Every finding on record at Timber Ridge Health and Rehabilitation

Based on observation, staff interview, and record review, the facility did not ensure food was stored and served in a safe and sanitary manner. This practice had the potential to affect 44 of 44 residents residing in the facility. Staff did not store food in a manner to ensure food safety, including proper labeling and dating practices. Staff did not accurately test parts per million (PPM) of the sanitizing solution or accurately complete testing logs. Kitchen equipment and food services areas were not in clean and condition. Staff did not follow safe food cooling protocols. Staff did not appropriately test and maintain dishwasher temperatures. In addition, staff engaged in an unsanitary dishwashing process. Staff did not wear hair restraints consistently throughout the kitchen. Staff did not complete appropriate hand hygiene.Findings include: On 5/4/26 at 9:08 AM, Surveyor and [NAME] (CK)-G began an initial kitchen tour and were joined by Kitchen Manager (KM)-F. On 5/5/26 Nursing Home Administrator (NHA)-A indicated the facility follows the Food and Drug Administration (FDA) Food Code. Food Labeling/Storage: The 2022 FDA Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food (TCS), Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 Celsius (C) (41 Fahrenheit (F)) or less for a maximum of 7 days. The day of preparation shall be counted as day 1. The 2022 FDA Food Code documents at 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food (TCS), Disposition: (A) A food specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). The facility's Date Marking for Food Safety policy, dated 3/1/26, indicates: .2. Food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening, the day/date the item must be consumed or discarded .6. The head cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. The dietary manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly . During the initial kitchen tour with KM-F and CK-G that began at 9:08 AM on 5/4/26, Surveyor observed numerous food storage concerns including the following examples: Dry Storage:~ An open bag of penne pasta that was not sealed shut and did not contain open or use-by dates.~ A unlabeled bulk container of bread crumbs (per KM-F) with no open or use-by dates. Surveyor and KM-F observed a scoop in the container.~ An unlabeled gallon container of an unidentified substance with no open or use-by dates. KM-F initially indicated the substance was salt, but then thought it was seasoning. KM-F stated the container had been on the counter as long as KM-F could remember. ~ Three unlabeled containers of oats (per KM-F) with no open or use-by dates. Surveyor and KM-F observed a metal scoop in one of the containers.~ Two unlabeled containers of white flour (per KM-F). Surveyor and KM-F observed a plastic scoop in one of the containers. Coolers:~ An open package of 30 jumbo hotdogs in a pan. Neither the pan or package were sealed and the hotdogs were left open to air. There were no open or use-by dates.~ A container of pina y narajas (pineapple and oranges) with a use-by date of 5/2/26.~ An unlabeled container of watermelon (per KM-F) with a use-by date of 4/27/26. The watermelon was dark red and floating in bubbly liquid. The pieces appeared grainy and mushy. ~ An unlabeled package of mushrooms (per KM-F) with no open or use-by dates.~ A bowl of macaroni salad with a use-by date of 4/29/26. Freezers:~ A container of marinara covered in ice crystals with no use-by date. KM-F indicated the marinara was past its use-by date.~ An unlabeled and unsealed bag of ciabatta bread (per KM-F) with no open or use-by dates.~ An unlabeled bag of pepperoni (per KM-F) with no open or use-by dates. During the initial kitcen tour that began at 9:08 AM on 5/4/26, Surveyor interviewed KM-F who indicated all food products should be sealed, labeled, and dated with open, made, and/or use-by dates. KM-F stated food that is past the use-by date should be discarded. KM-F did not know the use-by dates of many of the items. KM-F confirmed KM-F had food storage guidance sheets but thought the sheets were inaccurate and the use-by dates were not right. KM-F was not aware scoops should not be left in bulk food items. KM-F knew food should be sealed but stated the kitchen did not have enough containers. KM-F stated KM-F would order more containers when the budget allowed. On 5/5/26, Surveyor noted unit/kitchenette refrigerators were missing temperatures on the temperature logs. Sanitizing Solution: The 2022 FDA Food Code documents at 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization-Temperature, pH, Concentration, and Hardness: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the Environmental Protection Agency (EPA)-registered label use instructions. The 2022 FDA Food Code documents at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. The Ecolab Oasis 146 Multi-Quat Sanitizer data sheet indicates the sanitizing solution should be tested for effectiveness by measuring the PPM dilution range. Hydrion Quat test strips are the appropriate test strips. The sanitizing solution temperature should be tested and be within 65 to 75 degrees F. The effective PPM range is 150-400. The facility's Dietary Department Policy and Procedure (Sanitization) policy, dated 3/1/26, indicates: .4. Sanitizing of environmental surfaces must be performed using FDA appropriate Quat sanitizer . The facility's Dietary Department Policy and Procedure (Dishwashing and Manual Washing) policy, dated 3/1/26, indicates: .3. Sanitize with a chemical sanitizing solution of Quat for 1 minute. Parts per million (PPM) will be tested while water temperature reads between 65 and 75 and will have a PPM of 200-400 (pull a sample of water to cool down to desired temperature) .4. Temperatures of all three sinks should be recorded on a designated log as well as PPM test strip . During the initial kitchen tour that began at 9:08 AM on 5/4/26, Surveyor observed a container of Ecolab Oasis 146 Multi-Quat Sanitizer in the kitchen and an Ecolab Oasis 146 Multi-Quat Sanitizer data sheet posted above the three-compartment sink. Surveyor observed Hydrion sanitizer test strips above the sink. The dishwashing machine temperature and sanitizing solution testing logs were posted to the right of the sink. The log was filled out three times daily from 5/1/26 through 5/3/26 with the Quat sanitizer PPM and staffs' initials. There were missing entries for breakfast and lunch on 5/4/26 and 5/5/26. Surveyor noted there was no space on the log to record the temperature of the sanitizing solution. Surveyor noted every PPM entry was 400. On 5/4/26 at 10:13 AM, Surveyor asked KM-F to test the sanitizing solution. KM-F filled a bucket with sanitizer from the sink dispenser. KM-F dipped a test strip into the solution for 10 seconds and compared the strip to the color legend on the back of the test strip container. KM-F indicated the PPM was 400 or 500. KM-F was not aware of temperature testing requirements to ensure the effectiveness of the sanitizing solution. KM-F temped the sanitizing solution which was 80.4 degrees F. KM-F was not aware the temperature was outside the temperature range. KM-F did not document the temperature on the testing log. Cleanliness: The 2022 FDA Food Code documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. The 2022 FDA Food Code documents at 4-602.12 Cooking and Baking Equipment: (A) Food-contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. The 2022 FDA Food Code documents at 4-602.13 Nonfood-Contact Surfaces: Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The facility's Dietary Department Policy and Procedure (Sanitization) policy, dated 3/1/26, indicates: The food service area will be maintained in a clean and sanitary manner. 1. Kitchen, kitchen areas, and dining areas will be clean, free of litter/debris, and protected from vermin/insects. 2. All utensils, counters, shelves, and equipment shall be kept clean and maintained in good condition. All equipment, food contact surfaces, and utensils shall be washed, rinsed, and sanitized .4. Sanitizing of environmental surfaces must be performed using FDA appropriate Quat sanitizer .14. The food service manager will be responsible for scheduling dietary staff for regular cleaning of kitchen and dining areas. Food service staff will maintain cleanliness throughout their work areas throughout the day. The facility's Sanitation Inspection policy, revised 3/1/26, indicates: 1. All food service areas shall be kept clean, sanitary, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements. 3. The sanitation program will provide for inspections to be conducted of the food service areas. 4. Sanitation inspections will be conducted in the following manner: a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily. b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations. During the initial kitchen tour that began at 9:08 AM on 5/4/26, Surveyor and KM-F observed the following: ~ Stovetop burners were caked with food and debris that coated the burner surfaces and ran down the sides of the stove.~ Four 3 level carts used to transport food and clean dishes contained food and debris on each shelf.~ Food prep areas contained debris on the counters and shelves.~ The kitchen floor contained stains, dirt, spilled food/drinks, and food wrappers, including bread bag tags, and plastic bags.~ The toaster was covered with toast crumbs. The metal bottom of the toaster was not visible due to debris. ~ Metal grate shelves with clean food storage containers contained unidentified particles and debris. On 5/4/26 at 10:18 AM, Surveyor interviewed KM-F who verified the kitchen should be kept clean. Surveyor and KM-F observed the posted cleaning logs. The daily cleaning logs contained 24 daily cleaning assignments; all were marked as completed. There was an opening checklist of to do and cleaning items with 19 tasks; all were marked as completed. Examples of the tasks listed as completed included: ~ Toaster cleaned~ Range: burners, drip tray, backdrop~ Tables and shelves organized/cleaned~ Back prep area floor sweep/mop~ [NAME] and server line floor sweep/mop~ All work surfaces cleaned and sanitized~ Cleaning assignments from prior day completed and reviewed KM-F verified the items marked as completed were not completed. KM-F was unsure when the range/stovetop was last cleaned. KM-F indicated the toaster looked terrible and had not been cleaned that day. On 5/5/26 at 7:42 AM, Surveyor entered the kitchen and noted all 43 tasks on the kitchen cleaning log and opening checklist were marked as completed by CK-G. Surveyor noted food, dirt, grime, and debris were still on the range/stovetop, carts, the floor, and shelves, and the kitchen was in the same condition as the day prior aside from the toaster which had been cleaned. On 5/5/26 at 9:01 AM, Surveyor interviewed CK-G about the cleaning items marked completed by 7:42 AM. CK-G verified CK-G had not completed any of the tasks that day and had not completed them when CK-G signed off on all 43 tasks on 5/4/26. CK-G did not know why CK-G marked the tasks as completed. CK-G then stated CK-G cleaned the microwave that morning. CK-G did not know when the stovetop/range was last cleaned and verified the kitchen did not look clean. Food Cooling Temperatures: The 2022 FDA Food Code documents at 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less. The 2022 FDA Food Code documents at section 3-501.15 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. The facility's Dietary Department Policy and Procedure (Rapid Cooling of Foods), dated 3/1/26, indicates: Potentially hazardous foods should be cooled rapidly. Proper cooling of hot foods to a safe temperature minimizes the growth of microorganisms that may result in food contamination. 1. Rapid cooling is defined as cooling from 135 F to 70 F within two hours and then to a temperature of 40 F or below within the next four hours. The total cooling time between 135 F and 40 F is not to exceed six hours. During the initial kitchen tour that began at 9:08 AM on 5/4/26, Surveyor and KM-F observed a food cooling log posted in the kitchen. The log contained 23 food items for cooling. Seven of the items had not been cooled to 40 degrees or less. Examples of final logged temperatures included: ~ Ham - 50 ~ Soup - 109 ~ Chili - 66 ~ [NAME] - 64 ~ Sausage - 145 Surveyor interviewed KM-F who indicated food should be cooled to 40 degrees. KM-F indicated staff should document the food cooling progress on the log all the way through to 40 degrees or less. Dishwasher Temperatures: The 2022 FDA Food Code documents at 4-302.13 Temperature Measuring Devices, Manual Warewashing: Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 71 C (160 F). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine the surface temperatures of utensils are reaching 71 C (160 F). The regular use of irreversible registering temperature indicators provides a simple method to verify the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 71 C (160 F). The 2022 FDA Food Code documents at 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures: The temperature of hot water delivered from a warewasher sanitizing rinse manifold must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multi-use utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning. The surface temperature must reach at least 160 degrees F as measured by an irreversible registering temperature measuring device to affect sanitization. When the sanitizing rinse temperature exceeds 194 degrees F at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. The lower temperature limits of 165 degrees F for a stationary rack, single temperature machine, and 180 degrees F for other machines are based on the sanitizing rinse contact time required to achieve the 160 degree F utensil surface temperature.The 2022 FDA Food Code documents at 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing (B): In hot water mechanical warewashing operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the utensil surface temperature. The facility's Dishwasher Temperature policy, revised 3/1/26, indicates: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. 1. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. 2. Manufacture's instructions shall be followed for machine washing and sanitizing. For high temperature dishwashers (heat sanitization): a. The wash temperature shall be 150-165 F .b. The final rinse temperature shall be 180 F or above but not to exceed 194 F .6. Water temperatures shall be measured and recorded prior to each meal . The facility's Dietary Department Policy and Procedure (Dishwashing and Manual Washing) policy, dated 3/1/26, indicates: .2. Wash solution must maintain a temperature of 150 F or higher. 3. Rinse cycle temperature must maintain a rinse temperature of 180-194 F. 4. Dietary staff operating the dishwashing machine will check temperatures using the machine gauge with each washing cycle and will record the results in the facility's Dishwashing Temperature Log before breakfast, after lunch, and after dinner. Temperatures not meeting the appropriate temperature/range should be reported to the supervisor and corrected immediately. 5. The operator will check temperature calibration of the gauge and record results daily by using a temperature test strip following manufacturer's instructions. 6. Should hot water temperatures not meet appropriate guidelines, shutdown the machine (notify supervisor) until the temperatures or parts per million (PPM) are adjusted . On 5/4/26 at 10:13 AM, Surveyor interviewed KM-F who indicated machine temperatures run low on the dish machine gauges. KM-F stated KM-F doesn't use a temperature testing puck because it comes out low and is probably not correct because the plates come out hot. Surveyor observed signs on the dishwashing machine that indicated the wash temperature should be 155 F and the rinse temperature should be higher than 180 F. Surveyor observed the following dishwashing temperatures: ~ On 5/4/26 at 9:47 AM - Wash: 146 F, Rinse: 172 F ~ On 5/5/26 at 8:41 AM - Wash: 146 F, Rinse: 186 F~ On 5/5/26 at 8:52 AM - Wash: 142 F, Rinse: 186 F~ On 5/5/26 at 8:55 AM - Wash: 142 F, Rinse: 184 F~ On 5/5/26 at 8:56 AM - Wash: 140 F, Rinse: 186 F On 5/5/26 at 8:56 AM, Surveyor and CK-G observed CK-H run a temperature testing puck through the dishwasher which indicated the maximum temperature reached was 147 F. On 5/5/26 at 8:56 AM, Surveyor interviewed CK-G who observed the testing puck and indicated the puck usually runs low with a maximum temperature of 149, 150, or 153 degrees. CK-G did not know what the dishwashing temperature should be and indicated temperatures have been that low for a while. CK-G did not know how correct temperatures on the dishwashing log were achieved. On 5/5/26 at 9:07 AM, Surveyor interviewed CK-H who read the dishwashing temperatures of 155 F for the wash cycle and 180 F for the rinse cycle to Surveyor. CK-H indicated CK-H isn't supposed to do anything if the dishwasher doesn't reach the designated temperatures and stated there is no point in telling anyone. CK-H indicated management is aware the machine has not reached the required temperatures for several weeks because a repairman was at the facility 2 to 3 weeks ago to replace a part but the machine still doesn't work. CK-G indicated the repairman stated the machine isn't properly ventilated so it won't reach the appropriate temperatures. CK-H stated a second repairman serviced the machine but the temperatures are still consistently low. CK-H reported the low temperatures to management and KM-F. On 5/5/26, Surveyor observed the dishwashing temperature logs and noted missing entries for breakfast and lunch on 5/4/26 and 5/5/26. Entries on the log for 5/1/26 to 5/3/26 indicated the following temperatures: 150, 152, 153, 149, 153, 150, 153, 154, and 152 degrees F. The May 2026 temperature log contained the following rinse temperatures: 170, 174, 176, 170, 172, 171, 171, 173, and 170 degrees F. Unsanitary Dishwashing: The 2022 FDA Food Code documents at 2-301.14 When to Wash: Food employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles, and: .(E) After handling soiled equipment or utensils; .(H) Before putting on gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. The facility's Dishwasher Temperature policy, revised 3/1/26, indicates: .a. Hands are to be washed before and after running the dishwashing machine. Food service workers will also wash hands between placing dirty dishes on racks and taking clean dishes off rack as well as change aprons . On 5/4/26 at 9:11 AM, Surveyor observed CK-H load dirty dishes into a rack, push the rack into the dishwasher, and go to the clean dishes side. CK-H wore an apron but not gloves. CK-H did not cleanse hands or remove the soiled apron before putting away clean dishes. On 5/5/26 at 8:44 AM, Surveyor interviewed CK-H while CK-H did dishes with CK-G. CK-H stated dishes should be washed with two staff so one can stay on the clean side and one on the dirty side. CK-H stated if there is only one staff, the staff should cleanse hands before touching clean dishes. CK-H verified CK-H had not done so the day prior. Hair Nets: The 2022 FDA Food Code documents at 2-402.11 Hair Restraints: Effectiveness: (A) Except as provided in (B) of this section, Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens, and unwrapped single-service and single-use articles. The facility's Food Safety Requirements policy, revised 2/1/26, indicates: .Food will also be stored, prepared, distributed, and served in accordance with professional standards for food safety .7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects .d. Dietary staff must wear hair restraints to prevent hair from contacting food . On 5/4/26 at 9:11 AM, Surveyor observed CK-H wash dishes and work throughout the kitchen. CK-H wore a hairnet but not a beard restraint. CK-H had a full face beard over one inch in length and longer in front of the chin. On 5/4/26 at 9:47 AM, Surveyor observed KM-F with a beard restraint and a baseball hat that did not cover KM-F's hair. Approximately 3 inches of unrestrained hair was visible out the back and sides of the hat. Surveyor observed KM-F in the freezer, coolers, and kitchen prep areas on multiple occasions. On 5/5/26 beginning at 7:42 AM, Surveyor observed CK-H prep food and drinks in the kitchen for breakfast tray delivery without a beard restraint. On 5/5/26 at 9:06 AM, Surveyor observed Housekeeper (HK)-I walk though the kitchen to the dish area. HK-I did not wear a hairnet. On 5/5/26 at 9:06 AM, Surveyor interviewed HK-I who didn't know KH-I needed to wear a hairnet in the kitchen and was not told HK-I needed to wear one. On 5/5/26 at 11:53 AM, Surveyor observed CK-H prep food and drinks in the kitchen for lunch service without a beard restraint. Surveyor observed CK-H in multiple areas of the kitchen throughout the day without a beard restraint. On 5/5/26 at 12:11 PM Surveyor observed KM-F cook hamburgers on the flat top grill in a baseball hat with inches of unrestrained hair out the back and sides of the hat. Surveyor observed KM-F walk through the kitchen and prep area with unrestrained hair on multiple occasions. Hand Hygiene: The 2022 FDA Food Code documents at 2-301.14: Food Employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles. The 2022 FDA Food Code documents at 3-301.11 Preventing Contamination from Hands: (A) Food Employees shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, Food Employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. The facility's Handwashing Guidelines for Dietary Employees policy, revised 3/1/26, indicates: Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses .6. Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation .in the following situations: .h. Before donning gloves for working with food . On 5/5/26 at 11:53 AM, Surveyor observed CK-G serve lunch while wearing gloves. At 12:06 AM, Surveyor observed CK-G change gloves to change tasks. CK-G did not cleanse hands between glove changes. Surveyor also observed CK-G change gloves without cleansing hands while serving food at 12:27 PM and 12:41 PM. On 5/5/26 at 12:19 PM, Surveyor observed KM-F tell kitchen staff they needed to review policies for education. Surveyor observed the following policies on the counter for staff to read and sign: ~ Food Safety Requirements~ Sanitation Inspection~ Dishwasher Temperatures~ Date Marking for Food Service On 5/6/26 at 12:11 PM, Surveyor interviewed Registered Dietician (RD)-E who indicated kitchen staff should be aware of and follow all policies related to food preparation, storage, safety, cleanliness, and serving. On 5/6/26 at 12:27 PM, Surveyor interviewed KM-F who indicated cooked and opened food should be clearly marked with the name of the food, the date it was made or opened, and the use-by date. KM-F indicated staff should clean food storage areas and remove out-of-date foods. KM-F indicated nursing staff are responsible for maintaining temperature logs for unit kitchenette refrigerators/freezers. KM-F wasn't aware the sanitizing solution needs to be at a certain temperature to test for efficacy and verified the testing log did not include the temperature of the sanitizing solution. KM-F verified staff aren't cleaning the kitchen as indicated on the daily cleaning checklist and deep cleaning list and indicated it may be due to staff burnout. KM-F stated the state of the kitchen is embarrassing and verified staff should not sign the daily cleaning log for tasks that aren't completed. KM-F verified cooked food should be cooled to 40 degrees or below. KM-F stated staff should put food in shallow pans and/or in ice baths to cool and should document cooling temperatures until the food reaches a temperature of 40 degrees or below. KM-F thought the facility had a high temperature dishwashing machine but stated KM-F was told by NHA-A it was a low temperature chemical sanitizing machine and the low temperatures were fine. KM-F was aware information on the dishwashing machine indicated the temperature should reach a minimum of 155 for the wash cycle and 180 for the rinse cycle and reported the low temperatures to NHA-A. KM-F stated it is an old machine and two repairman have been there to address low temperatures in the past two months. KM-F stated one of the repairmen indicated the machine is faulty because it isn't properly ventilated. KM-F stated the temperature testing puck does not work and shows lower temperatures than the dishwashing machine gauges. KM-F verified KM-F did not order a new testing puck. KM-F confirmed staff should remove aprons and wash hands prior to touching clean dishes when moving from dirty dishes to clean dishes. KM-F stated every person who enters the kitchen needs to wear a hairnet and beard restraint (if applicable). KM-F stated KM-F put a box of hairnets by the kitchen entrance so staff can put one on prior to entering the kitchen. KM-F verified KM-F should have worn a hairnet to cover the hair coming out of KM-F's hat. KM-F also confirmed CK-G should have cleansed hands between glove changes. On 5/6/26 at 3:29 PM, Surveyor interviewed NHA-A who indicated kitchen staff should be aware of and follow policies related to food preparation, storage, safety, cleanliness, and serving. NHA-A stated NHA-A was told the dishwashing machine was a chemical sanitizing machine. After Surveyor indicated information on the dish machine indicated the wash temperature should reach 155 and the rinse temperature should reach 180 , NHA-A confirmed the dishwashing machine is a high temperature machine. NHA-A confirmed the dishwashing machine needs to be fixed or replaced because of the consistently low temperatures.

Based on observation, staff interview, and record review, the facility did not ensure meals were served at a safe and appetizing temperature and prepared in a way to conserve nutritive value. This practice had the potential to affect more than 4 of the 44 residents residing in the facility. Staff did not follow a recipe when preparing pureed food in order to conserve/ensure the nutritive value of the food. Staff did not appropriately temp meals served to residents. Food was served outside the designated temperature range. Findings include: The facility's Puree Food Preparation policy, revised 3/1/26, indicates: It is the policy of this facility to provide pureed food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance .1. Each resident must receive and the facility must provide food that is prepared by methods that conserve nutritive value, flavor, and appearance .5. Do not use water as an additive to prepare puree foods .6. Residents receiving pureed diets should always receive portions equivalent to those served on the regular or therapeutic diet .7. Pureed Food Preparation Guidelines per serving (more or less may be used depending on the consistency of the cooked food): Meats: add 1 teaspoon of beef broth or beef gravy; Poultry: add 1 teaspoon of chicken broth or chicken gravy; Fish: add 1 teaspoon mayonnaise; Noodles: add one teaspoon margarine; Vegetables (leaf, stem, or flower): add 2 teaspoons mashed potato flakes; Vegetables (root, tuber): add 1 teaspoon margarine . The publication All About Recipes, Part II from the College of Agriculture, Biotechnology and Natural Resources [NAME], A., and [NAME], S. 2021 indicates: It is important to follow a recipe to ensure accurate nutrition content, which is important for schools, hospitals, and nursing homes. Modifying a recipe by adding water lowers the nutritional quality of the food. Pureed Foods: On 5/5/26 at 11:42 AM, Surveyor observed [NAME] (CK)-G puree food in a food processor. CK-G stated CK-G was pureeing two servings of carrots with approximately 4 pumps of Simply Thick (a thickening agent). CK-G indicated two residents (R2 and R10) receive pureed food. Surveyor also observed CK-G puree seasoned ground beef with 4 pumps of Simply Thick. CK-G stated CK-G did not follow a recipe for the pureed carrots or seasoned ground beef. CK-G indicated the residents were having tacos (seasoned ground beef, cheese, lettuce, tomato, sour cream, and tortilla shell), refried beans, and carrots. Surveyor observed a container in the food prep area that CK-G stated contained two scoops of breadcrumbs and water mixed together for R2 and R10. CK-G stated CK-G did not measure the water or follow a recipe. CK-G indicated CK-G was giving R2 and R10 the breadcrumb mixture instead of a tortilla and stated residents on a pureed diet don't receive a taco; they receive meat and moistened breadcrumbs. When asked if that is what R2 and R10 wanted, CK-G was not sure. CK-G then put two plates of pureed meat and carrots into an unheated/cold oven. On 5/5/26 at 11:53 AM, Surveyor observed CK-G remove the plates of pureed food from the cold oven and use a whisk to place an undetermined amount of the breadcrumb mixture on each plate while leaving some in the dish. Surveyor noted R2 and R10 did not receive refried beans, a tortilla, or taco toppings, including cheese and sour cream. Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including dysphagia (difficulty swallowing) oropharyngeal phase, dementia with psychotic disturbance, anarthria (inability to speak) and dominant side paralysis after a stroke. R2 had an order for a regular diet, pureed texture, honey thick consistency. Surveyor was unable to interview R2. Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including dysphagia, quadriplegia, dementia, and Bell's palsy. R10 had an order for a no salt added diet, pureed texture, nectar thick consistency. Surveyor was unable to interview R10. On 5/6/25 at 11:51 AM, Surveyor observed CK-G serve lunch. CK-G had already pureed items for R2 and R10. CK-G stated the meal was turkey pot pie, carrots, and cranberries. CK-G stated CK-G pureed two servings of pot pie with 1 to 2 pumps of Simply Thick. CK-G also pureed 2 servings of carrots with 1 to 2 pumps of Simply Thick. CK-G was not sure the exact quantity of the items that were added. CK-G indicated CK-G did not follow a recipe. On 5/6/26 at 11:56 AM, Surveyor asked Kitchen Manager (KM)-F for pureed food recipes for the meals on 5/5/26 and 5/6/26. KM-F indicated KM-F doesn't have pureed food recipes. KM-F stated staff make the food and puree it with Simply Thick. When asked if R2 and R10's food should be made to the same consistency, KM-F indicated one should be nectar consistency and one should be honey consistency; however, K-F likes to make them mashed potato consistency. KM-F stated KM-F likes to double up on the thickening agent and use a liqid thickening agent (Simply Thick) as well as a couple scoops of a powdered thickening agent. KM-F showed Surveyor the powdered thickening agent and indicated the kitchen goes through thickening agents quickly because they are used often. On 5/6/26 at 12:02 PM, Surveyor asked CK-G why residents received carrots instead of brussel sprouts as indicated on the menu. CK-G stated CK-G didn't know. KM-F stated KM-F forgot the brussel sprouts. On 5/6/26 12:11 PM, Surveyor interviewed Registered Dietician (RD)-E who stated staff should follow a recipe to prepare pureed food. When asked if staff know where to find recipes, RD-E indicated staff do not have access to pureed food recipes which are located on the menu software. RD-E stated staff need to request the information from RD-E. RD-E verified staff should not use water to puree food as it has the potential to negatively impact the nutritional value. RD-E indicated staff should follow the menu. Residents on pureed diets should be offered the same food that's on the menu unless it's not a food that can be safely pureed. RD-E stated the issues have been on the facility's radar to fix. RD-E stated RD-E wants to ensure kitchen staff offer what is supposed to be offered so residents get the nutritional food they are supposed to receive. On 5/6/26 at 3:29 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated kitchen staff should be aware of and follow all policies related to food preparation and serving. Food Temperatures: Surveyor requested the facility's policy for food temperatures at serving and palatability and received the following: The facility's Dietary Department Policy and Procedures, dated 3/1/26, indicates: Food service employees shall prepare and serve food in a manner that complies with safe food handling practices .1. The danger zone temperatures that promote pathogenic microorganism growth that cause foodborne illness are between 41 ahrenheit (F) and 135 .7. Mechanically altered hot foods must stay above 135 during preparation . On 5/5/26 at 11:42 AM, Surveyor observed CK-H prepare hot and cold beverages. CK-H did not temp the beverages. Surveyor observed the facility's beverage temperature logs and noted missing entries, including one meal on 5/3/26, two meals on 5/4/26, and two meals on 5/5/26. On 5/5/26 at 11:53 AM, Surveyor observed CK-G plate food at the beginning of meal service. CK-G did not temp any food items on the steamtable. Surveyor reviewed the temperature log and noted there were no temperatures for the meal. On 5/5/26 beginning at 11:53 AM, Surveyor observed CK-G serve lunch. CK-G removed plates of pureed food for R2 and R10 from a cold oven. CK-G put the plates on trays and gave them to CK-H to put on the cart. CK-G did not temp the food on the plates. Before CK-H put the trays in the cart, Surveyor asked CK-G to temp the plates of pureed food. The taco meat on one plate was 82.4 and the carrots were 93.2 . CK-G did not temp the wet breadcrumb mixture and did not reheat the food to the appropriate serving temperature of 135 or higher. After temping the pureed food on one plate, CK-G put a cover on the plate and sent it back to CK-H who put the plate on the cart to be served. On 5/5/26 at 12:06 PM, CK-G verified CK-G did not take food temperatures and indicated CK-G would take food temperatures before the next meal. All of the food on the steamtable temped appropriately at 135 or higher except the hamburger patties (protein alternative) which temped at 122 . CK-G continued lunch service and served all the hamburger patties (even though they were not at a safe food temperature of 135 or higher). CK-G did not temp the grilled cheese sandwiches. Near the end of room tray service for the 300 wing, Surveyor requested a test tray. Surveyor noted room trays left the kitchen at 12:43 PM. KM-F stood next to CK-G while CK-G temped the items on the tray. KM-F did not provide assistance to CK-G when CK-G reported the temps to Surveyor. On 5/5/26 at 12:48 PM, Surveyor observed a family member exit a resident's room with coffee from a food tray that was just served on the 300 wing. The family member told staff the coffee wasn't hot and heated the coffee in the microwave. On 5/5/26 at 12:54 PM, Surveyor received a test tray and immediately took food temperatures which were as follows: ~ Soup - 127 degrees F~ Beans - 143.2 degrees F~ Taco - 147.2 degrees F~ Carrots - 137.2 degrees F~ Coffee - 112.2 degrees F~ Juice - 58.4 degrees F~ Milk - 55.4 degrees F Surveyor noted the soup, carrots, and coffee were not at a safe serving temperature of 135 . Surveyor noted the milk and juice were served above the safe serving temperature of 41 . On 5/6/26 at 12:11 PM, Surveyor interviewed RD-E who stated food and beverages coming from the kitchen should be served at the required temperature. RD-E confirmed pureed food should also be served at the appropriate temperature. RD-E verified kitchen staff should temp all food and drinks prior to service.On 5/6/26 at 12:27 PM, Surveyor interviewed KM-F who stated staff should know and temp every type and texture of food, including regular, ground, and pureed meat. KM-F stated drinks should be temped also. KM-F indicated staff should record the temperatures on the appropriate log.On 5/6/26 at 3:29 PM, Surveyor interviewed NHA-A who stated kitchen staff should be aware of and follow the facility's policies related to food temperatures.

Based on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 44 residents residing in the facility. R3 had open wounds on both feet and had an order for enhanced barrier precautions (EBP). R3's room entrance did not contain an EBP sign or other EBP protocol. R3's care plan did not indicate R3 was on EBP. R8 had open wounds on the buttocks. R8's room entrance did not contain an EBP sign or other EBP protocol. R8 did not have an order for EBP. R8's care plan did not indicate R8 was on EBP. R34 had a surgical wound and drain. R34's room entrance did not contain an EBP sign or other EBP protocol. R34 did not have an order for EBP. R34's care plan was not resident-specific for the surgical wound/drain and did not indicate R34 was on EBP. Staff carried soiled linens against their clothing and bare skin. Findings include: The facility's Enhanced Barrier Precautions policy, dated 2/1/26, indicates: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDROs). EBP refers to an infection control intervention designed to reduce the transmission of MDROs that employs targeted gown and glove use during high-contact resident care activities .1. a. All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions .c. The facility will have discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities .An order for EBP will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds .) and/or indwelling medical devices .even if the resident is not known to be infected or colonized with an MDRO .ii. Infection or colonization with a Centers for Disease Control and Prevention (CDC) targeted MDRO when contact precautions do not otherwise apply: .4. High-contact resident care activities include: a. Dressing; b. Bathing; c. Transferring; d. Providing hygiene; e. Changing linens; f. Changing briefs or assisting with toileting; g. Device care or use .h. Wound care; any skin opening requiring a dressing . 1. On 5/4/26, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including cellulitis of right lower limb, cellulitis of left lower limb, and type 2 diabetes. R3's Minimum Data Set (MDS) assessment, dated 4/16/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 had intact cognition. On 5/4/26 at 12:32 PM, Surveyor observed the entrance to R3's room which did not contain an EBP sign or a receptacle near the door for disposal of personal protective equipment (PPE). Surveyor observed a PPE cart in the hall near the room entrance that contained gloves and gowns. On 5/4/26 at 12:34 PM, Surveyor interviewed R3 who stated R3 had open wounds on both feet which required daily dressing changes. R3's medical record contained the following wound care orders: ~ Wound care to bilateral feet and right toes 1, 2, and 3: Carefully remove old dressing. Use clean water or wound cleanser. Moisten gauze with cleanser and cleanse the wound in a circular motion starting from the center of the wound and working toward the edge of the wound. Pat dry. Apply betadine-moistened gauze to all wounds, cover with an ABD, and secure with Kerlix. No compression. No ace wraps. Change twice daily. R3 had an order for EBP related to chronic wounds on R3's bilateral lower extremities. R3's care plan, dated 4/10/26, indicated R3 had an infection and wounds to both feet but did not indicate R3 was on EBP. On 5/5/26 at 4:33 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated all residents on EBP should have an EBP sign near their door, an EBP care plan, an order for EBP, and designated receptacles inside the room for PPE disposal. On 5/6/26 at 1:12 PM, Surveyor observed an EBP sign near R3's door but not a receptacle near the door for PPE disposal. 2. On 5/4/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including type two diabetes, diabetic retinopathy, fracture of right pubis, and fracture of multiple ribs. R8's MDS assessment, dated 4/16/26, had a BIMS score of 15 out of 15 which indicated R8 had intact cognition. On 5/4/26 at 1:37 PM, Surveyor observed the entrance to R8's room which did not contain an EBP sign, a receptacle near the door for PPE disposal, or a PPE cart. On 5/4/26 at 1:37 PM, Surveyor interviewed R8 who indicated R8 had open wounds on the buttocks which required dressing changes. R8 saw a physician for the wounds. R8 indicated staff wear gloves but not gowns during wound care. R8's medical record contained wound care orders for a pressure injury on R8's left and right buttocks. R8 did not have an order for EBP. R8's care plan did not indicate R8 was on EBP. On 5/6/26 at 1:34 PM, Surveyor observed the entrance to R8's room which did not contain and EBP sign, a receptacle near the door for PPE disposal, or a PPE cart. On 5/5/26 at 4:33 PM and 5/6/26 at 2:52 PM, Surveyor interviewed DON-B who indicated residents on EBP should have an EBP sign near their door, an EBP care plan, an order for EBP, and designated receptacles inside the room for PPE disposal. DON-B confirmed R8 had an open wound. DON-B stated R8's family asked that PPE receptacles near R8's room exit be removed because it was cluttered. DON-B indicated the receptacles needed to stay there otherwise there was no place for staff to remove PPE appropriately. 3. On 5/4/26, Surveyor reviewed R34's medical record. R34 was admitted to the facility on [DATE] and had diagnoses including morbid obesity and obstructive sleep apnea. R34's MDS assessment, dated 5/1/26, had a BIMS score of 13 out of 15 which indicated R34 had intact cognition. On 5/4/26 at 12:11 PM, Surveyor observed the entrance to R34's room which did not contain an EBP sign. There was a PPE cart near the door and other residents on EBP nearby. On 5/4/26 at 12:11 PM, Surveyor interviewed R34 and observed a drain with pink fluid that hung out the bottom of R34's shirt. R34 stated R34 had surgery and a wound with a surgical drain. R34 stated staff wear gloves to care for the wound and drain but do not wear gowns. R34's medical record did not contain an order for EBP. R34's care plan did not indicate R34 was on EBP and was not individualized related to the wound and drain from R34's surgical procedure. Sections of the care plan contained blank areas intended for staff to enter resident-specific information tailored to R34's needs. On 5/5/26 at 4:33 PM, Surveyor interviewed DON-B who indicated there should be an EBP sign near the entrance to R34's room. DON-B confirmed R34 should have an order for EBP. DON-B verified R34's care plan should indicate R34 is on EBP and should be individualized to R34's needs. DON-B stated night shift staff often update and individualize care plans, however, it's everyone's responsibility. On 5/6/26 at 1:14 PM, Surveyor interviewed Registered Nurse (RN)-K who indicated staff know a resident is on EBP because there is a sign outside the resident's room. RN-K verified EBP should be included on a resident's care plan. RN-K stated a resident on EBP should have receptacles inside their room designated for PPE disposal and should have an EBP order on their Medication Administration Record (MAR) or Treatment Administration Record (TAR). RN-K stated nurses should post EBP signs and ensure PPE carts and disposal receptacles are in place. On 5/6/26 at 2:28 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-J who stated CNA-J knows a resident is on EBP due to a sign outside the resident's door. CNA-J indicated EBP should be reflected on a resident's care plan. On 5/6/26 at 2:52 PM, Surveyor again interviewed DON-B who indicated residents with open wounds and/or MDROs should be on EBP. When Surveyor asked how staff know if a resident is on EBP, DON-B indicated an EBP sign is posted on or near the resident's door and the resident's care plan and Kardex will indicate the resident is on EBP. DON-B also stated there is a PPE cart outside the resident's door and receptacles near the exit of the room for PPE disposal. DON-B indicated the resident should have an order for EBP which is what staff use to set up the rest of the precautions. 4. On 5/6/26 at 2:46 PM, Surveyor observed Housekeeper (HK)-L exit a resident's room with an armful of soiled linens that were in contact with HK-L's clothing, bare forearms, and hands. HK-L put the soiled linens in a drop off room and returned to the resident's room. On 5/6/26 at 2:48 PM, Surveyor interviewed HK-L who stated HK-L was helping deep clean the resident's room. HK-L verified Surveyor's observation and indicated it was probably not an appropriate way to transport linens. On 5/6/26 at 3:29 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff should be aware of and use EBP. NHA-A indicated EBP should be included on a resident's care plan (if appropriate) which should be resident-specific. NHA-A also indicated staff should follow infection control practices with linens and resident cares.

Based on observation, staff and resident interview, and record review, the facility did not provide appropriate care and services to prevent urinary tract infections (UTIs) for 1 resident (R) (R1) of 4 sampled residents. R1 had urinary catheter valve also known as a Flip-Flo (R) that was not reflected in R1's plan of care. R1's care plan did not reflect R1's current care needs and R1's orders were not up to date. In addition, staff did not measure R1's urinary output and did not empy or clean R1's catheter bag. Findings include: The facility's Indwelling Catheter Use and Removal policy, dated 2/1/26, indicates: .Indwelling urinary catheters are catheters that remain in the bladder to assist with urinary elimination. The use of indwelling catheters for managing incontinence is not appropriate and increases the risk of urinary tract infections .1. The facility will conduct ongoing assessments for residents at risk for urinary catheterization and for residents with indwelling catheters .If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to: .Insertion, ongoing care, and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures .Appropriate indications for indwelling catheter use include: a. Acute urinary retention or bladder outlet obstruction; b. Need for accurate measurements of urinary output . Urinary Catheter Relias training indicates: .Many of the people you provide care for will have a urinary catheter. Unfortunately, urinary catheters often lead to infections and complications .Regular catheter care is important to prevent infection and other complications. Microbes, which cause infection, can enter the body through: .Portions of the equipment that touch a non-sterile surface, such as the floor .Follow your organization's policy on catheter care. Here are the steps to follow to provide basic catheter care: .11. Position and secure the drainage bag. The bed frame is a good place to hang the bag while the person is in bed. The drainage bag should be kept below the level of the person's bladder at all times. Do not place it on the floor. Once a bag touches the floor, it is contaminated. Place a bag cover over the bag to preserve the person's privacy . On 5/4/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including resistance to multiple antibiotics, retention of urine, and presence of urogenital implants. R1's Minimum Data Set (MDS) assessment, dated 4/10/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. On 5/4/26 at 1:24 PM, Surveyor observed the entrance to R1's room and noted an enhanced barrier precaution (EBP) sign. Surveyor also observed a cart with personal protective equipment (PPE) nearby. Surveyor observed two receptables inside the door of R1's room; one labeled linens and the other labeled garbage. A pile of folded cloths was on top of the linen receptacle. On 5/4/26 at 1:24 PM, Surveyor interviewed R1who stated R1 had a catheter with a plastic open and close attachment that R1 operated independently. R1 stated R1 went to the bathroom approximately every 2 hours and opened the valve to urinate. R1 stated R1 did all of R1's catheter care and staff did not assist. R1's medical indicated R1 had Foley catheter and contained the following orders: ~ Enhanced Barrier Precautions: PPE required for high-resident contact care activities. Indication: Foley catheter every shift for peripherally inserted central catheter (PICC) line with multidrug-resistant organism (MDRO) history (order date: 4/28/26) ~ Foley catheter: 16 French size, 10 milliliter (ml) balloon size. Diagnosis: urinary retention one time a day every 28 day(s) for chronic Foley for urinary retention (order date: 3/30/26) ~ Monitor Foley output every shift for (specify) Monitor output (order date: 4/22/26) ~ Change Foley catheter as needed (PRN) based on clinical indications of infection, obstruction, leakage, or if the closed system is compromised. PRN for Foley catheter (order date: 3/30/26) R1's Treatment Administration Record (TAR) for Foley output monitoring indicated staff recorded output on every shift of 250 ml to 2550 ml. An entry on the 5/1/26 PM shift indicated R1's output was 0 ml. R1's care plan did not contain information about R1's catheter, Flip Flo valve, catheter care, output monitoring, or EBP. R1's progress notes indicated R1's catheter was patent (clear, without kinks, flowing properly) and intact and catheter care was provided. A note on 4/30/26 at 9:54 PM indicated a catheter shunt was in place and R1 had been emptying on R1's own every 2 to 3 hours. R1 used a catheter bag at night. On 5/6/26 at 1:14 PM, Surveyor interviewed Registered Nurse (RN)-K who indicated R1 had a regular catheter. RN-K was not aware R1 had a Flip Flo valve and emptied R1's bladder during the day via the valve. RN-K stated R1 was probably wearing a regular catheter and emptying R1's Foley or leg bag. RN-K indicated a catheter and EBP should be reflected on a resident's care plan. When Surveyor asked if RN-K was familiar with R1's care plan, RN-K stated RN-K didn't know how to access a care plan. RN-K stated the facility switched to a new electronic documentation system approximately three months prior which is why things may be missing from R1's care plan. On 5/6/26 at 1:28 PM, Surveyor interviewed R1 who indicated R1 still had a Flip Flo valve and not a regular catheter. R1 stated staff had not assisted with the catheter since R1 had the Flip Flo installed during a urology appointment on 4/29/26. R1 stated staff had not emptied R1's catheter because R1 emptied it every 2 to 3 hours during the day and put on a catheter bag at night before bed. R1 stated R1 removes the Flip Flo device, rinses it with water, and lets it sit by the sink. In the morning, R1 drains the catheter bag and hangs it in the closet. Surveyor observed the bag in R1's closet which contained amber-colored urine in the bottom. R1 stated R1 had never cleaned the bag and sometimes urine remains in the bag. R1 stated staff do not clean the bag, change the bag, or measure R1's output. R1 also stated staff do not ask about R1's output at night or the Flip Flo valve during the day. On 5/6/26 at 1:45 PM, Surveyor informed RN-K that R1 emptied R1's catheter via a Flip Flo device. During the conversation, RN-K asked Certified Nursing Assistant (CNA)-M if R1 had a Flip Flo valve. CNA-M stated R1 no longer had a traditional catheter and used a spigot device. Surveyor asked CNA-M if staff helped clean the device or R1's catheter bag. CNA-M indicated staff previously cared for R1's traditional catheter by measuring output and completing catheter care, cleaning, and disinfecting; however, R1 does it on R1's own now. On 5/6/26 at 2:36 PM, CNA-M approached Surveyor and indicated CNA-M contacted R1 and R1's spouse to teach them how to clean the Flip Flo device and catheter bag. CNA-M stated R1 and R1's spouse were not aware they could use vinegar to clean and disinfect the Flip Flo and catheter bag. CNA-M was not aware R1 wasn't cleaning the catheter bag and was hanging it in the closet. When asked if cather care should be included in R1's plan of care, CNA-M indicated yes. On 5/6/26 at 3:03 PM, Surveyor discussed R1's Flip Flo valve with Director of Nursing (DON)-B who had not heard of the device and looked up the device on a computer. DON-B indicated R1 used to have a traditional catheter and DON-B was not aware it was changed to Flip Flo device. DON-B indicated catheter care and the Flip Flo device should be included in R1's care plan. DON-B indicated staff should clean and disinfect the catheter bag and Flip Flo device. DON-B didn't know how staff could chart the output for a Foley catheter when R1 didn't have a Foley catheter and emptied R1's bladder and catheter bag themself. DON-B also indicated EBP should be reflected on R1's care plan. On 5/6/26 at 3:05 PM, DON-B asked Assistant Director of Nursing (ADON)-N to join the conversation. ADON-N was also not aware R1 had a Flip Flo device and was doing R1's urinary cares, including emptying R1's bladder and cathether bag. ADON-N agreed the Flip Flo device and the care surrounding it should be on R1's care plan. ADON-N didn't know why staff documented R1's output when they were not providing catheter care.

Based on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 2 residents (R) (R16 and R34) of 2 sampled residents. R16 was on continuous oxygen. The nasal cannula and tubing for R16's room concentrator was not changed as ordered. R34 had sleep apnea and expressed the desire to use a continuous positive airway pressure (CPAP) machine. The facility did not obtain an order for the machine or assist R34 with using the machine. Findings include: The facility's Oxygen Concentrator policy, dated 2/2026, indicates: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators .5. Care of the Concentrator: .C. Nurse responsibilities: i. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. The facility's Oxygen Administration policy, revised 2/1/26, indicates: .4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. The type of oxygen delivery system. b. When to administer, such as continuous or intermittent and/or when to discontinue. c. Equipment setting for the prescribed flow rates. d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. e. Monitoring for complications associated with the use of oxygen .Types of delivery systems include: .d. CPAP mask - This mask is part of a system that allows a resident to receive continuous positive airway pressure CPAP), with or without an artificial airway. The system is comprised of a mask, tubing, and a machine that generates a constant flow of air pressure. Machines have different settings . 1. On 5/6/26, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] and had diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. R16's Minimum Data Set (MDS) assessment, dated 4/23/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R16 had intact cognition. R16's medical record indicated R16 was hospitalized from [DATE] through 3/17/26 for acute hypoxemic respiratory failure. R16 had an order to change R16's oxygen tubing every week and if soiled and store the tubing in a plastic bag when not in use (dated 5/6/26). On 5/6/26 at 9:35 AM, Surveyor observed R16 in a wheelchair with a nasal cannula and tubing (dated 5/6/26) connected to a portable oxygen tank set at 3 liters. R16's room concentrator was off and had a nasal cannula and tubing (dated 4/22/26) that was on R16's bed. On 5/6/26 at 9:35 AM, Surveyor interviewed R16 who indicated R16 would be on continuous oxygen for life after R16's most recent hospitalization. R16 indicated the tubing attached to the portable oxygen tank was changed that morning. R16 indicated R16 uses the room concentrator when in bed and the portable tank when in a wheelchair. On 5/6/26 at 10:33 AM, Surveyor interviewed Registered Nurse (RN)-D who confirmed R16's portable tank oxygen nasal cannula and tubing were changed that morning. RN-D verified the nasal cannula and tubing (dated 4/22/26) attached to R16's room concentrator should be changed at least weekly. On 5/6/26 at 10:40 AM, Surveyor interviewed Director of Nursing (DON)-B who verified oxygen tubing should be changed at least weekly. 2. On 5/6/26, Surveyor reviewed R34's medical record. R34 was admitted to the facility on [DATE] and had diagnoses including heart failure with ejection fraction, morbid obesity, and obstructive sleep apnea. R34's MDS assessment, dated 5/1/26, had a BIMS score of 13 out of 15 which indicated R34 had intact cognition. On 5/4/26 at 12:11 PM, Surveyor interviewed R34 and observed an unplugged CPAP machine on R34's bedside table. Parts of the machine were in a plastic bag. R34 indicated R34 would like to use the CPAP machine but staff won't put it on. R34 stated R34 used to use the CPAP machine at home every time R34 slept. R34 indicated staff say they cannot put the CPAP on R34 because they don't have the specifications for when to put it on. (Of note: R34's care plan and Kardex (an abbreviated care plan used by nursing staff) did not indicate R34 used a CPAP machine. In addition, R34 did not have an order for CPAP use.) On 5/5/26 at 4:23 PM, Surveyor interviewed DON-B who indicated the facility has a standing order for CPAP machines. DON-B stated if a resident is admitted with a CPAP machine, staff can use the standing order until they get a specific order. DON-B indicated if the resident hasn't received individualized orders prior to the respiratory therapist's monthly visit, DON-B ensures the respiratory therapist gets the settings in place. DON-B indicated there should be a physician order for CPAP use which should also be indicated on the resident's care plan. When Surveyor informed DON-B of R34's desire to use the CPAP machine, DON-B thought R34 had been refusing the CPAP machine. Surveyor and DON-B reviewed R34's progress notes which did not contain any documented refusals for CPAP use. On 5/5/26 at 4:36 PM, Surveyor noted R34's CPAP machine was not plugged in and some of the parts were in a plastic bag. Surveyor interviewed R34 who indicated staff had not offered to assist R34 with CPAP use. R34 indicated no one had approached R34 about setting up the machine or entering the operational settings. R34 indicated R34 had sleep apnea and wanted to use the machine. On 5/6/26 at 1:10 PM, Surveyor noted R34's CPAP machine was not plugged in and some of the parts were in a plastic bag. Surveyor interviewed R34 who indicated R34 still wanted to use machine. R34 indicated staff had not asked if R34 wanted to use the machine or offered to assist with set up. On 5/6/26 at 3:29 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated a resident's care needs should be care planned and a resident should receive therapy as ordered.

Based on observation, staff interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 resident (R) (R6) of 8 sampled residents. R6 had an order for acetaminophen. Staff attempted to administer the medication on 5/5/26 but R6 was unavailable. Staff returned the medication to a stock bottle of acetaminophen. Findings include:The facility's Medication Administration policy, dated 3/2026, indicates: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . On 5/5/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including compression fracture of T5/T6 vertebra. R6's Minimum Data Set (MDS) assessment, dated 4/29/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R6 had intact cognition. On 5/5/26 at 11:37 AM, Surveyor observed Nurse Tech (NT)-C obtain two 325 milligram (mg) tablets of acetaminophen from a stock bottle and put them in a medication cup for R6. NT-C attempted to administer the medication but R6 was unavailable. NT-C returned to the medication cart and poured the acetaminophen tablets back into the stock bottle. On 5/5/26 at 11:40 AM, Surveyor interviewed NT-C who indicated NT-C was told if a stock medication does not enter a resident's room, the medication can be returned to the original container. On 5/5/26 at 11:57 AM, Surveyor interviewed Registered Nurse (RN)-D who stated the facility's policy indicates medications that are undeliverable should be wasted so as not to create an opportunity for the medication to be returned to the wrong bottle. On 5/5/26 at 4:00 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated undeliverable medications should be wasted.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 29 residents residing in the facility. The cooler and dry storage area contained multiple open and undated items. In addition, one item was stored uncovered and open to air. Staff did not consistently document cooked food temperatures. Staff did not follow safe food cooling protocols. Findings include: During an initial kitchen tour that began at 9:10 AM on 2/10/25, Dietary Manager (DM)-G confirmed the facility employs contracted kitchen staff and follows the contracted company's procedures for food preparation and storage. The facility's contracted company's undated Food Storage Dry Goods policy indicates: All dry foods will be appropriately stored in accordance with the Federal Food and Drug Administration (FDA) Food Code .All packaged and canned food items will be kept clean, dry and properly sealed . The facility's contracted company's undated Food Storage Cold Foods policy indicates: All foods will be stored wrapped or in covered containers, labeled, dated, and arranged in a manner to prevent cross-contamination . Open/Undated Food Items: During an initial kitchen tour that began at 9:10 AM on 2/10/25, Surveyor observed the following undated items: Walk-in cooler: ~Two undated containers of hard-boiled eggs ~One undated container of oats ~One undated container of Cream of Wheat Dry storage area: ~One large open and undated bag of barley that was uncovered and left open to air ~An open and undated lemonade mix package that was not sealed and left open to air ~Two open, sealed, and undated lemonade mix packages. Reach-in cooler: ~An undated container of lemonade DM-G asked Surveyor to take the pitcher of lemonade out of the cooler so DM-G could dispose of it. DM-G stated DM-G was unsure when the lemonade was made. Cooked Food Temperatures: The facility's contracted company's undated Food Preparation policy indicates: All foods are prepared in accordance with the FDA Food Code .4. The Dining Services Director and cooks are responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees Fahrenheit (F) or less than 135 degrees F or per state regulation .Time/temperature control for safety (TCS) hot food items will be cooked to a minimum internal temperature for 15 seconds as follows: Poultry and stuffed foods 165 degrees F, ground meat 155 degrees F, fish, pork, or other meats 145 degrees F, and unpasteurized eggs 145 degrees F .TCS foods will be recorded at time of service and monitored periodically during meal service periods . On 2/11/25 at 7:37 AM, Surveyor reviewed the facility's cooked food temperature log and noted the following for February 2025: ~On 2/1/25, there were no cooked food temperatures documented for all three meals. ~On 2/2/25, there were no cooked food temperatures documented for breakfast or lunch. ~On 2/3/25, there were not cooked food temperatures documented for dinner. ~From 2/4/25 through 2/9/25, there were no cooked food temperatures documented for all three meals. DM-G confirmed to Surveyor that there were missing cooked food temperatures and indicated it was a constant battle with the cooks and staff. DM-G indicated on the days DM-G does the cooking, temperatures are always documented. Cooling Protocol: The facility's contracted company's undated Food Preparation policy indicates: All foods are prepared in accordance with the FDA Food Code .16. Prepared food items that are not intended for immediate service will be cooled using the following guidelines: Place in a shallow pans or cut/slice to promote cooling, time/temperature control for safety (TCS) foods will be cooled from 135 degrees F to 70 degrees F within 2 hours. TCS foods will be cooled from 70 degrees F to 41 degrees F within 4 hours. Total cooling time cannot exceed 6 hours. The clock starts at 135 degrees F. All TCS foods that are to be held for more than 24 hours at a temperature of 41 degrees F or less will be labeled and dated with a prepared day and use-by date . The facility's contracted company's undated Cooling Procedure indicates: 1. Use cooling logs to record the steps for cooling potentially hazardous foods . During an initial kitchen tour that began at 9:10 AM on 2/10/25, DM-G and Surveyor observed the following items in the walk-in cooler: ~One container of pureed gravy dated 2/9/25 ~One container of spaghetti sauce dated 2/8/25 ~One undated container of bacon and eggs ~One container of chicken breasts/patties dated 2/8/25 ~One undated container of oats ~One undated container of Cream of Wheat ~One container of ham salad dated 2/7/25 ~One container of turkey salad dated 2/7/25 On 2/11/25 at 7:37 AM, Surveyor interviewed DM-G who indicated the facility does not have cooling logs because staff are not supposed to save leftovers. DM-G indicated leftovers are now thrown away due to previous leftovers that did not contain dates and were not cooled via the facility's cooling process. DM-G indicated there should not be any leftovers in the cooler. During a continuous kitchen observation that began at 10:59 AM on 2/11/25, Surveyor observed the following items in the walk-in cooler: ~One container of rice dated 2/10/25 ~One container of baked beans dated 2/10/25 ~One container of beef gravy dated 2/10/25 ~One container of peas dated 2/10/25 DM-G verified Surveyor's observations and indicated the items should not have been saved from the previous day's meal and they were not documented on a cooling log.

Based on staff interview and record review, the facility did not ensure high-risk medications were monitored for 4 residents (R) (R11, R18, R19, and R26) of 5 residents reviewed for unnecessary medications. Staff did not monitor R11 for side effects or adverse reactions of pain medication. Staff did not monitor R18 for side effects or adverse reactions of anticonvulsant, pain, and diuretic medication. Staff did not monitor R19 or R26 for side effects or adverse reactions of pain and diuretic medication. Findings include: The Facility's Medication Utilization and Prescribing-Clinical Protocol (Policy), revised April 2018, indicates: 1. The staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medication to determine if the medication and doses are still relevant and are not causing undesired complications. 2. The staff and physician will monitor the progress of anyone with a probable adverse drug reaction and anyone for whom medications have been adjusted because of the possibility of an adverse drug reaction. 3. If the physician has stopped, tapered, or changed an existing medication, the staff will monitor for, document, and report any return of symptoms. The National Institutes of Health (NIH) National Library of Medicine, published 12/15/20, indicates: Medication Errors and Related Harm in High-Risk Situations .High Risk Mediations are drugs that are more likely to cause harm to a patient when they are used in error or taken inappropriately .These medicines require particular attention in the medication use process, mainly because of their potential toxicity, low therapeutic index, or high possibility of pharmacological interactions .Some Ways to Ensure Medication Safety in High-Risk Situations .the purpose of identifying a list of high-alert medications is to determine which drugs require special safeguards to reduce the risk of errors and minimize harm that can occur in different phases of the medication use process . According to Medlineplus.gov: Tramadol may cause side effects including, but not limited to: sleepiness, headache, nervousness, uncontrollable shaking of a part of the body, changes in mood, heartburn or indigestion, and dry mouth. According to Medlineplus.gov: Gabapentin may cause side effects including, but not limited to: drowsiness, weakness, dizziness, headache, uncontrollable shaking of a part of the body, double or blurred vision, anxiety, memory problems, strange or unusual thoughts, unwanted eye movements, nausea, vomiting, heartburn, diarrhea, dry mouth, constipation, increased appetite, weight gain, swelling of the hands/feet/ankles/lower legs, back or joint pain, fever, cough, sore throat, or flu-like symptoms, ear pain, red/itchy eyes, rash, itching, swelling of the face/throat/tongue/lips/eyes, difficulty swallowing, seizures, difficulty breathing, bluish-tinged skin/lips/fingernails and extreme sleepiness. According to Medlineplus.gov: Furosemide may cause side effects including, but not limited to: frequent urination, blurred vision, headache, constipation, diarrhea, fever, ringing in the ears, loss of hearing, rash, hives, blisters or peeling skin, itching, difficulty breathing or swallowing, and yellowing of the skin or eyes. According to Medlineplus.gov: Spironolactone may cause side effects including, but not limited to: vomiting, diarrhea, stomach pain or cramps, enlarged or painful breasts in men or women, vaginal bleeding in post-menopausal women, increased hair growth on parts of the body, drowsiness, restlessness, muscle weakness (pain/cramps), pain/burning/numbness/tingling of the hands or feet, inability to move arms or legs, changes in heartbeat, confusion, signs of dehydration (dry mouth, thirst, dizziness, unsteadiness, headache), unusual bleeding or bruising, lack of appetite, pain in the upper right part of the stomach, yellowing of the skin or eyes, flu-like symptoms, rash, hives, itching, difficulty swallowing or breathing, blood in stools, decreased urination, and fainting. According to Medlineplus.gov: Oxycodone may cause side effects including, but not limited to: dry mouth, stomach pain, drowsiness, flushing, headache, mood changes, changes in heartbeat, agitation, hallucinations, fever, sweating, confusion, shivering, severe muscle stiffness or twitching, loss of coordination, diarrhea, nausea, vomiting, loss of appetite, weakness, or dizziness, chest pain, rash, itching, difficulty breathing or swallowing, swelling of the face/mouth/tongue/lips/throat/hands/feet/ankles/lower legs, and seizures. According to Medlineplus.gov: Hydrocodone-Acetaminophen may cause side effects including, but not limited to: stomach pain, dry mouth, tiredness, headache, muscle tightening, ringing in the ears, difficulty falling asleep or staying asleep, uncontrollable shaking of a part of the body, increased sweating, agitation, hallucinations, fever, confusion, fast heartbeat, loss of coordination, diarrhea, nausea, vomiting, loss of appetite, weakness, dizziness, rash, difficulty breathing or swallowing; swelling of the face/mouth/tongue/throat/feet/legs/ankles, and difficult/frequent or painful urination. 1. On 2/11/25, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including end stage renal disease, dependence on dialysis, atrial fibrillation, congestive heart failure (CHF), type 2 diabetes, and anxiety. R11's medical record contained an order for: ~Tramadol HCI 50 milligrams (mg) one tablet every 6 hours as needed (PRN) for pain (dated 7/12/24). R11's medication order, medication administration record (MAR), and care plan did not contain monitoring for adverse reactions to the opioid medication. 2. On 2/11/25, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] and had diagnoses including cholecystitis, diabetes, anxiety, fracture of left clavicle, and sepsis. R18's medical record contained orders for: ~Gabapentin 100 mg two capsules (200 mg) three times daily for diabetic neuropathy (dated 12/13/24). ~Tramadol HCI 50 mg one tablet every 6 hours PRN for pain (dated 12/13/24). ~Furosemide (Lasix) 20 mg one tablet daily for edema (dated 12/13/24). ~Spironolactone 25 mg (0.5 tab/12.5 mg) daily for hypertension (dated 12/13/24). R18's medication orders, MAR, and care plan did not contain monitoring interventions for adverse reactions to the anticonvulsant, opioid, and diuretic medications. 3. On 2/11/25, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety, hypertension, generalized weakness, repeated falls, and heart failure. R19's medical record contained orders for: ~Furosemide 20 mg one tablet daily for hypertension (dated 10/15/24). ~Tramadol HCI 50 mg tablet three times daily (TID) PRN for pain (dated 11/6/24). ~Oxycodone HCI 5 mg .5 tablet (2.5 mg) every 4 hours PRN for acute pain (dated 10/15/24). R19's medication order, MAR, and care plan did not contain monitoring interventions for adverse reactions to the diuretic or opioid medications. 4. On 2/11/25, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes, atrial fibrillation, polyneuropathy, depression, long term insulin use, and CHF. R26's medical record contained orders for: ~Furosemide 40 mg one tablet daily for edema (dated 9/25/24). ~Oxycodone HCI 5 mg one tablet daily PRN prior to dressing change for acute pain (dated 9/20/24). ~Hydrocodone-acetaminophen 5/325 mg one tablet every 4 hours PRN for pain (dated 9/16/24). R26's medication orders, MAR, and care plan did not contain monitoring interventions for adverse reactions to the diuretic or opioid medications. On 2/12/25 at 8:29 AM and 12:11 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated monitoring interventions for medications are on a resident's MAR except diabetic monitoring which is on Certified Nursing Assistant (CNA) worksheets. DON-B indicated pain is monitored with routine/daily pain assessments, however, the facility does not routinely monitor for adverse reactions to opioid medication. DON-B indicated DON-B was not aware the facility should monitor for adverse reactions to opioid medication. DON-B also verified the facility missed diuretic monitoring.

Based on observation, staff interview, and record review, the facility did not ensure medications for 10 residents (R) (R8, R17, R9, R14, R15, R26, R16, R279, R23, and R12) of 29 residents in 1 of 2 medication carts were labeled or dated appropriately. In addition, the facility did not ensure expired medical supplies were removed from storage in 1 of 2 medication storage rooms. The North medication cart contained inhalers, eye drops, and an insulin pen that were not labeled or dated when opened. The North medication storage room contained several expired medical supplies. Findings include: The facility's Storage of Medications policy, dated 2001, indicates: .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The facility's Administering Medications policy, dated 2001, indicates: .9. The expiration/beyond use date on the medication label must be checked prior to administration. When opening a multi-dose container, the date opened shall be recorded on the container .14. Insulin pens will be clearly labeled with the resident's name or other identifying information. The facility's Insulin Administration policy, dated 2001, indicates: .4. Check expiration date .if opening a new vial, record expiration date and time on the vial (follow manufacturer's recommendation for expiration after opening). The facility's Administering Medictions Through a Metered Dose Inhaler policy indicates: .6. Check the label on the inhaler, confirm the medication name and dose with the resident's medication administration record (MAR) .7. Check the expiration date on the inhaler and return any expired medications to the pharmacy. Albuterol nebulizer solution instructions indicate: Storage conditions: Protect from light. Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within two weeks. Discard if the solution is not colorless. Lispro insulin pen manufacturer's instructions indicate: .Do not use after the expiration date. Unopened Humalog should be stored in a refrigerator (36 to 46 Fahrenheit (F) (2 to 8 Celsius (C)), but not in the freezer. Do not use Humalog if it has been frozen. In-use Humalog vials, cartridges, pens, and Humalog KwikPens should be stored at room temperature, below 86 F (30 C) and must be used within 28 days or be discarded, even if they still contain Humalog. Protect from direct heat and light. 1. On 2/11/25 at 8:09 AM, Licensed Practical Nurse (LPN)-C indicated to Surveyor when preparing to administer medication to R8 that R8's bottle of Flonase (nasal spray) was not properly labeled. LPN-C then wrote R8's name on the bottle for identification. 2. On 2/11/25 at 8:15 AM, Surveyor observed LPN-C administer medication to R17 including Artificial Tears (eye drops). Surveyor noted the bottle of Artificial Tears did not contain R17's name or an open date. On 2/11/25 8:19 AM, Surveyor interviewed LPN-C who confirmed there should be an open date and name on the bottle. 3. On 2/11/25 at 10:10 AM, Surveyor observed the North medication cart and noted the following: ~R9's Spiriva Respimat inhaler did not contain a name or open date. ~R14's Prednisone eye drops did not contain an open date. ~R15's liquid vitamin D did not contain an open date. ~R26's Lispro insulin pen did not contain an open date. 4. On 2/11/25 at 10:29 AM, Surveyor observed the North medication storage room and noted the following:. ~Two bloodborne pathogen protection kits with expiration dates of 10/2022 ~One bloodborne pathogen protection kit with an expiration date of 7/2024 ~One bottle of Purell hand sanitizer with an expiration date 5/2022 ~Two Bisacodyl suppositories with expiration dates of 12/2024 ~Duo-neb solutions for R16 and R26 with no open dates ~Albuterol nebulizer solutions for R17, R279, R23, and R12 with no open dates ~Two female urinary specimen kits with expiration dates of 11/1/24 ~Two Foley catheters with expiration dates of 2/28/24 ~Six Coude catheters 16 (French) with expiration dates of 11/28/24 ~One drainage leg bag with an expiration date of 7/29/23 ~Eighteen 3 milliliter (ml) syringes with expiration dates of 4/30/23 ~One box of contact layer dressing (10 total) with an expiration date of 9/2024 ~Two antifungal ointments with expiration dates of 9/2024 ~Two hand Sani-wipes with expiration dates of 11/2024 ~One Profore Lite multi-layer compression bandage system (kit of 4 rolls) with an expiration date of 12/1/24 ~One tube of Calazinc with an expiration date of October 2024 ~One container of Z-guard (zinc oxide paste) with an expiration date of 7/2024 ~Ten 30 gram insulin syringes with expiration dates of 10/31/22 ~Two purple top blood vials with expiration dates of 10/31/19 ~Twenty MaxPlus clean needless connectors with expiration dates of May/June 2024 ~One Care Fusion needless connector with an expiration date of 9/2022 ~Three Care Fusion Luer Lock caps with expiration dates of 3/20, 8/21, and 7/23 ~One replacement Luer Lock cap with an expiration date of 5/2017 ~One Luer Lock cap (female) with an expiration date of 1/2018 ~One COVID-19 reagent with an expiration date of 2/18/24 On 2/11/25 at 11:25 AM, Surveyor verified all expired items with LPN-C. On 2/11/25 at 1:30 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff typically label inhalers, eye drops, and insulin pens with the resident's name and an open date. DON-B also indicated there should not be expired items in the medication storage area.

Based on staff interview and record review, the facility did not notify the physician or court-appointed Guardian of a change in condition for 1 resident (R) (R8) of 1 sampled resident. R8 had a fall with a head injury on 1/14/25. R8's physician and court-appointed Guardian were not notified. Findings include: The facility's undated Fall Assessment Guidelines policy indicates: .12. Fall assessment to be documented in resident's chart. Family and Medical Doctor (MD) notifications as per facility policy . The facility's undated Reporting Head Injuries form indicates: All head injuries sustained by a resident will be reported to the primary care physician . From 2/10/25 to 2/12/25, Surveyor reviewed R8's medical record. R8 had diagnoses including adult failure to thrive, benign prostatic hyperplasia (BPH) without lower urinary tract symptoms, and mild cognitive impairment of uncertain origin. R8's Minimum Data Set (MDS) assessment, dated 11/27/24, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R8 had severely impaired cognition. R8 had a court-appointed Guardian for healthcare decisions. R8's medical record indicated R8 had a fall with a head injury on 1/14/25. R8's medical record did not contain a fall investigation, progress notes, or further information regarding the fall. Surveyor requested the fall investigation from Nursing Home Administrator (NHA)-A on 2/10/25. On 2/11/25, Surveyor reviewed a fall report for R8 that was dated 1/14/25. The fall report indicated R8 fell and hit R8's head on a garbage can under the sink while being assisted to the toilet by staff. R8 became weak and could not move R8's feet properly during the transfer. The fall investigation indicated R8 sustained a scrape to forehead with no further details. Surveyor noted R8's family representative was notified of the fall and injury, however, R8's court-appointed Guardian was not notified. The fall investigation did not indicate R8's physician was notified of the fall and head injury. On 2/12/25 at 10:53 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated there was no documentation that R8's court-appointed Guardian or physician were notified of the fall and injury. DON-B indicated R8's family representative was in the facility that day and was notified. DON-B indicated the physician was in the facility on the day of the fall and might have seen R8. DON-B reviewed R8's medical record and confirmed R8 was not seen by the physician that day.

Based on staff interview and record review, the facility did not report an allegation of abuse to the State Agency (SA) for 1 resident (R) (R2) of 1 sampled resident. On 12/13/24, R2 complained of arm pain during cares and indicated a staff was bruising R2. Staff discovered 2 round bruises on the back of R2's right arm and a reddened area on R2's right elbow. The facility did not report the potential allegation of abuse and injuries of unknown origin the SA in a timely manner. Findings include: The facility's undated Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy indicates: It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, mistreatment, exploitation, or misappropriation of property .Reporting and Response: It is the policy of this facility that abuse allegations .including injuries of unknown origin are reported per federal and state law .Injuries of unknown origin: An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident: The injury is suspicious because of the extent of the injury or the location or the number of injuries observed at one particular point in time or the incidence of injuries over time .The facility will ensure that all alleged violation involving abuse .are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including the State Survey Agency and Adult Protective Services where state law provide for jurisdiction in long term care facilities) . On 2/12/25, Surveyor reviewed a facility-reported incident (FRI) for a potential allegation of abuse and injuries of unknown origin that were reported to staff on 12/13/24. The facility's initial report was not submitted to the SA until 12/15/24. The FRI indicated R2 complained of arm pain during cares on 12/13/24 that included a transfer and repositioning. Staff noted 2 round bruises that measured .7 centimeters (cm) x .7 cm and a reddened area that measured 4 cm x 2 cm on R2's right elbow. R2 could not provide a consistent explanation of how the bruises occurred. R2 first stated to Registered Nurse (RN)-D, He is bruising me. RN-D interviewed R2 again later in the shift and R2 indicated R2 might have bumped R2's arm on the wheelchair tray. On 12/14/24, R2 indicated to several staff that R2 did not know where the bruises came from. R2 became upset when R2 was unable to remember what occurred. On 2/12/25, Surveyor reviewed R2's medical record. R2 had diagnoses including chronic obstructive pulmonary disease (COPD), ulcer of esophagus with bleeding, and history of falling. R2's Minimum Data set (MDS) assessment, dated 12/29/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R2 had moderate cognitive impairment. R2 was R2's own healthcare decision maker. On 2/12/25 at 8:35 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the incident was originally documented on a grievance form on 12/13/24 and an investigation was conducted through 12/14/24. NHA-A indicated NHA-A did not believe R2's statement was an allegation of abuse and conducted a grievance investigation for an injury of unknown origin. NHA-A indicated when NHA-A arrived at the facility on 12/15/24, NHA-A spoke to R2 and Director of Nursing (DON)-B and was confident that no abuse occurred. NHA-A indicated NHA-A and DON-B discussed R2's injuries of unknown origin and concluded the SA should be notified. NHA-A confirmed NHA-A was aware the initial report was not submitted timely and contacted the SA regarding why the report was submitted late. The facility did not complete abuse or reporting education following the incident.

Based on staff interview and record review, the facility did not ensure a potential allegation of abuse and injuries of unknown origin were thoroughly investigated for 1 resident (R) (R2) of 1 sampled resident. On 12/13/24, R2 complained of arm pain during cares and indicated a staff was bruising R2. Staff discovered 2 round bruises on the back of R2's right arm and a reddened area on R2's right elbow. The facility did not thoroughly investigate the potential allegation of abuse and injuries of unknown origin. Findings include: The facility's undated Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy indicates: .Injuries of unknown origin: An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident: The injury is suspicious because of the extent of the injury or the location or the number of injuries observed at one particular point in time or the incidence of injuries over time .Injuries of unknown origin must be immediately investigated to rule out abuse. Injuries may include but are not limited to, bruising of the inner thigh, chest, face and breast, bruises of an unusual size, multiple unexplained bruises, and/or bruising in an area not typically vulnerable to trauma .Protection: It is the policy of this facility that the resident will be protected from the alleged offender .Immediately upon receiving a report of alleged abuse, the Administrator or designee will coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable individual are of utmost priority. Safety, security. and support of the resident, their roommate if applicable, and other residents with the potential to be affected will be provided. This should include as appropriate: Procedures must be in place to provide the resident with a safe, protected environment during the investigation: .i. The alleged perpetrator will immediately be removed and the resident protected. Employees accused of alleged abuse will be immediately removed from the facility and will remain removed pending the results of a thorough investigation . On 2/12/25, Surveyor reviewed a facility-reported incident (FRI) regarding an incident involving R2 that occurred on the 12/13/24 PM shift. On 12/13/24, R2 complained of arm pain during cares that included a transfer and repositioning. Staff discovered 2 round bruises that measured .7 centimeters (cm) by .7 cm on the back of R2's right arm and a reddened area that measured 4 cm x 2 cm on R2's right elbow. The FRI indicated Certified Nursing Assistant (CNA)-E provided cares for R2 when R2 complained of right arm pain and bruising was noted. The FRI contained an interview with Registered Nurse (RN)-D who completed the initial assessment and interview with R2 which indicated R2 stated, He is bruising me. RN-D interviewed R2 again later in the shift and R2 indicated R2 might have bumped R2's arm on the wheelchair tray. R2 indicated to several staff on 12/14/24 that R2 did not know how the bruises occurred and became upset when R2 could not remember what occurred. A progress note documented by Social Worker (SW)-F indicated SW-F called R2's family representative and notified them of the bruising. Documentation indicated R2 said, he caused it and then stated R2 thought R2 bumped R2's elbow. Surveyor noted the facility did not thoroughly investigate the allegation of abuse or injuries of unknown origin or protect R2 and other residents from abuse during the investigation. Surveyor also noted staff education was not completed. From 2/10/25 to 2/12/25, Surveyor reviewed R2's medical record. R2 had diagnoses including chronic obstructive pulmonary disease (COPD), ulcer of esophagus with bleeding, and history of falling. R2's Minimum Data Set (MDS) assessment, dated 12/29/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R2 had moderate cognitive impairment. R2 was R2's healthcare decision maker. On 2/12/25 at 8:35 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated R2's injuries of unknown origin were documented on a grievance form on 12/13/24 and an investigation was conducted through 12/14/24. NHA-A indicated NHA-A did not believe there was an allegation of abuse or that R2's injuries of unknown origin were the result of abuse. NHA-A indicated when NHA-A arrived at the facility on 12/15/24, NHA-A spoke with R2 and Director of Nursing (DON)-B and was confident that no abuse occurred. NHA-A confirmed no staff members who cared for R2 on 12/13/24 were removed from resident care pending the results of the investigation. NHA-A verified R2 stated He is bruising me and CNA-E was the caregiver who provided care at the time of the incident. NHA-A indicated CNA-E handled the situation per the facility's policy and immediately notified RN-D to assess R2. NHA-A indicated due to those reasons and CNA-E's work ethic, NHA-A believed CNA-E would not intentionally cause injury to a resident and ruled out abuse as a cause of R2's injuries of unknown origin. NHA-A indicated despite the fact that CNA-E was an outstanding employee, CNA-E should have been placed on administrative leave or removed from resident care pending the results of the investigation. NHA-A also indicated education on the facility's abuse policy and procedure should be provided to all staff. NHA-A confirmed the facility's policy for abuse investigations should have been followed during the investigation.

Based on staff interview and record review, the facility did not ensure timely transmittal of Resident Assessment Information (RAI)/Minimum Data Set (MDS) information for 1 resident (R) (R279) of 15 sampled residents. The facility did not transmit an RAI/MDS assessment timely for R279. A Quarterly assessment due for R279 on 1/29/25 was not completed. Findings include: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019, states all Medicare and/or Medicaid-certified nursing homes must transmit required MDS records to the Centers for Medicare and Medicaid Services' (CMS') Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. Required MDS records include Admission, Quarterly, Annual, Discharge Assessments and Entry Tracking Records .Transmitted means electronically transmitting to the QIES ASAP System an MDS record that passes CMS' standard edits and is accepted into the system within 14 days of the assessment reference date (ARD) (last day of the resident assessment period) . On 2/12/25, Surveyor reviewed R279's medical record. R279 had diagnoses including unspecified dementia, urinary tract infection (UTI), fracture of left pubis, and retention of urine. R279's MDS assessment, dated 11/27/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R279 had intact cognition. R279 was R279's own healthcare decision maker. R279's medical record contained a Discharge RAI/MDS Assessment that was completed on 12/7/24 and an Annual RAI/MDS assessment that was completed on 11/27/24. Surveyor noted R279 was discharged to the hospital on 12/5/24 and readmitted to the facility on [DATE]. A Quarterly assessment had not been completed for R279. On 2/12/25 at 8:21 AM, Surveyor interviewed Director of Nursing (DON)-B who verified DON-B was responsible for completing RAI/MDS assessments and indicated R279 was due for a Quarterly assessment in January. DON-B was unsure how the assessment was missed and indicated reports are run continuously to ensure the timeliness of assessments. DON-B verified the assessment was not completed or transmitted.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R19 and R10) of 5 residents observed during the provision of cares. Staff did not ensure enhanced barrier precautions (EBP) were followed for R10 and transmission-based precautions (TBP) were followed for R19. Staff did not ensure medical equipment was sanitized in between resident use for R10. Findings include: The facility's Enhanced Barrier Precautions policy, dated 2001, indicates: .1. Enhanced barrier precautions (EBP)are used as an infection prevention and control intervention to reduce the transmission of multidrug-resistant organisms (MDROs) to residents. 2. EBP employ targeted gown and glove use in addition to standard precautions during high-contact resident care activities when contact precautions do not otherwise apply .5 EBP is indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization .b. Indwelling medical devices include .urinary catheters .9. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. The facility's Isolation-Initiating Transmission-Based Precautions policy, dated 2001, indicates: .2. Transmission-based precautions (TBP) are used when a resident meets the criteria for a transmissible infection and the resident has risk factors that increase the likelihood of transmission .3. When TBP is implemented, the Infection Preventionist: .d. Determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions . The facility's Isolation-Categories of Transmission-Based Precautions policy, dated 2021, indicates: .2. TBP are additional measures that protect staff, visitors, and others residents from becoming infected .Contact Precautions: 1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .7. Staff and visitors wear gloves when entering the room .8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room . The facility's Administering Medications policy, dated 2001, indicates: .22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable. 1. On 2/11/25 at 7:25 AM, Surveyor observed Licensed Practical Nurse (LPN)-C take R7's vital signs (blood pressure, pulse, and oxygen saturation level) and then listen to R7's lungs and bowel sounds with a stethoscope. LPN-C exited R7's room when finished but did not sanitize the equipment used. On 2/11/25 at 7:40 AM, Surveyor observed LPN-C enter R10's room to obtain vital signs. R10 was on EBP as indicated by a sign posted outside R10's door. LPN-C did not don a gown prior to entering R10's room. LPN-C obtained R10's vital signs and listened to R10's lungs. LPN-C then exited R10's room but did not sanitize the equipment used. LPN-C confirmed R10 was on EBP due to an indwelling catheter. On 2/11/25 at 7:48 AM, Surveyor observed LPN-C en route to obtain other resident's vital signs. Surveyor stopped LPN-C and asked if the vitals machine/equipment should be sanitized between residents. LPN-C stated, I guess maybe between each resident. When Surveyor asked about R10 who was on EBP, LPN-C confirmed R10 was on EBP and sanitized the equipment prior to entering the next resident's room. On 2/11/25 at 8:30 AM, Surveyor interviewed LPN-C who indicated personal protective equipment (PPE) should be worn for residents on EBP during catheter care, wound care, and personal cares. 2. On 2/11/25 at 7:35 AM, Surveyor observed LPN-C take medication into R19's room without donning PPE. A sign posted outside R19's door indicated R19 was on contact precautions. Previously (on 2/12/25 at 7:30 AM), LPN-C donned PPE when entering R19's room to take vital signs but did not don PPE when LPN-C returned with medication. On 2/11/25 at 1:30 PM, Surveyor interviewed Director of Nursing (DON)-B with Nursing Home Administrator (NHA)-A present. DON-B confirmed staff should wear a gown and gloves for personal cares, toileting, and bed changes for residents on EBP. When Surveyor asked the expectation for taking a full set of vital signs, DON-B indicated staff should use PPE related to the contact of the resident. DON-B also indicated staff should wear PPE when entering the rooms of residents on TBP.

Based on staff interview and record review, the facility did not ensure a physician and resident representative were notified timely of a change in condition for 1 resident (R) (R1) of 3 sampled residents. On 11/10/24, staff observed a suspected burn on R1's skin following use of a hot pack. Staff did not notify R1's Nurse Practitioner (NP) until 11/11/24 and did not notify R1's Power of Attorney for Healthcare (POAHC) until 11/14/24. Findings include: The facility's First Aid Treatment policy, with a revision date of 1/2024, indicates: .11. For residents who refuse treatment, the charge nurse and attending physician are notified. 12. Regardless of the nature or severity, any resident injury or illness is reported to the resident's attending physician and family, and documented in the resident's medical record. If the resident's attending physician is not available, follow the facility policy for Emergency Physician Care. On 12/3/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including acute and sub-acute endocarditis (infection of the inner heart lining and valves), end stage renal disease, dependence on dialysis, and discitis (infection of the spinal discs resulting in severe back pain and limited mobility). R1 had an activated POAHC who was responsible for R1's healthcare decisions. R1's Minimum Data Set (MDS) assessment, dated 10/17/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 did not have impaired cognition. R1's medical record indicated Licensed Practical Nurse (LPN)-C notified Director of Nursing (DON)-B via email on 11/10/24 at 6:42 AM that R1 had an ovular, raised, reddened burn on the lateral right hip after placement of a hot pack that was removed within two minutes. DON-B notified Nursing Home Administrator (NHA)-A via email on 11/10/24 of R1's skin alteration. NHA-A acknowledged receipt of the email on 11/10/24. DON-B notified R1's NP on 11/11/24 at 10:21 AM that R1 asked for a hot pack to be removed approximately five minutes after it was applied. R1 had what appeared to be two small blisters that were not fluid-filled. The nurse applied muscle rub to the same area less than an hour before applying the hot pack which may have contributed to the blisters. NHA-A notified R1's POAHC via email on 11/14/24 at 1:12 PM that R1 had a skin alteration described as a small, raised area after using a hot pack for less than two minutes. On 12/3/24 at 10:32 AM, Surveyor interviewed LPN-C who stated the raised, reddened blister-like area was discovered at approximately 6:15 AM by CNA-D and CNA-F who called LPN-C and LPN-E to observe the area. LPN-C notified DON-B and completed paperwork. LPN-C did not update R1's NP because LPN-C assumed LPN-E would follow-up since it was the end of LPN-C's shift. On 12/3/24 at 11:00 AM, Surveyor interviewed LPN-E who thought LPN-C had updated the appropriate people. On 12/3/24 at 2:14 PM, Surveyor interviewed DON-B who indicated typically the NP would be updated on the next rounding day unless it was urgent and required immediate attention. When Surveyor asked when R1's POAHC should have been notified, DON-B indicated the nurse who identified the concern should have followed through with notification. DON-B indicated the facility did not have documentation that staff education was completed for resident representative and provider notification and indicated staff were verbally updated.

Based on staff and resident interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R1) of 3 sampled residents. R1 developed skin redness with blisters (similar to second degree burn) following the use of a hot pack approximately 15 minutes after Licensed Practical Nurse (LPN)-C applied a topical analgesic (pain reducing) cream. Findings include: The facility's First Aid Treatment policy, with a revision date of 1/2024, indicates: .Goal is to provide first-aid intervention to injured residents .10. Residents and employees have the right to refuse first-aid treatment .11. For residents who refuse treatment, the charge nurse and attending physician are notified. The facility's Compress or Soak, Applying Warm policy, with a revision date of 11/2024, indicates: .If applying a reusable warm compress: 1. Follow instructions for heating reusable warm pack per manufacturer's instruction .check the skin under the application every five minutes .The following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed .4. The condition of the resident's skin .6. All assessment data obtained during the procedure .7. How the resident tolerated the procedure .8. If the resident refused the procedure, the reason(s) why and the intervention taken . On 12/3/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including endocarditis (infection of the inner heart lining and valves), end stage renal disease, dependence on dialysis, and discitis (infection of the spinal discs that can result in severe back pain and limited mobility). R1 had an activated Power of Attorney for Health Care (POAHC). R1's Minimum Data Set (MDS) assessment, dated 10/17/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 did not have impaired cognition. A progress note, written by LPN-C on 11/10/24 at 6:33 AM, indicated R1 used a hot pack and had a reddened, raised burn on the right hip. LPN-C placed a hot pack on R1's right lateral hip at approximately 12:00 AM due to R1's complaint of pain. LPN-C stated R1 felt the hot pack prior and had no concerns with the temperature. Shortly after the hot pack was applied, R1 indicated it was too hot and LPN-C removed it. On the 11/10/24 AM shift, Certified Nursing Assistant (CNA)-D and CNA-F discovered the reddened area and notified LPN-C and LPN-E. A progress note, written by LPN-E on 11/10/24 at 11:31 AM, indicated the reddened area was tender to touch and didn't bother R1 when in R1's chair. A progress note, written by LPN-H on 11/10/24 at 10:11 PM, indicated the reddened area did not appear raised, however, two blisters were noted. One blister was oval and measured 2 centimeters (cm). The other blister was round and measured 1 cm. There was also a pink/red area with a white center. R1 denied pain. LPN-H indicated LPN-H would contact the wound nurse. A progress note, written by LPN-C on 11/11/24 at 6:47 AM, indicated the 2 cm oval blister was intact and the skin was loose with no fluid present. The 1 cm round blister was pink and moveable with no fluid present. The third area was not related to the hot pack and appeared to be the start of a pressure injury. After LPN-C followed up with DON-B and the wound care nurse, LPN-C put metahoney (sic) (treatment used to promote healing of wounds) on the first blister. A progress note, dated 12/2/24 at 10:58 PM, indicated Registered Nurse (RN)-I completed a dressing change for an open blister on R1's right hip. A scab remained with no drainage or redness noted. On 12/3/24 at 10:32 AM, Surveyor interviewed LPN-C who indicated around 12:00 AM on 11/10/24, R1 complained of back pain, was in tears, and was concerned about an infection. R1 asked LPN-C to apply Muscle Rub (LPN-C could not remember the name of the product) to R1's right upper gluteal area. Approximately 10-15 minutes later, LPN-C gave R1 a hot pack. LPN-C indicated the hot pack was heated in the microwave for less than 2 minutes. After removing the hot pack from the microwave, LPN-C squeezed the hot pack to distribute the heat gel evenly. LPN-C put a cover on the hot pack, put the hot pack on LPN-C's wrist, and walked to R1's room. LPN-C put the hot pack on R1's right gluteal area and rolled R1 onto R1's back. R1 stated the hot pack was too hot. LPN-C repositioned the hot pack in the same area but R1 stated it was still too hot. LPN-C indicated the hot pack was in contact with R1's skin for a maximum of 2 minutes. LPN-C stated R1 requested the hot pack again for the same area between 1:30 and 2:00 AM. LPN-C reheated the hot pack for 30 seconds, put a cover on the hot pack, and returned to R1's room with the hot pack on LPN-C's wrist. When LPN-C put the hot pack on R1's gluteal area, R1 stated the hot pack did not feel good. LPN-C indicated the hot pack was covered and was put on top of R1's brief and gown. LPN-C left the hot pack on the bed within reach of R1 and indicated the hot pack was not touching R1 when LPN-C left the room. LPN-C verified LPN-C did not check R1's skin after removing the hot pack and indicated R1 did not inform LPN-C of any concerns during the night. A CNA checked on R1 between 4:00 and 5:00 AM and R1 did not report any concerns. At approximately 6:15 AM, CNA-D and CNA-F notified LPN-C and LPN-E of redness on R1's right upper gluteal area. LPN-C and LPN-E assessed but did not measure the area. LPN-C completed the required documentation and notified Director of Nursing (DON)-B. LPN-C did not provide care to the area because R1 did not complain of pain or discomfort. LPN-C indicated R1 was offered something cool to put on the site. R1 refused and stated R1 was fine. LPN-C did not update R1's Nurse Practitioner (NP) or complete any further follow-up because it was the end of LPN-C's shift and LPN-C assumed LPN-E would complete the follow-up. Surveyor reviewed R1's November 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) which indicated no topical cream or gel was administered. On 12/3/24, Surveyor observed a reusable hot/cold pack similar to what was used on R1. Instructions on the hot/cold pack indicated: Microwave Instructions for Hot Compress Use: 1. Place room temperature compress flat in microwave. Heat at full power for 45 seconds based on a 1200 [NAME] microwave .4. If additional heat is desired, reheat the compress for 10 seconds. Note: Let the compress return to room temperature before reheating. On 12/3/24 at 10:54 AM, Surveyor observed the microwave used to heat the hot pack and noted it was a 900 [NAME] microwave. On 12/3/24 at 11:00 AM, Surveyor interviewed LPN-E regarding R1's right gluteal area. LPN-E indicated after R1 stated the reddened area did not bother R1, LPN-E and LPN-C left R1's room. LPN-E stated R1 did not report any pain during the 11/10/24 AM shift. LPN-E visualized the area at 8:45 AM which was still pink, round, and slightly raised in the center. When Surveyor asked if LPN-E notified R1's NP, LPN-E indicated LPN-C completed the follow-up procedures and notified the appropriate people. On 12/3/4 at 12:43 PM, Surveyor interviewed R1 who stated R1 experienced back pain because R1's mattress sunk down while R1 was in bed. R1 stated LPN-C offered R1 a hot pack. R1 stated the hot pack felt cold but R1 decided to try it. LPN-C applied the hot pack and repositioned R1 who then fell asleep. R1 indicated LPN-C repositioned the hot pack approximately 10 to 15 minutes later and the hot pack remained there for the rest of the night. R1 stated the CNAs found the hot pack in the morning and stated, Guess we can take this out now. R1 stated the hot pack never felt hot. R1 denied asking LPN-C for Muscle Rub. R1 indicated R1 used topical pain medication for knee and shoulder pain. R1 indicated Muscle Rub would not work on R1's back because the pain was too deep and R1 needed help applying Muscle Rub due to arm pain. R1 denied pain in the reddened, blistered area and was not worried about scarring. On 12/3/24 at 1:17 PM, Surveyor interviewed CNA-D and CNA-F who indicated they were told during report that staff put a hot pack on R1's hip area but removed it after R1 indicated it was too hot. CNA-D and CNA-F indicated they knew to check the area for skin changes. CNA-D indicated a hot pack was not found in R1's bed. LPN-C and LPN-E were notified when CNA-D and CNA-F found the reddened area. LPN-C and LPN-E observed the area, but neither LPN offered R1 a cold pack. CNA-D stated R1 complained of pain every time the CNAs entered R1's room. CNA-F agreed. On 12/3/24 at 2:14 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Nurse Manager (NM)-G with DON-B on Speakerphone. NM-G indicated the topical medication should have been documented in R1's TAR. DON-B indicated the topical medication used on R1 was Muscle Rub (the facility's house stock) which was a medicated cream used to treat pain and arthritis. DON-B was unsure if Muscle Rub could be used with hot packs. DON-B indicated the facility had a standing order for the product and the order was activated for R1. DON-B and NHA-A did not provide documentation of staff education regarding the use of Muscle Rub concurrent with hot pack therapy. On 12/3/24 at approximately 2:45 PM, NM-G provided a Muscle Rub box and indicated there was not a package insert. Surveyor noted the active ingredients were menthol (chemical with cooling sensation) and methyl salicylate (analgesic pain reliever). The instructions stated not to use the product with a heating pad.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) for 1 resident (R) (R4) of 4 sampled residents. On 9/20/24, R4 alleged Certified Nursing Assistant (CNA)-C was rough during cares and staff reported there were red marks on R4's arms. The facility did not report the allegation of abuse to the SA. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy, with a revision date of 9/11/24, indicates: It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property .It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per federal and state law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including the State Agency and Adult Protective Services .). On 11/5/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including cerebral infarction, type 2 diabetes, hypertensive chronic kidney disease, and a history of falling. R4's Minimum Data Set (MDS) assessment, dated 10/21/24, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R4 had moderate cognitive impairment. R4's medical record indicated R4 had an activated Power of Attorney for Healthcare (POAHC) to assist with healthcare decisions. Surveyor reviewed a grievance, dated 9/20/24, that indicated CNA-D reported to Licensed Practical Nurse (LPN)-E that R4 wanted to talk with the Social Worker. CNA-D stated R4 told CNA-D that CNA-C took too long with cares, made R4 do most of the cares, and was rough with R4. CNA-D reported to LPN-E that R4 had red marks on R4's arms. The grievance indicated LPN-E assessed R4's arms and noted flat and irregular red areas in various spots. R4 denied pain or itchiness. The allegation of abuse was not reported to the SA. Surveyor also reviewed a facility-reported incident (FRI), dated 9/27/24, that indicated another resident (R2) alleged that CNA-C was rough during cares. The allegation of abuse was reported to the SA. On 11/5/24 at 12:06 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed the facility did not report R4's allegation of abuse to the SA. NHA-A was unsure why R4's allegation of abuse was not reported on 9/20/24, but R2's allegation of abuse was reported on 9/27/24.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R4) of 4 sampled residents. On 9/20/24, R4 alleged Certified Nursing Assistant (CNA)-C was rough during cares and staff reported there were red marks on R4's arms. The facility did not thoroughly investigate the allegation of abuse. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy, with a revision date of 9/11/24, indicates: It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property .E .It is the policy of this facility that abuse allegations .are promptly and thoroughly investigated .a. When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: .ii. Resident statements .iv. Involved staff and witness statements of events .vi. Injuries present including a resident assessment .It is the policy of this facility that the resident(s) will be protected from the alleged offender(s) .The alleged perpetrator will immediately be removed and the resident protected. Employees accused of alleged abuse will be immediately removed from the facility and will remain removed pending the results of a thorough investigation .Examine, assess, and interview the resident and other residents potentially affected immediately to determine an injury and identify any immediate clinical interventions necessary. On 11/5/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including cerebral infarction, type 2 diabetes, hypertensive chronic kidney disease, and a history of falling. R4's Minimum Data Set (MDS) assessment, dated 10/21/24, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R4 had moderate cognitive impairment. R4's medical record indicated R4 had an activated Power of Attorney for Healthcare (POAHC) to assist with healthcare decisions. Surveyor reviewed a grievance, dated 9/20/24, that indicated CNA-D reported to Licensed Practical Nurse (LPN)-E that R4 wanted to talk to the Social Worker. CNA-D stated R4 told CNA-D that CNA-C took too long with cares, made R4 do most of the cares, and was rough with R4. CNA-D reported to LPN-E that R4 had red marks on R4's arms. The grievance indicated LPN-E assessed R4's arms and noted flat and irregular red areas in various spots. R4 denied pain or itchiness. Surveyor noted the grievance did not indicate how the facility provided protection to R4 and other residents following the allegation of abuse and did not indicate if other residents were interviewed. The grievance also did not contain a skin assessments of R4's arms, notification to R4's physician, or corrective actions the facility took to prevent further potential abuse. Surveyor also reviewed a facility-reported incident (FRI), dated 9/27/24, that indicated another resident (R2) alleged that CNA-C was rough during cares. On 11/5/24 at 12:06 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed there was no documentation that nursing skin assessments were completed. On 11/5/24 at 12:06 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed other residents were not interviewed following R4's allegation of abuse because NHA-A felt confident that abuse did not occur. NHA-A stated when NHA-A spoke with R4, there were no red marks on R4's arms and R4 reported no concerns with cares. NHA-A confirmed CNA-C was not removed from resident care areas following the allegation of abuse. On 11/5/24 at 12:19 PM, Surveyor interviewed CNA-D who confirmed CNA-D saw red marks on R4's arms at the time the allegation was made and confirmed R4's exact word was that CNA-C was rough with cares. On 11/5/24 at 12:50 PM, Surveyor interviewed LPN-E who confirmed LPN-E assessed R4's arms immediately after the allegation and noted red marks on both of R4's arms. LPN-E did not recall if LPN-E completed a follow-up skin assessment.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) for 1 Resident (R) (R1) of 4 sampled residents. On 9/3/23, R1's family member alleged verbal/mental abuse by a staff member. The facility did not report the allegation of abuse to the SA. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy, with a revision date of 10/26/17, indicated: It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation .G .It is the policy of this facility that 'abuse' allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per federal and state law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Agency and Adult Protective Services .) On 12/18/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses to include diabetes mellitus and non-pressure chronic ulcer of left foot with necrosis of bone. R1's Minimum Data Set (MDS) assessments, dated 7/5/23 and 9/28/23, contained Brief Interview for Mental Status (BIMS) scores of 15 out of 15 which indicated R1 was not cognitively impaired. R1's Power of Attorney for Healthcare (POAHC) document, dated 6/27/23 and activated 10/8/23, indicated prior to 10/8/23, R1 was responsible for R1's own healthcare decisions. R1 passed away at the facility on 10/13/23. On 12/18/23, Surveyor reviewed a handwritten Complaint/Grievance Report regarding R1, dated 9/3/23, that indicated: Unit RN (Registered Nurse) (RN-C) attempted discussion with (R1) .(R1) has been fairly noncompliant (with) wound care. (RN-C) stated, Maybe we should contact your (family member) . On 12/18/23, Surveyor reviewed an email, dated 9/3/23 at 8:43 PM, from Director of Nursing (DON)-B to Nursing Home Administrator (NHA)-A and other members of the facility's interdisciplinary team that indicated: There was a bit of an issue with (R1) and (R1's family member) this evening. (R1's) wounds are looking worse - both heels, (R1's) shins, and (R1's) buttocks. (RN-C) was trying to reason with (R1) and going over risks/benefits of being compliant with orders. (R1) was insisting on not using a cushion - stating (R1) would sit on blankets or pillows. (R1) had refused the (brand name specialty air cushion) and sat in (R1's) wheel chair with no cushion for much of the day. After much discussion and (R1's) continued refusals, (RN-C) said, Maybe we should call your (family member)and discuss it with (family member). (RN-C) then did call (R1's family member) to update (family member) on the worsening wounds and (R1's) continual refusals. (RN-C) stated to (R1's family member), I even threatened to call you to try to get (R1) to understand in no way meaning RN-C had really threatened (R1). The (family member) became very angry and stated (family member) would absolutely be calling the State (SA) as that was ABUSE . On 12/18/23 at 3:35 PM, Surveyor interviewed NHA-A who indicated NHA-A felt the allegation did not qualify as an abuse allegation. NHA-A verified R1's family member used the term abuse according to the email sent to NHA-A by DON-B. NHA-A verified the facility's policy indicated allegations of abuse are to be reported to the SA timely.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 Resident (R) (R1) of 4 sampled residents. On 9/3/23, R1's family member alleged verbal/mental abuse by a staff member. The facility did not thoroughly investigate the allegation of abuse. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy, with a revision date of 10/26/17, indicated: It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation .E .It is the policy of this facility that 'abuse' allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are promptly and thoroughly investigated .F .It is the policy of this facility that the resident(s) will be protected from the alleged offender(s) .The alleged perpetrator will immediately be removed and the resident protected. Employees accused of alleged 'abuse' will be immediately removed from the facility and will remain removed pending the results of a thorough investigation .Examine, assess and interview the resident and other residents potentially affected immediately to determine an injury and identify any immediate clinical interventions necessary . On 12/18/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses to include diabetes mellitus and non-pressure chronic ulcer of left foot with necrosis of bone. R1's Minimum Data Set (MDS) assessments, dated 7/5/23 and 9/28/23, contained Brief Interview for Mental Status (BIMS) scores of 15 out of 15 which indicated R1 was not cognitively impaired. R1's Power of Attorney for Healthcare (POAHC) document, dated 6/27/23 and activated 10/8/23, indicated prior to 10/8/23, R1 was responsible for R1's own healthcare decisions. R1 passed away at the facility on 10/13/23. On 12/18/23, Surveyor reviewed a handwritten Complaint/Grievance Report regarding R1, dated 9/3/23, that indicated: Unit RN (Registered Nurse) (RN-C) attempted discussion with (R1) . (R1) has been fairly noncompliant (with) wound care. RN stated, Maybe we should contact your (family member) . On 12/18/23, Surveyor reviewed an email, dated 9/3/23 at 8:43 PM, from Director of Nursing (DON)-B to Nursing Home Administrator (NHA)-A and other members of the facility's interdisciplinary team, that indicated: There was a bit of an issue with (R1) and (R1's family member) this evening. (R1's) wounds are looking worse - both heels, (R1's) shins, and (R1's) buttocks. (RN-C) was trying to reason with (R1) and going over risks/benefits of being compliant with orders. (R1) was insisting on not using a cushion - stating (R1) would sit on blankets or pillows. (R1) had refused the (brand name specialty air cushion) and sat in (R1's) wheel chair with no cushion for much of the day. After much discussion and (R1's) continued refusals, (RN-C) said, Maybe we should call your (family member) and discuss it with (family member). (RN-C) then did call (R1's family member) to update (family member) on the worsening wounds and (R1's) continual refusals. (RN-C) stated to (R1's family member), I even threatened to call you to try to get (R1) to understand in no way meaning RN-C had really threatened (R1). The (family member) became very angry and stated (family member) would absolutely be calling the State (SA) as that was ABUSE . Surveyor noted the facility's Complaint/Grievance documents did not indicate how the facility-provided protection to R1 and other residents following the allegation of abuse or if other residents were interviewed. The Complaint/Grievance documents contained an interview with R1 completed by Social Worker (SW)-D on 9/5/23 that did not reference the allegation of abuse or how R1 felt about the allegation. On 12/18/23 at 2:12 PM, Surveyor interviewed SW-D who indicated SW-D learned of the abuse allegation on 9/4/23 when SW-D read the above email from DON-B. When asked when SW-D first interviewed R1, SW-D stated, I believe (NHA-A) went in first. (NHA-A) likes to lead on any abuse or neglect allegations. (NHA-A) then tells me what (NHA-A) needs from me. When asked if SW-D asked R1 during the 9/5/23 interview if R1 felt threatened by RN-C's comments, SW-D stated, Not specifically. I wanted (R1) to explain to me what happened. SW-D verified SW-D did not mention the allegation of abuse by RN-C to R1. When asked if SW-D interviewed other residents as part of the investigation, SW-D indicated NHA-A usually assigned members of the interdisciplinary team to interview other residents. SW-D did not recall whether or not SW-D interviewed other residents related to the allegation of abuse. On 12/18/23 at 2:19 PM, Surveyor interviewed NHA-A who indicated NHA-A met with R1 informally, but did not document the meeting. NHA-A stated NHA-A remembered meeting with RN-C and indicated NHA-A felt reassured through resident council meetings that no abuse had occurred. NHA-A indicated NHA-A would have met with R1 the next morning on 9/4/23. When asked what steps the facility took to ensure resident safety immediately following the allegation of abuse, NHA-A stated, Frequent checks on (R1). Surveyor reviewed the Complaint/Grievance investigation with NHA-A and indicated the investigation did not include an interview with R1 regarding whether or not R1 felt threatened by RN-C's comments, interviews with other residents, or intervention(s) to keep R1 and other residents safe during the course of the investigation. NHA-A indicated the facility did not have additional documentation other than what was provided to Surveyor On 12/18/23, Surveyor reviewed the facility's resident council meeting minutes, dated 9/18/23 and 10/16/23, which did not contain questions or concerns related to the above allegation of abuse. On 12/18/23 at 3:35 PM, Surveyor interviewed NHA-A who verified the facility did not remove RN-C from resident care pending the outcome of the investigation. NHA-A stated, I did not feel like it was abuse. NHA-A further stated, I observed no negative outcome when I interviewed (R1) .I felt no trepidation from (R1). NHA-A verified allegations of abuse require a thorough investigation and the facility's investigation, as a result of the Complaint/Grievance, dated 9/3/23, was missing components of a thorough abuse investigation. NHA-A stated, In my mind, I did not feel there was reportable abuse.

Based on observation, interview and record review, the facility did not ensure that 1 of 15 sampled residents received care and services to maintain the highest possible psychosocial and physical well-being. Resident #4 has a [DIAGNOSES REDACTED].#4 became distressed when staff exposed his genitals during peri care. This included Resident #4 hollering out for staff to stop and attempting to shield his peri area. Despite Resident #4 becoming distraught, staff did not cease cares. Staff became more forceful in attempting to complete peri care by restraining Resident #4's hands from shielding his peri area and prying open his legs. Resident #4 subsequently continued to yell throughout the entire process of peri care. Once staff were done and covered Resident #4, Resident #4 continued to be emotionally distressed requesting multiple times to be covered. This is evidenced by: Resident #4 has a current [DIAGNOSES REDACTED]. Resident #4 was also legally blind and very hard of hearing. Resident #4's current MDS (Minimum Data Set), dated 5/21/15, indicated Resident #4: ~ Vision was highly impaired; ~ Hearing impaired; ~ Has both short and long-term memory problems; ~ Cognitive skills were severely impaired; and ~ Required total assistance of 1 to 2 staff persons for all aspects of care. Resident #4's care plan was dated 3/26/15 and titled .Alteration in thought processes. Can be resistive with cares due to dementia and sensory impairments . had the following approaches: ~ 3/1/13, .speak loud and clear messages to resident and assess understanding; explain procedures thoroughly to compensate for visual loss . ~ 12/20/13, .recite prayers .calming music, likes church music .may need to go back and try to do cares, again later if agitated . ~ 3/26/15, .may need to go back and try to do cares, later if agitated .Tune television to favorite programs . While Resident #4's care plan identified Resident #4's resistance during care, there was no identification of the reason for resistance, the extent of the resistance, and specific ways of diminishing resistance. Resident #4's CNA (Certified Nursing Assistant) care plan had no directives for staff on how to manage Resident #4's distress during care. On 7/14/15 at 9:35 a.m., Surveyor # observed CNA-D and CNA-E assist Resident #4 with care. CNA-D gathered her supplies, indicated to Resident #4 that she and CNA-E were going to assist Resident #4 with bathing. CNA-D pulled Resident #4's bedding down to Resident #4's abdomen area and began to wash Resident #4's upper torso. Resident #4 said, Thank you, to CNA-D several times during the process of washing his upper torso. CNA-D and CNA-E assisted Resident #4 onto his right side and CNA-D began to wash Resident #4's buttock area. During the process of cleansing Resident #4's buttock area, Resident #4 began to holler out, That's painful, multiple times. CNA-D indicated to Resident #4 that she was not trying to hurt him but trying to cleanse his buttock area. CNA-D continued to cleanse Resident #4's buttock area while Resident #4 hollered out again, That's painful! and I'm bleeding! and Let me go! CNA-D stated to Resident #4 he was not bleeding and completed cleansing Resident #4's buttocks. CNA-D and CNA-E turned Resident #4 onto his back. CNA-D pulled Resident #4's bedding down to his ankles leaving Resident #4 completely uncovered with his genitals exposed. CNA-D began to assist Resident #4 with frontal peri care. During this process Resident #4 began to holler out, Don't let them do that! Don't let them do that! Please! Please! Let me go! multiple times. CNA-D indicated to Resident #4 that she needed to complete frontal peri care. Resident #4 attempted to shield his peri area with his hands. CNA-E held Resident #4's hands and told Resident #4 not to put his hands down there. Resident #4 continued to attempt to shield his peri area as well as pull his legs up and close them tightly together. CNA-D continued to attempt to cleanse Resident #4's peri area as Resident #4 continued to yell out, Let me go! Let me go! CNA-D again indicated to Resident #4 that she needed to cleanse his frontal peri area. CNA-D and CNA-E then attempted to open Resident #4's legs. CNA-E attempted to keep Resident #4's hands from shielding his peri area and with the other hand attempted to open Resident #4's legs. CNA-D opened Resident #4's leg with her hand then placed her elbow into Resident #4's inner thigh area to keep his legs apart and continued to attempt to cleanse Resident #4's peri area. Resident #4 continued to holler out, Let me go! Let me go! Resident #4 then began to yell out, Have mercy! Have mercy! CNA-E told CNA-D to stop attempting to complete peri care. CNA-D responded by indicating she needed to at least wash around Resident #4's Foley catheter. CNA-D proceeded to cleanse Resident #4's Foley catheter. Resident #4 continued to yell out, Let me go! Let me go! and Have mercy! CNA-D then pulled Resident #4's blanket up to Resident #4's peri area. Resident #4 grabbed the blankets and attempted to cover himself up stating, Cover me up! Cover me up! CNA-D indicated to Resident #4 that she needed to put Resident #4's shirt on. CNA-D and CNA-E proceeded to place Resident #4's shirt. CNA-D then covered Resident #4 with a blanket. Resident #4 was observed to grab the blanket and pull it all the way up to his chin. Resident #4 continued to state, Cover me up. Cover me up. CNA-D responded to Resident #4 that he was already covered. Surveyor # spoke with both CNA-D and CNA-E after the observation. CNA-D indicated Resident #4 resisted care as noted in the observation 90% of the time she took care of him. CNA-D indicated she had reported to the nurses the difficulty she had completing care. CNA-D indicated, Its been going on for a long time they should all know about it. CNA-D also indicated to Surveyor # with some frustration that she did the best she could do. Surveyor # also spoke with CNA-E. CNA-E concurred with CNA-D. CNA-E indicated what works sometimes is to give Resident #4 his hat to put on while doing peri care. CNA-E stated diversion did work when attempting to complete peri care. While CNA-E had this knowledge, there were no attempts at diversion during Resident #4's cares. On 7/14/15 at 2:55 p.m., Surveyor # spoke with RN-G. RN-G indicated Resident #4 refused care sometimes but staff could talk him through it. On 7/14/15 at 3:15 p.m., Surveyor # spoke with CNA-H. CNA-H indicated Resident #4 sometimes refused care and if Resident #4 started striking out she would stop. CNA-H indicated they always used two staff members for care. CNA-H stated when Resident #4 did refuse care she would try and talk him through care or just go back later. On 7/15/15 at 7:15 a.m., Surveyor # spoke with CNA-I. CNA-I indicated she worked on the unit Resident #4 resided. CNA-I indicated when she cared for Resident #4 he would refuse cares approximately one time per week. CNA-I indicated Resident #4 was very protective of his peri area and didn't like to be uncovered. CNA-I indicated when she assisted Resident #4 with peri care, including Foley catheter care, she would hold Resident #4's hands and talk into his left ear about his farm. CNA-I indicated this approach usually worked and helped Resident #4 get though peri care. CNA-I also indicated if Resident #4 began to holler out and refuse care she would try and talk to him again. CNA-I indicated if Resident #4 hollered out a second time she would cease care and come back later. On 7/14/15 at 12:10 p.m., Surveyor # spoke with RN-F (Registered Nurse). RN-F indicated she was the unit manager on the unit Resident #4 resided. Surveyor # asked RN-F about Resident #4. RN-F indicated Resident #4 did resist cares but it was not a daily occurrence. RN-F indicated Resident #4 was very hard of hearing and hears better from his left ear. RN-F stated staff needed to be sure Resident #4 heard them when explaining what they were going to do. RN-F indicated diversion worked well for Resident #4, and Resident #4 likes to reminisce about his farm. RN-F stated staff should be using this approach when doing cares for Resident #4. RN-F also indicated if Resident #4 continued to be resistive with cares staff needed to stop and reapproach later. Surveyor # relayed the observation as noted on 7/14/15. RN-F indicated CNA-D should have stopped care and reapproached later.

Based on observation, interview, and record review, the facility did not ensure that 1 of 16 sampled residents received the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident #5 was admitted to the facility for rehabilitation after a fall at home which resulted in a [MEDICAL CONDITION]. The [MEDICAL CONDITION] was surgically repaired. Resident #5 entered the facility without any cognitive deficits and was her own person. Prior to entering the facility, Resident #5 lived alone. Since being admitted to the facility, Resident #5 has had a decline in over-all physical and mental functioning including: ~Behavioral changes including fear, anxiety, [MEDICAL CONDITION], hallucinations, typically seen with [MEDICAL CONDITION], resistance to cares, refusing to eat and drink, and physical aggression; ~Significant decline in physical functioning; ~Significant weight loss of 67.1 pounds since admission (Refer to F325); ~Pressure ulcers; and ~Pain. The facility identified the changes in Resident #5's condition as behavioral related to dementia. This was done prior to completing a comprehensive assessment including considerations of the causative factors for the behaviors including past history, acute illness with [MEDICAL CONDITION], and pain. Subsequently the facility did not identify, assess, and care plan acute conditions. Observations and interviews with Resident #5 as well as Resident #5's guardian, revealed Resident #5 was fearful of staff, fearful of going to the bathroom, fearful of having cares done because all resulted in pain. Resident #5 has opted to therefore refuse many cares including getting out of bed. The facility had not identified Resident #5 as having pain. Resident #5 was not on pain medications. Additionally, Resident #5 had been hospitalized 2 times since admission to the facility due to an infectious process associated [MEDICAL CONDITION] and/or [MEDICAL CONDITION]. Both admissions resulted in an extended hospital stay. While the facility monitored Resident #5's I&O (intake and output) daily, there was no daily assessment of the tallied 24 hour totals nor was there intermittent hydration assessments to determine if Resident #5 was becoming dehydrated. This is evidenced by: Resident #5 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Surveyor # completed a review of Resident #5's hospital records dated 10/7/12. The records indicated Resident #5 sustained a fall when she got out of bed and spent approximately 12 hours on the floor before being found. Resident #5 was diagnosed with [REDACTED]. The admission MDS (Minimum Data Set) dated 10/22/12, indicated Resident #5: ~Did not have a serious mental illness; ~Was cognitively intact; ~Had no indicators of [MEDICAL CONDITION]; ~Had mood indicators per Resident #5 of feeling down, difficulty with sleep, feeling tired, and feeling of being a failure; ~Had no hallucinations or [MEDICAL CONDITION]; ~Had occasional verbal outbursts directed towards staff; ~Had occasional rejection of care; ~Required extensive assistance of 1 to 2 staff persons for transfers, bed mobility, bathing, dressing, and grooming, and did not walk; ~Required supervision when eating; ~Was frequently incontinent of bladder and continent of bowel; ~Had occasional pain rated at 7 on a numeric rating scale of 0-10; ~Weighed 223 pounds; ~Had no pressure ulcers; and, ~Received an antipsychotic medication every day. Resident #5's behavior, mood, and cognition CAA dated 10/16/12 indicated, "...was calling out and making repetitive noises But this has improved...alert and oriented and able to make her needs known...acute [MEDICAL CONDITION] outbursts may be associated with pain and fear of moving...Behavioral disturbance...occurs during specific activities, such as bath or transfers...new medication [MEDICATION NAME] was started in hospital for acute [MEDICAL CONDITION] (sic)...is also on [MEDICATION NAME] for anxiety...pain, fear of movement...at risk for pressure related skin breakdown...currently has intact skin except for surgical incision..." On 1/14/13 and 4/4/13, the facility completed a significant change in condition MDS related to a decline in Resident #5's overall physical and psychosocial functioning. The most current MDS, dated [DATE], indicated Resident #5: ~Had a severe cognitive impairment, and short-term memory problems; ~Cognitive skills were moderately impaired; ~Had indicators of [MEDICAL CONDITION] including inattention, altered level of consciousness, and psychomotor [MEDICAL CONDITION]; ~Had mood indicators assessed by staff of little interest or pleasure, poor appetite, trouble with concentration, and being easily annoyed; ~Had physical behavioral symptom directed towards staff, and other behavioral symptoms not directed towards staff; ~Rejected cares; ~Required extensive to total assistance of 1 to 2 staff persons for bathing, dressing, grooming, bed mobility, and using the toilet, and did not walk; ~Was always incontinent of both bowel and bladder; ~Had no pain; ~Weighed 172 pounds; and ~Had 2 stage II pressure ulcers. Resident #5's most current CAAs for behavior, cognition, and pressure ulcers was dated 4/4/13. The CAAs indicated, "...significant behavioral abnormalities. Including delusion, paranoia, and anxiety...dementia...Behavioral Disturbance: occurs during specific activities, such as bath or transfers...long history of unease in joining with others paranoid behavior...suspicious of [MEDICAL CONDITION] or other dementia's...decline in cognitive status...remains at risk for pressure related skin breakdown..." The facility identified most of Resident #5's behaviors were associated with some type of care. Pain was not triggered. Resident #5's behavior care plan was dated 1/16/13. The care plan indicated Resident #5 had behaviors of "...Socially inappropriate/disruptive; calling out, [MEDICAL CONDITION]: hearing voices from air conditioner, making up stories of people/situations that are not [MEDICAL CONDITION] of Care..." The care plan had the following approaches: ~Consult psychiatry regarding medication use; ~Assess for signs and symptoms of illness; ~Monitor medication use and effectiveness; ~Reapproach as needed; ~Calm environment; ~Involve family; ~Explain risks of refusing cares; ~Use yes/no question; ~Compromise; ~Reminisce about the past; and ~Calming music, enjoys classical Christian, Christmas, music and nature sounds. According to Resident #5's clinical record as well as Resident #5's Guardian, Resident #5 lived in Germany and spent her childhood years post World War II prior to coming to the United States. According to Resident #5's Guardian, Resident #5's childhood was difficult and plagued with fear and poverty. This information was not captured on Resident #5's plan of care. Resident #5's pain care plan was dated 10/16/12. The care plan had the following approaches: ~Assess physical symptoms of pain; ~Monitor and record complaints of pain; ~Administer medications as needed; and ~Offer non-pharmacological strategies for pain control. Further review of Resident #5's care plan found hydration was not identified as a problem, however, an approach contained within the care plan for incontinence, dated 10/21/12, directed staff to monitor I&O and to encourage fluid intake. In addition, Resident #5's comprehensive care plan did not include a problem identifying the 2 stage II pressure ulcers. Temporary care plans dated 1/14/13 and 3/27/13, indicated Resident #5 had inadequate intakes and was "at risk" for weight loss. It directed staff to assist Resident #5 with meals, to encourage intake of both food and fluid, to offer snacks, and to monitor weights. The care plan did not direct staff on how to assess or manage symptoms of dehydration. A temporary care plan dated 1/10/13, indicated Resident #5 had moisture related open areas to the right buttock. A temporary care plan dated 5/6/13, indicated Resident #5 had pressure ulcers on the buttocks. Resident #5 had 2 psychiatric evaluations. The first on 1/24/13 and the next on 3/18/13. Neither evaluation conclusively diagnosed dementia. HYDRATION According to "Diagnostic and Statistical Manual of Mental Disorders" Fourth Edition and "The Confusion Assessment Method: A Systematic Review of Current Usage, Journal of the American Geriatrics Society," [MEDICAL CONDITION] is an acute confusional state which includes signs and symptoms closely related to dementia. Symptoms include inattention, being easily distracted, cognitive changes, altered level of consciousness, hyper or hypoactive, and perceptual disturbances. According to the articles, the cause of [MEDICAL CONDITION] is typically physiologic in nature which can generally be identified through a diagnostic evaluation. The articles also indicated it is critical to recognize and treat [MEDICAL CONDITION]. Failure to do so could result in poor health outcomes, hospitalization s, or even death. The "Dehydration And Fluid Maintenance In the Long-Term Setting" indicates, "...Dehydration is defined as a loss of body water that causes significant signs and symptoms, including physiological and/or functional decline from the individual's baseline." It further defines physiological signs and symptoms as weight loss, dry eyes and/or mouth and tongue, changes in mental status, fever, postural [MEDICAL CONDITION], small amount of concentrated urine, urinary tract infections, pulse greater than 100 beats/minute and a systolic blood pressure of less than 100. It also defines functional signs and symptoms as lethargy and weakness, changes in mental status, falling, changes in ability to carry out activities of daily living, and increased combativeness and confusion. According to Nursing 2011, "Recognizing the Face of Dehydration," a systematic hydration assessment would include: ~A comprehensive health history including diseases which put a patient at risk; ~An assessment of medications including diuretics, beta-blockers, and antidepressants; ~Any historical [DIAGNOSES REDACTED]. ~A comprehensive physical assessment including vital signs, capillary refill time condition of skin and mucous membranes and appearance of tongue; ~Any indicators of [MEDICAL CONDITION]; ~Falls; ~Changes in functional status including muscle weakness, fatigue, confusion, lethargy and changes in level of consciousness; ~Diagnostic studies including color and specific gravity of urine; ~Signs and symptoms of infection; and ~Determination of the percentage of weight loss. The article also indicates, "...Don't assume that confusion is normal in older adults. Instead, promptly assess any change in mental status from baseline..." Surveyor # completed a review of Resident #5's admission dietary assessment dated [DATE]. The assessment indicated Resident #5 had a good appetite, ate independently, weighed 223.2 pounds, estimated fluid needs were 1800 cc's (cubic centimeters) per day, and Resident #5's calorie, protein, and fluid intakes were adequate. A nurse's note dated 1/13/13 states, "...Weight loss trend...lack of appetitive...Current weight 204.4...loss of 22.8 pounds since 10/25/12...Fluid intake fluctuates from inadequate to very high amounts; example on 1/12/13...consumed 720ml (milliliters); on 1/9/13...consumed 3780ml...Still receives HCTZ (hydrchlorothiazide a diuretic)...Resident is usually loud with outbursts towards staff, that include many refusals of care...Temp 99.6...Observe fluid intake and attempt to keep fluid intake at a therapeutic amount daily. Monitor for s/s (signs and symptoms) infection with low grade temp...WT (weight) today, which increases the total amount WT loss to 29 lbs (pounds)." The above nursing note indicated Resident #5 had a low grade temperature, had a significant weight loss, and intakes were declining. There was no hydration assessment completed to determine if Resident #5 was showing signs of dehydration. Additionally, the nursing note of 1/9/13 indicated Resident #5 had a low grade temperature. There were no other documented temperatures since 1/9/13. Nursing notes continue: ~2/19/13, "...calling out during the night. Upset that she needed to cut a tag out of her hat because the hat was not made in the USA..." ~2/28/13, "...Wt (weight) 176.6...Weight loss of 5 or more pounds in last 7 days...Eats 10% of meals...Continue to encourage to eat and drink..." The facility identified continued weight loss including a weight loss of 5 pounds or greater in the last 7 days. This was a significant indicator of dehydration. There was no hydration assessment completed. Nursing notes continue: ~3/2/13, "...Oral intake remains poor..." ~3/6/13, "...Fluid intake lower; will...monitor for s/s of dehydration...No void this shift..." ~3/7/13, "...Pulse: 100..." ~3/8/13, "...Pulse: 100...did accept cares..." Resident #5 had historical daily refusals for cares. Accepting cares was a change in Resident #5's condition. The facility also identified Resident #5's continued poor intake. Resident #5 now had an elevated pulse of 100. According to Resident #5's record, Resident #5's pulse was usually in the range of 60-80 beats per minute. Poor intake, weight loss, elevated pulse, and behavioral changes are all symptoms of dehydration. To date, there has been no hydration assessment completed. On 3/8/13, Resident #5 was seen by the orthopedic surgeon. The physician's progress note indicated, "...appears today lethargic and confused..." Nursing notes continue: ~3/10/13, "...Output: 0...Blood Pressure 90/60...accepted cares...only took in 120cc...Output: 0...son...called the on call doctor...to talk about his mother's condition. Writer updated Dr (doctor)...regarding not drinking a whole lot, not eating..Plan: discontinue 24hr (hour) monitoring. Condition resolved...Output: 0..." Resident #5 had further declined in condition. Resident #5's blood pressure was below 100 systolic. Resident #5 had no output for 3 shifts. The son, not the facility, called the physician. There was no comprehensive assessment completed, including a hydration assessment, to determine the cause of Resident's decline. To date there has been no temperature documented. Nursing notes continue: ~3/11/13, "...Output: 0...accepted cares...only 120cc accepted...so far...voided: 1...drank only 150cc...continue 24hr monitoring..." ~3/12/13, "...Has not had BM (bowel movement) in multiple days...incontinent: 1...accepted cares...voided: 1...Pulse 102...Temperature: 98.3...talking to people not present..Per son...res. (resident) stated to him that she feels 'empty like she is dead'...voided: 1..." ~ 3/13/13, "...accepting...cares...Output: 0...Output: 1 small...accept cares...Oral intake remains poor...T (temperature): 99.2...res. c/o (complained of) about the 'russians' to her son..." ~ 3/14/13, "...refused all fluids...thus far...output: 0...Pulse: 100...Intake...days...sips...Output: 0...Wt. 174.8 on 3/7/13...voided: 1...Wt. 167..." From 3/11/13 through 3/14/13 there was no documented comprehensive assessment completed, including a hydration assessment, in an attempt to determine the cause of Resident #5's significant decline in condition. Nursing notes continue: ~3/15/13, "...accepting....cares...Output: 0...Pulse: 100...Temp 100.5...complaints of sore throat and belly pain...Incontinent: 1...Weight changes: Weight loss of 5 or more pounds in last 7 days...lack of appetite...no [MEDICAL CONDITION] wt 167 date: 3/14/13 Last wt: 174.8 date: 3/7/13 2/28/13 wt 176.6...refuses to eat...T 101.2...Pulse: 112...res. sent to ER (emergency room ) for eval (evaluation) by non emergency ambulance..." On 3/15/13, Resident #5 was admitted to the hospital. Surveyor # completed a review of hospital's History and Physical dated 3/15/13. It indicated, "...Impression:...Urinary tract infection [MEDICAL CONDITION] evidenced by fever, leukocytosis, altered mental status...General deterioration...Severe [MEDICAL CONDITION]" The Discharge Summary dated 3/25/13 indicated, "...Sepsis secondary to urinary tract infection...Acute [MEDICAL CONDITION], resolving...Failure to thrive, [MEDICAL CONDITIONS] and [MEDICAL CONDITION] protein calorie [MEDICAL CONDITION] deterioration and deconditioning...At the time of admission, the patient was thought to have acute [MEDICAL CONDITION] probable secondary [MEDICAL CONDITION] and urinary tract infection...was not eating or drinking at that time because of her [MEDICAL CONDITIONS] did mildly improve after [MEDICAL CONDITION] resolved...She had [MEDICAL CONDITION] and other electrolyte abnormalities which have resolved now since the patient has started to eat..." Resident #5 returned to the facility on [DATE]. Nursing notes continue: ~3/25/13, "...Wt. 175.2..." ~3/28/13, "...Wt. 176.0..." ~4/18/13, "...Wt. 164.6...Weight loss of 5% in last 30 days...uncooperative and noncompliant at times...poor appetite...Temperature: 99.7...son would like UA (urinalysis) done..." ~4/19/13, "...allowed cares...T 100.4, fluids enc (encouraged), urine remains cloudy...more tired today..." ~4/20/13, "...Temperature: 99...allowed cares...Son at desk verbalizing that UA still has not been ordered...States resident is 'out of control and loopy'...frequently refuses fluid..." ~4/21/13, "...Son is very concerned his mother has a UTI...T 99.4...urine cloudy..." ~4/22/13, "...obtained urine specimen...Urine cloudy yellow..." ~4/25/13, "...UTI, resident is currently be treated at this time with antibiotics...Wt. 162.8..." Resident #5 has again shown a weight loss, poor appetite, and was diagnosed with [REDACTED].#5 was becoming dehydrated. Nursing notes continue: ~5/2/13, "...Quiet. Accepted cares...Resident loud, calling out all night, wanting ice and juice, but doesn't drink it... ~5/4/13, "...allowed cares...Taken small amount of fluid..." ~5/8/13, "...calling out most of the day shift..." ~5/10/13, "...calling out throughout the day shift...wanted juice, gave juice, then she didn't want it..." ~5/11/13, "...found on floor...room...Blood Pressure 90/60...Pulse: 100...Temperature: 98.2..." ~5/13/13, "...No BM x (times) 4 days...Accepted small amounts of liquid during the night...calling out...Doesn't know what she is calling out for..." ~5/16/13, "...Wt 156.1..." Resident #5 showed further weight loss, changes in mentation, had a fall, and was showing signs of constipation. All are indicators of dehydration. There was no comprehensive assessment completed, including a hydration assessment. Nursing notes continue: ~5/17/13, "...UA (Urinalysis) obtained...Urine cloudy and thick with a foul odor...became restless and aggressive towards staff...repeating phrases wanting to go to heal care center, wanting to be on the floor...assisted in recliner...where patient attempted to slide out on to floor...attempted to roll out either side of bed...Discussed ER (emergency room ) evaluation due to safety and decrease in safety awareness and increase in confusion...resident to ER for evaluation..." Resident #5 was admitted to the hospital on [DATE]. Surveyor # completed a review of Resident #5's hospital records. A History and Physical dated 5/17/13 indicated, "...one week history of altered mental status, decreased oral intake and refusing to take her medications...The patient is severely deconditioned...[DIAGNOSES REDACTED] (an acute psuedo-obstruction and dilation of the colon in the absence of any mechanical obstruction in severely ill persons). At some point, the patient complained of abdominal pain, nausea and vomiting. Abdominal plain films showed severe, [MEDICATION NAME] distention of the colon...there was no evidence of a small bowel obstruction...Those findings were compatible with [DIAGNOSES REDACTED]...Moderate protein calorie [MEDICAL CONDITION] it was felt that the patient had acute [MEDICAL CONDITION] on admission..." On 6/6/13 at 9:30 a.m., Surveyor # spoke with RN-D (Registered Nurse) about the facility's Hydration Management Program. RN-D indicated she was the full time nurse who worked the unit where Resident #5 resided. RN-D indicated I&Os were done on all new admissions. If there were any concerns with the I&O, it would be continued indefinitely. RN-D indicated all staff would fill in I&O on a working form, which was then placed into the facility's computer system. RN-D indicated the I&O was its own separate entity and not contained within the nursing notes. RN-D indicated I&O could then be accessed and viewed. Surveyor # asked RN-D when I&O was typically looked at. RN-D indicated when a concern arose, a nutrition consult was completed at which point I&O is reviewed over the past 7 to 10 days. RN-D indicated the nutrition consult was also the facility's hydration assessment. Surveyor # completed a review of the nutrition consults for Resident #5. The information contained the same information as noted in the nursing notes of 1/13/13, 2/28/13, 3/15/13, and 4/18/13. RN-D indicated the information was extracted from the nursing notes to generate the nutrition consult. None of Resident #5's nutrition consults addressed actual fluid intake. None of Resident #5's nutrition consults contained a hydration assessment. Surveyor # completed a review of a form titled "Task: I&O" for the period of 3/1/13 through 3/15/13. Surveyor # tallied and averaged the intakes and noted Resident #5's average intake over the 15 days prior to Resident #5's hospital admission was 754 cc's in 24 hours. Surveyor # also tallied and averaged intakes for a period of 7 days prior to Resident #5's hospital admission. The average intake was noted to be 560 cc's in 24 hours. According to Resident #5's admission dietary assessment, Resident #5's fluid requirements were 1800 cc's in 24 hours. Resident #5's fluid intake during the 7 days prior to admission to the hospital was 1240 cc's less (69% less) than what Resident #5's fluid requirements were. Surveyor # also completed a review of Resident #5's intakes 7 days prior to the hospital admission on 5/17/13. Surveyor # tallied and averaged the intakes. The average intake was noted to be 760 cc's in 24 hours (58% less than required). On 6/5/13, Surveyor # spoke with Resident #5's Guardian. Resident #5's Guardian indicated prior to Resident #5's fall at home, Resident #5 lived independently in an apartment. Resident #5's Guardian also indicated he was in the facility every day. Resident #5's Guardian indicated he was frustrated with the facility's failure to assess Resident #5's condition and respond to changes in Resident #5's condition. Resident #5's Guardian indicated he saw Resident #5 get "worse and worse," lose a tremendous amount of weight, and at times could not eat or drink. Resident #5's Guardian indicated prior to Resident #5's first hospital admission on 3/15/13, he knew Resident #5 was sick but when he requested the facility to complete a UA he was told she didn't have enough symptoms. Resident #5's Guardian indicated he had been asking the facility for a week if Resident #5 needed to go to the hospital and felt he had to "talk them into" sending Resident #5 to the hospital when Resident #5 finally went. Resident #5's Guardian indicated he felt Resident #5 was dying. Resident #5's Guardian indicated the hospital physician told him Resident #5 should have been evaluated 2 weeks prior to being admitted . Resident #5's Guardian indicated when Resident #5 became sick the second time it was like "pulling teeth" to get a UA done. PAIN According to "The Management of Persistent Pain in Older Persons," common pain behaviors in the cognitively impaired person include the following: ~Frown, sad or frightened face; ~Grimacing or any distorted facial expression; ~Sighing, moaning, grunting, chanting, calling out; ~Noisy breathing; ~Asking for help; ~Verbal abuse; ~Rigid, tense body posture, guarding; ~Fidgeting; ~Restricted movement; ~Gait or mobility changes; ~Aggressive, combative , resisting cares; ~Decreased social interaction; ~Socially inappropriate, disruptive; ~Withdrawn; ~Refusing food, appetite changes; ~Sleep and rest pattern changes; ~Increased confusion; ~Irritability or distress. The facility's practice was to use a numeric pain scale from 0 to 10. 0 meaning no pain and 10 meaning the worst pain imagined. Surveyor # completed a review of Resident #5's pain assessments since admission and noted the following: ~On 10/23/12, a pain assessment indicated Resident #5 had occasional pain rated at a 7 in her right hip. The assessment notes Resident #5 receives [MEDICATION NAME] medications and was satisfied with the current pain regimen. ~On 10/28/12, a pain assessment indicated Resident #5 had occasional pain rated at a 9 in her legs and right hip. The pain assessment noted, "...Effects of Pain: Mood: sllep (sic) and quality of life...when interviewing resident did not want to be asked questions. was very brief and short. said she is having pain affecting activities and sleep. on scheduled pain medication...would like one more pain medication scheduled to see if will help. informed resident she is able to have as needed pain medications between scheduled..." ~11/12/12, "[MEDICATION NAME] ([MEDICATION NAME])...was discontinued on 11/5/12...Pain...occasionally...Has Pain Made It Hard For You To Sleep At Night: yes at time...Rate: 05...right hip leg...Exacerbating Factors: position changes ADL's (activities of daily living)...Effect...Mood: sleep Quality of life..." ~12/10/12, "...Pain...Rarely...Worst Pain...08...RLE (right lower extremity)...with activity...ache...Exacerbating factors...Exercise Therapy Ambulation Transfers...Effects Of Pain: ADL Function: decreases independence...medication effective...Continue current regime..." Resident #5's [MEDICATION NAME] medication was discontinued on 11/5/12. According to Resident #5's clinical record, this was done to determine if the [MEDICATION NAME] was causing Resident #5's hallucinations and [MEDICAL CONDITION]. The record indicated the facility was going to assess Resident #5's response. Since that time, documentation indicated Resident #5 was having pain which interfered with her quality of life including mood, sleep, ability to tolerate transfers and ADLs. Despite this, there were no changes made to Resident #5's plan of care. On 1/14/13, the facility completed a significant change in condition MDS related to Resident #5's overall decline. The MDS indicated Resident #5 had long and short-term memory problems and cognition that was moderately impaired. Pain assessments continue: ~1/9/13, "...No pain..." ~3/25/13, "...Scheduled Pain Medication Regimen...No Received PRN (as needed) Pain Medications...No...Pain...No.." ~4/6/13, "...Pain...No..." ~5/31/12, "...Pain...No..." Surveyor # completed a review of Resident #5's MARs (Medication Administration Records) since admission to the present. Resident #5's last dose of [MEDICATION NAME] was 11/6/12. Surveyor # reviewed the doses of Tylenol Resident #5 received since November 2012 and noted the following: ~ November 2012, 16 doses of Tylenol. ~ December 2012, 13 doses of Tylenol. ~ January 2013, 10 doses of Tylenol. ~ February 2013, 0 doses of Tylenol. ~ March 2013, 1 dose of Tylenol. ~ April 2013, 0 doses of Tylenol. ~ May 2013, 0 doses of Tylenol. Surveyor # completed a review of Resident #5's nursing notes and behavior log and noted the following: ~On 10/31/12, Resident #5 began to show indicators of [MEDICAL CONDITION] including delusion, hallucinations, and inappropriate behaviors. On 11/5/12, facility in response discontinued Resident #5's [MEDICATION NAME] to assess if Resident #5's behaviors improved. ~11/8/12, "...verbal outbursts..." ~11/12/12, "...crying that her son die. She call him, but she was say he is dead...(sic)" ~11/15/12, "...Wanted water at faucet to run on full because the train station was on fire...screaming..." ~11/14/12, "...Calling out much of the night escalating to screaming..." ~11/18/12, "...screaming she wants a new bed...has germs and bugs on it..." ~11/29/12, "...talking to an empty room..." ~12/5/12, "...Complaining about a lady painting and poisoning her nails..." ~12/15/12, "...screaming randomly during supper..." ~12/19/12, "...Calling out..." ~12/24/12, "...Constantly on call light..." ~1/7/13, "...Refused to be toileted..." ~1/10/13, "...open area...R (right) buttock..." ~1/13/13, "...refused to be repositioned..." ~1/13/13, "...As soon as staff attempt to put pillow behind residents, she screams and calls out until pillow is removed...open area right buttock..." ~1/17/13, "...Refused to eat..." ~1/29/13, "...Refused toileting and reposition Refused breakfast and lunch..." ~2/3/13, "...refusing cares...yelling out during cares..." ~2/13/13, "...Repeating self yelling calling out..." ~2/14/13, "...new open area to left mid buttock..." ~2/15/13, "...Would not get out of bed..." ~2/19/13, "...calling out...Upset that she needed to cut a tag out of her hat because the hat was not made in the USA and wasn't good..." ~2/25/13, "...Refused to get out of bed..." ~3/11/13, "...Refused all fluids and turns..." ~3/12/13, "[MEDICAL CONDITION] of people in her room combative..." ~3/14/13, "...refused meals refused hydration refused oral cares..." ~3/30/13, "...scratching, pinching yelling and being altogether (sic) incooperative (sic) when transferring out of bed..." ~4/4/13, "...Refused to get up..." ~5/3/13, "...yelling out..." ~5/7/13, "...combative, trying to scratch..." ~5/7/13, "...Continues to have an open area to Left buttock..." ~5/15/13, "...refusing cares..." ~5/16/13, "...While resident was getting hair rinsed of (sic) in shower, resident kept grabbing at her hair to prevent CNA (Certified Nursing Assistant) from washing her hair out. Her fingernail then got caught in...tangled hair and when resident pulled it out her R (right) middle fingernail fell off..." ~5/17/13, "...trying to throw herself out of bed and chair - scratching kicking grabbing..." ~5/29/13, "...yelling scratching combative..." ~6/4/13, "...approached multiple time during the shift for cares. refused each time. extremely resistive, scratching, screaming...kicking, hitting trying to bite CNA's..." Resident #5 triggered almost every common pain behavior in the cognitively impaired person. This was not identified by the facility. On 6/5/13 at 10:10 a.m., Surveyor # spoke with Resident #5's Guardian. Resident #5's Guardian indicated Resident #5 had a lot of fear and anxiety when cares were done including attempts to transfer Resident #5. Resident #5's Guardian also indicated Resident #5's wheelchair hurt her and Resident #5 had pain in her buttock area. Resident #5's Guardian felt Resident #5 would not be so fearful if staff would come in and just talk with her instead of always coming in and doing something to h

Based on interview and record review, the facility did not ensure that 1 of 5 sampled residents maintained acceptable nutritional status including both body weight and protein levels. Resident #5 was admitted to the facility for rehabilitation after a fall at home. Since admission to the facility on [DATE], Resident #5 lost 67.1 pounds. While the facility identified the weight loss, no interventions that met Resident #5's dietary restrictions were attempted to prevent further weight loss. This is evidenced by: Surveyor # completed a review of Resident #5's clinical record and noted the following: Resident #5 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) dated 10/22/12, indicated Resident #5: ~ Required supervision when eating; ~ Weighed 223 pounds; ~ Had not had a weight loss; and ~ Had no nutritional approaches. Resident #5's nutrition CAA (Care Area Assessment) summary dated 10/25/12, indicated Resident #5 was eating well and hydration was adequate. The CAA indicated no care plan was to be developed as "...no special interventions needed..." The most current MDS dated [DATE], indicated Resident #5: ~ Weighed 172 pounds; and ~ Received a mechanically altered therapeutic diet. Resident #5's most current CAA for nutrition was dated 4/4/13. The CAA indicated, "...pureed diet, avg (average) meal intake is 38%, hydration intake fair...reduced ability to feed self...recent hospitalized for [REDACTED]." Resident #5's comprehensive care plan did not contain a nutrition problem. A temporary care plan dated 1/14/13 and 3/27/13 indicated Resident #5 had inadequate intakes and was at risk for weight loss. It directed staff to assist Resident #5 with meals, to encourage intake of both food and fluid, to offer snacks, and to monitor weights. Neither temporary care plan identified Resident #5's actual weight loss. Resident #5's weight record indicated that on 10/20/12, Resident #5's weight was 223.2# (pounds). Resident #5's dietary note dated 10/24/12, indicated Resident #5 had a good appetite, ate independently, weighed 223.2 pounds, estimated fluid needs were 1800 cc's (cubic centimeters) per day, and Resident #5's calorie, protein, and fluid intakes were adequate. Weight documented on 11/2/12 was 221.0#. A dietary note dated 11/15/12, indicated Resident #5's intakes remained adequate. According to the weight record, Resident #5 refused all weights during the month of December 2012. A dietary note dated 12/4/12, indicated Resident #5's intakes were gradually decreasing and staff would continue to monitor Resident #5's intake and weights. The facility had identified intakes were decreasing. There were no interventions implemented to improve intake. Weight documented on 1/13/13 was 198.2# A dietary note dated 1/14/13, indicated, "...Calorie and protein intake are inadequate related to physiological causes as evidenced by poor oral intake and refusal of meals...will give ensure..." On 1/17/13, a dietary note indicated the Ensure was discontinued as Resident #5 was refusing the Ensure as well as meals. Despite the continued weight loss and inadequate intake, there were no other interventions put into place to prevent further weight loss. Weights continue: ~1/25/13, 194.0# ~2/16/13, 193.2# ~2/28/13, 176.6# ~3/7/13, 174.8# ~3/26/13, 173.6# There were no further dietary notes until 3/26/13. On 3/26/13, a dietary note indicated Resident #5 had returned from the hospital on a pureed diet. The facility implemented a protein powder twice a day. This was after Resident #5 had already lost 49.6 pounds. Weight documented on 4/1/13 was 173.6# A dietary note dated 4/3/13, indicated, "...returned after being recently hospitalized for [REDACTED]. Despite the continued weight loss and [DIAGNOSES REDACTED]. Weights continue: ~4/8/13, 171.0# ~4/18/13, 164.6# ~5/16/13, 156.1# Since admission 8 months ago, Resident #5 had lost 67.1 pounds or 30.06%. There were no new interventions implemented aside from the protein powder twice a day. During this period, Resident #5 had also experienced inadequate fluid intakes, pressure ulcers, and overall decline in physical functioning. (Refer to F309.) On 6/6/13 at 8:05 a.m., Surveyor # spoke with the RD (Registered Dietician) and DM (Dietary Manager) about the facility's Weight Management Program. The RD indicated the facility had multiple supplements which could be given when a weight loss was noted, including high protein jello, magic cups, Boost, Ensure, milk shakes, calorie enhanced foods including a high calorie juice prepared by the kitchen staff. Surveyor # asked the RD why Resident #5 had not been started on additional supplements. The RD stated Resident #5 was lactose intolerant and they had limited supplements Resident #5 could have. Surveyor # asked why the facility had not implemented one of the supplements appropriate to Resident #5's diet. The RD did not respond. The RD indicated Resident #5's son was bringing in food/fluids Resident #5 enjoyed.