Every finding on record at Thrive of Fox Valley

Based on observation, interview, and record review, the facility failed to maintain a clean environment for residents. This applies to 3 of 5 residents (R1, R2, and R3) reviewed for housekeeping services in the sample of 5. Findings include:On May 4, 2026, at 9:30 AM, V3 (Housekeeper) stated it's impossible to get everything cleaned when they have only two housekeepers working on the floor. They have two housekeepers on the floor cleaning and one person in the laundry room today. V3 stated they have been working short and if the census drops, they will send staff home; however, with the third housekeeper gone, they still have the same amount of work to do. On May 4, 2026, at 10:18 AM V4 (Housekeeper) stated they normally have three housekeepers except when it's one of their days off or if someone calls off. V4 stated today is V12's (Housekeeper) day off. V4, stated sometimes they cut a housekeeper when the census drops but things are still dirty and need to be cleaned. V4 stated that when there are only two housekeepers on the floor, they each have 1.5 units to clean plus all their other responsibilities. V3 stated, They are killing us. It's too much when there are only two people. I'll be honest, we miss rooms when there are only two [housekeepers]. V3 stated, We don't have time to do every room.On May 4, 2026, at 10:00 AM, V3 stated the laundry staff is off on Wednesday and Saturday and there is only one laundry person, so when he is off, she also has to do the laundry. R3 stated she cannot clean all the rooms when she has to do discharges, and they are short a third housekeeper. R3 stated she does the discharges first and she will have to clean the missed rooms another day. 1.R1 was admitted to the facility on [DATE], with diagnoses that included pneumonia, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, anemia in chronic kidney disease, type 2 diabetes mellitus without complications and personal history of transient ischemic attack and cerebral infarction without residual deficitsOn May 4, 2026, at 11:01 AM, R1 stated that housekeeping had not cleaned his room yet and it hasn't been cleaned since Friday. R1 stated they do not clean his room every day. There were crumbs/debris on his floor all around R1's bed. R1's garbage can at the side of his bed full. There was a band aide wrapper on the floor at the foot of R1's bed and a white plastic tab. There was also a piece of plastic on the floor in the walkway between R1 and R2's bed.2. R2 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction, weakness, ataxia, dysphagia, and dysarthria and anarthria, need assistance with person care, and type 2 diabetes mellitus without complications.R2's Minimum Data Set (MDS) dated [DATE], showed him to be cognitively intact. On May 4, 2026, at 11:20 AM, R2 stated the housekeeping staff do not clean his room every day. There were crumbs/debris on floor by R2's bed. There was white cap that looked like something the nurse would have dropped.On May 4, 2026, at 4:35 PM R2's was partially in his wheelchair, and his room had a puddle of water under wheelchair and to the left of him. R2 stated it was spilled when the nurse gave him some medication. A bag of wet wipes was on floor to the left of R2, and a single wet wipe was under R2's wheelchair. R2's floor still had crumbs/debris, and the same white screw-on cap was on the floor. R2 stated he wanted his room to be cleaned, and no one had come to clean it. R1 (R2's roommate) still had crumbs around his bed and the same band aide wrapper that was on the floor earlier in the day was still there. R1 stated still no one had come to clean his room and he would like it to be cleaned. 3. R3 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease with acute exacerbation, repeated falls, epilepsy, muscle weakness, osteoarthritis, interstitial pulmonary disease, and chronic respiratory failure. R3's MDS dated [DATE], showed R3 had moderately impaired cognition.On May 4, 2026, at 11:30 AM, R3 stated they do not clean his room daily and he would like it cleaned every day. R3 stated they didn't clean over the weekend. R3's room had a lot of crumbs/debris on the floor, and a brown substance streaked on the floor by R3's bed. R3 stated when he saw housekeeping on Friday, they came in and swept the floor. They did not mop, and they partially cleaned the bathroom. There were a lot of food crumbs/debris on the floor by bed and along the wall coming from halfway into the room. There were pieces of plastic on the floor. R3's sink in the bathroom was very dirty with a white chalky substance and brown stains around the entire bowl. The top of the sink had a brown stain and a blue stain on it. R3 stated, you see the sink is not clean.On May 4, 2026, at 11:40 PM, V4 (Housekeeper) stated that she has not cleaned R3's room yet. V4 stated she tries to keep his room clean because he and his family complain about cleaning a lot. On May 4, 2026, at 1:45 PM V6 (Previous Housekeeping Supervisor) stated that it's almost impossible for housekeeping staff to get all the cleaning done when there are discharges and regular work.On May 4, 2026, at 2:14 PM, V7 (Environmental Services Director) stated that resident rooms should be cleaned every day. V7 stated they clean to prevent infections from spreading, to make sure residents have a good clean homelike environment. V7 stated the housekeepers shift are from 7:00 AM to 3:00 PM. Resident council minutes dated December 5, 2025, showed that a resident mentioned that housekeeping does not come every day. The facility's Cleaning and Disinfection/Non-Critical care and Shared Equipment policy dated September 2022, and revised April 2023 showed the following: Resident rooms, including rooms of residents on transmission-based precautions, are cleaned daily.

Based on interview and record review, the facility failed to administer a resident's (R2) as needed analgesic when requested.This applies to 1 of 3 residents (R2) reviewed for pain management.The findings include:R2's care plan said she had the potential for pain due to her chronic pain syndrome. The care plan had multiple interventions, including her need to receive her opioid medication as ordered. Also, for the staff to anticipate her need for pain relief and respond immediately to any complaint of pain. R2's MDS (Minimum Data Set) dated 3/25/2026 said she was cognitively intact. R2's EMR (Electronic Medical Record) showed she had an active order for Norco (analgesic) 10-325 mg (milligrams) one tablet every six hours as needed for pain.On 3/27/2026 at 11:40 AM, R2 said she was upset and frustrated because on the evening of 3/26/2026, she called to request Norco and did not receive it when requested. R2 said V7 (CNA/Certified Nurse Assistant) responded to her call light multiple times after she continued to call repeatedly for her medication. R2 said V7 informed her she had notified V5 (Registered Nurse/RN) of her request. R2 said she had chronic pain but was also experiencing acute pain in her left leg due to her cellulitis (skin infection). R2 said V5 finally administered her Norco at approximately 9:30 PM (approximately 3.5 hours later). R2 said V5 was unable to explain why there was a delay in her receiving her as-needed pain medication as requested.On 3/31/2026 at 10 AM, V7 (CNA) said on 3/26/2026, R2 called for her pain medication at around 6 PM, and she notified V5 (RN). V7 said, then R2 continued to call multiple times afterwards regarding her pain medication, and she continued to notify V5 of her request.R2's call light log document showed that on 3/26/2026, she called at 6:06 PM and continued to call an additional five times at 6:15 PM, 7:28 PM, 8:07 PM, 8:41 PM, and 9:13 PM.On 3/31/2026 at 10:40 AM, V5 (RN) said on 3/26/2026 at around 9 PM, another nurse on duty was going to administer R2's pain medication but did not have access to the medication. V5 said she then responded to R2's request, and R2 was upset when she administered her pain medication. V5 said she was unsure when she was originally notified of R2's request. R2's EMAR (Electronic Medication Administration Record) showed V5 (RN) administered her as needed (PRN) Norco 10-325 mg at 9:26 PM on 3/26/2026 and she was able to receive it after 6 PM.On 3/27/2026 at 1:20 PM, V2 (Director of Nursing/DON) said nurses were expected to administer pain medications as ordered upon request to ensure residents with pain were medicated appropriately. The facility's policy titled Pain Management, dated 1/01/2026, said the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Based on interview and record review, the facility failed to safely transport a resident (R1) in a wheelchair, resulting in him falling and sustaining multiple lacerations.This applies to 1 of 3 residents (R1) reviewed for accidents.The findings include:R1's EMR (Electronic Medical Record) showed he was admitted to the facility on [DATE] with multiple diagnoses, including chronic renal failure, dependent on hemodialysis, unsteadiness on his feet, need for assistance with personal care, reduced mobility, and glaucoma. R1's MDS (Minimum Data Set) dated 1/22/2026 said he was cognitively intact and was dependent with his transfers and lower body care needs. R1's Fall Risk Evaluation dated 1/15/2026 said he was at a high risk for falls. The EMR said he was transferred to the hospital on 3/11/2026 after he sustained a witnessed fall and did not return to the facility.On 3/31/2026 at 1 PM, R1 was interviewed over the phone. R1 said on 3/11/2026, V10 (Certified Nurse Assistant/CNA) was wheeling him in a wheelchair down the hallway after his dialysis treatment. When V10 all of a sudden stopped, it caused him to fly off his wheelchair because there was no footrest. R1 said he was unsure why V10 stopped suddenly when wheeling him. R1 said he sustained abrasions to his left knee and elbows, and his left knee still required treatment. R1 said he went to the hospital and was originally evaluated for possible acute left knee fracture and head injury, but the exams were negative for acute injuries. R1 continued to say that he was too upset after the incident and decided not to return to the facility. R1 said he was discharged to another facility for further rehab services.R1's fall incident dated 3/11/2026, said he had a witnessed fall in the hallway at 11:10 AM. R1 was being wheeled by V10 when he fell forward. R1 sustained lacerations to both his elbows and knees, and an abrasion to the top of his scalp.On 3/31/2026, multiple attempts were made to interview V10 (CNA) but remained unavailable.V10's (CNA) witness statement document dated 3/11/2026, said I was pushing patient from dialysis in the wheelchair, and he fell out the wheelchair onto the floor.On 3/31/2026 at 11 AM, V12 (Registered Nurse/RN) said she witnessed V10 wheeling R1 on 3/11/2026. V12 said V10 (CNA) suddenly stopped, and then R1 fell forward on his left side. V12 said she immediately assessed R1, and there was no footrest present. V12 said the footrest should have been used for proper positioning and to ensure safe transport.On 3/27/2026 at 2:40 PM, V14 (Physical Therapist Assistant) said R1 required the use of a wheelchair due to generalized fatigue. V14 said R1 also required nursing staff assistance and the use of footrests for his wheelchair mobility. V14 said R1 never displayed poor safety noncompliance with the use of his wheelchair, and his footrest should have been used to ensure his safety.On 3/27/2026 at 1 PM, V1 (Assistant Administrator) said V10 (CNA) was terminated after R1's fall incident because the facility was unable to confirm if the footrests were used during their investigation. V1 said the facility determined R1 abruptly fell forward because V10 failed to provide proper trunk support, causing his feet to go down. V1 said the facility expected the nursing staff to implement proper safety measures when transporting a resident in a wheelchair to ensure their safety.V10's (CNA) Performance Form dated 3/16/2026, said she transported [R1] that was weak after HD towards his room without taking appropriate support measures. Which led to the guest having subsequent fall with injuries. The form said V10 failed to follow the facility's safety procedures which jeopardized the safety of R1.R1's fall care plan was updated on 3/12/2026 and showed multiple interventions, including staff to ensure R1 was provided proper trunk support after dialysis when being transported, and anticipate his needs to prevent further incidents.R1's final fall investigation dated 3/16/2026, said R1 was admitted to the hospital and that the facility would reassess his wheelchair upon his return.The facility's policy titled Fall Prevention dated 01/2026, said the facility would provide services and care that ensures that the resident's environment remained as free from accidents hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. The policy continued to say that the interdisciplinary team would develop a plan for services to improve or maintain the resident's standing and sitting balance and other interventions to reduce the resident's risk for falls. The residents' plan would include specific, individualized information about the residents to reduce their risk for falls. And that interviews would be done with the residents to determine any factors that may predispose them for a fall with the goal to help prevent falls in their environment.The facility's policy titled Transfers Within the Facility dated 02/2025, said the facility would determine residents transfer ability according to resident transfer evaluation or therapy recommendations, and would according implement the recommendations. The policy also said footrests would be used for transport, and if not, the transport would be done slowly.

Based on interview and record review, the facility failed to provide educational instructions for a resident (R5) discharging with a cardiac monitor.This applies to 1 of 4 residents (R5) reviewed for discharges.The findings include:R5's EMR (Electronic Medical Record) said he was admitted to the facility on [DATE] with multiple diagnoses, including a new onset of cardiomyopathy, which required the use of a cardiac vest monitoring device. R5's MDS (Minimum Data Set) dated 3/20/2026 said he was cognitively intact and able to follow instructions. The EMR said he was discharged home on 3/20/2026, still requiring the use of the monitor.On 4/01/2026 at 12:30 PM, V21 (Registered Nurse/RN) said she readmitted R5 on 3/06/2026 and routinely cared for R5 during his stay at the facility. V21 said R5 did not have cardiac monitoring orders during his stay, and she forgot to enter them when he was readmitted . V21 said the orders were needed to ensure the monitor was checked to be working properly every shift. V21 said R5's cardiac monitor required daily battery changes to ensure his cardiac data was being transmitted off-site to his cardiologist. V21 said R5 would routinely call when his vest started to alarm or needed to be adjusted. V21 said she was unsure if R5 knew how to care for the monitor, but the nursing staff changed and charged the battery for him daily.R5's Order Summary Report for his readmission on [DATE] did not show an order for his cardiac vest monitor care. The report said he was admitted to the facility's Cardiopulmonary Program due to his diagnoses of pulmonary embolism and respiratory failure.R5's comprehensive care plan, initiated on 1/31/2026, said he was to discharge home. The care plan had multiple interventions, including Establish a pre-discharge plan with the resident/family/caregivers and evaluate progress and revise plan as needed. The care plan did not include a focus problem for his new cardiac condition and management of the cardiac vest monitor.On 4/01/2026 at 11 AM, V20 (RN) said she discharged R5 on 3/20/2026. V20 said R5 was discharged with his cardiac vest monitor in place. V20 said R5 did not have active orders for the management of his monitor but assumed that the battery was changed by the overnight nurse. V20 confirmed R5's vest was working, and he took the monitor's charger and extra battery with him. V20 said she assumed R5 knew how to care for the monitor and did not provide him with specific instructions. V20 said she provided R5 with his discharge summary form and a list of his medications. V20 said cardiac monitoring instructions were important to ensure the guest knows how to monitor complications and prevent readmissions.R5's Transition Home discharge form dated 3/20/2026 said he was discharged with a cardiac vest monitor. The form did not show R5 received specific discharge nursing instructions regarding the management of his cardiac device, cardiac complications, cardiology follow-up, and who to contact in case of device complications.On 4/01/2026 at 10:20 AM, V3 (Assistant Director of Nursing/ADON) said she reviewed R5's EMR and was unable to identify which cardiologist was managing his cardiac device. V3 said R5's EMR also did not show orders for nursing management of the device. V3 said R5 was admitted to the facility's Cardiopulmonary Program, but she was unfamiliar with the program's services. V3 further said the facility was unaware that R5 was readmitted to the ER (Emergency Room) after he was discharged on 3/23/2026 due to complications related to his cardiac device.R5's ER hospital note dated 3/23/2026 said he presented with bilateral lower extremity edema, which started after he was discharged from the facility. The note said R5 was previously given a LifeVest (cardiac monitor) due to his severe cardiomyopathy. R5 presented without the vest in place and reported it was not working due to battery complications. After multiple cardiac tests and a cardiology consult, R5 was discharged home with strict return precautions. R5 was educated on contacting the device's company for further assistance and how to monitor for cardiac complications.The facility's document titled Specialized Cardiopulmonary Program, undated, said the mission statement was to focus on patients with cardiac and respiratory disease and provide them with evidence-based treatment. Also, provide them with education and resources that would allow the patient to manage their disease process and achieve optimal outcomes. The programs discharging planning including determining their equipment needs and education.The facility's document titled LifeVest Questions and Answers, dated 2020, said the LifeVest was a wearable cardioverter defibrillator that was worn by patients at risk for sudden cardiac death (SCD). The device was designed to detect certain rapid life-threatening heart rhythms and automatically deliver a treatment shock to save a patient's life. It allows patients to return to most common activities for daily living with peace of mind that they have protection from SCD.The facility's policy titled Wearable Cardioverter-Defibrillator, dated 03/2023, said documentation was required for residents requiring the use of the device, including a prescription form from the prescribing physician. The policy included specific caring instructions for the device, including how frequently to change the battery, how to wash the vest, and how to respond to alerts.The facility's policy titled Discharges, dated 04/2023, said the facility would establish a discharge plan. Teaching would be done with the resident/family on any special tasks and would be documented in the nursing note/discharge note.

Based on observation, interview, and record review, the facility failed to assess and treat a resident's (R2) skin conditions as ordered.This applies to 1 of 3 residents (R2) reviewed for skin care.The findings include:R2's care plan said she had actual and was at risk for further skin impairment due to her left lower leg cellulitis and chronic lymphedema. The care plan's interventions included for the nursing staff to evaluate and treat her skin as ordered. R2's MDS (Minimum Data Set) dated 3/25/2026 said she was cognitively intact. R2's EMR (Electronic Medical Record) showed she had an active order for Nystatin powder (antifungal) to be applied to under her breast twice a day and wound consults as needed.On 3/27/2026 at 11:40 AM, R2 said she was upset and frustrated because on the evening of 3/26/2026, she requested V5 (Registered Nurse/RN) to assess her new open wound to her left anterior thigh but V5 did not assess or treat her wound. R2 said she was concerned regarding skin impairment because she was currently being treated for cellulitis (skin infection) on her left leg. R2 said her wound remained untreated and uncovered. R2 had an open linear wound to her left anterior mid-thigh area. R2 continued to say she had also requested her antifungal powder be applied as ordered to treat her rash under her left breast, but it was routinely not administered. R2 had a fungal rash underneath her left breast.R2's Medication Concern form dated 3/24/2026, showed she filed her concern regarding not receiving her Nystatin treatment as ordered.R2's ETAR (Electronic Treatment Administration Record) for March 2026 showed multiple omissions for the administration of Nystatin powder as ordered on 3/19/2026, 3/20/2026, 3/21/2026, 3/22/2026, 3/23/2026, and 3/24/2026.On 3/31/2026 at 10:40 AM, V5 (RN) said on 3/26/2026 she was assigned to R2. V5 said she was unsure if R2 reported her new skin alteration.On 3/27/2026 at 12:20 PM, V4 (Wound Care Nurse/WCN) said she was not aware of R2's new open wound to her left thigh. V4 assessed R2's skin and said her new open wound measured 3 x 0.4 x 0.1 cm (centimeters) and had serosanguinous drainage. V4 also said R2's fungal rash on her left breast still required ongoing treatment as ordered. V4 said she expected nurses to assess new skin alterations and notify the physician to obtain and initiate treatments. V4 also said nurses were expected to review the residents' ETARs and administer treatments as ordered to ensure proper skin management.R2's Wound Summary assessment dated [DATE] said her new facility-acquired trauma wound was classified as an abrasion to her left medial thigh distal. The wound measured 3 x 0.4 x 0.1 cm with 100 % bright pink or red tissue with serosanguinous drainage.The facility's policy titled Wound Policy and Procedure, dated 01/2026, said the facility was committed to providing a comprehensive wound management program to promote the residents' highest level of function and well-being. Any resident with a wound would receive treatment and services consistent with the resident's goals of treatment. Typically, the goal is one of promoting healing and preventing infections. The policy said accountability was part of the facility's Wound Management Program, which identified staff participation to prevent and treat wounds accordingly.

Based on observation, interview, and record review the facility failed to assess, monitor, document, and care plan a resident with a cholecystostomy drain and failed to provide care and services for a resident needing staff assistance for 2 of 4 residents (R2, R4) reviewed for quality of care in the sample of 4. The findings include: 1. On 3/18/25 at 11:06 AM, R4 was sitting up in a wheelchair in her room. R4 had a cholecystostomy drainage bag sitting next to her in the wheelchair. R4 stated she had a gallbladder attack in hospital and the bag is from that. R4 stated there is some drainage into the bag and the nurses drain it. R4 lifted her shirt and showed this surveyor the cholecystostomy incision site on the right side of her abdominal area. R4's incision site had gauze covering the insertion area with the drainage tube coming out. The gauze was covered with a transparent dressing. The gauze had a nickel size dried brownish red area of drainage around the drainage tube. There was no date on either dressing. R4 stated this dressing is from the hospital, no one here has changed it or looked underneath the dressing. V12 (R4's) son was sitting bedside and confirmed that the dressing around the insertion site of the cholecystostomy was the one the hospital put on. On 3/18/25 at 10:07 AM, V6 Licensed Practical Nurse stated R4 has a drain that needs to be emptied and documented once a shift. V6 stated R4's drain has a small amount of golden colored drainage usually. V6 stated she was not aware of dressing change orders or monitoring for the insertion site. On 3/18/25 at 11:31 AM, V2 Director of Nursing stated nurses should be looking and assessing R4's cholecystostomy insertion site to monitor for signs and symptoms of infection. V2 stated there should be orders for dressing changes to the site and if the hospital discharge orders did not contain orders the nurse should reach out to the doctor for orders. R4's face sheet shows R4 was admitted on [DATE] with a diagnosis of calculus of gallbladder with acute cholecystitis with obstruction. R4's Admission assessment dated [DATE] shows Does the Resident have surgical drain? NO is marked. R4's Progress Note dated 3/9/25 shows the resident does not have a surgical drain. R4's Care Plan shows R4 is at risk for alteration in skin integrity related to fall, hematoma center forehead, acute displaced fractures of left and right nasal boned, calculus of gallbladder with acute cholecystitis, chole tube, acute kidney injury, respiratory failure. There are no interventions listed for monitoring or care of R4's cholecystostomy drain. R4's Physician Orders (POS) shows orders dated 3/9/25 to cleanse area with normal saline, apply clean dry split sponge to site and secure with tape, as needed (order does not address what area being cleansed). The same POS contains an order to empty drain, measure and record amount of drainage. Notify doctor of any abnormal drainage and color change. There are no orders to monitor the cholecystostomy site. On 3/18/25 at 1:25 PM, V13 Nurse Consultant stated she was not sure what the order to cleanse are with normal saline was for and would get the order clarified. R4's Infectious disease Nurse Practitioner note dated 3/10/25 shows routine cholecystostomy tube care per facility protocol and Needs follow up with Gastrointestinal/Surgery for drain management. The facility's Wound Policy and Procedure dated 5/23 shows Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically, the goal is one of promoting healing and preventing infection. 45395 2. R1's medical record indicated resident admitted to facility on 03/07/2025 with a past medical history not limited to: acute kidney failure, urinary tract infection, morbid obesity, gout, and bilateral primary osteoarthritis of the knee. R1's Brief Interview for Mental Status Evaluation dated 03/07/2025 documented score of 15 which indicated no cognitive impairment. R1's care plan report with date initiated of 03/07/2025 reads in part: activities of daily training (ADL's) self-care performance deficits and limitations in physical mobility, resident is incontinent with interventions to check every 2-3 hours and as needed for incontinence and is at risk for skin integrity and falls. R1's order summary report as of 03/18/2025 showed order for occupational therapy 3-4 times per week for 4 weeks to include but not limited to ADL's and bed mobility; and skilled physical therapy services 3-4 times per week for 4 weeks to include but not limited to therapeutic exercises and activities. On 03/18/2025 at 11:04 AM, R1 stated a few days after she came to the facility (couldn't recall date), she had spilled ice water on her bed at around 6:30 AM. R1 stated she pressed her call light for staff assistance and when someone finally came, she asked for her wet sheets to be changed but was told someone would be back to help her. R1's call light was turned off and the staff member left the room. R1 stated when her breakfast tray was brought in around 9:00 AM, she again asked the staff member to change her bed linens and was told it would be done after all trays were passed but no one came back. R1 then stated her son came in around lunch time and her cold and wet bed linens still had not been changed so her son went to the desk and informed staff that R1's bed linens needed to be changed. R1 added that she had pressed her call light multiple times for several hours to have the bed linens changed, but a staff member didn't come into the room to provide assistance until after 1:00 PM. R1 added that when staff did come, she asked them to assist her roommate (R2) first because she had an incontinence episode in her wheelchair. On 03/18/2025 at 11:46 AM, V2 (Director of Nursing) stated she expects for staff to answer all call lights within a timely manner, normally within 10-15 minutes. V2 added that staff should not turn off a call light without providing assistance, and the call light should remain on until all of the resident's needs are met. Call light policy last reviewed 01/2024 reads in part, the call light system is provided as a tool for residents to communicate with staff .Staff members will acknowledge and respond to the call light by entering the resident's room and determining and assisting with the resident's needs.

Based on interview and record review, the facility failed to have clear resident care policies to ensure a resident's neurological evaluations were completed and monitored after an unwitnessed fall. This applies to 1 of 3 residents (R1) reviewed for quality of care in a sample of 5. Findings include: R1's Face Sheet showed she was admitted on [DATE] with diagnoses that included personal history of pulmonary embolism, other pulmonary embolism with acute cor pulmonale, personal history of transient ischemic attack (TIA) and cerebral infarction without residual effects. R1's MDS (Minimum Data Set) showed moderate cognitive impairment. R1's 10/4/2024 progress note written by V13 (on-call Physician) from 9:00 PM showed she experienced an unwitnessed fall and was on a blood thinner. The Orders section showed Assess pain per protocol and Monitor with neuro-checks per protocol. The facility's Post-Fall policy (revised 5/2023) showed If the resident reports hitting head, if there is any indication of head injury, or if ANY incident is un-witnessed, the neuro check protocol will be implemented, and reported to the physician. The facility's Neurological Assessment policy (reviewed 9/2023) showed Neurological assessments are done upon physician order when indicated for a change of resident condition, unwitnessed fall, and head injuries. The policy continues to outline elements for neurological assessment as observations for pain, behaviors, level of consciousness, orientation, speech, strength, pupil size and reaction to light, and vital signs. The policy then showed 10. Determinations of how often to check above are based on physician or nurse practitioner order or change of resident condition. On 11/14/2024 at 4:00 PM, V13 (on -call MD/Medical Doctor) stated a resident with an unwitnessed fall has to have neuro-checks regularly. V13 stated R1's neuro-checks should have been completed all through the night with specific times, and he expects the facility protocol to be used to monitor for changes. V13 stated only checking once is not appropriate, as neuro-checks can show signs of a head injury, such as brain bleeding. Or intracranial pressure. R1's Electronic Medical Records (EMR) showed an initial Post-Fall Neurological Evaluation form was completed after her fall on 10/4/2024 at 8:40 PM. A progress note in R1's EMR showed neuro-checks (with notation of pupil size) were completed only one more time on 10/5/2024 at 2:00 PM.

Based on interview and record review the facility failed to resolve Resident Council and individual resident's concerns regarding extended wait times for call light response. This applies to 3 of 3 residents (R1, R2, and R4) reviewed for improper nursing care related to call light response times, in the sample of 4. The findings include: The Resident Council Meeting Minutes dated May 23, 2024, showed . 7. Guests (residents) voiced they take a long-time answering call light. Resolution: This was communicated to Director of Nursing and Administration There were 6 patients (residents) in attendance at the meeting. The Resident Council Meeting Minutes dated June 26, 2024, attended by 5 patients (residents), showed under New (business) .1. Guest (resident) complained about the call lights not being answered quickly and voiced she understands the aides have a lot of people to take care of, but facility can get more help for CNAs and nursing would be great. The Resident Council Meeting Minutes dated July 24, 2024, attended by 5 patients (residents), showed . Old Items .1. Guest complained about call lights not being answered quickly and voiced she understands the aides have a lot of people to take care of, but if the facility can get more help for CNAs and Nurses then would be great. Resolution: This was addressed to all management team and to Nursing and in IDT. In resolution a training was given in to all Nursing staff and other department staff to be responsible to answer call lights as long as they are able to address concerns .and .New Items: .4. A couple guest (resident) addressed concerns on call light response time. They agreed that .they would like to have a quicker response time especially when needing help to use the restroom . V1 (General Manager/Administrator) provided documentation of an all staff in service regarding call lights was completed on July 11, 2024, prior to the July 24, 2024, Resident Council Meeting, where residents again voiced concern regarding the need for staff to respond to the call light more quickly. A review of the grievance log for the months of June, July, and August, showed R1's daughter filed a grievance with V9 (Rehab Director) that showed call lights are on too long and need to be answered quicker. On August 29, 2024, at 4:18 PM, when concern form was first reviewed, there was no response written on the concern form section Immediate Response Taken. On August 29, 2024`at 4:52 PM, V1 was asked about where grievance resolution would be documented. V1 stated the resolution would be under the Immediate Action Taken section on the concern form, and was unsure why R1's August 11, 2024, concern form regarding call lights did not have a resolution documented. R1 returned with the form at 5:15 PM that included an undated, documentation on R1's August 11, 2024, concern form regarding call lights, Immediate Action Taken. R1's concern regarding call lights dated August 11, 2024, now had undated documentation showed Ongoing education regarding call light response was conducted for all nursing staff in section 1000 (R1's nursing unit). V1 provided in service documentation dated August 12, 13, and 14, 2024. V1 stated what else can be done? regarding extended wait times for call light response. On August 29, 2024, at 2:42 PM, R1 stated she continues to have concerns with her call light not being answered timely especially on the night shift and weekends. R1 stated she hears the staff talking in the hallway while her call light is on but is unsure why staff don't come into her room. R1 stated she has waited so long, at least 30 minutes that she has urinated on herself because she couldn't hold it any longer waiting for her call light to be answered. R1 demonstrated she was able to activate her call light. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including nondisplaced condylar fracture of the humerus, chronic kidney disease, history of falls, osteoporosis, malignant neoplasm of the esophagus, and cognitive communication deficit. R1's MDS (Minimum Data Set) dated August 9, 2024, showed R1 had moderate cognitive impairment, and required assistance with ADLs including dependent on staff for transfer, bathing, toileting and lower body dressing, partial assistance with personal hygiene, and set up assistance with eating. On August 29, 2024, at 2:35 PM, R2 stated she has a concern regarding her call light being answered promptly especially on the night shift and weekend shifts. R2 stated she is unsure of the exact date, but she has waited for an hour for her call light to be answered during the night shift. R2's EMR showed R2 was admitted to the facility on [DATE], with multiple diagnoses including acute cystitis without hematuria, cellulitis of left upper limb, chronic pancreatitis, difficulty walking and vascular dementia. R2's MDS dated [DATE], showed R2 was cognitively intact, and required assistance with ADLs including dependent on staff for toileting, transfer and lower body dressing, partial assistance with oral and personal hygiene and upper body dressing, substantial assistance with bathing and bed mobility and set up assistance with eating. On August 29, 2024, at 2:47 PM, R4 stated she had concerns with her call light not being answered promptly, especially when she had a migraine headache and was waiting for her call light to be answered to ask for her medication. R4 stated she has waited for what seemed like 30 minutes but did not recall a specific date of when that occurred. R4 stated and her husband who was at her bedside agreed, since she first arrived at the facility, she has had a problem with her call light being responded to timely. R4's EMR showed R4 had admitted to the facility on [DATE], with multiple diagnoses including enterocolitis due to clostridium difficile infection, generalized weakness, protein calorie malnutrition, anxiety disorder, and migraine, unspecified. R4's MDS dated [DATE], showed R4 was cognitively intact, and required assistance with ADLs including partial assistance with toileting, bathing, lower body dressing, bed mobility and transfer, and set up assistance with personal hygiene and independent with eating. The Facility's policy titled Grievances dated April 2023, showed Purpose .and respond with prompt efforts to resolve while keeping the resident and/or resident representative appropriately apprised of progress toward resolution .Resident Council and filing a Grievance .All grievances identified during the Resident Council meeting will be submitted immediately to the Grievance Official for investigation and resolution .As necessary, the Grievance Official and facility leadership will take immediate action to prevent further potential continuations of any additional or like resident concerns while a grievance is being investigated .and .QAPI .Our facility will track and analyze the grievance process and findings for trends, performance gaps, and opportunities for individual education, system and systemic improvement. The facility will incorporate the Grievance process into the Quality Assurance and Performance Improvement program.

Based on interview and record review the facility failed to administer medications timely in accordance with the facility policy. This applies to 2 of 3 (R2, R4,) in a sample of 3 reviewed for timely administration of medications. The findings include: R4's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including [NAME] Barre Syndrome, [NAME] Nile virus, pulmonary embolism without acute cor pulmonale, And generalized muscle weakness. R4's MDS (Minimum Data Set) dated July 23, 2024, showed R4 was cognitively intact, and was dependent on staff assistance with ADLs including eating, oral hygiene, bed mobility, bathing, dressing, toilet hygiene, and transfer. R4's Medication Administration Audit report, dated July 26, 2024-July 27, 2024, showed R4 medication scheduled to be administered at 9:00 AM, included Amlodipine Besylate tablet 2.5 mg, (milligrams) daily, Metoprolol Tartrate tablet 25 mg, twice a day, Apixaban 5 mg. twice a day, Aspirin 81 mg. daily, Ferrous Sulfate tablet 325 mg, daily, Thiamine HCL tablet 100 mg daily, Folic Acid 1 mg daily and Megestrol Acetate suspension 400mg/10ml(milliliters) daily. The Medication Audit report showed the scheduled 9:00 AM medications on July 26, 2024, were administered as follows: Amlodipine Besylate at 10:58 AM, Metoprolol Tartrate at 10:58 AM, Apixaban at 10:57 AM, Aspirin at 11:00 AM, Ferrous Sulfate at 10:59 AM Thiamine at 11:00 AM, Folic Acid at 10 :59 AM and Megestrol Acetate at 11:01 AM. The Medication Audit report showed the scheduled 9:00 AM medications on July 27, 2024, were administered as follows: Amlodipine at 11:25 AM, Megestrol Acetate at 11:27 AM, Thiamine at 11:28 AM, Folic Acid at 11:27 AM, Aspirin 81 mg at 11:26 AM, Metoprolol Tartrate at 11:27 AM, Apixaban at 11:26 AM, and Ferrous Sulfate at 11:27 AM. Review of R4's progress notes of July 26 and 27, 2024, showed there was no notification to the prescriber regarding the late administration of scheduled medication. On August 6, 2024, at 11:05 AM R4's wife stated she is at R4's bedside every day, all day and she is concerned that R4's medications are administered late. R2's EMR (Electronic Medical Record) showed R2 was most recently admitted to the facility on [DATE], had previously been in the facility on January 6, 2023, and discharged [DATE]. R2 had multiple diagnoses including spinal stenosis lumbar region, other disorders of the peripheral nervous system, diabetes type 2, morbid obesity due to excess calories, malignant neoplasm of the colon, hidradenitis suppurativa, polyneuropathy and unspecified asthma. R2's MDS (Minimum Data Set) dated 8/2/2024 showed R2 to be cognitively intact. On August 3, 2024, at 2:20 PM, R2 stated she had a concern that sometimes her medication is given to her later than scheduled, especially her medication for pain. R2's Medication Administration Audit report, dated July 28, 2024, showed R2 scheduled medication for 9:00 AM included Tylenol Codeine tablet 300-30 mg give one tablet by mouth every 12 hours. R2's Medication Audit report showed R2's Tylenol codeine tablet scheduled to be given at 9:00 AM was administered at 1:25 PM. Review of R2's progress note showed there was no note indicating the prescriber had been notified of the medication being administered late nor guidance when to administer the next scheduled dose, as the order showed medication to be administered every 12 hours. On August 6, 2024, at 10:44 AM, V2 (Director of Nursing/DON) stated it is the expectation for nurses to contact the prescriber when medications are not available from the pharmacy or administered late. The Facility's policy titled Medication Pass Times, dated revision May 2023, showed Medications are administered according to a standard schedule, resident needs and physicians' orders .1. The following is a list of scheduled medication times .person centered liberalized medication pass windows .AM: 7AM - 10 AM .the medication pass times below will be utilized according to provider orders .a. QD (every day/daily) 9:00 AM.

Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 57 residents. On [DATE] at 12:14 AM, V11 (Dietician) said there are zero NPO (Nothing by Mouth) residents that do not eat from the facility kitchen. On [DATE] starting at 9:55 AM, the facility kitchen was toured in the presence of V9 (Dietary Manager). V9 stated, frozen items can be used for six months from the date it is received. The following expired items were observed in the refrigerator/freezer: 1. Feta Cheese, crumbled, 2 bags of 5 lbs each with received date of [DATE]. 2. Cheese Ravioli 2 bags of 5 lbs each with received date of [DATE]. 3. Chopped Spinach 12 bags of 2 lbs each with received date of [DATE]. 4. Eggo Frozen waffles: 5 packets of 12 waffles each with received date of [DATE]. 5. One loaf of wheat bread with received date of [DATE]. 6. One loaf of gluten free bread with received date of [DATE] 7. Two loaves of gluten free bread with received date of [DATE] (Currently one resident on gluten free diet). 8. One open partially used bag of pepperoni with received date of [DATE] 9. One open partially used bag of pizza sausage with expiry date of ,d+[DATE]. 10. One Boston cream pie with no received date or expiry date. 11. One 5 lb bag of frozen cranberries with received date of [DATE] 12. One 10 lb partially used bag of white corn grits with received date of [DATE] and with expiry date of [DATE] 13. One 3 lb bag of chicken and herb stuffing with no received or expiry date. 14. One 10 lb bag of [NAME] Crumbs with received date of [DATE] 15. Two 5 lb bags of [NAME] Crumbs with received date of [DATE] On [DATE] at 11:30 AM, V9 (Dietary Manager) stated, all expired items should be discarded so they are not accidentally given to the residents with the potential to make the residents sick. V9 stated, he does not have a policy on food storage.

Based on observation, interview, and record review the facility failed to provide a resident with a functioning over bed light and failed to provide an adaptive call/light button. This applies to 2 (R26, R31) of 2 residents reviewed for accommodation of needs in a sample of 19. Findings include: 1. R26 was admitted to the facility on [DATE] with diagnoses that include displace comminuted fracture of shaft of humerus of right arm, moderate protein calorie malnutrition, polyneuropathy, intrahepatic bile duct carcinoma, secondary neoplasm of right lung, hyperlipidemia, hypothyroidism, muscle weakness, depression, and anxiety. On 07/23/24 at 11:42 AM, R26's call light was hanging on the left side of her bed near the floor out of her reach. R26 stated her hands are paralyzed and she has macular degeneration. R26 stated she has difficulty pressing the call light button. R26 stated she requires assistance with everything, but she doesn't think the staff is completely aware of her care needs. R26 stated she has waited as long as three hours after pressing her call light but when staff come in the room, they say they did not hear her call light. On 07/23/24 at 12:24 PM, V15 Family Member stated R26's call button works but R26 does not have the dexterity to make it work. V15 stated he noticed a few days ago R26 was unable to activate the call light. V15 stated R26 has neuropathy in her hands and macular degeneration so R26 was unable to make the call button work. On 07/23/24 at 12:24 PM, V5 LPN (Licensed Practical Nurse) stated the facility did have another type of call device that would be accessible for R26's use. R26's MDS (Minimum Data Set) dated 7/9/24 shows she is cognitively intact with a BIMS (Brief Interview for Mental Status) scores of 15. R26's MDS documents she requires substantial / maximal staff assistance with toileting. R26's care plan dated 7/5/24 states R26 has an ADL self-care performance deficit and limitations in physical mobility. R26 requires assistance with ADL functioning related to impaired mobility, weakness, and debility secondary to hospitalization for a right humerus fracture and hyponatremia. R26 has impaired vision function intervention keep call light and other key items within reach. 2. R31 was admitted to the facility on [DATE] with diagnoses that includes displaced intertrochanteric fracture of left femur, pleural effusion, muscle weakness. Atrial fibrillation, osteoporosis, anxiety, chronic kidney disease, insomnia, history of liver transplant, immunodeficiency, and type 2 diabetes. R31's MDS (Minimum Data Set) dated 7/16/24 shows she is cognitively intact with a BIMS (Brief Interview for Mental Status) scores of 13. On 07/23/24 at 1:36 PM, R31 stated her over bed light was broken and would not turn off. There was no string or button to turn the light off. R31 stated the light fixture was covered with a sheet by staff so she could get rest. R31 stated the light fixture broke two days after her admission. On 07/23/24 at 2:25 PM, V6 RN (Registered Nurse) stated she did not realize R31's over bed light was broken and would not turn off. V6 RN stated there are no repair requisitions. If something is not working, she will try to trouble shoot herself or call maintenance to notify them of the repair need. On 07/24/24 at 11:10 AM, V3 EVS (Director of Environmental Services) stated staff verbally notify him of repair request but are encouraged to use the tells system to report repair requests. V3 EVS stated he was not notified of R31's light fixture needing repair until the morning of 7/24/24. The computer requisition system is available to all staff in the facility. V3 stated staff should not have place a sheet over the light fixture as it could cause a fire. Staff should have informed him of the repair need when they knew about it because it would take all of five minutes to repair. On 07/25/24 at 2:02 PM, V2 DON (Director of Nursing) stated the admitting nurse should assess what type of call light is appropriate for a resident. Sometimes we know what type of call device a resident will require before they arrive. Sometimes the resident will inform us they cannot activate the call light. The nursing staff should be doing an assessment to make sure the resident is able to activate the call light. We have enough pad type call devices if a resident was having difficulty activating the call light. If equipment is broken all staff are responsible for reporting it. Staff can either call repair request or enter the request in the computer. If something isn't working or breaks during their stay, we notify maintenance. If the light wasn't turning off and the resident couldn't sleep, we could have moved them to another room. The staff should not have placed a sheet over the light. The facility repair requisition for the broken overbed light was generated on 7/24/24 at 7:34 AM. The facility's policy Call Light -Ability to Use dated 01/2024 states the call light system is provided for the residents to communicate with staff. Resident will be evaluated for the ability to use the call light system on admission, quarterly and annually. If residents are determined to be physically unable to use call lights, alternative call buttons will be provided. Staff members will ensure call lights are within reach of a resident who is able to cognitively use a call light each time they leave the room. The facility's policy Reporting Maintenance Issues dated 04/2022 states all non-emergent maintenance related concerns will be logged into the requisition system in the electronic documentation system to add workorders. All emergency situations (electrical, flooding, alarms, structural damage) need to be reported immediately to the EVS director number posted at the nursing stations.

Based on observation and interview the facility failed to provide timely incontinence care. This applies to 1 (R26) of 3 residents reviewed for assistance with ADLs (Activities of Daily Living) in a sample of 19. Findings include: R26 was admitted to the facility on [DATE] with diagnoses that include displace comminuted fracture of shaft of humerus of right arm, moderate protein calorie malnutrition, polyneuropathy, intrahepatic bile duct carcinoma, secondary neoplasm of right lung, hyperlipidemia, hypothyroidism, muscle weakness, depression, and anxiety. On 07/23/24 at 11:42 AM, R26 stated she requires assistance with everything, but she doesn't think the staff is completely aware of her care needs. R26 stated the first time she saw staff was at 10:40 AM and she was not provided incontinence care at that time. R26 stated she had been in the same soiled undergarment since the previous night. On 07/23/24 at 11:56 AM, after surveyor request V5 LPN (Licensed Practical Nurse) and V6 RN (Registered Nurse) assisted R26 with incontinence care. R26's gown, disposable undergarment, absorbent bed pad, transfer sheet and bottom sheet were saturated with urine. R26 had pink blanchable skin on her right elbow, left shoulder blade, right buttock, and bilateral heels. R26's left buttock was not blanchable. On 07/23/24 02:08 PM, V7 C.N.A. stated prior to entering R26's room during her incontinence care at 11:56 AM he last provided incontinence care at 7:15 AM. On 07/25/24 at 2:02 PM, V2 DON (Director of Nursing) stated incontinence care should be provided every two hours and as needed so residents are not soaking in urine. Urine causes your skin to break down and can contribute to the development of a urinary tract infection. If urine has soaked through the brief to the absorbent pad and sheet the resident had been left too long without being provided care. R26's MDS (Minimum Data Set) show she is cognitively intact with a BIMS (Brief Interview for Mental Status) scores of 15. R26's MDS documents she requires substantial / maximal staff assistance with toileting. R26's care plan dated 7/5/24 states R26 has an ADL self-care performance deficit and limitations in physical mobility. R26 requires assistance with ADL functioning related to impaired mobility, weakness, and debility secondary to hospitalization for a right humerus fracture and hyponatremia. R26 is incontinent related to impaired mobility, weakness, debility and requires assistance with toileting. Intervention for R26 includes assist with toileting, clean peri area with each incontinent episode and change disposable brief as needed. The facility's ADL policy dated 04/2023 states the facility will provide all residents with care, treatment, and services according to the resident's individualized care plan.

Based on observation, interview, and record review the facility failed to ensure the residents received their medications per physician's orders and resident's choices for 2 of 2 residents (R260 and R262) reviewed for medication administration in the sample of 19. Findings include: 1. On 7/23/24 at 12:25 PM, R260 was sitting on her WC (wheelchair) next to her bed. R260 stated, she had not received her Trospium 20 mg since she was admitted to the facility, i.e. about eight days. R260 stated, she had been on Trospium for past one to two years and that she needed it for urinary incontinence. R260 stated, she ensured that the medicine was listed on the discharge documents from the hospital and hence the facility knew that she was on this medicine before she arrived at the facility. R260's face-sheet showed an admitted [DATE] with multiple diagnoses including Multiple Sclerosis, Urge incontinence and Anxiety. R260's MDS (Minimum Data Set) dated 7/22/24 showed she was cognitively intact. R260's Progress Notes showed: 7/16/24 10:26 AM Trospium Chloride Oral Tablet 20 MG Give 1 tablet by mouth two times a day related to MULTIPLE SCLEROSIS (G35) take before meals On order 7/18/24 6:34 PM Trospium Chloride Tablet 20 MG Give 1 tablet by mouth two times a day for Urinary incontinence Not available 7/19/24 9:59 AM Trospium Chloride Tablet 20 MG Give 1 tablet by mouth two times a day for Urinary incontinence Not available 7/19/24 5:59 PM Trospium Chloride Tablet 20 MG Give 1 tablet by mouth two times a day for Urinary incontinence Not available 7/20/24 5:05 PM Trospium Chloride Tablet 20 MG Give 1 tablet by mouth two times a day for Urinary incontinence Pharmacy supplied Oxybutine (R260) wants tropsium. 7/21/24 4:08 PM Trospium Chloride Tablet 20 MG Give 1 tablet by mouth two times a day for Urinary incontinence On order 7/22/24 8:17 AM Trospium Chloride Tablet 20 MG Give 1 tablet by mouth two times a day for Urinary incontinence Would not take oxybutynin the therapeutic interchange pharmacy and MD(medical doctor) aware 7/23/2024 08:56 AM Trospium Chloride Tablet 20 MG Give 1 tablet by mouth two times a day for Urinary incontinence Not available 7/23/2024 1:11 PM Trospium Chloride Tablet 20 MG Give 1 tablet by mouth two times a day for Urinary incontinence Pharmacy sent interchange oxybutynin, (R260) refused. Pharmacy to send medication today 2. On 7/23/24 at 1:07 PM, R262 was sitting on his wheelchair in his room with his wife next to him. R262 and his wife stated, he had not received his eye drops for glaucoma for two days. R262's wife stated, she brought what they had at home to the facility & that is what the facility is using for the resident now. R262's face-sheet showed an admitted [DATE]. R260's MDS (Minimum Data Set) dated 7/23/24 showed he was cognitively intact. R262's Progress notes dated 7/17/24 at 10:13 PM showed: Latanoprost Solution 0.005 % Instill 1 drop in left eye at bedtime for Eye drop Not available R262's MAR (Medication Administration Record) for July 2024 showed Latanoprost Solution 0.005 % was not administered to the resident on 7/17/24. On 7/23/24 at 12:53 PM, V8 (RN-Registered Nurse) stated, R260 did not receive Trospium 20 mg BID (twice a day) for urinary incontinence, since admission as the medicine was not available in the cart. V8 (RN) stated, if any medicine is not available for any resident, the nurse on the unit has to follow up with the pharmacy. If they cannot get it, the DON gets it for them. On 7/25/24 at 12:37 PM, V2 (DON-Director of Nursing) stated, the medication for any new admission is made available as soon as possible, latest within less than 24 hours. V2 (DON) stated, facility also have pixies for commonly used medications as a back-up for new admissions. V2 (DON) stated, before the resident is discharged from the hospital, floor nurse gets report from the hospital and can check with the pharmacy if the medicine is available. If the resident is taking any specialty medicine, the nurse liaison, the admission director, the administrator, and the DON discuss the medicine required and make arrangements to make it available for the resident by the time resident arrives at the facility. V2 stated, she is not sure why the medicine got so delayed for R260. The floor nurse should have called the pharmacy & followed up as to why the medicine is not sent. If they have a hard time getting the medicine from the pharmacy, they should have reported and asked for help from any nursing managers. Also, the floor nurses should have informed the Physician sooner than what they did, which was 5 days later. On 7/25/24 at 12:55 PM, V2 (DON) stated, the fact that R262 did not get his eye drops is a mistake on the part of the nurse. It is not OK that R262 did not receive the medicine. It is a medication error and should not have happened. Facility policy on Medication Administration dated 04/2024 does not include the process of making the medications available to the residents on time.

Based on observation, interview, and record review the facility failed to ensure the resident received respiratory care services that are in accordance with professional standards of practice for 3 of 3 residents (R15, R20 and R265) reviewed for respiratory therapy in the sample of 19. Findings include: 1. On 7/23/24 at 12:20 PM, R15 was sitting on his WC (wheelchair) next to his bed. Observed R15's CPAP (continuous positive airway pressure) mask with tubing not in use and not contained in a bag. On 7/24/24 at 10:00 AM, observed R15's CPAP mask with tubing not in use and not contained in a bag. R15's face sheet provided by the facility on 7/25/24 showed he was last admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease and Asthma. R15's Physician order report for July 2024 showed, CPAP/BiPAP (bilevel positive airway pressure) at bedtime and in the morning cleanse mask and allow to air dry after removal. 2. On 7/23/24 at 1:00 PM, R20 was in semi-Fowler's position in bed. Observed R20's nebulization mask with the container for the medication on the bedside table uncovered/not bagged. R20's face sheet provided by the facility on 7/25/24 showed she was last admitted to the facility on [DATE] with diagnoses to include asthma and anxiety. R20's Physician order report for July 2024 showed, ipratropium-albuterol solution 3 ml inhale every four hours as needed for wheezing. 3.On 7/23/24 at 1:20 PM, R265 was in semi-Fowler's position in bed. Observed R265's CPAP mask with tubing not in use and not contained in a bag. R265's nebulization mask with the container for the medication was on the nightstand uncovered/not bagged. R265's face sheet provided by the facility on 7/25/24 showed he was last admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. R265's Physician order report for July 2024 showed, ipratropium-albuterol solution 3 ml inhale every eight hours as needed for wheezing. R265's Physician order report for July 2024 showed, CPAP/BiPAP at bedtime and in the morning cleanse mask and allow to air dry after removal. On 07/25/24 at 12:28 PM V2 (DON - Director of Nursing) stated, after giving a nebulization treatment, the medicine container and the mask should be rinsed and placed on a clean surface either on a clean towel or paper towel to air dry until next treatment. When not in use, the nebulization mask and the medicine container is stored in a designated bag, to prevent collection of dust or dirt on the equipment and possible potential for infection. V2 (DON) stated, CPAP & BiPAP masks are also stored in a designated bag to prevent collection of dust and possible potential for infection. Facility policy on Nebulizers dated 01/23 showed, .23. When equipment is completely dry, store in a plastic bag with resident's name and the date on it.

Based on interview and record review, the facility failed to administer ordered intravenous antibiotics for residents with infections. This applies to 2 of 4 residents (R3 and R44) reviewed for intravenous medications in a sample of 19. Findings include: 1. R3's EMR (Electronic Medical Record) showed R3 was to be receiving vancomycin IV (intravenous) antibiotic for MRSA (Methicillin-resistant Staphylococcus aureus) bacteremia infection. On 7/25/2024 at 2:29 PM, V12 (Pharmacist) stated she was dosing R3's vancomycin IV antibiotic medication as ordered by his provider. V12 stated patients receiving vancomycin IV require their medication therapeutic blood levels to be closely monitored because if too high the medication could be toxic or if too low it could be nontherapeutic. V12 stated she determines a patient's target tr (trough) blood medication level range based on the type of infection being treated to ensure the medication is effective. V12 stated vancomycin IV dosages and frequencies are then adjusted based on the patient's tr results. V12 stated R3 had an order to start vancomycin IV 1.5 G (grams) every 3 days on 7/13/2024. V12 stated R3's EMR was reviewed, and it was noted R3 had not started on his antibiotic as ordered. V12 stated the facility was notified on 7/13/2024 of the recommendation to continue with the current order and to obtain a tr lab draw on 7/17/2024 AM prior to the administration. V12 stated on 7/16/2024 she reviewed R3's EMR and noted R3 last received his vancomycin medication on 7/14/2024 AM and had a tr level of 4.8 (low) on 7/16/2024. V12 said she notified the facility on 7/16/2024 to change the dose and start R3 on 1 G every 24 hours on 7/17/2024, R3's target tr goal range level was 12-18, and a need for tr lab draw on 7/19/2024 AM prior to the administration. Then V12 stated she reviewed R3's EMR on 7/23/2024 and noticed R3's tr level on 7/19/2024 was less than 3 (too low) and the vancomycin recommendation from 7/16/2024 was not carried out. V12 stated she was concerned because R3 was nontherapeutic for the treatment of his blood infection. V12 stated she contacted the facility on 7/23/2024 to clarify R3's vancomycin administration doses, and V13 (Registered Nurse) confirmed R3's antibiotic order recommendation from 7/16/2024 was not carried out and R3 did not receive the correct doses and frequencies. V12 stated she then reinstructed the facility to start vancomycin 1 G every 24 hours on 7/23/2024 and repeat tr level on 7/26/2024. V12 stated the pharmacy dispenses the number of antibiotic infusion doses needed based on the order and they contact the facility daily to confirm if any change in the number of doses needed to ensure the facility has the medications available. V12 also stated the facility has access to a medication pyxis machine that has IV antibiotics available at all times, including vancomycin and cefazolin. On 7/25/2024 at 11:08 AM, V14 (Infectious Nurse Practitioner) stated she was managing R3's blood infection. V14 stated the pharmacist was to be dosing R3's vancomycin IV because the antibiotic required close monitoring and titrating of dosages to ensure R3 received a safe and effective therapeutic dose to treat his infection. V14 stated she expected the facility to follow the pharmacist's recommendations and administer antibiotics as ordered. On 7/25/2024 at 2:29 PM, V2 (Director of Nursing) stated she expects nurses to administer scheduled intravenous antibiotics as ordered and for them to document in patients' EMAR (Electronic Medical Administration Record) once administered. V2 stated she also expects nurses to follow pharmacy recommendations for the dosing and management of IV antibiotics as ordered to ensure the correct doses are being administered. R3's July 2024 EMAR showed R3 did not receive his ordered vancomycin IV 1.5 G on 7/13/2024. R3's EMAR showed R3 was also not started on vancomycin IV 1 G daily on 7/17/2024 and continued to receive the incorrect dose and frequency from 7/17/2024 through 7/22/2024. R3's Order Summary Report dated 7/25/2024 showed R3 was started on vancomycin IV 1 G daily on 7/23/2024, not on 7/17/2024. 2. R44's EMR showed R44 was to be receiving cefazolin IV (intravenous) medication for a right-hand infection. On 7/25/2024 at 1:00 PM, V4 (Nurse Manager) was asked to review R44's EMAR and said the EMAR showed R44 did not receive her scheduled cefazolin IV antibiotic doses on 7/03/2024 at 6 AM, 7/16/2024 at 2 PM, and 7/22/2024 at 6 AM. R44's EMAR showed R44 scheduled cefazolin IV 2 G was omitted on 7/03/2024 at 6 AM, 7/16/2024 at 2 PM, and 7/22/2024 at 6 AM. R44's Order Summary Report dated 7/25/2024 showed R44 was to start on cefazolin IV 2 G every 8 hours on 6/30/2024 until 8/11/2024 for an acute osteomyelitis (infection) of the right hand. The facility's policy titled Infusion Therapy Medication Administration with a revised date of 8/2014 showed Purpose: To provide for the safe, accurate, and effective administration of parenteral medications directly into the vascular system. The facility's policy titled Physician's Orders with a revision date of 06/2023 showed Policy: All medications will be administered as ordered by a health care professional. The facility's policy titled Medication Administration with a revision date of 05/2023 showed Procedures .Document medication taken, or refused by resident, including time and resident response to medication.

Based on interview and record review the facility failed to ensure ostomy care was provided in a manner to prevent skin irritation. This applies to 1 of 2 residents (R1) reviewed for ostomies in the sample of 7. The findings include: R1's face sheet shows he is a [AGE] year-old male admitted to the facility on [DATE]. R1's diagnoses include end stage renal failure, dependence of renal dialysis, acute respiratory failure with hypoxia, orthostatic hypotension, ileostomy status, gout, pain in right foot and primary osteoarthritis in right foot and ankle. On 5/22/24 at 12:02 PM, V5 (RN) stated R1's ostomy would leak often, his appliance would have to be changed two to three times a shift. Sometimes we would use tape to reinforce it to the skin. There was skin irritation around R1's stoma site. R1 would report burning around the site. On 5/22/24 at 1:04 PM, V16 (Licensed Practical Nurse-LPN) stated R1's ostomy was leaking a lot, sometimes we would have to change it two to three times a shift. R1 report burning around the stoma area. We would use wipes around the stoma and sometimes apply the skin prep. On 5/22/24 at 1:27 PM, V17 (Certified Nursing Assistant-CNA) stated R1's ostomy would leak all the time, from the bottom of the appliance. Stool was leaking on his skin. R1's skin was raw he would say it was burning from the fecal matter. The nurse knew about the skin irritation. On 5/23/24 at 9:27 AM, V21 (RN-Registered Nurse) said R1's ostomy leaked quite often. R1 reported burning when it leaked. There was some irritation around the stoma site. I did not report to the wound nurse. On 5/23/24 at 9:41 AM, V20 (RN) stated R1's ostomy would leak, the appliance would have to be changed two to three times a shift because it was not adhering to the skin. There was skin irritation around the stoma. On 5/22/24 at 11:23 AM, V9 (Wound Nurse) stated nursing should notify me if there is any skin issues for residents who have ostomies. Ostomies should be changed as needed. You don't want to keep ripping them off because it could cause irritation to the skin. Most of the skin issues are from the ostomy leaking, because there is not a good seal to the skin. She saw R1's ostomy and at the time it was not leaking. I would expect nursing to notify me if the appliance continued to not adhere to skin so I could take a look at it and recommend treatment. On 5/22/24 at 2:46 PM, V2 (DON) stated she knew there was some issues with R1's ileostomy leaking at the time V9 was notified, but it was not leaking. Standard of care includes documentation of the skin around the stoma site and report any skin irritation. There should be ostomy orders and care for each resident with an ostomy. Nursing should notify the wound nurse if there is skin breakdown around the stoma site. V2 confirmed R1 did not have ostomy care orders. R1's nurses note dated 4/20/24 documents R1's ileostomy bag was leaking. R1's nurses note dated 4/25/24 documents excoriation skin around the bottom of the stoma site. R1's nurses note dated 4/25/24 documents ostomy leaking. R1's Physician Progress note dated 5/1/24 documents R1 has been having problems with leaking from the ileostomy as well as skin issues around his site .he should have his ostomy cut so that minimal skin is exposed. R1's Physician Orders, Medication/Treatment Orders dated May 2025 does not include ostomy care orders. R1's current care plan shows R1 has an ostomy with interventions include to monitor stoma color for any changes, provide ostomy care per protocol. The facility's Colostomy-Ileostomy Care revised 2023 states, wash around the colostomy site with appropriate skin cleansing preparation, evaluate resident skin noting, apply barrier cream, apply paste if needed, replace clean or new drainage bag, ensure bag is adhered to the skin .document in nursing noted any skin issued and condition of stoma, report these issues to physician, ostomy appliances are changed weekly and PRN as standard of care .

Based on interview and record review the facility failed to ensure a CPAP machine (continuous positive airway pressure machine) was operated as ordered by the physician for 1 of 3 residents (R1) reviewed for CPAP machines in the sample of 3. The findings include: R1's face sheet printed on 11/2/23 showed an admitted [DATE] and diagnoses including but not limited to atherosclerosis of left leg arteries, right side paralysis, heart disease, diabetes mellitus, aphasia (difficulty speaking), and need for assistance with personal care. R1's facility assessment dated [DATE] showed severe cognitive impairment and the use of a CPAP machine. R1's admission progress note dated 10/25/23 stated the physician was notified of the new admit, diagnoses of recent left femoral popliteal bypass surgery, left great toe ulcer, staples to surgical incision to left lower leg, and left groin incision. The note showed orders for lab work to be done in the morning. R1's order summary report showed an order start dated 10/25/23 for: Administer CPAP at night every night shift. R1's medication administration record showed the order was performed as ordered by the night nurse (V6). On 11/1/23 at 3:20 PM, V3 (R1's daughter) stated she arrived at the facility in the afternoon on 10/26 (day after admission). V3 said she noticed R1's CPAP machine on the nightstand and a large jug of fluid next to it. The jug was labeled as hemodialysis fluid (solution used to filter the blood during kidney treatments). V3 said it should have been distilled water. V3 said she opened the CPAP reservoir chamber, and it had an unusual odor similar to vinegar. The chamber had a strange, thick residue inside of it. V3 said she notified a floor nurse (V4) who came to the room and saw the jug. V3 said R1's physician was in the facility, and V4 went to notify him of the situation. On 11/2/23 at 10:15 AM, V4 (Wound Care Nurse) stated she was approached by V3 in the hallway sometime in the afternoon on 10/26 and told there was something not right with R1's CPAP machine. V4 said she looked at the machine with V3. It was half filled with a liquid and there were crystals near the top of the reservoir. V4 said a jug was next to it with a purple label and it was hemodialysis solution. V4 said she immediately notified R1's physician. On 11/2/23 at 10:32 AM, V5 (R1's physician) stated he was notified by V4 in the afternoon on 10/26 that hemodialysis fluid had been administered to R1 in the CPAP machine. V5 said he had been with R1 earlier in the day for the initial assessment and was familiar with him. V5 said he reassessed R1 after learning of the mistake with the breathing machine. R1's vital signs and oxygen saturation levels were baseline with earlier in the day, but he looked uncomfortable. V5 said the lab work from that morning showed elevated white blood cells which could be due to the recent surgery. V5 said he could not be sure if the dialysis solution was or was not a contributing factor to the lab results. V5 said he had never seen a dialysis solution inhaled before and was uncertain of the result. V5 said he researched it and found a potential side effect was pulmonary irritation. V5 said R1 was not a dialysis patient and there was no reason the jug should have even been in the room. V5 said it is never appropriate for a dialysis solution to be used in a CPAP machine. Distilled water is the normal standard of care. V5 said he ordered R1 to be sent immediately to the local emergency room for further evaluation. On 11/2/23 at 11:10 AM, V6 (Licensed Practical Nurse) stated she was R1's nurse the night of 10/26/23. V6 said she went to the central supply room to get supplies for his CPAP machine. V6 said she picked up a jug of fluid she thought was distilled water. V6 said she dashed in and out of the room. V6 said she typically sees dialysis fluid in a bag, and she did not bother to read the label on the jug. V6 said she filled R1's CPAP machine with the solution sometime between 9 and 11 PM and he wore the mask all night. V6 said he was still asleep and wearing the mask when her shift ended around 7:30 AM. The facility's CPAP/BiPAP Respiratory Care policy review dated May 2023 states under the use of humidifier section: Physician may order use of humidifier during CPAP or bi-level therapy to reduce nasal congestion as humidifier adds moisture to air delivered by unit. Use only distilled water in humidifier (reservoir). R1's progress noted dated 10/26/23 at 5:05 PM stated R1 was taken to the local emergency room by paramedics, report given to emergency room nurse that dialysis solution (Naturalyte) 1.K-2.5 CA (potassium and calcium solution) was put in the CPAP machine overnight and was inhaled by guest, with breathing discomfort. R1's emergency room notes dated 10/26/23 showed R1 presented with suspected use of dialysis fluid in his CPAP machine last night, discussed with poison control, repeat x-ray in the morning, monitoring for signs of acidosis, not wheezing, no respiratory complaints, vital signs are stable, elevated procalcitonin, negative lactate, elevated white count which is increasing as well, could be stress reactive and postoperative but is climbing, well-appearing and nontoxic, CT is stable, labs otherwise stable, given antibiotic coverage with cultures pending, daughter does not want him to go back to nursing facility after mishap last night, awaiting bed assignment. R1's progress noted dated 10/26/23 at 10:15 PM stated R1 was admitted to the local hospital for leukocytosis (elevated white blood cells), lethargy, low sodium level, and exposure to chemical inhalation.

Based on interview and record review the facility failed to follow their policy for assessment of a resident's surgical wounds and failed to follow physician orders for wound/incision care. This applies to 1 of 3 residents (R2) reviewed for wounds in the sample of 7. The findings include: The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE], and was discharged to the local hospital on April 10, 2023. R2 did not return to the facility. R2 had multiple diagnoses including, malignancy of the vulva, [NAME] Syndrome (autoimmune disease), hypogammaglobulinemia (low antibody levels), diabetes, rheumatoid arthritis, polyneuropathy, muscle weakness, unsteadiness on feet, restless legs syndrome, and depression. R2's MDS (Minimum Data Set) dated April 10, 2023, shows R2 was cognitively intact, was able to eat with supervision, required limited assistance with walking, locomotion and personal hygiene, and extensive assistance with bed mobility, transfers between surfaces and toilet use. R2 was occasionally incontinent of bowel and bladder. R2's MDS continues to show R2 had surgical wounds present on admission requiring surgical wound care, and no other skin breakdown. The facility's admission Nursing Evaluation dated April 5, 2023, at 4:50 PM shows: Skin Integrity: Groin: Surgical incision to peri/groin area. Wound edges well approximated with no drainage. JP (Jackson Pratt) drain to right inner thigh. Other: Bruising to right lower abdomen. The facility does not have any further documentation to show the location of R2's surgical wounds/incisions. Furthermore, the facility does not have any documentation of the length, width, and depth measurements, direction, and length of any tunneling and undermining, the appearance of the wound base, any drainage amount or characteristics, or appearance of the wound edges. R2's hospital After Visit Summary dated April 5, 2023, at 12:47 PM shows: When to call your doctor: Temperature > (greater than) 100.4 (degrees Fahrenheit), vulvar/vaginal bleeding that soaks a sanitary napkin every 2-4 hours, yellow (pus-like), green or odorous discharge from vaginal or from the sutures . Additional instructions (daily weights, wound care): You have sutures over your vulva area that will dissolve in about 4-6 weeks. The sutures may open a little so do not be alarmed. If the incision opens, please call. You have small dissolvable sutures with glue over the right and left groin area. Do not scrub the glue off the glue. The glue will gradually crumble off with normal bathing. 1. Please keep your incisions clean and dry. Please check the incisions lines with a mirror a few times a day to ensure it's dry. You should let soapy water run over groin incisions and vulvar area, then thoroughly rinse and pat dry. The vulvar area gets moist and are places that infection can occur so please keep clean and dry. Some women use a hair dryer on cool setting holding it a foot away to get dry. Please check the incisions especially in the fold areas a few times a day to ensure it's dry. 2. Please use peri-bottle or spray bottle to clean the vulvar area after each urination or bowel movement. You can use one peri-bottle for soapy water to clean area and another peri-bottle with warm water to rinse area. Then pat dry with soft towel. You can use a hair dryer on cool to keep area dry. 3. Keep ice pack on vulva to decrease swelling. Please ice at least 2-3 times a day leaving on about 30 minutes or until ice has melted. 4. For right and left groin incisions: You have small incisions where the lymph nodes have been removed. The incisions will dissolve. You have glue over the incisions that will gradually crumble off with normal bathing. Do not scrub off the glue. You can let the soapy water run over this area, rinse thoroughly and then pat dry. The EMR shows the following order for R2 dated April 5, 2023: Use peri bottle for soapy water to clean vulvar area and another peri bottle with warm water to rinse are. Pat dry with soft towel after each urination or bowel movement. The facility does not have documentation to show R2's wounds were cleaned as ordered by the physician, with soapy water after each urination or bowel movement. The facility does not have documentation to show R2's incisions were assessed for drainage, or that the incisions were assessed several times a day to ensure the incisions were kept dry. The facility also does not have documentation to show an ice pack was applied to R2's vulva area two to three times a day to reduce swelling in the vulva area, as shown on the hospital discharge instructions. The EMR shows the facility did not initiate physician orders for monitoring the bilateral lower extremity and vulva surgical sites until April 8, 2023, three days after R2 was admitted to the facility. On October 19, 2023, at 1:58 PM, V1 (Administrator) said, We did not have a wound care nurse at the time of [R2's] admission. The admitting nurse did some of the wound assessment. I can show documentation that CNAs (Certified Nursing Assistants) were doing incontinence care, but I do not have documentation to show the physician's order was followed for cleaning with soap and water after each urination, bowel movement, or incontinence episode. Facility documentation shows R2 was assessed one time by V9 (Attending Physician) from April 5, 2023, to April 10, 2023. On April 6, 2023, at 10:21 AM, V9 (Attending Physician) documented, Chief Complaint: Paget's disease of the vulva. This is a [AGE] year-old female . who presented to outside hospital with chief complaint of persistent extramammary Paget's disease of the vulva. Patient is s/p (Status Post) full simple vulvectomy with complex closure per plastic surgery . Wound care evals are ongoing as appropriate . Skin: Please see nursing note for full skin exam . V9's (Attending Physician) documentation does not show he assessed R2's surgical wounds, including the vulva incisions, during his examination. Facility documentation shows R2 was assessed by V13 (Infectious Disease NP-Nurse Practitioner) on April 6, 2023, and April 10, 2023. V13's documentation does not show R2's vulva incisions were assessed by V13. On October 19, 2023, at 3:08 PM, V13 (Infectious Disease NP) said she did not assess R2's vulva incisions on April 6, 2023 or April 10, 2023. V13 continued to say, On April 10, 2023, I documented there was improvement, but I was only referring to the bilateral thigh areas of redness. The EMR shows V18 (LPN-Licensed Practical Nurse) documented the following on April 10, 2023, at 9:15 AM: As per patient, she does not feel well, and would like to transfer to [local] hospital which is part of the health system her surgeon is affiliated with. Nurse called provider, made aware with new orders to transfer to [local] hospital On October 19, 2023, at 11:42 AM, V9 (Attending Physician) said, It would be my expectation that the facility staff clean the incisions as ordered and they should have done an assessment of all incisions daily. There is no way to say if the care was ever done if the staff did not document it. They should have documented what the wounds looked like and followed their policy. There should have been more nursing documentation about those three incisions. I saw the resident one time, and I did not assess her incisions, including the vulva area during that visit on April 6, 2023. The facility's policy entitled Wound Policy and Procedure dated March 2020 and revised/reviewed 05/2023 shows: Policy: .Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically the goal is one of promoting healing and preventing infection unless a resident's preferences and medical condition necessitate palliative care as the primary focus . Procedure: Admission Wound Assessment and Management: At the time of admission, the discharge records from the prior facility are reviewed for information relating to wounds or alteration in skin integrity. Staging from another facility is not adopted for use in the facility. Any wounds assessed will be captured in the [EMR software] nursing evaluation, in progress notes or by completing [wound round documentation] (within 2-6 hours of admission). The admission wound assessment should include at a minimum: Interview of resident or family about history of skin alterations, skin alterations present on admission, .recent surgical procedure . Comprehensive assessment of any wound to include: Location of wound, length, width, and depth measurements recorded in centimeters, direction and length of tunneling an undermining, appearance of the wound base, type and percentage of tissue in wound, drainage amount and characteristics including color, consistency, and odor, appearance of wound edges, description of the peri-wound condition or evaluation of the skin adjacent to the wound, presence or absence of new epithelium or wound rim.Orders are verified or obtained as needed, assessments and interventions implemented are documented in the clinical record. The facility's policy continues to show ongoing wound assessment should take place weekly or more frequently. The facility's ongoing assessments should include comprehensive wound assessments, wound complications including infection, and progress towards healing. The facility's policy entitled Post-Surgical Site Monitoring dated March 2020 and revised/reviewed May 2023 shows: Policy/Procedure: 1. Upon admission or readmission, a skin assessment will be completed by licensed nursing staff to identify the presence of any skin alterations, including but not limited to post-surgical incisions. 2. Incisional care will be provided as ordered by the provider. 3. Abnormal assessment findings, including but not limited to: surgical dehiscence, signs or symptoms of infection, increased pain at surgical site, decreased range of motion etc. will be reported to the provider.

Based on observation, interview and record review, the facility failed to serve pureed and mechanical soft diet consistencies to residents with diet orders for the same. This applies to 5 of 5 residents (R1, R7, R11, R27, R99) reviewed for dining in the sample of 17. The findings include: On August 22, 2023 at 11:42 AM, V5 (Cook) was observed preparing pureed meals in the facility kitchen. V5 stated that he is pureeing the lunch meal consisting of Greek marinated chicken and green beans for 2 residents (R1 and R11) based on production sheet. V5 stated that he is serving cream of rice instead of pureeing the rice. During the pureeing process, V5 added three pieces of chicken (about 4 oz each piece) into a blender with minimal amount of broth and pureed the same. The final product appeared granular with uneven texture. V5 put two 4 oz scoops of cooked green beans into another blender and pureed the same with minimal broth and thickener. The final product had small pieces of green beans that were not able to be mashed in between the fingers. Prior to transferring into service bowls, V4 (Dietary Manager) was notified and V4 agreed that these items needed to be pureed more. On August 22, 2023 at 11:55 AM, during meal service in the facility kitchen, V5 (Cook) was noted to serve R7, R27 and R99 a mixture of white rice and wild rice. R7, R27 and R99 diet tickets showed mechanical soft, chopped [meat] consistency. The wild rice had hard pieces of rice grains with outer skins intact. V5 stated that the herbed rice did not come in and therefore he substituted it with the wild rice mixture. On August 22, 2023 at 11:57 AM, V3 (Dietitian) stated that the pureed consistency should be more like baby food with the consistency like apple sauce or mashed potato. V3 stated that she will look into the policy for mechanical soft and report back whether wild rice is allowed. V3 brought back an undated policy titled Dental Soft (Mechanical Soft) which included as follows: This consistency diet is for individuals with limited or difficulty in chewing regular textured food. Generally, the diet consists of food of nearly regular textures but eliminates very hard, sticky, crunchy or hard to chew foods. On testing the wild rice pieces, V3 agreed that the consistency was hard. V3 added that anytime a meal item is substituted, a form should be filled out and approval obtained from Dietitian for the substitute item. Policy titled Puree Diet (effective date 1/17/2016) included as follows: Policy: This diet may be used to help provide adequate nutrition to guests with swallowing problems, guest who have problems with chewing due to refusal or pain or guests who are transitioning back to solids following the removal of feeding tube. Procedure: The regular menu is followed and served in smooth puree with no lumps or whole particles. Recipe for both Pureed Greek Marinated Chicken and Pureed Green Beans showed to add gradual amount of liquid or thickener to achieve a smooth, pudding or soft mashed potato consistency. Facility Diet Type Report printed on August 21, 2023 showed that R1 and R11 were on pureed diets and R7, R27 and R99 were on mechanical soft, chopped diets. Policy titled Making Menu Substitutions (taken from Dining Service Menu guide, 2022) included as follows: Please be aware that making changes on your menu, whether just one-time substitution or a permanent menu change, requires approval from your consultant Dietitian. A log of substitutions must be kept on file, including what food item(s) was/were substituted, the date, reason for the substitution(s) and what new food item(s) was/were served.

Based on observation and interview, the facility failed to provide a bed that could comfortably accommodate a resident. This applies to 1 of 1 resident (R19) reviewed for accommodation of needs in the sample of 17. The findings include: R19's EMR (Electronic Medical Records) included that R19 was recently admitted on [DATE] and discharged to the hospital on August 15, 2023 and subsequently readmitted on [DATE]. R19's face sheet included diagnoses of malignant neoplasm of upper lobe, right bronchus or lung, secondary malignant neoplasm of brain, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease,difficulty in walking, not elsewhere classified, cognitive communication deficit, pain in right ankle and joints of right foot, spinal stenosis, cervical region, cervicalgia. R19's Admission MDS (Minimum Data Set) dated August 9, 2023 showed that R19 was moderately impaired in cognition and required extensive assistance of one person for bed mobility and transfers. R19's height recorded on admission August 3, 2023 in the weight and vitals section showed 73.0 inches. R19's care plan intervention dated August 3, 2023 included to anticipate and meet the resident's needs. On August 21, 2023 at 10:57 AM, R19 was resting in his bed with his legs placed sideways with feet extended out of bed. When asked, R19 stated that the bed was not big enough. V6 (R19's wife), who was present in the room, stated that R19 is 6 feet 1 inch in height and that the bed is too short for him. V6 stated that she requested for a longer bed right away on admission. V6 added He was here almost two weeks last time and when I asked for it they never did give it. On August 22, 2023 at 12:48 PM, R19 was sitting up in bed eating lunch with legs folded underneath him. R19 appeared uncomfortable in that position and shook his head when asked if he was able to straighten his legs. R19's wife was at bedside and stated They haven't done anything about the bed. This information was relayed to V1 (Administrator) who stated that she will look into it. On August 23, 2023 at 12:03 PM, on further enquiry, V1 (Administrator) stated that the facility does have extended beds and she will relay this information to maintenance.