Every finding on record at Ventana by Buckner

Based on observations, interviews, and record review, the facility failed to make information on how to file a grievance or complaint available t the resident for 2 of 2 confidential residents reviewed for grievances. The facility failed to notify residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner.These failures could affect resident's ability to file a grievance without the fear of discrimination, reprisal, retribution, and their right to anonymously file their grievance.Findings included:Observation on 03/16/26 at 2:45 PM revealed there were no grievance forms available in any common areas nor indications of places to find grievance forms. Interview on an undisclosed date and time with six confidential residents revealed the residents were unaware where grievance forms were located. The residents stated that they did not know how to anonymously file a grievance. Interview on 3/16/26 at 11am with Resident #33's representative expressed concerns about how many times the staff come and go out of the resident's room asking the same questions and delegating resident #33 requests to other staff members. Interview on 3/16/26 at 11:15am with Resident #66 expressed concerns about care but was unaware of grievance forms. Confidential residents expressed if they needed to know how to fill out an anonymous grievance. Interview on 3/18/26 at 12:00 noon with CNA D who has worked at this facility for three years. CNA D stated if a resident or family wants to fill out a grievance report she would tell an Administrator. CNA D stated there are no grievance forms available. CNA stated if a resident or family member are wanting to file an anonymous grievance CNA D would call an Administrator. Interview on 3/18/26 at 2pm with SW who stated if a family or resident informs the SW they want to fill out a grievance, the SW will assist them. If SW is not available, the resident or family would go to ADON to fill out the grievance. If the resident or family wanted to fill out a grievance anonymously, the SW said there might be grievance forms at the nurse's station for the resident or family to use. If grievance forms are unavailable for the resident or family to fill out anonymously a resident or family member would feel they do not have a way to express their concerns. Interview on 03/18/26 at 4:23pm with DON, she stated that she did not know that there needed to be a system in place for residents to have a way to file a Grievance anonymously. She stated that residents can file a Grievance with the Social Worker or any staff member. She stated that there was a potential risk for possible harm if a resident did not have a way to file a grievance anonymously. The DON stated potential harm included someone feeling scared to say anything about a staff member, which could lead to retaliation.Review of the facility's policy titled, Grievances dated revised October 21, 2025, revealed that the Residents and/or families may submit complaints or suggestions to the Grievance Official, department head or Executive Director.Complaints or suggestions are directed to the designated Grievances Official. The [facility] will respond and investigate all grievances and complaints within the community. Review of the Code of Federal Regulations Resident's Rights subsection Grievances revealed.The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The facility must make information on how to file a grievance or complaint available to the residents.Record review of the facility's Grievance policy revealed no information about the submission of grievances being completed and submitted anonymously.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (300 Hall) out of 2 hallways reviewed for accidents and hazards. 1.The facility failed to ensure that the mechanical lift in Resident #58's bathroom on 300 Hall was locked and secured when not in use. This failure could place residents at risk of falls and/or injuries.Findings Included:Record review of Resident #58's admission face sheet dated 03/18/26 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses that included: dementia, hypertension (high blood pressure), displ commnt fx shaft or l femr (displaced, comminuted fracture of the shaft of the left femur), osteoarthritis (chronic joint disease, characterized by the gradual breakdown of protective cartilage that cushions the ends of bones), metabolic encephalopathy (a syndrome of global brain dysfunction caused by chemical imbalances, toxins, or systemic illness rather than structural brain damage), Afib (the most common type of treated heart arrhythmia, characterized by a rapid, irregular heartbeat caused by chaotic electrical signals in the heart's upper chambers (atria), arteriosclerosis heart disease of native coronary artery w/o chest pain (heart disease from plaque buildup in the coronary arteries without chest pain), metabolic encephalopathy (a broad term for brain dysfunction caused by underlying systemic illnesses-such as organ failure, infections, or chemical imbalances-that deprive the brain of energy or create toxic environments), and hearing loss. Record review of Resident #58's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 06 indicating severe cognitive impairment. Resident #58's MDS Assessment reflected she was incontinent and required total assistance with ADL Care and received hospice services. Record review of Resident #58's Care Plan dated 01/26/2026 reflected,Problems: [Resident #58] had a history of falls on 12/10/25 and 12/29/25, since her admission to the facility. Goals:[Resident #58] will maintain current level of mobility with no increase in the incidence of falls/injuries over the next 90 days.Interventions:Assist [Resident #58] to wear non-stick footwear that fits.Engage [Resident #58] in activities that improve strength, balance, and posture as tolerated and document results.Instruct [Resident #58] on safety measures to reduce the risk of falls use of handrails.Keep areas free of obstructions to reduce the risk of falls or injury to [Resident #58]. In an observation and interview with Resident #58 on 03/16/26 at 11:13 AM was alert and was watching television while lying in bed. Resident #58's bed was observed in a low position. Resident #58 was observed wearing non-slip socks. Resident #58 stated that the mechanical lift in her bathroom had been in her room for a while. Resident #58 was unable to confirm how long the mechanical lift had been in her bathroom. Resident #58 stated that the staff use the mechanical lift when they give her a bath. Resident #58 was unable to differentiate which staff used the mechanical lift. Resident #58 did know how many staff members use the mechanical lift when it was in use. Resident #58 was unable to confirm or deny if she had any falls since her admission to the facility. Observation of Resident #58's room on 03/16/26 at 11:17 AM revealed an unlocked and unsecured mechanical lift parked inside of the doorway inside of the bathroom entry. Observation of Resident #58's room on 03/16/26 at 2:46 PM revealed an unlocked and unsecured mechanical lift parked inside of the doorway inside of the bathroom Observation of Resident #58's room on 03/17/26 at 10:15 AM revealed an unlocked and unsecured mechanical lift parked inside of the doorway inside of the bathroom. Observation of Resident #58's room on 03/17/26 at 3:50 PM revealed an unlocked and unsecured mechanical lift parked inside of the doorway inside of the bathroom. Observation of Resident #58's room on 03/18/26 at 10:30 AM revealed an unlocked and unsecured mechanical lift parked inside of the doorway inside of the bathroom. In an interview on 3/18/26 at 10:35 AM with LVN A, she stated that there were not any mechanical lifts in any resident's room on the 300 hall. Observation of Resident #58's room on 03/18/26 at 10:43 AM revealed an unlocked and unsecured mechanical lift parked inside of the doorway inside of the bathroom. In an interview on 3/18/26 at 11:05 AM with LVN A, she stated that she had been employed at the facility since August 2025. LVN A stated that she was assigned to the 300 hall where Resident #58 resided. She stated that she was unaware that the mechanical lift in Resident #58's bathroom was unlocked. She stated that the facility did not provide the mechanical lift in Resident #58's bathroom. LVN A stated that the mechanical lift in Resident #58's bathroom was provided by the resident's hospice care agency. LVN A stated that she had observed the mechanical lift in Resident #58's bathroom on several occasions. She stated that the mechanical lift in Resident #58's bathroom is used by the hospice nurse when patient care is being provided to Resident #58. LVN A stated that she had not used the mechanical lift in Resident #58's bathroom. LVN A stated that she had not observed any staff operate and use the mechanical lift for patient care for Resident #58. LVN A stated that she was unaware that mechanical lifts needed to be locked in the bathroom area when not in use. She stated that she had taken In-Service Trainings on Hoyer and Mechanical Lift usage and safety. LVN A stated that she could not recall when she had previously taken In-Service Trainings on Hoyer and Mechanical Lift usage and safety. LVN A stated that mechanical lifts should always be locked in the common areas, such as the hallways when they are not being used. LVN A stated that harm could be caused to anyone when a mechanical lift is unlocked. She stated that someone could break a body part, such as an arm or leg when a mechanical lift is unlocked. In an interview on 3/18/26 at 11:12 AM with CNA B, she stated that she had been employed at the facility for 1 month. CNA B stated that she was assigned to the 300 hall where Resident #58 resided. She stated that she was unaware that the mechanical lift in Resident #58's bathroom was unlocked. CNA B stated that she had observed the mechanical lift in Resident #58's bathroom on several occasions when she had done patient care for her. CNA B stated that she had never checked to confirm if the mechanical lift in Resident #58's bathroom was locked or unlocked. CNA B stated that she had not used the mechanical lift in Resident #58's bathroom. CNA B stated that she had not observed anyone use the mechanical lift in Resident #58's bathroom. She stated that she had taken previous In-Service Trainings on mechanical lift safety and usage. CNA B stated that she could not recall when she took her last In-Service Trainings on mechanical lift usage and safety. CNA B stated that harm could be caused to a resident or anyone that enters the bathroom when a mechanical lift is unlocked. She stated that someone could be harmed depending on their fall and receive a head injury or broken bones. An email was sent to the Administrator on 03/18/26 at 12:31 PM, requested the facility's policy on accidents and hazards. An attempted telephone call to Resident #58's POA was unsuccessful on 03/18/26 at 3:02 PM. In an interview with the DON on 03/18/26 at 4:15 PM, she stated that she had been employed at the facility for 2 years. The DON stated that she was unaware that the mechanical lift in Resident #58's bathroom was parked and was observed unlocked and unsecured on 03/16/26, 03/17/26 and 03/18/26. The DON stated that the mechanical lift in Resident #58's room was provided by the resident's hospice care agency. She stated that Resident #58 often refuses care and the mechanical lift is not used by her staff on the resident. The DON stated that her expectation is that all mechanical lifts are to be locked when they are not being used. The DON stated that all staff have been educated and trained on the proper usage and safety of mechanical lifts. The DON stated that she could not recall when the staff received their last In-Service Training on mechanical lifts. She stated that she will reeducate staff with In-Service training on Mechanical Lifts and Mechanical Lift Storage and Safety. She stated that there was a risk to anyone to be injured due to an unlocked and unsecured mechanical lift. The DON stated that there was potential for harm to anyone who attempted to pull themselves up using an unlocked and unsecured mechanical lift, which can cause injuries. The DON stated that the facility did not have any policies regarding mechanical lifts and accidents and hazards. In an interview with RN G on 03/18/26 at 4:25 PM, she stated that she was the Hospice Nurse for Resident #58. RN G stated that she had several residents that she visited at the facility on her schedule. She stated that Resident #58 has dementia and received hospice services. RN G stated that Resident #58's memory will go in and out, meaning that some days she will remember something and other days, she will have total memory loss. RN G stated that she did not know if the hospice care agency for Resident #58 provided the mechanical lift that was currently in the resident's room. RN G stated that she did not use the mechanical lift for Resident #58. RN G stated on several occasions, she observed the CNAs use the mechanical lift in Resident #58's bathroom for patient care. RN G stated that she was unaware that the mechanical lift in Resident #58's bathroom remained unlocked for 3 days. RN G stated that mechanical lifts should always be locked when they are not in use to prevent injuries. Record Review of facility's policies for Mechanical Lift Transfer, Safe Handling, and Care of Community Property. did not provide any information regarding accidents and hazards relating to mechanical lifts.

Based on observation, interview and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 of 3 (Resident #90) residents reviewed for parenteral fluids. The facility did not ensure Resident #90's midline dressing was changed per the physician orders. This failure could place residents at risk for receiving care that is not safe and at risk for infectionReview of Resident #90's face sheet dated 03/18/26 reflected she was a [AGE] year old female, and she was admitted to the facility on [DATE]. Admitting diagnoses included, pressure-induced deep tissue damage of left heel, dementia, chronic ulcer of heel and midfoot. Review of Resident #90's care plan dated 03/18/26 reflected the resident had a midline (IV catheter is a peripheral vascular access device inserted into a vein in the upper arm, with the tip located near the axilla, suitable for short- to moderate-term intravenous therapy.) Review of Resident #90's physician order dated 03/18/26 reflected an order dated 03/01/26 indicated to change central line/midline dressing every seven days. Observation on 03/18/26 at 01:46 PM revealed Resident #90 was in the wheelchair, and she had a midline line to the upper left arm and the dressing was dated 3/5/26. Resident #90 was not intervieweble. In an interview on 03/18/26 at 02:14 PM with LVN E she stated she was not sure when the midline dressing was supposed to be changed. She stated the resident had a midline and dressing needed to be changed per the orders to keep the midline in place and to prevent infection. In an interview on 03/18/2026 at 2:24 PM with the DON she stated there were three residents in the facility with midlines. The DON stated she expected the midline dressing to be changed once weekly (every 7 days) and as needed and per the physician orders. She stated that the charge nurses were responsible for completing the midline dressing changes. The DON stated there was no assigned staff who was responsible for checking to make sure the midline dressing was changed timely. The DON stated the midline dressing was to be changed to prevent infection. In an interview on 03/18/2026 at 3:26 PM with ADON revealed she was the infection preventionist. She stated she was informed by the DON that Resident #90's midline dressing had not been changed. The ADON stated, she expected the charge nurse to complete midline dressing by physician order and facility policy (every seven days) to prevent infection. Review of facility policy dated 10/21/25 and titled PICC line reflected, . 4. An RN will normally provide dressing changes as needed and as ordered; however, an LVN can change the PICC line dressing so long as there is documented training and skills competence check off on file. This is the only policy provided by the facility, the DON indicated the facility did not have any other policy on midline IV dressing change.

Based on observations, interviews, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 Resident (Resident #1) of 6 residents reviewed for foot care. The facility failed to provide adequate foot care for Resident #1 who had a standing order for podiatric services. Resident #1's toenails were chipped, thick, and long. This failure could put residents at risk for infection, impaired mobility, and poor foot health as well as a decline in their quality of life. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (elevated blood pressure), anxiety (a normal human emotion, but it can become a disorder when feelings of worry and fear are intense, persistent, and interfere with daily life), and Vascular dementia, moderate, with psychotic disturbance (Dementia: a decline in mental ability severe enough to interfere with daily life). Resident #1 had a BIMS score of 10/15 which indicated Resident #1's cognition was moderately impaired. Further review revealed Resident #1 needed supervision or touching assistance for personal hygiene. Review of Resident #'1s Comprehensive Care Plan, created date 11/25/24, reflected the following: Problem: [Resident #1] requires Extensive assistance required with bathing, hygiene, dressing, and grooming. Goal: [Resident #1] Will be odor free, dressed and out of bed daily over the next 90 day. [Resident #1] will assist with ADLs to the highest degree possible. Intervention. Podiatrist to examine feet and trim nails. Schedule appointment as needed per physician's orders. STATUS: Active (Current). Record review of doctor orders revealed Resident#1 had a standing order dated (11/11/24) for podiatric referral May have . podiatry evaluation and treatment as indicated Notes: Instructions: Therapeutic Range: Source: Nursing Protocol as Needed Starting 11/12/2024. Review of the podiatry Schedule for visit date: 06/04/25 under title Patients with ‘do not treat (DNT)' Status revealed Resident #1 DNT date 03/27/25, and DNT reason No Consent on file. Review of the last six months weekly skin assessment revealed no indication of Resident #1's toenails status. An observation and interview on 07/15/25 at 09:17 AM revealed Resident#1 was lying in bed. CNA A removed Resident #1's socks during the morning routing care to get him out of bed. Resident #1's toenails #2, #3, #4, and #5 on both feet were long approximately 0.4 centimeter in length extending from the tip of his toes. Resident #1's both feet toenails #4, and #5 were growing out sideways; toenails #3 was growing straight, and #4 was curling forward. Resident #1's left big toenails showed signs of separation from the nail bed at the base of the nail plate. When asked if he would like his toenails trimmed, Resident #1 stated sure. Interview on 07/15/25 at 09:35 AM CNA A stated it was his responsibility to let the nurse know about the residents' toenails needing to be trimmed. He stated he had been working with Resident #1 for few months but did not notice that his toenails needed trimming. CNA A stated the risk when the toenails got bigger, the Resident could be uncomfortable. Interview on 07/15/25 at 09:41 AM RN B looked at Resident #1 toenails and stated they were long and chipped, and needed a podiatry consult. She stated nurses do weekly skin assessment and report to SW and the SW scheduled the consult. RN B stated Resident #1 should be on the podiatry consult list. RN B stated the podiatric services came in every three months to residents' toenails care. She stated last time she did the skin assessment on Resident#1 was last week, during which she did not noticed his toenails condition. RN B stated the risk to Resident #1 was he could scratch himself, potential skin issue, or if the toenails got cut in the shoes will be uncomfortable. Observation on 07/15/25 at 12:07 PM with the SW revealed she checked the podiatry referral file. Interview with the SW revealed she did not see Resident#1 name on the referral list. The SW stated the referral was sent, and the podiatric services asked on 3/28/2025 for a consent. She stated, she asked Resident #1's family member to fill out a consent but never got it back. The SW stated she tried to contact them again but did not have the document for the day of the request for the consent. When asked about the second quarter podiatry scheduled treatment, she stated the consent was not singed yet. She stated her assistant will be able to provide the reason. Interview on 07/15/25 at 12:28 PM the SWA stated, she could not remember any referral done for Resident #1, and there was an order. She stated it was the responsibility of the SW, and she was just helping her. Observation revealed the SWA searched Resident #1's file in the system. Interview revealed Resident # 1 was referred to podiatry. The SWA stated Resident # 1 was not seen during first visit of the year on 03/28/25, and on the second visit on June 4, 2025, because there was no consent done. When asked for the follow up with the family for the consent, she stated, she contacted the family member after the first visit over the phone and was unable to remember or provide any reason for not getting the consent for the podiatric treatment for Resident #1 for the last six months. Observation and interview on 07/15/25 at 2:06 PM revealed the DON looked at Resident #1's toenails and stated they were long, chipped and the nail of the left big toe was separating from the nail bed. She stated her expectation; Resident #1 needed a podiatry consult especially for the big toe on the left foot. The DON stated it was the responsibility of the CNAs and nurses to do nail care or report it to the appropriate department for follow up. She stated the risk was Resident infection, and pain. She stated the staff were in-serviced to do weekly skin assessment, and if they find something like that to bring it to her attention so she could follow up on it. Interview on 07/15/25 at 2:36 PM the Administrator stated the nurses should let the SW work know about Resident #1's toenails needing care. She stated it was the responsibility of the SW to make referrals and get the consent from the family. She further stated if the nurses were able to do the care without harming the Resident they should do it. She stated the risk to the Resident was discomfort. Review of the facility policy titled Foot care date October 2024, revealed Residents receive appropriate care and treatment in order to maintain mobility and foot health. Policy Interpretation and Implementation. 1. Residents are provided with foot care and treatment in accordance professional standards of practice. 3. Residents are assisted in making appointments and with transportation to and from specialists (Podiatrist.) as needed. 4. Trained staff may provide routine foot care (.toenail clipping) within professional standards of practice for residents without complication processes .

Based on observation, interview and record review the facility failed to 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 infection of communicable diseases and infections for one of one resident (Resident #1) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene with gloves change, while providing incontinence care to Resident # 1. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (elevated blood pressure), anxiety (a normal human emotion, but it can become a disorder when feelings of worry and fear are intense, persistent, and interfere with daily life), and Vascular dementia, moderate, with psychotic disturbance (Dementia: a decline in mental ability severe enough to interfere with daily life). Resident #1 had a BIMS score of 10/15 which indicated Resident #1's cognition was moderately impaired. Further review revealed Resident #1 urinary continence/ bowel continence, always incontinent. Review of Resident #'1s Comprehensive Care Plan, created date 11/25/24, reflected the following: Problem: [Resident #1] requires Extensive assistance required with ., hygiene, . Goal: [Resident #1] Will be odor free, dressed and out of bed daily over the next 90 day. [Resident #1] will assist with ADLs to the highest degree possible. Intervention. Assist with ADLs. Observation on 07/15/25 at 09:17 AM of Resident #1's incontinent care, provided by CNA A revealed Resident #1 was lying in bed. CNA A entered Resident #1's room, donned gloves, got a clean brief, Resident #1's shoes, clothes, adjusted the bed, and got trash can next to the bed. CNA A removed gloves, donned clean gloves, without any form of hands hygiene. CNA A uncovered Resident #1 got the clean brief and put it on the bed. CNA A unfastened Resident #1's brief and pushed it between Resident's legs. CNA A cleaned Resident #1's front area with wipes, one at a time, and pushed the wipes between Resident #1's legs. CNA A helped Resident #1 turn to his right side. CNA A removed the dirty brief; the brief was wet with urine; put it in the trash can and cleaned Resident #1's buttocks area using one wipe per stroke. CNA A removed gloves, donned clean gloves without any form of hands hygiene, and put the clean brief on Resident #1. CNA A changed gloves without any form of hands hygiene and proceeded to get Resident #1 dressed, and out of his bed to wheelchair. Interview on 07/15/25 at 09:35 AM CNA A acknowledged he was changing gloves without any form of hands hygiene during Resident #1's incontinent care. CNA A stated he washed his hands after he finished the morning care for another resident, before coming to Resident #1's room. CNA A stated he was supposed to follow proper hand hygiene and wash or sanitize his hands before putting on the clean gloves. He stated that adhering to proper hand hygiene was important to prevent the spread, and development of infection to residents. In interview on 07/15/25 at 11:06 AM the DON stated infection control was important during residents' care. The DON stated during care the staff were supposed to sanitize hands upon entering the resident's room. The DON stated the staff were expected to complete hand hygiene before care and after care, she also stated during incontinent care the staff were supposed to change gloves and use hand sanitizer. The DON stated hand hygiene was to be completed for infection control. Record review of the facility's policy, revised 01/23/25, and titled Hand Hygiene, reflected, Hand hygiene is the most important procedure for preventing the spread of infections. Hand hygiene should be performed: Upon arrival at the workplace and before going home. After using the toilet, blowing nose, and covering a cough or sneeze. Before and after eating. Before and after client contact. After removing gloves. Before invasive procedures. After touching contaminated items.

Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for one (Resident #36) of six residents reviewed for quarterly assessments. The facility did not ensure Resident #36's Quarterly MDS Assessment, dated 10/28/24, was completed withing 92 days of the previous assessment. These failures could place residents at-risk of not having their assessments completed timely. Findings included: Record review of Resident #36's Face Sheet dated 12/1/7/24 reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #36's EHR reflected her Quarterly MDS Assessment with Assessment Reference Date 10/28/24 was created and submitted on 12/17/24. Resident #36's previous Quarterly MDS Assessment reflected and Assessment Reference Date of 7/25/24 and was completed on 8/5/24. In an interview on 12/17/24 at 1:57 PM, The MDS Nurse stated she realized she had missed Resident #36's Quarterly MDS Assessment and had completed and submitted it that day. She stated the risk of missing MDS assessments was that residents may need an updated care plan and changes in condition could be missed. In an interview on 12/17/24 at 2:05 PM, the DON stated she was told by the MDS Nurse that morning that she had missed Resident #36's Quarterly MDS Assessment which was due in October. She stated she had encouraged her to set up a calendar with reminders of when the assessments were due. The DON stated the MDS Nurse was responsible for timely completion of the assessments. She stated she monitored the Discharge MDS assessments to ensure they were completed but it was the MDS Nurse's responsibility to monitor the others. She stated the risk for missing MDS assessments was changes in the resident's condition could be missed which were important for care planning. Record review of the facility's policy titled, Minimum Data Set (MDS), dated revised 11/26/2024, reflected: Service Standard [company name] will complete accurate resident assessments and submit assessments in accordance with current federal and state submission timeframes .3. Timeframes for completion and submission of assessments is based on current requirements published in the RAI manual .

Based on interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for one (Resident #36) of six residents reviewed for accuracy of assessments. The facility failed to ensure that Resident #36's Quarterly MDS Assessment included interviews conducted within the required timeframes. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #36's Face Sheet dated 12/17/24 reflected a [AGE] year-old female admitted to the facility on [DATE] . Record review of Resident #36's EHR reflected her Quarterly MDS Assessment with Assessment Reference Date 10/28/24 was created and submitted on 12/17/24. Record review of Resident #36's Quarterly MDS dated [DATE] reflected, Look back period for all items is 7 days unless another time frame is indicated. MDS Section C reflected a BIMS had been conducted and she had score of 3 indicating severely impaired cognition. Section D reflected a mood interview (PHQ-9) been conducted with a score of 0, indicating none or minimal depression. Her diagnoses included Non-Alzheimer's dementia and depression. Section Z0400 (used to identify who completed each section of the assessment) reflected no entry was made for sections C or D. In an interview on 12/17/24 at 1:57 PM, The MDS Nurse stated she realized she had missed Resident #36's Quarterly MDS Assessment and had completed and submitted it that day. She stated she obtained the information for the assessment from the resident's clinical record. The MDS Nurse stated sections C and D should have had dashes entered because the interviews were not completed during the look back period. She stated she must have entered the information from her previous assessment in error and would submit a correction. She stated accuracy of a MDS assessment was important because, if a change was captured then the resident may need an updated care plan. In an interview on 12/17/24 at 2:05 PM, the DON stated she was told by the MDS Nurse that morning that she had missed Resident #36's Quarterly MDS Assessment which was due in October. The DON stated the MDS Nurse was responsible for timely completion and accuracy of the assessments. She stated she monitored the Discharge MDS assessments to ensure they were completed but it was the MDS Nurse's responsibility to monitor the others. The DON stated she was not aware of the errors made with the BIMS and mood interviews. She stated the risk for inaccurate MDS assessments was changes in the resident's condition could be missed which were important for care planning. In a record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.19.1 dated October 2024 reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts . In addition, the assessment must represent an accurate picture of the resident's status during the observation period of the MDS .Section C: Cognitive Patterns .Coding Tips Attempt to conduct the interview with ALL residents. The interview is conducted during the look-back period of the Assessment Reference Date (ARD) .If the resident interview was not conducted within the look-back period (preferably the day before or day of the ARD .the standard 'no information' code (a dash '-') entered in the resident interview items .Section D: Mood .Coding Tips Attempt to conduct the interview with ALL residents. The interview is conducted during the look-back period of the Assessment Reference Date (ARD) .If the resident interview was not conducted within the look-back period (preferably the day before or day of the ARD .the standard 'no information' code (a dash '-') entered in the resident interview items . Record review of the facility's policy titled, Minimum Data Set (MDS), dated revised 11/26/2024, reflected: Service Standard [company name] will complete accurate resident assessments and submit assessments in accordance with current federal and state submission timeframes .2. The MDS coordinator will ensure that appropriate edits are made prior to submitting the MDS data.

Based on interview and record review the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for one (Resident #67) of 3 residents reviewed for discharge planning. The facility failed to develop and implement a discharge plan for Resident #67 who's goal was to return to the community. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge. Findings included: Record review of Resident #67's Face Sheet dated 12/18/24 reflected he was a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. Record review of Resident #67's Admission MDS assessment dated [DATE] reflected he was cognitively intact, he used a cane for mobility, and he required partial to maximum assistance with ADLs. His diagnoses included urinary tract infection, diabetes, and depression. His overall goal was discharge to the community and active discharge planning was already occurring for the resident to return to the community. Record review of Resident #67's Discharge assessment-return not anticipated MDS dated [DATE] reflected the discharge was unplanned. Record review of Resident #67's Care Plan dated 12/18/24 reflected: Problem-Impaired bed mobility. Goals included: A discharge plan will be developed with [Resident #67] and family/caregivers related to bed mobility needs. Interventions included: Prior to discharge, determine that all necessary durable medical equipment and assistive devices are available and ready for use by [Resident #67]. Utilizing the interdisciplinary team, determine discharge needs such as home health services and/or outpatient therapy. There were no other entries related to discharge planning or goals located within the Care Plan. Record review of Resident #67's physician's orders revealed no order for discharge was located. Record review of Resident #67's physician progress note dated 10/30/24 reflected: Date of Service 10/29/24. History of present illness: .Pt is a 90 yo M who presented to OSH with confusion and found with bronchitis, UTI. Pt started on abx and improved. Remainder of stay was uneventful but OSH records limited on review. Once pt was stable, pt was noted to benefit from continued medical oversight and therapy before dc to home, so pt was transferred to [nursing facility name] for such needs. Pt today is in room, I assisted the tech with care. Pt denies pain, feels well. States he is waiting on room to be made upstairs so he can move in by end of week. DON unaware. No other complaints . Record review of resident #67's nursing notes reflected the following entries: Entry dated 10/30/24 4:49 AM: Received resident in room lying in bed with eyes open, sitter at bedside. Resident remains on skilled nursing services for dx: UTI. Alert and oriented x 2-3, respiration even and unlabored, continues on po ABT Amoxicillin 875 mg day 2/3 and Doxycycline 100mg capsule day 2/2 related to UTI with NARN, incontinent of bowel and bladder, incontinent care provided as needed, no s/s of acute distress nor discomfort noted, able to verbalize needs, on cont. 02 2lpm via N/C, safety maintained, bed in comfortable low position, call light within reach, will continue to monitor and update any changes. Entry dated 10/31/24 at 8:03 PM reflected: Pt. discharged to Assisted Living facility today per MD orders patient V/S stable no complaints of pain or discomfort BBS clear BSx4 family RP notified of change medications reviewed and transferred with patient. Record review of Resident #67's EHR revealed no discharge planning documentation was located within his record. During an interview on 12/18/24 at 10:05 AM, the Administrator stated no discharge planning had been completed for Resident #67. She stated the social worker was previously responsible for conducting discharge planning and his was missed because she left . She stated His Discharge MDS reflected an unplanned discharge because he wanted to leave sooner than initially expected. He just said he was ready to go and wanted to leave. She stated she was unsure whether he had any home health needs and would look for any additional documentation. No additional documentation related to discharge planning was provided. During an interview on 12/18/24 at 11:07 AM, the DON stated the social worker was responsible for discharge planning. She stated Resident #67 resided in the facility's Assisted Living unit and returned there after receiving skilled therapy in their unit. She stated she did not believe he required any additional services, and he left on the same level of care he had prior to his admission. The DON stated the risk of not completing discharge planning was residents may be on different medications or treatments that they were not on prior to admission and treatments could be missed. Record review of the facility's policy titled, Discharge Summary dated revised 11/26/24 reflected: The purpose of the discharge summary and the post discharge plan of care with instructions is to assist the resident in adjusting to his/her new living environment by providing continuity of care information. 1. When anticipating a resident's discharge or upon the death of a resident, complete a discharge summary including: .d. a post-discharge plan of care developed with participation of the resident/resident's representative, or legal guardian; and with the resident's consent, the resident's representative, which will assist the resident to adjust to his/her new living environment. This includes where the individual plans to reside, any arrangements that have been made for the resident's follow up care, and any post-discharge medical and non-medical services .4. Member(s) of the Interdisciplinary Team will review the Discharge Plan of Care with the resident/resident's representative before the discharge is to take place. 5. A copy of the post-discharge plan of care and summary will be given to the resident and the receiving facility. A copy will be retained in the resident's medical records.

Based on interview and record review, the facility failed to ensure residents had a discharge summary that included a recapitulation of the resident's stay, medication reconciliation, and a post-discharge plan of care for one (Resident #67) of 3 residents reviewed for discharge summaries. The facility failed to complete a discharge summary for Resident #67 when he discharged home from the facility. This failure could place residents at risk of a recapitulation of the stay being unavailable to help ensure continuity of care once they went back home. Findings included: Record review of Resident #67's Face Sheet dated 12/18/24 reflected he was a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. Record review of Resident #67's Admission MDS assessment dated [DATE] reflected he was cognitively intact, he used a cane for mobility, and he required partial to maximum assistance with ADLs. His diagnoses included urinary tract infection, diabetes, and depression. His overall goal was discharge to the community and active discharge planning was already occurring for the resident to return to the community. Record review of Resident #67's Discharge assessment-return not anticipated MDS dated [DATE] reflected the discharge was unplanned. Record review of Resident #67's Care Plan dated 12/18/24 reflected: Problem-Impaired bed mobility. Goals included: A discharge plan will be developed with [Resident #67] and family/caregivers related to bed mobility needs. Interventions included: Prior to discharge, determine that all necessary durable medical equipment and assistive devices are available and ready for use by [Resident #67]. Utilizing the interdisciplinary team, determine discharge needs such as home health services and/or outpatient therapy. Record review of Resident #67's physician's orders revealed no order for discharge was located. Record review of Resident #67's physician progress note dated 10/30/24 reflected: Date of Service 10/29/24. History of present illness: .Pt is a 90 yo M who presented to OSH with confusion and found with bronchitis, UTI. Pt started on abx and improved. Remainder of stay was uneventful but OSH records limited on review. Once pt was stable, pt was noted to benefit from continued medical oversight and therapy before dc to home, so pt was transferred to [nursing facility name] for such needs. Pt today is in room, I assisted the tech with care. Pt denies pain, feels well. States he is waiting on room to be made upstairs so he can move in by end of week. DON unaware. No other complaints . No other issues at this time . Record review of Resident #67's nursing notes reflected the following entries: Entry dated 10/30/24 4:49 AM: Received resident in room lying in bed with eyes open, sitter at bedside. Resident remains on skilled nursing services for dx: UTI. Alert and oriented x 2-3, respiration even and unlabored, continues on po ABT Amoxicillin 875 mg day 2/3 and Doxycycline 100mg capsule day 2/2 related to UTI with NARN, incontinent of bowel and bladder, incontinent care provided as needed, no s/s of acute distress nor discomfort noted, able to verbalize needs, on cont. 02, 2 lpm via N/C, safety maintained, bed in comfortable low position, call light within reach, will continue to monitor and update any changes. Entry dated 10/31/24 at 8:03 PM reflected: Pt. discharged to Assisted Living facility today per MD orders patient V/S stable no complaints of pain or discomfort BBS clear BSx4 family RP notified of change medications reviewed and transferred with patient. Record review of Resident #67's EHR revealed no discharge summary documentation was located within his record. Record review of a Clinical Notes Report dated 12/18/24 from Resident #67's Assisted Living facility reflected the following: Entry dated 10/31/24 7:34 PM: Resident transferred back to AL. to [room number] this afternoon alerts and oriented x 4 denies any pain or discomfort resp. even and unlabored no sob, noted no coughing or congestion noted. Resident stated, I am very happy I am returning to my room, and I feel better now. All medications verified with [physician name] and all order updated. Resident [eats] in the dining room and appetite fair encourage by mouth fluids tolerated well. vitals checked stable. will continue to monitor. During an interview on 12/18/24 at 10:05 AM, the Administrator stated no discharge planning had been completed for Resident #67. She stated the social worker was previously responsible for completing discharge summaries and his was missed because she left. She stated His Discharge MDS reflected an unplanned discharge because he wanted to leave sooner than initially expected. He just said he was ready to go and wanted to leave. She stated other staff were assisting with social work duties such as referrals and a new one would be starting the following week. During an interview on 12/18/24 at 11:07 AM, the DON stated no discharge summary was completed for Resident #67 because the Social Worker was responsible for it and she left. She stated resident #67 was returning to his assisted living apartment within the same facility and she believed he left on the same level of care he had prior to his hospitalization and skilled stay. She stated he would have been discharged with his medications and would look for any other documentation that may be available. She stated the risk for failing to complete a discharge summary was they may be on different medications than when previously at home and could possibly miss changes in treatments or equipment needed. om In an interview with the DON on 12/18/24 at 3:37 PM, she stated she had been unable to locate any documentation of a discharge summary other than the clinical note from the assisted living facility indicating his medications had been verified and ordered. Record review of the facility's policy titled, Discharge Summary dated revised 11/26/24 reflected: Service Standard It is the service of [company name] to complete a discharge summary to his/her new living environment. The purpose of the discharge summary and the post discharge plan of care with instructions is to assist the resident in adjusting to his/her new living environment by providing continuity of care information. 1. When anticipating a resident's discharge or upon the death of a resident, complete a discharge summary including: a. A recapitulation of the resident's stay that includes, but is not limited to diagnose, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. b. A final summary of the resident's stay at the time of discharge. c. Reconciliation of all pre-discharge medications with the resident's post discharge medications (both prescribed and over the counter) d. a post-discharge plan of care developed with participation of the resident/resident's representative, or legal guardian; and with the resident's consent, the resident's representative, which will assist the resident to adjust to his/her new living environment. This includes where the individual plans to reside, any arrangements that have been made for the resident's follow up care, and any post-discharge medical and non-medical services. 2. Information for a receiving facility must include, but are not limited to the resident's: a. Contact information for the resident's medical provider; b. Resident's representative information including contact information; c. Advance Directive information; d. All special instructions of precautions for ongoing care, as appropriate; e. Comprehensive care plan goals; f. All other necessary information, including a copy of the resident's discharge summary .

Based on observation, interview, and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 23% based on 10 errors out of 43 opportunities which involved 1 of 4 residents (Resident #32) and 1 of 3 staff (LVN A) reviewed for medication error, in that: LVN A crushed medication and mixed all the fourteen (14) medications together and administered through a gastrostomy tube (surgically placed to provide direct access to a human's stomach for supplemental feeding, hydration, or medication) to Resident #32 These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: Record review of Resident #32's face sheet dated 12/18/24 revealed an [AGE] year-old male who admitted on [DATE]. his diagnoses included pneumonitis ( general term that refers to swelling and irritation, also called inflammation, of lung tissue)due to inhalation of food and vomit, hypertension pain, constipation, muscle spasm, gastro-esophageal reflux disease without esophagitis (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach, called the esophagus.), muscle weakness, muscle wasting, lack of coordination, difficulty in walking, anxiety disorder and gastrostomy status, Record review of Resident#32's quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 out of 15, which indicated severe cognitive impairment. He required assistance from staff with ADL care. Record review of Resident #32's care plan dated 12/28/24 revealed Resident #32 receiving tube feedings, with goal for Resident #32 to receive adequate nutrition without side effects associated with tube feedings (aspiration, diarrhea, dehydration) Record review of resident #32's physician orders for December 2024 revealed orders for: Ferrous sulfate 300 mg (60 mg iron)/5 ml oral liquid (5ml ) liquid (ml) g-tube, lactobacillus acidoph-l.bulgaricus 1 million cell tablet (1) tablet g-tube, aspirin childrens 81 mg chewable tablet (1) tablet, chewable g-tube, fexofenadine 180 mg tablet (1) tablet g-tube, gabapentin 400 mg capsule (1) capsule g-tube, magnesium 400 mg (as magnesium oxide) capsule (1) capsule g-tube, melatonin 5 mg tablet (1) tablet g-tube, metoprolol tartrate 50 mg tablet (1) tablet g-tube, glycopyrrolate 1 mg tablet (1 tablet) tablet g-tube, escitalopram 5 mg tablet (1) tablet g-tube, cefdinir 300 mg capsule (1) capsule g-tube, doxycycline hyclate 100 mg capsule (1 cap) capsule g-tube, nexium 40 mg capsule, delayed release (1 packet) capsule, delayed release (enteric coated) g-tube and flush enteral feeding tube with 15ml of tap water before & after each individual medication administration per g-tube. In an observation on 12/17/24 at 09:20 AM revealed LVN A administering the following medication to Resident #32 though the g-tube; Aspirin 81 mg chewable, cefdinir 300 mg capsule, doxycycline hyclate 100 mg , esomeprazole delayed realize 40 mg, iron supplement 15 cc, gabapentin 400 mg, probiotic supp 1 cap magnesium oxide 400 mg, glycopyrrolate 1 mg, ropinirole hcl 0.25 mg, allergy relief 180 mg LVN A prepared the medications on the medication cart and opened the capsules and mixed them in one medication cup and then crushed all the tablets together and placed them in one medication cup . LVN A then proceeded to the resident's room with three medication cups of medicine and informed Resident #32 he was going to administer his medications via the g-tube. LVN A checked for placement and residual and then flushed with about 40 cc of water and then proceeded to administer medications. After administering the liquid potassium, he administered the crushed tablets, but the g-tube clogged up, then he poured the medication back to the drinking plastic cup and poured water to the syringe and tried to unclog the tube several times until it was unclogged. LVN A then added the medication that were in the medication cup with the medications in the plastic cup and mixed all the medications together and administered. After medication administration he then flushed with about 40 cc of water. In an interview on 12/17/24 at 01:46 PM with LVN A he stated where he had worked before, he was able to mix all the medications together cocktail because there was an order but Resident #32 did not have an order to cocktail, so he was supposed to administer the medications separately. LVN A stated when medications being cocktailed could lead to some medications having a chemical interaction that could cause a negative effect on the resident. In an interview on 12/18/24 at 03:07 PM with the DON she stated LVN A had informed her that he did not complete the medication administration right. The DON stated the nurse reported he cocktailed the medications. The DON stated the nurse was not supposed to cocktail the medications unless there was an order to do so, but the resident did not have the order. The DON stated the medications were not supposed to be cocktailed because they could interact and cause and negative effect to the resident. Facility policy review dated 10/23/24 titled Gastrostomy (G-tube) Policy reflected, . This service standard shall serve as a guideline and shall not replace sound clinical judgement based on the resident's condition, status, and plan of care.Unless a resident had an identified and documented risk for fluid overload, G-tube medications will be administered one at a time with a flush of at least 15cc before and after the administration of each medication unless the physician's orders specify otherwise.

Based on observation, interview and record review the facility failed to 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 infection of communicable diseases and infections for one of six residents (Resident #1) reviewed for infection control. CNA Z failed to perform hand hygiene during while providing incontinence care to Resident # 1. This failure could place the residents at risk for infection. Findings include: Record review of Resident #1's face sheet, dated 03/28/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included fracture of the patella (the bone at the front of knee joint), Alzheimer's disease (is a brain disorder that causes memory loss, thinking problems, behavior changes, and brain cell death) and dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Record review of Resident #1's care plan, dated 12/21/23, reflected the resident was incontinent of bowel and blader and had an ADL self-care performance deficit related to cognitive impairment, and the intervention was for the resident incontinence care to be managed by staff. Observation on 03/28/24 at 09:44 AM revealed CNA Z provided incontinent care for Resident #1. CNA Z entered Resident #1's room, gloved without performing hand hygiene and proceeded to provide the residents with care. CNA Z unfastened the brief and cleaned the resident's front area, turned Resident #1 to her side, and removed the dirty brief. Resident #1 was soiled in urine. CNA Z then placed the dirty brief in the trash can and cleaned the resident's buttocks area. After cleaning the resident, without any form of hand hygiene or change of gloves, CNA Z applied the clean brief, turned the resident on her back and fastened the brief. After care, CNA Z completed hand hygiene. In an interview on 03/28/24 at 10:05 AM with CNA Z, CNA Z stated she was supposed to complete hand hygiene before and after care. CNA Z stated after cleaning the resident she was supposed to clean her hands and change gloves before applying the clean brief. CNA Z stated she was supposed to complete hand hygiene to prevent the spread of infection. CNA Z stated she completed a hand hygiene and infection control in-service about four months ago. In an interview on 03/28/24 at 11:49 AM with the ADON, she stated infection control was important during care. ADON A stated during incontinent care the staff were to use the hand sanitizer or wash hands if they were physically soiled. ADON A stated the staff were expected to complete hand hygiene before care and after care, she also stated during incontinent care the staff were supposed to change gloves and use hand sanitizer when taking off the dirty brief before applying the clean one. ADON A stated hand hygiene was to be completed for infection control. ADON A stated she was the infection preventionist and in-service on infection control was done twice a year. ADON stated it was her responsibility and the responsibility of the nurses in the units, ADON B and the DON to make sure the CNAs followed proper hand hygiene during residents' care. In an interview on 03/28/24 at 12:12 PM with the DON, she stated staff doing direct resident care were supposed to wash their hands before given care and afterward. She stated the CNAs were supposed to change glove, with hand hygiene when going from dirty to clean during incontinent care and perform hand hygiene before putting on the clean gloves. The DON stated hand hygiene was to be completed to prevent cross contamination from dirty to clean. The DON stated it was the responsibility of the nurses in the units, ADONs and DON to make sure the facility hand hygiene policy was followed by all the staff during resident care. Record review of the facility's policy, revised 01/23/24, and titled Hand Hygiene, reflected, Hand hygiene is the most important procedure for preventing the spread of infections. Hand hygiene should be performed: Upon arrival at the workplace and before going home. After using the toilet, blowing nose, and covering a cough or sneeze. Before and after eating. Before and after client contact. After removing gloves. Before invasive procedures. After touching contaminated items.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure two of the four handwashing sinks had a garbage receptacle next to the sink. 2.The facility failed to ensure food items in the refrigerators (4), freezers (4) and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 4. The facility failed to ensure the ice machine filters and vent/grate and outer surface was free from dirt and dust. 5. The facility failed to ensure the ice machine chute guard was clean. 6. The facility failed to ensure the ice cream in the ice cream freezer was covered. 7. The facility failed to ensure items not in their original containers were labeled and dated. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of the small kitchen on [DATE] at 10:19 AM revealed the following: -The smaller kitchen area to the right of the main kitchen: -at handwashing sink #1 there was a black large rolling pallet on the floor with a gray dish drying/storing rack on top of it in front of the sink, blocking it. -There was no garbage receptacle next to the handwashing sink #1. -The ice machine had a plastic vent located on the front side of the machine, the vent slats and filters (2) had dirt and dust on them. Ice machine: around the ice machine, just above the ice chest compartment, there was a dried white calcified/hardened substance. -Ice Machine: the chute guard had 4 gray greasy smudges and the right lower corner of the chute guard had some dark colored specks. -Across from handwashing sink #1 was a prep table with a juice machine and cappuccino machine on it. On the table in front of the juice machine were several dried sticky shiny red spots. -The floor on the side of the room (right side) had dried stains of varying colors. -Next to the reach-in freezer, on a shelf near a side door leading out to the dining room: 2nd row from the top there were 2 small white bins with 3 drawers each. -Bin #1 (one on the left): Top drawer- there were white individual sugar packets, no received by date, no consumed by or discard by date. Middle drawer- blue individual zero calorie sweetener packets, no received by date, no consumed by or discard by date. Bottom drawer- green individual raw sugar packets no received by date, no consumed by or discard by date. -Bin #2 (one in the middle): Top drawer- yellow individual zero calorie sweetener packets, no received by date, no consumed by or discard by date. Middle drawer- tan individual sweetener packets, no received by date, no consumed by or discard by date. Bottom drawer- pink individual zero calorie sweetener packets, no received by date, no consumed by or discard by date. Bin #3 (one on the right): Top drawer- white individual pepper packets, no received by date, no consumed by or discard by date. Middle drawer- individual packets of ketchup, pepper, sweet & sour sauce, no label of item description, no received by date, no consumed by or discard by date. Bottom drawer- individual yellow mustard packets, no received by date, no consumed by or discard by date. -,d+[DATE] oz. bottles of ketchup, previously opened, there was no received by date, no opened date. -,d+[DATE] oz. clear condiment bottle with a white lid containing dry dark granulated material, there was no label of item description, no opened date, no consume by or discard by date. -,d+[DATE] oz. clear condiment bottle with a white lid containing a dry white granulated material, there was no label of item description, no opened date, no consume by or discard by date. -3rd row from top: Left bin- clear square bin with brown individual liquid creamer containers, there was no received by date, no opened date, no consume by or discard by date. -Middle bin- clear square bin with white individual liquid creamer containers, there was no received by date, no opened date, no consume by or discard by date. -Right bin- clear square bin with blue individual liquid creamer containers, there was no received by date, no opened date, no consume by or discard by date. -4th row from top: 1 small, opened box of granulated parmesan cheese packets, no received by date, no opened date, no consume by or discard by date. -1 medium, opened box with individual packets of iodized salt with a clear plastic bag with individual packets of iodized salt, previously opened. There was no received by date, no opened date, no consume by or discard by date on the bag or the box it was sitting in. -On prep. table next to the reach-in refrigerator was a clear 4-gallon container with a lid of a thick pale yellow soft formed material, labeled use by 7 days Prepped: [DATE] Discard: [DATE], no label of item description. -Large Shelf on left side of the small kitchen: 3rd row from top row: more than 10 boxes of various teas, previously opened, no received by dates, no opened dates, no consume by or discard by dates. -2nd shelf, closest to door, top row: -1- 2 lbs. bag of cappuccino mix, previously opened, wrapped in plastic wrap, no received by date, no opened date, no consume by or discard by date. Observations of the Ice Cream Freezer on [DATE] at 10:40 AM revealed the following: -1 Extra-large container of strawberry ice cream with a lid, the left side of the lid was up, exposing the ice cream to air. -5 Extra-large containers of varying ice creams with lids, there was no received by date, no opened date, no consume by or discard by date. Observations of the Reach-in freezer on [DATE] at 10:52 AM revealed the following: -On a sheet pan there was a medium white foam cooler with dry ice and two orange sticky notes. The first note reflected, don't touch DRY ICE its dangerous to contact the second note read, ask FSD, -On the same sheet pan there was a white plastic bag tied close with a sticky note that had a person's name on it. -On the same sheet pan there was a chocolate chip cookie ice cream sandwich, there was no received by date, no consume by or discard by date. -,d+[DATE] oz. lemon meringue pies with lids, there was no received by date, no consume by or discard by date. -1 extra-large container of strawberry ice cream, there was received by date, no opened date, no consume by or discard by date. Observations of the Reach-in refrigerator on [DATE] at 10:54 AM revealed the following: -Right side door, top row: -,d+[DATE] oz. can of diet cola, no received by date, identifier, if for resident. 1-small clear square container with a green lid with shredded yellow cheese, labeled use by 3 days Prepped: [DATE] Discard: [DATE], no label of item description and passed its facility set expiration date. -1- small clear square container with ranch dressing packets, there was no received by date, no consume by or discard by date. -2nd row from top: ,d+[DATE] pack 42.2 oz. cartons of liquid decaf coffee, no received by date, no consume by or discard by date. -,d+[DATE] pack 42.2 oz. cartons of liquid caffeinated coffee, no received by date, no consume by or discard by date. -2 medium white bowls of lemon pieces covered with plastic wrap, labeled use by 3 days Prepped: [DATE] Discard: [DATE], no label of item description. -3rd row from top: -1 full size sheet pan covered in plastic wrap, with 22 white and 4 black small bowls, containing a swirled pale-yellow formed material, labeled use by 3 days Prepped: [DATE] Discard: [DATE], no label of item description. -4th row from top: -1 full size sheet pan covered in plastic wrap with 10 small black bowls of a thick white creamy material and yellow shredded cheese and a thick pale yellow thick material, use by 3 days Prepped: [DATE] Discard: [DATE], no label of item description for each item in the bowl, no individual consume by or discard by dates for each item in the bowl. -On the same sheet pan, 10 mini stainless-steel containers with chopped bacon, no label of item description, no consume by or discard by date. -1 large clear square container covered with plastic wrap that had multiple small clear plastic 2 oz. condiment cups with lids, contained varying colored and thickness of substances. There was no label of item descriptions, no received by, no opened date, and no consume by or discard by for each item or group of same items noted. -,d+[DATE] oz. lemon meringue pies with lids, there was no received by date, no consume by or discard by date. --35 oz. previously opened lemon meringue pie with lid, there was no received by date, no opened date, no consume by or discard by date. -Left side door, 4th row: -,d+[DATE].4 oz. plastic container of cranberry juice from the juice machine, no received by date, no consume by or discard by date. Observations of the Main Kitchen on [DATE] at 10:59 AM revealed the following: -Handwashing sink #3, near entrance door, has no garbage receptacle near it or next to it. -On shelf next to reach-in refrigerator, top row: -1 small square clear container with a lid containing 00 pizza flour, labeled: Use by 14 days Prepped: [DATE] Discard: [DATE]. -1 small square clear container with a lid containing brown dry coarse light brown crumbs, labeled, Use by 5 days Prepped: [DATE] Discard: [DATE], no label of item description. -On 2nd row from top row: 1 medium clear square containers with a lid containing croutons, labeled, Use by 30 days Prepped: [DATE] Discard: [DATE], no label of item of description. -1 large clear square containers with a lid containing croutons, labeled, Use by 30 days Prepped: [DATE] Discard: [DATE], no label of item of description. -1 large square clear container with a lid containing croutons labeled: Use by 5 days Prepped: [DATE] Discard: [DATE], no label of item description. Observations of the Reach-in refrigerator #2 on [DATE] at 11:01 AM revealed the following: -3rd row from top: -Medium clear square container with a lid containing a thick white liquid labeled use by 30 days Prepped: [DATE] Discard [DATE], no label of item description. -,d+[DATE] oz previously opened, plastic container of cranberry juice, dated [DATE], no opened date, no consume by or discard by date. -Top row: -,d+[DATE] oz. plastic containers with lids contained honey vinaigrette labeled, use by 7 days Prepped: [DATE] Discard: [DATE]. -4th row from top: -1 5lb previously opened white plastic tub with a lid of creamy peanut butter, labeled use by 30 days Prepped: [DATE] Discard: [DATE]. -1- 32 oz. cylindrical stainless-steel pan of baked beans covered with plastic wrap, labeled use by 3 days Prepped: [DATE] Discard: [DATE], and no label of item description. -1 medium square clear container with a lid containing a thick red liquid, labeled, Prepped: [DATE] Discard: [DATE], there was no label of item description. Observations of the Walk-in refrigerator #3 on [DATE] at 11:28 AM revealed the following: - 1st shelf, to the right of the door, 2nd row from the top row: -1 extra-large clear rectangle container with various bags of different colored tortilla products: 1- large clear plastic bag, previously opened, of red triangle tortilla chips. There was no label of item description, no received by date, no opened date, no consume by or discard by date. -2 small bags of more than 20 medium purple tortillas, no label of item description, no received by date, no consume by or discard by date. - 1 small bag of more than 20 medium purple tortillas, with a large tear in the bag, left opened to air, no label of item description, no received by date, no opened date, no consume by or discard by date. -Approximately 15 small bags of more than 20 medium tortillas, no label of item description, no received by date, no consume by or discard by date. -5th row from top: -1 extra-large clear square container with a sheet pan placed on top for a lid; it contained 3 bags of whole peeled potatoes; the pan did was up on the left side leaving the potatoes open to air. There was a whole in one of the bags, no label of item description, no opened date. Observations of the Dry Storage Room on [DATE] at 11:43 AM revealed the following: -1 medium box with more than ,d+[DATE] oz bags of vanilla pudding mix, previously opened, no received by date, no consume by or discard by date, no manufacturer's expiration date. -Last shelf on left side in the back, bottom row: 1 extra-large clear square container with a lid contained yellow cornmeal, labeled opened [DATE], there was no label of item description, no received by date, no consume by or discard by date. -,d+[DATE] lbs. bag of triple cleaned pinto beans, previously opened, labeled opened [DATE], bag left open to air, no received by date, no consume by or discard by date. -3rd row from top: -,d+[DATE]-gallon clear plastic container with a lid contained white rice, labeled opened [DATE], no label of item description, no received by date, no consume by or discard by date. Observations of the Walk-in freezer #2 on [DATE] at 11:37 AM revealed the following: -Shelf near the door on the right side, bottom row: a large box of various types of breads in a clear plastic bag, left open to air, no label of item description, no received by date, no opened date, no consume by or discard by date. In an interview on [DATE] at 011:40 AM with the Sous Chef, she stated the EC received the inventory, sous chefs, there are 3, dispersed inventory to assigned areas. Then the porter placed the inventory in the areas and on the shelves. The Sous Chef stated they used First in First Out (FIFO) system. In an interview on [DATE] at 02:50 PM with the EC, she stated personal items were not allowed in the areas (refrigerators, freezers, dry storage, prep. areas) with food items for the residents. She stated condiments, once opened, like the ketchup, were kept for no more than 30 days. The EC stated the AM Sous Chef, and the Lead cook did the inventory. She stated it was everyone's job in the kitchen to check for outdated/expired food items. She said, it is everyone's job to do the labeling. She stated it was the Dietary Aides' responsibility to know the residents' diets/allergies/likes and dislikes. The EC stated leftovers were kept in the refrigerator for 3 days and opened items were kept in the freezer for 3 months. She stated they put opened dates on opened items when they are initially opened. When she was shown the plastic bag in the freezer with a name on it, she told one staff member we need to find out who (person's name on the bag) is . She stated they would do an in-service and the Chefs and Leads will do monitoring to ensure the subject matter of the in-service (labeling, securing closed, dating, etc.) will be put into practice. The EC stated cross-contamination was a risk/harm to residents regarding the vents and filters being dirty. Review of the facility's Food and Nutrition Services Policy dated [DATE]: Revised [DATE], reflected A Director of Food and Nutrition will be designated to oversee all food and nutrition services with frequently scheduled consultation from a qualified dietitian or other clinically qualified nutrition professional. Food and Supplies Storage: Service Standard: Supplies for 7 days of staple food and 2 days for perishable food will be kept on hand. Food and supplies will be stored according to current standards of practice. Procedure: Safe Food Storage: General standards for food storage will include the following: 1. Dry Food Storage should be maintained in a clean and dry area free of contaminants.2. Refrigerator Storage Safe Practices include: . d. Labeling, dating and monitoring foods. Food Safety: . 6. Food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety. 7. Refrigerator in resident rooms must be monitored by the facility staff for adequate temperature and expiration dates of food. 9. The facility will follow food-handling practices in the distribution of the food. 10. The community will make effort to assure the safe consumption of food. Sanitation: Service Standard: [NAME] strives to prepare, distribute, and serve food under sanitary conditions. Procedure: 1. Food is prepared, distributed, and served to resident under sanitary conditions.3. Follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. 4. Safe food handing for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes. Review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . section ,d+[DATE].11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in LAW, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18. Section ,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section ,d+[DATE].17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. Chapter 5 . Section ,d+[DATE].11 Using a Handwashing Sink (A) A Handwashing Sink shall be maintained so that it is accessible at all times for Employee use. Section ,d+[DATE].16 Storage Areas, Rooms, and Receptacles, Capacity and Availability . (B) A receptacle shall be provided in each area of the Food establishment or premises where refuse is generated or commonly discarded, or where recyclables or returnables are placed. (C) If disposable towels are used at handwashing lavatories, a waste receptacle shall be located at each lavatory or group of adjacent lavatories. Section ,d+[DATE].113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: . www.fda.gov eCFR- Code of Federal Regulations are indicating within the text by an *- www.ecfr.gov

Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that are to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #62) of four residents reviewed for care plan. The facility failed to implement Resident #62's care plan to address nutrition and, anticoagulant therapy. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs. Findings included: Review of Resident #62's admission MDS assessment, dated 10/15/23 revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included atrial fibrillation (irregular heartbeat), post-polio syndrome (polio), Cardiac Aortic Disease (blocked arteries), and nutritional instability (with weight loss and weight gain of greater than 5-10%). The resident was alert an oriented with a BIMS score of 11 and usually understood others. Resident #62 required assistance of one staff member for set up and clean up. The assessment reflected the resident was 5 feet 5 inches in height and weighed 118 pounds. Review of the physician's orders dated 10/15/23 revealed Resident #62 admitted with an order for anticoagulation medication Eliquis 5 mg two times a day for Atrial fibrillation. Review of the Medication Administration Record dated 10/15/23 revealed Resident #62 was receiving the medication, Eliquis 5 mg, as the physician had order. Review of Resident #62's care plan on 11/02/23 reflected no care plan had been initiated for Resident #62 reflecting no goals for nutrition or anticoagulant therapy. Observation and interview on 11/01/23 at 12:19 p.m. revealed Resident #62 was sitting up in bed, and she was assisting herself to eat. The resident stated she liked the food; it was just too much to eat sometimes. The resident stated they gave her a supplement daily if she did do not eat well. The dietician had spoken to her about her inconsistent weight gain and loss, but she really had been like that most of her life. Interview on 11/02/23 at 9:06 a.m. with the ADON revealed she, the other ADON, the DON and the floor nurses (charge nurses) were responsible for updating resident care plans. She further stated We (nursing administration) thought you might be talking to us about the care plans. We have no MDS nurse right now. We have one starting soon and the care plans are either behind or not started. The ADON stated the DON was aware and not having care plans initiated could lead to residents possibly not getting the care that was needed or recommended . Interview on 11/02/23 at 12:00 p.m. with LVN B reveled she did not update care plans; she was never told to update care plans. Interview on 11/03/23 at 8:20 a.m. with LVN A revealed he had worked at the facility since August of 2023, he had been told by the DON to update care plans on the residents he oversaw if he had the time. LVN A stated he had not had time to update any care plans. Interview on 11/03/23 at 1:34 p.m. with the DON revealed the MDS Coordinator was responsible for initiating and updating the care plan as needed. The DON stated the facility had hired a new MDS Coordinator, but she had not started working yet. The DON stated the nursing administrative team had been trying to update and initiate the care plans but had not accomplished the goals. She was not aware Resident #62's care plan was not initiated to reflect the goals required to care of her, to include nutrition and medication. Review of the facility's only policy titled Charting and Documentation dated October 17, 2023, reflected the following: All services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional, or psychological, shall be documented. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on observation, interview, and record review the facility failed to ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, for 2 of 4 residents (Resident #32 and Resident #43) reviewed for care plans. The facility did not update Resident #32's care plan to reflect specific instructions for hospice and end of life. The facility did not update Resident #43's care plan to reflect specific instructions for hospice and end of life. This failure could place residents at risk for not receiving appropriate care and intervention to meet their current needs. The findings were: Review of Resident #32's MDS annual assessment dated [DATE], reflected she was a [AGE] year-old female admitted on [DATE]. His diagnoses included Parkinsonism (neurological disease), atrial fibrillation (heart rate dysfunction), and mild protein calorie malnutrition. Her BIMs score of 3 reflected her cognitive status was severely impaired. She required moderate to maximum assist of one staff member for activities of daily living. Section O of the MDS was marked for Hospice Care. Record review of the Physician's orders for Resident #32 dated 05/26/23 reflected to admit to Hospice services. Record review of Resident #32's Care Plan initiated on 08/31/23 reflected, there were not a care plan goals to reflect specific instructions for hospice services. Review of Resident #43's MDS annual assessment dated [DATE], reflected he was an [AGE] year-old male admitted on [DATE]. His diagnoses included: Hypertension (increased blood pressure), parkinsonism (neurological disease), dementia, and chronic obstructive pulmonary disease (unable to breath well). His BIMs score of 3 reflected his cognitive status was severely impaired. He required moderate to maximum assist of one staff member for activities of daily living. Record review of Physician orders Resident #43 dated 08/21/23 reflected to admit to Hospice services. Record review of Resident #32's Care Plan initiated on 08/31/23 reflected, there were not a care plan goals to reflect specific instructions for hospice services. Interview on 11/02/23 at 9:06 a.m. with the ADON revealed she, the other ADON, the DON and the floor nurses (charge nurses) were responsible for updating resident care plans. She further stated we (nursing administration) thought you might be talking to us about the care plans, we have no MDS nurse right now, we have one starting soon and the care plans are either behind or not started. The ADON stated the DON was aware and not having care plans initiated could lead to residents possibly not getting the care that was needed or recommended. Interview on 11/02/23 at 12:00 p.m. with LVN B reveled she did not update care plans, she was never told to update care plans. Interview on 11/03/23 at 8:20 a.m. with LVN A revealed he had worked at the facility since August of 2023, he had been told by the DON to update care plans if he had the time on the residents he oversaw. LVN A stated he had not had time to update any care plans. Interview on 11/03/23 at 1:34 p.m. with the DON revealed the MDS Coordinator was responsible for initiating and updating the care plan as needed. The DON stated the facility had hired a new MDS coordinator ,but she had not started working yet. The DON stated the nursing administrative team has been trying to update and initiate the care plans but had not accomplished the goals. She was not aware Resident #32's care plan was not initiated to reflect the goals required to care of her and concerning Hospice goals. Review of the facility's policy only titled Charting and Documentation dated October 17, 2023, reflected the following: All services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional, or psychological, shall be documented. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for the resident, consistent with the resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental, and psychosocial needs that were identified in the comprehensive assessment, for 2 of 5 residents (Resident #3 and Resident #4) reviewed for comprehensive care plans. The facility failed to ensure Resident #3's and Resident #4's Comprehensive Care Plan reflected a revision of their plan of care after falls. This deficient practice could place residents at risk for not receiving the appropriate care and services needed to maintain optimal health Findings included: Record review of the face sheet dated 10/08/22 for Resident #3 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Resident #3's care plan with the effective date of 07/01/22 revealed no evidence Resident #3 was identified as a fall risk or the resident had suffered a fall. The care plan revealed no interventions to prevent falls. Review of Resident # 3's MDS dated [DATE] revealed she had a Brief Interview of Mental Status (BIMS) of 13 indicating cognitively intact. She required extensive assistance with one-person physical assistance with transfers. The resident required a wheelchair for mobility. The MDS did not reflect the resident previously had any falls. Review of Resident #3's fall risk assessment dated [DATE] revealed she had a score of 10 indicating she was a high fall risk. Review of incident reports for Resident #3 revealed she had a fall on 09/04/22 and 10/08/22. The fall on 09/04/22 reflected the resident had not injures. The fall on 10/08/22 reflected the resident suffered a lump and purplish bruising on the nasal bridge of the nose and a side frontal hematoma. Review of Resident #4's face sheet dated 10/19/22 revealed she was an 88- year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's care plan with the effective date of 08/08/22 revealed no evidence of interventions in place to prevent falls. Review of Resident #4's MDS dated [DATE] revealed she had a BIMS of 14 indicating cognitive intact. Resident #4 required extensive assistance with the help of one person with physical assist with transfers. The MDS reflected the resident had a previous fall. Review of Resident #4's fall risk assessment dated [DATE] revealed the resident had a score of 2, indicating a low risk for falls. Review of Resident #4's care plan with the effective date of 08/08/22 revealed no evidence of interventions in place to prevent falls. Review of Resident #4's incident report dated 08/09/22 revealed the resident was found on the floor and stated she had fallen. The resident had bruising on both arms and redness on her bottom. An interview with the DON on 10/19/22 at 10:57 am revealed Resident #3 and Resident #4 care plans did not reflect interventions regarding falls. The care plans had no mention of the previous falls of 08/09/22, 09/04/22 and 10/08/22. She stated the facility had recently hired (2 weeks) a new MDS coordinator to update the care plans for the residents. Updating the care plans are important to ensure all staff are aware of the interventions to prevent further falls. An interview with the MDS coordinator on 10/19/22 at 11:13 am revealed she was recently hired and was not aware of the care plans not being updated. It was her responsibility going forward to ensure care plans are updated to include interventions. Record review of the facility's Falls policy dated 01/13/22 d. the staff will collaborate to identify and address modifiable fall risk factors, and interventions to try to minimize the consequences of risk factors are not modifiable. Review of the Care Plan policy dated 04/26/22 revealed no information regarding updating care plans with fall interventions.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of care within 48 hours of the resident's admission for two (Resident #15 and Resident #145) of four residents reviewed for base line care plans. The facility failed to complete Resident #15 and Resident #145 baseline care plan within 48 hours of admission that included the minimum required healthcare information of initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure placed residents at risk of not receiving effective and person-centered care. Findings included: Review of Resident #15's undated Face Sheet, reflected she was a [AGE] year-old female admitted to the facility on [DATE] . Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's Initial Care Plan, dated 06/28/22 reflected Resident #15 had the potential for infection. The care plan did not address physician orders, dietary orders, therapy services, and social services. Review of Resident #145's undated Face Sheet, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #145's Initial Care Plan, dated 08/30/22 reflected Resident #145 was a fall risk. The care plan did not address physician orders, dietary orders, therapy services, and social services In an interview on 09/08/2022 at approximately 1:00 pm with the DON, she stated care plans are initiated and completed by the charge nurse upon a resident's admission into the facility and she tracked for completion. The DON did not state how she tracked care plans. The DON stated she became aware of incomplete baseline care plans today and she and the ADON were in the midst of auditing all care plans and would in-service clinical staff on the importance of creating and completing care plans timely and completely. The DON would not state the potential risk(s) posed to the residents by not having a care plan. Review of the facility's New Admission Assessment policy, revised 04/26/22 reflected After admission, the following departments will assess the resident: 1. Nursing (RN/LVN) will conduct an initial nursing assessment. 2. Activities will conduct an evaluation of resident activity needs and preference. 3. Dietary Services will conduct an evaluation of resident food allergies, likes, and dislikes and 4. Social Services will conduct a social services assessment. The information will be used in the development of the resident's care plan

Based on interview and record review, the facility failed to provide adequate supervision to prevent an accident for one (Residents #1) of three residents reviewed for incidents/accidents and supervision. The facility failed to supervise Resident #1, who had a history of [CONDITION(S)] accident with left [CONDITION(S)] (stroke) and needed one-person physical staff assistance, in the bathroom by herself without a call light within reach. Resident #1 fell from her wheelchair and sustained a fracture to her left ankle. These failures had the potential to affect residents with assistance and transfer needs by placing them at risk for injuries including fracture, hospitalization and death. Findings included: Review of Resident #1's Face Sheet, dated 04/30/21, revealed she was a [AGE] year- old female admitted to the facility on [DATE] with diagnosis of [CONDITION(S)] accident left [CONDITION(S)]. Review of Resident#1's Nursing Admission Assessment Comprehensive, dated 04/30/21, revealed Resident #1 was alert and orientated with no speech problem and no communication deficit. She had left sided weakness with limited range of motion to her left arm and leg, and used a wheelchair for mobility. Review of Resident #1's care plan, dated 04/30/21, related to problems with stroke which affected her left side revealed she was self-care deficit and in need assistance with ADLs. She was at risk for falls and encouraged resident to use call light. Record review of Physical Therapy Plan of Care for Resident #1's reflected she was admitted for physical therapy services on 04/30/21 and occupational therapy services on 05/01/21 for generalized muscle weakness, difficulty walking, unsteady on feet, and lack of coordination. Review of Resident #1's Incident Report revealed on 05/03/21 at 6:30 PM Resident #1 was found on the bathroom floor beside her wheelchair. She complained of pain to her left shoulder and right hip. Pain medication was administered. Review of Resident #1's Clinical Notes Report, dated 05/05/21, revealed PT had taken Resident #1 to the bathroom to brush her teeth. LVN E heard Resident #1 scream out. LVN E found her in the bathroom on the floor. Resident #1 complained of left shoulder and right hip pain. An order for an x-ray was received from the physician. On 05/04/21 at 3:28 PM Resident #1 complained of pain to the left ankle with bruising. An order for a new x-ray was received. An entry 05/04/21 at 10:48 PM reflected the x-ray technician arrived at the facility at 10:35 PM. An entry on 05/05/21 at 10:27 AM reflected the x-ray results came back reflecting the resident had a fracture to her left ankle. An order to send the resident to the emergency room for evaluation was received. An entry 05/05/21 at 10:29 AM reflected emergency services was called and Resident#1 was transferred to the hospital. Review of Resident #1's X-Ray report, dated 05/04/21 at 11:31 PM, revealed the report reflected a fracture involving the distal fibula and posteromedial malleolus; conclusion: ankle fracture. In an interview on 06/28/21 at 10:45 AM with the DON revealed there was a nine-hour delay reporting the results of Resident #1 x-ray of the left ankle fracture to the floor nurses. The DON stated on 05/04/21 at 1:27 AM the results came through as an e-mail to her cell phone. She stated it was so early in the morning; she was asleep and did not see the results until later in the day around 10:00 AM. She stated all faxes, physician orders, laboratory results, and x-ray results go to the Administrator, DON and ADON; they were the only staff that had the program on their cell phones. The DON stated the floor nurses did not have access to the program. She stated she or the ADON usually read the results and informed the nurses of the results of the x-rays, laboratory results, and physician orders. In an interview with Resident #1 on 06/29/21 at 1:35 PM revealed the therapist (name unknown) wheeled her to the bathroom and placed her in front of the sink to brush her teeth She stated she was left by herself in the bathroom. Resident #1 stated when she could not open her bottle of mouth wash, she yelled for help several times because she did not have a call light within her reach. She stated the call light was on the other wall by the commode and she could not reach it. She stated she leaned forward and attempted to use the bottle of mouth wash to push the red-light switch on the wall for help, the wheelchair rolled out from underneath her and she fell to the floor. She stated her arm and leg hurt her bad. She stated she screamed out for help and a nurse came in and help her. She denied unlocking her wheelchair. In an interview with COTA on 06/29/21 at 10:17 AM revealed she pushed Resident #1 in her wheelchair to the bathroom and placed her in front of the sink to brush her teeth. She stated she had locked the wheelchair and then explained that she would return after the resident asked her to leave the bathroom for privacy. She stated the call light was across the room by the commode and the cord to the call light was not long enough to reach the sink area. She stated she told a charge nurse and a CNA (names unknown) the resident was at the sink and she was very impulsive and needed supervision. She stated when she arrived back to the resident's room about 5 minutes later the resident was on the floor. COTA stated the resident stated she was reaching for an object on the floor and that she fell to the floor. She stated it was her responsibility to stay with the resident or in the resident's room since she had taken her into the bathroom. In an interview on 06/28/21 at 7:20 PM with LVN E stated she was getting report from LVN D when she heard Resident #1 scream out. She stated when she arrived in the room Resident #1was sitting on the floor next to her wheelchair. She stated she asked her how she had fallen and the resident stated she was trying to reach something and slide out of the wheelchair and onto the floor. She stated she was not aware the resident was in the bathroom and that COTA left her in the bathroom to brush her teeth. LVN E stated when COTA returned, she asked Resident #1 how did the wheelchair get unlocked, why did you unlock this wheelchair and the resident did not respond. In an interview on 06/29/21 at 11:58 AM with CNA G revealed she had put Resident #1 in bed and was not aware that COTA had taken her to the bathroom. She stated she had seen the nurses rushing to Resident #1's room when is entered the residents room see seen her on the floor and the resident stated she was reaching for something when she slipped out of the wheelchair and fell to the floor. In an interview on 06/29/21 at 7:40 PM with LVN F revealed she was worked 05/04/21 from 6:00 AM to 6:00 PM. She stated Resident#1 complained of pain to her left ankle around 3:30 PM. She stated she assessed her ankle and noted some bruising. LVN F stated Resident #1's family member was in the room and she requested for Resident #1's ankle to be x-rayed. She stated she notified the physician and was given a new order for an x-ray to Resident #1's left foot and ankle. She stated pain medication was administered. In an interview on 06/29/21 at 10:00 AM with DON revealed her expectations was not to leave residents in the bathroom unsupervised. The DON stated if the resident asked for privacy the staff was to stay in the resident's room to be able to hear the resident calling for help. The DON stated the risk factors could be skin tears, falls with injury and hospitalization s. She stated the facility did not have a policy and procedure for accidents, hazards and supervision. Record review revealed there was no policy related to accidents and supervision. The facility did not provide a policy at the time of exit on 06/29/21

Based on observation, interview, and record review the facility failed to store, distribute, and serve food in (one of three kitchens) in accordance with professional standards for food safety in the kitchen area on unit 200. The facility failed to maintain the salad dressing and pudding at the required temperature for cold foods at 41 degrees or lower. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: On 06/27/21 at 1:00 PM observed salad dressing and pudding in small plastic container sitting on the serving counter on the 200 unit. The temperature of the items were: Ranch dressing was 67 degrees Fahrenheit and the pudding was 70 degrees Fahrenheit taken by the Administrator used a facility thermometer. In an interview on 06/27/21 at 11:40 AM with CNA C revealed she did not temp the food items in the streamer before plating the food. She stated she had not been told to take the temperature of the food before serving it, that the kitchen took the temperatures before the food was transferred from the kitchen. Interview with the DM on 06/27/21 at 12:20 PM she stated when the food was delivered to the kitchen on unit 200 kitchen the dietary aide from the main kitchen took the temperatures of the food items and placed them in the refrigerator or on the steam table. The DM stated the staff on the unit who served the food to the residents did not take the temperature of the food before serving to the residents. Interview with the DM on 06/27/21 at 2:03 PM she stated the cold food was removed from the refrigerator and set on counter was not placed in or on ice to keep it cool. A review of the Point of Meal Service Temp Log and Service Time dated 06/27/21, indicated the dessert was 36 degrees Fahrenheit. The facility's policy dated 01/20/21 and titled Food Safety indicated on number 6. Food will be stored, prepared, distributed and served in accordance with professional standards for food service safety.

Based on interview and record review, the facility failed to ensure residents who had not used [CONDITION(S)] drugs were not given these drugs unless the medication was necessary to treat a condition as diagnosed and documented in the clinical record in an effort to discontinue these drugs for one (Resident #78) of 3 residents reviewed for [CONDITION(S)] medications. A. The facility failed to ensure there was adequate indications for Resident #78's [MEDICATION(S)] ([CONDITION(S)] medications) and [MEDICATION(S)] (anti-depressant). These failures could place residents at risk for possible [CONDITION(S)] medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary [CONDITION(S)] medications. Findings included: A review of Resident #78's clinical record indicated the resident was admitted to the facility on [DATE] with the following diagnoses: [CONDITION(S)], [CONDITION(S)] ( irregular heart rhythm), Diabetes, Hypertension and Dementia without Behavioral Disturbances. A review of Resident #78's hospital discharge record, dated 06/22/21, indicated the resident had a diagnosis of Dementia and to continue [MEDICATION(S)] and [MEDICATION(S)]. A review of Resident #78's Physician's Medication Profile, dated 06/22/21, indicated the resident was to be provided [MEDICATION(S)] 25 milligrams at bedtime for Alzheimer's Disease and [MEDICATION(S)] 10 milligrams (mgs) twice daily for depression. A review of Resident #78's [CONDITION(S)] Consent, dated 06/23/21, indicated the resident was to be provided [MEDICATION(S)] and [MEDICATION(S)] for diagnoses of Alzheimer's, Dementia. A review of Resident #78's Medication Administration Record for June 2021 indicated the resident was provided [MEDICATION(S)] 25 mgs at bedtime and [MEDICATION(S)] 10 mgs twice daily. A review of Resident #78's Care Plan report, 06/22/21, indicated resident was provided psychoactive medications and had the potential for adverse effects. Interview on 06/29/21 at 12:45 PM with the DON she stated when a resident was admitted the accepting nurse verified with the doctor to continue [CONDITION(S)] medications and ensure proper diagnoses were used. Interview on 06/29/21 at 12:50 PM with LVN A she stated when a resident was admitted the accepting nurse verified with the doctor to continue [CONDITION(S)] medications and ensure proper diagnoses were used. Interview on 06/29/21 at 12:55 PM with RN B she stated when a resident was admitted the accepting nurse verified with the doctor to continue [CONDITION(S)] medications and ensure proper diagnoses were used. Interview with the attending physician on 06/29/21 at 1:30 PM she stated the nurses contacted her with a new admission and she would usually continue all the resident's medications and refer the resident to psychiatric services if needed. She stated because the residents on the SNF unit were usually short term stay she did not want to change the medications. A review of the facility's [CONDITION(S)] Drugs, dated 01/20/21, indicated For newly admitted residents on anti-psychotic or [CONDITION(S)] medications, the dose, duration and rational needs to be evaluated by the prescriber within 7 days of admission.