Every finding on record at Villa Maria West Skilled Nursing Facility

The facility failed to develop a baseline care plan that included respiratory care for Resident #49, as evidenced by: Resident #49, was admitted on [DATE] and receiving multiple respiratory treatments, did not have a baseline care plan developed until six days after admission.The findings included:On 09/09/2025 at 9:45 AM, Resident #49 was observed seated in a wheelchair watching television. The resident reported no concerns and revealed she had two weeks remained in rehabilitation following a fall at home. On 09/10/2025 at 8:34 AM, the resident actively participated in therapy, with no concerns noted or reported. During the observation on 09/11/2025 at 10:15 AM, the resident was again seated in a wheelchair, and no concerns were noted or reported. A review of the medical record for Resident #49 showed an admission date of 09/04/2025, with diagnoses including Encounter for other specified aftercare and Chronic Obstructive Pulmonary Disease (COPD). The admission Minimum Data Set (MDS) was in progress at the time of review. The Entry MDS was completed on 09/08/2025, and the Assessment Reference Date (ARD) was set for 09/10/2025. Review of Physician orders dated between 09/04/2025 and 09/09/2025 indicated that the resident received multiple active respiratory treatments. These included Budesonide (Pulmicort) 0.5 mg/2ml (0.5 milligrams per 0.5 milliliters) via nebulizer twice daily, Formoterol Tartrate (Brovana) 5 mcg/2 ml (5 micrograms per 2 milliliters) nebulization solution twice daily, and Ipratropium-Albuterol solution every six hours via nebulizer. A pulmonology consultation was ordered on 09/08/2025 for pneumonia. Additional orders included Prednisone 10 mg daily for five days, Cefuroxime 250mg orally twice daily for pneumonia, and an order dated 09/04/2025 to check oxygen saturation.Review of Progress notes from 09/07/2025 and 09/08/2025 documented treatment for pneumonia and COPD. On 09/10/2025 at 11:30 AM, the Manager of Clinical Reimbursement, MDS Registered Nurse confirmed that although the ARD was set for 09/10/2025 and baseline care plan initiation was scheduled for that day, the resident had been receiving multiple respiratory interventions since 09/04/2025. The MDS RN acknowledged that the baseline care plan had not been completed and lacked interim documentation outlining essential respiratory treatments or goals.Despite clear orders for multiple inhaled and oral medications, consults, and respiratory monitoring, the facility failed to develop or implement a baseline care plan within 48 hours of admission that addressed the resident's respiratory needs.Following the interview, on 09/10/2025 at 12:40 PM, the Director of Nursing (DON) entered the conference room and hand-delivered a newly created baseline care plan. This plan had been developed only after the surveyor's inquiry, confirming that the baseline care plan was not completed within the regulatory time frame and was created in response to surveyor involvement.A review of the facility's Policy and Procedures for Baseline Care Plan for Care Planning, effective 12/03/2004, revised 02/22/2026, and reviewed 10/16/2024, revealed the following: The policy indicated that care, treatment, and services are planned to ensure appropriateness to the resident's needs. The facility provides an individualized, interdisciplinary plan of care addressing all resident needs, strengths, limitations, and goals. Care planning is implemented through integration of assessment findings, prescribed treatment plans, and development of reasonable and measurable goals. Documentation is completed using computerized care planning. The procedure specified that an interim care plan must be completed no later than 72 hours after admission.

Based on observations, staff interviews, and records review, the facility failed to implement effective corrective actions to address previously identified deficiencies. This is evidenced by the repeated citation of F655 - Development of a Baseline Care Plan. Despite prior citations and the opportunity for corrective action, the facility did not demonstrate sustained compliance. At the time of the survey, 22 residents were residing in the facility. The findings included:Review of the facility's survey history revealed, during a recertification survey with exit date 05/15/ 2024, F655 Development of a baseline care plan was cited related to facility's failure to develop a baseline care plan for oxygen use for one resident.During this survey with exit dated 09/11/2025, the facility did not develop Resident #49's baseline care plan for respiratory care.On 09/11/2025, at 12:30 PM, a Quality Assurance and Performance Improvement (QAPI) review was conducted with the Director of Nursing and the Administrator. The facility's Quality Assurance and Performance Improvement (QAPI) policy and procedure dated February 14, 2025, was reviewed with no concerns noted. The facility has a Quality Assurance and Assessment (QAA) Committee that meets every month on the second Wednesday. The most recent meeting was on September 13, 2025. Sign-in sheets showed that all required team members attended, including representatives from nursing, therapy, social services, dietary, and environmental services.The committee's primary objective is to ensure a safe, person-centered care environment. through data-driven analysis, collaborative problem-solving. The team uses data, teamwork, and improvement plans to fix problems. Every day at 9:02 AM, staff meet to find and solve issues early. Staff can also report concerns in other ways, like talking to supervisors.The committee chooses projects based on risk and how much they affect residents and prioritizes projects based on risk and resident impact, using structured tools to help the team decide what to focus on. Progress is tracked through audits and staff feedback. Current improvement plans focus on hospital transfers and nutrition services. Other top issues include pressure ulcer prevention and fall reduction. All actions are checked and updated to make sure they work and stay in place and follow-up action revisions are conducted systematically to ensure accountability and sustained improvement.Review of the facility's Policy titled: Quality Assurance and Performance Improvement reviewed on 02/14/25I. MissionAs part of Catholic Health Services, Our Mission is to provide health care and services to those in need, to minimize human suffering, to assist people to wholeness and to nurture an awareness of their relationship with God.Il. VisionOur vision is to strive to improve the health, independence and spiritual life of the elderly, the poor, and the needy in the Archdiocese, through innovative and proactive approaches to:Managing care and providing services.Facilitating transitions across levels of care.Community partnerships and collaboration.Advocacy efforts.III. QAPI ObjectivesThe primary objectives of Quality Assurance & Performance Improvement (QAP) is to monitor, assess and improve performance of critical focus areas, improve healthcare outcomes and reduce and prevent medical/health care errors on a continuous basis throughout the facility.

Based on observation, record review and interview, the facility failed to develop a baseline care plan for oxygen use for one (Resident #78) out of one sampled resident reviewed for oxygen therapy. The findings included: During the observational tour on 05/13/24 at 08:10 AM, Resident #78 was observed in bed receiving oxygen(O2) via nasal cannula (NC) connected to the wall oxygen supply. The resident reported that he is on oxygen at 2 liters. An observation of the oxygen flow meter revealed the oxygen was set at 4 liters per minute. (Photo Obtained) The resident reported he fell at his house in April 2024, fractured five ribs and had a pneumothorax. On 05/13/24 at 11:51 AM, Resident #78 was observed sitting up in a wheelchair and looking at his phone. He had a garden salad from home on his bedside table and he reported he preferred the salad his wife brought him. The oxygen nasal cannula was observed on, but the level was not checked at this time. On 05/14/24 at 08:33 AM, Resident #78 was observed in bed awake. A staff person from the Physical Therapy (PT) was at the residents bedside. The PT staff person reports the resident did not want to get out of bed this morning so the physical therapy would be provided in the resident's room. Observation revealed, the O2 via NC was set at 2 liters on the wall oxygen flow meter. A review of Resident #78's electronic medical record revealed, an admitted [DATE] with diagnoses to include Acute Respiratory Failure, Congestive Heart Failure (CHF) Exacerbation, Chronic Obstructive Pulmonary Disease (COPD) Exacerbation and Pacemaker insertion. Review of the physician's orders revealed an order on 5/8/24 for 02 at 2 liters per minute. A review of Resident #78's electronic medical record revealed, a Baseline Care Plan and Summary that included the resident's admitted , diagnoses, code status, Physician, Diet order, allergies, Medications, Physical Therapy, Occupational Therapy, Consults, Problem and Care Plan Goals. The Baseline Care Plan did not include information about the resident's order for oxygen at 2 liters per minute. On 05/15/24 at 9:53 AM, interview and record with the Director of Nurses (DON) revealed that the oxygen was not included on the Baseline Care Plan and Summary and the Interim Care Plan-Admission. The DON contacted the Minimum Data Set (MDS) Coordinator for the care plan. On 05/15/24 at 10:15 AM, the DON brought a comprehensive care plan that included a care plan for the potential for shortness of breath, alteration in respiratory status due to COPD, alteration in respiratory status due to status post (s/p) exacerbation of CHF and potential for hypoxia related diagnosis of CHF. The interventions included: Administer oxygen and nebulizer treatments as ordered. This information related to oxygen use was not included on the Baseline Care Plan and Summary and the Interim Care Plan-Admission.

Based on observation, record review and interview, the facility failed to follow the urinary catheter care plan for one out of one (Resident #79) sampled resident reviewed for catheter care. The findings included: During tour on 05/13/24 at 08:55 AM, Resident #79 was observed sitting in a wheelchair at the sink in the resident's room. The resident was dressed, and a family member was at his bedside. A urinary catheter was observed on the right side of the wheelchair at the same level where the resident was sitting. The white side of the drainage bag was observed, and the drainage bag was not in a privacy bag. The resident's family member reported facility staff are going to give Resident #79 a leg bag for the catheter. The drainage bag was not observed to be below the resident's bladder. Observation on 05/13/24 at 09:02 AM revealed, Resident #79 being rolled out of the room in a wheelchair by a staff person from the therapy department. The urinary catheter was in the same position on the wheelchair. Observation on 05/13/24 at 09:20 AM revealed the resident was in the therapy room, sitting in the wheelchair. A gait belt was placed on him, the resident was observed standing and sitting with a therapy staff member at his side. Observation on 05/13/24 at 12:02 PM revealed, the resident sitting at bedside eating lunch. The urinary catheter bag was at the head of the resident bed and the tubing was on the resident's bed. The urinary catheter bag was observed next to the blue privacy bag. The drainage bag was not inside the privacy bag. Observation on 05/14/24 at 08:50 AM revealed, the resident was in bed, the urinary catheter was at the foot of the bed, below the bladder, the urine was amber, and appeared to have a small amount of mucous in in the tubing. A review of Resident #79's electronic medical record revealed, Resident #79 was admitted to the facility on [DATE] with diagnoses to include Urinary Retention due to an Enlarged Prostate. The resident had a physician order for 5/9/24 - Provide [ brand] catheter care every shift and on 5/10/24 - Diagnosis for [indwelling catheter] use: Urinary Retention due to enlarged prostate. A review of the residents Minimum Data Set (MDS) revealed the assessment was in the process of being completed. A review of the residents care plans revealed Care Plans for At Risk for an Infection due to the use of an indwelling catheter-dated 5/9/24. The Care Plan interventions included, Make sure drainage bag hangs below level of bladder and is covered when out of bed. This care plan was not followed. Interview on 05/14/24 at 01:49 PM with the Director of Nurses (DON) about the urinary catheter observations.

Based on observation, record review and interview, the facility failed to follow the facility's policy and procedure for catheter care for one out of one resident (Resident #79) reviewed for urinary catheter care. The findings included: During tour on 05/13/24 at 08:55 AM, Resident #79 was observed sitting in a wheelchair at the sink in the resident room. The resident was dressed, and a family member was at his bedside. A urinary catheter was observed on the right side of the wheelchair at the same level where the resident was sitting. The white side of the drainage bag was observed, and the drainage bag was not in a privacy bag. The resident's family member reported that facility staff are going to give Resident #79 a leg bag for the catheter. The drainage bag was not observed to be below the residents bladder or in a privacy bag. Observation on 05/13/24 at 09:02 AM revealed, Resident #79 being rolled out of the room in a wheelchair by a staff person from the therapy department. The urinary catheter was in the same position on the wheelchair. Observation on 05/13/24 at 09:20 AM revealed the resident was in the therapy room, sitting in the wheelchair. A gait belt was placed on him, the resident was observed standing and sitting with a therapy staff member at his side. Observation on 05/13/24 at 12:02 PM revealed, the resident sitting at bedside eating lunch. The urinary catheter bag was at the head of the resident's bed and the tubing was on the resident bed. The urinary catheter bag was observed next to the blue privacy bag. The drainage bag was not inside the privacy bag. Observation on 05/14/24 at 08:50 AM revealed, the resident was in bed, the urinary catheter was at the foot of the bed, below the bladder, the urine was amber, and appeared to have a small amount of mucous in in the tubing. A review of Resident #79's electronic medical record revealed, Resident #79 was admitted to the facility on [DATE] with diagnoses to include Urinary Retention due to an Enlarged Prostate. The resident had a physician order for 5/9/24 - Provide [] catheter care every shift and on 5/10/24 - Diagnosis for [indwelling catheter] use: Urinary Retention due to enlarged prostate. A review of the residents Minimum Data Set (MDS) revealed the assessment was in the process of being completed. A review of the resident's care plans revealed, Care Plans for At Risk for an Infection due to the use of an indwelling catheter-dated 5/9/24. The Care Plan interventions included, Make sure drainage bag hangs below level of bladder and is covered when out of bed. This care plan was not followed. Interview on 05/14/24 at 01:49 PM with the Director of Nurses (DON) about the urinary catheter observations. The facility's policy for catheter care was requested. The facility policy and procedure for [] Catheter Care, effective 5/28/2008 and reviewed 4/14/2024 revealed, Policy: It is the policy of this facility that catheter care will be provided to all residents with indwelling catheters at least daily and more often as needed due to soiling with feces or when it is deemed necessary by the nurse. The Purpose: The purpose of the catheter care is to prevent possible urinary tract infections from bacteria spreading from the perineal area and external catheter into the bladder. Basic Procedures: The catheter and drainage bag should be kept as a closed system with the drainage bag kept at a level lower that the bladder to allow drainage by gravity.

Based on observation, record review and interview, the facility failed to ensure oxygen therapy was accurately administered as ordered by the physician for one (Resident #78) out of one resident reviewed for the use of oxygen. The finding included: During the observation tour on 05/13/24 at 08:10 AM, Resident #78 was observed in bed receiving oxygen(O2) via nasal cannula (NC) connected to the wall oxygen supply. The resident reported that he is on oxygen at 2 liters. An observation of the oxygen flow meter revealed the oxygen was set at 4 liters per minute. (Photo Obtained) The resident reported he fell at his house in April 2024, fractured five ribs and had a pneumothorax. The resident was working on a crossword puzzle and wasn't observed to be in distress. On 05/13/24 at 11:51 AM, Resident #78 was observed sitting up in a wheelchair and looking at his phone. He had a garden salad from home on his bedside table. He reported he preferred the salad his wife brought him. The oxygen's nasal cannula was observed on, but the level was not checked at this time. On 05/14/24 at 08:33 AM, Resident #78 was observed in bed awake. A staff person from the Physical Therapy (PT) was at the residents bedside. The PT staff person reported that the resident did not want to get out of bed this morning so the physical therapy would be provided in the resident's room. Observation revealed, the O2 via NC was set at 2 liters on the wall oxygen flow meter. A review of Resident #78's electronic medical record revealed, an admitted [DATE] with diagnoses to include Acute Respiratory Failure, Congestive Heart Failure (CHF) Exacerbation, Chronic Obstructive Pulmonary Disease (COPD) Exacerbation, Pacemaker insertion. A review of the physicians orders revealed an order on 5/8/24 for 02 2 liters/min (liters/minute). A review of Resident #78's Minimum Data Set (MDS) revealed it was incomplete and in the process of being completed. A review of Resident #78's electronic medical record revealed, a Baseline Care Plan and Summary that included the residents admitted , diagnoses, code status, Physician, Diet order, allergies, Medications, Physical Therapy, Occupational Therapy, Consults, Problem and Care Plan Goals. The Baseline Care Plan did not include information about the resident's order for oxygen at 2 liters per minute. On 05/15/24 at 9:53 AM, interview and record with the Director of Nurses (DON) revealed that the oxygen was not included on the Baseline Care Plan and Summary and the Interim Care Plan-Admission. The DON was informed the oxygen was observed at 4 liters per min on 05/13/24 and a photo was obtained. The DON contacted the Minimum Data Set (MDS) Coordinator for the care plan. On 05/15/24 at 10:15 AM, the DON brought a comprehensive care plan that included a care plan for the potential for shortness of breath, alteration in respiratory status due to COPD, alteration in respiratory status due to status post (s/p) exacerbation of CHF and potential for hypoxia related diagnosis of CHF. The interventions included Administer oxygen and nebulizer treatments as ordered. A review of the facility's policy and procedure for Respiratory effective 8/12/2019 and reviewed on 4/14/2024 revealed, Policy: It is the policy of the facility to provide respiratory therapy services to patients/residents when ordered by a physician. Purpose: To ensure that all patients/residents in the facility have access to prescribed respiratory therapy services when medically indicated. Procedures included: 2. Upon receipt of a physician order for Respiratory Therapy, the nurse will contact the respiratory therapist during the hours of respiratory therapy coverage. 3. Services provided by the respiratory therapist may include (but are not limited to) the following depending upon the clinical needs of the patient/resident: b. Provision and maintenance of respiratory equipment (e.g., O2 concentrator, O2 set-up nebulizer machine, suction machine, etc.)

Based on observation, record review and interview the facility failed to follow infection control standards and procedures during blood glucose monitoring for one (Resident # 228) out of one resident reviewed. As evidenced by Licensed Practical Nurse (Staff A) taking the entire blood glucose monitoring machine in the kit along with all the supplies enclosed into the resident's room to perform blood glucose monitoring. The findings included: On 05/13/24 at 11:42 AM during blood glucose monitoring observation for Resident #228 with Licensed Practical Nurse (Staff A), Staff A checked Resident #228's blood glucose treatment orders, proceeded to enter the resident's room with the complete blood glucose monitoring machine kit/case, applied a barrier on the overbed table, placed the blood glucose monitoring kit/case the on barrier, identified resident, explained treatment, washed hands, donned gloves, opened the blood glucose monitoring kit/case containing the machine and supplies .performed blood glucose check .dispose of supplies in biohazard bag, cleaned the machine with disinfecting wipes, let dry, washed hands exited room. Disposed of the biohazard as required washed hands .etc. Review of Resident #228's the medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Type II Diabetes Mellitus. Review of the Physician's Orders Sheet for May 2024 revealed Resident #228 had orders that included but not limited to: Insulin Solution Pen Injector Subcutaneous Dose: per sliding scale order before meals and at bedtime for Diabetes Mellitus. During an interview on 05/13/24 at 11:53 AM, Staff A was asked about taking the entire blood glucose monitoring kit/case into the resident's room, Staff A stated: I should only take the supplies I need into the resident's room to perform the treatment and when I leave the room, I would discard any leftover unused supplies that were taken in the room. Interview on 05/14/24 at 01:38 PM Director of Nursing (DON) revealed the facility's policy does not directly address whether or not the nurses can take the entire blood glucose monitoring kit/case into the room during treatment, usually the nurses will place the machine and the supplies they need for treatment on a tray and then enter the room. The nurses have been trained how to maintain infection control standards during the blood glucose checks to avoid any issues or contamination. Review of the facility policy and procedures titled Blood Glucose Monitoring . revision date 6/20/2018 states: Only an operator who has demonstrated competence may perform blood glucose monitoring, utilizing the [brand] Inform II, to determine a resident's blood glucose level. Testing shall be performed upon capillary, arterial, or venous whole blood and the results will be recorded in the patient's record. Quality control is performed by the nursing staff. Fingerstick Sample Collection: Step 1 Assemble all the materials you will need to collect a blood sample Glove, skin, preparation pad, auto disabling single use lancet device, gauze, or cotton ball.

Based on records review, observation and interview, the facility failed to offer and provide group activities to residents, with the potential to affect all residents in the facility, including Resident #175. The census at the time of the survey was 17 residents. The findings included: The facility's Admission Packet documented, Recreational activities that are fun and therapeutic are regularly planned for residents. These include arts and crafts, exercise, films, games, and sports. We also offer group discussions of current events. A member of the Recreational Therapy department will meet with you to discuss your special interests, hobbies, and talents. Music is enjoyed regularly in the facility, especially during the holiday and birthday celebrations. People from the community of all ages, from elementary school children to senior citizens come to entertain. A monthly calendar of activities is distributed to residents and posted in your room and throughout the facility. The facility's website documented: Your collaborative care team includes: * Medical directors * Registered nurses * Licensed practical nurses * Certified nursing assistants * Dieticians * Activities coordinators * Social workers * Case managers * Occupational, physical and speech therapists The Facility Assessment, most recently reviewed on 09/02/22, documented, A monthly activity calendar is provided to the residents. The Resident council meeting is held on a monthly basis. Due to the short length of stay of our patients, each meeting held has new residents therefore we are unable to have an elected president. The Activities Calendar provided by the facility and posted at the nurse's station showed that there was only one activity per day, which consisted of: Sundays at 11:00 AM - 'Mass (Channel 11)' Mondays at 11:30 AM - - 'Sensory activity' on 12/05/22 and 12/19/22 - 'Crossword Packets' on 12/12/22 and 12/26/22 Tuesdays - - on 12/06/22 at 1:00 PM - 'Resident Council' (it was stated during the entrance conference that the facility did not have a Resident Council) - on 12/13/22 at 11:30 AM - 'Sensory Activity' - on 12/20/22 and 12/27/22 at 11:00 AM - 'Arts & Crafts 1:1' Wednesdays at 11:00 AM - 'Mass (Channel 11) Thursdays - - On 12/01/22 and 12/29/22 at 11:30 AM 'Sensory Activity' - On 12/08/2, 12/15/22 and 12/22/22 at 11:00 AM 'Arts & Crafts 1:1' Fridays at 11:30 AM - 'Crossword Packets' Saturdays 'Crossword Packets Available in Dining room' Resident #175 was admitted on [DATE]. A care plan date dated 12/23/22 indicate [Resident's name] is alert, able to make needs known and engages in activities of choice daily. The goal of the care plan was documented as, Will continue to engage in activities of choice daily through next review date as evidenced by staff observations and daily participation records. With a target date of 01/22/23. Interventions to the care plan included: * Provide arts/crafts material books-for-the-blind crossword puzzles deck of cards large print reading material magazines pen/pencil stress ball television channel listing word search for in-room activities PRN and encourage family to bring favorite games, books or leisure items from home if requested. * Provide spiritual assistance, refer to pastoral care for support and comfort measures. * Invite and escort if needed to group programs, social events daily. * Establish their likes and dislikes and what is most important to them through the activity assessment and assist to achieve personal goals related to activities during their stay. * Provide/post monthly recreation calendar of events. During an observation and interview with Resident #175, on 12/27/22 at 11:23 AM, when asked about participation in activities, Resident #175 replied, Today is the first day that I have done anything, and it was therapy. I had an operation on 12/19/22 and came here on the 21st. Every morning, They start at about 5:30 AM in the morning. at 6:00 AM they came with breakfast. Then I asked for a bath .I had breakfast today at 7:00 AM and then they took me to the bathroom. at about 9:30 AM they took me down to therapy. I was in my room for about an hour, and they took me back down again to therapy. I would like to do table games. I cannot walk. During an interview, on 12/27/22 at 12:33 PM, Staff B, OTA (Occupational Therapy Assistant) was asked about activities, Staff B replied, I walk around and go from room to room I ask them if they would like items that they can do in their room, paint things or craft things, books, word search, activity books, playing cards. Since the COVID, we haven't used the activity room. The patients could come on their own (to the Activity Room). Staff B stated that there was no Activities Director. The director left in October, they are looking for someone, but they haven't found anybody. Nobody has been asking me to take them to the Activities Room. The schedule for mealtimes showed that lunch is served to the residents from 12:00 PM to 1:00 PM. On 12/27/22 at 11:48 AM, lunch was being served to the residents in their rooms. During an interview, on 12/29/22 at approximately 9:00 AM, with the Human Resource Manager, when asked about Activities staff, the Human Resources Manager replied, We have an OTA that does activities. We had an Activities Director a long time ago and that switched over to the therapy department. During an interview, on 12/29/22 at 9:39 AM, the Administrator revealed the department went through the transition to the new therapy contractor, our OT (Occupational Therapy) ran the activities. There was no documentation of resident's participation in an activities program.

Based on observation, interview, and record review, it was determined that the facility failed to follow the approved menu to ensure that the nutritional needs of 17 of 17 facility residents (Includes sampled Resident #4, Resident #30, Resident #36, Resident #75, Resident #76, Resident #77, and Resident #78) were being met. The findings included. During the observation of the lunch tray line in the main kitchen on 12/28/22 at 11:30 AM, it was noted that the serving portion of the Chili -Texas Cowboy (entree) was a 4-ounce ladle portion and the pureed Chili was a 4-ounce scoop for Regular, Carbohydrate Controlled, Mechanical Soft, and No Added Salt diets. It was noted that bot entrees were being served in a 4-ounce dessert/vegetable dish which could not include the 3 once protein portion and 4-ounce carbohydrate portion,. A review of the approved menu production sheets and resident menus for the lunch meal on 12/28/22 both documented an 8-ounce portion to be served. At the request of the surveyor a copy of the standardized recipe for the Texas Cowboy Chili was obtained. A review of the recipe documented that the entree portion to be served was 1-1/2 cups (12 ounces). Interview with the Food Service Director and Cook (Staff A) during the observation revealed that they were unaware the recipe documented a 12-ounce portion, and the approved menu/production sheet documented an 8-ounce portion. it was further discussed with the FSD and Registered Dietitian that the residents were receiving an insufficient serving of the Chili entree. it was noted during the interview that the Chili portion size did not meet the minimum 3-ounce cooked protein as per the approved menu. A review of the facility diet census for 12/28/22 indicated that all 17 facility residents were affected by the entree for the lunch meal of 12/28/22. The 17 residents included sampled Resident #4, Resident #30, Resident #36, Resident #75, Resident #76, Resident #77, and Resident #78. Further review of Resident #30's clinical record indicated the resident was admitted to the facility on [DATE] clinical diagnoses included but not limited to Congested Heart Failure (CHF), Diabetes, Rectal Bleeding and Hypertension. Physician orders dated 12/22/2022 included: Daily Weights, Pureed Diet with -Nectar Consistency Liquids. Order Dated 12/23/2022 - Diabetes Snack BID (twice daily), Vitamin C 500 mg daily for vitamin deficiency, Folic Acid 1 mg at bedtime (Q HS) for vitamin deficiency. Active Critical Care Sugar Free 30 ml BID - Protein Wound healing. Glucerna 240 ml QD - Diabetic Supplement. Order dated 12/28/2022- Stage II Pressure Ulcer Coccyx. Review of the resident's weight history indicated: 12/27/22 - 141.1 pounds 12/26/22 -Refused 12/24/22 - Refused 12/23/22- Refused 12/22/22 - Refused Review of Dietary Notes dated 12/23/22 documented the resident states appetite has decreased, PO (by mouth) intake 50-75%, Active Critical Care BID for wound healing, MNA (The Mini Nutritional Assessment) scores indicate Risk For Malnutrition, BMI (Body Mass Index) =21.8 (Malnutrition).

Based on record review, observation and interview, the facility failed to act on a resident's request for psychiatry consultation for 1 (Resident # 176) of 1 resident reviewed for Behavioral Health. The findings included: Resident #176 was admitted to the facility on [DATE]. Resident #176's care plan, initiated on 12/27/22, documented, [Resident Name] is at risk for side effects, adverse reaction related to use of antidepressant medication required for diagnosis of depression. The goal of the care plan was documented as, Will have no side effects or adverse reaction to use of antidepressant over the next 30 days. Interventions to the care plan included - * Psychiatrist to evaluate and treat for mood state and medication review as indicated. * Maintain fall precautions. * Instruct staff on daily interventions that will respect, understand, and manage the resident's condition and support their safety and rights. * Observe for side effects, adverse reaction: dry mouth, constipation, changes in appetite, insomnia, fatigue, increased agitation or irritability, and falls. * Monitor and document moods and behaviors if they persist with treatment. * Discuss side effects of medication with resident and/or health care surrogate. Resident #176's Orders included: (Eliquis) Apixaban 2.5 mg tablet - by mouth twice a day for DVT Prophylaxis - 12/17/22 Sertraline HCI 100 Mg tablet by mouth daily for Major depressive disorder - 12/17/22 Tramadol HCI 50 mg tablet by mouth every 6 hours as needed - 12/17/22 During an interview with Resident #176 and the resident's son, on 12/27/22 at 12:53 PM, Resident #176's son stated, I think that we need to have someone see him. I told the nurse about a week ago. I believe the person for psychiatry is out for the holidays. Resident #176's son further stated, He came in here . for about a week and was feeling very nauseous and was sent to the hospital and then came back. He is a very independent person, he drives, cooks and cleans and now that he is in this state, he has been very depressed. Resident #176 echoed the statements made by his son and stated that he was feeling 'depressed' and wished to be seen by a psychiatrist/psychologist. During an interview, on 12/28/22 at 12:08 PM with Staff C, LPN, when asked about the psychiatrist services, Staff C replied, She comes every Monday. She wasn't here this week because of the holiday. Usually when we put the order, we give the secretary the order and she call to make to make the appointment. During an interview, on 12/28/22 at 12:27 PM, with Staff D, LPN, when asked of the process when a resident requests psychiatry consult, Staff D replied, in that case, I notify the psychiatry doctor right away and then and she would give an order for medication, and she would tell me that she would see him. If the doctor is out for vacation, we notify the facility doctor, and he passes by to evaluate the patient until the psychiatrist is back. On 12/28/22 at 12:34 PM, Staff C called the psychiatrist and was answered by answering service and reported that she was waiting for a call back. When it was reported to Staff C and Staff D that Resident #176 had stated that he felt 'depressed' Staff D replied, He had an order put in on 12/18/22 (as a new admission). She has not seen the patient yet. The order is for one month. His brother asked about seeing a psychiatrist, but sometimes he will wake up with a little headache. They told me about two weeks ago. I told the secretary. On 12/28/22 at 1:36 PM Medical Records reported that there was no documentation of the resident stating that he was depressed and requested to see psychiatry.

Based on observation, interview and record review, the facility failed to ensure proper temperature in the reach-in refrigerators and safe holding temperature during tray line. As evidenced by two reach-in refrigerators and cold sandwiches in the cooler on the tray line were over 41 degrees (°) Fahrenheit (F). This has the potential to affect all residents (twenty-six) residing in the facility at the time of the survey. The findings included: Review of the Policy and Procedure for Food Handling Guidelines (HACCP), revised 1/21 revealed Prior to preparation, chill potentially hazardous ingredients to 41° F for food that will be eaten without further cooking. Examples include salads, sandwiches, cut leafy greens and produce and reconstituted food. Products are chilled again after preparation to 41° F before being served. Remove from the refrigeration only quantities of foods that are immediately needed for preparation and can be processed within 30 minutes. Return unused food (ingredients) and prepared food to refrigerator storage within the shortest time period possible to ensure that potentially hazardous food does not exceed 45° F. It further showed in the cold holding temperatures that Food should be held cold for service at a temperature of 41° F or less. On 07/26/21 at 09:47 AM, during the initial tour accompanied by the Director of Dining Service revealed that the thermometer inside the reach-in Refrigerator number 4 showed a temperature of 48° F. The Director of Dining Service found the thermometer was dropped on the bottom of the refrigerator. The food inside refrigerator number 4 showed the temperature for the ham at 59° F and 56° F (two samples), cheese at 57° F and peaches at 49° F. The Director of Dining Service stated that they were going to throw out the ham and cheese immediately. The thermometer for the reach-in Refrigerator number 3 showed a temperature of 50° F inside. The temperature of the sampled [MEDICATION(S)] and turkey sandwich that were inside refrigerator number 3 showed the [MEDICATION(S)] was 55° F and turkey cheese sandwich was 43° F. Regarding [MEDICATION(S)], the Director of Dining Service stated that they had just finished making it using can [MEDICATION(S)] at room temperature and they finished making the turkey sandwiches 15 minutes ago and it takes two hours to reach the required temperature. The Director of Dining Service stated that she kept samples of the sandwiches and [MEDICATION(S)] in refrigerator number 3 to check again after 2 hours. On 07/26/21 at 11:29 AM, observation of the food tray line revealed that the two samples of ham and cheese sandwich placed in the tray line cooler showed a temperature of 57° F and 54° F and the sliced peach was 56° F. The Director of Dining Service stated that they had made the sandwiches at that time, but she would throw them out. The Director of Dining Service calibrated the thermometer and checked the temperature again and no changes noted. At 11:44 AM the temperature for refrigerator number 4 was 56° F and the samples held by the Director of Dining Service in the refrigerator number 3 since 9:47 AM showed the temperatures were still over 41° F. The turkey sandwich showed a temperature of 44° F and the [MEDICATION(S)] sandwich showed a temperature of 46° F. On 07/26/21 at 12:10 PM, dining observation revealed Resident #221 had a ham sandwich on his food tray. The surveyor immediately went to the kitchen and again checked the temperature of the ham sandwiches that were in the food tray line cooler. At 12:25 PM the Director of Dining Service checked the temperature of two ham sandwiches available in the tray line cooler and noted the temperatures were 51° F and 53° F and the Director of Dining Service then threw them away. The Director of Dining Service stated that she was going to request for someone to get back all ham sandwiches from the floor. At 12:36 PM, the surveyor went to Resident #221's room and noticed that Resident #221 had the ham sandwich in his hand ready to eat it and was eating the bread at the top of the ham sandwich. The surveyor called Staff B, a Licensed Practical Nurse (LPN) and requested the ham sandwich be taken out. Staff B, LPN explained to Resident #221 that she had to take the sandwich out because it probably was out of temperature range. On 07/28/21 at 09:03 AM during an interview the Director of Dining Service revealed that the cook checks the thermometers inside of the refrigerators and they have temperature a log to document the information. The temperatures are taken twice, in the morning and in the night. They had to let the Director of Dining Service know if there is a problem with the refrigerators. On 07/26 they were filling refrigerator number 4 and they left the door opened for quite some time and that raised the temperature in the refrigerator. The Director of Dining Service revealed that now she knows that the thermostat was frozen and apparently took too long to set the temperature. The Director of Dining Services acknowledged that the temperature was not okay during the initial tour and the ham and cheese were thrown out because they were above the required temperature zone. In refrigerator number 3, the sandwich was not at the right temperature because they had just finished to making them. The Director of Dining Services stated that more sandwiches were made after the surveyor left the kitchen around 9:30 AM and she (the Director of Dining Service) did not know where the staff put the sandwiches that they made. The Director of Dining Services stated that the staff got the ham from the walk-in refrigerator. The sandwiches on the tray line on 7/26/2021 were out of temperature range and she had no idea how long they were on the tray line because she threw them away. The Director of Dining Services was asked if the temperature was checked for the ham sandwiches prepared before being sent it to Resident #221 and she replied that she was not in the kitchen at that time. The Director of Dining Services stated that she had asked the dietitian to go to the floor and to get the ham sandwiches for all the residents and the dietitian told the Director of Dining Service that she did. The Director of Dining Service was informed that on 07/26/21 Resident #221 was about to eat the ham sandwich and the surveyor called Staff B, LPN to stop Resident #221 from eating the ham sandwich. On 07/28/21 at 09:22 AM, during an interview with Staff A, Food & Nutrition Services staff revealed that he made sandwiches on 7/26/2021 around 9:30 AM. He did not remember if he had placed them in the refrigerator number 3 or refrigerator number 4. Staff A stated that the cooler was placed in the tray line when the tray line was about to start. Staff A stated that he made more sandwiches after 11:30 AM and he placed them straight on the tray line.

Based on observation, record review and interview, the facility failed to assess a resident for self-administration of medications prior to allowing the resident to self-administer medications this affected 1 out 12 sampled residents (Resident #171). The findings included: During the Medication Administration observation on 7/28/2021 at 8:35 AM, Staff C, a Licensed Practical Nurse (LPN) was observed to give Resident #171 her nasal spray, [MEDICATION(S)] 50 MCG/ACT (Micrograms/Actuation). The resident was observed to give herself 2 sprays in each nostril, then the resident blew her nose after administering the 2 sprays and then Staff C, wiped off the infuser and replaced the cap. On 7/28/2021 at 9:10AM, after Staff C completed the medication administration, Staff C was asked about the resident blowing her nose after the nasal sprays were given. Staff C reported, Resident # 171 was not assigned to self-administer medication and demonstrated where the information would be documented in the instructions section on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff C was asked, whether the resident was trained to give the nasal sprays since she blew her nose after administering the sprays and Staff C reported, they could do that, meaning they could train the resident to self-administer the nasal sprays. During an interview with resident #171 on 7/29/2021 at 10:20AM, about whether she had been trained to administer her nasal spray, the resident reported she had been trained by her physician to administer the nasal sprays a long time ago and she didn't remember the exact date and she reported, the medication was prescribed for her allergies and it was 2 sprays in each nostril. During the review of Resident #171's medical record, it was noted the resident was admitted to the facility on [DATE] and was status post [MEDICAL RECORD OR PHYSICIAN ORDER] .Administration Instructions: Max (maximum) dose 2 sprays in each nostril per day. The resident had a Brief Interview of Mental Status (BIMS) score of 12 indicating the resident was moderately impaired in cognition. During the review of the facility's policy and procedure for Self Administration of Medication, effective 5/28/2008 and reviewed on 1/12/2021 revealed the policy documents, Self-administration of medications by residents is generally allowed but not encouraged. The competency of the resident is assessed prior to allowing resident's to self-administer medications. A resident felt to be mentally or physically incompetent or incapacitated will not be allowed to self-administer medications Procedure Residents who wish to administer medications must be determined competent in administration prior to the granting of approval for medication administration .Competency will be assessed by the Interdisciplinary Care Plan Team A care plan will be developed appropriate to resident's needs It was noted, this policy was not followed for Resident #171. The resident was not assessed prior to being allowed to self-administer the nasal spray and the resident did not have a care plan to self-administer the nasal spray.

Based on observations, interviews, and records reviewed, the facility failed to demonstrate effective plans of action were implemented to correct previous identified quality deficiencies in problem-prone areas. As Evidenced by repeated deficient practice identified related to food temperatures during consecutive annual survey. Cross Reference F812. The findings Included: Record review of the facility's survey history revealed, during the annual survey with an exit dated 08/07/2019 the facility was cited F812(Food procurement, store/prepare/serve food in a sanitary manner) due to the temperature of milk, [MEDICATION(S)], and pound cake being over 40 degrees Fahrenheit (° F). Review of the facility's Plan of Correction dated 08/22/2019 revealed : To prevent re-occurrence and ensure that this occurrence did not happen again; an in-service was conducted by the Food Service Director in regards to proper cooling temperatures and the procedures to holding temperature. An in-service was also conducted to explain the proper temperatures for all food items. The Food Service Director in-serviced the kitchen employees on August 07, 2019 on the state and federal Policy and Procedures for Food Handling Guidelines that explained that foods should be held cold for services at a temperature of 40 degrees Fahrenheit or less. During this annual survey an observation on 07/26/21 at 09:47 AM revealed refrigerator number 4 thermometer inside was 48° F. The temperature for the peaches was at 49° F, ham 59° F, and 56° F (two samples taken), and cheese was 57° F. Review of the facility's Policy and Procedure for Food Handling Guidelines reviewed on 07/29/2021 revealed: Foods should be held cold for service at a temperature of 41 degrees Fahrenheit (F) or less. On 07/29/2021 at 1:05 PM, the Director of Nursing (DON) revealed the Quality Assurance Program Improvement (QAPI) committee meeting meets on a monthly basis and includes all department heads. The DON reported that currently the facility's main focus is to work on infection control, vaccinations, testing, and wound prevention. The DON reported that for the concern identified with the food temperatures, the technician came and fixed the refrigerators temperature thermometers and rounds are being conducted. They are also keeping a log of the temperatures.

Based on observation, interview, and record review the facility failed to: 1) ensure that food was served under sanitary conditions during dining as evidenced by staff not [MEDICATION NAME] proper hand hygiene, and 2) failed to ensure proper holding temperatures during tray line observation as evidenced by food in the cold section with an internal temperature over 41 degrees Fahrenheit (F). The Findings included: 1). Dining observation of the 3rd Floor dining area on 08/05/2019 at 11:51 am revealed Certified Nursing Assistant (Staff H) placing something in the trash; the trash receptacle had to be pressed by her hand to discard the item. After throwing the object away, Staff H proceeded to pour a beverage for a resident and assist with moving the meal cart. There was a hand sanitizer dispenser in the dining area, however, Staff H did not use it, or any other hand hygiene method. Dining observation of the 3rd Floor dining area on 08/05/2019 at 11:53 am revealed both the Occupational Therapist (Staff F) and Certified Nursing Assistant (Staff G) discard items in the trash receptacle that needed to be pressed by their hands. The staff members did not practice hand hygiene; they did not use the hand sanitizer dispenser, or any other method of hand hygiene. Both staff members continued to assist residents; Staff G was observed providing napkins to a resident after not [MEDICATION NAME] proper hand hygiene. Interview with Staff H, Staff G, and Staff F on 08/06/2019 at 12:31 PM revealed that the process was that they cleaned their hands before providing the meals, as well as cleaning the resident's hands. After giving the meals they cleaned their hands again; they used wipes or the hand sanitizer dispenser. All staff members stated that they should have used the hand sanitizer dispenser after touching the trash can. Interview with the Director of Nursing (DON) on 08/06/2019 at 1:07 PM revealed that staff were supposed to use either the hand sanitizer dispenser, or hand sanitizing wipes, when providing meals in the dining. She stated that was going to in-service staff and remove the trash can that needed to be touched when discarding items. 2). Record review of the facility Policy and Procedure for Food Handling Guidelines reviewed on 01/31/2019 revealed that Foods should be held cold for service at a temperature of 41 degrees Fahrenheit (F) or less. Same information found in the Hazard Analysis and Critical Control Point (HACCP) Plan revised on 12/17/2019. Observation on 08/06/19 at 11:35 AM during the tray line in the cold section revealed internal temperature of Milk at 45 F, Tuna fish sandwich at 51 F and Pound cake at 47 F. The Food and Nutritional Services Director (FNS) got a thermometer from a refrigerator and measured the internal temperature of the Cooling Counter that it was 49 F. FNS discarded the milk and sandwiches that was in this section. During initial observation of this area the staff was starting tray line, there was no thermometer and the food was not on ice. Interview on 08/06/2019 at 2:36 PM with FNS revealed that, the staff had to check the food temperature on the tray line before the line started and middle-point of the tray line. In case the cold food was over 41 F, they should return the food back to the refrigerator. If the food was milk, ham sandwich or tuna sandwich and if the staff did not know for how long it was out of the temperature range , the staff should throw those foods away. In the case of the ham sandwiches, if the staff knew that the temperature was higher than 41 F for a few minutes, they toasted them. Today, after FNS noticed that some of the food temperatures was over 41 F, she asked the staff to fill the containers with ice and put all food that should be kept in low temperature iced down. the FNS stated that [NAME]orrow they planned to do the same. They had a log that the staff took notes of the food temperature, as soon they took the food out of refrigerator. Because the tuna sandwich, milk and yogurt were not part of the menu, the temperature of those items were not checked on the log. On 08/06/2019 at 2:57 PM Staff E, Dietary Supervisor, revealed that she worked the afternoon shift starting at 3:00 PM. Staff [NAME] was responsible for the cold area on the tray line. Staff E, prepared desserts and then put them in the freezer until the temperature went down to 32 F. The tray line for dinner started at 4:30 PM. Staff [NAME] took foods from the refrigerator and place them on the tray line around 4: 20 PM. Staff [NAME] checked the temperature of all the food that was in the cold area when the tray line started and in the middle of the tray line. Staff [NAME] stated that normally, the cold food was not over 41 F, the food is kept at least to 36 F to 38 F by the time they hit the floor. Staff [NAME] stated that she did not keep the cold food on the tray line on ice, because the cold compartment was a refrigerator. Staff [NAME] left the thermometer in the cold section of the tray line. She checked two samples of the milk in the middle of the tray line. Staff E, left the tuna sandwiches and ham sandwiches inside the refrigerator and took them as needed.

Based on observations, record review and interviews the facility failed to ensure the emergency kit medications for the one medication room in the facility was restocked with emergency insulins and readily available to be administered in event of an emergency. This deficient practice has the potential to affect all six insulin dependent residents out of the twenty residing in the facility at the time of the survey. The findings included: On 08/05/19 at 9:18 am, during an observation of the medication room with the Director of Nursing, it was revealed that the Emergency Kit (EKit) was missing emergency insulins that were removed from the Ekit and not reordered. The EKit was located in a designated locked compartment in the medication room's refrigerator, the Ekit was numeric lock seal was missing. There were three signed emergency drug slips in the emergency Ekit. One of the three signed emergency drug kit slips indicated the EKit was opened on 5/11/2019 Lock seal ( 01) . The slip dated 5/11/2019 indicated, [MEDICATION NAME] R insulin 3 milliliters (ml) 100 units/ml injectable , one pen was removed from the emergency kit for resident (Room #). The slip dated 5/25/2019 at 5:00 PM [MEDICATION NAME] 70/30 mix insulin (flex pen)100 units/ml injectable one pen was removed for resident (Room #). The slip dated 7/24/2019 indicated one Insulin Kwik pen was removed for resident. ( Room #) At approximately 9:23 am during review of the medication list attached to the EKit ,in the presence of the Director of nursing the list indicated the medications that were provided and should be available in the EKit in an emergency included the following: Basaglar insulin (Kwickpen) 100 units/ml injectable =1 [MEDICATION NAME]100 units/ml injectable =1 [MEDICATION NAME] N insulin 3 ml 100 units/ml injectable =1 Humbling R insulin 3 ml 100 units/ml injectable =1 Admelog insulin([MEDICATION NAME]) 100 units/ml injectable pen =1 [MEDICATION NAME] Mix 70/30 insulin (flex pen)100 units/ml injectable pen =1 [MEDICATION NAME] 25 mg suppository =3 [MEDICATION NAME] 1 ml vial =2 Safety pen needles (5) On 08/05/2019 at 9:27 am the Director of Nursing agreed that the numeric seal lock lock was missing from the Ekit and that it has been opened since (MONTH) 11, 2019 and medications were missing . Interview on 08/05/19 at 12:08 PM Staff B a Licensed Practical Nurse (LPN), revealed that the EKit is not replaced until it is empty. On 8/05/2019 at 12:26 PM , Staff A , an LPN revealed that when an item is removed from the EKit a slip is completed and includes the lock number that was removed and the medication should be written on the slip . The original is left in the box and the paper original is faxed to the pharmacy and as a precaution anything that is removed is documented. On 08/05/19 at 03:38 PM the Director of Nursing revealed that the EKit in the med room should be kept locked, when the kit is opened pharmacy should be contacted for a replacement to be made. The DON acknowledged the concern with items that were not available in event of an emergency. The Director of nursing stated that when the nurses remove an item they should fax pharmacy and the nurses are held responsible when they remove items. The Director of nursing stated that the pharmacy was contacted today and the EKIt for the refrigerator will be replaced. On 08/05/2019 at 3:44 PM, Staff (C) a Registered Nurse (RN) stated that the procedure for removing items from the EKit is based on the emergency condition or situation of the resident if the medication is needed immediately. Whenever the emergency kit is opened I document the lock number on the slip from the book, I write what is removed from the kit on the slip, get a new lock and put it on the EKit. On 08/05/19 at 4:14 PM staff D, a Licensed practical Nurse revealed that when a medication is removed from the EKit it should be written on the slip from the book, pharmacy should be notified and documented.

Based on observation, interview, and record review the facility failed to honor resident meal choices for two sampled residents (#293 and 290) out of 19 sampled residents. This has the potential to affect 24 resident who eat orally. The findings included: 1. Record review revealed resident #293 was admitted to the facility on [DATE]. During interview on 04/30/2018 at 01:17 PM with resident #293 via Spanish speaking surveyor to translate, she revealed she has been at the facility since 4/09/2018. Resident #293 said she was able to make choices about her routine, but she had no choices about food. She said, Only today did they come to ask me what I wanted to eat. Today a lady came with a list, but until today I did not know I could choose from a menu. This is why my sister brought me food today and has been bringing me food. The food items here are very repetitive. At times if I ask they will bring me an alternate, but I had no idea I could choose from a menu until today. The food does not have as much flavor as I like. Breakfast is always eggs and bacon. I get no choice. I like pancakes, but I have only had them once or twice. I do not like milk, so I do not eat cereal, but they bring it anyway. Today is the first day I have seen the Dietitian about my preferences. The possibility to choose never existed until today. If the staff saw that I did not eat they would sometimes ask if I wanted a sandwich, but there was no choice. During interview on 05/02/2018 at 12:25 PM with resident #293 via a Spanish speaking Certified Nursing Assistant (staff F) to translate, she revealed she received a menu for her selections for yesterday and today, but she said that this is the first menu I have seen since I came here. I have never seen a menu to select my meals from the time I arrive until Monday when the Dietitian came to see me. Observation on 05/03/2018 at 12:06 PM revealed resident # 293 was in her room eating lunch. During an interview conducted by a Spanish speaking surveyor to interpret, resident #293 said her lunch was good today. She said she received what she marked on her menu. She stated she has been able to have a selective menu since Monday after the survey began. She said, Before that, I did not even know there was a menu to select my food. It has been much better the last three day. Review of a nutrition progress note dated 4/30/2018 revealed the following note, met with patient and updated food preferences. Will continue to monitor and follow up as needed. Review of the electronic tray ticket program used to record the resident's diets and meal preferences revealed all preferences for resident #293 were entered into the program on 5/01/2018. Multiple food preferences that were added to the tray ticket on 5/1/2018 included: dislikes-scrambled eggs (provide hard cooked egg), no chocolate, no green beans, no pasta, no seeds, no beef, no hot beverages, no hot cereal and no milk. Daily requests included lemon lime soda and tossed salad. Review of the Dietary Recommendation Form used by the Registered Dietitian revealed on 4/10/2018 Resident # 293's diet was changed to remove the low fat restriction and add an HS (hour of sleep) snack. There are no additional forms to indicate preferences were obtained or recorded. 2. Record review revealed resident #290 was admitted to the facility on [DATE]. During interview on 04/30/2018 at 11:20 AM with resident #290, he said he filled out a menu when he first arrived and I got some of what he selected. He said, This week they are giving me whatever they want. I was supposed to be on a regular diet and they put me on low fat. They finally changed that. If the nutritionist is here I can get something else, otherwise I have to eat what they give me. Even when I mark the menu they don't send the correct items. This week I did not get a chance to select what I wanted because they did not bring the menu. During interview on 04/30/2018 at 12:25 PM with resident #290, he said, even if you mark a menu, they do not send you what you ask for and I do not always get a menu to make the choice. Observation on 04/30/2018 at 12:35 PM revealed the Dietitian was in resident #290's room. The dietitian was observed with a selective menu in her hand and was reviewing the menu and making menu selections with resident # 290 . During an interview on 05/02/2018 at 09:55 AM with resident #290, he said the nutritionist came to see him Monday and asked me about his preferences. He said, She also brought a menu with her and asked me what I wanted to eat. I believe we reviewed the menu for the next few days. This is the first time I received assistance to fill out a menu. Prior to that, sometimes they would give me a menu to mark and other times I did not get the menu. Either way, they just send you what they want. I had never been asked about my preferences before. Last night they did not even send me anything to drink with my dinner. I like iced tea but there was nothing to drink on my tray. Sometimes I get coffee in the morning, I do not drink coffee. During interview on 05/02/2018 at 11:55 AM with the Registered Dietitian (staff E), she said, when a resident is admitted to the facility I usually come in the next day to review their food preferences. If a resident comes in on a Friday night I will see them on Monday, if they come early Friday, I see them on Friday. The facility has a selective menu. If a resident does not want to go through the selection process they will just get the house menu. It the patient chooses to have a menu to select, they are provided with a menu the day of admission. I usually give them the menu for a few days and then when that runs out, the menu is delivered for the next few days. We have a filing system so we know which is the last day they filled out the menu. We have menus that are tailored to the therapeutic diet, so the items they select are not restricted on the diet. I also keep a record of preferences which is also faxed down to the kitchen. the Food Service Director (FSD) inputs the preferences into the electronic system. I check the system about weekly to make sure the preferences are correct. If a resident does not want to fill out a menu they get the house meal unless it is something they do not want based on preference. For instance, if the house menu is beef and they do not eat beef, they will get the alternate choice. We have alternates which include, chef salad, tuna salad, baked fish, grilled chicken, sandwiches. The nursing department will call the kitchen or communicate it directly to me. I am usually on the unit at least one meal per day. During interview 05/02/2018 at 12:30 PM with resident # 290, he said, today I received everything that was marked on the menu and my lunch was better. The problem before today was that they were making substitutions to the items I selected or they were not giving me a menu at all. Review of a nutrition progress update dated 4/30/2018 revealed the Dietitian met the patient at bedside during meal rounds. Updated food preferences and helped fill out selective menu. Will continue to monitor and follow-up as needed. Review of the Dietary Recommendation Form used by the Registered Dietitian revealed on 4/23/2018 resident # 290's diet was changed to remove the low fat restriction and preferences were obtained. On 4/24/18 the note indicated a selective menu would be placed on the dinner tray. Review of the electronic tray ticket program used to record resident's diets and meal preferences revealed an entry on 04/23/2018 that indicated resident #290 dislikes hot beverages. Review of the facility's policy and procedure titled Nutritional Service Rounds revised 2/7/2018 revealed the purpose is to determine residents likes/dislikes and overall acceptance of meal service and to identify any error or deficiencies in the tray meal service.

Based on observation, interview, and record review, the facility failed to protect resident's privacy for one resident (Resident #290) related to posting Protected Health Information (PHI) in the resident's room as evidenced by two signs depicting the speciality of the doctor for follow up appointments for a [MEDICAL CONDITION] disease medical doctor specialist and an orthopedic medical doctor specialist out of 33 sampled residents during the time of the survey. The findings included: Record review of the face sheet revealed that resident #290 was admitted on [DATE] and had the following diagnoses, but not limited to, dislocation of the right hip prosthesis. Record review of the Physician Order Sheet (POS) for (MONTH) (YEAR) for resident #290 revealed an order on 4/20/2018 to have follow up appointment with the [MEDICAL CONDITION] disease doctor in two weeks and to follow up with the orthopedic medical doctor in one week. Observation on 5/01/2018 at 11:29 AM of the room for resident # 290 revealed that there were two appointment notice signs posted below the television in the resident's room. The appointment notice signs were made of paper with a length of approximately 8 1/2 X 11 inches The sign on the left depicted the name of the resident, the name of medical specialist doctor and the disease speciality of [MEDICAL CONDITION] disease was listed. The Appointment notice signs contained the address of the medical appointment, the date of 5/8/2018 at 2 PM and the transportation arrangement. The second appointment notice sign on the right depicted the name of the resident, the name of the medical specialist doctor and the orthopedic (ortho) speciality was listed. The Appointment signs contained the address of the medical appointment, the date of 5/17/2018 at 9 am and the transportation arrangement. The bottom of the sign read needed X-ray. During an interview on 5/01/2018 at 11:38 AM with staff C, Licensed Practical Nurse (LPN), she revealed that she saw the appointment notice signs in the room of resident # 290 that were below the television. Staff C, LPN noted that the secretary had placed the appointment notice signs that were in the resident's room that contained the name of the medical doctor specialist of orthopedic and [MEDICAL CONDITION] disease. On 5/01/2018 at 11:42 AM, the Director of Nursing (DON) revealed that she didn't have a problem with the appointment notice signs posted in the resident's room, since there was no diagnoses and only the type of medical doctor specialist. The DON took the sign down and made some changes to the signs for resident #290. Interview on 5/03/2018 at 9:52 AM with staff D, Registered Nursing (RN) Supervisor revealed that the secretary did the follow up appointments and she checked the appointments. Staff D, RN supervisor explained that: She puts the appointment information in the appointment book. She puts the appointment notice in the appointment book, one copy goes in the medical record and one copy goes in the patient's room. Staff D, RN supervisor said that the appointment notice contained the name of the resident, the name of the doctor, the type of specialist, address, telephone number and transportation arrangement, time of the appointment and date of the appointment. Staff D, RN supervisor concluded: This was the speciality of the doctor and it was not patient information. Interview on 5/03/2018 at approximately 10 AM with the DON revealed that she removed (used white-out) the information that listed the speciality of the doctor. Record review of the facility policy dated 2/07/2018 titled: Confidentiality of Information: General issues - it is the policy of this facility to maintain an individuals right to privacy and confidentiality of information. Information concerning residents, visitors and staff shall be managed with the highest degree of appropriateness and confidentiality, pursuant to organization wide policy and procedures.

Based on observation, interview, and record review, the facility failed to ensure that two pill crushers were maintained in a clean and sanitary condition as evidenced by west wing pill crusher observed with brown buildup on the outside and rust-like buildup in the inside and south wing pill crusher observed with brown-buildup on the outside and dark rust-like build up in the inside for two pill crushers observed during the time of the survey. The findings included: Observation and interview on 4/30/2018 at 5:08 PM with staff A, Registered Nurse (RN) revealed that she saw the brown build-up along the inside and outside of the pill crusher located on the west unit. Observation and interview on 4/30/2018 at 5:12 PM with the Director of Nursing (DON) revealed that she thought there was rust in the inside of the pill crusher on the west unit and stated, It is dusty. Observation on 4/30/2018 at 5:18 PM with staff B, Licensed Practical Nurse (LPN) revealed that the front of the pill crusher had a dust-like buildup and the inside of the pill crusher was rust-like on the south wing. Interview on 4/30/2018 at 5:18 PM with staff B, Licensed Practical Nurse (LPN) revealed that the staff saw that the front of the pill crusher had a dust-like buildup on the outside and the inside of the pill crusher was rust-like on the south wing. Interview on 4/30/2018 at 5:21 PM with the DON revealed that she saw the buildup along the inside and outside of the pill crusher for the south wing. Record review of the facility policy revised on 2/7/2018 titled Infection Control and Environmental Services: Purpose - To control the spread of infection within the facility by maintaining a thoroughly clean and safe environment. Equipment: All equipment including cords and wheels, shall be wet cleaned with approved germicide daily before returning to storage.

Based on observation, interview and record review, the facility failed to maintain the hot water temperatures within an acceptable range of 105F (Fahrenheit) to 115F for 18 out of 20 rooms tested during stage-1 of the survey. This has the potential to affect all 23 residents residing in the facility at the time of this survey. The findings include: Interview on 04/24/2017 at 3:13 PM with the Engineering Director revealed, he covered the entire building including the Nursing Home. He stated, the boiler room for the facility was located on the roof. Observation of the boiler room revealed, it is a large spacious room with a high ceiling. The room was observed to be clean on the floors, walls, and equipment. There were two large Air Conditioning units as you entered the room. There were two large water heaters located in an adjoined room to the left of the entrance door. The water heater tanks have a blue sticker with black letters that read Soft Water. The water heater tanks had a yellow sticker noted in black letters that read Hot Water. The tanks have a large thermometer located on the right upper area. The first tank (GWH-1) had a temperature setting of 90F (Fahrenheit) degrees and the second tank (GWH-2) had a temperature setting of 120F. Interview on 04/24/2017 at 3:31 PM with the Engineer Director revealed, the facility had a total of three water heater tanks. The water heater tank used only for the kitchen was located on the first floor. The two tanks located in this boiler room contained what he called the Domestic Water which meant they are used for the residents/patients rooms on the second and third floor. The following was revealed in resident rooms: Room 301: Water temperature tested on [DATE] at 7:55 AM in the sink located outside of the bathroom revealed a temperature reading of 120F degrees. Room 302: Water temperatures tested on [DATE] at 7:58 AM revealed, the sink located outside of the bathroom was 120F degrees. The water temperature tested on [DATE] at 9:43 AM in the sink located inside the bathroom revealed the temperature was 120F. Room 303: Water temperatures tested on [DATE] at 8:01 AM revealed the temperature in the sink outside of the bathroom and inside of the bathroom was both 120F. Room 304: Water temperature tested on [DATE] at 8:05 AM revealed it was 120F at the sinks located inside and outside of the bathroom. Room 305: On 4/25/17 at 8:40 AM the results of the water temperature tested in the sink(s) inside and outside of the bathroom was 120F degrees. Observation on 4/24/17 at 12:50 PM in room 328, the room for resident # 151, and Resident # 6 showed a water temperature in the bathroom and room sinks was 118F. Observation conducted on 04/25/2017 at 12:42 PM in room 328 the room for resident # 151, and resident # 6 revealed the temperature in the bedroom sink was 118F. During an interview conducted on 4/24/17 at 12:50 PM with Resident #151, she reported she uses the sink in her room with staff supervision. She said, she adjusted the temperature by herself and that staff were always with her when she used the sink. An observation of Room 311 on 04/24/2017 at 11:38 am revealed the hot water in the handwashing sinks felt hot to touch. An observation of Room 309 on 04/24/2017 at 11:33 am revealed the hot water in the handwashing sinks felt hot to touch. A second observation of Room 309 on 04/24/2017 at 02:48 pm revealed the hot water in the handwashing sinks felt hot to touch. At this time a dial stem thermometer calibrated with ice and water was used to measure the hot water temperature. The thermometer read 120 degrees Fahrenheit. An observation of Room 312 on 04/24/2017 at 02:58 pm revealed the hot water in the handwashing sinks felt hot to touch. At this time a dial stem thermometer calibrated with ice and water was used to measure the hot water temperature. The thermometer read 121 degrees Fahrenheit. An observation of Room 308 on 04/24/2017 at 03:49 pm revealed the hot water in the handwashing sinks felt hot to touch. At this time a dial stem thermometer calibrated with ice and water was used to measure the hot water temperature. The thermometer read 120 degrees Fahrenheit. A second observation of Room 308 on 04/25/2017 at 01:57 pm revealed the hot water in the handwashing sinks felt hot to touch. At this time a dial stem thermometer calibrated with ice and water was used to measure the hot water temperature. The thermometer read 120 degrees Fahrenheit. An observation of Room 310 on 04/24/2017 at 01:56 pm revealed the hot water in the handwashing sinks felt hot to touch. At this time a dial stem thermometer calibrated with ice and water was used to measure the hot water temperature. The thermometer read 120 degrees Fahrenheit. Room 313: Water temperature was tested on [DATE] at 2:02 PM revealed it was 122F degrees at the sink outside of the bathroom. The water temperature tested on [DATE] at 11:21 AM, again showed a water temperature of 122F. Room 333: Water temperature tested on [DATE] at 1:27 PM revealed it was 120F degrees at the sink outside of the bathroom. The water temperature was again tested on [DATE] at 11:25 AM, it showed a water temperature of 120F. Room 332: Water temperature tested on [DATE] at 09:01 AM revealed it was 120F degrees at the sink outside of the bathroom. Observations during an environmental tour with the Engineering Director, conducted on 04/25/2017 beginning at 8:40 PM revealed that the above mentioned concerns remained in rooms 313 and room 332. The water temperature tested in room 302 showed a temperature of 124F. The Engineering Director later agreed that it was a concern and stated he would immediately start making corrections.

Based on observations, interviews and record review, the facility failed to ensure that the lifting equipment was stored under sanitary conditions. The lifting equipment was observed in the resident's bathroom instead of the equipment storage room. This deficient practice has the potential to affect all the residents who were residing in the facility and using the lifting equipment at the time of the survey. The findings include: During observation of Resident # 137's bathroom on 04/24/2017 at 11:37 AM, the lifting equipment was observed inside the bathroom. During another observation of Resident # 137's bathroom on 04/24/2017 at 3:32 PM, the lifting equipment was still located in the bathroom. During an interview with Staff A on 04/26/2017 at 3:41 PM she revealed, the lifting equipment was supposed to be stored in the storage room and confirmed that it wasn't supposed to be placed in the resident's bathroom. Interview with the Environmental Services Director on 04/27/2017 at 10:30 AM he revealed, the lifting equipment shouldn't be in the resident's bathroom, but it should be stored in the storage area on the unit. During an interview with the Director Of Nursing (DON) on 04/27/2017 at 12:30 PM, she revealed the lifting equipment was should be stored inside the storage room and should not be placed in the resident's bathroom unless it was going to be used by staff. Record review of the facility's policy on Patient Mechanical Lift, policy # 2049, last reviewed on 02/01/2017 revealed: The lifting equipment will be located in accessible areas on the floor. Whenever a lift is removed from the temporary parking area it will be signed out on the sign out board. The equipment will be returned to the location upon completion of a lift.