Every finding on record at Vivo Healthcare Wauchula

Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food, in accordance with professional standards for food service safety. The findings included: 1) During the initial kitchen/food service observation tour conducted on 06/24/24 at 9 AM and accompanied with the facility's Certified Dietary Manager (CDM), the following were noted: a) The entire surface of the storeroom floor (10' X 20') was noted to be in disrepair with large areas of the concrete broken, rust, and peeling paint. It was discussed with the CDM that there were areas of standing water in pockets of the missing concrete surface which house bacteria that staff transfer into the main kitchen area. Also peeling paint is also transferred in the kitchen area. b) The exterior door and entry area to the walk-in refrigerator was noted to be rust laden and build-up of a black mold type matter. It was discussed with the CDM that the entry door and door area are not cleaned properly on a regular basis. c) Observation of the entry door of the walk-in refrigerator noted that the gaskets was covered in a black mold type matter and the door gasket had a large tear (approx 2'). It was noted that the unit was not operational during tour however it was discussed that the gaskets be placed prior to restart to ensure that the unit is cooling properly. d) Observation of the Reach-in Refrigerator #1 noted that the door gasket was covered in a black mold type matter and that the gasket had a large tear (1.5'). It was discussed with the CDM that the gasket requires replacement and needs to be properly cleaned on a regular basis. The CDM stated that she has requested a gasket replacement for months. e) Observation of the Reach-in Refrigerator #1 noted that a case of fresh eggs ( 15 dozen) was being stored directly over individual cartons of milk (48 individual). It was discussed with the CDM that there was potential of food contamination if raw eggs spilled onto the cartons of milk. f) Observation of the Reach-in #1 refrigerator noted left over containers of food dated: Beef Stroganoff (06/21), cooked rice (06/21). The CDM stated that left-over foods are to be discard after 48 hours and further stated that the left-over foods should have been discarded. g) Observation of the wood cutting board (5') that was attached to the steam table noted that the exterior was in disrepair and covered in a black mold type matter. It was discussed that the cutting board was too heavily worn to properly cleaned and should be replaced. h) Observation of the food preparation skillet pans (5) and commercial sheet pans were covered with a black carbon build-up. It was discussed with the CDM that use of the pans could result in food contamination during preparation and should be replaced. i) Numerous commercial dish racks (6) were noted to be heavily worn and had a build-up of black mold type matter. It was discussed with the CDM that the dish racks be replaced. j) Observation of the 3-compartment sink noted that a heavily soiled cleaning rag was placed over the water faucet. It was discussed that cleaning rags must be stored in a sanitizing solution when not in use. A chemical test of the cleaning rag bucket noted that there was no measurable chemical sanitizer in the solution to meet the regulatory requirement (Quaternary ). k) Observation of the bench mounted commercial can opener noted that the entire opening stem and cutting blade was covered in a black mold type matter. It was discussed with the CDM to replace the unit. l) Observation of the juice dispensing machine noted that the whole exterior including the top had large areas of dried juice matter. It was discussed with the CDM that the dispenser is not being properly cleaned on a regular basis. m) Observation of the commercial ice machine noted that water was continuously draining from the machine onto the floor area. It was noted that 3 large blankets were on the floor to soak up the water. It was discussed with the CDM that the wet blankets cannot remain on the floor and that the machine must be repaired. Photographic evidence obtained for Example #1 : a-m. 2) During a second observation tour of the kitchen on 06/25/24 at 11:15 AM, and accompanied with the CDM, the following were noted: n) Numerous flying insects (4) were noted to be located in the food preparation and serving area. The surveyor requested that the facility's pest control company be called for treatment on 06/25/24. o) Observation of the lunch meal noted hot foods located on the serving steam table. At the request of the surveyor the temperatures of the hot and cold foods were taken by the CDM with the use of the facility's calibrated digital food thermometer. The temperatures of the foods were noted to not be in regulatory compliance of 41 degrees F or below (cold foods) or 135 degrees F or higher(hot foods). The temperatures were recorded as follows: * Kielbasa & Noodles = 118 degrees F (surveyor requested reheating) * Pureed Buttered Noodles = 125 degrees F (surveyor requested reheating * Watermelon = 71 degrees F * Pureed Watermelon = 71 degrees F 3) During a third kitchen/food service observation conducted on 06/26/24 at 11:30 AM and accompanied with the Certified Dietary Manager (CDM), the following was noted: p) Staff were noted to be handling clean silverware by the eating stem resulting in contaminated silverware being placed of resident food trays. It was discussed with the CDM that silverware is not being properly washed to make sure clean silverware is stored with the handle up to ensure that it is being handled in a sanitary manner. 40153 4) A record review revealed Resident #22 was readmitted on [DATE] with diagnoses of End-Stage Renal Failure, Type 2 Diabetes, and dependency on dialysis. The Quarterly Minimum Data Set, dated dated dated [DATE] showed that Resident #22 had a Brief Interview of Mental Status (BIMS) score of 03, which indicated the resident was severely cognitively impaired. A review of the Physician's order revealed an order for dialysis at 11:30 AM pick-up and return time at 4:00 PM, dated 02/21/24. In an observation conducted on 06/24/24 at 12:01 PM, Resident #22 was noted in bed with two ham and cheese sandwiches wrapped in saran wrap with no ice packs or insulated lunch bag at the side table. In this observation, Staff A, Licensed Practical Nurse, stated that Resident #22 was offered his lunch tray and refused. Staff A further said that the two ham and cheese sandwiches were provided to Resident #22 for his snack during his dialysis treatments and that he was on his way to dialysis. Continued observation showed transportation services placing Resident #22 on a stretcher, and the two ham and cheese sandwiches were placed on top of Resident #22's medical chart underneath Resident #22's head (photographic evidence obtained). In an interview conducted on 06/24/24 at 12:10 PM with Staff B, Certified Nursing Assistant stated that Resident #22 did not want his lunch tray and that he likes the ham and cheese sandwiches when he goes to dialysis.

Based on observation, interview, and record review, it was determined that the facility failed to follow physician ordered fluid restriction diet for 2 ( Residents #214, and #22) of 2 sampled residents. The findings included: *Review of facility's policy for Fluid Restriction on 06/24/24 noted the following: Policy : It is the policy of the facility to ensure that fluid restrictions will be followed in accordance with physician's orders. Policy Explanation: Fluid restrictions are basically the restriction of fluid intake. This may be due to underlying medical conditions that may cause fluid build-up such as Congestive Heart Failure (CHF), or End Stage Renal Disease (ESRD), in addition to electrolyte disorders such as hyponatremia. Fluid restriction can vary according to the resident's condition and the physician judgement. Compliance Guidelines: (1) The nurse will obtain and verify the physician's order for the fluid restriction and an order written to include the breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition department and the nursing department. (2) The fluid restriction distribution will take into consideration the amount of fluid to be given at meal times, snacks, and medication passes. (3) Water will not be provided at the bedisde unless calculated into the daily total fluid restriction . 1) During the review of the clinical record of Resident # 214 on 06/24/24, it was noted a current physician's order dated 06/21/24 for a 1500 cc Fluid Restriction per day. The order further documented dietary to receive 750 cc per day and nursing to receive 750 cc per day. Routine observation conducted on 06/24/24 at 1 PM noted a 16 ounce Styrofoam container on the resident's bedside table that was full of water. The resident stated that she has been drinking from the Styrofoam cup and had no knowledge of the physician ordered fluid restriction. Interview with the Director of Nursing and Certified Dietary Manager following the observation were noted to state that fluids are not allowed at the bedside of Resident #214. Routine observations of the lunch meal on 06/25/24 at 12:30 PM noted the meal tray delivered to the room of Resident #214. Review of the meal ticket documented a Mechanical Soft diet and 1500 cc Fluid Restriction . Further review of the ticket noted no documentation of how much fluid was to be served for the lunch meal . During the observation of the lunch meal in the main dining room on 06/26/24 at 12 :15 PM, it was noted that Resident #214 was present for the meal . Further observation noted that the resident's meal ticket that was located on the dining room table documented a Mechanical Soft - Fluid Restriction of 360 cc for the lunch meal and documented 4 ounces (120 cc)of Lemonade and 8 ounces (240 cc) - Milk to be served. Further observation noted that the resident received the 120 cc of Lemonade and 240 cc of Milk, however the resident received an additional 8 ounces (240 cc) of Coffee with the meal. The surveyor requested the Certified Dietary Manager (CDM) and Charge Nurse who was in the dining room to observe the resident's beverages that were served. Both the CDM and the Charge Nurse confirmed the surveyors findings that the fluid restriction for the meal was not followed and the resident received an additional 240 cc of fluid with the meal. It was also noted that the dietary department sent the correct amount of fluids on the tray, however nursing staff who pass beverages prior to the main meal were not aware of the fluid restriction and served the resident an additional 240 cc of coffee. It was further discussed that nursing staff working in the dining room for meal service be in-serviced on any resident with a physician's order for fluid restriction. Interview with the Certified Dietary Manager during the observation of the 06/26/24 meal noted she was unaware that the specific fluids and amounts for each meal that add up to 360 cc per meal. Interview with Director of Nursing during the 06/26/24 observation noted to state that she was not aware the meal tickets failed to document the amount of fluids to be served with all meal. 40153 2) A record review revealed Resident #22 was readmitted on [DATE] with diagnoses of End-Stage Renal Failure, Type 2 Diabetes, and dependency on dialysis. The Quarterly Minimum Data Set, dated dated dated [DATE] showed that Resident #22 had a Brief Interview of Mental Status (BIMS) score of 03, which indicated the resident was severely cognitively impaired. The Physician's orders revealed an order for fluid restriction of 960 milliliters (ml) per day: Dietary to provide 200 ml for Breakfast, Lunch, and Dinner. Nursing administers 120 ml every shift for hydration and medication, dated 03/28/24. In an observation conducted on 06/24/24 at 10:10 AM, Resident #22 was in bed. The side table was noted with three bottles of 16 ounces each of sodas and 16 ounces of water in a Styrofoam cup provided by the facility. This showed that the fluids supplied by the facility were 480 ml for Breakfast and not 200 ml as per Physicians' orders. In an observation conducted on 06/25/24 at 11:50 AM, Resident #22 was in bed. The side table was noted with three bottles of 16-ounce sodas each and 16-ounce water in a Styrofoam cup provided by the facility. A progress note dated 06/24/24 revealed Resident #22 to have a soda bottle in the room; the Resident stated that the family brought it in and was educated on fluid restriction. The Resident said, I want my Pepsi. A review of the care plan dated 06/18/24 showed a care plan for nutrition and dialysis that needed to document Resident #22's fluid restrictions. Further review did not show any interventions regarding fluid restrictions, nor was any education provided to the family on fluid restrictions prior to 06/24/24. In an interview conducted on 06/26/24 at 12:05 PM with Staff B, the Certified Nursing Assistant (CNA) stated that she attends staff meetings with the nurses and is told about any residents who are on fluid restrictions. She further said that she would go into residents' rooms to make sure that they were the correct residents on fluid restriction and that the appropriate fluids were provided.

Based on observations, interviews and record review, the facility failed to ensure residents were treated in a dignified manner when entering the resident's room and during medication administration for 2 of 5 residents observed for medication pass administration (Residents #38 and #165). The findings included: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity dated 09/01/23 included in part the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain dignity and respect resident rights. 12. Maintain resident privacy. Review of the facility's policy titled, Medication Administration with a revised date of 09/01/23 included in part the following: Policy Explanation and Compliance Guidelines: 5. Knock or announce presence. 7. Provide privacy. 1.) Record review for Resident #38 revealed the resident was originally admitted to the facility on [DATE] with a most recent readmission on 04/01/24 with diagnoses that included: Urinary Tract Infection, Cognitive Communication Deficit, Major Depressive Disorder, Anxiety Disorder. Review of the Minimum Data Set (MDS) for Resident #38 dated 04/05/24 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 6, indicating severe cognitive impairment. During med pass observation conducted on 06/25/24 at 9:20 AM with Staff C Licensed Practical Nurse (LPN) for Resident #38, Staff C, LPN entered room without knocking and did not close door or pull privacy curtain for administration of medications to resident lying in bed. 2.) Record review for Resident #165 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Muscle Wasting and Atrophy and Type 2 Diabetes Mellitus with Hyperglycemia. Review of the MDS for Resident #165 dated 06/18/24 revealed in Section C a BIMS score of 9, indicating moderate cognitive impairment. Review of the physician's orders for Resident #165 revealed an order dated 06/20/24 for Humalog Injection Solution (Insulin Lispro), Inject intramuscularly before meals and at bedtime for DM (Diabetes Mellitus). Inject as per sliding scale: if 0 - 200 = 0 units If BS is below 70 notify MD.; 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 12 units If bs (Blood Sugar) is above 450 notify MD (Medical Doctor). During an observation on 06/25/24 at 10:40 AM of blood glucose (blood sugar) monitoring for Resident #165 performed by Staff C, LPN, the LPN entered the resident's room without knocking. The LPN checked the resident's blood glucose which was 313. The LPN then administered Humalog insulin (coverage) subcutaneous (6 units) into the resident's abdomen while resident was sitting in wheelchair facing the door to the room with the door open, no privacy curtain pulled and residents/staff/visitor walking by in the hall. During an interview conducted on 06/25/24 at 10:50 AM with Staff C, LPN who stated she worked for the facility for a year. When asked about entering resident's rooms should she knock, she said no, the residents all know who she is and that she is going to be giving them their medications. When asked if she should provide privacy for the residents during medication administration, she said she should have closed the door or pulled the privacy curtain.

Based on observations, interviews, and record review, the facility failed to practice hand hygiene while donning and doffing gloves during med administration observation for 2 of 5 residents reviewed for medication pass (Residents #165 and #38), and during tracheostomy care for 1 out of 1 resident reviewed for respiratory care (Resident #38). The findings included: Review of the facility's policy titled, Hand Hygiene dated 09/01/23 included in part the following: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning (applying) gloves, and immediately after removing gloves. Hand Hygiene Table After handling contaminated objects Before performing invasive procedures Before applying and after removing personal protective equipment (PPE), including gloves. Before and after handling medications. Before performing resident care procedures After handling items potentially contaminated with blood, body fluids, secretions, or excretions. Review of the facility's policy titled, Medication Administration with a revised date of 09/01/23 included in part the following: Policy Explanation and Compliance Guidelines: 4. Wash hands or ABR (Alcohol Based Rub) prior to administering medication per facility protocol and product. 1.) Record review for Resident #21 revealed the resident was originally admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] with diagnoses that included: Personal History of Traumatic Brain Injury, Aphasia, and Encounter for Attention to Tracheostomy. Review of the Minimum Data Set (MDS) for Resident #21 dated 06/10/24 documented in Section C a Brief Interview of Mental Status (BIMS) was not completed due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #21 revealed an order dated 04/27/24 Tracheostomy care provided every day and evening shift. On 06/25/24 at 2:00 PM, an observation was made of tracheostomy care provided to Resident #21 by Staff C, Licensed Practical Nurse (LPN). Staff C, LPN gathered supplies, applied gown and clean non-sterile gloves without performing hand hygiene (HH). Staff C, LPN removed her gloves, did not perform HH, applied clean non-sterile gloves, with her left hand she removed the old inner canula and disposed of it, during this time the resident was making a gurgling type of sound while coughing and had copious secretions coming out of the tracheostomy. Staff C, LPN applied clean non-sterile gloves and replaced the inner canula. Staff C, LPN then placed gauze under the trach ties, around the trach, then replaced the trach ties, removed her gloves, performed HH. This indicated Staff C, LPN did not perform HH before initially starting the procedure and applying gloves, nor did she perform HH between glove changes. During an interview conducted on 06/25/24 at 2:23 PM with Staff C, LPN who stated she has worked at the facility for 1 year. Staff C, LPN stated she made a mistake; she should have washed her hands before applying the PPE (Personal Protective Equipment). 2.) Record review for Resident #38 revealed the resident was originally admitted to the facility on [DATE] with a readmission on 03/19/24 with diagnoses that included: Urinary Tract Infection, Cognitive Communication Deficit, Major Depressive Disorder, and Anxiety Disorder. During a Medication Pass observation conducted on 06/25/24 at 9:20 AM with Staff C Licensed Practical Nurse (LPN) for Resident #38, Staff C LPN did not perform hand hygiene before or after handling medications, nor did she perform hand hygiene before applying gloves or after removing gloves. 3.) Record review for Resident #165 revealed the resident was admitted to the facility on [DATE] with diagnoses included: Muscle Wasting and Atrophy and Type 2 Diabetes Mellitus (DM) with Hyperglycemia. Review of the MDS for Resident #165 dated 06/18/24 revealed in Section C, a BIMS score of 9, indicating moderate cognitive impairment. Review of the Physician's orders for Resident #165 revealed an order dated 06/20/24 for Humalog Injection Solution (Insulin Lispro) Inject intramuscularly before meals and at bedtime for DM Inject as per sliding scale: if 0 - 200 = 0 units If BS is below 70 notify MD.; 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 12 units If bs is above 450 notify MD. During a Medication Pass observation conducted on 06/25/24 at 10:40 AM with Staff C, LPN who was administering insulin to Resident #165, the LPN applied gloves without using hand hygiene and administered Humalog insulin (coverage) subcutaneous into the resident's abdomen. Staff C, LPN then removed her gloves and did not perform hand hygiene. During an interview conducted on 06/25/24 at 10:50 AM with Staff C, LPN she stated she worked for the facility for a year. When asked if she should perform hand hygiene before and after handling medication she said yes. When asked if she should perform hand hygiene before applying and after removing gloves, she said yes, she was nervous and forgot.

Based on interviews and record review, the facility failed to accurately document code status for 1 of 29 sampled residents (Resident #50). The findings included: Record review for Resident #50 revealed the resident was admitted to the facility on [DATE] with a readmission on 06/21/24 with diagnoses that included the following: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Generalized Anxiety Disorder, Major Depressive Disorder, and Aphasia Following Cerebral Infarction. Review of the Minimum Data Set for Resident #50 dated 04/22/24 documented in Section C, a Brief Interview of Mental status score of 0, indicating severe cognitive impairment. Review of the Physician's Orders for Resident #50 revealed an order dated 6/21/24 for Code Status: Full Code Review of the Social Services Progress note for Resident #50 dated 09/10/23 documented the following: Confirmed with Proxy that resident is a DNRO code status. Review of the Care Plan for Resident #50 dated 08/10/23 with a focus on Advance Directives-I am a DNR Code Status- Do Not Resuscitate in the event of no heartbeat and no respirations. The goal was for Advance directive will be followed per MD orders. The interventions included: If code status changes update medical record. Provide comfort measures as indicated when end of life is eminent. Provide resident and family privacy as needed. Review code status quarterly to ensure preferences are honored. Review of the Care Plan Progress Note for Resident #50 dated 08/16/23 documented the following: Care plan meeting held at this time with IDT members. Resident #50's Brother requested to called for care plans but did not answer. He requested a copy of care plans. Review of current plan of care. Resident adjusting well to recent admission to facility. Will continue to follow current plan of care and adjust as needed. Copy of care plans provided for brother. Review of the Care Plan Progress Note for Resident #50 dated 01/31/24 documented the following: Care plan meeting held today with IDT and friend. Review of current plan of care. Resident stable at this time. Will continue to follow current plan of care adjust as needed. During an interview conducted on 06/24/24 at 2:08 PM with Staff A, Licensed Practical Nurse (LPN) who stated she has worked at the facility for 1.5 years. When asked how she identifies what the code status is for a resident, she stated she would check in the Electronic Medical Record (EMR) at the top of the dashboard and the code status is located there. When asked if the code status is blank, what would she do, she said she would check the order and look in miscellaneous for any documentation for code status, such as a DNR (Do Not Resuscitate) form. When asked about Resident #50, she looked for the code status in the EMR in the dashboard, and acknowledged it was blank. Staff A, LPN then checked the orders for the resident and acknowledged the resident had an order for full code. Staff A, LPN then checked in miscellaneous for the resident and located a DNR form. Staff A, LPN said she will call the family and the physician to address immediately. During an interview conducted on 06/25/24 at 1:00 PM with the Social Service Director (SSD) who was asked about advanced directives specifically code status he said when a resident comes in, the nurse will talk to resident or family to discuss code status. The SSD will confirm with resident/family what the code status is. The SSD said he is responsible to make sure code status was in orders correctly and care plan implemented and updated as needed. The resident went out to hospital on 06/18/24 and returned on 6/21/24 and upon return the nurse must have put him in as a full code status unbeknownst to him. Had he known this he would have called the family to confirm they still wanted the resident to be a do not resuscitate. The SSD said the incident of making the resident a full code was done without his knowledge and he would have addressed the code status with the family as they were adamant about the resident being a do not resuscitate given his health issues.

Based on observation, interview, and record review it was determined that the facility failed to prepare food in a form designed to meet the individual needs of 5 (Residents #23, #24, #26, #36, and #41) of 5 sampled residents with physician ordered pureed diet. The findings included: *Review of the facility's policy for Pureed Food Preparation noted a Date Implemented of 09/01/23 and Reviewed by Clinical Services. Further review of the Policy Explanation and Compliance Guidelines noted: (2) Pureed foods should be prepared in such a manner to prevent lumps or chunks. The goal is a smooth, soft, homogenous consistency similar to soft mashed potatoes. (3) If the food item requires chewing, it will be excluded from the pureed diet. References: Center for Medicare & Medicaid Services, State Operation Manual (SOM), Appendix PP Guidance to Surveyors for Long Term care Facilities (November 2017 Revision) 1) During the observation of the lunch meal in the main kitchen on 06/24/24 at 11:15 AM, and accompanied with the facility's Certified Dietary Manager (CDM), pureed foods located in the serving steam table were observed by the surveyor. The observation noted that the Pureed Chicken Tenders, Pureed Baked Macaroni & Cheese, and Pureed Mixed Vegetables all were noted to be lumpy and visible pieces of foods in all 3 pureed foods. At the request of the surveyor the pureed foods were taste tested by the surveyor and the CDM. The test tasting was confirmed by the surveyor and the CDM that all 3 pureed foods were not pureed to a smooth consistency and pieces of foods could be tasted. It was discussed with the CDM that pureed food should be pureed to a smooth pudding like consistency and no food lumps be present. It was stated that the lunch cook (Staff D ) was not preparing foods to a proper pureed consistency and not testing the pureed foods prior to serving. Staff D stated no training of preparation of Pureed foods for residents with physician ordered pureed diet with diagnoses of Dysphagia. The surveyor requested that the lunch pureed foods be sent back to be pureed to the proper consistency prior to be served for the 06/24/24 lunch meal. 2) During the observation of the lunch meal in the main kitchen on 06/25/24 at 11:15 AM, and accompanied with the facility's Certified Dietary Manager (CDM), pureed foods located in the serving steam table were observed by the surveyor. The observation noted that the Pureed Kielbasa and Pureed Cabbage, were noted to be lumpy and visible pieces of foods in the 2 pureed foods. At the request of the surveyor the pureed foods were taste tested by the surveyor and the CDM. The test tasting was confirmed by the surveyor and the CDM that the 2 pureed foods were not pureed to a smooth consistency and pieces of foods could be tasted. It was discussed with the CDM that pureed food should be pureed to a smooth pudding like consistency and no food lumps be present. It was stated that the lunch cook (Staff E) was not preparing foods to a proper pureed consistency and not testing the pureed foods prior to serving. Staff E stated no training of preparation of Purred foods for resident's with physician ordered pureed diet with diagnoses of Dysphagia. The surveyor requested that the lunch pureed foods be sent back to be pureed to the proper consistency prior to be served for the 06/25/24 lunch meal. 3) During the review of the facility's Diet Census for 06/24/24, it was noted that there were currently 5 facility residents with physician ordered Pureed Diet, with diagnoses that included Dysphagia. The 5 residents included Sample Residents #23, #24, #26, #36, and #41. Review of the sampled resident's clinical records on 06/24-25/24 noted the following: Resident #23: Date of Admission: 06/06/24 Diagnoses: Dysphagia, Protein-Calorie Malnutrition Current Physician Order: Pureed Diet (06/20/24) Resident #24 Date Of Admission: 06/18/24 Diagnoses: Protein-Calorie Malnutrition, Failure To Thrive, and Dysphagia Current Physician Order: Pureed Diet with Nectar Thick Liquids (06/18/24) Resident #26: Date Of Admission: 8/1/23 Re-admission Diagnoses: Dysphagia Current Physician Orders: Pureed Diet with Nectar Thick Liquids (06/08/22) Resident #36 Date Of Admission: 3/28/24 Diagnoses: Dysphagia, Protein-Calorie Malnutrition Current Physician Orders: Pureed Diet (06/24/24) Resident #41 Date Of Admission: 01/01/23 Diagnoses: Dysphagia Current Physician Orders: Pureed Diet with Fortified Foods (07/07/23)

Based on interview and record review, the facility attending physician failed to document on irregularities identified with recommendations by the consulting pharmacist for 1 of 5 residents sampled for Unnecessary Medications (Resident #2). The findings included: Review of the facility's policy titled, Medication Regimen Review dated 08/07/22 included in part the following: The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. Policy Explanation and Compliance Guidelines: 6. d) Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Record review for Resident #2 revealed the resident was admitted to facility 01/10/23, the resident went out of the facility on 03/10/24 and was readmitted to the facility on [DATE] with diagnoses that included: Fracture of Unspecified Part of Neck of Right Femur, Major Depressive Disorder, and Generalized Anxiety Disorder. Review of the Minimum Data Set for Resident #2 dated 05/06/24 revealed in Section C a Brief Interview of Mental Status score of 15 indicating the resident is cognitively intact. Review of the Pharmacy Medication Regimen Review for Resident #2 dated 03/21/24 documented: Currently receiving digoxin. Daily pulse recommended with use. Please consider ordering, if appropriate. The Physician/Prescriber Response was not addressed. There was an indication on the form that documented was out to hospital with no signature or date. Review of the Pharmacy Medication Regimen Review for Resident #2 dated 03/21/24 documented: Currently receiving Cholestyramine for diarrhea without stop date. Please evaluate continued need. Consider adding stop date, if appropriate. The Physician/Prescriber Response was not addressed. There was an indication on the form that documented was out to hospital with no signature or date. Review of the Pharmacy Medication Regimen Review for Resident #2 dated 03/21/24 documented: Currently receiving Tramadol which has a potential for dizziness and drowsiness, increasing the risk of falls. Per clinical record, with recent falls. Please evaluate possible causal relationship. Consider trial discontinue Tramadol and start alternate therapy (i.e.: Ibuprofen or Acetaminophen), if necessary. The Physician/Prescriber Response was not addressed. There was an indication on the form that documented was out to hospital with no signature or date. Review of the Pharmacy Medication Regimen Review for Resident #2 dated 03/21/24 documented: Per clinical record resident with recent falls. Recommend to check 25-hydroxyvitamin D levels in those with advanced age and recent falls. Please consider ordering and if necessary, initiating Vit D3 50,000 IU once weekly for 6 weeks then monthly thereafter. The Physician/Prescriber Response was not addressed. There was an indication on the form that documented was out to hospital with no signature or date. During an interview conducted on 06/26/24 at 9:51 AM with the Director of Nursing (DON) who was asked if the consultant pharmacist reviews the medication regiment every month for every resident, she said yes. When asked about medication review recommendation for Resident #2 for the month of March, the DON said the resident was out to the hospital. When asked when the resident went out to the hospital and returned to the facility, she acknowledged the resident was out from 3/10/24 and returned on 3/19/24. When asked why the recommendations were not addressed, she said it must have been missed.

Based on observations, interviews, and record review, the facility failed to provide tracheostomy care in accordance with professional standards of practice and failed to implement appropriate interventions for tracheostomy care for 1 of 1 resident sampled for respiratory care (Resident #21). The findings included: Review of the facility's policy titled, Tracheostomy Care dated 09/01/23 included in part the following: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Compliance Guidelines: 2. The facility will provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, tracheostomy care and/or suctioning. 3. Tracheostomy care will be provided according to the physician's orders, comprehensive assessment and individualized care plan such as monitoring for resident specific risks for possible complications, psychosocial needs as well as suctioning as appropriate. 4. Based upon the resident assessment, attending physician's orders, and professional standards of practice, the facility in collaboration with the resident/resident's representative will develop a care plan that includes appropriate interventions for respiratory care. Review of the Tracheostomy care: An evidence-based guide located at: https://www.myamericannurse.com/tracheostomy-care-an-evidence-based-guide-to-suctioning-and-dressing-changes/ included in part the following: Under the Section When to suction Suctioning is done only for patients who can't clear their own airways. Its timing should be tailored to each patient rather than performed on a set schedule. Start with a complete assessment. Findings that suggest the need for suctioning include increased work of breathing, changes in respiratory rate, decreased oxygen saturation, copious secretions, wheezing, and the patient's unsuccessful attempts to clear secretions. According to one researcher, fine crackles in the lung bases indicate excessive fluid in the lungs, and wheezing patients should be assessed for a history of asthma and allergies. Record review for Resident #21 revealed the resident was originally admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] with diagnoses that included: Personal History of Traumatic Brain Injury, Aphasia, and Encounter for Attention to Tracheostomy. Review of the Minimum Data Set for Resident #21 dated 06/10/24 documented in Section C a Brief Interview of Mental Status was not completed due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #21 revealed an order dated 04/26/20 for Tracheostomy care provided, change disposable inner cannula (Shiley size 4) every day shift. Review of the Physician's Orders for Resident #21 revealed an order dated 04/27/24 Tracheostomy care provided every day and evening shift related to Encounter for Attention to Tracheostomy. Review of the Care Plan for Resident #21 dated 09/16/18 with a focus on the resident has a tracheostomy r/t (related to) injury Nontraumatic brain injury Congestion. The goals were for the resident to have clear and equal breath sounds bilaterally, no s/sx (signs/symptoms) of infection, and to have no abnormal drainage around trach site through the review date. The interventions were to: Ensure that trach ties are secured at all times, Monitor/document for restlessness, agitation, confusion, increased heart rate (Tachycardia), and bradycardia. Monitor/document level of consciousness, mental status, and lethargy PRN. Monitor/document respiratory rate, depth and quality. Check and document every shift/as ordered. Provide good oral care daily and PRN (As needed). Reassure resident to decrease anxiety. Suction as necessary. Tube Out Procedures: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help Immediately. There were no interventions for providing tracheostomy care. On 06/25/24 at 2:00 PM, an observation was made of tracheostomy care provided to Resident #21 by Staff C Licensed Practical Nurse (LPN). The LPN gathered supplies, applied gown and clean non-sterile gloves (Staff C, LPN did not wear any eye protection). The LPN then proceeded to touch the resident as well as several objects in the room before removing her gloves, and applied clean non-sterile gloves, she then opened the tracheostomy kit, did not unfold or use the sterile field located in the kit, opened the saline, removed the sterile gloves, performed hand hygiene (HH), applied sterile gloves with poor technique (touching the open end of the glove with sterile gloved hand touching her wrist as she placed the glove on the other hand, she then used both hands with sterile gloves to adjust the towel on the resident's chest, pushed the resident's hair behind her neck, with her left hand she removed the old inner canula and disposed of it, during this time the resident was making a gurgling type of sound while coughing and had copious secretions coming out of the tracheostomy spilling over and onto the LPNs gloved hand holding the tracheostomy. The LPN then removed her gloves, performed HH, applied clean non-sterile gloves, and replaced the inner canula. Staff C, LPN then placed gauze under the trach ties, around the trach, then replaced the trach ties, removed her gloves, performed HH. The LPN did not listen to breath sounds, obtain oxygen saturation, or provide suctioning any time prior to, during or after the tracheostomy care. During an interview conducted on 06/25/24 at 2:23 PM with Staff C, LPN who stated she has worked at the facility for 1 year. The LPN stated she made a mistake; she should have washed her hands before applying the PPE (Personal Protective Equipment) and she should have used a mask during the procedure. When asked if suctioning should be provided prior to or after or in conjunction with tracheostomy care, she said no, not for this resident, she does that all of the time (coughing up secretions) and if you suction her, she will just produce more secretions. When asked if replacing the inner canula is a sterile procedure, she said no. During an interview conducted on 06/26/24 at 12:00 PM with Staff F, Licensed Practical Nurse (LPN) who was asked about tracheostomy care for a resident, he said he would suction the resident as necessary, there should be extra supplies at the bedside such as suctioning, inner cannulas, and an Ambu bag. When asked if it is considered a sterile procedure to change the inner canula, he said yes, it is a sterile procedure, and you should wear sterile gloves. During an interview conducted on 06/26/24 at 12:45 PM with Staff, G LPN, Unit Manager of east wing she stated she has worked at the facility as a Unit Manager for 8 months. When asked about tracheostomy care for residents, she said it should be performed at least twice a day. When asked if staff should perform hand hygiene before putting on gloves and after removing them, she said yes. When asked if replacing an inner canula for a resident is a sterile procedure, she said yes, it is considered a sterile procedure. When asked about the care plan for tracheostomy for Resident #21, she acknowledged the care plan interventions should include tracheostomy care, but it did not.

Based on observations, interviews, and record review, the facility failed to follow tube feeding as per the Physician ' s orders for 1 of 1 resident review for tube feeding (Resident #21). The findings included: Resident #21 was admitted on [DATE] with a diagnosis of traumatic brain injury and gastroesophageal reflux disease. A review of the Physician ' s orders revealed an order for tube feeding Jevity 1.5 (tube feeding formula) starting at 10:00 AM to run for 50 milliliters (ml) an hour for 20 hours and to turn the tube feeding off at 6:00 AM. In an observation conducted on 06/24/24 at 10:05 AM, Resident #21 was noted in bed with the tube feeding running at 50 ml an hour. The tube feeding bag was noted to have Jevity 1.5 (tube feeding formulary), which started on 06/24/24 at 10:00 AM and was at the 1000 ml level in a 1000 ml capacity bottle. In an observation conducted on 06/24/24 at 2:05 PM (about four hours later), Resident #21 was noted with the tube feeding running at 50 ml an hour. The same tube feeding bottle was observed earlier, which started on 06/24/24 at 10:00 AM and was now at the 900 ml level out of a 1000 ml capacity bottle. This showed that only 100 ml of tube feeding formulary was given in four hours. In an observation conducted on 06/25/24 at 9:00 AM, Resident #21 was noted in bed with the tube feeding off. In an observation conducted on 06/25/24 at 12:30 PM, Resident #21 was in her chair with the tube feeding running at 50 ml an hour. The tube feeding bag was noted at the 1000 ml mark out of a 1000 ml capacity bottle. In this observation, Staff C, Licensed Practical Nurse, said she started the tube feeding bottle at 10:00 AM this morning and that Resident #21 is tolerating her tube feeding well. In an observation conducted on 06/25/24 at 2:45 PM, Resident #21 was in the room with the tube feeding bottle Jevity 1.5 running at 50 ml an hour, which was started on 06/25/24 at 10:00 AM. The tube feeding was noted at the 950 ml level out of a 1000 ml capacity bottle. This showed that only 50 ml was administered in about 4.5 hours. In an observation conducted on 06/26/24 at 12:05 PM, the Resident was noted in bed, with the tube feeding Jevity 1.5 that started on 06/26/24 at 10:00 AM. The bottle was noted at the 1000 ml mark out of a 1000 ml capacity bottle. In an interview conducted on 06/27/24 at 10:55 AM, Staff C, Licensed Practical Nurse, stated she was about to hang a new tube feeding bottle for Resident #21. She further said that Resident #21 is tolerating her tube feeding well. The Quarterly Minimum Data Set, dated dated dated [DATE] revealed that Resident #21 was severely cognitively impaired. The Nutrition Risk Evaluation dated 03/06/24 revealed Resident #21 tolerated the tube feeding very well and relies on tube feeding to meet 100% of nutritional needs. The care plan dated 06/10/24 showed monitoring/documentation of any residuals. Provide tube feedings as ordered and flushes as ordered. In an interview conducted on 06/27/24 at 11:00 AM with the Administrator, she was informed of the findings.

Based on observations, interviews, and record reviews, the facility failed to monitor nutritional status in a timely manner for one of one residents reviewed for Dialysis (Resident #22). The findings included: The facility's policy titled, Nutritional Management, dated 09/1/2023 revealed the following: A systematic approach is used to optimize each resident's nutritional status: Identifying and assessing each resident's nutritional status and risk factors. Evaluating/analyzing the assessment information. Developing and consistently implementing pertinent approaches. Monitoring the effectiveness of interventions and revising them as necessary. A record review revealed Resident #22 was readmitted on [DATE] with diagnoses of End-Stage Renal Failure, Type 2 Diabetes, and dependency on Dialysis. The Quarterly Minimum Data Set, dated dated dated [DATE] showed that Resident #22 had a Brief Interview of Mental Status (BIMS) score of 03, which indicated the resident was severely cognitively impaired. The Physician orders revealed an order dated 02/21/24 for Dialysis every Mondays, Wednesdays and Fridays. Fluid restrictions 600 milliliters for Breakfast, Lunch and Dinner which was dated 03/28/24. Regular texture, thin consistency, double protein Portion for breakfast. Magic cup/ frozen nutritional treat 3 times a day dated 03/26/24. The Admission/Readmission Nutritional assessment dated [DATE] showed the following: Resident #22 is on Dialysis and has an unspecific protein-calorie malnutrition history. He consumes on average over 76% of his meals and receives frozen nutritional treats 3 times a day. It further showed to continue monitoring nutritional parameters and follow up as needed. The care plan, which was revised on 03/21/24, showed the following: Resident #22 is at risk for malnutrition secondary to a history of significant weight loss with Dialysis. Contact renal Dietitian, to assess labs, obtain updates, and modify nutritional intervention as appropriate. It further revealed to provide nutritional interventions as appropriate. Further review of the care plan did not address the fluid restrictions as ordered above. A review of the nutritional progress notes did not show a note addressing the order for fluid restrictions (dated 03/28/24) until 05/23/24, which was seven weeks later. An interview conducted on 06/24/24 at 1:40 PM with the Dietary Manager who stated that they had hired a Registered Dietitian to cover this facility remotely. The remote facility's Dietitian has yet to come into the facility physically to see the residents. The Dietary Manager said that for high nutritional-risk residents, the Director of Nursing would review the data and contact the newly hired dietitian. She further said that it is the Director of Nursing responsibility to contact the facility's Dietitian. In a phone interview on 05/24/24 at 2:20 PM, the facility's newly hired Dietitian stated he started working about 1.5 weeks ago. He said that high nutritional-risk residents are the ones who are on Dialysis, on nutritional support, have significant weight loss and pressure ulcers. The high nutritional-risk residents should be followed monthly with progress notes, and the residents on Dialysis will contact the dialysis Dietitian to discuss the residents and review labs. According to the facility's Dietitian, an admission assessment is completed on admission and is titled, Nutritional Risk Evaluation and should be done quarterly. The Nutritional Risk Evaluation looks at anthropometric data (measurements of the human body), labs, calculations for nutritional needs, evaluation, and any nutritional recommendations. When asked if he had done any quarterly assessments on any residents, he said no and that he had only been working for less than a month. Further review of the facility's electronic system did not reveal that Resident #22 had completed a quarterly nutritional risk evaluation. In an interview conducted on 06/27/24 at 9:30 AM, the Minimum Data Set Coordinator stated the facility's Dietitian will complete the nutritional care plans, but since the facility is between Dietitians, she has been trying to catch up on the dietary portions of the care plans. She said yes when asked if she completed the nutrition care plan for high-risk residents. When asked who updated the care plan on Resident #22, she stated the Dietary Manager, which was in March of 2024. In an interview conducted on 06/27/24 at 11:00 AM with the facility's Administrator she was informed of the findings.

Based on observation, interviews, and record review, the facility failed to obtain orders for catheter care for a resident admitted with an indwelling Foley catheter for 1 of 1 resident sampled for urinary catheter (Resident #31). The findings included: Record review for Resident #31 revealed the resident was admitted to facility on 02/04/22 with the most recent readmission on 06/21/24 that included diagnoses of Urinary Tract Infection and Neuromuscular Dysfunction of Bladder. Review of the Minimum Data Set for Resident #31 dated 04/22/24 revealed in Section C Brief Interview of Mental Status (BIMS) score of 15, which indicated a cognitive response. Review of the Admission/Readmission Nursing Evaluation for Resident #31 dated 06/21/24 documented under Section K Urinary: Does the resident have a catheter? Was answered yes. Catheter type/size? Was answered 16Fr. Reason for catheter - Neuromuscular dysfunction of the bladder. Review of Medication Administration Record (MAR) for Resident #31 from 06/21/24 to 06/24/24 for catheter care documented no catheter care was performed on 06/21/24, 06/22/24, and 06/23/24. Review of the Certified Nursing Task for Foley Care Every Shift for Resident #31 from 06/21/24 to 06/23/24 revealed no documentation of foley care provided. Review of the Physician's Orders for Resident #31 from 06/21/24 to 06/23/24 revealed no orders for foley catheter care. Review of the Care Plan for Resident #31 dated 03/04/23 with a focus on Urinary catheter r/t (related to) Neurogenic bladder. The goals were for the resident to show no s/sx (signs/symptoms) of Urinary infection and for the resident to be/remain free from catheter-related trauma through review date. The interventions included: Change catheter as needed. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to MD for signs and symptoms UTI. Provide catheter care to prevent UTI. Provide privacy bag to drainage bag at all times. Secure foley catheter to thigh with securement device as tolerated. On 06/24/24 at 10:20 AM, an observation was made of Resident #31 sitting up in bed with the foley catheter drainage bag covered with privacy covering hanging from bed. During an interview conducted on 06/24/24 at 10:24 AM with Resident #31 she said she just got back from hospital, she had a bladder and blood infection. She said she was pouring blood for about 2 weeks and there were big white things in the tubing. She said she is better now and has no cramping and is receiving antibiotics. During an interview conducted on 06/25/24 at 2:00 PM with Staff H, Certified Nursing Assistant (CNA) who was asked about documenting foley catheter care, she said it would be documented in Point of Care (Tasks) for foley care. During an interview conducted on 06/26/24 at 2:30 PM with Staff A, Licensed Practical Nurse (LPN), who was asked if a resident has a foley catheter do they need an order for the catheter and/or care? The LPN stated yes. When asked about Resident #31, she acknowledged the resident did not have any order for a foley catheter or care from 06/21/24 to 06/23/24, she said all of the orders for foley catheter for Resident #31 were written on 06/24/24. During an interview conducted on 6/26/24 at 11:30 AM with the Director of Nursing (DON) who was asked about when a resident is admitted or readmitted to the facility with a foley catheter, do they need an order for catheter care, she said yes. When asked what the expectation is for putting in the order, the DON said it should be immediately. When asked who would put the order in, she said the admitting nurse.

Based on observations, interviews and record review, the facility failed to assess the safety of smoking for 1 of 1 resident reviewed for smoking (Resident #37). The findings included: A review of the facility's policy titled, Resident Smoking, dated 09/01/23, revealed the following: The facility provides a safer and healthier environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Residents who smoke will be further evaluated using the Resident Smoking Safety Screen to determine whether supervision is required for smoking or if the resident is safe to smoke at all. In an interview conducted on 06/24/24 at 11:00 AM, Resident #37 stated that he smokes about 1-3 cigarettes a day. The facility has its own smoking schedule, and smoking is in the back patio near the dining room. When asked about the smoking supplies, Resident #37 reported that they were located in the nurse's station in a locked box. A record review showed Resident #37 was admitted on [DATE] with diagnoses of major depressive disorder, hyperlipidemia, and hypertension. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #37 with a Brief Interview of Mental Status Score (BIMS) score of 15, which indicates he is cognitively intact. A review of the quarterly nursing evaluation dated 03/15/24, under section F1, revealed that Resident #37 was smoking. The Care plan initiated on 03/12/24 revealed the following: Resident #37 smokes cigarettes and will safely use tobacco products in designated areas through the following review. Smoking assessment on admission, quarterly and as indicated. In an interview conducted on 06/25/24 at 1:30 PM, Resident #37 stated that he smokes every day and has been smoking for the last few months in the facility. In an interview conducted on 06/25/24 at 1:39 PM with Staff D, Certified Nursing Assistant (CNA), reported that Resident #37 smokes every day and that he has been smoking for months in the facility. A review of the Smoking Safety Screen showed that a safety smoking screen was completed for the first time on 06/24/24 for Resident #37. In an interview conducted by Staff E, a Licensed Practical Nurse (LPN) she stated they do a smoking assessment on admission and will then complete a quarterly evaluation as well. The smoking assessment is titled, Smoking Safety Screen and is located under the assessment tab in the electronic system. Staff E further said that the admission and readmission nursing evaluation will determine whether the resident smokes. When asked if a Smoking Safety Screen was completed on Resident #37 before 06/24/24, she said no. A review of the admission/readmission nursing evaluation dated 04/25/22, under section F1, revealed that Resident #37 was not smoking. In an interview conducted on 06/27/24 at 10:30 AM with the Administrator, she was told of the findings.

Based on observations, interviews, record reviews, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance (QA) Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the POC for deficient practice identified during a recertification survey conducted on 11/15/2022, and a comparative survey conducted on 12/15/2022. The facility was cited during the recertification survey for F656, and F684. The facility was cited during the comparative survey for F644, F656, F658, F842, and F880. On 2/02/2022 a revisit survey was conducted and the facility was recited at F644, F656, F658, F684, F842, and F880. The facility had developed a Plan of Correction with a completion date by 01/15/2023. The facility had not comprehensively implemented the Plan of Correction for the identified quality deficiencies. Findings Included: 1) A review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses, including but not limited to, cerebral infarction, muscle weakness, abnormalities of gait and mobility, dementia, vitamin D deficiency, protein calorie malnutrition, and lack of coordination. On 6/04/2022 Resident #2 was hospitalized after a fall at the facility and diagnosed with a right femur fracture, and cognitive communication deficit. On 11/03/2022 Resident #2 was sent to the hospital for swelling and edema to the right lower leg and was diagnosed with a right tibial fracture. The resident did not return to the facility. A review of the Order Summary Report revealed orders dated 6/09/2022 as: Activity: Up as tolerated unless otherwise specified, and May use assistive devices (pillow/wedge cushion/positioner) for positioning. Device in use direction. A review of the Minimum Data Set (MDS) quarterly assessment completed on 9/15/2022, revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 03, indicating severe cognitive impairment. A review of Section G: Functional Status indicated Resident #2 required extensive assistance (resident involved in activity, staff provide weight-bearing support), by two+ persons for physical assistance during transfers. Resident #2 was assessed to require total dependence with the support of two+ persons for physical assistance during bathing. A review of the Comprehensive Care Plan revealed a focus area as follows: Resident #2 has an ADL (activates of daily living) self-care performance deficit related to weakness (Initiated on 6/27/2022). Goal: Resident #2 will maintain current level of function through the review date. Interventions/Tasks: the resident requires total assistance by 2 via mechanical total lift staff to transfer between surfaces. A review of the October 2022 nursing task documentation for Resident #2 indicated the following: ADL (Activities of Daily Living) bathing Monday and Thursday 7-3 shift documented as 4,2 (Total Dependence, One-person physical assist) six times, 3,2 (Physical help in part of bathing activity, One-person physical assist) one time, 0,2 (Independent, One-person physical assist) one time, and RR (resident refused) one time. ADL Transferring for day shift documented as 4,3 (Total Dependence, Two-person physical assist) 24 times, 3,2 (Extensive assist, One-person physical assist) four times, and 2,2 (Limited assistance, One-person physical assist) one time. A review of the November 2022 nursing task documentation for Resident #2 indicated the following: ADL bathing Monday and Thursday 7-3 shift revealed no documentation for the task on 11/3/2022. ADL Transferring for day shift documented as 2,2 (Limited assistance, One-person physical assist) on 11/1/2022, and 4,2 (Total Dependence, One person physical assist) on 11/2/2023. No documentation for the task was noted for 11/3/2023. A review of the progress notes revealed the following documentation: 11/2/22 2300: PT [Physical Therapist] notified nurse that right leg appears shorter than left leg and that right foot is externally rotated. PT educated that pillow was propped on right side of right foot and should be positioned that way. Pillow in place. No signs of distress noted. Scheduled pain med's administered. S/P [status post] 1 hour pain pill in effect. Call light within reach. Res [Resident] is able to make needs known. Will continue to monitor. This was a Late entry note created on 11/5/2022 at 1:50:19 A review of a SBAR (situation, background, assessment, response) Communication Form dated 11/03/2022 revealed the following documentation: Pain evaluation: resident has new pain to right lower leg in the front. Resident showing non-verbal signs of pain described; Repeated troubled calling out loud moaning or groaning, Crying, Sad/frightened/frown, Tense, Distressed pacing, Fidgeting, Distracted or reassured by voice or touch. Transfer to ER [emergency room ] for further evaluation. On 2/1/22 at 4:36 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA stated she was notified by the DON of Resident #2 being diagnosed with a right tibial fracture on 11/3/2022. She stated the nurse caring for the resident had reported to the DON the resident went to the hospital for edema and redness to the right lower extremity. The NHA stated the first sign of edema and redness noticed by the nursing staff occurred on 11/3/23 when the resident complained of pain. The DON stated there was no indication of a problem with the right leg for Resident #2 prior to 11/3/23. The NHA stated the nurse was notified by an aide about pain and swelling to the right lower leg after the morning shower at 8:30 a.m. on 11/3/23. The DON stated the nurse gave the resident some pain medication at the time and did not notice any problems with the leg that seemed urgent. The DON stated later in the day, the nurse noticed a discoloration to the lower leg, and the leg was warm to the touch, so the nurse immediately notified the doctor and sent the resident out to the hospital around 1:00 p.m. on 11/3/23. The NHA stated she was not sure of what had caused the injury but she believed the fracture was pathological and any sudden movements could have caused a break due to the resident's condition. The NHA stated the resident had gone to meals during the day of the incident and had no complaints of pain during that time. The NHA stated the resident had all of her normal activities that day. The DON stated Resident #2 was a Hoyer lift for all transfers at the time of the incident. The DON stated the resident always had some pain every day so it was not unusual for her to complain of pain and the resident was getting a routine medication for pain. The DON stated the resident was in pain when she went out and confirmed the type of pain described was not like every day pain Resident #2 usually had. The NHA stated they did competencies related to proper use of the Hoyer lift, abuse, and neglect training, and how to assure staff are following the care plan and Kardex related to transfers and lifts. The NHA stated she never felt there was any abuse/neglect or a fall associated with the injury. She stated she felt it was the Resident's condition that was the root cause of the injury. On 2/2/23 at 11:25 a.m. an interview was conducted with the MDS Coordinator. She stated she recalled the incident with Resident #2 on 11/3/23. She stated she was asked by Staff N, Registered Nurse (RN) to take a look at Resident #2's leg due to some swelling. She stated when she went into the room she observed the resident's right lower leg to be swollen, warm to touch, and red with a purplish-blue color starting to appear. She stated she thought the resident could possibly have a blood clot and she told the nurse to call the doctor to inform him. She stated Staff N, RN and Staff Q, RN were caring for the resident at the time. On 2/2/23 at 12:25 p.m. a telephone interview was conducted with Staff R, CNA (Certified Nursing Assistant). Staff R confirmed she was providing care for Resident #2 on 11/3/23 on the day shift (7am to 3pm). She stated she had taken care of the resident a few times a week on a regular basis. She stated Resident #2 required total care and required the use of a Hoyer lift for all transfers. She stated Resident #2 previously had a brace on her right leg, but therapy said it was fine to have it off and she did not wear it anymore. She stated after breakfast on 11/3/23 she gave Resident #2 a shower. Staff R, CNA stated a Hoyer pad was under the resident in her wheelchair so she put the resident into the shower chair and undressed her and gave her a shower. She stated she noticed her right leg was swollen and the resident was complaining of pain in her leg during the shower. She stated when she finished the shower she dressed Resident #2 and put her back in the wheelchair. She stated she was the only one using the Hoyer lift to transfer the resident because she could not find anyone to help her, so I did it by myself. She stated she was the only staff member in the shower room with Resident #2 during the shower. She stated she notified the nurse because the leg looked extra swollen and the resident was complaining of a lot of pain. She stated she had another aide help get the resident back in bed and she elevated the leg and sent the nurse in to see the resident. She stated the leg was pinkish/purple and very swollen and Resident #2 was in pain. She stated Resident #2 was yelling in pain. She stated the pain Resident #2 was exhibiting was much more than usual. She stated the resident did go to breakfast and lunch during the day. She stated Resident #2 had never complained of that intense of pain before. Staff R stated she had given a statement to the DON and NHA. On 2/2/23 at 12:45 p.m. a telephone interview was conducted with Staff Q, RN. Staff Q stated he was familiar with Resident #2. He stated the resident was located in the area he was assigned and he had a lot of contact with the resident. Staff Q, RN stated Resident #2 had dementia and a very involved family. He stated the family wanted the resident to participate in activities and be out of the bed as much as possible especially or meals. The RN stated Resident #2 required extensive to total assistance for all ADL's. He stated the resident required a Hoyer lift for transfers. The nurse stated the aides did most of the transfers and they would close the doors during the transfers. Staff Q, RN stated he was caring for Resident #2 on 11/3/23 when the incident occurred. He stated early in the morning the resident was taken to the shower by an aide. He stated after the shower Resident #2 was laid down and he was informed the resident was complaining of pain to her right lower leg. Staff Q stated he assessed the resident and noted some swelling with some discoloration to the leg. He stated he provided pain medication and notified the doctor about the swelling and the resident was transferred to the hospital for evaluation. He stated he was notified by the hospital the resident had a fracture and he notified the DON, the doctor, and the family. Staff Q stated he was not notified of any fall or accident by anyone. On 2/2/23 at 1:00 p.m. a telephone interview was conducted with Staff S, CNA. Staff S verified she was the aide caring for Resident #2 on the night shift of 11/3/23 (11p to 7a). She stated she did not recall any complaints from Resident #2 during the night about pain in her leg. She stated she provided care and did not notice any swelling in her right leg while performing incontinence care. On 2/2/23 at 1:30 p.m. a telephone interview was conducted with Staff T, Physical Therapist (PT). Staff T stated he saw Resident #2 on the afternoon of 11/2/23 for therapy. He stated the resident was having discomfort in her right leg so she did not want to get out of bed. He stated he noticed the right leg was in external rotation with a pillow underneath. He stated he repositioned the leg and informed the nurse on how to position the leg in the future. He stated the resident had normal swelling due to the previous fracture and he did not notice any other problems with the leg. On 2/2/23 at 1:45 p.m. a telephone interview was conducted with the Primary Care Physician (PCP). The PCP stated the resident had dementia and she had a previous fracture to the right femur. The PCP stated there was a question about how the new fracture occurred and he thought it was probably associated with her bone density condition. He stated he could not recall what was said related to the 11/22 fracture. He stated he was notified but he did not have a recollection of what happened. He stated he knew there was new education and training done at the facility after the incident. A review of the policy titled Comprehensive Care Plans, implemented 9/7/22, indicated the following: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. .8. Qualified staff responsible for carrying out interventions specified in the car plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. A review of the policy titled Accidents and Supervision, implemented 9/7/22, indicated the following: Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazards and risks 2. Evaluating and analyzing hazards and risks 3. Implementing interventions to reduce hazards and risks 4. Monitoring for effectiveness and modifying interventions when necessary. Policy Explanations and Compliance Guidelines: The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. .3. Implementation of interventions-using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff b. Assigning responsibility c. Providing training as needed d. Documenting interventions e. Ensuring the interventions are put into action .i. Resident-directed approaches may include: i. Implementing specific interventions as part of the plan of care ii. Supervising staff and residents, etc. iii. Facility records document the implementation of these interventions A review of the policy titled Safe Resident Handling/Transfers, implemented 10/3/22, indicated the following: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. .Compliance Guidelines: 1. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. .3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting excepts in medical emergencies. .10. Two staff members must be utilized when transferring residents with a mechanical lift. 11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually, and as the need arises or changes in equipment occur. 12. The staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. 13. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. 14. Resident lifting and transferring will be performed according to the resident's individual plan of care. On 1/31/2023 at 9:00 a.m. surveyors entered the facility to conduct a revisit survey. A sign was visible at the front entrance which stated mask use was required in the facility due to community transmission rate being high. Surgical masks were available at the front desk to don prior to entrance into the care areas. During the entrance conference it was determined there were two active cases of COVID-19 in the facility. A facility tour was conducted on 1/31/2023 starting at 10:25 a.m. All hallways, common areas, resident room areas, and nursing areas were toured. There were a large number of rooms noted to be on Enhanced Barrier Precautions with caddy's on the doors and Personal Protective Equipment (PPE) supplies available. The signage indicated what PPE needed to be worn upon entry into the room. room [ROOM NUMBER] was noted to be on Droplet Precautions and the door was closed. A caddy and PPE supplies were hanging on the door. room [ROOM NUMBER] was noted to be on Contact Precautions and a caddy with signage and PPE was on the door. A list of rooms on isolation and the reason for isolation was requested from the facility. At 10:45 a.m. Resident #9 was observed seated in a wheelchair in the hallway directly across from the nursing station. A Foley catheter tubing was observed coming out of his shorts and the catheter tubing was hanging on the ground wrapped around the wheel of the wheelchair. The catheter tubing was not secured to his leg. The tubing was visible with urine noted and the catheter tube itself was visible coming out of his shorts. The catheter bag was visible with urine and was touching the floor. Several staff members and residents were present in the area and the Foley could be seen by anyone in the area. The resident was able to state his name but could not answer any other questions when asked. An interview was conducted with Staff A, Licensed Practical Nurse (LPN), at the time of the observation. Staff A, LPN was observed to be at the nurse's station and wearing a surgical mask with her nose exposed. The nurse stated the resident should not have the tubing and bag touching the floor and the catheter should be secured to the leg so that it could not be dislocated if pulled easily. The nurse stated she would take care of the situation. Staff B, Certified Nurse Aide (CNA), came over to assist the resident back to his room to correct the situation. Staff B, CNA was observed standing behind the resident wheelchair with her surgical mask exposing her nose. She stated the resident should have a privacy bag with tubing secured and not able to touch the ground when he is out of bed in the wheelchair. She stated she was taking the resident to his room to fix the situation. At 10:55 a.m. Resident #7 was observed seated in a wheelchair in the hallway directly across from the nursing station. A Foley bag and tubing were observed hanging under his wheelchair and touching the ground. Staff B, CNA stated both residents were going to be taken back to the room to fix the Foley catheters by putting them into a privacy bag and making sure the catheters could not touch the ground. At 10:59 a.m. an interview was conducted with Staff C, CNA, in the hallway. Staff C, CNA was observed to be wearing a surgical mask with her nose exposed. The aide stated she had infection control training and COVID exposure training and stated this was done recently for all the staff since November of 2022. A review of the medical record indicated Resident #9 was admitted to the facility with diagnoses, including but not limited to, metabolic encephalopathy, convulsions, Parkinson's, dementia, and Cerebral Vascular Accident (CVA). A review of the order summary for Resident #9 indicated the following active orders for February 2023: Anchor Foley catheter to prevent excessive tension and facilitate flow of urine every shift; Change Foley catheter bag as needed or with signs/symptoms of infection, after urine specimen obtained; Foley Catheter care with soap and water every shift and as needed; Foley catheter size 16 FR 10 milliliter balloon; May change Foley catheter every 28 days and as needed for leakage or blockage; Privacy bag for drainage bag at all times while in bed, while walking, or in wheelchair every shift. A review of the Minimum Data Set (MDS) for Resident #9, dated 1/31/23, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 03, indicating severe cognitive impairment. A review of the Comprehensive Care Plan for Resident #9, dated 1/25/2023, revealed the following: Focus Area: Urinary Catheterization Care Plan Goal: The resident will be/remain free from catheter-related trauma through review date. Interventions included: Provide catheter care to prevent UTI (urinary tract infection); Provide privacy bag to drainage bag at all times. A review of the medical record indicated Resident #7 was admitted to the facility with diagnosis, including but not limited to, obstructive and reflux uropathy, colostomy, abdominal distension, and toxic megacolon. A review of the order summary for Resident #7 indicated the following active orders for February 2023: Anchor Foley catheter to prevent excessive tension and facilitate flow of urine every shift; Change Foley catheter bag as needed for leakage; Change Foley catheter bag every night shift every 14 days for urinary retention; Foley Catheter care with soap and water every shift and as needed; Monitor and secure catheter to prevent pulling, position catheter below bladder, cover with dignity bag, position away from view if urine visible in bag every shift; Privacy bag for drainage bag at all times while in bed, while walking, or in wheelchair every shift. A review of the Minimum Data Set (MDS) for Resident #7, dated 12/19/22, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 00, indicating the resident was rarely or never understood and a score could not be obtained. A review of the Comprehensive Care Plan for Resident #7, dated 5/31/218 and revised on 10/30/2022, revealed the following: Focus Area: Urinary Catheterization Care Plan; Urinary catheter related to Neurogenic bladder Goal: The resident will show no signs and symptoms of urinary infection through review date. Interventions included: Provide catheter care to prevent UTI (urinary tract infection); Provide privacy bag to drainage bag at all times. An interview was conducted on 2/1/23 at 10:41 a.m. with Staff K, LPN Infection Control Nurse (ICN). Staff K stated she had been in the ICN role since November 2022 and had taken the Infection Control training courses to assume the role. Staff K indicated she was responsible for all of the infection control training for the staff in the facility. The ICN stated in-service education had been completed for all staff related to the use of masks during high transmission rates in December 2022. Staff K stated Infection Control is part of the Quality Assurance and Performance Improvement (QAPI) process currently and a meeting is held monthly to review progress. She stated audits for the proper use of masks had been completed and the audits are still continuing once a week. The ICN indicated the only time she had seen staff not wearing masks properly was when they were coming out of the break room. Staff K stated, I guess I'm not surprised to see that some of the staff have not had their masks on properly but they were all trained. A review of the policy titled Catheter Care, implemented 9/7/2022, indicated the following: Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: .9. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine and off the floor. A review of the policy titled Infection Prevention and Control Program, implemented 8/25/2022 and revised 1/6/2023, indicated the following: Policy: this facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 2. All staff are responsible for following all policies and procedures related to the program. .12. Resident/Family/Visitor Education and Screening: .d. Passive screening, such as signs, are posted in the facility to alert family members and visitors to adhere to handwashing, respiratory etiquette, and other infection control principles to limit spread of infection from family members and visitors. .15. Staff Education: a. All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function. b. All staff shall demonstrate competence in relevant infection control practices. c. direct care staff shall demonstrate competence in resident care procedures established by out facility. A review of the policy titled Coronavirus Prevention and Response, implemented 9/26/22 and revised on 9/29/2022, indicated the following: Policy: This facility will respond promptly upon suspicion of illness associated with a SARS-CoV-2 infection in efforts to identify, treat, and prevent the spread of the virus. Policy Explanation and Compliance Guidelines: .3. The use of select infection prevention and control (IFC) measures (e.g., use of source control, screening, testing of admissions) are influenced by levels of SAR-CoV-2 transmission in the community and will be utilized to determine appropriate IPC measures. .9. Source control measures include: .e. When SARS-CoV-2 community transmission levels are high, source control is recommended for everyone in the healthcare setting when they are in areas of the facility where they could encounter residents. A review the facility policy titled QAPI with QA and Risk Management Program, implemented on 9/7/2022, indicated the following: Policy/Plan: Center should implement a specific Quality Assurance and Risk Management Program that includes collecting data under a written QAPI plan to coordinate and evaluate activities under the QAPI program meeting including the development of Performance Improvement Projects (PIPs) under the QAPI plan if necessary. Purpose: To provide a structured process by which customer care and organizational functions are continually and systematically reviewed in the context of a quality improvement model. In so doing, organizational compliance with regulatory requirements and professional standards of care should be enhanced and the achievement of Center goals and objectives realized, thereby providing the foundation for positive Customer outcomes. Process: .2. Performance is measured through data collection which yields information about the stability of existing processes, opportunities for improvement, changes that should lead to improvement and sustaining improvement. 2.1 Suggested priorities for AW monitoring are established based on but not limited to: .2.1.2 Regulatory requirements; 2.1.3 Deficiencies cited by regulatory agencies; 37999 2) The following observations were made of staff members wearing surgical masks inappropriately: - On 1/31/23 at 11:09 a.m., identified Staff D, Housekeeper, standing in the entrance to room [ROOM NUMBER] with a surgical mask below the chin. - On 1/31/23 at 11:42 a.m., observed Staff I, Personal Care Assistant (PCA) enter the kitchen from the dining room wearing surgical mask below the nose. The staff member left the kitchen and returned a moment later continuing to wear surgical mask below the nose. - Staff H, Hospice Certified Nursing Assistant (CNA) was observed, on 1/31/23 at 12:05 p.m., standing in the middle hallway of the East wing. The staff member was wearing a surgical mask below the chin as she looked into the units shower room. A few moments later Staff H was observed at the end of the north hallway speaking with a resident with the surgical mask below the nose and propelled the resident from that area toward the nursing station with the mask below the chin. - On 1/31/23 at 12:07 p.m., Staff F, CNA, was observed wearing surgical mask below the nose as passing out lunch trays to residents. - On 1/31/23 at 12:07 p.m., Staff C, CNA was observed entering room [ROOM NUMBER] with a lunch tray while wearing surgical mask below nose. - During the passing of lunch trays on 1/31/23 at 12:09 p.m., Staff C, CNA, was observed removing a tray from the meal cart and enter room [ROOM NUMBER] wearing a surgical mask below the nose. The staff member continued to observed as leaving the room, at 12:13 p.m. on 1/31/23 to be wearing the mask below the nose. - On 1/31/23 at 12:28 p.m., Staff C and Staff G, agency Licensed Practical Nurse (LPN), were observed behind the West wing nursing station wearing surgical masks below their noses. - On 2/1/23 at 7:45 a.m., Staff J, agency LPN was observed sitting behind the West wing nursing station without a mask. The staff member reported working at the facility frequently. - Staff M, CNA, was observed, on 2/1/23 at 9:03 a.m., passing water cups to room [ROOM NUMBER] while wearing a surgical mask below nose. - On 2/1/23 at 11:13 a.m., Staff E, CNA, was standing at the East wing nursing station speaking with Staff O while wearing surgical mask below nose. An interview was conducted on 1/31/23 at 4:13 p.m., with Staff L, CNA. The staff member stated the blue door caddies were just to hold supplies (Personal Protective Equipment, PPE) and the yellow door caddies were for (residents with) COVID. On 2/1/23 at 9:05 a.m., Staff N, Registered Nurse (RN) reported not knowing why residents were on Enhanced Precautions. The staff member stated just to prevent the spread of anything. On 2/1/23 at 7:35 a.m., an observation was made of Resident #16 sitting on the front porch of the facility. The resident was sitting in a wheelchair, wearing oxygen in nares, wearing a non-slip sock on left foot, and the right foot was wrapped with rolled gauze. Resident #16 reported being on the way to an appointment to have fluid removed from abdomen. The rolled gauze was stained a tan-brown color, the end of the gauze was unattached approximately 6 inches, colored a wet-looking brown color and lying on the ground. The resident confirmed there was a wound (underneath the gauze) and reported asking for the dressing to be changed but they're having a hard time in there today. The Staffing Coordinator and Staff B, Certified Nursing Assistant (CNA) arrived to the area and the Coordinator asked for the resident to wear a sock on the right foot. Resident #16 reported not wanting to wear a sock because it drained so much and was so big. An unknown staff member arrived and the resident allowed a large royal blue sock to be placed over the stained dressing. The coordinator and unknown staff [TRUNCATED]

Based on observations, record reviews, and interviews, the facility failed 1) to maintain the ceiling in a safe and sanitary manner in one of one kitchen observed and, 2) failed to store food in accordance with professional standards, related to storing opened food without a date, in the kitchen and in one of two nourishment refrigerators. Findings included: An initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM) on 11/07/22 at 10:30 a.m. A hole was observed in the ceiling near the dish washing area with exposed wires. The CDM stated that's where they removed the ceiling fan from. An opened bag of grits was observed next to the stove without an opened date. This was confirmed by the CDM, and she immediately labeled the opened bag of grits. The refrigerator in the nourishment room on the east wing was observed to contained an opened gallon of ice cream undated and an opened bag of chicken nuggets without an opened date. The CDM immediately discarded the items. She reported the nursing staff were responsible for labeling and dating foods in the nourishment refrigerators. The policy provided by the facility Nourishment Refrigerator/Freezer Storage with a revised date of 10/29/22 revealed the following: Policy Explanation and Compliance Guidelines: 2. All items should be dated with date of storage. 4. Follow manufacturer's guidelines for unopened times in their original packaging using Use-By date. 6. Food from outside sources for residents must be labeled with the resident's name, date item placed and a Use-By date. Monitor for freshness.

3) A review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of dementia, anxiety disorder, and major depressive disorder. Resident #4's medical record also revealed a diagnosis of impulse disorder added on 9/26/2022 and a diagnosis of unspecified mood disorder added on 10/20/2022. A review of Resident #4's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/6/2022 revealed, under Section I - Active Diagnoses, Resident #4 had diagnoses of Non-Alzheimer's dementia, anxiety disorder, depression, unspecified mood disorder, and impulse disorder. A review of Resident #4's PASARR assessment, dated 8/25/2022 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections Anxiety Disorder, Depressive Disorder, and Other (specify), were not checked. A review of Resident #12's medical record revealed Resident #12 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction. Resident #12's medical record also revealed a diagnosis of dementia added on 6/7/2019 and a diagnosis of major depressive disorder added on 6/18/2020. A review of Resident #12's Quarterly MDS assessment, with an ARD of 1/4/2023 revealed, under Section I - Active Diagnoses, Resident #12 had diagnoses of Non-Alzheimer's dementia and depression. A review of Resident #12's PASARR assessment, dated 5/24/2020 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selection Depressive Disorder was not checked. An interview was conducted on 2/2/2023 at 10:27 AM with the facility's Director of Nursing (DON). The DON stated the facility's MDS Coordinator revised PASARR assessments to ensure residents PASARR assessments had the appropriate diagnoses on them. An interview was conducted on 2/2/2023 at 10:46 AM with the facility's MDS Coordinator. The MDS Coordinator stated an audit was conducted to ensure residents with diagnoses of schizophrenia and schizoaffective disorder had their PASARR assessments revised due to them possibly requiring a level II screening. Other MI or suspected MI on the PASARR assessments were not identified and the PASARR assessments were not updated to include them. The MDS Coordinator was not able to state why Resident #4 and Resident #12's PASARR assessments were not revised. An interview was conducted on 2/2/2023 at 11:12 AM with the facilities Social Services Director (SSD). The SSD stated he was tasked with identifying any new diagnoses in the facility residents that may be considered for a level II PASARR screening and was not tasked with ensuring the accuracy of the PASARR assessments. A review of the facility policy titled Resident Assessment - Coordination with PASARR Program, last revised on 1/6/2023, revealed under the section titled Policy, The facility coordinates assessments with preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines, any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II review. Examples include: - A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder. - A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. A review of Resident #19's medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, abnormalities of gait and mobility, dementia, and fall from one level to another. A review of Resident #19's physician's orders revealed an order, dated 6/22/2022, for a floor mat to the resident's bedside with a bedside commode on top of the mat, verify every shift. An observation was conducted 2/1/2023 at 1:47 PM in Resident #19's room. Resident #19 was observed resting in bed with a floor mat on the right side of the bed. A bedside commode was not observed on Resident #19's floor mat or anywhere in the resident's room. An observation was conducted 2/2/2023 at 9:47 AM in Resident #19's room. Resident #19 was observed resting in bed with a floor mat on the right side of the bed. A bedside commode was not observed on Resident #19's floor mat or anywhere in the resident's room. During the observation, Staff M, Certified Nursing Assistant (CNA) entered Resident #19's room. Staff M, CNA stated Resident #19 no longer used a bedside commode and had not used one for a long time because the resident required a mechanical lift for her transfers. An interview was conducted on 2/2/2023 at 9:55 AM with Staff O, Licensed Practical Nurse (LPN). Staff O, LPN observed Resident #19's order for a floor mat with a bedside commode on top of it and stated it was signed off as completed by the nurse every shift to verify the presence of the mat and the bedside commode. Staff O, LPN also stated if they did not observe the bedside commode on the mat in the resident's room, the order should not be signed off as completed. Staff O, LPN stated she did not receive education related to documentation in the medical record and she had only been working in the facility for a couple of weeks. A review of Resident #19's Medication Administration Record (MAR) revealed an order, dated 6/22/2022, for a floor mat to the resident's bedside with a bedside commode on top of the mat, verify every shift The order was signed off as verified on 2/1/2023 for the 7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM shifts and on 2/2/2023 for the 7 AM to 3 PM shift. An interview was conducted on 2/2/2023 at 10:27 AM with the facility's Director of Nursing (DON). The DON stated Resident #19 no longer used a bedside commode and had not used a bedside commode for several months due to a decline in the resident's abilities. The DON addressed Resident #19 had a physician's order for a bedside commode and verified the order was being marked as completed by the nursing staff. The DON stated the order should have been revised once the resident was no longer using the bedside commode and nursing staff should not be signing off on the MAR if they did not actually verify the bedside commode was in place. The DON was not able to state how new employees were being educated related to the accuracy and documentation in the medical record. A review of the facility policy titled Documentation in Medical Record, last revised 12/1/2022 revealed under the section titled Policy, each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. An interview was conducted on 2/2/2023 with the facility's Nursing Home Administrator (NHA) and Regional Director of Clinical Services (RDCS). The RDCS stated the facility did not review resident PASARR assessments for accuracy when they developed their plan of corrections for the previously cited F644 and the NHA stated they were only looking at residents who had diagnoses of schizophrenia or schizzoaffective disorder. The NHA also stated staff members should not be signing off on a treatment in the medical record they are not performing and an order should be discontinued if it is no longer needed. Based on observations, interviews, record reviews, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance (QA) Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the POC for deficient practice identified during a recertification survey conducted on 11/15/2022, and a comparative survey conducted on 12/15/2022. The facility was cited during the recertification survey for F656, and F684. The facility was cited during the comparative survey for F644, F656, F658, F842, and F880. On 2/02/2022 a revisit survey was conducted and the facility was recited at F644, F656, F658, F684, F842, and F880. The facility had developed a Plan of Correction with a completion date by 01/15/2023. The facility had not comprehensively implemented the Plan of Correction for the identified quality deficiencies. Findings Included: 1) A review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses, including but not limited to, cerebral infarction, muscle weakness, abnormalities of gait and mobility, dementia, vitamin D deficiency, protein calorie malnutrition, and lack of coordination. On 6/04/2022 Resident #2 was hospitalized after a fall at the facility and diagnosed with a right femur fracture, and cognitive communication deficit. On 11/03/2022 Resident #2 was sent to the hospital for swelling and edema to the right lower leg and was diagnosed with a right tibial fracture. The resident did not return to the facility. A review of the Order Summary Report revealed orders dated 6/09/2022 as: Activity: Up as tolerated unless otherwise specified, and May use assistive devices (pillow/wedge cushion/positioner) for positioning. Device in use direction. A review of the Minimum Data Set (MDS) quarterly assessment completed on 9/15/2022, revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 03, indicating severe cognitive impairment. A review of Section G: Functional Status indicated Resident #2 required extensive assistance (resident involved in activity, staff provide weight-bearing support), by two+ persons for physical assistance during transfers. Resident #2 was assessed to require total dependence with the support of two+ persons for physical assistance during bathing. A review of the Comprehensive Care Plan revealed a focus area as follows: Resident #2 has an ADL (activates of daily living) self-care performance deficit related to weakness (Initiated on 6/27/2022). Goal: Resident #2 will maintain current level of function through the review date. Interventions/Tasks: the resident requires total assistance by 2 via mechanical total lift staff to transfer between surfaces. A review of the October 2022 nursing task documentation for Resident #2 indicated the following: ADL (Activities of Daily Living) bathing Monday and Thursday 7-3 shift documented as 4,2 (Total Dependence, One-person physical assist) six times, 3,2 (Physical help in part of bathing activity, One-person physical assist) one time, 0,2 (Independent, One-person physical assist) one time, and RR (resident refused) one time. ADL Transferring for day shift documented as 4,3 (Total Dependence, Two-person physical assist) 24 times, 3,2 (Extensive assist, One-person physical assist) four times, and 2,2 (Limited assistance, One-person physical assist) one time. A review of the November 2022 nursing task documentation for Resident #2 indicated the following: ADL bathing Monday and Thursday 7-3 shift revealed no documentation for the task on 11/3/2022. ADL Transferring for day shift documented as 2,2 (Limited assistance, One-person physical assist) on 11/1/2022, and 4,2 (Total Dependence, One person physical assist) on 11/2/2023. No documentation for the task was noted for 11/3/2023. A review of the progress notes revealed the following documentation: 11/2/22 2300: PT [Physical Therapist] notified nurse that right leg appears shorter than left leg and that right foot is externally rotated. PT educated that pillow was propped on right side of right foot and should be positioned that way. Pillow in place. No signs of distress noted. Scheduled pain med's administered. S/P [status post] 1 hour pain pill in effect. Call light within reach. Res [Resident] is able to make needs known. Will continue to monitor. This was a Late entry note created on 11/5/2022 at 1:50:19 A review of a SBAR (situation, background, assessment, response) Communication Form dated 11/03/2022 revealed the following documentation: Pain evaluation: resident has new pain to right lower leg in the front. Resident showing non-verbal signs of pain described; Repeated troubled calling out loud moaning or groaning, Crying, Sad/frightened/frown, Tense, Distressed pacing, Fidgeting, Distracted or reassured by voice or touch. Transfer to ER [Emergency Room] for further evaluation. On 2/1/22 at 4:36 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA stated she was notified by the DON of Resident #2 being diagnosed with a right tibial fracture on 11/3/2022. She stated the nurse caring for the resident had reported to the DON the resident went to the hospital for edema and redness to the right lower extremity. The NHA stated the first sign of edema and redness noticed by the nursing staff occurred on 11/3/23 when the resident complained of pain. The DON stated there was no indication of a problem with the right leg for Resident #2 prior to 11/3/23. The NHA stated the nurse was notified by an aide about pain and swelling to the right lower leg after the morning shower at 8:30 a.m. on 11/3/23. The DON stated the nurse gave the resident some pain medication at the time and did not notice any problems with the leg that seemed urgent. The DON stated later in the day, the nurse noticed a discoloration to the lower leg, and the leg was warm to the touch, so the nurse immediately notified the doctor and sent the resident out to the hospital around 1:00 p.m. on 11/3/23. The NHA stated she was not sure of what had caused the injury but she believed the fracture was pathological and any sudden movements could have caused a break due to the resident's condition. The NHA stated the resident had gone to meals during the day of the incident and had no complaints of pain during that time. The NHA stated the resident had all of her normal activities that day. The DON stated Resident #2 was a Hoyer lift for all transfers at the time of the incident. The DON stated the resident always had some pain every day so it was not unusual for her to complain of pain and the resident was getting a routine medication for pain. The DON stated the resident was in pain when she went out and confirmed the type of pain described was not like every day pain Resident #2 usually had. The NHA stated they did competencies related to proper use of the Hoyer lift, abuse, and neglect training, and how to assure staff are following the care plan and Kardex related to transfers and lifts. The NHA stated she never felt there was any abuse/neglect or a fall associated with the injury. She stated she felt it was the Resident's condition that was the root cause of the injury. On 2/2/23 at 11:25 a.m. an interview was conducted with the MDS Coordinator. She stated she recalled the incident with Resident #2 on 11/3/23. She stated she was asked by Staff N, Registered Nurse (RN) to take a look at Resident #2's leg due to some swelling. She stated when she went into the room she observed the resident's right lower leg to be swollen, warm to touch, and red with a purplish-blue color starting to appear. She stated she thought the resident could possibly have a blood clot and she told the nurse to call the doctor to inform him. She stated Staff N, RN and Staff Q, RN were caring for the resident at the time. On 2/2/23 at 12:25 p.m. a telephone interview was conducted with Staff R, CNA (Certified Nursing Assistant). Staff R confirmed she was providing care for Resident #2 on 11/3/23 on the day shift (7am to 3pm). She stated she had taken care of the resident a few times a week on a regular basis. She stated Resident #2 required total care and required the use of a Hoyer lift for all transfers. She stated Resident #2 previously had a brace on her right leg, but therapy said it was fine to have it off and she did not wear it anymore. She stated after breakfast on 11/3/23 she gave Resident #2 a shower. Staff R, CNA stated a Hoyer pad was under the resident in her wheelchair so she put the resident into the shower chair and undressed her and gave her a shower. She stated she noticed her right leg was swollen and the resident was complaining of pain in her leg during the shower. She stated when she finished the shower she dressed Resident #2 and put her back in the wheelchair. She stated she was the only one using the Hoyer lift to transfer the resident because she could not find anyone to help her, so I did it by myself. She stated she was the only staff member in the shower room with Resident #2 during the shower. She stated she notified the nurse because the leg looked extra swollen and the resident was complaining of a lot of pain. She stated she had another aide help get the resident back in bed and she elevated the leg and sent the nurse in to see the resident. She stated the leg was pinkish/purple and very swollen and Resident #2 was in pain. She stated Resident #2 was yelling in pain. She stated the pain Resident #2 was exhibiting was much more than usual. She stated the resident did go to breakfast and lunch during the day. She stated Resident #2 had never complained of that intense of pain before. Staff R stated she had given a statement to the DON and NHA. On 2/2/23 at 12:45 p.m. a telephone interview was conducted with Staff Q, RN. Staff Q stated he was familiar with Resident #2. He stated the resident was located in the area he was assigned and he had a lot of contact with the resident. Staff Q, RN stated Resident #2 had dementia and a very involved family. He stated the family wanted the resident to participate in activities and be out of the bed as much as possible especially or meals. The RN stated Resident #2 required extensive to total assistance for all ADL's. He stated the resident required a Hoyer lift for transfers. The nurse stated the aides did most of the transfers and they would close the doors during the transfers. Staff Q, RN stated he was caring for Resident #2 on 11/3/23 when the incident occurred. He stated early in the morning the resident was taken to the shower by an aide. He stated after the shower Resident #2 was laid down and he was informed the resident was complaining of pain to her right lower leg. Staff Q stated he assessed the resident and noted some swelling with some discoloration to the leg. He stated he provided pain medication and notified the doctor about the swelling and the resident was transferred to the hospital for evaluation. He stated he was notified by the hospital the resident had a fracture and he notified the DON, the doctor, and the family. Staff Q stated he was not notified of any fall or accident by anyone. On 2/2/23 at 1:00 p.m. a telephone interview was conducted with Staff S, CNA. Staff S verified she was the aide caring for Resident #2 on the night shift of 11/3/23 (11p to 7a). She stated she did not recall any complaints from Resident #2 during the night about pain in her leg. She stated she provided care and did not notice any swelling in her right leg while performing incontinence care. On 2/2/23 at 1:30 p.m. a telephone interview was conducted with Staff T, Physical Therapist (PT). Staff T stated he saw Resident #2 on the afternoon of 11/2/23 for therapy. He stated the resident was having discomfort in her right leg so she did not want to get out of bed. He stated he noticed the right leg was in external rotation with a pillow underneath. He stated he repositioned the leg and informed the nurse on how to position the leg in the future. He stated the resident had normal swelling due to the previous fracture and he did not notice any other problems with the leg. On 2/2/23 at 1:45 p.m. a telephone interview was conducted with the Primary Care Physician (PCP). The PCP stated the resident had dementia and she had a previous fracture to the right femur. The PCP stated there was a question about how the new fracture occurred and he thought it was probably associated with her bone density condition. He stated he could not recall what was said related to the 11/22 fracture. He stated he was notified but he did not have a recollection of what happened. He stated he knew there was new education and training done at the facility after the incident. A review of the policy titled Comprehensive Care Plans, implemented 9/7/22, indicated the following: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. .8. Qualified staff responsible for carrying out interventions specified in the car plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. A review of the policy titled Accidents and Supervision, implemented 9/7/22, indicated the following: Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazards and risks 2. Evaluating and analyzing hazards and risks 3. Implementing interventions to reduce hazards and risks 4. Monitoring for effectiveness and modifying interventions when necessary. Policy Explanations and Compliance Guidelines: The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. .3. Implementation of interventions-using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff b. Assigning responsibility c. Providing training as needed d. Documenting interventions e. Ensuring the interventions are put into action .i. Resident-directed approaches may include: i. Implementing specific interventions as part of the plan of care ii. Supervising staff and residents, etc. iii. Facility records document the implementation of these interventions A review of the policy titled Safe Resident Handling/Transfers, implemented 10/3/22, indicated the following: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. .Compliance Guidelines: 1. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. .3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting excepts in medical emergencies. .10. Two staff members must be utilized when transferring residents with a mechanical lift. 11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually, and as the need arises or changes in equipment occur. 12. The staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. 13. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. 14. Resident lifting and transferring will be performed according to the resident's individual plan of care. On 1/31/2023 at 9:00 a.m. surveyors entered the facility to conduct a revisit survey. A sign was visible at the front entrance which stated mask use was required in the facility due to community transmission rate being high. Surgical masks were available at the front desk to don prior to entrance into the care areas. During the entrance conference it was determined there were two active cases of COVID-19 in the facility. A facility tour was conducted on 1/31/2023 starting at 10:25 a.m. All hallways, common areas, resident room areas, and nursing areas were toured. There were a large number of rooms noted to be on Enhanced Barrier Precautions with caddy's on the doors and Personal Protective Equipment (PPE) supplies available. The signage indicated what PPE needed to be worn upon entry into the room. room [ROOM NUMBER] was noted to be on Droplet Precautions and the door was closed. A caddy and PPE supplies were hanging on the door. room [ROOM NUMBER] was noted to be on Contact Precautions and a caddy with signage and PPE was on the door. A list of rooms on isolation and the reason for isolation was requested from the facility. At 10:45 a.m. Resident #9 was observed seated in a wheelchair in the hallway directly across from the nursing station. A Foley catheter tubing was observed coming out of his shorts and the catheter tubing was hanging on the ground wrapped around the wheel of the wheelchair. The catheter tubing was not secured to his leg. The tubing was visible with urine noted and the catheter tube itself was visible coming out of his shorts. The catheter bag was visible with urine and was touching the floor. Several staff members and residents were present in the area and the Foley could be seen by anyone in the area. The resident was able to state his name but could not answer any other questions when asked. An interview was conducted with Staff A, Licensed Practical Nurse (LPN), at the time of the observation. Staff A, LPN was observed to be at the nurse's station and wearing a surgical mask with her nose exposed. The nurse stated the resident should not have the tubing and bag touching the floor and the catheter should be secured to the leg so that it could not be dislocated if pulled easily. The nurse stated she would take care of the situation. Staff B, Certified Nurse Aide (CNA), came over to assist the resident back to his room to correct the situation. Staff B, CNA was observed standing behind the resident wheelchair with her surgical mask exposing her nose. She stated the resident should have a privacy bag with tubing secured and not able to touch the ground when he is out of bed in the wheelchair. She stated she was taking the resident to his room to fix the situation. At 10:55 a.m. Resident #7 was observed seated in a wheelchair in the hallway directly across from the nursing station. A Foley bag and tubing were observed hanging under his wheelchair and touching the ground. Staff B, CNA stated both residents were going to be taken back to the room to fix the Foley catheters by putting them into a privacy bag and making sure the catheters could not touch the ground. At 10:59 a.m. an interview was conducted with Staff C, CNA, in the hallway. Staff C, CNA was observed to be wearing a surgical mask with her nose exposed. The aide stated she had infection control training and COVID exposure training and stated this was done recently for all the staff since November of 2022. A review of the medical record indicated Resident #9 was admitted to the facility with diagnoses, including but not limited to, metabolic encephalopathy, convulsions, Parkinson's, dementia, and Cerebral Vascular Accident (CVA). A review of the order summary for Resident #9 indicated the following active orders for February 2023: Anchor Foley catheter to prevent excessive tension and facilitate flow of urine every shift; Change Foley catheter bag as needed or with signs/symptoms of infection, after urine specimen obtained; Foley Catheter care with soap and water every shift and as needed; Foley catheter size 16 FR 10 milliliter balloon; May change Foley catheter every 28 days and as needed for leakage or blockage; Privacy bag for drainage bag at all times while in bed, while walking, or in wheelchair every shift. A review of the Minimum Data Set (MDS) for Resident #9, dated 1/31/23, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 03, indicating severe cognitive impairment. A review of the Comprehensive Care Plan for Resident #9, dated 1/25/2023, revealed the following: Focus Area: Urinary Catheterization Care Plan Goal: The resident will be/remain free from catheter-related trauma through review date. Interventions included: Provide catheter care to prevent UTI (urinary tract infection); Provide privacy bag to drainage bag at all times. A review of the medical record indicated Resident #7 was admitted to the facility with diagnosis, including but not limited to, obstructive and reflux uropathy, colostomy, abdominal distension, and toxic megacolon. A review of the order summary for Resident #7 indicated the following active orders for February 2023: Anchor Foley catheter to prevent excessive tension and facilitate flow of urine every shift; Change Foley catheter bag as needed for leakage; Change Foley catheter bag every night shift every 14 days for urinary retention; Foley Catheter care with soap and water every shift and as needed; Monitor and secure catheter to prevent pulling, position catheter below bladder, cover with dignity bag, position away from view if urine visible in bag every shift; Privacy bag for drainage bag at all times while in bed, while walking, or in wheelchair every shift. A review of the Minimum Data Set (MDS) for Resident #7, dated 12/19/22, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 00, indicating the resident was rarely or never understood and a score could not be obtained. A review of the Comprehensive Care Plan for Resident #7, dated 5/31/218 and revised on 10/30/2022, revealed the following: Focus Area: Urinary Catheterization Care Plan; Urinary catheter related to Neurogenic bladder Goal: The resident will show no signs and symptoms of urinary infection through review date. Interventions included: Provide catheter care to prevent UTI (urinary tract infection); Provide privacy bag to drainage bag at all times. An interview was conducted on 2/1/23 at 10:41 a.m. with Staff K, LPN Infection Control Nurse (ICN). Staff K stated she had been in the ICN role since November 2022 and had taken the Infection Control training courses to assume the role. Staff K indicated she was responsible for all of the infection control training for the staff in the facility. The ICN stated in-service education had been completed for all staff related to the use of masks during high transmission rates in December 2022. Staff K stated Infection Control is part of the Quality Assurance and Performance Improvement (QAPI) process currently and a meeting is held monthly to review progress. She stated audits for the proper use of masks had been completed and the audits are still continuing once a week. The ICN indicated the only time she had seen staff not wearing masks properly was when they were coming out of the break room. Staff K stated, I guess I'm not surprised to see that some of the staff have not had their masks on properly but they were all trained. A review of the policy titled Catheter Care, implemented 9/7/2022, indicated the following: Policy:

Based on observation, interview, and record review, the facility failed to ensure a resident centered care plan was developed and implemented related to two anti-depressant medications, for one resident (#55) of five residents sampled for unnecessary medications. Findings included: On 11/08/2022 at 3:39 p.m., Resident #55 was observed to be sleeping in bed with the television on. A second observation was conducted on 11/08/2022 at 4:44 p.m. of Resident #55 lying in bed watching television, smiling at the television screen, and dressed appropriately for the time of day. A medical record review for Resident #55 indicated she was originally admitted on [DATE] and readmitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, Resident #55 had a Brief Interview for Mental Status (BIMS) score was 10, indicating moderate cognitive impairment. A review of Physician Orders revealed Resident #55 had the following orders in place: -[MEDICATION(S)] capsule ([MEDICATION(S)]) 20 Milligrams (MG) One capsule taken orally in the morning for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Trazadone HCL Tablet 50 MG One tablet taken orally at bedtime for Major Depressive Disorder. A review of Resident #55's Care Plan, dated 10/08/2022, did not include a focus area for the prescribed anti-depressant medications; goals for use of the medications; or interventions for use of the medications to be followed by facility staff. On 11/08/2022 at 4:30 p.m. an interview was conducted with the Staff A, Registered Nurse (RN)/Minimum Data Set (MDS) Coordinator. Staff A confirmed Resident #55 did not have an updated care plan focus area, goals, and appropriate interventions for the anti-depressant medications. Staff A, (RN)/MDS Coordinator stated I see the resident (#55) had a new order (for [MEDICATION(S)]) on October 20, 2022, and the other medication (Trazadone) to be started on October 21, 2022. She stated, The care plan was revised on October 28, 2022, and should have been caught by me or someone else on the interdisciplinary team, and the care-plan updated, (for both medications). A review of the facility policy titled Care Plan Revisions Upon Status Change, with revision and implementation date 09/7/2022, Page 01 of 01 reads under Policy The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing a revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident's representative if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to a new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care.

Based on observations, interviews, and record reviews, the facility failed to 1)provide care and services in accordance with physician's orders and the plan of care for one resident (#271) of three residents sampled for nutrition services and, 2) failed to document an alteration in skin integrity for one resident (#32) of one resident sampled for skin impairments. Findings included: 1) A review of Resident #271's medical record revealed Resident #271 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #271's physician's orders revealed a dietary order, dated 10/20/2022, for a Nothing by Mouth (NPO) diet. A review of Resident #271's care plan revealed a problem, dated 10/21/2022, that Resident #271 was NPO and relied on tube feedings to meet 100% of estimated nutritional needs. A review of Resident #271's Progress Notes revealed a note, dated 10/25/2022 at 5:35 PM, documented by Staff G, Registered Nurse (RN) that read: Resident #271's Resident Representative (RR) observed Resident #271 eating a grilled cheese sandwich in his room and asked Staff G, RN if Resident #271's diet order had changed from NPO. Staff G, RN informed the RR that Resident #271's diet order had not changed and that the resident was still NPO. Staff G, RN then removed the food and a beverage cup from Resident #271's room. A telephone interview was attempted on 11/8/2022 at 9:24 AM with Staff G, RN. The telephone call was not answered and a voicemail message was left, but Staff G, RN did not return the call. A telephone interview was conducted on 11/8/2022 at 9:28 AM with Staff B, Certified Nursing Assistant (CNA). Staff B, CNA stated she was Resident #271's CNA on 10/25/2022 and it was the first time she had worked with the resident. Around 4:30 PM, while delivering dinner trays to the floor, Staff B, CNA went into Resident #271's room and noticed he did not have a dinner tray in his room. Staff B, CNA observed a beverage cup and a container of pudding in Resident #271's room and assumed Resident #271 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff B, CNA went to the kitchen and told a cook Resident #271 was not served a dinner tray. The cook, who Staff B, CNA was not able to name, informed her Resident #271 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff B, CNA then served the grilled cheese sandwich to Resident #271 and the resident consumed half of the sandwich. Later, Resident #271's RR then asked Staff B, CNA for a spoon for the pudding in the resident's room, which was provided by Staff B, CNA. Staff B, CNA stated the resident's diet order was not correctly entered so, to the best of her knowledge and the fact that Resident #271 had a beverage cup and pudding at the bedside, the resident was ordered a regular diet. Staff B, CNA also stated the facility did not have a system in place for CNA's to verify resident diets at that time. A telephone interview was conducted on 11/8/2022 at 12:09 PM with Resident #271's RR. The RR stated on 10/25/2022, she arrived at the facility during dinner meal service and noticed Resident #271 had two halves of a grilled cheese sandwich on a tray at his bedside and Resident #271 had consumed one sandwich before her arrival. Resident #271 also had a container of pudding on the meal tray and the RR activated the call light to speak with the nurse on duty. After approximately 45 minutes, the nurse responded to the room and was not aware of Resident #271's order of NPO. The RR was not able to state if Resident #271 had received regular food or beverages before 10/25/2022. An interview was conducted on 11/8/2022 at 2:48 PM with the facility's Nursing Home Administrator, Staff C, Regional Director of Clinical Services (RDCS) and Staff D, RDCS. The NHA stated on 10/25/2022, Staff B, CNA provided a meal tray to Resident #271 that had a grilled cheese sandwich and a container of pudding on it. Staff B, CNA did not realize Resident #271 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff C, RDCS stated Staff B, CNA did not verify Resident #271's diet order and should have checked the resident's plan of care before serving them food. Resident #271's RR was present at the time and asked Staff G, RN if the resident's diet order had changed. Staff G, RN informed the RR Resident #271's diet order was NPO and removed the food and beverages from the resident's room. Staff C, RDCS stated Staff B, CNA received the grilled cheese from Staff F, Cook, who also did not verify Resident #271's diet order before providing the food. A telephone interview was conducted on 11/9/2022 with Staff F, Cook. Staff F, Cook stated on 10/25/2022, Staff B, CNA approached him in the facility kitchen and stated Resident #271 was missing a dinner tray. Staff F, Cook asked what the diet order was for Resident #271 and Staff B, CNA did not know. Staff B, CNA then requested some grilled cheese sandwiches for Resident #271, which Staff F, Cook provided. Staff F, Cook stated the facility did not have a process for kitchen staff to check diet orders at the time of the incident and he was not aware that Resident #271 had a diet order for NPO. A review of the facility policy titled Therapeutic Diet Orders, revised on 10/29/2022 revealed under the section titled Policy, the facility provides all residents with food in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. The policy also stated under the section titled Policy Explanation and Compliance Guidelines dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. 2) On 11/07/22 at 1:24 p.m., Resident #32 was observed in his room sitting in the wheelchair next to his bed. He did not speak and pointed to his ear during an attempt to interview him. Resident #32 had dry scabbed areas on both hands. On 11/14/22 at 11:22 a.m., the resident was observed sitting in the wheelchair next to his bed watching TV. Resident #32 again did not say anything in an attempt to interview him. Dry scrabbed areas were observed on both hands. A review of the Admission Record revealed Resident #32 was initially admitted into the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Section C: Cognitive Patterns of the annual Minimum Data Set (MDS), dated [DATE], indicated Resident #32 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating the resident was cognitively intact. Section M: Skin Conditions revealed the resident did not have any ulcers, wounds, or skin problems. A review of the Order Summary Report for September 2022 to November 2022 revealed the following order related to wounds on the hand: Monitor wound appearance on right palm of hand for signs and symptoms of infection. Notify doctor for redness, warmth, pain, [CONDITION(S)], drainage, or odor every shift. There was no order in place for the wound on the left hand. A review of the Skin Head to Toe Weekly Skin Checks from September 2022 to November 2022 revealed Resident #32 only had an abrasion on the right palm. There was no indication on the skin checks that he had an abrasion on the left palm. A review of the monthly Skin & Wound Evaluation dated 09/19/22 indicated the resident had an in house acquired abrasion on the right palm. There was no documentation related to the abrasion on the left palm. A review of the Care Plan related to diabetes initiated on 09/12/19 revealed interventions, that included but were not limited to, check all of body for breaks in skin and treat promptly as ordered by the doctor. On 11/15/22 at 10:00 a.m., the Director of Nursing (DON) stated she did not find any documentation related to the wound on the left hand. She stated it was a dry scabbed area, but it was not open. She stated the wound care doctor saw him yesterday and put in new orders for the wound after the concern was brought to her attention. The DON stated she would expect to see documentation on the skin checks related to the area on the left hand and he should have had orders in place for treatment. The Skin & Wound Evaluation dated 11/14/22 completed by the wound care doctor indicated the resident had an in house acquired abrasion on the left dorsum. The area of the wound was 0.4 cm, length was 1.1 cm, and the width was 0.7 cm. The wound bed was eschar and 100% of the wound filled. The surrounding tissue was dry/flaky. The notes section indicated the wound was assessed by the wound care doctor for callus like area to left hand over healed surgical site. The doctor assessed and diagnosed as abrasion. Order received for skin prep daily The policy provided by the facility Skin Evaluations revised 08/22/22 revealed the following: It is our policy to perform a full body skin evaluation as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. 7. Documentation of skin assessment a. Include date and time of the assessment, your name, and position title. b. Document observation (e.g., skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurement, color, type of tissue in wound bed, drainage, odor, pain). e. Document if resident refused assessment and why. f. Document other information as indicated or appropriate.

Based on record review and interviews, the facility failed to monitor behaviors and side effects for [CONDITION(S)] medications for one resident (#63) out of five residents sampled for unnecessary medications. Findings included: A review of the Admission Record for Resident #63 revealed he was initially admitted into the facility on [DATE] with diagnoses that included major depressive disorders and unspecified dementia. Section C: Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #63 was rarely/never understood. Section N: Medications of the MDS indicated he received antipsychotics and antidepressants for seven days. A review of the Order Summary Report with active orders as of 09/01/22 to 11/01/22 revealed the following orders: [MEDICATION(S)] HCL Tablet 10 milligrams (MG)- Give 1 tablet by mouth at bedtime related to down syndrome, unspecified dementia without behavioral disturbance [MEDICATION(S)] Tablet 7.5 MG- Give 1 tablet by mouth at bedtime related to major depressive disorder [MEDICATION(S)] Tablet 5 MG- Give 1 tablet by mouth two times a day for mood disturbance related to unspecified dementia without behavioral disturbance There was no order in place related to behavior monitoring or side effect monitoring for [CONDITION(S)] medications. A review of the Medication Administration Record for 09/01/22 to 11/01/22 revealed no documentation related to behavior monitoring or side effect monitoring for [CONDITION(S)] medications. A review of the Care Plan focus area related to [CONDITION(S)] medications, indicated the following interventions: Monitor/document for side effects and effectiveness; Monitor/document/report as needed any adverse reactions of [CONDITION(S)] medications; Monitor/record occurrence of target behavior symptoms; and Monitor for side effects and effectiveness On 11/14/22 at 10:21 a.m., the Director of Nursing (DON) stated Resident #63 did not have an order in place for side effect and behavior monitoring related to [CONDITION(S)] medications. She stated both orders were discontinued due to a medication change. She stated Resident #63 was taken off [MEDICATION(S)] on 06/26/22 and a new [CONDITION(S)] medication was added on 10/05/22, and the order for side effect and behavior monitoring was not added. She stated the nurses should be monitoring side effects and behaviors every shift for residents who are prescribed [CONDITION(S)] medications.

Based on observations, record reviews, and interviews the facility failed to provide an activity program based on the assessment and care planned preferences for three (#40, #7, and #42) of three residents reviewed for activities out of a total sample of 29 residents. Findings included: 1. Review of Resident #40's Admission record revealed an original admitted in 2016. Review of the annual Minimum Data Set (MDS) assessment, dated 2/4/21, revealed that the resident was rarely/never understood therefore the Brief Interview for Mental Status (BIMS) was not conducted. Continued review of the MDS revealed the resident had short and long term memory impairment and was unable to participate in the activity preference interview. The staff assessment of activity preferences was completed and listed that the resident had no activity preferences check marked. A review of the prior MDS annual assessment conducted 3/12/20 revealed the resident interview for activity preferences was conducted. This indicated that it was somewhat important for the resident to listen to music, be around animals, keep up with the news, do her favorite activities, go outside to get fresh air, and participate in religious services or practices while residing in the facility. Review of Resident #40's active care plan last reviewed 2/25/21 revealed a focus care area of: Resident need to attend large and small group activities to provide mental and social stimulation from others and surroundings. The goal was to attend and participate in an least 2 activities weekly. The interventions to assist in meeting the goal included: Activity and Certified Nursing Assistant staff to encourage participation in activities of interest, spending time outside, games, birthdays/holiday celebrations, offer pet, volunteer, and spiritual visits when available, place calendar in room, assist with gaining access to activities where they occur, and invite and encourage family and friend to participate. Observations of Resident #40 in her room on 3/24/21 at 9:23 a.m. revealed the resident's room was located at the end of the hallway. The resident's television (TV) was on, sound was off, and the screen of the television showed an unchanging picture of an elderly woman, and read jump to a scene, cast, awards, theatrical trailer, film flash. Two additional observations of Resident #40 in her room on 3/24/21 at 12:16 p.m. and 3:29 p.m. revealed the TV continued with the title page of the movie, Driving Miss Daisy with no sound. Continued observations of Resident #40 on 3/25/21 at 7:33 a.m. and 12:12 p.m. revealed the title page of Driving Miss Daisy with no sound continued to be present on Resident #40's television. At 7:35 a.m. on 3/26/21, the title page of Driving Miss Daisy continued to be observed on Resident #40's television with no sound. Resident #40 was not in the facility at this time. At 12:54 p.m. on 3/26/21, an observation with the Activity Director of Resident #40's room was conducted. The television was not on, no sound was present in the room, and a staff member was sitting with the resident's roommate (Resident #7). The Activity Director stated she didn't know who turned the movie on, it was a personal movie, and she usually played music for the resident. Observations on 3/24/21, 3/25/21, and 3/26/21 revealed no sound or music was heard in the resident's room. During an interview on 3/24/21 at 3:21 p.m., the Activity Director stated the facility offers 1:1 activities, does word searches, story cards, and reminiscent games. The Director identified that she was the only person in the activity department and that her documentation was written in notebooks as she was still learning the electronic record system. On 3/25/21 at 12:04 p.m., Staff Member J, Certified Nursing Assistant (CNA), stated she sometimes brings music into Resident #40's room for her and her roommate (Resident #7) to listen to. An interview was conducted, on 3/26/21 at 12:35 p.m., with the Activity Director. She stated that she took the position a month ago. The Activity Director stated, I usually go in there and play some music for her (referring to Resident #40), will play movies for her, and took her outside for 15 minutes. She stated she usually goes to visit the resident every day and knows the resident from outside of the facility. The Director reported that she took the resident outside for 15 minutes on Tuesday (3/23/21) and played music for her about 2:30 p.m. on Monday (3/22/21). The Activity Director had a notebook next to her and without reviewing it, she stated she does not document any activities that were done with Resident #40. The staff member confirmed that she had not conducted any activity assessments for Resident #40. The Activity Participation Review, dated 9/30/20, indicated Resident #40 preferred and participated in 1:1 activities in her room [ROOM NUMBER]-3 times per week. The review did not describe any of the resident's favorite activities. The Recreation Services Assessment, dated 11/21/20, indicated Resident #40 had intact hearing and vision, limited fine motor abilities and did not participate in any activities and did not show any interest in having any in her room. 2. Review of Resident #7's admission record revealed she was admitted to the facility in 2015. The Admission Record included [DIAGNOSES REDACTED]. On 3/24/21 at 9:28 a.m., Resident #7's television was observed to be unplugged with the cord wrapped around the top of the television. An observation of the roommate's television (Resident #40) revealed it was across the room and had no sound. At 8:39 a.m. on 3/25/21, Resident #7 was observed lying partially on the floor mat next to her bed. The Certified Nursing Assistant went into the room to assist the resident. The television was still in the same state and no meaningful activities were observed. On 3/25/21 at 12:15 p.m., the cord of the resident's TV continued to be wrapped around the top of it. At 1:06 p.m. on 3/25/21, Staff Member H, Licensed Practical Nurse (LPN), confirmed that Resident #7's television cord was wrapped around top of the television and was not plugged in. She unwrapped the cord and found that the cord did not reach an electrical outlet in the room. On 3/26/21 at 12:47 p.m., an observation was conducted with the Activity Director of Resident #7 and #40's room. An LPN was sitting with Resident #7, who was lying curled up on her bed. The television was no longer present for Resident #7. A review of the care plan for Resident #7 last reviewed on 3/21/21 revealed the following focus care area: Impaired neurological status related to: [MEDICAL CONDITION]'s Chorea. The interventions related to the focus area included involve the resident in activities that don't depend on patient's ability to communicate: music, parties, and games. Continued review of the 3/21/21 care plan revealed an additional focus area of: Sometimes having behaviors which include hitting during care, putting self on floor, kicking, refusing privacy offered . The interventions instructed the Certified Nursing Assistant (CNA) to offer something as a diversion such as a TV program. An additional focus area on the 3/21/21 revealed the resident declined attending most group activities because of her condition and diagnosis. The goal for this focus indicated resident will choose independent activities that she has an interest in such as watching TV, reading, or spending time outside. The interventions included to offer pet, volunteer, and spirituals visits when available, place calendar in room and assist with resident ability to gain access where the activities occur. At 12:40 p.m. on 3/26/21, the Activity Director reported that Resident #7 had been in bed since she's been having changes. The Director identified that she doesn't play the television for the resident. She stated that Resident #7 heard the music that was played for her roommate, Resident #40, and she does not take the resident outside. The Activity Director did not report any activities were conducted with the resident and stated she had not documented any activities provided to Resident #7. The staff member confirmed she had not completed any activity assessments on Resident #7. A review of Resident #7's most recent annual MDS dated [DATE] and the prior annual MDS dated [DATE] revealed that the resident was rarely/never understood therefore the BIMS was not conducted. Continued review of the MDS's revealed the resident had short and long term memory impairment and was unable to participate in the activity preference interview. The staff assessment indicated the resident had no activity preferences. 3. On 03/23/21 at 11:18 a.m. and on 03/24/21 at 9:11 a.m., Resident # 42 was observed laying in bed without any activity or engagement from staff. On 3/23/21 at 3:11 p.m., Resident #42 was observed laying in bed with a filled-out crossword puzzle. Resident #42 stated she does not do have much to do sometimes. On 03/25/21 at 9:56 a.m., Resident #42 stated that she wished they played bingo more often. When asked when she last played bingo, Resident #42 stated it had been a while. Resident #42 stated that she loves crosswords and reading short books. Resident #42 said, It will be nice to be able to go to the library again. I'd like to get more books and word searches. Resident #42 stated that she also liked to watch game shows and listen to the radio. Review of Resident #42's admission record revealed the resident was admitted to the facility in September of 2020. A review of the most recent quarterly MDS assessment dated [DATE] revealed Resident #42 had a BIMS of 13, indicating cognitively intact. A review of the most recent comprehensive MDS was an admission MDS dated [DATE]. The resident's BIMS score on the 8/14/20 assessment was 15. A review of the activity preference section of the admission MDS revealed the resident was interviewed on her preferences. The resident reported that it was somewhat important to listen to music, keep up with the news, do her favorite activities, and go outside to get fresh air when the weather was good. A review of Resident #42's care plan dated 2/23/21 revealed a focus area of: Activities Care Plan. Resident is at risk for social isolation related to COVID restriction. The goal for the care plan was resident will participate in 1 to 2 activities of choice per week. Interventions included: Encourage resident to participate in room activities such as music therapy, communion, church visits, radio, watching TV, visitors, and puzzles. Resident #42 enjoys: visitors and family, arts and crafts activities, playing games on phone, and reading. On 03/24/21 at 3:22 p.m., Staff A, Admissions Coordinator stated that she was assisting with activities and filling in for social services because the facility did not have anyone in these roles. Staff A stated she was playing multiple roles since December 2020, until about a month ago (February 2021). Staff A reported that no one was facilitating group activities and 1:1 activities were done by different individuals. Staff A stated there was no documentation kept of the 1:1 visits by the various individuals. An interview was conducted with the Activity Director on Wednesday, 03/24/21 at 4:00 p.m. The Activity Directed stated that she just started in the activity role about a month ago. The Activity Director stated that she was responsible for the activities calendar, and she determined the activities based on prior calendars and reported that the residents like the same thing. The Activity Director stated that they have movies on Wednesdays. When asked what time the movie was scheduled for since today was a Wednesday, the Activity Director stated she did not have a time. The Activity Director stated she was working on a plan for facilitating 1:1 activities. She stated that she was new to the computer system and did not know how to document electronically. When asked for documentation of activities offered in January and February 2021, she stated she did not have any records. The Activity Director stated that she was the only one in her department and was responsible for all group and 1:1 activities in the facility. On 3/26/21 at 10:40 a.m., an interview was conducted with the Admissions Coordinator and the Activity Director related to Resident #42's activities. The Activity Director stated that she had not reviewed the activity care plan for Resident #42. The Admissions Coordinator reported that the resident liked puzzles and loved bingo among other activities. The Activity Director reported that they had not offered bingo and other group activities due to COVID and not having anyone in the activities position. During an interview on 3/26/21 at 12:35 p.m., the Activity Director reported that a staff member plays bingo on Saturdays and there were no activities in the facility on Sundays. A review of the facility's policy titled, Activities and Social services, with an issue date, 02/01/2016 and a revision date 1/2021, revealed a policy statement of: The residents have a right to choose the types of activities and social events in which they wish to participate. Policy interpretation and implementation included: (1) residents are encouraged to choose the type of recreational cultural and religious activities and social events in which they prefer to participate (2) social services director and activity staff will evaluate the individual's personal history and preferences. (3) The care planning team will develop the resident's activity and social care plans and will give the resident an opportunity to choose when, where and how he or she will participate. (7) Activities will be scheduled periodically during the day as well as evenings and weekends.

Based on observations, interviews and record review, the facility failed to ensure respiratory equipment was maintained in a sanitary manner for 2 (#1 and #15) of 2 residents. Findings included: Review of the medical record for Resident #1showed a readmission date of [DATE], with an initial admission date of [DATE]. As per the admission face sheet, [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE], section C - cognitive patterns, revealed a brief interview for mental status (BIMS) of 15, indicating intact cognitive status; Section G - Functional status indicated resident required extensive assistance with two plus person assist for activities of daily living (ADL's) including bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Continued review of the physician's orders [REDACTED]. notify MD (medical doctor) if any of these symptoms present. On 03/23/21 at 11:42 a.m., Resident #1's oxygen canula was observed on the floor. Staff C, PCA (Patient Care Aide) was present and confirmed the observation. Staff C stated it should not be on the floor and was observed picking the canula and tubing up and placing it on top of the concentrator. Staff C did not clean or store the cannula in a plastic bag. During an interview immediately following the observation, Resident #1 stated he uses oxygen as needed several times daily. During an interview with Staff G, Licensed Practical Nurse (LPN) on 03/23/21 at 11:55 a.m. she stated the resident will independently put on or remove his oxygen throughout the day. Staff G confirmed that the canula should not be placed on the floor and should be stored in a clean, dated bag. She stated she would replace it with a new one. Staff G further the resident would be educated on proper canula storage. A further review of the medical record for Resident #15 revealed no orders to monitor respiratory equipment's sanitation and storage. There was also no documented care of equipment, and no documentation of when the tubing and cannula were last replaced, or who was expected to ensure sanitary storage. On 03/23/21 at 12:16 p.m. and on 03/24/21 at 09:28 a.m., Resident #15's Nebulizer cannula was observed on the nightstand not covered, and placed on top of a pair of shoes. A review of the medical record for Resident #15 revealed physician's orders [REDACTED].>[MEDICATION NAME] sulfate nebulization solution 2.5mg (milligrams)/3ml (milliliters) 0.083% [MEDICATION NAME] suspension 0.5mg [MEDICATION NAME] - [MEDICATION NAME] solution 0.5 - 2.5mg [MEDICATION NAME] propionate suspension 50 mcg (micrograms) Oxygen at 3 liters via nasal canula to maintain oxygen saturation above 90% Observe for signs and symptoms of respiratory complications, sore throat fever, notify MD (medical doctor) if symptoms persist. On 03/25/21 at 03:00 p.m. an observation was made of the nebulizer cannula, sitting on top of a pair of shoes on the nightstand. Staff G was present and confirmed the observation. In a subsequent interview conducted immediately after the observation Staff G stated the resident's canula was recently changed and the resident moves her stuff around in her room. Staff G picked up the nebulizer cannula and placed it inside a bag. Staff G confirmed that it should not be stored in the open on top of shoes, and said, we should all keep an eye on it. A further review of the medical record for Resident #15 revealed no orders to monitor respiratory equipment's sanitation and storage. There was also no documented care of equipment, and no documentation of when the tubing and cannula were last replaced, or who was expected to ensure sanitary storage. An interview was conducted on 03/26/21 at 03:02 p.m. with Staff G, LPN and Staff H, LPN. They stated they could not locate orders to clean or change equipment for Resident #1 or Resident #15. During the interview, Staff G confirmed there should be an order to monitor care, maintenance, and storage of respiratory equipment. Staff G confirmed staff should store nasal cannulas and nebulizer mouth pieces in a clean, dated bag. A facility's policy labeled, policy & procedure Respiratory Infection Control Practices with an issue date 01/01/2014; Revision date: 01/2021 revealed a purpose to provide infection control guidelines to help prevent infections associated with respiratory therapy equipment. Section (f) and (g) states to change oxygen cannula and tubing weekly and as necessary. Keep oxygen cannula and tubing in a plastic bag when not in use. Section (e) and (f) states that the expectation is to wipe mouthpiece with damp paper towel or gauze sponge. Store in a plastic bag, marked with date and resident's name between uses.

Based on observations, interview and record review the facility failed to maintain an environment free of accident hazards for one resident (#49) currently residing in the facility with a first degree burn on 3/17/18 and second degree burn on 2/17/18 from hot liquids. Two former residents no longer residing in the facility (Resident #164 with a first degree burn on 10/8/17 and Resident #16 with a burn on 10/1/16 for hot liquids out of 57 residents sampled. Findings Included: 1. Review of the Incident log revealed Resident #49 with a first degree burn on 3/17/18 from direct heat exposure in the resident room. Resident #49 with a 2nd degree burn on 2/17/18 from direct heat exposure on facility grounds with in house treatment. Resident #164 with a first degree burn on 10/7/17 from temp exposure - heat in the dining room with in house treatment. Resident #16 was not on the log as the incident occurred on 10/1/16. Resident #49 was admitted on [DATE] with a readmitted [DATE] on hospice services and [DIAGNOSES REDACTED]. During initial tour on 3/19/18 at 7:30 p.m. Resident (49) stated, that everything was good and that the facility was treating him well without issues. A small red area was noticed on the right knee and the resident stated that he scratched it and it was fine and covered the leg. Review of the MDS 2/5/18 revealed the resident with a Brief Interview for mental status (BIMS) score of 15 (cognitively intact). During a follow up interview with Resident (49) on 03/21/18 at 11:55 a.m., the resident stated, he did not burn himself that he scraped himself. When asked about a burn he became irate and stated that he spilled his hot drink and the state should not be nosey about it. The resident restated, he was fine and did not want to talk to the surveyor. The resident then added that he now drinks out of an insulated cup with a handle and a lid and he was fine with that because he only likes hot tea and coffee and stated he was at fault and the state needed to leave him alone because he spilled the cup and it was his fault. Review of the nursing notes dated 3/17/18 at 4:21 p.m. revealed, The nurse heard resident yelling, HELP! from his bedroom. Upon entering room, resident's foam cup with tea was noted on the bedside table, minimal spillage of beverage noted on tabletop. Evaluated resident, right knee noted to be a little red in color. Resident denied pain to knee. Stated, This is nothing really. Thank goodness you came fast enough, it could have been worse if the cup had opened up. Doctor notified with resident own responsible party. Review of the shower sheets dated 3/17/18 revealed the resident with a right leg marked without dimensions and circled for (11. abnormal color). During an interview on 3/22/18 at 11:30 a.m. with staff member L, wound care nurse. Staff member (L) stated that wounds such as the burn are not measured and documented, only pressure wounds. The staff member was asked for the measurements of the wound which occurred on 3/17/18. The staff member returned with a shower sheet dated 3/22/18 with a right knee measurement of 20 x 6.5 x 0 with red area and no blisters documented. The wound care nurse stated that new orders were given for a small area in the center of the burn which will be started today as they now need wound care. Review of the incident report dated 3/17/18 from the DON revealed the resident with first degree burn from direct heat exposure in the residents room on 3/17/18 at 3:00 p.m. with the narrative of the incident described as: This nurse heard resident yelling, HELP! from his bedroom. Upon entering room, resident's foam cup with tea was noted on the bedside table, minimal spillage of beverage noted on tabletop. Evaluated resident, right knee noted to be a little red in color. Resident denied pain to knee. Stated, This is nothing really. Thank goodness you came fast enough, it could have been worse if the cup had opened up. Immediate actions taken: evaluate, wound care assessed and only red, no blistering noted. Review of the Hospice Interdisciplinary plan of care revision/ physician orders [REDACTED]. Hand size 6.5 x 20 cm. Review of the care plan revealed the resident with a liquid burn on the right knee with date of 3/19/18 Device: cup with closing lid and handle for hot liquids. Review of the Nursing notes dated 2/17/18 at 4:10 p.m., revealed the resident was visiting with family outside and the father brought him inside and stated he spilled his coffee on his leg. Pants were wet with coffee stain. CNA put resident in bed and observed a burned area with a blister on the right upper thigh. Pain level 6/10 with as needed medication given. Management and hospice notified. New order received to cleanse area and apply [MEDICATION NAME] covered by a dry dressing. Resident aware no voiced concerns. Review of the treatment administration record (TAR) revealed the resident with monitoring wound appearance every shift dated 2/19/18. [MEDICATION NAME] 1% cream, cleanse right upper thigh with normal saline, pat dry, the applying layer of cream to area, cover with dry dressing daily until resolved dated 2/17/18 with discontinue date of 2/19/18.(NAME)1% cream, cleanse burn area to right upper thigh with normal saline, pat dry, then apply thin layer of cream to area, cover with dry dressing daily until resolved dated 2/19/18 with discontinue date of 3/13/18. Review of the 2/17/18 shower sheet revealed the right leg with a circle and nothing denoting what was in the circle. During an interview on 03/21/18 at 11:57 a.m., with staff member (H), CNA she stated, Resident #49 is only allowed to have his hot liquids in a handled cup because he burned himself twice. Once with water and once with coffee. Neither were heated in the microwave. They came out of the coffee pot and hot water dispenser. She stated she knew this because the burn in (MONTH) was the drink she poured for the resident in a Styrofoam cup. 2. Review of Resident #164 with admitted [DATE], readmit on 1/2/18 and discharge on 2/6/18 with a [DIAGNOSES REDACTED]. Review of Resident #164 shower sheet dated 10/8/17, revealed the resident with a left abdominal and left lower leg burn. Review of the nursing notes dated 10/8/17 at 6:53 a.m., revealed Resident #164 with a dressing to left inner thigh clean, dry and intact. No increased redness. Review of the nursing notes dated 10/8/17 at 11:34 a.m., revealed a late entry from 10/7/17 at 0800. CNA brought to nurses attention that resident's hot coffee fell on her lap. Upon assessment resident alert and oriented times 3. Skin assessment completed resident noted with no injuries to her abdomen or bilateral legs. Resident denied pain. CNA educated on assisting resident with hot beverages. Review of the treatment administration record, revealed an order for [REDACTED]. Review of the treatment administration record revealed an order for [REDACTED]. Review of the residents BIMS score dated 9/21/17 revealed score of 9 (moderately impaired) 3. Review of Resident #16 with admitted [DATE], readmitted [DATE] and discharge of 3/19/18 with a [DIAGNOSES REDACTED]. Review of the shower sheet dated 10/1/16 revealed the resident with a right upper thigh burn. Review of the nursing notes dated 10/1/16 at 6:45 p.m. revealed the resident with fluid filled blister to right upper leg. Resident stated she spilled coffee on her leg. Resident did know when or how event occurred. Review of the 10/2/16 nursing notes at 3:23 a.m. revealed the resident with a blister on the right upper thigh. Soaked with saline and patted dry, applied ointment, covered with dry dressing. Review of the treatment administration record revealed triple antibiotic ointment - cleanse area to right upper leg with normal saline, pat dry, apply triple antibiotic ointment and apply dry dressing as needed until resolved dated 10/1/16 with discontinue date of 10/3/16. Review of the resident BIMS score dated 9/14/16 revealed the resident with a BIMS of 4 (severe impairment). During an interview on 03/21/18 at 12:30 p.m., with staff member (I), CNA, She stated, I assist in the dining room and when I get residents coffee, they get it in a plastic coffee cup, if they request a larger cup it is in Styrofoam. The coffee does come out of the coffee machine in the kitchen and is really hot. When I get my residents coffee, I add 2 to 3 ice cubes and they are happy with that and its not too cold. I did have one resident drop coffee on herself in the dining room and burned herself. I do not know how long ago that was and she is still a resident but out to the hospital for other issues. During an interview on 03/21/18 at 01:00 p.m., with the Administrator she stated, Resident #164 received a first degree burn from coffee in the dining room on 10/10/17 and they did a therapy referral and supervised the resident with hot liquid and added to preferably add a lid to her coffee. The Administrator stated that Resident #164 was drinking out of a plastic coffee cup which does not have a lid. The Administrator stated, she never looked to see what the temperature was coming from the coffee pot as it has to brew very hot. The Administrator was asked about another burn for Resident #16 since it was not on the incident and accident log. The Administrator stated that she would need to see how long ago that incident happened as she was unaware of the time frame and only knew the two names on the log with coffee burns. 4. During an interview on 03/21/18 at 2:31 p.m. with the Assistant Director of Nursing (ADON) and the Administrator. The ADON stated, After the burn for Resident #164, the resident was given a clear handled cup with spout for all meals to prevent spills. Resident #16 was found to have a fluid filled blister on her right upper leg and restorative took her and supervised the resident with occupational therapy involved. The investigative note read that the resident was observed on 10/1/16 with periods of shaking and could have spilled the liquid on herself. The resident was observed with a blister on her right upper leg fluid filled and restorative took her and supervised the resident with occupational therapy. The ADON stated that Resident #49 was visiting with family outside on 2/17/18, the family obtained a cup of coffee from the facility for the resident and gave him the coffee which he spilled. They advised the resident that he needed a coffee cup with a lid after the burn. The coffee at the time was in the 16 ounce Styrofoam cup which has a lid that can be used for drinking. The ADON then stated that the resident on 3/17/18 sustained another burn from coffee and we bought him a copco personal travel mug with a lid and handle but was just informed by the staff that he threw the cup and did not want the new cup. The Administrator stated that Resident #49 put the coffee on his bedside table and he bumped the bedside table and spilled the liquid on to his leg which then caused a burn. The Administrator stated, we did not investigate the coffee maker and the temperatures or if the coffee maker has adjustable temperatures but the coffee has to be set high to brew. I do not have coffee temperatures and have not checked the coffee temperatures to see how hot the coffee comes out or if the coffee pot can be set at a lower temperature. During an interview on 3/17/18 at 3:00 p.m., with staff member (J) speech therapy, she stated Resident #16 was on therapy case load when discharged but unsure if she was at the time of the burn. Resident #164 was evaluated on 10/10/17 screened but not picked up for therapy. Resident #49 was evaluated on 2/1/18 but that screen was prior to [MEDICAL CONDITION] we did not have a referral to be screened on 2/17 and 3/17. 5. During an interview and observation on 3/21/18 at 12:26 p.m. with the CDM and Registered Dietician Consultant revealed the machine used for coffee and hot water for tea was a Grindmaster Corporation Model P-300E. At 12:26 p.m. the water was expelled from machine into a 16 oz. Styrofoam cup and temperature was taken and read at 190 degrees. Another temperature of the hot water was taken and read at 12:29 p.m. It was 181 degrees. The CDM stated, In the past they were given two cups (placed one Styrofoam cup into another) with a lid and a straw or stirrer to prevent burns. Coffee was made and expelled into another 16 oz. Styrofoam cup at 12:30 p.m. and the temperature read 181 degrees. The temperature of the coffee taken again at 12:31 p.m. read at 176 degrees. During an interview on 03/22/18 at 09:33 a.m. with the Administrator, she stated, they have the policy information from manufacturer and can adjust the temperature and will see about having it lowered today since they worked with the residents and accommodated the needs but did not want to make the coffee too cold and not palatable. The surveyor at 9:32 a.m. on 3/22/18 poured hot water from the carafe and made hot cocoa to test temperature. The Styrofoam cup sat open without a lid from 9:32 a.m. to 9:46 a.m the cocoa was stirred then a sip of the cocoa was tested and stung the top of the surveyors mouth. The CDM tempted the water at 10:09 a.m. from the carafe which measured 143 degrees. At 10:07 a.m. the CDM stated that she had someone coming to adjust the thermostat on the coffee pot today instead of waiting for someone from Tampa to do it next week. The CDM tested the coffee from the carafe after pouring into a foam cup, the temp read 134.6 degrees. On 3/22/18 at 11:16 a.m. observation of the kitchen staff preparing beverage cart for lunch confirmed hot water and coffee were not poured into the coffee pitchers. At 11:19 a.m. a Styrofoam cup was used to fill the coffee pitcher with coffee which holds 2.2 liters. At 11:21 a.m. the second air pot (coffee pitcher) was filled. A total of 27 residents were observed in the dining room. The creamer used is non- dairy powdered cream. The first cup of coffee from the beverage cart was filled at 11:23 a.m. with 20 cups of coffee served with the final cup served at 11:45 a.m. The cook tested the coffee from the air pot coffee pitcher at 11:45 a.m., with a temperature of 167.5 degrees. During an interview with Resident #47 on 3/22/18 at 10:15 a.m., she stated that she drinks coffee and the coffee is hot but she lets it cool off before she drinks it. During an interview with Resident #33 on 3/22/18 at 9:50 a.m., she stated that the coffee is hot and she can not hold it for long so she lets it sit on the table and cool off before drinking it. During an interview with Resident #23 on 3/22/18 at 10:00 a.m., he stated that the coffee is pretty hot when he gets it so he has to let it cool for a while. During an interview on 3/22/18 at 12:10 p.m., with the previous maintenance supervisor who came in as a favor to turn the thermostat down on the coffee maker and the CDM stated that the thermostat is adjustable and they turned it half way down to see what the temperature would be and could adjust back up in small increments if needed for palatability. The CDM stated she had no idea the coffee maker could be adjusted and now knows how to adjust the thermostat. The CDM stated that she took a cup of coffee directly from the coffee machine and let it sit for 25 minutes. The coffee sitting in a small plastic coffee cup with a lid read 145.6 degrees after 25 minutes. On 3/22/18 at 3:10 p.m., after the thermostat was reduced at 12:10 p.m., the temperature of the coffee and water were checked. The coffee was brewed at 1:30 p.m. and left in the coffee machine. The coffee dispensed out of coffee machine into a 8oz styrofoam cup read 166.1 degrees and at 3:11 p.m. and water from the hot water dispenser read 127.2 degrees. During an interview with the Director of Clinical Operations (DCO), on 3/22/18 at 3:45 p.m., the residents are the first priority and we have completed the plan of action to keep our residents safe. It has been approved by corporate. During an interview with the CDM on 3/22/18 at 3:40 p.m., she stated that the temperatures were lower since adjusting the thermostat and now will adjust the thermostat if needed based on the residents complaints. The CDM stated that she will complete temperatures from the coffee machine and the air pots since they maintain temps for four hours. Then stated that since the airpots hold the temperatures for four hours they will use the carafes only to dispense the coffee or hot water. An interview was conducted with the Administrator during the QA mandatory facility task on 3/22/2018 at 11:41 a.m., she stated, If we see we have had a decline in something we will focus on that area. We did not bring [MEDICAL CONDITION] the QA meeting. We felt we had addressed them with the residents individually. It is based on palatability. The DON and DCO on 3/22/18 at 4:00 p.m., stated they did not have a policy to investigate events. They stated they use an Event Response form to investigate. The DCO provided the team with a plan of action for the residents related to the coffee at 4:30 p.m., on 3/22/18. The DON on 3/22/18 at 4:10 p.m., stated that the staff in and out of the building would be inserviced via a text message that goes to all staff and they would need to come to her another representative for the training on how to dispense coffee to residents from this point forward. Review of the Event Response form is not dated with three pages revealed: III. System Review - Evaluate system compliance and determine the need to modify or enhance to prevent/risk event from reoccurring. Modification must be timely, relevant to the event, and clearly documented with the investigation. Review the event and system changes in QAPI. Review of the manufacturer instructions for the Grindmaster Corporation Model P-300E on page six revealed the coffee machine thermostat comes with the factory setting of 200 degrees. On page seven the optional brew thermostat adjustment revealed the factory setting is set at 192 degrees. This can be adjusted with directions given.