Every finding on record at Trucare Living Centers

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Residents #49 and #53) reviewed for infection control. 1. The facility failed to ensure CNA C performed hand hygiene between glove changes during peri-care on 12/15/25 with Resident #49. 2. The facility failed to ensure CNA A and LVN B followed enhanced barrier precautions and wore a gown and gloves when providing direct care to Resident #53 on 12/15/2025. These failures could place residents at risk for cross contamination and infection. Findings: 1. Record review of a facility face sheet dated 12/16/25 for Resident #49 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including dementia and arthritis. Record review of a Quarterly MDS dated [DATE] for Resident #49 indicated a BIMS score of 10, which indicated he had moderately impaired cognition. He required total assistance with toileting hygiene. He was always incontinent of bowel and bladder. Record review of a comprehensive care plan dated 9/15/25 for Resident #49 indicated he was incontinent of bowel and bladder with an intervention to check every 2 hours and provide incontinent care as needed. During an observation on 12/15/25 at 10:41 am CNA A and CNA C were observed performing incontinent care on Resident #49. CNA C was observed to remove her gloves after completing incontinent care and proceeded to put on a clean pair of gloves before applying a clean brief without performing hand hygiene. During an interview on 12/15/2025 at 10:52 am, CNA C said she had been working here for about 6 years. She said she realized she had not sanitized between the last glove change, and she knew she should have. She said it was to prevent infections in residents. During an interview on 12/17/2025 at 9:06 am IP said she expected her staff to perform hand hygiene before and after care and with each glove change to help prevent an increased risk of infections in the residents. During an interview on 12/17/2025 at 9:56 am DON said she and IP were responsible for infection control. She said she expected her staff to properly perform hand hygiene by washing or sanitizing their hands between glove changes. She said the residents could be at an increased risk of infection if proper hand hygiene procedures were not followed. She said she would be educating staff on handwashing and monitoring closer for compliance going forward. During an interview on 12/17/2025 at 10:14 am Administrator said she expected staff to follow policy and procedures regarding hand hygiene before and after care, and between glove changes. She said residents could be exposed to infections if they are not followed. Record review of a Personnel Competency Review dated 12/17/25 for Fourth Quarter 2025 for CNA C, indicated she had been successfully checked off on perineal care and PPE. Record review of a facility policy titled Handwashing/Hand Hygiene dated 7/17/2012 read: .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: .m. after removing gloves . and .perform hand hygiene before applying non-sterile gloves . 2. Record review of Resident #53's facility face sheet revealed Resident #53 was a [AGE] year-old male that admitted to the facility on [DATE] with a diagnosis of pneumonia. Record review of Resident #53's comprehensive care plan dated 12/05/2025 revealed Resident #53 was on enhanced barrier precautions due to pressure ulcers and proper use of PPE to be observed, use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDRO. Record review of Resident #53's admission MDS assessment dated [DATE] revealed Resident #53 had a BIMS of 12 indicating moderately impaired cognition, was dependent on staff for all activities of daily living and had a pressure ulcer. Record review of Resident #53's order summary report dated 12/17/2025 did not reveal an order for EBP. During an observation on 12/15/2025 at 10:14 AM Resident #53 had a sign on his door indicating EBP, and there was a PPE cart inside the door of his room. During an observation on 12/15/2025 at 10:22 AM CNA A and LVN B entered Resident #53's room to reposition him. They both applied gloves but no gown and began providing care. Both adjusted his linen and lifted him into the bed and then readjusted his pillows and linens. They removed their gloves and performed hand hygiene before leaving the room. During an interview on 12/15/2025 at 10:25 AM CNA A said she was trained on EBP but had gotten confused on applying a gown and gloves for positioning. She said that she did make contact with the resident and his linens so she should have applied a gown and gloves before completing the task. She said by not following EBP she could spread infections to other residents. During an interview on 12/15/2025 at 10:26 am LVN B said she had received training on EBP and had also gotten confused on using a gown for positioning. She said the gown acted as a barrier between her and the resident and positioning a resident would require both gown and gloves. She said by not following EBP infections could spread. During an interview on 12/17/2025 at 9:03 am the Infection Preventionist said that she and the DON were responsible for oversight of the infection control program. She said that all staff were trained in EBP on hire, annually and as needed throughout the year. She said that EBP should be followed, and staff should be wearing a gown and gloves for high contact care to prevent the transmission of pathogens. She said she expected all staff to follow the infection control program. During an interview on 12/17/2025 at 9:55 am the DON said that she and the Infection Preventionist were responsible for oversight of the infection control program including EBP. She said that for residents that require EBP staff should be wearing gowns and gloves with all high contact care. She said she expected EBP to be followed every time high contact care was given to prevent the spread of infections. During an interview on 12/17/2025 at 10:13 am the Administrator said that the DON and Infection Preventionist were responsible for oversight of the infection control program. She said all staff were trained in EBP on hire, yearly and as needed, including competency checks for EBP. She said she expected all staff to follow the infection control policy and procedures to prevent the spread of infections. Record review of a course completion history report dated 12/17/2025 indicated CNA A had completed EBP training on 7/23/25 and LVN B had completed EBP training on 8/05/2025. Record review of an undated staff tool titled Enhance Barrier Precautions indicated, .Wear gown and gloves for high contact care including:DressingBathing/showeringTransferringProviding hygieneChanging linens Changing briefs or assisting with toiletingDevice care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilatorWound care: any skin opening requiring a dressing . Record review of a facility policy dated 6/17/2024 titled Enhanced Barrier Precautions indicated, .Enhanced Barrier Precautions shall be used at this facility per CDC requirements.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 4 residents (Resident #58) reviewed for care plans.The facility failed to ensure Resident #58's care plan reflected intervention of prophylaxis antibiotic indefinitely for prevention of urinary tract infection.This failure could place residents at risk of not receiving appropriate care to meet their current needs. The findings included: Record review of a face sheet dated 12/16/2025 for Resident #58 indicated she originally admitted on [DATE] and readmitted to the facility on [DATE] and was [AGE] year-old female with diagnoses of atrial fibrillation (rapid heart rate) malnutrition, lack of coordination. Record review of a Quarterly MDS assessment dated [DATE] for Resident #58 indicated she had moderate impairment in thinking with a BIMS score of 9. Resident #58 was dependent on personal hygiene including toileting. Section N - Medications indicated Resident #58 was taking a high-risk drug classified as antibiotic during the last seven days. Record review of Resident #58's care plan for bowel- bladder incontinence initiated 5/02/2023 indicated no interventions for long term use of prophylactic antibiotic use of Macrobid 100 milligrams every hour of sleep for prevention urinary tract infection. Record Review of physician order summary dated 12/16/2025 indicated Resident #58 originally admitted to the facility 09/30/2022 and readmitted after an acute hospital stay on 08/26/2025. Record Review of an acute hospital Discharge summary dated [DATE] indicated Resident #58 was treated for a urinary tract infection and discharged with a new prescription for Macrobid 100milligram by mouth every hour of sleep indefinitely for management of urinary tract infections. During an interview on 12/16/2025 at 11:30 AM the MDS Coordinator said she was responsible for revising and updating the care plans. The MDS Nurse said that Resident #58 had been taking Macrobid every hour of sleep for urinary tract prophylaxis since 08/26/2025. She said she did include the antibiotic on her quarterly MDS dated [DATE] and failed to update the care plan with interventions appropriate to long-term use of Macrobid for prevention of urinary tract infections. The MDS Coordinator said the risk to the residents could include all members of the IDT not knowing what was going on with the residents or any needed change in interventions not being addressed. The MDS Coordinator said she would update the care plan to addresspossible complications of long-term antibiotic use. During an interview on 12/17/2025 at 10:00 AM, the DON said the MDS Coordinator was responsible for updating and revising the comprehensive care plans. She said other staff would update them as well, whenever needed. She said she would get communications during the morning meetings if there was something about a resident that needed to be updated on the care plan. She said the MDS Coordinator also does reviews quarterly and after each MDS assessment such as a change of condition. She said if interventions were not included in the care plan, staff may not know resident needs and changes in care provided.During an interview on 12/16/2025 at 4:30 pm the Administrator said she was aware that Resident #58 had a problem with her care plan and interventions for long term antibiotic use had not been addressed. She said MDS Coordinator was responsible for updating and revising the comprehensive care plans and the care plan had already been updated. She said if interventions were not included in the care plan, staff may not know resident needs and changes in care provided. Record review of a facility policy titled Comprehensive Care Plan Revision dated 03/01/2022 reflectedPolicy Statement:An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.Policy Interpretation and ImplementationI. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.2. The Interdisciplinary Team documents in the CAT (Care Area Triggers) summary sheet and/or records in the clinical record: a. The residents' status in triggered CAT areas; b. The team's rationale for deciding whether to proceed with care planning; and c. Evidence that the team considered the development of care planning interventions for all CAT's triggered by the MDS.3.Each resident's Comprehensive Care Plan has been designed to: a. Incorporate identified problem areas, b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d .Reflect treatment goals and objectives in measurable outcomes; e. Identify the professional services that are responsible for each element of care; f. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; and g. Enhance the optimal functioning of the resident by focusing on a rehabilitative program.4. The resident's Comprehensive Care Plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MOS).5. Care plans are revised as changes in the residents' condition dictate. Care plans are reviewed at least quarterly and any significant change in status.6. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. When such refusals are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 12 residents and 1 of 1 medication rooms (Resident #26 and medication room B) reviewed for pharmacy services. 1. The facility failed to remove Resident #26's insulin that had expired on [DATE] from the nurse medication cart. 2. The facility failed to date when tuberculin PPD was opened. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization. Findings: 1. Record review of Resident #26's facility face sheet revealed Resident #26 was a [AGE] year-old female that was admitted on [DATE] with a diagnosis of senile degeneration of the brain (impaired memory). Record review of Resident #26's comprehensive care plan dated [DATE] indicated Resident #26 had diabetes mellitus and was on insulin, to give diabetes medication as ordered by doctor and monitor for side effects and effectiveness. Record review of Resident #26's quarterly MDS assessment dated [DATE] revealed Resident #26 had a BIMS of 09 indicating moderately impaired cognition and had received insulin. Record review of Resident #26's order summary report dated [DATE] revealed Resident #26 had an order for Admelog SoloStar 100 unit/ml Solution pen-injector, and to inject as per sliding scale before meals and at bedtime. During an observation of station A's nurse medication cart on [DATE] at 8:15 am Resident #26 had a syringe of Admelog Solostar insulin that was in use on the cart and dated [DATE]. During an interview on [DATE] at 8:16 am LVN B said all insulin should be dated when opened and the nurses should use the insulin storage policy to ensure the insulin was replaced appropriately. She said that Admelog insulin was to be discarded after 28 days and was not sure how it was missed on the cart. She said that medications that were past the use by date could have decreased potency or adverse effects. During an interview on [DATE] at 9:55 am the DON said that when insulin was removed from the refrigerator and placed on the medication cart the nurses should date the syringe and use the insulin storage requirement tool to know how long the medication was good for. She said the nurses should be checking their medication carts regularly and before administering any medication to ensure that it was within date. She said she expected the nurses to follow the storage requirements for medications to prevent adverse reactions. Record review of an undated nurse tool titled Insulin Storage Requirements revealed Admelog Solostar was good for 28 days after opening at room temperature. 2. During an observation of the medication room located at station B with the DON on [DATE] at 8:00 am there was an opened undated bottle of tuberculin PPD (used to detect tuberculosis infection) (Aplisol) in the refrigerator. During an interview on [DATE] at 8:02 am the DON said that the charge nurses were responsible for the administration of TB, and the vial should be dated when opened because it was only good for 30 days. She said that using TB that was past the administration date could cause false readings or adverse reactions. During an interview on [DATE] at 8:11 am LVN B said that when a resident was admitted the nurse administered the TB to the resident. She said the nurse should check the dates before administering. She said the vial was good for 28 days after opening and should be dated when opened and disposed of after 28 days to avoid inaccurate results. During an interview on [DATE] at 10:13 am the Administrator said that the nurses were responsible for proper labeling and storage of multiuse vials and insulin. She said that all nurses were trained on hire and as needed on proper medication storage and labeling. She said that TB should be dated when it was opened and discarded by the directions and if used past the date could cause false readings or medication ineffectiveness. She said Insulin should be checked by the nurses before administering and not given if it was expired. She said insulin should be discarded per the medication guidelines to prevent any possible complications. Record review of an untitled nurse tool dated [DATE] indicated, .tuberculin purified protein derivative (Aplisol) keep refrigerated and discard opened product after 30 days. Record review of a facility policy titled Storage of Medications dated [DATE] revealed, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 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 .

43994 46273 Based on observations, interviews and record reviews the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 5 of 18 residents (Residents #53, #70, #13, #74, and #130) reviewed for care plans in that: The facility failed to develop a comprehensive care plan for the use of enabler bars for Resident #13 that were put into use on 4/3/21. The facility failed to develop a comprehensive care plan for the use of side rails for Resident #74 that were put into use on 5/29/24. The facility failed to develop a comprehensive care plan for the use of a side rails for Resident #130 that was put into use on 7/30/24. The facility failed to develop a comprehensive care plan for the use of side rails for Resident #53 that was put into use on 12/7/2023. The facility failed to develop a comprehensive care plan for the use of side rails for Resident #70 that was put into use on 5/31/2023. This failure could place residents at risk of inappropriate care and decreased quality of life. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings included: Record review of a facility face sheet dated 09/17/24 for Resident #130 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia (Inability to adequately maintain adequate oxygen in the blood), reduced mobility and gastro-esophageal reflux disease (heart burn). Record review of a comprehensive MDS dated [DATE] for Resident #130 Section C (Cognitive Patterns) indicated that he was moderately cognitively impaired. Section P indicated no use of bed rails. Record review of a comprehensive care plan dated 08/05/24 for Resident #130 indicated interventions for use of an enabler bar for bed mobility, requires 1-2 staff participation to reposition and turn in bed. May use enabler bars to turn/reposition in bed. Use of side rails were not addressed. Record review of a face sheet for Resident #53 dated 9/17/2024 for Resident #53 indicated she admitted to the facility 2/21/2024 and was [AGE] years old with diagnosis of acute and chronic respiratory failure (a condition that makes it difficult to breathe on your own), type 2 diabetes, COPD (a lung disease causing restricted airflow and breathing problems) and osteoarthritis (inflammation of one or more joints). Record review of active physician orders for Resident #53 dated 9/17/2024 indicated an order with a start date of 12/7/2023 for use of enabler bars to turn and reposition in bed. Record review of a Quarterly MDS assessment dated [DATE] for Resident #53 indicated she did not have any impairment in thinking with a BIMS score of 15. She used a walker or wheelchair in the 7 day look back period. She was independent with the ability to roll left and right, sit to lying and lying to sitting on side of bed. Physical restraints of bed rails were not used. Record review of a care plan for Resident #53 dated 12/19/2023 indicated she had an ADL self-care performance deficit related to activity tolerance with interventions for bed mobility: requires 1 staff participation to reposition and turn in bed. May use enabler bars to turn/position in bed added on 9/17/2024. Record review of an Admission Record dated 9/17/2024 for Resident #70 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of unspecified tracheostomy (tube that in in the neck that allows them to breathe through the tube instead of their mouth or nose) and hypertension. Record review of active physician orders dated 9/17/2024 for Resident #70 indicated an order that may use enable bars to turn and reposition in bed that started on 5/31/2023. Record review of a Quarterly MDS Assessment for Resident #70 dated 7/20/2024 indicated she did not have any impairment in thinking with a BIMS score of 15. She used a walker and wheelchair during the 7 day look back period. Restraints and alarms indicated no use of bed rails. Record review of a care plan for Resident #70 dated 4/13/2023 indicated she had an ADL self-care performance deficit related to mobility status with an intervention for bed mobility: requires 1 staff participation to reposition and turn in bed. May use an enabler bar to turn/reposition in bed dated 9/17/2024. Record review of a facility face sheet dated 9/17/24 for Resident #74 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Urinary tract infection, type 2 diabetes mellitus, and reduced mobility. Record review of a comprehensive MDS assessment dated [DATE] for Resident #74 indicated that she had a BIMS score of 7, which indicated that she had severely impaired cognition. She was dependent on staff for transfers, rolling left to right, sitting to lying, and lying to sitting on side of bed. Assessment indicated that bed rails were not used. Record review of a comprehensive care plan dated 8/27/24 for Resident #74 indicated that she had an ADL self-care performance deficit, required 2 staff participation to reposition and turn in bed, and may use enabler bar to turn/reposition in bed was added on 9/17/24. Record review of a physician's order summary report dated 9/17/24 indicated that Resident #74 had the following order dated 8/26/24: .may use enabler bars to turn and reposition in bed . Record review of a Side Rail/Mobility/Positioning Bar Assessment - V 1 dated 9/10/24 for Resident #74 read .Please specify the type of rails being used . and form then read .1/4 rails, enabler bars, both sides . Record review of a facility form titled Physical Device Consent and Acknowledgement dated 5/30/24 for Resident #74 read .Type of Device Recommended by Inter-Disciplinary Team (IDT): .Side rails; 1/4 side rails and 1/2 side rails . During an observation on 9/16/24 at 10:11 am Resident #74 was observed lying in bed with 1/4 rails observed on both sides of bed. Resident did not speak. Record review of a facility face sheet dated 9/17/24 for Resident #13 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: congestive heart failure, reduced mobility, and repeated falls. Record review of a Quarterly MDS assessment dated [DATE] for Resident #13 indicated that he had a BIMS score of 7, which indicated that he had severely impaired cognition. He was dependent with transfers, required substantial/maximal assistance with sitting to lying and with lying to sitting, and required partial/moderate assistance with rolling left to right. Assessment indicated that bed rails were not used. Record review of an Order Summary Report dated 9/17/24 for Resident #13 indicated that he had the following order dated 5/31/23: .May use enabler bars to turn and reposition in bed . Record review of a comprehensive care plan dated 7/2/24 for Resident #13 indicated that he was at risk for falls and had an ADL self-care performance deficit. Care plan did not address the use of enabler bars or side rails. Record review of a facility form titled Physical Device Consent and Acknowledgement for Resident #13 read .Type of restraint recommended by inter-disciplinary team (IDT) .Side Rails - 1/4 side rail . During an interview on 9/17/2024 at 2:27 PM, MDS Coordinator said she had been employed at the facility for [AGE] years. She was responsible for the care plans, MDS assessments and PASSR. She said she revised care plans daily and quarterly with MDS assessments. She said what the Surveyors were calling side rails in the facility were called enabler bars and that was what corporate staff told them they were . She said the care plans already had enablers on them and they do not consider them as side rails. During an interview with the MDS Co-Ordinator on 09/18/24 09:49 AM the MDS Co-Ordinator said she had worked at the facility for [AGE] years and she used the orders and observations to code the MDS and complete the care plan for resident #130. She said she uses the term enabler when addressing the rails on resident's beds. During an interview on 09/18/24 at 9:55 am Administrator said that going forward she was expecting the MDS nurse to complete assessments and care plans accurately. She said residents could be at risk of not getting the care they needed since care plan focus areas were pulled over from assessment data on the MDS. Record review of a facility policy titled Care Plan Revised date 03-01-2022, read .An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical. nursing, mental, and psychological needs is developed for each resident .3. Each resident's Comprehensive Care Plan has been designed to: a. Incorporate identified problem, area: Incorporate risk factors associated with identified problems. Record review of a facility policy titled Care Plans-Comprehensive revised on 3/1/2022 indicated, .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents' medical, nursing, mental and psychological needs is developed for each resident. 4. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). 5. Care plans are revised as changes in the resident's condition dictate. Care plan are reviewed at least quarterly and any significant change in status .

Based on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 4 of 24 residents (Resident #53, #70, #74,and #16) reviewed for bed rails. 1.The facility failed to attempt to use an alternative for the use of bedrails and complete quarterly side rail assessments for Resident #53 who readmitted to the facility on [DATE] and a order with a start date of 12/7/2023 for use of enabler bars to turn and reposition in bed. 2.The facility failed to attempt to use an alternative for the use of bedrails and complete quarterly side rail assessments for Resident #70 who admitted to the facility on [DATE] and an order for Resident #70 that reflected the use of enable bars to turn and reposition in bed that started on 5/31/2023. 3.The facility failed to attempt to use an alternative for the use of bedrails for Resident #74 who admitted on [DATE] and an order dated 8/26/24: .may use enabler bars to turn and reposition in bed . 4. The failed to attempt to use an alternative for the use of bedrails and complete quarterly side rail assessments for Resident #16 who admitted to the facility on [DATE] and a siderail assessment was done one time in past 12 months on 05/16/2024 This failure could place residents at risk of entrapment or injury. Findings included: 1.Record review of a face sheet for Resident #53 dated 9/17/2024 indicated she readmitted to the facility 2/21/2024 and was [AGE] years old with diagnosis of acute and chronic respiratory failure (a condition that makes it difficult to breathe on your own), type 2 diabetes, COPD (a lung disease causing restricted airflow and breathing problems) and osteoarthritis (inflammation of one or more joints). Record review of active physician orders for Resident #53 dated 9/17/2024 indicated an order with a start date of 12/7/2023 for use of enabler bars to turn and reposition in bed. Record review of a Quarterly MDS assessment dated [DATE] for Resident #53 indicated she did not have any impairment in thinking with a BIMS score of 15. She used a walker or wheelchair in the 7 day look back period. She was independent with the ability to roll left and right, sit to lying and lying to sitting on side of bed. Physical restraints of bed rails were not used. Record review of a Side Rail/Mobility/Positioning Bar assessment dated [DATE] for Resident #53 indicated the resident made the request for side rails, no diagnoses was indicated, type of rails used 1/4 rails for both sides for bed mobility, and indicated it was care planned. Record review of a care plan for Resident #53 dated 12/19/2023 indicated she had an ADL self-care performance deficit related to activity tolerance with interventions for bed mobility: required 1 staff participation to reposition and turn in bed. May use enabler bars to turn/position in bed was added on 9/17/2024. Record review of a Side Rail/Mobility/Positioning Bar assessment dated [DATE] for Resident #53 indicated the resident made the request for side rails, no diagnoses was indicated, type of rails used 1/4 rails for both sides for bed mobility, and indicated it was care planned. Record review of a physical device consent and acknowledge form for Resident #53 dated 12/7/2023 indicated use of 1/4 side rails to assist with self-care-bed mobility was signed by the residents RP. During an observation and interview on 9/16/2024 at 11:56 AM, Resident #53 was in her room sitting on the side of her bed and said she had been at the facility since December 2023. She had 1/4 rails on both sides of the bed. During an observation and interview on 9/18/2024 at 8:14 AM, Resident #53 was in her room. She said on admission to the facility, the bed rails were on the bed when she arrived, and no one asked her if she wanted to keep them or not. She said she was able to move them up and down and did not remember if she signed a consent or not. She said she always kept the rails in the upright position, so they were positioned by her head to grab. Observation of 1/4 rails were in the upright position on both sides of the bed. 2. Record review of an Admission Record dated 9/17/2024 for Resident #70 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of unspecified tracheostomy (tube that in in the neck that allows them to breathe through the tube instead of their mouth or nose) and hypertension. Record review of active physician orders dated 9/17/2024 for Resident #70 indicated an order that reflected Resident #70 may use enable bars to turn and reposition in bed that started on 5/31/2023. Record review of a Quarterly MDS Assessment for Resident #70 dated 7/20/2024 indicated she did not have any impairment in thinking with a BIMS score of 15. She used a walker and wheelchair during the 7 day look back period. Restraints and alarms indicated no use of bed rails. Record review of a Side Rail/Mobility/Positioning Bar Assessment for Resident #70 dated 4/19/2024 indicated the request for use of side rails was done by the resident for right sided weakness. Type of rails used were 1/4 rails. Alternatives tried prior to the use of side rails were staff and was care planned. Record review of a care plan for Resident #70 dated 4/13/2023 indicated she had an ADL self-care performance deficit related to mobility status with an intervention for bed mobility: requires 1 staff participation to reposition and turn in bed. May use an enabler bar to turn/reposition in bed dated 9/17/2024. Record review of a physical device consent and acknowledgement for Resident #70 dated 3/27/2023 for use of 1/4 side rails as enablers indicated the resident signed consent electronically on 3/27/2023. Record review of a Side Rail/Mobility/Positioning Bar Assessment for Resident #70 dated 4/19/2024 indicated the request for use of side rails was done by the resident for right sided weakness. Type of rails used were 1/4 rails. Alternatives tried prior to the use of side rails were staff and was care planned. During an observation and interview on 9/16/2024 at 9:31 AM, Resident #70 was in bed awake, using oxygen via (through) her trach. She had 1/4 rails on both sides of the bed. During an observation on 9/16/2024 at 9:45 AM, 1/4 rails were on the bed in an upright position that looked like assist bars on the bed. During an observation and interview on 9/18/2024 at 8:20 AM, Resident #70 was in her room eating breakfast and 1/4 rails were in the upright position on both sides of the bed. She said when she admitted to the facility no one asked her if she wanted the bed rails or not. She said they did not explain to her any risks associated with having the bed rails on the bed. She said she was able to let the bed rails up and down on her own. She said she did remember signing a consent form for the rails when she admitted . 3. Record review of a facility face sheet dated 9/17/24 for Resident #74 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Urinary tract infection, type 2 diabetes mellitus, and reduced mobility. Record review of a comprehensive MDS assessment dated [DATE] for Resident #74 indicated that she had a BIMS score of 7, which indicated that she had severely impaired cognition. She was dependent on staff for transfers, rolling left to right, sitting to lying, and lying to sitting on side of bed. Assessment indicated that bed rails were not used. Record review of a comprehensive care plan dated 8/27/24 for Resident #74 indicated that she had an ADL self-care performance deficit, required 2 staff participation to reposition and turn in bed, and may use enabler bar to turn/reposition in bed was added on 9/17/24. Record review of a physician's order summary report dated 9/17/24 indicated that Resident #74 had the following order dated 8/26/24: .may use enabler bars to turn and reposition in bed . Record review of a Side Rail/Mobility/Positioning Bar Assessment - V 1 dated 9/10/24 for Resident #74 read .Please specify the type of rails being used . and form then read .1/4 rails, enabler bars, both sides . Record review of a facility form titled Physical Device Consent and Acknowledgement dated 5/30/24 for Resident #74 read .Ineffective alternatives for use of this device to manage the medical symptom have included: lowest level intervention/first intervention . During an observation on 9/16/24 at 10:11 am Resident #74 was observed lying in bed with 1/4 rails observed on both sides of bed. Resident did not speak. 4. Record review of a facility face sheet dated 09/17/2024 indicated Resident #16 was a [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of muscle weakness (generalized), moderate dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and muscle wasting. Record review of a comprehensive care plan initiated 04/30/2018 and updated 9/17/2024 indicated Resident #16 had an ADL self-performance deficit and bed mobility requires 2 staff participation to reposition and turn in bed and that she may use enabler bar to turn and reposition in bed and an intervention of side rails to aid in mobility and promote independence. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #16 had a BIMS of 09 indicating moderately impaired cognition. She was totally dependent on staff for transfers and rolling left to right. Record review of active physician orders for Resident #16 dated 9/18/2024 indicated an order with a start date of 05/31/2023 for use of enabler bars to turn and reposition in bed. Record review of quarterly assessments and a siderail assessment for Resident #16 show that they were done one time in past 12 months on 05/16/2024. During an observation on 09/16/2024 at 10:11 AM, Resident #16 was lying in bed. She was on an air mattress and quarter siderails were raised on left and right side of bed. During an observation on 09/17/2024 at 07:35 AM, Resident #16 was lying in bed. She was on an air mattress and quarter siderails were raised on left and right side of bed. During an observation on 09/18/2024 at 8:45 AM, Resident #16 was lying in bed. She was on an air mattress and quarter siderails were raised on left and right side of bed. During an interview on 9/17/2024 at 2:27 PM, MDS Coordinator said she had been employed at the facility for [AGE] years. She was responsible for the care plans, MDS assessments and PASSR. She said she revised care plans every day and quarterly with MDS assessments. She said what the Surveyors are calling side rails in the facility were enabler bars and that what was told to them by their corporate staff. came from corporate staff. She said she did not code side rails on the MDS assessments as side rails because they consider them enabler bars until the Surveyors brought it to their attention on 9/16/2024. During an interview on 9/17/2024 at 2:34 PM, the Maintenance Supervisor said he had been employed at the facility since July 31, 2024. He said he had never worked in maintenance before. He said she inspected the rails on the beds monthly, 2nd week of the month and checked all of the beds in the facility. He said his first inspection was in August 2024 and did not find anything on his first assessment. He said he had a form that he used to check for the zones in the beds for measuring the space between the mattress and the frame of the bed. He said if he had a question that the Administrator would not answer, then he would call the corporate maintenance for answers. He said he also checked the assist bars to ensure they were able to go up and down but had not changed a bed side rail out and did not know if they were the correct ones that went with the beds. He said as far as he knew, all the bed rails in facility came on the beds that they were on and he just checked the functionality of them. He said if he noticed they were loose, he would tighten them. During an interview on 9/17/2024 at 2:48 PM, the Regional Nurse said she had been in her position for [AGE] years. Said that bed rails in the facility were classified as enabler bars to assist in bed with mobility. They looked at the side rails as 1/2 rails that covered 3/4 of the side of the bed and they were used as enabler bars but said she would go and look facility wide at the side rails. During an interview on 9/17/2024 at 2:59 PM, the DON said she had been employed at the facility for 4 years. She said they always classified the bars on beds as enablers as it allowed the residents to help turn themselves and they were able to hold on if they wanted to while being turned. She said rails were on the beds on admission to the facility. She said side rails were not a restraint. When residents come in to admit, they ask the resident or family if they want the enabler bars on bed. She said they did offer alternatives but was not sure and told the Surveyors that they would have to ask staff if they ask that. She said consents were included in the admission packet and signed before admission in the facility. She said if a resident/family requested not to have rails, then they would offer a lower bed, or other alternatives, and etc. She said the side rail assessments should be completed every 3 months and the charge nurses were responsible for completing them. She said they did check the mattresses in the facility for risk of entrapment. During a follow up interview on 9/17/2024 at 3:16 PM, the Regional Nurse said the problem with the side rails on the bed were the placements of some of them being in the middle of the bed. She said residents could be at risk for entrapment. Record review of facility log forms titled Bed Rail Inspection dated 6/19/24, 7/17/24, 7/18/24, and 8/15/24 indicated that facility was inspecting beds in the facility with bed rails for entrapment risk. Record review of a facility policy titled Proper Use of Side Rails revised 11/27/2017 indicated, .The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfers of residents. 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. bed mobility; b. ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. risk of entrapment from the use of side rails; and d. that the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails . 46273 49017

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 2 of 11 residents reviewed for quality of care, (Resident #6 and #281) in that: The facility failed to remove worn, damaged and bleached mechanical lift slings from service for Residents #6 and #281. The facility failed to obtain physician orders for mechanical lift transfers for Resident #6. This deficient practice could result in a loss of quality of life due to injuries. Findings included: Record review of a facility's face sheet dated 5/21/24 for Resident #6 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Lack of co-ordination, osteoarthritis (degeneration of the bones) and muscle weakness. Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated that she was rarely/never understood, and that Resident #6 was severely cognitively impaired. Assessment also indicated that she was totally dependent with transfers. Record review of a comprehensive care plan dated 8/27/24 indicated that Resident #6 was totally dependent on a mechanical lift with the assistance of 2 persons for transfers. Record review of a physician order report dated 09/17/24 for Resident #6 indicated that she did not have a physician order for mechanical lift transfers. Record review of a facility face sheet dated 09/16/2024 indicated Resident #281 was an [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of displaced intertrochanteric fracture of right femur (common hip fracture), reduced mobility and chronic obstructive pulmonary disease (a condition that limits airflow into and out of the lungs). Record review of a comprehensive care plan initiated 06/24/2024 indicated Resident #281 required transfer assist of 2 staff with or without mechanical device. Record review of an admission MDS assessment dated [DATE] indicated Resident #281 had a BIMS of 07 indicating severely impaired cognition. Resident required moderate to maximal assistance with transfers and moderate assist with rolling left to right. During an observation on 09/16/2024 at 10:11 AM, of a Hoyer lift sling under Resident #281 while he was sitting in his wheelchair, the colored connection tabs were faded, light in color and the care label was illegible and shrunken. During an observation and Interview on 09/16/24 at 10:15 AM Resident #6 in room sitting in chair watching TV dressed neatly, denies any problems with staff. She was sitting in a chair with a Hoyer lift sling underneath her. The straps are faded in color they all appear to be a light purple pink not bright Blue, Bright Purple, or Bright green. During an interview with the DON on 9/17/2024 at 07:49 AM who said that she was aware that the resident was in a sling that needed to be replaced and that a new sling was being delivered and would be replaced as soon as it arrived. During an Interview on 09/16/24 10:31 AM with CNA A, unable to answer why or what she would look for to ensure the Hoyer sling was safe. During an interview on 09/16/24 10:32 AM with CNA B said she would look for rips or tears on the Hoyer sling before use. Asked her what is wrong with Resident #6's Hoyer sling, and she could not give an answer. During an observation and interview on 09/16/24 10:40 AM with the DON who said she was not aware faded slings needed to be taken out of service. She said the faded slings would be removed from service immediately. During an interview with the DON on 9/17/2024 at 07:49 AM she said that she was aware that the resident was in a sling that needed to be replaced and that a new sling was being delivered and would be replaced as soon as it arrived. During an interview on 9/17/24 at 10:06 AM, Laundry Aide said she had been employed at the facility for [AGE] years. She said the Hoyer lift slings were washed with personals, if there were a lot of them, they were washed by themselves. She said if a resident was in isolation and the laundry arrived in a yellow bag, the slings would be washed, and the wash included bleach. She said the slings were hung up to dry. She said they used a log in the past when the lift slings came into the laundry to keep track but no longer use it and no one has informed her that she needed to. She said once the slings were removed from the washer, she would inspect them for any tears or frays, if they had them would discard them in the trash. During an interview and observation on 09/17/24 at 10:10 am, the DON said sling pads should be inspected by the staff before using them to transfer a resident and that worn sling pads could put residents at risk for falls. During an interview on 09/17/24 at 11:00 am, Med Aide D said she had been employed [AGE] years. She said she looked for signs of wear on the lift pads such as loose strings and faded coloring on the straps. She said if she observed any signs of wear, she would not use the lift pad to transfer a resident. She said worn pads could break causing a resident to fall. During an interview on 09/17/24 at 11:10 pm, Med Aide E said she had been employed for about two years. She said she would look for loose seams, faded colors, rips and tears on the lift pads before use. She said that lift pads that had faded coloring, loose seams, and rips or tears could break while using them, and a resident could fall. During an observation on 09/17/24 at 12:30 pm, Medical Record Staff brought in approximately 12 new Hoyer lifts slings for the staff to put in rotation and remove any faded and worn slings out of rotation. During an interview on 09/18/24 at 10:30 pm, the Administrator said there could be a chance of the sling breaking if it was worn. She said they ordered new slings, and the DON would be inspecting them routinely from then on. She said they educated the CNAs, and they would be expecting the CNAs to inspect all slings prior to using them for a resident. Record review of the facility's policy titled Lifting Machine, using a Portable revised March 2014 read .The purpose of this procedure is to help lift residents using a manual device . There were no interventions to ensure the sling were examined before use for rips, frays, tearing or other indications of potential failure as specified by the manufacturer. Record review of the facility's policy titled Safety and Supervision of Residents revised March 2014 read .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Record review of manufacture guidelines Full Body Slings - Instructions for use accessed at www.medline.com on 09/18/24 read .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use . and .Do not remove sling labels. If sling labels are removed or no longer legible, sling must be immediately removed from use . 49017

43994 46273 Based on observations, interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 6 of 15 residents (Residents #40, #53, #70, #74, #17, and #7) reviewed for MDS assessment accuracy. 1.The facility incorrectly coded Resident #40 as having received Insulin in previous 14 days while a resident on his MDS Assessment. 2.The facility failed to accurately code on the MDS assessments for Resident's #53 on 8/10/2024, #70 on 7/20/2024, #74 on 8/29/2024 and #7 on 8/7/2024 who had side rails on their bed. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1. Record review of the facility face sheet dated 9/17/2024 for Resident #40 reflected that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), reduced mobility and muscle weakness. Record review of a Quarterly MDS dated [DATE] for Resident #40 indicated that he had a BIMS score of 12, indicating that he had moderately impaired cognition. Section O, question O0100, 2c indicated that resident had received Insulin in the previous 14 days. Record review of the medication administration record for Resident #40 for the months of July 2024 and August 2024 indicated that he had not received insulin for the look-back period (previous 14 days) of the MDS. Resident received a weekly injection of Bydureon BCise 2 MG/0.85ML which was not insulin. Record review of Resident #40's care plan revised 6/22/24 indicated problem: Diagnosis of Diabetes with an intervention to monitor effectiveness of medications. Record review of Resident #40's physician orders dated July and August 2024 indicated that he had no orders for insulin. During an Interview on 09/18/24 at 11:20 AM the MDS Co-Ordinator said that she thought the Bydureon BCise 2 MG/0.85ML Auto-injector was a type of insulin and coded the MDS to reflect that in error. The MDS Co-Ordinator said the MDS must be completed accurately to ensure proper care is planned for the resident. 2. Record review of a face sheet for Resident #53 dated 9/17/2024 for Resident #53 indicated she admitted to the facility 2/21/2024 and was [AGE] years old with diagnosis of acute and chronic respiratory failure (a condition that makes it difficult to breathe on your own), type 2 diabetes, COPD (a lung disease causing restricted airflow and breathing problems) and osteoarthritis (inflammation of one or more joints). Record review of active physician orders for Resident #53 dated 9/17/2024 indicated an order with a start date of 12/7/2023 for use of enabler bars to turn and reposition in bed. Record review of a Quarterly MDS assessment dated [DATE] for Resident #53 indicated she did not have any impairment in thinking with a BIMS score of 15. She used a walker or wheelchair in the 7 day look back period. She was independent with the ability to roll left and right, sit to lying and lying to sitting on side of bed. Physical restraints of bed rails were not used. Record review of a care plan for Resident #53 dated 12/19/2023 indicated she had an ADL self-care performance deficit related to activity tolerance with interventions for bed mobility: requires 1 staff participation to reposition and turn in bed. May use enabler bars to turn/position in bed added on 9/17/2024. During an observation and interview on 9/16/2024 at 11:56 AM, Resident #53 was in her room sitting on the side of her bed. She said she had been at the facility since December 2023. She had 1/4 rails on both sides of the bed. During an observation and interview on 9/18/2024 at 8:14 AM, Resident #53 said on admission to the facility bed rails were on the bed when she arrived, and no one asked her if she wanted to keep them or not. She said she always kept the rails in the upright position, so they were positioned by her head to grab. 1/4 rails were observed in the upright position on both sides of the bed. Record review of an Admission Record dated 9/17/2024 for Resident #70 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of unspecified tracheostomy (tube that in in the neck that allows them to breathe through the tube instead of their mouth or nose) and hypertension. Record review of active physician orders dated 9/17/2024 for Resident #70 indicated an order that may use enable bars to turn and reposition in bed that started on 5/31/2023. Record review of a Quarterly MDS Assessment for Resident #70 dated 7/20/2024 indicated she did not have any impairment in thinking with a BIMS score of 15. She used a walker and wheelchair during the 7 day look back period. Restraints and alarms indicated no use of bed rails. Record review of a care plan for Resident #70 dated 4/13/2023 indicated she had an ADL self-care performance deficit related to mobility status with an intervention for bed mobility: requires 1 staff participation to reposition and turn in bed. May use an enabler bar to turn/reposition in bed dated 9/17/2024. During an observation and interview on 9/16/2024 at 9:31 AM, Resident #70 was in bed awake, using oxygen via (through) her trach. She had 1/4 rails on both sides of the bed. Record review of a face sheet for Resident #7 dated 9/17/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of type 2 diabetes, anemia, contracture of left hand (a shortening and hardening of the muscles) and hypertension. Record review of active physician orders for Resident #7 dated 9/17/2024 indicated an order that they may use enabler bars to turn and reposition in bed dated 5/21/2023. Record review of a Quarterly MDS Assessment for Resident #7 dated 8/7/2024 indicated he had moderate impairment in thinking with a BIMS score of 6. He was dependent on staff with assistance with rolling left and right, sitting to lying, and lying to sitting on side of bed. The use of bed rails was not used. Record review of a care plan for Resident #7 dated 6/15/2016 indicated he had an ADL self-care performance deficit related to limited mobility with interventions of bed mobility: may use enabler bars for help with repositioning and turning in bed dated 6/27/2016. During an observation on 9/16/2024 at 9:21 AM, Resident #7 was in bed resting with eyes closed. He had 1/4 rails on both side of the bed in the middle with sheep skin covering them. During an observation on 9/17/2024 at 12:20 PM. Resident #7 was in bed watching tv and the 1/4 rails that were on the bed were up in the middle of the bed. The rails had sheep skin covering both of them. Record review of a facility face sheet dated 9/17/24 for Resident #74 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Urinary tract infection, type 2 diabetes mellitus, and reduced mobility. Record review of a comprehensive MDS assessment dated [DATE] for Resident #74 indicated that she had a BIMS score of 7, which indicated that she had severely impaired cognition. She was dependent on staff for transfers, rolling left to right, sitting to lying, and lying to sitting on side of bed. Assessment indicated that bed rails were not used. Record review of a comprehensive care plan dated 8/27/24 for Resident #74 indicated that she had an ADL self-care performance deficit, required 2 staff participation to reposition and turn in bed, and may use enabler bar to turn/reposition in bed was added on 9/17/24. Record review of a physician's order summary report dated 9/17/24 indicated that Resident #74 had the following order dated 8/26/24: .may use enabler bars to turn and reposition in bed . Record review of a Side Rail/Mobility/Positioning Bar Assessment - V 1 dated 9/10/24 for Resident #74 read .Please specify the type of rails being used . and form then read .1/4 rails, enabler bars, both sides . Record review of a facility form titled Physical Device Consent and Acknowledgement dated 5/30/24 for Resident #74 read .Type of Device Recommended by Inter-Disciplinary Team (IDT): .Side rails; 1/4 side rails and 1/2 side rails . During an observation on 9/16/24 at 10:11 am Resident #74 was observed lying in bed with 1/4 rails observed on both sides of bed. Resident did not speak. During an interview on 9/17/2024 at 2:27 PM, MDS Coordinator said she had been employed at the facility for [AGE] years. She was responsible for the care plans, MDS assessments and PASSR. She said she revised care plans every day and quarterly with MDS assessments. She said what the Surveyors are calling side rails in the facility were enabler bars and that what was told to them by their corporate staff. She said she did not code side rails on the MDS assessments as side rails because they consider them enabler bars until the Surveyors brought it to their attention on 9/16/2024. During an interview on 9/17/2024 at 2:48 PM, the Regional Nurse said she had been in her position for [AGE] years. Said that bed rails in the facility were classified as enabler bars to assist in bed with mobility. They looked at the side rails as 1/2 rails that covered 3/4 of the side of the bed and they were used as enabler bars but said she would go and look facility wide at the side rails. During an interview on 9/17/2024 at 2:59 PM, the DON said she had been employed at the facility for 4 years. She said they always classified the bars on beds as enablers as it allowed the residents to help turn themselves and they were able to hold on if they wanted to while being turned. She said rails were on the beds on admission to the facility. She said side rails were not a restraint. During a follow up interview on 9/17/2024 at 3:16 PM, the Regional Nurse said the problem with the side rails on the bed were the placements of some of them being in the middle of the bed. She said residents could be at risk for entrapment. During an interview on 09/18/24 12:04 PM, the Administrator said the MDS assessments should reflect accurate information to ensure the highest level of well-being for the resident. Record review of a facility polity titled Resident Assessment Instrument (MDS 3.0) revised 3/1/2022 indicated, .A comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. 1. Within fourteen (14) days of the resident's admission, a comprehensive assessment of the resident's needs will be made by the Interdisciplinary Assessment Team. 6. Within seven (7) days of the completion of the resident assessment, a comprehensive care plan will be developed. 4. Information derived from the comprehensive assessment enables the staff to plan care that allows the resident to reach his/her highest practicable level of functioning and to meet their unique care needs. 7. All persons who have completed any portion of the MDS 3.0 Resident Assessment Form must electronically sign each document attesting to the accuracy of such information . Record review of manufacturer www.astrazeneca-us.com accessed 09/18/2024 indicated Bydureon BCise Auto injector, generic name: exenatide extended release, drug class Incretin Mimetics (GLP-1 Agonists) Record review of facility policy titled Certifying Accuracy of the Resident assessment dated 2001 with revision date of November 2019 indicated .The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment .

Based on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 6 Residents (Resident #53) reviewed for PASSAR (Preadmission Screening and Resident Review Services). The facility failed to ensure Resident #53 had a new level 1 PASSAR completed with a diagnosis of bipolar disorder on admission 12/7/2023. These failures could place residents at risk of not receiving the needed PASSAR services to meet their individual needs and could result in a decreased quality of life. The findings included: Record review of a face sheet for Resident #53 dated 9/17/2024 for Resident #53 indicated she admitted to the facility 2/21/2024 and was [AGE] years old with diagnosis of acute and chronic respiratory failure (a condition that makes it difficult to breathe on your own), type 2 diabetes, COPD (a lung disease causing restricted airflow and breathing problems), osteoarthritis (inflammation of one or more joints) and bipolar disorder (a mental illness characterized by extreme mood swings) that was effective on 12/7/2023. Record review of a care plan for Resident #53 dated 12/19/2023 indicated she would have a PASSR screening according to regulatory guidelines. This was completed on 12/7/2023 and revealed a need for no specialized services. Record review of a Quarterly MDS assessment dated [DATE] for Resident #53 indicated she did not have any impairment in thinking with a BIMS score of 15. A referral was not made to the local contact agency because the referral was not wanted. During an interview on 9/17/2024 at 3:50 PM, the MDS Coordinator said she had been employed at the facility for [AGE] years and was responsible for the coordination of PASSR. She said she missed on the diagnosis list for Resident #53 that she had bipolar on admission to the facility on [DATE]. She said she was not aware of it until 9/16/2024 when the Surveyor questioned her about an evaluation for PASSR for the resident. She said Resident #53 should have had a PASSR evaluation on admission with her mental illness diagnosis of bipolar. She said she was responsible for looking at the orders and would run an order report daily and just missed recognizing that Resident #53 had a mental illness diagnosis of bipolar. She said she generated a new PASSR Level 1 (PL1) today 9/17/2024 and contacted the local authority to notify them to conduct an evaluation with the resident. She said residents could be at risk for a relapse or exacerbation of their mental illnesses if they did not get the services they qualified for. She said she submitted the new PL1 into the portal in SIMPLE and would be waiting on a response. She said she had training on PASSR in the past and was not sure how it was missed with Resident #53, and it was an error on her part. During an interview on 9/18/2024 at 2:27 PM, the Administrator said she was made aware on yesterday 9/17/2024 about Resident #53 not having a PASSR evaluation on admission to the facility. She said she was told it was an oversight on the MDS Coordinator's part. She said the MDS Coordinator has a regional support contact that provides offsite checks and going forward would have her supervisor check to ensure residents had coordination of services if necessary. She said they would put a plan in place to check in the facility and with corporate. A copy of a PASSR policy was requested from the facility and was told they did not have a policy and they followed the RAI manual for guidance.

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 1 of 11 resident's (Resident #54) personal refrigerators reviewed for food and nutrition services. The facility failed to ensure a personal refrigerator on [DATE] for Resident #54 did not contain a jar of mayonnaise with an expiration date of [DATE]. These failures could place residents at risk for food borne illnesses. Findings include: Record review of a face sheet for Resident #54 dated [DATE] indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of venous insufficiency (occurs when the veins in the legs have difficulty returning blood to the heart), malignant neoplasm of prostate (prostate cancer) and dementia. Record review of a resident/patient refrigerator log dated [DATE] indicated on [DATE] the refrigerator was checked as indicated by the initials of RNA. Record review of an Admission MDS Assessment for Resident #54 dated [DATE] indicated he had moderate impairment in thinking with a BIMS score of 8. He required set up or clean up assistance with eating. Record review of a care plan for Resident #54 dated [DATE] indicated he had an ADL self-care performance deficit related to activity intolerance with interventions for eating: required set up help from staff participation to eat. During an observation and interview on [DATE] at 9:12 AM, Resident #54 was in his room sitting up in a wheelchair. He had a personal refrigerator in his room that had a jar of mayonnaise that expired [DATE]. He said he ate foods from his refrigerator and that staff checked it. During an observation and interview on [DATE] at 8:17 AM, Resident #54 was in his room and the jar of mayonnaise was not in his refrigerator. He said a staff member removed it on yesterday [DATE]. During an interview on [DATE] at 8:25 AM, RNA said she had been employed at the facility for 11 ,d+[DATE] years and was responsible for checking the personal refrigerators on halls 200 and 400. She said she checked the refrigerators daily for expired food items or foods that had been left for more than 3 days and then would throw them away. She said she checked Resident #54's refrigerator daily but did not remember seeing a bottle of expired mayonnaise. She said she did not keep a log of the refrigerators that she checked and only put the temperatures on the temperature log that was on the refrigerators. She said residents could be sick from eating foods that were expired especially mayonnaise. She said she had not removed anything from his refrigerator. She said some residents would get upset if they removed foods from their personal refrigerators but Resident #54 did not. During an interview on [DATE] at 2:13 PM, the DON who said the personal refrigerators were the responsibility of the restorative aides. She said they were responsible for checking refrigerators daily for temperatures, foods that are not left more than 3 days, and milk to make sure it was not spoiled. She said residents could be at risk for food poisoning or getting sick if items were left in their refrigerators. During an interview on [DATE] at 2:27 PM, the Administrator said the RNAs were responsible for checking the personal refrigerators daily for temperatures and foods. She said the department heads checked daily to be sure the temperatures were done and what was in the refrigerators. She said she removed the expired mayonnaise from Resident #54's refrigerator on Monday night [DATE]. She said going forward she would continue to have the RNA's check the refrigerators daily and would require the department heads to check daily as well. She said residents could get ill if they ate expired foods. Record review of a facility policy titled Foods Brought by Family/Visitors revised on [DATE] reflected, .Staff must be aware of, and approve, food(s) [NAME] to a resident by family/visitors. 1. Family members should inform nursing staff of their desire to bring foods into the facility. 7. The nurse staff is responsible for discarding perishable foods on or before the use by date .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 4 residents (Resident #39) reviewed for pharmacy services. The facility did not ensure medications were properly administered to Resident #39. This failure could place residents at risk for the unsafe administration of medications and not receiving prescribed doses of ordered medications. Findings: Record review of facility face sheet dated 8/15/2023 indicated Resident #39 was admitted on [DATE] with diagnoses of respiratory failure with hypoxia (low oxygen level) and end stage renal disease. Record review of quarterly MDS dated [DATE] revealed Resident #39 had a BIMS of 12 indicating mild cognitively impairment. Record review of comprehensive care plan dated 06/28/2023 did not indicate Resident # 39 could safely self-administer medications. Record review of physician order dated 9/13/2020 indicated Resident #39 took Carafate 1 gram 1 tablet by moth four times a day. Physician order dated 6/12/2023 indicated Resident #39 took Sevelamer 800mg 1 tablet by mouth three times a day. During an observation on 08/14/23 at 09:50 am Resident # 39 had a medicine cup with 2 tablets present: 1 white imprinted with R789 and 1 pink imprinted with 1712. Resident #39 stated he was asleep, and the worker left the medicine for him to take. Resident #39 stated the staff handed him the medicine cup and did not watch him take his medicine. During an interview on 8/14/2023 at 12:36 pm MA A stated she had been a medication aide since 1995 and employed at the facility for 8 years. She stated she gave Resident # 39's medicine and she watched him turn the medicine cup up to his mouth before she walked out of the room but did not ensure he took them. She stated the medicines in the medicine cup were Carafate and sevelamer. She stated she had been trained on proper medication administration and ensuring residents took their medicine and by not doing so could affect the resident or other residents if they were to take medicine that was left in the room. During an interview on 08/15/23 at 8:38 am the DON stated she and the ADON were responsible for all training and MA A had been properly trained on medication administration. She stated she expected all staff passing medications ensured medications were taken by the resident and by not doing so could cause the resident not to get the benefit of their medicine or another resident could take them. During an interview on 8/16/2023 at 9:48 am the Administrator stated the medication aide and nurses were to make sure all medications were taken before leaving the resident's room. She stated she expected no medications were left at the bedside to prevent an adverse event from occurring with the resident. Record review of Personnel Competency Review dated Second Quarter 2023 for Med Pass indicated in checklist, Resident is observed to ensure medication is swallowed. Record review of medication pass audit dated 2/10/2023 indicated, 24. Medication is not left at the bedside Record review of facility policy titled Administering Medications dated 11/25/2017 indicated, .Medications shall be administered in a safe and timely manner .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 4 of 17 residents reviewed for care plans. (Resident #53, Resident #29, Resident #32, and Resident #31). -Resident #53's order to be repositioned every hour was not addressed in the comprehensive care plan. - Resident #29's Incontinent of bowel and bladder status was not addressed in the comprehensive care plan. - [CONDITION(S)] Medications for Resident #32's was not addressed in the comprehensive care plan. - Resident #31's care plan had a status for wanting Cardiopulmonary resuscitation (CPR) and a Do-Not-Resuscitate (DNR). The care plan did not address her wishes to have a shower once a week in the AM on her care plan. These failures could place residents at risk of not having individual needs met, a decreased quality of life, developing a pressure injury and delay wound healing. Findings include: 1. Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #53 was [AGE] year-old, admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent MDS dated [DATE] indicated Resident #53 sometimes understood others and was sometimes understood. The MDS indicated a BIMS score of 1, indicating the resident was severely cognitively impaired. The MDS indicated Resident #53 was totally dependent on staff for bed mobility and dependent to roll to the left or to the right. Resident #53 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the comprehensive care plan dated [DATE] indicated Resident #53 had an actual skin impairment with a stage IV pressure area that he was receiving treatment for. An intervention was needing assistance to turn/reposition at least every 2 hours. An observation on [DATE] at 7:41 AM revealed Resident #53 was positioned to the left side with pillows under his right side. An observation on [DATE] at 8:45 AM revealed Resident #53 was positioned to the left side with pillows under his right side. An observation [DATE] at 9:44 AM revealed Resident #53 was positioned to the left side with pillows under his right side. An observation on [DATE] at 10:24 AM revealed Resident #53 was positioned to the left side with pillows under his right side. An observation on [DATE] at 10:45 AM revealed Resident #53 was positioned to the left side with pillows under his right side. During an interview on [DATE] at 08:48 AM, CNA D revealed she looked at the care plan every day because things could change for residents. She said Resident #53 was turned every 2 hours. She said she had been trained to check the care plan. She said she knew how often to turn the resident by looking at the care plan. She said she did not check the orders. She said it was the nurse's responsibility to check the doctor's orders. During an interview on [DATE] at 9:23 AM, LVN E revealed she checked the resident's orders every shift. She said Resident #53 was to be turned every hour. She said Resident #53 had a doctor's order to be turned every hour. She said the care plan indicated to turn Resident #52 every 2 hours, but the doctor did order for the resident to be turned every hour. She said it was standard practice for a resident to be turned every 2 hours. She said the resident not being turned per doctor's orders could put the resident at risk for further skin breakdown. She said it could also slow healing on his existing wound or cause the wound current wound to regress. During an interview on [DATE] at 9:57 AM, the DON revealed the MDS nurse was responsible for updating care plans. She said if there was an order with a specific intervention, she would expect for that order to be care planned. She said if there was a doctor's order for a resident to be turned every hour then the resident should be turned every hour. She said the resident not being turned per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 10:29 AM, the MDS Nurse said she was the one responsible for updating care plans. She said her process was to go through the orders and 24-hour reports for what needed to be updated in the care plan. She said it depended on the order or specific intervention if it should be care planned. She said the order for Resident #53 should have been care planned. She said she really was not sure how this could negatively affect the resident. During an interview on [DATE] at 10:59 AM, the Administrator said she would have expected the Q 1 hour turn order for Resident #51 to have been care planned. She said if she were the nurse on the floor her aides would know to turn the resident every hour because she would verbally tell them. She said the MDS Nurse was the one responsible for updating care plans and the corporate nurse was the one responsible for making sure the care plans are up to date. She said not following the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Record Review of Resident #29s consolidated physicians' orders, undated indicated Resident #29 was a 67 y/o male with a history of Diabetes, [CONDITION(S)] (CHF), End Stage [CONDITION(S)] and [CONDITION(S)] (hypertension). Record Review of the MDS dated [DATE] indicated Resident #29 had a BIMS score of 10, he was moderately impaired in cognition. Section G Functional status of the MDS indicated Resident #29 was scored a 1 and 2 for section I. toilet use for supervision and one-person physical assist. MDS section H bowel and bladder indicated the resident was occasionally urinary incontinence and frequent bowel incontinence. Record Review of MDS dated [DATE] indicated Resident #29 had frequent bladder and bowel incontinence. Record Review of Resident #29s care plan dated [DATE] indicated Resident #29 had an ADL self-care performance deficit r/t activity intolerance. The goal was Resident #29 will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. Interventions were for skin inspection daily (initiated on [DATE]), PT/OT, bell to call for assistance, skin inspection, bathing, oral care, dressing and eating. The MDS did not address interventions for toileting or bowel and bladder. During interview on [DATE] at 10:34 AM, The MDS coordinator stated all MDS indicators should be care planed. The MDS coordinator stated she was the one responsible for updating the care plans and MDS's and she does not have a backup to assist with updating the care plans while she was out on leave. The MDS coordinator stated she was RUGS (Resource Utilization Group) certified when asked who was responsible for training her. The MDS coordinator stated not care planning for Resident #29's bowel and bladder status could not negatively impact the resident because the nurses complete weekly skin assessments to monitor for skin breakdown. 3. Record Review of Resident #32s consolidated physicians' orders undated indicated that Resident #32 was a [AGE] year-old male with a history of [CONDITION(S)] disease (brain disease), dementia with Lewy Bodies and history of falling. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #32 was taking [MEDICATION(S)] tablet 25 mg 1 tab by mouth at bedtime related to dementia with Lewy bodies. Record Review of Resident #32's undated care plan did not indicate [CONDITION(S)] medications-antipsychotic medications. Record Review of Resident #32's MDS dated [DATE] indicated a BIMS score of 12 for mildly impaired cognition. Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received r antipsychotic. During interview with LVN C on [DATE] at 09:07 AM, LVN C stated that it was the responsibility of the MDS coordinator to complete and update all care plans. During interview on [DATE] at 02:36 PM, the DON could not provide a care plan with [CONDITION(S)] medication on it for Resident #32 she stated she would have to ask the MDS coordinator because she was responsible for completing the care plans. The DON stated [CONDITION(S)] meds should be listed on the care plans. The DON stated [CONDITION(S)] meds not being care planned could not impact the residents negatively that she knew of. The DON stated she does not know if bowel and bladder should be care planned or not if indicated on the MDS because she does not complete the MDS. The DON stated not care planning bowel and bladder cannot negatively impact the resident in any way that she knew of. The DON stated she was responsible for backing up the MDS coordinator when she was out on leave, but that never happened. The DON stated the MDS coordinator was sick with COVID and was working from home today. During interview on [DATE] 08:25 AM the ADMIN stated the MDS coordinator was responsible for completing care plans. She stated the MDS coordinator was out on leave this week and everyone was responsible for updating the care plans as needed, including the ADMIN and DON. The ADMIN stated corporate staff trained the MDS coordinator. The ADMIN stated they have meetings every morning and weekly to discuss any changes in the care plans. The ADMIN stated floor nurses inform management daily of changes and the IDT team/ therapy/MDS coordinator meet daily to discuss. The ADMIN expected the MDS coordinator to care plan the MDS triggers. The ADMIN stated if triggers such as bowel and bladder or [CONDITION(S)] drugs were not on the care plan, it would not negatively impact the residents because staff knows our residents and provides good care. The ADMIN stated that management and floor nurses know which residents are incontinent and which ones could potentially lead to problems. 4. Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #31 was [AGE] years old, female and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] revealed Resident #31 was usually understood and usually understood others. The MDS revealed Resident 31 # had a BIMS score of 15 which indicated intact cognition and required limited assistance for dressing and personal hygiene, extensive assistance for toilet use, and supervision for eating and bathing. Record review of the undated care plan revealed Resident #31 had ADL self-care performance deficit related to activity intolerance. The intervention included bathing with physical assistance three times a weekly and as necessary. The care plan revealed Resident #31 was a full code. Interventions included MD/family will be notified of condition change, staff will honor resident with privacy during CPR, and if code status changes, code status will be posted in chart. The care plan also revealed Resident #31 was a DNR status. Interventions included code status documented in chart, if resident arrest, staff will not perform CPR and staff informed of code status. Record review of an out of hospital DNR order dated [DATE] revealed Resident #31 wanted DNR for code status. Record review of the shower scheduled dated [DATE] revealed Resident shower days were Mondays, Wednesdays, and Fridays. During an interview on [DATE] at 11:02 a.m., CNA F said Resident #31 wanted her showers once a week on Thursdays. She said the shower schedule said three times a week on Mondays, Wednesdays, and Fridays. She said it should be care planned for once a week, like she prefers. She said it was important to have accurate care plan documented so Resident #31 gets what she wants. During an interview on [DATE] at 11:39 a.m., with a family member and Resident #31. Resident #31 said she wanted her showers once a week. She said her shower preference was not bought up in the care plan meetings. The family member of Resident #31 said the questions they ask during the meetings, do not trigger them to mention the shower schedule preference. The family member said during the meetings, they do not ask about preferences. Resident #31 said her code status was DNR and she would want it on all documents. During an interview on [DATE] at 10:30 a.m., the MDS coordinator said Resident #31 should only have DNR code status on her care plan. She said she updated care plans when the residents received new orders, quarterly, and as needed. She said she never saw Resident #31 had two different code statuses. She said the full code status was not added by her and the person who added did not placed it in the nursing section. She said she normally only looked in the nursing section of the care plan. She said the corporate MDS coordinator was responsible for ensuring she has formulated accurate care plans. She said the corporate MDS coordinator reviews the care plans monthly for updates. She said the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She said Resident #31 having two different code status which could delay treatment or actions of the staff during an event. She said the last care plan meeting with Resident #31 and a family member, Resident #31 only mentioned she wanted showers in the morning. She said the CNAs or nurses should notify her of Resident #31's changes in preferences. She said care plans should be accurate because CNAs look on them to know how to care for the residents. During an interview on [DATE] at 11:26 a.m., CNA G said she had returned to the facility 4 weeks ago but had been employed 3 years ago. She said she was the CNA for Hall 400B where Resident #31 resided. She said Resident #31 only wanted her showers on Thursdays at 6am. She said when she was previously employed, Resident #31 only wanted shower on Fridays. She said when she started 4 weeks ago, Resident #31, other CNAs, and nursed told her she preferred her showers once a week. She said her shower schedule says three times a week which was probably on her care plan. During an interview on [DATE] at 12:09 p.m., the DON said she knew Resident #31 wanted her showers once a week but could not recall the exact day. She said she did not know why her shower schedule and care plan had three times a week. She said it should be on Resident #31 care plan, but all CNAs know her preference. She Resident #31 was a DNR code status and it should be the only status on her care plan. She said the DON, Admin, and corporate MDS coordinator monitor care plans and MDSs. She said care plans are reviewed for accuracy or updated when residents have new orders and care plan meetings. She said she did not know how Resident #31 two code status on her care plan got missed. She said code status are on the charts, at the nursing station, and on the crash cart but if staff only looked at the care plan, it could delay treatment. During an interview on [DATE] at 2:21 p.m., the Administrator said changes in preference was asked during care plan meetings. She said it was important to gain accurate information during care plan meetings so the resident feel like they have a part in their care. She said Resident #31 could feel angry or sad her preference was not documented. She said a staff member was sent to get validation from Resident #31 of what day she wanted her showers so her care plan could be updated. She said she expected Resident #31's care plan to only have a DNR code status which the MDS coordinator and corporate MDS coordinator was responsible for. Review of a facility's Care Plan - Comprehensive policy dated [DATE] indicated, .develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain .each resident's Comprehensive Care Pan has been designed to .incorporate identified problem areas .identify the professional services that are responsible for each element of care .aid in preventing or reducing declines int eh resident's functional status and/or functional levels .

Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care are provided such care, consistent with professional standards of practices for 2 of 16 residents reviewed for respiratory care. (Resident #13 and Resident #22) The facility failed change Resident #13's nasal cannula weekly, have an oxygen concentrator filter free of gray, fuzzy particles, and water in the humidification bottle. The facility failed to ensure the oxygen concentrator tubing and humidification bottles were dated when changed for Resident #22. These failures could place residents at risk of not receiving appropriate respiratory care and contribute to respiratory infections. Findings included: 1. Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #13's consolidated physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] revealed Resident #13 was usually understood and usually understood others. The MDS revealed Resident #13 had a BIMS score of 9 which indicated moderately impaired cognition and required extensive assistance for ADLs. The MDS revealed Resident #13 had oxygen therapy while a resident. Record review of the undated care plan revealed Resident #13 was on oxygen therapy. The care plan revealed Resident #13 had ADL self-care performance deficit related to activity intolerance. During an observation on 6/27/22 at 10:24 a.m., Resident #13 was laying bed with a nasal cannula on her face. The nasal cannula was dated 6/2/22 and the humidifier bottle was without water. The oxygen concentrator had a black filter with white and gray particles. During an observation on 6/28/22 at 9:51 a.m., Resident #13 was sitting up in her wheelchair with a nasal cannula on her face. The nasal cannula was dated 6/2/22 and the humidifier bottle was without water. The oxygen concentrator had a black filter with white and gray particles. 2. Record Review of Resident #22 consolidated physicians' orders dated 12/16/2019 indicated Resident #22was an [AGE] year-old make that has a history of [CONDITION(S)] (respiratory disease) and chronic respiratory failure. An Order dated 12/16/19 indicated the resident was to receive O2 at 3LPM via NC continuous every shift. Record Review of the MDS dated [DATE] indicated under section C0400 Recall that Resident #22 has a BIMS score of 15 for cognitively intact. Pulmonary section of the MDS indicates a history of [CONDITION(S)], chronic respiratory failure and [CONDITION(S)] or hypercapnia (respiratory disease). Section J1100 shortness of breath of the MDS was checked (z.) indicating none of the above. Section 0 of the MDS was checked indicating oxygen performed while a resident of the facility and within the last 14 days. Record Review of the care plan dated 1/20/22 indicated Resident #22 has [CONDITION(S)]. The goal indicated that Resident #22 will be free of respiratory infections through the review date. Interventions indicated Resident #22 will be given oxygen therapy as ordered by the physician. During observation on 06/27/22 02:40 PM, Resident #22 was wearing O2 at 3L via n/c, the oxygen bag was dated 6/3/22, there was no date on the O2 tubing, indicating the tubing had not been changed. During observation on 06/28/22 at 08:59 AM Resident #22 was sitting up in bed watching TV, she had O2 in place, the oxygen tubing, and humidifier bottle were dated 6-3-22. During observation on 06/28/22 at 02:27 PM, Resident #22 was sitting up in wheelchair watching TV, her oxygen tubing and humidifier bottle were dated 6/28/22. During an interview with LVN C on 06/28/22 at 09:07 AM, LVN C stated she has worked at facility for 9 years. LVN C stated that it was the responsibility of the 10-6 nurse to change O2 tubing every Wednesday at night. LVN C stated that it was not documented anywhere that O2 tubing changes are done, and the staff just know when O2 tubing changes need to be done. LVN C stated that it was the responsibility of all nurses to check O2 tubing if they go into the resident's room to look at their O2 tubing. LVN C stated residents are at risk for infection if O2 tubing was not changed. During interview with LVN A on 06/29/22 at 10:19 AM (night shift nurse for all of B halls) stated that she had worked at the facility for 1 month. LVN A stated she worked Wednesday night and was responsible for changing all the O2 tubing weekly on Wednesday nights. LVN A stated that there was no reason why the O2 tubing should not have been changed. LVN A stated it was every nurse's responsibility to check the O2 tubing date when they go into the resident's room. LVN A stated that if O2 tubing was not changed it can lead to infection. During interview with DON on 06/28/22 at 02:36 PM, DON stated O2 tubing should be changed weekly on 10-6 shift by nursing staff. DON stated that every nurse or any staff goes into the resident's room should check O2 tubing date and water level in humidification bottle. DON stated she expected staff to make sure O2 tubing was changed weekly, water in humidification bottle, and dust free concentrator filters. DON stated the facility had staff assigned to each hall who ensure oxygen tubing was dated and changed weekly, clean filters, and water filled bottles. DON stated if O2 tubing was not changed weekly residents might not get good oxygen flow from the tubing. DON stated proper respiratory equipment management was important to prevent respiratory infection which could cause decreased quality of life for each resident. DON stated O2 tubing changes are not documented anywhere, and staff knows it is changed every Wednesday. During interview with ADMIN on 06/29/22 at 08:25 AM, ADMIN stated she has worked at facility since 2010. ADMIN stated the policy was to change O2 tubing weekly on Wednesday night. ADMIN stated she expected all staff to follow the policy. ADMIN stated O2 tubing changes are not documented anywhere, but staff should label the tubing, so they know it has been done. ADMIN stated everyone was responsible for checking O2 tubing dates when they go into resident rooms. ADMIN stated management does Guardian Angel rounds daily. ADMIN stated the department head for B-hall residents was out of the office this week and did not complete Guardian Angel rounds for B-Hall. ADMIN stated she did not think about covering those halls for the employee that was out. The ADMIN stated that there was always a potential for infection if O2 tubing was not changed per policy. Record Review of the facility's policy on oxygen administration does not indicate when disposable equipment should be changed. The policy indicated reporting information in accordance with facility policy and professional standards of practice.

Based on interview and record review the facility failed to ensure the residents had the right to make choices about aspects of his or her life in the facility that were significant for 1 (Resident #31) of 17 residents reviewed for self-determination. The facility failed to honor Resident #31's wishes to shower on Thursday's morning at 6 a.m. This failure could place residents at risk for not having the opportunity to exercise their rights of autonomy. Findings included: Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] revealed Resident #31 was usually understood and usually understood others. The MDS revealed Resident 31 # had a BIMS score of 15 which indicated intact cognition and required limited assistance for dressing and personal hygiene, extensive assistance for toilet use, and supervision for eating and bathing. Record review of the undated care plan revealed Resident #31 had ADL self-care performance deficit related to activity intolerance. Intervention included bathing with physical assistance three times a weekly and as necessary. Record review of the shower scheduled dated 6/24/22 revealed Resident shower days were Mondays, Wednesdays, and Fridays. During an interview on 6/28/22 at 10:20 a.m., Resident #31 said she liked to take her once a week shower before breakfast around 6 a.m. She said it was too much for her to get dressed for breakfast then undress for a shower after breakfast. She said she was getting showers at 6 a.m. then she started to get push back about. She said CNA F and CNA G told her they would make sure when they worked on Thursdays, they would make sure she got a shower at 6 a.m. She said it made her feel terrible when she could not get her showers on Thursdays at 6 a.m. She said it hurt her feelings to see other residents get showers before breakfast, but it was a big deal for her to get a shower before breakfast. During an interview on 6/28/22 at 11:02 a.m., CNA F said Resident #31 wanted her showers once a week on Thursdays. She said the shower schedule said three times a week on Mondays, Wednesdays, and Fridays. She said Resident #31 normally sits by the shower room on Thursday at 6 a.m. She said she normally worked the 200 hall and would come to the 400 hall when possible, where Resident #31 resided to give her showers at 6 a.m. She said it was important to honor Resident #31's wishes to have a shower at 6 a.m. on Thursdays so she could feel comfortable and get what she wants. During an interview on 6/29/22 at 11:26 a.m., CNA G said she had returned to the facility 4 weeks ago but had been employed 3 years ago. She said she was the CNA for Hall 400B where Resident #31 resided. She said Resident #31 only wanted her showers on Thursdays at 6am. She said when she was previously employed, Resident #31 only wanted shower on Fridays. She said when she started 4 weeks ago, Resident #31, other CNAs, and nursed told her she preferred her showers once a week. She said her shower schedule says three times a week on Mondays, Wednesdays, and Fridays. She said it was frustrating to ask her three times a week and must chart refused. She said charting refusal on Resident #31's chart, made her look non-complaint. She said Resident #31 probably feels frustrated and her wishes are not being honored. She said Resident #31 gets upset when CNAs ask her if she wants a shower on M, W, F. She said when she worked on Thursdays, she tried to make sure Resident #31 got her showers at 6 a.m. During an interview on 6/29/22 at 11:39 a.m., with a family member and Resident #31. Resident #31 said she wanted her showers once a week. She said her shower preference was not bought up in the care plan meetings. The family member of Resident #31 said the questions they ask during the meetings, do not trigger them to mention the shower schedule preference. The family member said during the meetings, they do not ask about preferences. The family member said Resident #31 has told she could not get her showers on Thursday at 6a.m. Resident #31 said about three months ago, staff told her she could not get showers in the morning before breakfast. She said she gets most of her showers on Thursday mornings, but it was only because she waits at the shower door with her stuff. She said she felt like if she did not sit by the shower room, CNAs would not come and get her for showers. She said some CNAs made her feel like it was a burden to give her a shower at 6 a.m. During an interview on 6/29/22 at 12:09 p.m., the DON said she knew Resident #31 wanted her showers once a week but could not recall the exact day. She said she did not know why her shower schedule and care plan had three times a week. She said Resident #31 wanting showers at 6 a.m., was inconvenient because it was shift change and CNAs were getting other residents up for breakfast. She said she did not know why Resident #31 felt like she would only get her showers at 6 a.m. if she waited by the shower room. She said the facility tried to accommodate her but Resident #31 may have felt like she was not important which could upset her. She said charting refusal on Resident #31's chart, made her look non-complaint. During an interview on 6/29/22 at 2:21 p.m., the Administrator said changes in preference was asked during care plan meetings. She said Resident #31 could feel angry or sad her preference was not documented. She said a staff member was sent to get validation from Resident #31 of what day she wanted her showers so her care plan could be updated. Record review of a facility's Residents' Right policy dated April 2019 revealed .be treated with dignity, courtesy, consideration and respect .make your own choices regarding personal affairs, care, benefits, and services .

Based on observation, interview and record review the facility failed to ensure the resident environment was free of accident hazards for 1 of 6 residents (Resident #31) reviewed for accidents. The facility failed to maintain a rolling shower chair, resulting in a wheel falling off during use and causing Resident #31 to fall. This failure could place residents at risk for injury. Findings included: Review of Resident #31's physician's orders, dated May 2021, indicated Resident #31 resided on B hall, was [AGE] years old and admitted to the facility on [DATE] with diagnoses of heart failure, anxiety, [CONDITION(S)], and hypertension. Review of Resident #31's MDS, dated [DATE], revealed Resident #31 was cognitively intact and required limited assistance of one person for transfers and personal hygiene and extensive assistance of one person for bathing. Review of Resident #31's care plan, revised 5/3/21, revealed resident had a fall. Interventions included all shower chairs were inspected, maintenance immediately removed shower chair from building, staff to inspect shower chairs prior to use. Review of an incident report created by LVN H on 5/03/2021 at 10:15 AM for Resident #31 indicated CNA E notified the nurse that Resident #31 had fallen in the shower room due to a wheel falling off the front of the shower chair. According to the report no injuries were observed and the resident denied pain. During an interview on 05/04/21 at 8:18 AM Resident #31 said she was in a shower chair yesterday morning with CNA E. She stated the wheel came off the shower chair and she fell . Resident #31 stated PT B had to pick her up. She denied injury During an observation on 05/04/21 at 9:30 AM, a broken shower chair was sitting outside of the maintenance office with a missing front left wheel. During an interview on 05/04/21 at 9:40 AM NA D said yesterday in the shower with Resident #31, a wheel fell off the shower chair and the resident fell to floor. During an interview on 05/04/21 at 9:45 AM, CNA E said Resident #31 was trying to slide herself back into the shower chair and had to jump because she had short legs. The wheel came out from under the chair and the chair fell over with the resident in the chair. CNA E said she usually braced the shower chair against the wall of the shower while the resident positioned herself. She said if the shower chair was picked up, the front wheel would fall off and it had been like that a while. She said there was a maintenance fix-it book to write broken things in, but she did not write it in there because she knew not to pick up the shower chair. She was not sure if maintenance was aware of the problem. During an interview on 05/04/21 at 9:50 AM MAIN C said he was not aware he needed to keep old maintenance logs and was not aware of any problems with shower chairs before yesterday. The May maintenance log had one entry from May 3, 2021 and was the broken shower chair. MAIN C was able to locate a March maintenance log which contained 2 entries and neither concerned broken shower chairs. During an interview on 05/04/2021 at 9:55 AM PT B said he had to help pick up Resident #31 from the shower room floor, but Resident #31 did not mention what had happened and he did not observe the shower chair. During an interview on 5/4/21 at 1:45 PM CNA G said A hall had two shower chairs and one of them had half a wheel, but both of them had disappeared today. She said the quarantine hall had their own shower chair and B hall had their own shower chairs. During an interview on 5/4/21 at 2:50 PM CNA F said the shower chair which broke with Resident #31 had a wheel which would slide off when the chair was picked up. She said it was broke, fixed, and then broke again about a month ago. She said normally they would write things that break in the fix-it book, but about a month ago, she told the maintenance man about the broken wheel and thought she did not need to write it down in his book. During an interview on 05/04/21 at 4:00 PM, the administrator said she expected equipment to be in safe working order and problems be reported to maintenance and herself immediately. She said she was not aware the shower chair was broken. Review of the facility policy, Equipment-General Use for All Residents, revised 7/17/2012, revealed, wheelchairs, walkers, crutches, canes, etc., are maintained by our facility

Based on observation, interview and record review the facility failed to follow their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 of 22 residents (Resident #24) reviewed for food safety. The facility failed to monitor the temperature of Resident #24's personal refrigerator, ensure foods were stored at an appropriate temperature and expired foods were removed. This deficient practice could place residents at risk for food borne illnesses. The findings included: Observation on [DATE] at 10:42 a.m., revealed Resident # 24's personal refrigerator had no temperature log as required by facility policy. The refrigerator contained an undated plastic container with brown unknown food item inside and three eight ounces of unopened milk cartons and one opened milk carton, all labeled with expiration date of [DATE]. The refrigerator thermometer revealed a temperature of 60 degrees. The freezer had defrosted, and the freezer pan was overflowing onto the items below. During an interview on [DATE] at 4:30p.m. the Administrator said she wrote down the resident's name and room number, said she would look into it. Her expectation is for staff to follow policy. During an observation and interview on [DATE] at 10:45 a.m. Resident # 24 said facility staff remove items from her personal refrigerator for her since she cannot reach the refrigerator and was unable to walk. A [DATE] temperature log was observed on top of the refrigerator with no temperatures documented for [DATE], [DATE], [DATE]. During an interview on [DATE] at 1:30 p.m., the administrator said she was aware of the problem regarding recording the temperature on resident's personal refrigerator and had completed an audit of all personal refrigerators to prevent illness. The administrator provided the policy regarding personal refrigerators. During an interview on [DATE] at 11:15 a.m. regarding resident's personal refrigerators Housekeeper A said, nursing was responsible for cleaning and checking the refrigerators. She said she only cleaned the outside. Review of the policy regarding Personal Refrigerators dated [DATE] revealed 1. Personal refrigerators, either owned by the facility or family/residents, must be maintained at or below 40 degrees. The facility will provide thermometers for each personal refrigerator. 2. The facility will keep a daily log to ensure that temperatures are maintained according to policy.

Based on observation, interview, and record review, the facility failed to serve food that was palatable and at a safe and proper temperature for 1 of 2 meals reviewed for food palatability. (lunch 07/23/19) The facility did not provide palatable and appetizing food for the residents for the 07/23/19 lunch meal. Resident #s 2, 4, 29, 34, 41, 62, 65, 71, and 75 complained of cold food, tough foods, mushy vegetables, undercooked food, and food that was poorly seasoned. This failure could place residents who received food from the kitchen at risk for diminished meal satisfaction and potential weight loss due to poor meal intake. Findings included: 1. During an interview on 07/22/19 at 09:03 AM Resident #4 said sometimes when they get baked fish it smells bad, the french fries and hamburger buns were cold, and the vegetables were mushy. 2. During an interview on 07/22/19 at 09:28 AM Resident #75 said the food was not good and it was the same thing all the time. She said there was no gravy with the chicken tenders and the rolls were burned on one side. 3. During an interview on 07/22/19 at 12:45 PM Resident #65's husband was feeding her the meatloaf and potatoes and he had a small pile of burned bits of meatloaf set off the plate onto the tray. He said the meatloaf had been burned and he said he wasn't going to feed her burned food. 4. During an interview on 07/23/19 at 07:18 AM the ombudsman said she had visited the facility the previous evening and she said the residents complained the pork chops were tough. She said food was an ongoing issue at the facility and they had formed a food committee. 5. During the resident council interview on 07/23/19 at 11:00 AM, Resident #s 2, 4, 29, 34, 41, 62, and 71 complained sometimes the food was really good and sometimes awful, rice was not cooked thoroughly and was not flavorful and the pork chops were tough at times like they had been the previous evening had been tough. 6. During observation on 07/23/19 at 12:48 PM along with the DM, the test trays indicated the following: *Regular tray- Italian sausage, green beans, potato wedges, roll, lemon cake. The Italian sausage and the potato wedges were cold. The roll was extra dark brown and appeared over cooked. *Alternate tray- breaded chicken patty on a bun, buttered corn, herbed noodles. The chicken patty was not hot, had no flavor and was dry and hard to swallow. The bun was room temperature. The corn was flavorful but was cool. The herbed noodles had no visible herbed seasoning, they were cold, had no flavor and was unappetizing. During an interview on 07/23/19 at 12:58 PM, the DM agreed with the findings on the palatability of the food on the test trays. A dietary roster dated 07/22/19 indicated 72 residents received food from the kitchen.

Based on observation, interview, and record review, the facility failed to maintain the kitchen equipment in good repair for 1 of 1 stove reviewed for safe operating equipment. (Kitchen stove) The facility did not ensure the stove in the kitchen was in good repair. This failure could place residents who ate food from the kitchen at risk of foodborne illness and poor quality of food served. Findings included: During an observation on 07/23/19 at 10:50 AM, Cook A removed a sheet pan of rolls from the left side oven and they were very dark in appearance and a few were almost black and appeared burned. She said she did not know what temperature the oven was cooking at because the oven knob was missing from the left side oven. Cook A said the knob had been off the oven for about 2 months, she said the oven repairman was at the facility a couple of months ago and set the temperature on the oven. She said the right side oven cooked too slow for her and she let the dietary aides use it to cook their desserts. During an interview on 07/23/19 at 10:55 AM, the district manager, said they were trying to find a part. The district manager said they had a knob that had been on the oven but it would not stay on because it was too large. During an interview on 07/24/19 at 10:00 AM, the administrator said he was not aware the oven was not working properly, he said the district manager told him yesterday about the missing knob. The administrator said a repairman had come and repaired the handle on the left oven door about 2 months ago. During an interview on 07/24/19 at 10:40 AM, the administrator brought an invoice dated 05/28/19 indicating the thermostat on the left oven needed replacing. The administrator said he must have overlooked that on the invoice because he would have gotten that repaired. He said he would check with the repairman to see if the thermostat had been replaced. An invoice dated 05/24/19 indicated the repair service came to the facility and picked up the door for the left oven and calibrated the right oven. A return trip on 05/28/19 indicated the left door was installed, the door frame was replaced, both ovens were checked and the left oven needed a thermostat. During an interview on 07/24/19 at 11:15 AM, the administrator said the repairman had not replaced the thermostat but would come later that day or the next day and replace it.

Based on observation, interview, and record review, the facility failed to ensure that nurse aides demonstrated competency in techniques necessary to care for needs as identified through assessments and described in the plan of care for 1 of 7 residents reviewed for incontinent care. (Resident #17) CNA B repeatedly wiped Resident #17's perineal area in the wrong direction. This failure could place residents who require assistance with incontinent care at risk for cross contamination and infections. Findings include: During an observation on 07/24/19 at 08:40 AM CNA B provided incontinent care with the assistance of CNA C to Resident #17 who had a small BM. CNA B wiped Resident #17's rectal peri area from the coccyx toward the base of the labia. This occurred twelve times in the wrong direction. During an interview on 07/24/19 at 09:05 AM, CNA B said she had not washed her hands and had not applied the barrier cream correctly. CNA B said those were the only mistakes. During an interview on 07/24/19 at 02:45 PM, the DON said her main expectation during the performance of incontinent care was for the staff to maintain proper infection control standards. Wash hands prior to performing incontinent care, sanitize with glove changes. With regards to providing incontinent care on female residents, it was particularly important to wipe away from the vagina, starting from the base of the labia. A Perineal Care Policy revised (MONTH) 2012 indicated .9. For a female resident: . b. Wash perineal area from front to back. e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and the transmission of disease and infection for 1 of 7 residents observed for incontinent care. (Resident #17) CNA B repeatedly wiped Resident #17's perineal area in the wrong direction. This failure could place residents who require assistance with incontinent care at risk for cross contamination and infections. Findings include: A face sheet dated 07/25/19 indicated Resident #17 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS dated [DATE] indicated Resident #17's cognition was severely impaired, she required extensive assistance of one - two persons for performance of all ADLs and she was always incontinent of bladder and bowel. The most recently updated care plan printed on 07/25/19 indicated Resident #17 required extensive one-two person assistance for ADLs. During an observation on 07/24/19 at 08:40 AM CNA B provided incontinent care with the assistance of CNA C to Resident #17 who had a small BM. CNA B did not wash her hands prior to initiating care. CNA B wiped Resident # 17's posterior perineal area from the coccyx toward the base of the labia (back to front), twelve times in the wrong direction. During an interview on 07/24/19 at 09:05 AM, CNA B said she had not washed her hands and had not applied the barrier cream correctly. During an interview on 07/24/19 at 02:45 PM, the DON said her main expectation during the performance of incontinent care was for the staff to maintain proper infection control standards. Wash hands prior to performing incontinent care, sanitize with glove changes. The DON said with regards to providing incontinent care for female residents, it was particularly important to wipe away from the vagina, starting from the base of the labia. A Perineal Care Policy revised (MONTH) 2012 indicated .9. For a female resident: . b. Wash perineal area from front to back. e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks.

Based on observation, interview, and record review, the facility failed to serve food that was palatable and at a safe and proper temperature for 1 of 2 meals reviewed for food palatability. (lunch 07/10/18) The facility did not provide palatable and appetizing food for the residents for the 07/10/18 lunch meal. Resident #s 4, 10, 15, 18, 20, 22, 35, 42, 45, 60, 61, 73, 79, 80, and 338 complained of cold food, hard and dry foods, mushy vegetables, undercooked and overcooked food, and food that was poorly seasoned. This failure could place 84 residents who received food from the kitchen at risk for diminished meal satisfaction and potential weight loss due to poor meal intake. Findings included: 1. The Resident Council Minutes from the meetings included the following: *03/26/18 -in the Dietary section the resident council complained the pasta and rice were undercooked, and the dumplings in the chicken and dumplings were not cooked. Several of the residents stated the biscuits were always burnt on the bottom and were too hard to eat. The resident council said the vegetables needed to be steamed so they can chew it easier. *06/25/18- in the Dietary section the resident council complained the vegetables, rice and breads were either overcooked or undercooked. The resident council requested that the food have more flavoring to it. *05/29/18 - in the Dietary section the resident council complained that most vegetables are either not cooked enough or cooked too much and are not edible. 2. During an observation and interview on 07/09/18 at 07:55 a.m., Resident #22 complained there was no butter and the sausage was too tough to eat. The sausage patty on his breakfast tray was dark colored and hard in appearance. During an interview on 07/09/18 at 08:51 a.m., Resident #79 said the food was not always good. During an interview on 07/09/18 at 08:53 a.m., Resident #s 15 and 18 said the food was not so good. They said it was not cooked right and they had the same things over and over. During an interview on 07/09/18 at 09:07 a.m., Resident #10 said the kitchen staff did not know how to cook the food. He said the food was just not right; it was overcooked and undercooked. During an interview on 07/09/18 at 09:11 a.m., Resident #60 said the food was not so good. She said it was not cooked right and they served chicken patties a lot. During an interview on 07/09/18 at 08:45 a.m., Resident #4 complained about the sausage being hard and not eating because of it. During an interview on 07/09/18 08:07 a.m., Resident #35 said the food was not good and it was either undercooked or overcooked. During an interview on 07/09/18 08:10 a.m., Resident #42 said sometimes the food was like they took it out of the can without cooking it and put it on the plate to serve. She said it needed seasoning. During an interview on 07/09/18 at 8:47 a.m., Resident #45 said the lunch and dinner meals were cold and had no seasonings on the vegetables like the lima beans or mashed potatoes. He said the food was always cold. He said it did no good to tell anyone or complain because nothing changed. During an interview on 07/09/18 at 8:48 a.m., Resident #20 said the lunch and dinner meals were cold and had no flavor. During an interview on 07/09/18 at 8:30 a.m., Resident #73 said the food was cold at times and they did not provide condiments, for example, sugar, salt and pepper. She said she ate her meals in her room. During an interview on 07/09/18 8:20 a.m., Resident #338 said the food could be better. He said the food did not taste good or sometimes it would be cold. During an interview on 07/09/18 at 12:30 p.m., Resident #61 was sitting in her room said she did not like the food at all to start with but learned to mix her food together and it was tolerable. She said they did not put any butter or salt in the food and they cooked the vegetables too soft and they were mushy. She said she just had to learn to eat the food here. During an interview on 07/09/18 01:05 p.m., Resident #80 was sitting in the dining room with her daughter. She had a stack of her diet slips that she had written on indicating she did not receive the food she had ordered or when she received a sandwich. She said the sandwiches they received were dry and had no condiments of any kind. She said the sandwiches were either a piece of cheese, a piece of salami, or a piece of bologna. She said she did not like sandwiches and did not eat them when they brought them to her. She indicated she usually gave them away to someone else. She said they had talked with the administrator and the DON numerous times in the past year and nothing was done. She said the sweet potatoes were okay today but sometimes the same food was not edible on another day. The daughter confirmed everything her mother was saying. The resident said she always went to the Resident Council meetings and she would be sure to come to the resident group interview meeting tomorrow. 3. During observation on 07/10/18 at 1:17 p.m., along with the RDM, the test trays indicated the following: *Regular tray- chicken parmesan, broccoli florets, and spaghetti noodles. The broccoli florets were mushy, overcooked, and had no seasoning. The dessert served was canned butterscotch pudding which had a canned aftertaste. It was not chilled, it had been served directly from the cans in the dry pantry and had no whipped topping to enhance the flavor or appearance. *Alternate tray- turkey patty, pinto beans, and rice. The turkey patty was not warm and had a horrible aftertaste that resembled a mold-like taste. It was slightly gritty in texture as it was chewed. It was not appetizing. The rice appeared as a scoop of white rice. It was cold in temperature, had no butter, and no flavor. It was very bland and unappetizing. The test tray did not have any butter or margarine on the tray to add to any foods. During an interview on 07/10/18 at 1:17 p.m., the RDM agreed with the findings on the palatability of the food on the test trays. A dietary roster dated 07/09/18 indicated 84 residents received food from the kitchen.

Based on interview, and record review, the facility failed to implement their written policies and procedures to prohibit mistreatment, neglect, abuse or misappropriation of resident property for 1 of 6 residents reviewed for neglect. (Resident #12) Resident #12 required two person assist with turning and repositioning. CNA A turned and repositioned Resident #12 alone and the resident sustained [REDACTED]. This was determined to be past non-compliance since the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place 5 residents who were dependent on two staff for turning and repositioning at risk for falls and injuries. Findings included: The Abuse Policy and Procedure revised 12/16/14 indicated, .Neglect is defined as failure to provide goods and treatments and services necessary to avoid physical harm, mental anguish, or mental illness . Physician orders [REDACTED].#12 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders included to be gentle with transfers. The most recent MDS dated [DATE] indicated Resident #12's cognition was intact. She had no impairment in decision making and required total dependence of two persons for bed mobility. A care plan for [MEDICAL CONDITION] dated 03/12/15 indicated Resident #12 had a history of [REDACTED]. An incident report dated 05/18/15 indicated Resident #12 reported hearing a loud pop when being turned and repositioned. An x-ray report dated 05/19/15 noted Resident #12 had a left distal humerus fracture. During an interview on 06/02/15 at 10:00 a.m., Resident #12 was lying in bed. She said when CNA A turned her and rolled her over, her arm cracked. Resident #12 said it was supposed to be two but only one came that time to assist with turning and repositioning. During an interview on 06/03/15 at 1:05 p.m., CNA A said she grabbed the sheet and pulled Resident #12 over to reposition her in bed. She said when she moved Resident #12; the resident said my shoulder popped. CNA A said Resident #12 required two people with turning and repositioning, but she moved Resident #12 by herself. During an interview on 06/02/15 at 2:48 p.m., the DON said Resident #12 required two persons for turning and repositioning, but one person provided care to the resident. She said as a result of the incident CNA A was suspended pending the investigation. The DON provided the investigation report on 06/02/15 at 2:48 p.m., regarding Resident #12. The report dated 5/18/15 included an in-service on abuse/neglect, transfers, and positioning; and Resident #12's care plan revised to include three persons for all activities of daily living. The investigation also included safe surveys conducted by the social worker who interviewed other residents regarding staff treatment. A Turning a Resident On His/her Side Away From You policy revised 06/04/12 noted, .Review the resident's care plan to assess for any special needs of the resident. The CMS 672 dated 06/02/15 indicated 5 residents were dependent on two staff for turning and repositioning.

Based on interview, and record review, the facility failed to implement their policies and procedures to prohibit mistreatment, neglect, abuse or misappropriation of resident property for 1 of 6 residents reviewed for neglect. (Resident #12) Resident #12 required two person assist with turning and repositioning. CNA A turned and repositioned Resident #12 alone and the resident sustained [REDACTED]. This was determined to be past non-compliance since the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place 5 residents who were dependent on two staff for turning and repositioning at risk for falls and injuries. Findings included: Physician orders [REDACTED].#12 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders included to be gentle with transfers. The most recent MDS dated [DATE] indicated Resident #12's cognition was intact. She had no impairment in decision making and required total dependence of two persons for bed mobility. A care plan for [MEDICAL CONDITION] dated 03/12/15 indicated Resident #12 had a history of [REDACTED]. An incident report dated 05/18/15 indicated Resident #12 reported hearing a loud pop when being turned and repositioned. An x-ray report dated 05/19/15 noted Resident #12 had a left distal humerus fracture. During an interview on 06/02/15 at 10:00 a.m., Resident #12 was lying in bed. She said when CNA A turned her and rolled her over, her arm cracked. Resident #12 said it was supposed to be two but only one came that time to assist with turning and repositioning. During an interview on 06/03/15 at 1:05 p.m., CNA A said she grabbed the sheet and pulled Resident #12 over to reposition her in bed. She said when she moved Resident #12, the resident said my shoulder popped. CNA A said Resident #12 required two people with turning and repositioning, but she moved Resident #12 by herself. During an interview on 06/02/15 at 2:48 p.m., the DON said Resident #12 required two persons for turning and repositioning, but one person provided care to the resident. She said as a result of the incident CNA A was suspended pending the investigation. The DON provided the investigation report on 06/02/15 at 2:48 p.m., regarding Resident #12. The report dated 5/18/15 included an in-service on abuse/neglect, transfers, and positioning; and Resident #12's care plan revised to include three persons for all activities of daily living. The investigation also included safe surveys conducted by the social worker who interviewed other residents regarding staff treatment. A Turning a Resident On His/her Side Away From You policy revised 06/04/12 noted, .Review the resident's care plan to assess for any special needs of the resident. The Abuse Policy and Procedure revised 12/16/14 indicated, .Neglect is defined as failure to provide goods and treatments and services necessary to avoid physical harm, mental anguish, or mental illness. The CMS 672 dated 06/02/15 indicated 5 residents were dependent on two staff for turning and repositioning.