DON), Resident 10's medical record and sertraline physician orders, dated December 7, 2021 to January 23, 2025, were reviewed. The physician orders indicated sertraline was initially prescribed for depression on December 7, 2021 to November 5, 2024 and the indication was changed to chronic pain on November 6, 2024 to January 23, 2025. When asked if there was documentation of the clinical justification for the new indication chronic pain, the DON stated she would follow-up. During the same interview, the DON stated the facility's psychotropic medication administration and monitoring process was as follows: - Upon admission of a resident with psychotropic medications, the facility needed to ensure the resident had a physician's order for the psychotropic medication with an accurate diagnosis and corresponding behavior manifestation; - If the physician's order was unclear, nursing staff needed to clarify with the physician; - Psychotropic medications were reviewed monthly, or more often if needed, by the Interdisciplinary team (IDT) which included the Social Services Director, DON or designee, the Activities Director, and other staff involved in the residents' care; and - All psychotropic medications were reviewed by a psychiatric provider and the Consultant Pharmacist. On January 29, 2025 at 5:33 p.m., during a follow-up interview with the DON, the DON confirmed there was no documentation in Resident 10's medical record of the clinical justification for the new sertraline indication chronic pain on November 6, 2024 and stated there should have been documentation. On January 30, 2025 at 10:33 a.m., during an interview with the Social Services Director (SSD), the SSD stated the facility's psychotropic medication review process was as follows: - The day after an admission, any resident with psychotropic medications were reviewed to ensure the appropriate medication orders were obtained; and - Psychiatric consults were scheduled with the appropriate provider if needed. During the same interview, the SSD reviewed Resident 10's medical record and sertraline orders dated December 7, 2021 to January 23, 2025. The SSD acknowledged sertraline was initially prescribed for depression on December 7, 2021, and the indication was changed to chronic pain on November 6, 2024. The SSD stated there was no documentation of an initial psychiatric assessment on November 5, 2024 (the day the resident was admitted ) or on November 6, 2024 (the day after admission). Additionally, the SSD reviewed the LN [Licensed Nurse] - Psychoactive Medication Evaluation, dated November 6, 2024 and confirmed the evaluation did not indicate why sertraline indication was changed to chronic pain. The SSD stated there should have been documentation in Resident 10's medical record of the clinical justification for the new sertraline indication chronic pain on November 6, 2024. The SSD stated the Interdisciplinary Team (IDT) had a meeting on December 16, 2024 to review Resident 10's reported issues from the weekend and did not discuss the sertraline indication change from depression to chronic pain. On January 30, 2025, at 2:21 p.m., during a follow-up interview with the DON, she stated it was important for psychotropic medications to have a clear indication and documented clinical justification for use to ensure appropriate monitoring for effectiveness and to ensure the resident was provided the correct medication. A review of the facility's policy and procedure titled Psychotropic Drug Use, dated August 2017, indicated, .The Licensed Nurses shall review the classification of the drug, the appropriateness of the diagnosis, and its indication/behavior monitors and related adverse side effects prior to verification of admission orders the Attending Physician .Upon initial comprehensive assessment, the Social Services designee shall review new admissions for any psychiatric, mood or behavior disorders, mental and psychosocial difficulties, and/or physician's orders for psychotropic medications. These residents will be referred to the facility's Psychotropic Drug Review Committee and/or the Psychiatrist to ensure .Psychotropic medication was prescribed to treat a specific diagnosed condition as documented in the clinical record . A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for sertraline, revised August 2023, indicated, Indications and Usage .indicated for the treatment of .Major depressive disorder (MDD) in adults .Obsessive-compulsive disorder (OCD) in adults and pediatric patients 6 years and older .

Based on observaton, interview, and record review, the facility failed to ensure care and treatment was provided according to the physicians orders and plan of care, for two of 15 residents (Residents 14 and 286) when: 1. For Resident 14 and 286, the blood sugar levels were outside of the parameters and; 2. For Resident 14, the blood pressure (B/P - force exerted by blood against the walls of the arteries) was not monitored prior to administering the medication to treat high blood pressure. These failures had the potential for a delay in care and treatment and could cause a decline in the residents overall health condition. Findings: 1a. On January 28, 2025, at 3:20 p.m., Resident 14 was observed at the nurses station trying to get the attention of the nursing staff due to his Dexcom (brand name of a blood glucose monitoring device inserted under the skin) monitor showing an increase in blood sugar. On January 29, 2025, at 4:30 p.m., an interview was conducted with Resident 14. Resident 14 stated he would show the staff his personal blood glucose monitor when his blood sugar would increase or decrease. Resident 14 stated his blood sugar increased and licensed nursing staff would not give insulin (medication to help regulate blood sugar levels) until the licensed nurse performed the blood sugar check at 4:30 p.m. Resident 14 stated he had a personal blood glucose monitoring device inserted under the skin that could monitor the blood glucose levels. Resident 14 stated the device would alarm if the blood sugars increased or decreased. A review of Resident 14's Admission Record, indicated, Resident 14 was admitted to the facility on [DATE], with diagnoses which included, diabetes mellitus (the body has trouble controlling blood sugar). A review of Resident 14's Minimum Data Set (MDS - a resident assessment tool), indicated Resident 14 had a Brief Interview for Mental Status (BIMs - short cognitive screening test) score of 15 (cognitively intact). A review of Resident 14's Medication Administration Record, included a physician order, dated January 14, 2025, which indicated, .Insulin Lispro (medication which regulates blood sugar) Injection Solution 100 unit/ml (milliliter - unit measurement), insulin Lispro Inject as per sliding scale: if 150 - 200 = 2 units; 201-250 = 4 units; 251- 300 = 6; 301- 350 = 8; 351- 400 = 10; 401- 450 = 12; 451- 500 = 14 units over 500 administer 14 units and notify md (physician), subcutaneously (beneath the skin) before meals and at bedtime for diabetes mellitus . A review of Resident 14's Progress Notes, for the month of January indicated, a blood sugar level of 500 on January 14, 2025, at 4:30 p.m. A further review of Resident 14's record indicated, there was no notification provided to the physician on January 14, 2025 at 4:30 p.m. when Resident 14's blood sugar level was 500. On January 30, 2025, at 4:06 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the blood sugar of 500 on January 14, 2025, at 4:30 p.m., was not reported to Resident 14's physician and should have been. 1b. A review of Resident 286's Admission Record, indicated Resident 286 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus. A review of Resident 286's Minimum Data Set (MDS - a resident assessment tool), dated January 27, 2025, indicated Resident 286 had a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). A review of Resident 286's Physician Order, dated January 23, 2025, indicated, .Insulin Aspart (medication used to decrease blood sugar levels) Injection Solution (Insulin Aspart) Inject as per sliding scale: if 70 - 150 = 0; 151 - 200 = 2U; 201-250 = 4U; 251-300 = 6U; 301-400 = 10U BS (blood sugar) over 400 call Medical Doctor (MD - physician) subcutaneously before meals and at bedtime for diabetes mellitus . A review of Resident 286's Medication Administration Record, for the month of January 2025, indicated a blood sugar level of 442, on January 23, 2025, at 9 p.m. Further review of Resident 286's record indicated there was no documented evidence the physician was notified of Resident 286's blood sugar level of 442 (above 400), on January 23, 2025, at 9 p.m. On January 30, 2025, at 5:02 p.m., an interview and concurrent record review was conducted with the DON. The DON stated if the blood glucose level is above 400, the licensed nurse should give 10 units of insulin and notify the physician. The DON further stated the physician was not contacted when Resident 286 blood sugar level was 442 on January 23, 2025, at 9 p.m. A review of the policy and procedure titled, Diabetes Mellitus - Resident Management, revised January 2025, indicated, .medication management .follow physician's order for glucose monitoring .specific resident need .notify the residents physician when blood sugars are out of range per orders . 2. A review of Resident 14's Admission Record, indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included heart failure. A review of Resident 14's Physician Order, dated December 27, 2024, indicated, Lisinopril (medication used to treat high blood pressure) Oral Tablet 20mg (milligram - unit of measurement). Give 1 tablet by mouth in the evening for Hypertension (pressure in blood vessels is to high) HOLD if SBP (systolic blood pressure) is < (less than) 110. A review of the Medication Administration Record, dated January 2025, indicated, Resident 14 SBP was not taken prior to administering Lisinopril on January 2, 5, 10, 11, 13, 14, 15, 16, 18, 19, 20, 21, 22, 25, 26, 27, 28, and 30, 2025 (18 days). On January 30, 2025, at 5:58 p.m., an interview and concurrent record review was conducted with the DON. The DON stated licensed nurse should check and document the resident's blood pressure prior to administering lisinopril for Resident 14. The DON stated licensed nursing need to follow the physician orders to know if it was appropriate to administer the medication according to the parameters ordered by the physician. The DON stated if lisinopril was given when the blood pressure is below the parameters, the resident could experience adverse effects from a low blood pressure. A review of the policy and procedure titled Medication Administration, dated January 2025, indicated .administering unit doses and previously prepared drugs .take vital signs if required .hold drugs if indicated .

Based on observation, interview, and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents, when Resident 18 was missing documentation for the administration of a controlled substance (CS - those with high potential for abuse and addiction) medications, during the medication cart inspection. The CS medication was signed out of the Controlled Medication Count Sheet (an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate it was administered to the resident. Additionally, the CS medication was wasted (not administered to the resident and discarded) without two licensed nurses' documentation on the count sheet according to the facility's policy for Resident 18. These failures resulted in inaccurate accountability of CS medications, which had the potential for misuse or diversion. Findings: On January 27, 2025, Resident 18's record was reviewed. Resident 18 had a physician's order, dated November 16, 2024, for hydrocodone-acetaminophen (Norco, a potent controlled medication for pain) 5/325 mg, 1 tablet by mouth every 8 hours as needed for severe pain. On January 27, 2025 at 10:53 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, she stated the facility's process for CS medication administration was as follows: - Ask the resident about pain location; - Check the Count Sheet to find out when pain medication was last given; - Pour pain medication (remove from locked drawer of medication cart); - Sign Count Sheet and MAR at the same time; and - If the pain medication was not given or refused by a resident, need to waste with another nurse witness and both nurses needed to sign the Count Sheet. On January 27, 2025, at 10:58 a.m., during a concurrent interview and record review with LVN 1, a review of Resident 18's Controlled Medication Count Sheet, for Norco 5/325 mg and the Medication Administration Record, for the months of November and December 2024, indicated Norco was signed out from the count sheet but was not documented as administered on the MAR on the following dates and times: - November 29, 2024, at 20:57 (8:57 p.m.); - December 8, 2024 at 21:15 (9:15 p.m.); - December 18, 2024 at 21:24 (9:24 p.m.); - December 20, 2024 at 21:04 (9:04 p.m.); and - December 26, 2024 at 05:20 (5:20 a.m.). In a concurrent interview, LVN 1 acknowledged one Norco 5/325 mg tablet for Resident 18 was unaccounted in November 2024 and four Norco 5/325 mg tablets were unaccounted in December 2024. Additionally, Resident 18's Count Sheet for Norco 5/325 mg indicated one tablet was wasted on December 21, 2024 at 21:04 (9:04 p.m.) and did not have a second nurse witness documented on the Count Sheet. LVN 1 stated the nurse should have had another nurse sign on the Count Sheet as a witness for the wasted Norco 5/325 mg tablet. On January 28, 2025 at 2:08 p.m. during an interview with the Director of Nursing (DON), the DON stated the expectation during CS medication administration was for the nursing staff to have immediately document on the count sheet and in the MAR. The DON confirmed the discrepancies and acknowledged the missing documentations in the MAR for the dates and times as listed above for Resident 18. The DON stated the administrations should have been documented on the MAR. Additionally, the DON stated the expectation for wasting CS medications was for two licensed nurses to co-sign. The DON stated nursing staff must document wasted on the Count Sheet with two licensed nurse initials every time. The DON said, [Nurses] Cannot destroy [CS medication] without a witness. The DON confirmed and acknowledged the Norco 5/325 mg tablet was wasted without two licensed nurses' initials on December 21, 2024, at 21:04 (9:04 p.m.) for Resident 18. The DON stated documentation of CS medication was important to prevent diversion and to ensure residents received the medication but not double dosed if too soon to be given. The DON stated following the process for wasting CS medication was important for accountability and transparency to prevent diversion. A review of the facility's policy and procedure titled Medication Administration, dated August 2021, indicated, .The staff administering the medication must record such information on the resident's MAR before administering the next resident's medication . During a review of the facility's P&P, titled Controlled Medications - Storage and Reconciliation, dated January 2022, the P&P indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: date and time of administration; amount administered; signature of the nurse administering the dose, completed after the medication is actually administered .When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record, on the line representing that dose .

Based on interview and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR), for one of five residents reviewed for unnecessary medications (Resident 10), when Resident 10 received sertraline (brand name for Zoloft, medicatuion used to treat depression) without an appropriate indication and/or clinical justification for its use. This failure had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects for the residents. Finding: On January 29, 2025, a review of Resident 10's clinical record indicated Resident 10 was initially admitted to the facility on [DATE] and recently readmitted on [DATE] with diagnoses which includes major depressive disorder (depression). A review of Resident 10's medical record indicated she had received sertraline prescribed for depression on December 7, 2021 to November 5, 2024. A review of Resident 10's medical record included a physician's order, dated November 6, 2024, which indicated sertraline 150 milligrams (mg - unit of measurement) by mouth one time a day for chronic pain. A review of Resident 10's medical record indicated a current physician's order dated January 23, 2025 for sertraline 150 mg by mouth one time a day every Monday, Wednesday, Friday, Sunday for chronic pain and one time a day every Tuesday, Thursday, Saturday for chronic pain. On January 29, 2025 at 4:07 p.m., during a concurrent interview and record review with the Director of Nursing (DON). The DON stated the physician orders indicated sertraline was initially prescribed for depression on December 7, 2021 to November 5, 2024 and the indication was changed to chronic pain on November 6, 2024 to January 23, 2025. When asked if there was documentation of the clinical justification for the new indication chronic pain, the DON stated she would follow-up. During the same interview, the DON stated the facility's psychotropic medication administration and monitoring process was as follows: - Upon admission of a resident with psychotropic medications, the facility needed to ensure the resident had a physician's order for the psychotropic medication with an accurate diagnosis and corresponding behavior manifestation; - If the physician's order was unclear, nursing staff needed to clarify with the physician; - Psychotropic medications were reviewed monthly, or more often if needed, by the Interdisciplinary team (IDT) which included the Social Services Director, the DON or designee, the Activities Director, and other staff involved in the residents' care; and - All psychotropic medications were reviewed by a psychiatric provider and the Consultant Pharmacist (CP). A review of the CP's monthly MRRs for Resident 10 on November 25, 2024, December 31, 2024, and January 18, 2025, indicated there were no recommendations from the CP related to the sertraline indication change from depression to chronic pain. On January 29, 2025 at 5:33 p.m., during a follow-up interview with the DON, the DON confirmed there was no documentation in Resident 10's medical record of the clinical justification for the new sertraline indication of chronic pain on November 6, 2024 and stated there should have been documentation. Additionally, the DON stated the CP should have identified the indication change and reported the irregularities during the MRRs on November 25, 2024, December 31, 2024, and January 18, 2025. On January 30, 2025 at 2:33 p.m., during a telephone interview with the CP, the CP stated the MRR process was as follows: - Medications for all residents were reviewed monthly, including review of the MAR, laboratory results, diagnoses, and documentation of clarifications; and - If medication changes or adjustments were needed, the CP sent the documented recommendations to the facility. During the same telephone interview, the CP stated she did not identify or report when the sertraline indication was changed from depression to chronic pain for Resident 10 during the MRRs on November 25, 2024, December 31, 2024, and January 18, 2025. The CP acknowledged the irregularity should have been identified and reported. A review of the facility's policy and procedure titled Medication (Drug) Regimen Review (MRR), revised January 2022, indicated, .The MRR includes identification of irregularities, medication-related errors, adverse consequences, and use of unnecessary drugs .Unnecessary drug is defined as medications ordered .without adequate indications for its use .

Based on observation, interview, and record review the facility failed to ensure infection control practices were followed when the Certified Nursing Assistant (CNA) was observed not to perform hand hygiene prior to and after passing out lunch trays. This failure had the potential for staff to spread infection to residents who are already medically compromised. Findings: On January 29, 2025, at 11:48 a.m., CNA 1 was observed passing out lunch trays without washing or sanitizing his hands. On January 29, 2025, at 12:00 p.m., an interview was conducted with CNA 1. CNA 1 stated he should have washed and sanitized his hands prior to touching the lunch tray and after placing the tray with the resident. On January 30, 2025, at 10:23 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated during meal distribution prior to touching plates, staff should wash or sanitize their hands before and after handling each tray and after every three residents, the staff should wash their hands. A review of the policy and procedure titled Hand Hygiene, 2023, indicated, .use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents .before and after entering isolation precaution settings .before and after eating or handling food .before and after assisting a resident with meals .

Based on observation, interview, and record review, the facility failed to ensure a care plan was developed and implemented to address a personal monitoring device used to measure blood glucose levels, for one of 15 residents (Resident 14). This failure had the potential for staff to not be aware of Resident 14 care needs and provide appropriate treatment related to the blood sugar monitoring device. Findings: On January 28, 2025, at 3:20 p.m., Resident 14 was observed at the nurse's station trying to get the attention of the nursing staff due to his Dexcom (brand name of a blood glucose monitoring device inserted under the skin) monitor showing an increase in blood sugar. On January 29, 2025, at 4:30 p.m., an interview was conducted with Resident 14. Resident 14 stated he would show the staff his personal blood glucose monitor when his blood sugar would increase or decrease. Resident 14 stated his blood sugar increased and licensed nursing staff would not give insulin (medication that helps regulate blood sugar levels) until the licensed nurse performed the blood sugar check at 4:30 p.m. Resident 14 stated he had a personal blood glucose monitoring device inserted under the skin that could monitor the blood glucose levels. Resident 14 stated the device would alarm if the blood sugars increased or decreased. Resident 14 stated he should get the blood glucose device inserted under his skin every 10 days. On January 29, 2025, a review of Resident 14's Admission Record, indicated, Resident 14 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (the body has trouble controlling blood sugar). A review of Residents 14's Medication Administration Record, included a physician order, dated January 8, 2025, which indicated, .Dexcom G7 Sensor Miscellaneous (Continuous Glucose System Sensor) Inject 1 application subcutaneously in the evening every 10 day(s) for blood sugar checks. Change Dexcom G7 Sensor every 10 days . Further review of Resident 14's record indicated there was no care plan developed to address the use of the personal blood glucose monitoring device. On January 29, 2025, at 5:40 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the licensed nurses should compare the blood sugar results from Resident 14's Accu-Check with the Dexcom monitor reading. The DON stated there was no care plan for the use of the Dexcom . The DON stated there should be a care plan to address the use of the Dexcom device for Resident 14. A review of the policy and procedure titled Comprehensive Resident Centered Care Plan, dated January 2022, indicated, .It is the policy of this facility that the interdisciplinary team (IDT - a group of healthcare professionals) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframe to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment .within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person centered care .the baseline care plan will include the minimum healthcare information necessary to properly care for the resident including, but not limited to: initial goals based on admission orders .physician orders .dietary orders .therapy orders .social services orders .and PASARR recommendations, if applicable .the residents comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments .

Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the State Agency (SA) as required within two hours, for one of two residents reviewed (Resident 2). This failure had the potential to put residents at risk for further abuse. Findings: On January 17, 2025, at 8:30 a.m., an unannounced visit was made to the facility for an allegation of abuse. On January 17, 2025, at 9:23 a.m., an observation with a concurrent interview was conducted with Resident 2. Resident 2 was in his room, alert, and interviewable. Resident 2 stated he had an incident with Resident 1, he did not recall the date, but it was around 4:00 a.m. Resident 2 stated he had an argument with Resident 1 and he pushed him on the arm by the elevator door. Resident 2 stated he did not sustain injuries. On January 17, 2025, Resident 2 ' s record was reviewed. Resident 2 was admitted to the facility on , with diagnoses including urinary tract infection, unspecified heart failure, other acute kidney failure, Klebsiella Pneumoniae, other symptoms and signs concerning food and fluid intake, chronic idiopathic constipation, Type 2 Diabetes Mellitus without complications, other abnormalities of gait and mobility, and need for assistance with personal care. The progress notes dated, January 2, 2025 indicated Resident 2 had an altercation with Resident 1 on January 2, 2025 at 4:00 a.m. On January 17, 2025, at 4:33 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated on January 2, 2025, at around 4:00 a.m., he heard the yelling between Resident 1 and 2 but he did not actually witness the incident. LVN 1 stated Resident 2 was already on the floor by the time he arrived on the scene. LVN 1 stated he reported the incident to the Administrator on January 2, 2025, at around 7:00 a.m. LVN 1 stated he should have reported the incident to the Administrator immediately. On January 17, 2025, at 4:48 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she worked on January 2, 2025, and at around 4:00 a.m., she had witnessed the incident between Residents 1 and 2. CNA 1 stated she had reported the incident to LVN 1, who was already present by then. CNA 1 stated she also reported it to the Administrator around three hours later from the time the incident had occurred. CNA 1 stated the incident should have been reported within two hours. On January 22, 2025, at 8:33 a.m., an interview was conducted with the Administrator. The Administrator stated the incident between Residents 1 and 2 was reported to him on January 2, 2025, at around 9:00 a.m., the Administrator stated the incident was reported to the SA via facsimile about an hour or so. The Administrator stated the incident between Residents 1 and 2 should have been reported to the SA within two hours. The Administrator further stated facility staff should be able to report abuse incidents to the SA via phone call or fax the completed SOC 341 (form used to report allegations of abuse to the elderly). The Administrator stated instructions on how to report an abuse is available at the nursing station. The facility ' s policy and procedure titled, Abuse: Prevention of and Prohibition Against, dated November 28, 2017, indicated, .each resident has the right to be free from abuse .the Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse .allegations of abuse .will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations .

Based on interview and record review the facility failed to ensure necessary treatment and services to promote healing of pressure injuries (a localized area of skin damage caused by prolonged or intense pressure on the skin, often over bony parts of the body) are provided in a timely manner, for one of three residents (Resident A), when: - The pressure injury on the sacral area (lower portion of spinal column) was not identified on admission and treatment orders not initiated timely; and - Treatment orders were not administered as ordered by the physician. These failures had the potential in the delay in care and treatment of Resident A's pressure injury which could affect healing. Findings: On November 6, 2024, at 12: 30 p.m., an unannounced visit to the facility was conducted to investigate complaints and facility reported incident of quality of care and neglect. On November 6, 2024, at 1:30p.m., an interview and concurrent record review was conducted with the Treatment Nurse (TN). The TN stated when Resident A was admitted to the facility, it was hard to notice the wound on the resident's sacrum, due to the resident ' s dark skin tone. The TN stated Resident A came from the hospital with a scaral wound which was unable to stage because of presence of necrotic tissue (black dead tissue) and was difficult to see and took two people to examine her sacral area because the resident had loose skin around her bottom, it. The TN stated she forgot to document a description of the sacral wound bed on Resident A's skin assessment note, dated October 22, 2024. The TN stated Resident A's sacral wound bed had an eschar (dark colored leathery dead tissue) present when she assessed it on October 15, 2024. The TN stated the facility's protocol for prevention of pressure injury which includes a wound consult. The TN stated usually a wound consultant comes in and would document an assessment of the wound weekly and would give any treatment recommendations for the licensed nurse to implement, but there was no wound consult done. The TN stated she last worked on October 29, 2024, and returned to work on November 5, 2024. On November 6, 2024, at 4:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident A did not have an order for a wound care consult upon identification of the pressure injuries. The DON stated but Resident A did not see a wound care consultant. On November 6, 2024, a review of Resident A ' s medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included a urinary tract infection (bladder infection) and dementia (problems with thinking and remembering). A review of Resident A's Initial Admission Record, dated October 14, 2024, indicated, .Patient had dry skin on lower extremities and red heel, has edema (swelling) at both lower extremities and her left upper arm. Has pressure injury on sacrum .Signed date: 11/04/2024 (November 4, 2024) . A review of Resident A's Audit Report .Admission Assessment, dated November 12, 2024, indicated documentation on the pressure injury on the sacrum was added on November 4, 2024, and not on admission on October 14, 2024. A review of Resident A's care plan, dated October 14, 2204, indicated, .has pressure ulcer development r/t (related to) poor mobility, requires assistance with adls (Activities of Daily Living) .pt (patient) admitted with left heel P/I .sacrum p/i .right heel p/i .Interventions .Administer treatments as ordered and monitor its effectivenesss .Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress . A review of Resident A's Order Summary Report, indicated the following physician's order: - .(L)(left) heel P/I (pressure injury): Cleanse with NS (normal saline) pat dry apint (sic) with betadine cover with DD (dry dressing) every day shift for 21 days ., date ordered October 15, 2024; - .(R)(right) heel P/I: with NS pat dry apint (sic) with betadine cover with DD (dry dressing) every day shift for 21 days ., date ordered October 15, 2024; - .Sacrum P/I: Cleanse with NS pat dry apply xeroform cover with DD every day shift for 21 days ., date ordered October 15, 2024; and - .Sacrum P/I: Cleanse with NS pat dry paint with beetadine cover with DD every day shift for 21 days ., date ordered October 19, 2024. A review of Resident A ' s Treatment Administration Records (TAR), indicated all treatment orders were completed on the day the treatment was scheduled for October 2024. A review of Resident A's Administration Audit Report, indicated the following: - Left heel treatment scheduled for October 15, 2024, was documented as administered on October 19, 2024; - Sacrum pressure injury treatment scheduled for October 16, 17, and 18, 2024, was documented as administered on October 19, 2024; - Right heel treatment scheduled for October 16, 17, 18, and 19, 2024, was documented as administered on October 22, 2024. - Sacrum P/I scheduled for October 19 and 21, 2024, was documented as administered on October 23, 2024; - Sacrum P/I scheduled for October 20, 2024, was documented as administered on October 24, 2024. A review of Resident A's Skin Pressure Ulcer Weekly, dated October 29, 2024, indicated documentation of Resident A's pressure injuries completed by the TN on November 4, 2024. A review of Resident A's Progress Notes, indicated the following: - November 3, 2024, at 9:44 a.m., indicated, .Foul odor wound at sacrum . - November 3, 2024, at 3:27 p.m., indicated, .Obtained order from (name of physician) to have Rocephin (brand of antibiotic) for wound infection and do wound culture (laboratory test to check presence of bacteria on the wound) . - November 3, 2024, at 5:34 p.m., indicated, .Resident continues to have malodor to the coccyx wound, large amount of purulent (containing pus) exudate (fluid that leaks out of blood vessels into nearby tissues) noted . - November 4, 2024, at 3:42 p.m., indicated, .patient was transferred to hospital . On November 12, 2024, at 1:05 p.m., an interview was conducted with the Licensed Vocational Nurse (LVN). The LVN stated the admission nurse was responsible for completing a head to toe assessment on admission. On November 12, 2024, at 1:55 p.m., an interview was conducted with the Minimal Data Set (MDS) nurse. The MDS stated she does fill in when needed as the treatment nurse. The MDS stated she performed a skin evaluation on Resident A on October 30, 2024, but did not complete the note. The MDS stated she did not feel confident with wound care notes and did not measure Resident A ' s sacral wound or document the wound description. The MDS stated she usually would leave that for the treatment nurse to complete. On November 12, 2024, at 2:30 p.m. an interview and concurrent record review was conducted with the TN. The TN stated the admission nurse was to complete the initial assessment on a new resident and one of the assessments to be completed including the skin. The TN stated she does not remember why she did not complete her initial skin assessment note for Resident A on October 15, 2024, she made changes to her documentation on October 18 and 22, 2024, but she should not have waited to complete her documentation. The TN sated she did Resident A's treatment to her heels and sacrum starting on October 15, 2024, and did not document consistently or daily as her audit report indicated, she should be signing off treatments the day they were completed not two or three days after. On November 12, 2024, at 4:30 p.m., an interview and concurrent record review was conducted with the Registered Nurse (RN). The RN stated the initial admission assessment included a full body skin check, and after the assessment, we notify the doctor with our findings, and ask for orders. The RN stated she forgot to put Resident A ' s sacral pressure injury on the initial assessment, she forgot to document it on October 14, 2024 and when she remembered she added it on November 4, 2024. A review of the facility ' s undated policy titled, Change of Condition Reporting, indicated, .all changes in resident condition will be communicated to the physician .timely notification of a change in resident condition .change in a resident ' s condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit .or acute care evaluation .document resident change of condition and response in nursing progress notes per policy and update resident care plan, as indicated . comprehensive care plan completed . A review of the facility ' s policy and procedures titled, Skin Management System, dated December 2023, indicated, .Residents will have a head to toe skin assessment by a licensed nurse at the time of admission. Any skin lesions will be documented on the Nursing Admission Assessment. A treatment order will be obtained from the attending physician for areas requiring treatment .A plan of care will be initiated to address areas of actual skin breakdown. The plan of care will be reviewed and revised as needed. Resident will have ongoing head to toe assessment done weekly, incorporated into the LN Weekly Summary review .report of all wounds and their progress will be updated by the treatment nurse weekly .

Based on interview and record review the facility failed to ensure a change in cognitive status was addressed, for one of three residents reviewed (Resident A), when Resident A exhibited hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there) and increasing confusion. In a addition, there was no plan of care developed to address Resident A's hallucinations and confusion. This failure resulted in a delay in the care and treatment for Resident A when the resident was transferred to the general acute hospital three days after onset of hallucinations and increasing confusion. Findings: On November 1, 2024, at 9:30 a.m., an unannounced visit to the facility was conducted to investigate a complaint. On November 1, 2024, a review of Resident A ' s medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included a left foot amputation and diabetes mellitus (abnormal blood sugar). A review of Resident A's Minimum Data Set (MDS - an assessment tool), dated October 7, 2024, indicated Resident A had a BIMS (Brief Interview of Mental Status) score of 11 (moderate cognitively intact). A review of Resident A's Progress Notes, indicated Resident A had episodes of confusion on October 7 to 12, 2024, and was started on antibiotic (medication to treat infection) due to elevated white blood cell count (WBC - found in the blood, part of the body ' s immune system, helps fight infections) . There was no documented evidence Resident A exhibited hallucinations on October 7 to 12, 2024. A review of Resident A ' s care plan, dated October 7, 2024, indicated, Resident A .has elevated WBC 16.7 (normal range 4.5 to 11) .interventions .Monitor/document/report to MD (medical doctor) s/sx (signs and symptoms) of delirium (serious disturbance in mental abilities resulting in confused thinking and reduced mental awareness); changes in behavior, altered mental status, wide variation in cognitive functions throughout the day, communication decline, disorientation, periods of lethargy (lack of energy), restlessness and agitation, altered sleep cycle . A review of Resident A's Progress Notes, dated October 13, 2024, at 11:47 a.m., indicated .patient is alert and verbally responsive .patient had increase confusion saying he seen his wife in the room, even though, wife not present .had tremors and jittering. Dr. [name] notified and order to send patient to hospital for increased confusion . On November 1, 2024, at 2:30 p.m., an interview was conducted with Resident B. Resident B stated he was roommates with Resident A from October 1 to 13, 2024, until Resident A was transferred to the hospital. Resident B stated Resident A was a different person from the time he was admitted to the facility, until he was sent out to the hospital, Resident A was deteriorating, he was not doing well. Resident B stated about three nights before Resident A was sent to the hospital, Resident A kept grabbing at the curtains, and talking to people who were not there, saying he sees spirits, Resident A knocked over a food tray one night, and the staff came in to see what happened, it made a lot of noise when it fell . Resident B stated someone finally evaluated Resident B and sent him to the hospital. Resident B stated Resident A began to get tremors, his hands were shaking, Resident A was normally talkative, watched television or was talking on his phone, but two days before Resident A went to the hospital, he was quiet, the television was not on, and was not talking on the phone, this was not normal for Resident A. On November 1, 2024, at 2:40 p.m., and interview and a concurrent record review was conducted with the Registered Nurse (RN). The RN reviewed Resident A ' s medical record and stated Resident A had increased confusion over the past three days and hallucinations prior to being sent out. The RN stated Resident A was acting confused, talking to himself, seeing his [family member] in the room but was not there, Resident A was hallucinating. The RN stated, the doctor was aware, but no change of condition was documented, no SBAR (situation, background, assessment, recommendation- a communication tool used by healthcare workers when there is a change of condition among the residents) form was completed, and no care plan was updated to include confusion, ALOC (altered level of consciousness), or hallucinations. The RN stated Resident A should have been re-evaluated when the resident exhibited hallucinations and increasing confusion three days prior to being sent out. A review of the facility ' s undated policy and procedure titled Change of Condition Reporting, indicated, .all changes in resident condition will be communicated to the physician .timely notification of a change in resident condition .change in a resident ' s condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit .or acute care evaluation .Symptoms and unusual signs will be communicated to the physician promptly .document resident change of condition and response in nursing progress notes per policy and update resident care plan, as indicated .comprehensive care plan completed .

Based on observation, interview, and facility document review, the facility failed to follow the policy and procedure to provide an environment free of pests, when fruit flies and one mosquito were observed flying and landing in the kitchen. This failure had the potential to lead to food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in the facility residents who eat food prepared in the kitchen. Findings: On December 3, 2023, at 10:22 a.m., an observation was conducted with the Certified Dietary Manager (CDM) in the kitchen. Six black flies were observed landing on the wall in front of the CDM's office, and two black flies landed in the dish washing area. In a concurrent interview with the CDM, the CDM stated those flies were fruit flies. In addition, the CDM stated it was not OK to have fruit flies or any kind of pests in the kitchen because pests could go onto the food. On December 3, 2023, at 10:24 a.m., during the kitchen observation with the CDM, one fruit fly landed on the wall by the window of the dry storage room. In a concurrent interview, the CDM stated it was another fruit fly. On December 3, 2023, at 10:35 a.m., the CDM and surveyors observed one fruit fly flying around the juice machine. The CDM stated it was a fruit fly. On December 3, 2023, at 10:38 a.m., during a kitchen observation with the CDM, one fruit fly was observed on the wall above the two compartment sink. In a concurrent interview with DA 2, DA 2 described the fruit fly landing above the two-compartment sink as a bug. On December 3, 2023, at 10:54 a.m., during an observation with the CDM in the disposable item storage room, one mosquito was observed flying around. The CDM stated there was a mosquito. On December 4, 2023, at 11:10 a.m., during an observation with the Maintenance Director (MTD), two flies landed above the exit door to the dining area. A concurrent interview the MTD stated those flies were fruit flies. In addition, MTD stated he was not aware there were fruit flies in the kitchen and no staff had reported them to him. On December 4, 2023, at 9:10 a.m., an interview with the Infection Preventionist (IP) was conducted. The IP stated she was not aware of any pest problem in kitchen. The IP's expectation was the kitchen should be pest free, as pests could introduce possible contamination of foods provided to residents. On December 4, 2023, at 9:21 a.m., an interview was conducted with the Administrator (ADM). The ADM stated she was not aware of any fruit flies in the kitchen. The ADM further stated there had been a mosquito issue in the kitchen area a month ago. The ADM's expectation was there should be no pests in the facility. On December 4, 2023, at 3:01 p.m., an interview was conducted with Registered Dietician (RD) 1. RD 1 stated the kitchen was expected to be pest free to prevent cross contamination of residents' foods. The facility's policy and procedure titled, Pest Control, revised May 2022, was reviewed. The policy indicated, .It is the policy of this facility to provide an environment free of pests .

Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed in the kitchen when: 1. Clean water pitchers were stored on dirty grey plastic shelves; 2. Dust was observed in several kitchen and storage areas, equipment, and ventilation vents; 3. Four rusting silver storage shelves were found in the disposable item storage room; 4. One roast beef was observed defrosting in a shallow two-inch pan; 5. Two Dietary Aides (DA) were observed with their hair not fully covered with hair net; and 6. Several open packages of food items were observed in the walk-in-freezer. These failures had the potential to cause food-borne illnesses in a highly susceptible resident population. Findings: 1. On December 3, 2023, at 10:09 a.m., an observation with the Certified Dietary Manager (CDM) was conducted in the kitchen. One set of grey plastic shelves, where clean water pitchers were stored, showed brown grime on the shelves. During a concurrent interview with the CDM, she stated the grey plastic shelves were dirty. The CDM further stated cross contamination could happen with clean water pitchers stored on the dirty shelves. On December 4, 2023, at 3:01 p.m., during an interview with Registered Dietitian (RD) 1, RD 1 stated clean water pitchers stored on the dirty shelves posed a potential risk for cross contamination. RD 1's expectation was that the shelves used to store clean water pitchers should be clean, with no dust and no dirt accumulated. The facility's policy and procedure titled Sanitation, revised 2023, was reviewed. The policy indiated .all .shelves .shall be kept clean . 2. On December 3, 2023, at 9:14 a.m., an observation of the walk-in refrigerator was conducted with the CDM. There was a cooling ventilator observed mounted under the ceiling, containing two black plastic fan coves on the front, and metal ventilation intake (used to allow air to enter into ventilation spaces) grids on the back. The cooling ventilator wa observed to have accumulation of grey and black debris. During a concurrent interview with the CDM, she stated the grey and black debris on the front and back of the ventilator was dust. The CDM further stated, it was not good to have dust on the cooling ventilator because dust could contaminate food stored in the refrigerator. On December 3, 2023, at 9:23 a.m., an observation of the clean kitchenware storage room was conducted with the CDM. Grey and black debris was observed on the ventilation intake on the ceiling. In addition, the storage shelves, used store clean kitchenware, were covered with brown debris. Durign a concurrent interview, the CDM stated the grey, black, and brown debris was dust. On December 3, 2023, at 9:27 a.m., a kitchen observation was conducted with the CDM. The silver-colored spice holding shelves were observed to have grey and black debris accumulated. In a concurrent interview, the CDM stated the spice storage shelves were covered with dust and were not clean. On December 3, 2023, at 9:37 a.m., a kitchen observation was conducted with CDM. The cart used to store clean baking sheets, clean large plastic containers and plastic lids, was covered with grey particles after the surveyor touched the shelves. During a concurrent interview conducted the CDM stated the cart was dusty. On December 3, 2023, at 9:53 a.m., an observation was conducted with the CDM in the dish washing area. The silver-colored storage shelves, used to store clean kitchenwares, were observed to becovered with black and brown debris. During a concurrent interview with the CDM, the CDM stated the black and brown debris was dust. On December 3, 2023, at 10:25 a.m., an observation of the ice machine was conducted with the CDM. The wall behind the ice machine was covered with grey and black debris. During a concurrent interview, the CDM states the dust should be cleaned. On December 3, 2023, at 10:47 a.m., an observation of the juice area was conducted with the CDM. Thre were open juice boxes on the storage shelves near the juice machine that were sticky. In addition, the shelves were covered with grey and black debris. During a concurrent interview, the CDM stated the shelves should be clean. On December 4, 2023, at 3:01 p.m., an interview was conducted with RD 1. RD 1 stated all areas in the kitchen should be clean and free from dust to prevent cross contamination. The facility's policy and procedure titled, Sanitation, revised 2023, was reviewed. The policy indicated .all .shelves .shall be kept clean . A review of the Federal and Drug Administration (FDA) Food Code 2022, 4-602.13 Nonfood-Contact Surfaces, indicated, .the presence of food debris or dirt on non-food contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests . 3. On December 3, 2023, at 10:25 a.m., an observation of the disposable items storage room was conducted with the CDM. Four silver-colored storage shelves were observed to have brown colored grime. During a concurrent interview, the CDM stated the brown colored grime was rust. The CDM further stated rust on food storage shelves could potentially cause cross contamination, and they needed to be replaced or painted. The facility's policy and procedure titled, Sanitation, revised 2023, was reviewed. The policy indicated .All equipment shall be maintained as necessary and kept in working order .all .shelves .shall remain in good repair and shall be kept clean, free from breaks and corrosion . 4. On December 3, 2023, at 10:34 a.m., a ten-pound (lb- a unit of measurement) roast beef was observed defrosting under running water, in a two-inch shallow pan with only a quarter of the meat submerged into water at the two-compartment sink (sink used for food preparation). On December 3, 2023, at 10:41 a.m., an observation and concurrent interview was conducted with the CDM. The CDM stated the use of a two-inch shallow pan to defrost the ten-pound roast beef was not an appropriate method. The CDM further stated staff should use a big, deep bowl to fully submerge the roast beef into the water to defrost the meat. On December 4, 2023, at 3:01 p.m., an interview was conducted with RD 1. RD 1 stated dietary staff were supposed to put the roast beef into a large, deep pan to fully submerge the meat into water to properly defrost the meat. RD 1 further stated not defrosting meat the right way can cause residents to get sick. RD 1 expected the staff to follow the correct procedures to defrost meat. The facility's policy and procedure titled, Thawing of Meats, revised 2023, was reviewed. The policy indicated, .Thawing meat properly .Submerge under running, portable water .with a sufficient pressure to flush away loose particles . 5. On December 3, 2023, at 11:31 a.m., an observation was conducted with DA 3 in front of the three-compartment sink (three sinks used for cleaning kitchenware, one for washing, one for rinsing and one for sanitizing). DA 3's hair was not fully covered with a hair net. On December 3, 2023, at 12:03 p.m., DA 3 was observed with the CDM at the three-compartment sink. During a concurrent interview, the CDM stated DA 3's hair was not fully covered by hair net. The CDM further stated all hair should be fully covered with a hair net. On December 4, 2023, at 3:01 p.m., an interview was conducted with RD 1. RD 1 stated dietary staff were expected to have their hair fully covered while working in the kitchen since there was potential risk that hair might get into foods and cause cross contamination. RD 1 expected the dietary staff's hair to be fully covered while working in the kitchen. The facility's policy and procedure titled, Dress Code, revised 2023 was reviewed. The policy indicated, .Hat for hair, if hair is short, which completely covers the hair. Hair net for hair if hair is long (over ears or longer) . 6. On December 3, 2023, at 9 a.m., an observation of the walk-in freezer was conducted with the CDM. The following food items were found open without appropriate covering and exposed to air: - One half box of cod; - One half box of turkey franks; and - One box with eight donuts. In a concurrent interview, the CDM stated all opened food items needed to be sealed and stored in airtight containers or bags to prevent freezer burn. On December 4, 2023, at 3:01 p.m., an interview was conducted with RD 1. RD 1 stated opened food items in the freezer needed to be fully covered and sealed to prevent freezer burn. The facility's policy and procedure titled, Procedure for Freezer Storage, revised 2023, was reviewed. The policy indicated, .Store frozen foods in an airtight moisture resistant wrapper .to prevent freezer burn .

Based on observation, interview and record review the facility failed to maintain the cleanliness of their reusable equipment, when seven clean oxygen concentrators (a medical device that gives patients extra oxygen) and two Intravenous (IV) poles (a medical device used to hang medicine to administer to patients) were observed partially covered and found in the soiled linen room. This failure had the potential for the transmission of microorganisms from the contaminated linen to residents during the delivery of care. Findings: On December 6, 2023, at 10:31 a.m., an observation of the soiled linen room was conducted with the Housekeeper (HK). There were seven oxygen concentrators observed to be partially covered with plastic bags (top part covered with plastic). In addition, there two IV poles also observed to be partially covered with plastic bags. There was a clean sign taped observed against the wall above the oxygen concentrators and red tape on the floor demarcating the clean area where the equipment was stored. Directly next to the clean equipment were two large open containers with several bags of soiled linens. Across the soiled linen containers is the garbage chute (a passage where garbage is carried to a receptacle at the bottom of a building). In a concurrent interview with the HK, the HK stated the oxygen concentrators were cleaned, covered, and brought into the room. The HK further stated the soiled linen were bagged and brought through the entrance past the clean concentrators, and placed in the soiled linen containers. She stated the garbage was to be brought into the room past the clean oxygen concentrators then disposed of through the garbage chute. On December 6, 2023, at 10:47 a.m., a concurrent observation and interview was conducted with the Director of Nursing (DON) in the soiled linen room. The DON stated the clean oxygen concentrators and IV poles were next to the open soiled linen containers and were partially covered with plastic bags. The DON stated the oxygen concentrators and IV pole should be fully covered with plastic bags after being disinfected. On December 6, 2023, at 3:10 p.m., a concurrent observation and interview was conducted with the Infection Preventionist (IP) in the soiled linen room. The IP stated the oxygen concentrators were partially covered and they should be fully covered. The IP stated the facility did not have a written policy for it. On December 6, 2023, at 5:42 p.m., a concurrent observation and interview was conducted in the soiled linen room with Licensed Vocational Nurse (LVN) 2. LVN 2 stated the oxygen concentrators were not fully covered and there was a potential for contamination with the soiled linen and garbage coming in and out of the room. There was no facility policy for appropriate storing of reusable equipment in relation to infection pevention. A review of an article titled Care Cleaning and Disinfection of Oxygen Concentrators Between Patients, published by the World Health Organization (WHO - a United [NAME] agency dedicated to global health and safety), dated January 2022, indicated, .Ensure cleaned oxygen concentrator is stored in an area where there is low risk of contamination between uses .

Based on observations, interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. Dietary Aide (DA) 1 did not follow manufacturer's guideline time length for testing the red bucket Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces). 2. Certified Dietary Manager (CDM) was unable to accurately verbalized how long the [NAME] test strip need to dip into the red bucket Quat sanitizer for testing the concentration of Quat sanitizer. 3. DA 3 did not follow manufacturer's guideline time length for placing kitchen wares into sanitizing solution in sanitizer sink. 4. DA 3 was unable to accurately test the sanitizing solution in sanitizer sink. 5. Registered Dietitian (RD) and CDM were unable to accurately verbalized how long kitchen wares need to place into the sanitizing solution in sanitizer sink. 6. Dietary staff did not use proper method to defrost meat. (Cross Referred F812) These failures had the potential to cause foodborne illness for 35 out of 35 sampled residents who received foods from the kitchen. 1. On December 3, 2023, at 9:56 a.m., a concurrent observation and interview was conducted with DA 1. DA 1 was observed to test the red bucket Quat sanitizer with the Quat sanitizer test strip. DA 1 was observed to only dipped the Quat test strip in the Quat sanitizer for 5 (five) seconds. In a concurrent interview, DA 1 stated she needed to dip the Quat sanitizer test strip in the Quat sanitizer solution for 16 seconds for testing the concentration. On December 4, 2023, at 3:01 p.m., RD 1 was interviewed. RD 1 stated the Quat sanitizer test strip needed to dip in Quat sanitizer solution for 10 seconds for testing the concentration. RD 1 stated a false reading of the concentration of Quat sanitizer could happen if the manufacturer's guideline time length for testing concentration of Quat sanitizer was not followed properly. RD 1 further explained food contact surfaces could not be properly sanitize if the Quat sanitizer is not in the right concentration and could lead to food born illness and cross contamination. RD 1 stated her expectation was for the dietary staff to follow the manufacturer instructions for testing the Quat sanitizer solution. A review of the undated facility's Quat sanitizer test strip container's instructions, indicated, .Dip paper in quat solution .for 10 (ten) seconds . A review of the facility's policy and procedure titled, Quaternary Ammonium Log Policy, indicated, .The concentration of the ammonium in the Quaternary sanitizer will be tested to ensure the effectiveness of the solution .Read instructions on Quaternary container and test strips for .length of time the strip needs to be in contact with the solution .Follow container and test strip instructions . A review of the facility's document titled, Job Description Dietary Aide, dated December 27, 2021, indicated, . Position Summary: To provide assistance in all dietary functions in accordance with current applicable federal, state, and local standards, guidelines and regulations .The assurance that quality nutritional service are provided on a daily basis and that the dietary department is maintained in a clean, safe and sanitary manner . 2. On December 3, 2023, at 10:08 a.m., a concurrent interview and record review with the CDM was conducted. The CDM stated she agreed with DA 1 statement regarding the Quat test strip needed to be dipped for 16 seconds to test the Quat sanitizer concentration in the red bucket. Reviewed the Quat sanitizer test strip container's instructions with the CDM. The CDM read the instructions and stated, Dip paper in quat solution .for 10 seconds . On December 4, 2023, at 3:01 p.m., an interview with RD 1 was conducted. RD 1 stated the Quat sanitizer test strip needed to be dipped in the Quat sanitizer for 10 seconds for testing the concentration. RD 1 stated a false reading of the concentration of Quat sanitizer could happen if the manufacturer's guideline time length for testing concentration of Quat sanitizer was not followed properly. RD 1 further explained food contact surfaces could not be properly sanitize if the Quat sanitizer is not in the right concentration and could lead to food born illness and cross contamination. RD 1 stated her expectation was for the dietary staff to follow the manufacturer instructions for testing the Quat sanitizer solution. A review of the facility's policy and procedure titled, Quaternary Ammonium Log Policy, indicated, .The concentration of the ammonium in the Quaternary sanitizer will be tested to ensure the effectiveness of the solution .Read instructions on Quaternary container and test strips for .length of time the strip needs to be in contact with the solution .Follow container and test strip instructions . A review of the facility's document titled, Job Description Dietary Supervisor, dated December 27, 2021, indicated, . Position Summary: To provide assistance in all dietary functions in accordance with current applicable federal, state, and local standards, guidelines and regulations .The assurance that quality nutritional service are provided on a daily basis and that the dietary department is maintained in a clean, safe and sanitary manner . 3. On December 3, 2023, at 11:31 a.m., a concurrent observation of the 3-compartment sinks (three sinks used for cleaning kitchen wares, one for washing, one for rinsing and one for sanitizing) was conducted with DA 3. DA 3 was observed to use the 3-compartment sinks to clean the kitchen wares. DA 3 was observed to dip the kitchen wares into the sanitizing solutions in the sanitizer sink for 1 (one) second. In a concurrent interview, DA 3 stated she needed to place the kitchen wares into the sanitizing solutions in sanitizer sink for 1 (one) minute and she admitted she did not place the kitchen wares into sanitizing solutions for 1 minute. On December 4, 2023, at 3:01 p.m., an interview was conducted with RD 1, RD 2, and the CDM. RD 2 stated the dietary staff needed to place the kitchen wares into the sanitizing solution in the sanitizer sink for 1 (one) minute. RD 1 explained placing kitchen wares less than manufacturer's instructions time length could cause for the kitchen wares to be not properly sanitized. RD 1 expectation was for the dietary staff to follow the manufacturer guidelines time length to place the kitchen wares into the sanitizing solution. According to the USDA Food Code 2022, Section 4-501.114 Manual and Mechanical Ware washing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness, (C) A quaternary ammonium compound solution shall (2) Have a concentration as specified under S 7-204.11 and as indicated by the manufacturer's use directions included in the labeling. A review of the undated sanitizer manufacturer's use directions for 3-compartment sink cleaning procedures posted above the 3-compartment sinks, indicated, .Sanitize .Place items in sanitizing solutions for 1 minute . A review of the undated facility's policy and procedure titled, 3-Compartment procedure for manual dishwashing, indicated, .The third compartment is for sanitizing .Immerse all washed items for 1 minute . A review of the facility's document titled, Job Description Dietary Aide, dated December 27, 2021, indicated, .Position Summary: To provide assistance in all dietary functions in accordance with current applicable federal, state, and local standards, guidelines and regulations .The assurance that quality nutritional service are provided on a daily basis and that the dietary department is maintained in a clean, safe and sanitary manner . 4. On December 3, 2023, at 11:35 a.m., a concurrent observation of the 3 compartment sinks and interview with DA 3 was conducted. DA 3 was observed to check the sanitizing solution in the sanitizer sink. DA 3 was observed to dip the test strip into the sanitizing solution and compared the test strip with the ppm (parts per million -a unit of measurement) reference colors on the test strip container. In a concurrent interview, DA 3 stated the ppm should be between 0 -100 ppm. On December 3, 2023, at 12:04 p.m., the CDM was interviewed. She stated the ppm range should read between 200 -400 ppm when the sanitizing solution at the sanitizer sink was to be tested . According to the USDA Food Code 2022, Section 4-501.114 Manual and Mechanical Ware washing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness, (C) A quaternary ammonium compound solution shall (2) Have a concentration as specified under S 7-204.11 and as indicated by the manufacturer's use directions included in the labeling. A review of the undated sanitizer manufacturer's use directions for 3 compartment sink cleaning procedures posted above the 3-compartment sinks, indicated, .Sanitize .Test to assurance proper solution strength 200 ppm - 400 ppm . A review of the undated facility's policy and procedure titled, 3-Compartment procedure for manual dishwashing, indicated, .The third compartment is for sanitizing .Must read 200 ppm . A review of the facility's document titled, Dietary Department Inservice/Education, dated August 11, 2023, indicated, .Manual ware washing and proper drying procedures. The document showed DA 3 was in attendance of the inservice training. A review of the facility's document titled, Job Description Dietary Aide, dated December 27, 2021, indicated, .Position Summary: To provide assistance in all dietary functions in accordance with current applicable federal, state, and local standards, guidelines and regulations .The assurance that quality nutritional service are provided on a daily basis and that the dietary department is maintained in a clean, safe and sanitary manner . 5. On December 4, 2023, at 3:01 p.m., an interview with RD1, RD 2, and the CDM was conducted. RD 1 stated the kitchen wares needed to be placed in the sanitizing solution for 30 seconds in the sanitizer sink. In the other hand, the CDM did not know how long the kitchen wares needed to be placed in the sanitizing solution in the sanitizer sink. RD 2 stated the kitchen wares needed to be placed into the sanitizing solution in the sanitizer sink for 1 (one) minute. RD 1 stated the placing kitchen wares less than the manufacturer's instructions time length could cause for the kitchen wares to be not properly sanitized. RD 1 expectation was for the dietary staff to follow the manufacturer's guidelines time length to place the kitchen wares into the sanitizing solution. According to the USDA Food Code 2022, Section 4-501.114 Manual and Mechanical Ware washing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness, (C) A quaternary ammonium compound solution shall (2) Have a concentration as specified under S 7-204.11 and as indicated by the manufacturer's use directions included in the labeling. A review of the undated sanitizer manufacturer's use directions for the 3-compartment sink cleaning procedures posted above the 3-compartment sinks, indicated, .Sanitize .Place items in sanitizing solutions for 1 minute . A review of the undated facility's policy and procedure titled, 3-Compartment procedure for manual dishwashing, indicated, .The third compartment is for sanitizing .Immerse all washed items for 1 (one) minute . A review of the facility's document titled, Job Description Consultant Registered Dietitian, revised [DATE], indicated, .Conduct kitchen inspections for safety and sanitation . A review of the facility's document titled, Job Description Dietary Supervisor, dated December 27, 2021, indicated, . Position Summary: To provide assistance in all dietary functions in accordance with current applicable federal, state, and local standards, guidelines and regulations .The assurance that quality nutritional service are provided on a daily basis and that the dietary department is maintained in a clean, safe and sanitary manner . 6. On December 3, 2023, at 10:34 a.m., the two-compartment Prep sinks (sinks used for food production) was observed to have a 10 pound (lb. - a unit of measurement) roast beef defrosting under running water in a 2-inch shallow pan. The roast beef was observed to be partially submerged (about 1/4) into the water. On December 3, 2023, at 10:41 a.m., a concurrent observation of the two-compartment Prep sinks and interview with the CDM was conducted. The CDM verified using a 2-inch shallow pan to defrost a 10-pound roast beef was not the appropriate method. The CDM stated the dietary staff should use a big, deep bowl to fully submerge the roast beef into the water to defrost the meat. On December 4, 2023, at 3:01 p.m., an interview with RD 1 was conducted. RD 1 stated the dietary staff should put the roast beef into a large deep pan fully submerge the meat into the water to properly defrost the meat. RD 1 stated not defrosting meat the right way could cause residents to get sick. RD 1 expectation was for the dietary staff to follow the correct procedures to defrost meat. A review of the facility's policy and procedure titled, Thawing of Meats, revised 2023, indicated . Thawing meat properly .Submerge under running, portable water .with a sufficient pressure to flush away loose particles .

Based on interview and record review, the facility failed to promptly assess and provide interventions for one (Resident A) of three sampled residents' complaint of multiple episodes of diarrhea (loose, watery bowel movements). This failure resulted in delayed treatment which caused Resident A to be admitted to the acute care hospital with severe dehydration (fluid intake fails to match fluid loss which could lead to kidney failure and/or death) caused by the diarrhea, emergency surgery to remove the resident's entire large intestine, septic shock (complication of an infection with low blood pressure and inadequate blood flow to the organs) and death secondary to severe [MEDICAL CONDITION] (C. diff - a species of bacteria that can cause symptoms ranging from loose, watery bowel movements, life-threatening inflammation and swelling of the colon or large intestine, up to death). Findings: On (MONTH) 12, (YEAR), at 11:35 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to quality of care and infection control concerns. On (MONTH) 12, (YEAR), Resident A's record was reviewed. Resident A was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Resident A's physician orders [REDACTED].>a. (MONTH) 27, (YEAR), [MEDICATION NAME] (medication for infection) 750 mg (milligram)/150 ml intravenously (IV-administered into the vein) one time a day every two days until (MONTH) 31, (YEAR), for gram positive cocci (bacteria); and b. (MONTH) 27, (YEAR), [MEDICATION NAME] (medication for infection) 250 mg IV one time a day for positive gram cocci (bacteria causing infection). Resident A's nursing note dated (MONTH) 27, (YEAR), indicated Resident A was admitted for IV antibiotic therapy and PT (physical therapy)/OT (occupational therapy) services. The document did not indicate any abnormal gastrointestinal issues or symptoms on admission. Resident A's occupational therapy note dated (MONTH) 4, (YEAR), indicated Resident A had diarrhea since the day of (MONTH) 3, (YEAR). The document indicated Resident A had increased confusion during therapy session. The occupational therapy note indicated a nurse was informed regarding Resident A's diarrhea. Resident A's physical therapy notes were reviewed and indicated the following: a. (MONTH) 4, (YEAR), Resident A had complaints of diarrhea, and a nurse was notified; b. (MONTH) 5, (YEAR), Resident A had been having diarrhea for the past 3 days. The document further indicated Resident A was having increased fatigue and was very impulsive. There was no documented evidence Resident A's episodes of diarrhea as reported by PT and OT staff were assessed on (MONTH) 3, 4, 5, (YEAR). There was no evidence any interventions were initiated until (MONTH) 5, (YEAR). The facility documentation of Resident A's bowel movements dated (MONTH) 1 to 7, (YEAR), was reviewed and indicated: a. (MONTH) 1, (YEAR), Resident A had one large bowel movement; b. (MONTH) 2, (YEAR), Resident A had no bowel movement; c. (MONTH) 3, (YEAR), Resident A had one small bowel movement; d. (MONTH) 4, (YEAR), Resident A had four bowel movement (more frequent compared to past three days); The document indicated Resident A's bowel movement had a loose consistency. e. (MONTH) 5, (YEAR), Resident A had two bowel movements; f. (MONTH) 6, (YEAR), Resident A had one bowel movement; and g. (MONTH) 7, (YEAR), Resident A had two bowel movements. There was no documented evidence Resident A's change in frequency and consistency of bowel movement on (MONTH) 4, (YEAR), was assessed. Resident A's physician order [REDACTED]. The physician order [REDACTED]. (Sic) Resident A's CBC, BMP and stool for [MEDICAL CONDITION] were not collected until (MONTH) 7, (YEAR). (two days after physician had ordered the tests and four days after diarrhea was initially reported). Resident A's laboratory work-ups were reviewed and indicated: a. (MONTH) 8, (YEAR), (completed) WBC (white blood cells- diagnose presence of infection) was 11.17 (high) normal was between ,[DATE]; b. (MONTH) 8, (YEAR), (completed) [MEDICAL CONDITION] toxin was positive. Resident A's nursing note dated (MONTH) 8, (YEAR), (five days after the diarrhea started) indicated Resident A was started on [MEDICATION NAME] 250 mg oral (by mouth) every 6 hours x 2 (times two) weeks regimen due to positive [MEDICAL CONDITION]. On (MONTH) 29, (YEAR), at 2 p.m., a telephone interview was conducted with Resident A's family member. She stated Resident A had multiple loose stools on (MONTH) 3, (YEAR). Resident A's family member stated she had asked a nurse to call the physician. She further stated the nurse did not notify the physician, and Resident A's diarrhea continued and worsened. Resident A's family member stated the facility did not do anything until (MONTH) 5, (YEAR). She stated the laboratory work-ups and the specimen (stool) were not collected until (MONTH) 7, (YEAR). On (MONTH) 3, (YEAR), at 12:30 p.m., Resident A's facility physician was interviewed. He stated Resident A's family member informed him of the resident's (Resident A) diarrhea on (MONTH) 5, (YEAR). The facility physician stated he held the discharge order to home he had already written for (MONTH) 5, (YEAR), and ordered a stool specimen for [MEDICAL CONDITION]. He further stated the facility did not inform him of Resident A's episodes of diarrhea. The physician stated the facility should have collected the stool specimen for him to identify what caused the diarrhea so he could start the treatment. On (MONTH) 24, (YEAR), at 9:06 a.m., Certified Nursing Assistant (CNA) 1 (worked on (MONTH) 2 and 3, (YEAR), according to staffing schedule) was interviewed. She stated Resident A had loose stools three to four times on her shift (morning shift). CNA 1 stated she reported the issue to a licensed nurse. On (MONTH) 24, (YEAR), at 10:09 a.m., a Restorative Nurse Assistant (RNA) who worked on (MONTH) 4, (YEAR), according to staffing schedule, was interviewed. He stated Resident A had three to four time loose stools on (MONTH) 4, (YEAR). The RNA stated he reported the BM (bowel movement) status of Resident A to a charge nurse on (MONTH) 4, (YEAR). There was no evidence the episodes of loose stools on (MONTH) 2, 3, and 4, (YEAR), were clearly documented in Resident A's record. There was no evidence these episodes of loose stools reported by the CNA 1 on (MONTH) 2, and 3, (YEAR), and the RNA on (MONTH) 4, (YEAR), were acknowledged, and assessed by any licensed nurse. Resident A's nursing notes dated (MONTH) 8, (YEAR), at 14:39 (2:39 p.m.) indicated Resident A had a 4 lbs. (pound) weight loss in a week. The note further documented Resident A was weak and unable to consume adequate meal intake due to recent diarrhea episode. Resident A's nursing notes dated (MONTH) 8, (YEAR), at 15:38 (3:38 p.m.) indicated Resident A's family member requested that the resident be transferred to an acute hospital, d/t (due to) weakness, and for further evaluation. On (MONTH) 24, (YEAR), the facility's policy and procedure, [MEDICAL CONDITION] undated, was reviewed. The policy read: The policy of this facility is to inform the doctor if patient has three or more episodes of loose stools. This facility will provide guidelines for the care of residents with [MEDICAL CONDITION], verified by culture or by evidence of positive cytotoxin assay (testing for toxins), and to prevent transmission of [MEDICAL CONDITION] to others. The policy further documented, Diarrhea 1. Consider [MEDICAL CONDITION] as cause of diarrhea, especially in the elderly, those with tube feeding, those who have received antibiotics or anti-neoplastics ([MEDICAL CONDITION]) within the past two (2) weeks, and those who have had [MEDICAL CONDITION]. Resident A's hospital records were reviewed and indicated the following: a. (MONTH) 8, (YEAR), history and physical at the acute emergency department, .Patient with h/o (history of)[MEDICAL CONDITION](hypertension- high blood pressure) presents with 5 days history of abdominal pain, diarrhea, and abdominal distention .BUN (24 H) (blood urea nitrogen- to detect health of kidney; normal - ,[DATE]), Creatinine (2.230 H) (measures kidney function; normal - 0XXX,[DATE].020) .WBC (20.8 H up from 11.17 on (MONTH) 7, (YEAR), test; normal - 4XXX,[DATE].8 .Impression: Severe diffuse [MEDICAL CONDITION] and proctitis (inflammation of the rectum) . b. (MONTH) 9, (YEAR), Resident A went into respiratory and kidney failure with impending septic shock; c. (MONTH) 10, (YEAR), Resident A had emergency surgery for [REDACTED]. Resident A remained in the intensive care unit after surgery until she died on (MONTH) 25, (YEAR). She required and received treatment from [MEDICAL CONDITION], infectious diseases, and cardiology physicians throughout the hospital stay. Resident A's discharge summary from the acute hospital (MONTH) 25, (YEAR) (22 days after the family informed the facility that Resident A was having episodes of diarrhea), indicated Resident A, had expired (passed away) on (MONTH) 25, (YEAR). The document further indicated, Cause of Death: Septic shock secondary to severe [MEDICAL CONDITIONS] .toxic .acute kidney disease (happens when the kidneys suddenly lose the ability to eliminate excess salts, fluids, and waste materials from the blood) . A copy of Resident A's death Certificate was obtained on (MONTH) 13, (YEAR), and listed the causes of death as SEPTIC SH[NAME]K, HEALTHCARE FACILITY ACQUIRED PNEUMONIA, and [MEDICAL CONDITIONS].

Based on observation, interview, and record review, the facility failed to ensure safety and supervision was provided for one of three sampled residents (Resident A) when: 1. Resident A's one-to-one sitter (constant observer for residents requiring direct supervision for safety) was discontinued without a completed evaluation of safety by the interdisciplinary team; 2. Resident A, who was identified with elopement (leaving without accompaniment or knowledge of staff) risks, did not have an elopement evaluation on multiple admissions to the facility; and 3. Resident A's elopement risk care plan to provide a one-to-one sitter was not implemented; This failure resulted in Resident A's attempted elopement by jumping off the facility's entrance porch, causing multiple injuries, re-hospitalization , and increased the potential for further harm, injuries, or even death. Findings: On (MONTH) 20, (YEAR), at 10:05 a.m., an unannounced visit was made to the facility for the investigation of a facility-reported incident. On (MONTH) 20, (YEAR), at 10:12 a.m., Resident A was observed in bed, awake, with a one-to-one sitter at the bedside. In a concurrent interview with Resident A, she stated she jumped over the balcony a few weeks ago. Resident A was able to answer basic questions consistently. She stated, prior to her going out onto the balcony, she was pissed that day with some of the nurses because she wanted to go downstairs but they did not allow her to do so. Resident A stated how she got out of her room through the sliding doors, climbed onto the rails of the balcony on the second floor of the building, and walked on the roof of the entrance porch. Resident A pointed out the place where she eventually landed when she fell . The distance where the resident landed (from the roof of the entrance porch to the ground floor) was approximately 10-12 feet high. On (MONTH) 20, (YEAR), at 10:51 a.m., Resident B was interviewed. Resident B stated he witnessed the incident on (MONTH) 12, (YEAR), at around 10 a.m., when Resident A landed on the ground after falling from the roof of the entrance porch. Resident B stated he was sitting in the lobby, looking at the entrance glass doors when he saw a resident falling from the roof next to the bench at the entrance of the facility building. Resident B stated he called one of the staff and told them to call the ambulance. On (MONTH) 20, (YEAR), at 11:04 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated she was the charge nurse/treatment nurse on (MONTH) 12, (YEAR) for the 8 a.m. to 4:30 p.m. shift. LVN 1 stated Resident A was taken to her room on the second floor after her smoke break ended at around 9:50 a.m. LVN 1 stated Resident A did not have a sitter. LVN 1 stated after five to ten minutes, at around 10 a.m., they received notification that one of their residents was outside of the building after a fall off the balcony. LVN 1 stated she called 911, and immediately assessed Resident A. LVN 1 stated Resident A complained of a headache with a pain level of four out of ten (ten being the worst) and was noted with slurred speech, but had no noted physical injuries. On (MONTH) 20, (YEAR), at 11:18 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated she was working on (MONTH) 12, (YEAR). CNA 1 stated CNA 2 took Resident A outside to smoke after breakfast. CNA 1 stated at around 10 a.m., Resident A requested to go down, and she told Resident A that she was still taking care of another resident. CNA 1 stated she told Resident A to give her a couple of minutes to finish. CNA 1 stated she heard on the facility radio a few minutes later that Resident A was already outside of the building. On (MONTH) 20, (YEAR), at 11:26 a.m., LVN 2 was interviewed. LVN 2 stated she was the charge nurse for Resident A on (MONTH) 12, (YEAR). LVN 2 stated Resident A was impulsive and always wanted to get up without thinking. She stated Resident A needed a 24-hour sitter. On (MONTH) 20, (YEAR), at 11:51 a.m., CNA 2 was interviewed. CNA 2 stated she was working on (MONTH) 12, (YEAR), when the incident occurred. CNA 2 stated around 9:30 a.m., on (MONTH) 12, (YEAR), she took Resident A on a wheelchair outside of the building for a smoke break. CNA 2 stated, after the smoke break, she took Resident A back to her room and endorsed her care to LVN 2. CNA 2 stated Resident A had behavior issues with periods of confusion, and was at danger from falls and accidents. CNA 2 stated Resident A needed a sitter. On (MONTH) 20, (YEAR), Resident A's record was reviewed. Resident A was initially admitted on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Resident A was transferred to the acute hospital on (MONTH) 23, (YEAR), for further evaluation after a fall incident in the facility. Resident A was readmitted to the facility on (MONTH) 30, (YEAR). The Skilled Nursing Facility History & (and) Physical, dated (MONTH) 9, (YEAR), indicated, Resident A had fluctuating capacity to understand or make decisions .Assessment & Plan .needs sitter this time, monitor . The plan of care titled, Elopement risk/wanderer r/t (related to) Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness .Date Initiated: 10/08/2017 (October 8, (YEAR)), indicated: Goal .Will not leave facility unattended through the review date .Target Date 01/30/2018 (January 30, (YEAR)). Interventions: 1:1 sitter during daytime hours. The facility's time record for Resident A's sitter indicated a 1:1 sitter was started on (MONTH) 7, (YEAR), and was discontinued on (MONTH) 19, (YEAR). The Progress Notes titled, Fall Committee IDT (interdisciplinary team), dated (MONTH) 31, (YEAR), indicated, She was admitted requiring a 1:1 sitter for safety and re-direction. During admission process (resident's name) was found by staff to be crawling on the floor in her room specifically in between her bed and the sliding door . The Progress Notes, dated (MONTH) 5, (YEAR), at 12:38 p.m., indicated Resident A had over 10 attempts of getting out of bed and laying on the floor mat .Pt (patient) also continues on crawling outside of her room .Hospice notified that patient requires 1:1 (sitter) for safety. The Progress Notes titled, Fall Committee IDT, dated (MONTH) 6, (YEAR), at 3:18 p.m., indicated, .follow up regarding unwitnessed fall which occurred on 11/04/2017 (November 4, (YEAR)) .She was found by staff to be crawling on the floor in the doorway of her room. She sustained a right elbow abrasion and a right eye discoloration and right sclera (white outer layer of the eyeball) bleed .staff recognized (resident's name) as a high fall risk based on her behaviors, confusion and impaired physical mobility .She required a one on one sitter for safety and re-direction. The sitter was discontinued before resident sustained [REDACTED]. The Progress Notes, dated (MONTH) 6, (YEAR), at 3:29 p.m., indicated, .Patient with several attempts crawling outside of the door and walking with an unsteady gait. Patient continues as a fall risk with bed and chair alarms that are not effective due to patient's agitation and not staying in one place longer than 2 minutes. Hospice notified of need for 1:1 (sitter) for safety . The Progress Notes, dated (MONTH) 12, (YEAR), at 11:52 a.m., indicated at Approximately 1000 (10 a.m.) nursing staff notified that a resident was on the first floor and needed assistance. Nursing staff arrived at scene and found resident sitting on bench, witnesses stated resident had fallen .New orders to send resident to (name of general acute care hospital) for further evaluation. The general acute care hospital's Neurology Consultation Note, dated (MONTH) 13, (YEAR), was reviewed. The notes indicated: .Per other historians patient climbed over railing and fell from balcony >10 ft (greater than 10 feet) which was unwitnessed. Pt was found sitting on bench with multiple abrasions . .Noncontrast CT of head (computed tomography scan- use of computer-processed combinations of many x-ray measurements taken from different angles of the brain) showed 3.1 X 2.5 cm (centimeters) L (left) posterior frontal lobe hemorrhage (bleeding in the front part of the brain), increased from previous CT done 2-3 weeks ago, new small subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), new subdural hematomas (pool of blood between the brain and its outermost covering) . The Skilled Nursing Facility History & Physical, dated (MONTH) 17, (YEAR), indicated, History: 52 y.o. (year-old) female with re-hospitalized on [REDACTED].New subdural hematoma per CT, post frontal hemorrhage . There was no documented evidence that an elopement evaluation was completed on Resident A's admission and readmission to the facility on (MONTH) 7, (YEAR), and (MONTH) 30, (YEAR). There was no documented evidence of a safety evaluation for Resident A from the physician or the interdisciplinary team prior to discontinuing the sitter on (MONTH) 20, (YEAR). There was no documented evidence Resident A had a sitter from (MONTH) 31, (YEAR) to (MONTH) 12, (YEAR), the date of the incident, as identified in the plan of care. On (MONTH) 19, (YEAR), at 11:25 a.m., Resident A's record was reviewed with the Director of Nursing (DON). The DON confirmed there was no elopement evaluation completed on Resident A's admission and readmission to the facility on (MONTH) 7, (YEAR), and (MONTH) 30, (YEAR). The DON confirmed there was no evaluation by the physician or the interdisciplinary team for the safety of Resident A before discontinuing the 1:1 sitter on (MONTH) 20, (YEAR). The DON stated the sitter was discontinued due to non-coverage by the insurance, and the care plan for 1:1 sitter was not properly implemented. The facility's policy and procedure titled, Elopement-Policy and Assessment, revised (MONTH) 2007, was reviewed. The policy indicated: It is the policy of this facility to provide a safe environment for all residents. The facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement .elopement is defined as slipping away secretly, running away, leaving without accompaniment or knowledge of the staff . .Each resident's level of supervision required will be assessed .This information will be documented in the resident's medical record, and used in the care planning process . .Residents with an elopement incident from the facility either on or off the grounds shall be considered at higher risk for further attempts at elopement .If exacerbation of the behavior continues, 1:1 supervision will be considered until the physician can assess the resident for cause .

Based on interview and record review, the facility failed to ensure one resident (Resident 2) in a universe of 34 maintained acceptable parameters of nutritional status when the resident lost eight pounds in seven days. The facility failed to timely address the significant weight loss, to evaluate the needs of the resident and to implement new interventions. Findings: On [DATE], at 10:25 a.m., an unannounced visit was made to the facility for the investigation of two complaints. A review of Resident 2's medical record was conducted. Resident 2 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. obstructive [MEDICAL CONDITION] disease ([MEDICAL CONDITION]- group of lung diseases that block airflow and make it difficult to breathe), and [MEDICAL CONDITION] (kidney damage). Review of Resident 2's facility document titled, Physician order [REDACTED]. The POLST further indicated that medical interventions were to include, Full Treatment- primary goal of prolonging life by all medically effective means. Review of Resident 2's facility document, titled Order Summary Report, indicated the following order, dated [DATE], NPO (nothing by mouth) diet, for Dysphagia. Review of a facility order for Resident 2 dated, [DATE], indicated, Enteral Feed (delivery of nutritionally complete fluid directly into the stomach) Order every shift CONTINUOUS FEEDING OF: GLUCERNA FORMULA AT 50CC/HR (50 milliliters per hour) X24 (for 24) HRS (hours) VIA ENTERAL FEEDING PUMP. This order would have provided Resident 2 with 72 grams of protein and 1440 calories in 24 hours of continuous administration as documented in the RD (registered dietician) Nutrition Risk Assessment. Review of Resident 2's facility care plan with a creation date of [DATE], indicated, Focus- Has potential nutritional problem r/t (related to) NPO DIET .Goal -Will maintain adequate nutritional status as evidence by maintaining weight with no s/sx (signs or symptoms) of malnutrition through review date .Intervention/Tasks -Monitor/record/report to MD (doctor) PRN (as needed) s/sx of malnutrition: .significant weight loss. The National Center for Biotechnology Information, U.S. National Library of Medicine defines clinically significant weight loss as a loss of 4.5 kg (approximately 9 pounds) or > 5% (greater than 5%) of the usual body weight over a period of ,[DATE] months. Review of Resident 2's facility document, titled Nutrition/Hydration Risk Evaluation, dated [DATE], indicated the resident received a score of 10, which was considered High risk. The document further indicated, .If the Total Score is 10 or Greater, a prevention protocol should be initiated immediately and documented in the care plan. A review of Resident 2's facility document titled, RD-Nutrition Risk Review, dated [DATE], indicated, .1.Clarify enteral order: glucerna 1.2 50ccx24 hrs providing 1200cc/1440 cals .85 y o (year old) M (male) Bmi (Body Mass index- a measure of body fat based on height and weight) 18.4 (average male BMI is 18XXX,[DATE].9) .goal; .wt (weight) to fluc (fluctuate) <5% (less than 5 percent) Continue to monitor . Review of Resident 2's weight while in the facility indicated on [DATE], at 10:04 a.m., his weight was 116 pounds, on [DATE], at 12:54 p.m., his weight was 114 pounds. Resident 2 was weighed seven days later on [DATE], at 2:23 p.m., his weight was 106 pounds. Resident 2 lost eight pounds in seven days, an approximately 8% (exactly 7.98 %) weight loss. Resident 2's facility document, titled PHYSICIAN'S PROGRESS NOTES, with an entry date of [DATE], indicated, NP visit .Pt (patient) c/o (complaint of) too full with ongoing tube feeding .Tube feeding decreased to 40cc/hr due to c/o fullness .Dietary to reassess tube feeding . Review of Glucerna 1.2 nutritional data found that when Resident 2 was receiving 50cc/hr for 24 hours he was receiving 72 grams of protein per day with 1,440 calories. When the feeding was reduced to 40cc/hr for 24 hours Resident 2 was reduced to 57.6 grams of protein and only 1,152 calories per day. Review of Cleveland Clinic's article, titled Nutritional Guidelines for People with [MEDICAL CONDITION], indicated, .People with [MEDICAL CONDITION] use more energy while breathing than the average person. Therefore, the [MEDICAL CONDITION] (breathing) muscles in someone with [MEDICAL CONDITION] might require up to 10 times the calories needed by a person without [MEDICAL CONDITION]. It is important to consume enough calories to produce energy in order to prevent wasting or weakening . Review of Resident 2's facility nursing notes found only one entry for [DATE], at 12:04 p.m. That entry indicated, (Nurse Practitioner's name) NP cam (sic) in today- feeding rate changed to 40cc. order noted and carried out. No other documentation was found in the resident's record that indicated the nursing staff had documented the resident's complaint of fullness or an explanation as to why the feeding rate had been decreased from 50cc to 40cc or what the change in caloric or protein intake would be. There was also no documentation that indicated the RD had been notified on [DATE], to reassess tube feeding as the physician's progress noted had indicated. Review of Resident 2's facility care plan with a creation date of [DATE], indicated, Focus- Requires tube feeding r/t Dysphagia, Chewing problem, Swallowing problem .Goal -Will maintain adequate nutritional status and hydration status aeb (as evidence by) no s/sx of malnutrition and dehydration through review date .Intervention/Tasks -RD to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feedings as needed . Review of a facility nursing note for Resident 2 dated [DATE], at 10:21 a.m., indicated, NP IN TO SEE PT. (patient) WITH NNO (no new orders) AT THIS TIME. Further review of this entry found no documentation that the NP had been informed of the eight pound weight loss identified on [DATE]. Review of Resident 2's facility, Daily Skilled Note, dated [DATE], at 12:59 p.m., indicated, .resident continues on coc (change of condition) for wt (weight) loss of 8 lbs (pounds), resident continues on glucerna feeding, rd to see resident today for further eval. (evaluation) . Review of a facility nursing note for Resident 2 dated [DATE], at 5:07 p.m., indicated, RESIDENT CONTINUES ON COC FOR WT LOSS OF 8 LBS, RESIDENT CONTINUES ON GT (gtube) FEEDING GLUCERNA 1.2 @ (at) 40CC/HR CONTINOUSLY, WILL CONT (continue) TO MONITOR AND ENSURE RESIDENT IS MONITORED BY REGISTERED DIETICIAN AND IS GETTING ADEQUATE CALORIE INTAKE . Review of a facililty nursing note for Resident 2, dated [DATE], at 3:46 a.m., indicated, WT LOSS .RESIDENT CURRENLTY (sic) ON DAILY MONITORING FOR WT LOSS OF -8LBS. RESIDENT CONTINUES WITH GTUBE FEEDING GLUCERNA AT 40cc/hr . Review of a facility nursing note for Resident 2, dated [DATE], 10:23 a.m., indicated, LATE ENTRY: [DATE] Resident noted with wt loss of -8 lbs .(NP's name) NP notified with orders for RD to review . Further review of Resident 2's medical record found this entry was the only documentation that indicated the NP had been informed of Resident 2's eight pound weight loss. This was a two day delay in notification. No documentation was found that indicated the physician was ever notified. Continued review of Resident 2's medical record found no documentation that indicated the resident's eight pound weight loss had been acknowledged or addressed by the Registered Dietician prior to his discharge to the acute hospital on [DATE]. Review of Resident 2's facility care plan with a creation date of [DATE], indicated, Focus- Has unplanned weight loss r/t Acute illness .Goal -Stable weight fluctuation <5% (less than 5%)/week .Intervention/Tasks -Glucerna 1.2 40cc/hr .If weight decline persists, contact physician and dietician immediately, monitor and evaluate any weight loss . Review of the Academy of Nutrition and Dietetics/American Society for [MEDICATION NAME] and Enteral Nutrition indicated malnutrition in the context of acute illness was a loss of greater than 2% of body weight in one week and would clinically be characterized as severe malnutrition. Review of Resident 2's facility document titled, Nursing Home to Hospital Transfer Form, dated [DATE], at 11:37 a.m., indicated, Reason for transfer: Other-[MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION](increased heart rate), VOMITING X1 (one time) BROWN EMESIS (vomit). An interview was conducted with the facility's Director of Nursing (DON) on [DATE], at 2:16 p.m. The DON was asked if a weight loss of eight pounds in seven days would have been considered a change in condition for Resident 2. The DON stated, Yes. The DON was asked if the physician or NP should have been informed of the weight loss when it had been identified. The DON stated, Yes. The DON further stated the physician and or NP should have been notified but stated there was usually a 24 hour turn around after weights had been taken. A phone interview was conducted with the facility's Registered Dietician (RD) on [DATE], at 8:38 a.m. The RD was asked why Resident 2's tube feeding was ordered for 24 hours. The RD stated the physician had ordered the 24 hour feeding. The RD was then asked why it had taken her nine days to do an initial assessment on a high risk resident. The RD stated it was possible that she had not been informed of the resident's admission; the RD further stated that she had had 14 days to do the assessment. The RD was then asked if she had been informed of the resident's complaint of fullness on [DATE]th or of the eight pound weight loss identified on [DATE]. The RD stated the facility had not informed her of Resident 2's complaint of fullness or of the resident's eight pound weight loss. The RD further stated that the facility does not call her or contact her between her weekly visits to the facility. The RD stated the day of her weekly visits vary due to her schedule. Review of the facility's policy and procedure titled, Policy/Procedure- Best Practices, Section: Care and Treatment, Subject: Nutrition, revised [DATE], indicated, .It is the policy of this Facility to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and protein levels .Significant weight loss 5% in one (1) month, 7.5% in three (3) months, .should be addressed in the care plan . The policy further indicated, .Dietary Evaluation: 1. Each resident's nutritional status is assessed by the Registered Dietician or his/her designee on admission .and following a change in condition .When appropriate, additional nutrition will be offered to all high risk residents .Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days .will be evaluated by the Interdisciplinary Team to determine the cause of weight loss .Once weight gain or loss as described above is identified, the Interdisciplinary Team will: .notify the attending physician . Review of the acute hospital records titled, Discharge Summary, dated [DATE], for Resident 2 indicated, Admission Diagnosis: [REDACTED]. Further review of the acute hospital records indicated, Resident 2 died on [DATE], at 7:49 p.m. The discharge [DIAGNOSES REDACTED]. Severe protein malnutrition .

Based on interview, and record review, the facility failed to ensure facility staff had the adequate training in proper evacuation techniques during disaster situations when four out of six facility staff on duty were not able to competently verbalize the proper procedures for evacuating residents during a disaster. This failure had the potential to result in staff not being able to properly evacuate a potential population of 38 residents during a fire/disaster situation which could result in injury and death for the facility residents. Findings: On April 29, 2016, at 5:30 p.m., during a tour of the facility, it was observed that the facility had seven floors. The skilled nursing facility was located on the second floor. There were two elevators (one was out of service) available to transport residents, visitors, and staff. There were two stair wells on both sides (north and south) of the building. On May 2, 2016, at 2 p.m., the Administrator was interviewed. The Administrator stated the facility currently had 29 residents with two bed holds (two residents in a hospital). He stated out of the 29 in-patients, 12 were wheelchair bound, 13 were ambulatory, and four were bed bound residents. The Administrator stated the skilled nursing facility was located on the second floor. He stated during a fire situation, there were stair chairs available for use by staff to evacuate the residents on the skilled unit who were not ambulatory. On May 2, 2016, at 2:45 p.m., the Director of Staff Development (DSD) was asked to provide the fire drill log for drills conducted at the facility since January 2015. The DSD said she would need to locate the log as it was not in the Fire/ Disaster manual kept on the nursing station. On May 2, 2016, at 3:05 p.m., a Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated she worked on the evening shift. She stated during a disaster, they (staff) would evacuate the residents using the stair wells and stair chairs. She was not able to verbalize the process on how to evacuate residents who were totally dependent and bed bound. On May 2, 2016, at 3:10 p.m., DSD was interviewed. She stated the facility provided in-services staff regarding disasters. She stated the facility had a liaison that did training for disasters at least every six months. The DSD stated she also provided other in-services to ensure staff would be trained regarding proper evacuation procedures during disasters. On May 2, 2016, at 4:15 p.m., the DSD provided a document titled, Fire drill evacuation plan and fire chair, dated February 24, 2016. The document indicated 32 of the 88 facility staff had signed and attended the mandatory inservice. In a concurrent interview, with the DSD, she stated the in-service on February 24, 2016, was mandatory for all staff. She stated she had a tracking system for staff that did not attend the in-services and would make sure they would be given information regarding the in-services. On May 2, 2016, at 4:30 p.m., a Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 was asked to describe the evacuation procedures used during disasters. He stated he would lead ambulatory residents to the stairs located on both sides of the building. LVN 1 stated he would use the elevator for the residents who were wheelchair bound (could malfunction and trap occupants). He was not sure how to evacuate the residents who were totally dependent and bed bound. He stated he would probably call for outside help to evacuate those residents. On May 2, 2016, at 4:40 p.m., CNA 2 was interviewed regarding evacuation procedures. CNA 2 stated she would use sheets to evacuate residents who were wheelchair bound and bed bound. She was not aware of the availability of stair chairs which could also be used for transferring residents who were wheelchair bound down stairs to the evacuation area. CNA 2 stated she was not aware the facility had the stair chairs and did not have the knowledge on how to use them. On May 2, 2016, at 4:45 p.m., the DSD presented copies of the facility fire drills. She stated that she had to get copies of the form Fire Drill Reports from (Name of the company who provided fire/disaster training). She said that she could not find a log in the office. There were 16 forms listed as Fire Drill Report and four forms listed as Disaster Drill Report. The reports were dated from January 16, 2015, through April 26, 2016. There was no way to ensure that staff from all three shifts from the skilled nursing unit had attended the fire drills since staff from the assisted living units were also invited to attend the same drills. On May 2, 2016, at 4:55 p.m., CNA 3 was interviewed regarding evacuation procedures. CNA 3 was not aware of the availability and proper use of the stair chairs for evacuation during a fire/disaster situation. The documents provided by the DSD titled, All Staff in-services Education Record, were reviewed. The documents indicated there were 26 staff who did not have record of receiving the mandatory in-service related to Fire drills & (and) Evacuation Plan & Fire Chair which was initiated on February 24, 2016. The facility policy titled, FIRE/INTERNAL EVACUATION PLAN FOR THE GROVE CARE AND WELLNESS, revised, February 24, 2016, indicated, Primary response to the emergency is to remove occupants as swiftly and safely as possible. The occupants in the effected room or area . of the fire/internal disaster will be evacuated immediately. If ambulatory: assisted in walking out, if wheel chair: will be rolled out, if bed fast: rolled out, if bed fast and may be safely carried: follow procedures for emergency carries .The elevators are to be sent to the ground floor and placed on hold. Personnel are directed to use exit stairways for evacuation of resident at either end of the facility in event of a fire /internal disaster . The document titled, Fire and disaster Policy/Procedure Manual, revised February 24, 2016, indicated several techniques for emergency carries. The techniques for emergency carries were: 1. Semi-ambulatory rescue by one person: The resident and rescuer stand in line as close as possible with the resident in front .; 2. Semi-ambulatory Rescue by one or two persons: The resident and rescuer stand side-by-side in a chorus line as close as possible with the resident in the middle .; 3. Pack-Strap Carry by one person: The resident and rescuer stand side-by side in a chorus line as close as possible with the resident in the middle .; 4. Extremities Carry by Two person .; 5. Seat Carry by Two Persons .; 6. Blanket Drag by One or More Rescuers .; 7. Kneel drop by one or more persons .; and 8. Evacuation Stair Chair (located on the 2nd floor in each stairwell) .