Every finding on record at Waters of Mckenzie a Rehabilitation & Nursing CTR

Based on policy review, emergency menu review, observation, and interview, the facility failed to ensure the emergency food supply was completely stocked to accurately reflect the emergency menu requirements. The facility had a census of 45 with 45 residents receiving a meal tray. The findings include: 1. Review of the undated facility policy titled, Emergency and Disaster Planning, revealed .The following shall be maintained by the Dietary Manager and available in case of an emergency disaster.Planned three to seven day emergency menus.emergency food, water and supplies to match the emergency menu. Emergency stock shall be rotated to use prior to the manufacturer's expiration date. Review of the 3 Day Emergency Menu, revealed .Day 1 Breakfast.Juice.Hot or Cold Cereal.Corned Beef Hash.Bread, Pastry or Crackers.Milk (Fresh or Recon [Reconstituted]).Day 2 Breakfast.Juice.Hot or Cold Cereal.Corned Beef Hash.Bread, Pastry or Crackers.Milk (Fresh or Recon).Day 3 Breakfast.Juice.Hot or Cold Cereal.Corned Beef Hash.Bread, Pastry or Crackers.Milk .Day 1 Lunch.Ravioli.Cooked Vegetables.Bread, Pastry or Crackers.Applesauce.Milk (Fresh or Recon).Day 2 Lunch. Chili.Cooked Vegetables.Mashed Potatoes.Bread, Pastry or Crackers.Chilled Peaches.Milk (Fresh or Recon).Day 3 Beef Stew.Mashed Potatoes.Cooked Vegetables.Bread, Pastry or Crackers.Applesauce.Milk (Fresh or Recon).Day 1 Dinner.Tuna Salad.Cooked Vegetable.Potato Salad. Bread, Pastry or Crackers.Vanilla Pudding.Milk (Fresh or Recon).Day 2 Dinner.Chicken and Dumplings.Cooked Vegetable.Bread, Pastry or Crackers.Vanilla Pudding.Milk (Fresh or Recon).Day 3 Dinner.Ravioli.Cooked Vegetable.Bread, Pastry or Crackers.Chocolate Pudding.Milk (Fresh or Recon). During an observation and interview in the Emergency Food Supply Room with the Food Services Director (FSD) on 6/28/2026 at 12:07 PM, revealed the facility did not have all food items stocked that was on the Emergency menu. The FSD confirmed the facility failed to have emergency food supply stock for the following items: 1. Bread 2. Ravioli 3. Tuna 4. Beef Stew 5. Vanilla Pudding 6. Chocolate Pudding 7. Applesauce 8. Chicken and Dumplings 9. Potato Salad 10. Milk (fresh or reconstituted) 11. Can Vegetables During an interview on 6/29/2026 at 12:57 PM, the Certified Dietary Manager (CDM) was asked who was responsible for ensuring the items on the menu are in the supply area. The CDM replied, Myself and the Food Services Director is to check daily, and I am to review when I am in the building. Staff does pull from the supply, but they are to replace immediately. We can also order via food delivery service whenever those items are pulled. The CDM was then asked in the event of an emergency and food delivery service is not available what would she do. The CDM replied, The items should have already been in place. They should be in stock at all times. They should replace immediately.

Based on Academy of Nutrition and Dietetics Scope of Standards and Practice, S-W-A-T (Skin-Weight-Assessment-Team) Program review, medical record review, observation, and interview, the facility failed to notify the physician or nurse practitioner (NP) of weight loss and failed to ensure the Registered Dietitian completed a nutritional assessment and made nutritional recommendations for 1 of 4 (Resident #5) sampled residents reviewed for weight loss. The findings include: 1. Review of the Academy of Nutrition and Dietetics Revised 2024 Scope and Standards of Practice for the Registered Dietitian Nutritionist, published 1/2024, revealed .The Revised 2024 Scope and Standards of Practice for the Registered Dietitian Nutritionist (RDN) serves as a key resource for RDNs to understand the practice environment and standards that guide PRD practice.to demonstrate and assure safe and quality practice for the individuals and organizations they serve.The standards reflect the.responsibility, and accountability of the RDN.depict the expectations for competent care of the patient/client/customer [resident], delivery of services, and professional practice outcomes.The scope and standards promote:.ethical.timely.effective.and person-centered food, nutrition, and related services.improved nutrition and health related outcomes.Nutrition Intervention Plan of Care.RDN Role.Determine or recommend nutrition prescriptions and initiate interventions such as medical Nutrition Therapy. Review of the undated facility program titled, S-W-A-T Program, revealed .Purpose: To identify residents who are at nutritional risk for weight loss .to address and monitor those residents who already have identified deficits with either weight loss .It is the intent of the facility to assess the nutritional status .of each resident and to timely address any issues or any potential issues related to weight .The SWAT team will monitor residents who meet the criteria .on a weekly basis to ensure that measures are in place to avoid weight loss in at risk for weight loss residents .based on their medical assessments and overall health status .Members of the SWAT Team who monitor residents for nutritional .concerns consist of, but are not limited to .Administrator (when available) .Director of Nursing .Assistant Director of Nursing .Primary Nurse Manager of the residents of focus .MDS [Minimum Data Set] coordinator .Dietary Manager .Dietician (when available) .Medical Director (when available) .Nurse Practitioner (when available) .This team will appropriately determine clinical and dietary interventions to best address each individual resident's needs based on observation, assessment, and review. Any dietary issues will be reviewed by the Dietician on their next visit. Any dietary issues that are more than routine in nature, will require immediate contact of the Dietitian for review and input. Emergent issues will be immediately referred to the attending physician .S-W-A-T will follow protocols listed on the S-W-A-T form addressing significant weight issues .or potential for these concerns . 2. Review of the medical record revealed Resident #5 was initially admitted to the facility on [DATE] with diagnoses including Parkinsons Disease with Dyskinesia, Adult Failure to Thrive, Dysphagia, and Schizoaffective Disorder. Review of the Physician's Orders dated 12/28/2023, revealed .Monthly weights . Review of the Physician's Orders dated 6/17/2024, revealed .Observe for any new onset and/or worsening side effects with Psychotropic Drugs Common side effects: Involuntary Movements .Upset Stomach/Diarrhea .Appetite/Weight Changes, Constipation .every shift for Anti-Anxiety, Anti-Depressant, Antipsychotic, Sedative/Hypnotics . Review of the Care Plan dated 11/19/2025, revealed .I have the diagnosis of failure to thrive and I am at risk for imbalanced nutrition .I will have improved appetite and energy through next review .Assess nutritional status: weight, BMI [Body Mass Index], mid-arm circumference, dietary intake per policy .Diet per physicians' orders .Provide supplements as ordered .I will tolerate diet as ordered and have no weight complications .My weight will be stable .Serve my diet as ordered and offer exchanges for any food I am unable to chew .Diet per MD [Medical Director] order and RD [Registered Dietician] eval [evaluate] as needed .Notify MD of worsening in symptoms .Observe for chewing difficulty .Observe for diet tolerance and that food served is appropriate .I have the following medical & [and]/ or mental health conditions/behaviors which may compromise my nutritional status in the future: degenerative disease of basal ganglia; Parkinson's .adult failure to thrive .dysphagia .extrapyramidal and movement disorder .schizoaffective disorder .Has verbalized a desire to lose weight with no goal weight at this time .I will have no significant weight changes through the next review .I will maintain current weight through next review .Observe for swallowing or chewing problems with meals. Notify MD if noted and refer to Speech therapy for screening.Review/Evaluate my medications, vitals, weights as needed .Weigh me monthly or per facility protocol .Risk for Dysphagia .I will safely masticate [to chew food] and swallow a diet of the least restrictive consistency to ensure adequate nutrition and hydration without over s/sx of aspiration daily through next review . Administer medications as ordered and observe for side effects, effectiveness .Monitor weight and appetite .Observe for signs of malnutrition .notify MD .RD to follow up for further recommendations .Speech therapy, as ordered to eval and treat as indicated .Supplements as ordered. Review of the medical record revealed Resident #5 weighed 174 pounds (lbs) on 12/2/2025. Review of the medical record revealed Resident #5 weighed 172 lbs on 3/2/206. Review of the Physician's Orders dated 4/20/2026, revealed .General diet, Mechanical Soft with Pureed Meat texture, Thin Liquids consistency .May have bread and chopped meat sandwiches upon request . Review of the medical record revealed Resident #5 weighed 178.6 lbs on 5/2/2026. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated he was cognitively intact, required set-up or clean-up assistance for eating, had no swallowing issues, and was on a mechanically altered diet. Resident #5 had no dental issues and received occupational and physical therapies. Review of the medical record revealed Resident #5 weighed 144.8 lbs on 6/2/2026, which indicated a 33.8 lbs weight loss in 1 month. Review of the physician's orders dated 6/4/2026, revealed .reweigh.one time order . Review of the Neurology Nurse Practitioner (NP) dated 6/4/2026, revealed .The patient reports intermittent exacerbation of tremor, described as occasionally severe .Dysphagia is present .Sialorrhea [excessive saliva flow] .The patient notes that symptoms may occasionally worsen following administration of carbidopa-levodopa [medication to treat Parkinson's Disease] .initiate amantadine [medication used to treat Parkinson's Disease and its symptoms] for drooling .Order speech therapy to address swallowing difficulties .Orders Placed .Ambulatory referral to Physical Therapy pending review .Ambulatory referral to Speech Therapy Pending Review . Review of the Physician's Orders dated 6/4/2026, revealed an order for Amantadine Hydrochloride 100 mg, 1 capsule by mouth two times a day for Parkinson's disease. Review of the Interdisciplinary Rehabilitation (Rehab) Screen conducted by the Speech Therapist (ST) dated 6/5/2026, revealed Resident #5 requested to try Occupational Therapy (OT) to target tremors. The Speech Therapist (ST) referred to Physical Therapy (PT) and OT, and ST planned to rescreen in 3-4 weeks. Review of the Occupational Therapy Evaluation and Plan of Treatment dated 6/9/2026, revealed .Reason for Referral: Pt [Patient] with decline in self-care and strength with neurologist recommendation for ongoing therapy course .Patient Behaviors .Attentive and Confused .Clinical Impressions: Pt presents with increase in B [Bilateral] UE [Upper Extremity] tremors and decreased UE strength impacting performance with self-care tasks such as oral care, opening food package.Pt is excellent candidate for therapy secondary to .ability to retain new information .the patient is at risk for .further decline . Review of the medical record revealed Resident #5 weighed 144.8 lbs on 6/9/2026. Review of the Registered Dietitian (RD) progress note dated 6/11/2026, revealed .Monitoring for weight loss. Weight: 144.8# [pounds-lbs] (6/9) Weight change: sig [significant] loss x [times] 30/90/180 days Diet: mech [mechanical] soft w/ [with] pureed meats regular diet w/ thin liquids.REVIEW: Rsd [resident] added to SWAT r/t [related to] sig loss, reweighed to confirm loss. Intake slightly less than normal .Unintended weight loss r/t [related to] decreased intake aeb [as evidenced by] sig loss x30 [times 30] days. PLAN: Cont [continue] poc [plan of care]. RD available for consult. Review of the facility document titled, Weekly Weight Schedule (Updated 6-14-26 [2026]), revealed Resident #5 was added to the weekly weight schedule. Review of the medical record revealed Resident #5 weighed 143.3 lbs. on 6/16/2026. The only intervention implemented from 6/2/2026, when Resident #5's severe weight loss was identified, until 6/18/2026, was a re-weight and weekly weights. Review of the RD progress note dated 6/18/2026, revealed .Monitoring for weight loss. Weight: 143.3# (6/16), 144.8# (6/9) Weight change: sig loss x30/90/180 days Diet: mech soft w/ pureed meats regular diet w/ thin liquids.REVIEW: Rsd added to SWAT r/t sig loss, reweighed to confirm loss. Intake slightly less than normal .Unintended weight loss r/t decreased intake aeb sig loss x30 days. PLAN: Recommend adding pudding w/ dinner tray. Cont poc. RD available for consult . Review of the revised care plan dated 6/18/2026, revealed NUTRITION INTERVENTIONS: 6/18/26- Add pudding to evening meal . Review of the NP progress noted dated 6/22/2026, revealed .Patient has experienced rapid, unintended weight loss of ~35 lb [approximately 35 pounds] (~20%) over the past 6 weeks, confirmed by serial weights and dietary review. Loss is associated with slightly decreased intake and mechanical soft/pureed diet for dysphagia, but no acute medical or psychiatric decompensation .Assessment and Plan Summary .Continue monthly weights .Megestrol Acetate [appetite stimulant] Tablet 20 MG [milligram] Give 1 tablet by mouth one time a day for decreased appetite and weight loss . Review of the medical record revealed Resident #5 weighed 143.2 lbs. on 6/23/2026. Review of the RD progress note dated 6/25/2026, revealed . RD review r/t SWAT. Monitoring for weight loss. Weight: 143.2# (6/23), 143.3# (6/16), 144.8# (6/9) Weight change: sig loss x30/90/180 days Diet: mech soft w/ pureed meats regular diet w/ thin liquids.REVIEW: Rsd added to SWAT r/t sig loss, reweighed to confirm loss. Intake slightly less than normal .Unintended weight loss r/t decreased intake aeb sig loss x30 days. PLAN: Cont poc. RD available for consult . Review of the NP progress note dated 6/26/2026, revealed .Patient [Resident #5] is also requesting Ensure [nutritional supplement] with meals in relation to his recent weight loss . Review of the physician's orders dated 6/26/2026, revealed an order to give Ensure 237 milliliters by mouth with meals and record the percentage consumed. Review of the physician's orders dated 6/26/2026, revealed .Megestrol Acetate Tablet 20 MG.Give 1 tablet by mouth one time a day for decreased appetite and weight loss . During a telephone interview on 6/29/2026 at 10:41 AM, the RD was asked when she was made aware of Resident #5's weight loss. The RD stated, I was not intentionally notified but they entered his weights by 6/5/2026. So, they got the weight on 6/2/2026 and we would have talked about him on 6/4/2026, but there would be no documentation until the reweight on 6/9/2026 and the meeting on 6/11/2026 . The RD was then asked what interventions were put in place. The RD stated, The reweight for 6/9 .and we would see that there was actually a weight loss. The RD was asked why she would wait until 6/18/2026 to put in an intervention of pudding with meals. The RD stated, He was stable [he had not lost any weight between 6/2/2026 and 6/9/2026] the first week, so we added him to the SWAT on 6/11 and were going to monitor him. And with his Parkinsons and his mechanically altered diet it's hard to make changes with his diet. The RD was asked if a resident has a significant weight loss of 30 or more pounds in one month, would she expect the facility to contact her right away. The RD stated, In a perfect world that would be great, but that's not always the case. The RD was asked if she considered a weight loss of 30 or more pounds in one month to be more than routine in nature or emergent in regard to weight loss. The RD stated, Yes. The RD was asked what she feels contributed to Resident #5's weight loss. The RD stated, Disease progression. During an interview in the resident's room on 6/29/2026 at 11:05 AM, Resident #5 was asked what do you think contributed to your weight loss. Resident #5 stated, I don't really know. There isn't a lot of taste with the food now that they grind it up. During an observation in the dining area on 6/29/2026 at 3:10 PM, the Maintenance Director and the DON showed a sticker on the scale with the date of 2/20/2026 as being the last time the scale was calibrated. This writer observed a 10-pound weight being placed on the scale and the scale gave a reading of 9.8 pounds. The DON then re-zeroed out the scale and the resident stood up, walked to the scale, and stood on the scale for weight to be obtained. Resident #5's weight according to the scale was 141.6 pounds. During an interview on 6/30/2026 at 9:44 AM, the DON was asked when she made the physician aware of Resident #5's weight loss. The DON stated, The MD signed off on the reweight order for 6/4/2026, but I did not contact him to make him aware of the weight loss.We talked about it in our monthly .meetings and I can look and see if there was any documentation of us talking about [Named Resident]. The DON was asked according to the SWAT Program documentation, should the MD or NP have been notified of Resident #5's weight loss right away. The DON stated, Yes. The DON was asked if the MD or NP was notified when the weight loss was identified on 6/2/2026. The DON stated, No. The DON was asked if the RD should have been notified right away. The DON stated, Yes. The DON was asked who was responsible for notifying the RD. The DON stated, Me. The DON was asked who is responsible for notifying the MD or NP. The DON stated, Me. The DON was asked if the RD made any recommendations when she was notified on 6/4/2026. The DON stated, We just talked about it because I didn't think it was an actual weight loss due to poor documentation in previous months, and she said we should reweigh. The DON was asked if a reweight only was a good intervention for that kind of weight loss. The DON stated, No. The DON was asked what the RD's recommendation or intervention was on 6/11/2026. The DON stated, .weekly weights and watch for another week. The DON was asked if continuing the Plan of Care (POC) and weekly weights were a good intervention for (Resident #5's) weight loss. The DON stated, No. The DON was asked what interventions the RD put in place in the next SWAT meeting on 6/18/2026. The DON stated, Add pudding to meals. The DON was asked if the RD made any recommendations during the SWAT meeting on 6/25/2026. The DON stated, No. The DON was asked if Resident #5 had continued to lose weight in the month of June. The DON stated, No. The DON was asked who makes the recommendations in these (SWAT) meetings. The DON stated, The RD makes the recommendations. The DON was asked if recommendations for shakes and puddings require approval by the MD or NP. The DON stated, No. During an interview on 6/30/2026 at 10:38 AM, the NP was asked when and how she was notified of Resident #5's weight loss. The NP stated, I found out when he [Resident #5] told me he had lost weight on 6/22/2026. The NP was asked if she should have been notified before 6/22/2026 by facility staff. The NP stated, Yes. The NP was made aware of the SWAT meeting on 6/11/2026 after a week of monitoring and then asked if the intervention of continuing the POC for another week was a good intervention with Resident #5's weight loss. The NP stated, No. During a telephone interview on 6/30/2026 at 2:04 PM, the MD was asked if he was aware of Resident #5's weight loss between 5/2/2026 and 6/2/2026. The MD stated, No. The MD was asked if he would expect the facility to make him aware of that weight loss in a timely manner. The MD stated, Well, I would expect them to notify the NP in the facility and if it was something she needed help with she would make me aware. The MD was then asked if he thought the facility should have made the NP aware of Resident #5's weight loss before 6/22/2026, if it was discovered on 6/2/2026. The MD stated, Yes.

Based on facility document review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when 1 of 1 ice machine was observed to have a dark slimy buildup on the inner seal. The census was 46 with 44 residents receiving a tray from the kitchen. The findings: 1. Review of the undated, facility document titled, Physical Plant-Monthly Inspections, revealed .Ice Machines: Clean filters and check water filter and observe for proper operation. Look for any calcium, lime, or algae. Check to ensure it is in a clean and sanitized state. This includes all ice machines throughout the facility including Dietary . 2. Observation and interview on 4/14/2025 at 8:44 AM, with the Dietary Manager (DM) revealed the ice machine had a black, slimy substance all around the inside seal. The DM was asked who was responsible for cleaning the ice machine. The DM stated, Maintenance. The DM was asked if it was clean. The DM stated, No. Observation and interview on 4/15/2025 at 8:38 AM, with the DM revealed the ice machine had a black, slimy substance all around the inside sea. The DM was asked if the ice machine had been cleaned. The DM stated, I told maintenance, and he must not have cleaned it. The DM stated that she would tell him again and we could come back to check it later. During an interview on 4/15/2025 at 4:15 PM, the Regional Dietary Manager (RDM) was asked who was responsible for cleaning the ice machine. The RDM stated, Maintenance. The RDM was asked who is ultimately responsible for the ice machine. The RDM stated kitchen . During an interview on 4/15/2025 at 5:06 PM, the Administrator was asked if there should be black slime on the ice machine. The Administrator stated, Absolutely not.

Based on facility policies, record review, observations, and interviews the facility failed to provide Oxygen therapy as ordered by the Physician for 1 of 1 (Resident #13) reviewed for Respiratory Care. The findings include: 1. Review of the undated facility policy titled, Oxygen Administration Guidelines, revealed, .Review order for oxygen administration to include .flow rate . Review of the facility policy titled, Guidelines For Physician Orders, dated 6/18/2023, revealed .It is the policy of the facility to follow the orders of the physician .All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility . 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Acute Ischemic Heart Disease, Occlusion and Stenosis of Left Carotid Artery, Cerebral Infarction, and Hypertension. Review of the Care Plan dated 1/28/2025 revealed .Administer O2 [oxygen] as ordered per MD [Medical Doctor] .Observe concentrator and/or E [emergency] tank for correct setting of liter . Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 1, which indicated that Resident #13 was severely cognitively impaired. Further review revealed no shortness of breath and oxygen therapy was received. Review of the Physician's Orders dated 3/29/2025, revealed .Oxygen 3 L [liter] PRN as needed for SOB [Shortness of Breath] 3L prn to keep O2 Sat above 91% [percent] . Review of the Medication Administration Record (MAR) dated 4/2025, revealed no documentation of administration of PRN O2. During observations in Resident #13's room on 4/14/2025 at 12:00 PM and 3:09 PM and 4/15/2025 at 7:49 AM, revealed Oxygen concentrator set on 1.5-2 L. During interview and observation on 4/15/2025 at 8:02 AM Licensed Practical Nurse (LPN) C was asked what Resident #13 O2 orders was, LPN C stated, 2L. LPN C was asked to show the O2 orders, LPN C stated, .it changed to 3L . LPN C was asked to show what Resident #13 O2 was set on, LPN C changed O2 setting to 3L. During an interview on 4/15/2025 at 4:33 PM the Director of Nursing (DON) confirmed that staff was expected to follow Physician orders for O2 settings.

Based on facility policy, medical record review, observation and interview the facility failed to ensure dignity and resident choice was met for 1 (Resident #33) of 1 sampled resident reviewed for activities of daily living. The findings include: 1. Review of the undated facility policy titled, CALL LIGHTS, revealed, .It is the policy of the facility to have a system in placed to allow the staff to respond promptly to a resident's call for assistance .Never make the resident feel as though you are too busy to give assistance. If you yourself cannot provide the requested assistance, assure the resident that you will take their request to the appropriate staff. Follow through with this commitment and follow up to see if the resident had the need met. NEVER TURN OFF A CALL LIGH THEN FAIL TO SEE THAT THE RESIDENT'S REQUEST WAS ADDRESSED Review of the undated facility policy titled, Resident Rights, revealed, .The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident . 2. Review of the medical record revealed Resident #33 was admitted on [DATE], with diagnoses which included Muscle Wasting and Atrophy, Chronic Pain Syndrome, Need for assistance with personal care, and Anorexia. Review of the Annual Minimum Data Set assessment (MDS) dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review revealed Resident #33 was dependent for chair/bed-to-chair transfer. During an observation and interview on 4/14/2025 at 3:50 PM, Resident #33 stated, leave the door open I want to see how long it takes her to come down here and put me to bed . Resident #33 turned on his call light at 3:50 PM. Observation on 4/14/2025 at 3:51 PM, revealed 2 staff members sitting at nurses' station where call light was sounding. Observation on 4/14/2025 at 3:57 PM, Resident #33 still awaiting to be placed in bed. Observation on 4/14/2025 at 3:58 PM, Wound Nurse answered the call light and told the resident I will go see if I can find your Certified Nursing Assistant (CNA). Observation on 4/14/2025 at 3:59 PM, Resident #33 continued to wait to be placed in his bed. Observation on 4/14/2025 at 4:04 PM, Resident #33 had rolled into the hall still awaiting to be placed in bed. Observation on 4/14/2025 at 4:05 PM, a CNA takes him into his room then walked back out. Observation on 4/14/25 at 4:08 PM, Resident #33 continued to sit in his wheelchair by his bed. Observation on 4/14/25 at 4:11 PM, Resident #33 continued to be up in his wheelchair. Observation on 4/14/2025 at 4:12 PM revealed 3 staff members are sitting at the nurse's station. Observation on 4/14/2025 at 4:13 PM, the Wound Nurse told Resident #33, I am looking for the CNA so I can help put you to bed. Observation and interview on 4/14/2025 at 4:14 PM, Resident #33 stated, .this is always a problem when I get back from smoking . Observation on 4/14/2025 at 4:16 PM, Resident #33 had been waiting 26 minutes to be put to bed. Observation on 4/14/2025 at 4:16 PM, the CNA was standing at the desk which he told at 4:05 PM, he wanted to go to bed. Observation on 4/14/2025 at 4:19 PM, Resident #33 continued to remain up in his room in his wheelchair. During an interview on 4/15/2025 at 8:08 AM, Resident #33 stated, .I finally went to bed after about 2 hours. It seems to happen every time that CNA is here . Observation on 4/15/2025 at 1:45 PM, Resident #33's call light was on and sounding at the nurse's station. Resident #33 stated, .I am waiting to go back to bed .I went to smoke at 1:00 PM, I been waiting about 15 minutes . Observation on 4/15/2025 at 1:48 PM, CNA E answered Resident #33's call light and told the resident let me go see if I can find your CNA, referring to the CNA assigned to him today. CNA E goes to room [ROOM NUMBER] where his CNA was providing care. CNA E told the CNA he was wanting to go to bed through the door. CNA E stated, I will let him know you're in another room. CNA E goes back to Resident #33's room and informed him the CNA was in another resident's room providing care. Observation on 4/15/2025 at 1:54 PM, Resident #33 continued to be up in his wheelchair waiting to be placed in the bed. Observation on the hall on 4/15/2025 at 1:58 PM, CNA F (CNA assigned to Resident #33) came out of room [ROOM NUMBER] where she had been providing care. CNA F goes to Resident #33's room and told the resident .I will have to go find someone to help . Observation on hall on 4/15/2025 at 2:05 PM, CNA F and another care giver goes into Resident #33's room. Resident #33 had waited 20 minutes. Observation on 4/15/2025 at 2:10 PM, Resident #33 was in the bed. During an interview on 4/16/2025 at 11:50 AM, the Director of Nursing (DON) was asked what she expected staff to do when a call light is on. The DON stated, .I would expect them to answer it timely .they should meet the residents need .a CNA should not say let me find your CNA .the call light should be left on until their needs are met .I would expect the staff to provide the care even if that was not their resident that was to long for a resident to wait to go to bed .

Based on policy review, medical record review, observation, and interview, the facility failed to assess 1 of 1 resident (Resident #197) reviewed for self-administration of medication. The findings include: 1. Review of the undated facility policy titled, Medication Self Administration, revealed .procedures for determining if the resident can safely self-administer .Residents .will be assess at the time of admission .to determine if the practice is safe, based on the results of the Resident Assessment-Self-administration Tool .assessment results will be discussed with the attending physician and an order obtained to self-administer if appropriate . 2. Review of the medical record revealed Resident #197 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Respiratory Failure, and Liver Disease. Basic Interview for Mental Status had not been assessed due to recent admit and in process. Review of the Physician Order Sheet dated April 2025, revealed .Levalbuterol HCl Nebulization Solution 0.63 MG [milligrams] /3ML [milliliter] 6 ml inhale orally via nebulizer .related to Chronic Obstructive Pulmonary Disease . Observation in the Resident's room on 4/15/2025 at 7:41 AM, Resident #197 was sitting on the edge of the bed with the nebulizer mask on and treatment going, and no nurse was present in the room. Observation on 4/15/2025 at 7:49 AM, Licensed Practical Nurse (LPN) A entered Resident #197's room and discontinued the nebulizer treatment. During an interview on 4/15/2025 at 1:08 PM the Director of Nursing (DON) confirmed that there should be an assessment for self-administration and a physician order for a resident to self-administer medications.

Based on medical record review, observation, and interview the facility failed to implement interventions on care plan for 1 of 3 (Resident #26) sampled residents reviewed for accidents. The findings include: Review of the medical record revealed Resident #26 admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Dementia, Osteoarthritis, Difficulty in Walking, and History of Falling. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive abilities. Review of Resident #26's Progress Note dated 8/8/2024 revealed, .Note Text: Resident witnessed on floor beside bed. Bed was in low position. She states that she rolled over and slid onto the floor. She was lying on her right hip .Arms noted under her upper body. Legs straight .Nurse and CNA had been in resident's room [ROOM NUMBER] min prior to fall. She was lying in bed, facing the wall at that time . Review of Resident #26's current comprehensive care plan revealed, .I'm at Risk for Falls as evidenced by the following risk factors and potential contributing Diagnosis: COPD .emphysema; acute respiratory failure with hypoxia; anxiety disorder; major depressive disorder; CHF [Congestive Heart Failure]; difficulty in walking history of falls; need for assistance with personal care; reduced mobility; peripheral vascular disease; unspecified dementia . Continued review of Resident #26's care plan revealed an intervention dated 8/8/2024 for define borders to the bed. During an observation and interview on 4/14/2025 at 2:25 PM, Family Member (FM) G reported she has had numerous falls since she admitted . FM G pulled up Resident #26's sleeve and she was noted to have bruising to the right elbow and 3 steri strips (used to help seal a wound by pulling the two sides of skin together) were noted. Observation on 4/15/2025 at 10:05 AM, Resident #26 was in the bed sleeping. No device or mattress noted to follow the care plan intervention for define borders of bed to help prevent falls. During an observation and interview on 4/15/2025 at 10:10 AM, Certified Nursing Assistant (CNA) F was asked what would be in place to meet the fall intervention for defined borders for her bed. CNA F stated, .we use a pool noddle sometimes, bolsters or the mattress may be raised on the edge . CNA F was asked to assess Resident #26's bed for the defined border. CNA F verified Resident #26 does not have anything to define the borders to her bed. During an observation and interview on 4/15/2025 at 10:15 AM, the MDS Coordinator was asked what would consist of defined borders on a fall care plan. MDS Coordinator stated, .either pool noddle, rolled up blanket, or a certain kind of mattress . The MDS Coordinator was asked to observe Resident #26's bed and asked if the resident had the intervention in place to define the borders of her bed. The MDS Coordinator stated, .no, it should be on the bed . During an interview on 4/15/2025 at 10:20 AM, the Director of Nursing was asked if a resident has an intervention for define borders to prevent falls should it be followed. The DON stated, .Yes, it should be on the bed .

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure PRN (as needed) psychotropic medications for 1 (Resident #26) of 5 sampled residents reviewed for unnecessary medications were limited to 14 days duration. The facility failed to obtain a physician's assessment or documented rationale for continued use of the medication. The findings include: 1. Review of the undated facility policy titled, GUIDELINES FOR PSYCHOTROPIC MEDICATION, revealed .Based upon each individual resident's comprehensive assessment, the facility will ensure that residents who have not previously been on a psychotropic drug (s) are not given these meds unless the medication is necessary to treat a specific condition/diagnoses .PRN [as needed] Orders for Psychotropic Medications: PRN orders for psychotropic drugs will be limited to 14 days, unless the physician identifies and documents rationale to extend he medication beyond 14 days. PRN antipsychotics drugs will be limited to 14 days and will not be renewed unless the physician evaluates the resident for appropriateness of the medication . 2. Review of the medical record revealed Resident #26 admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure with Hypoxia, Chronic Diastolic Heart Failure, and Major Depressive Disorder. Review of the Order Review History Report dated 3/15/2025 - 4/15/2025, revealed an order for Lorazepam (Antianxiety medication give for Anxiety) Oral Tablet 0.5 mg (milligram) by mouth every 6 hours as needed for anxiety related to Acute Respiratory Failure with Hypoxia, Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. Continued review revealed Resident #26 had an order for PRN antianxiety medication since 1/14/2025. Continued review revealed an order for Buspar HCl (Hydrochloride) give 10 mg tablet two times a day for anxiety routinely. Further review revealed an order for Lorazepam give 0.5 mg tablet two times a day for anxiety routinely. Review of the Medication Administration Record (MAR) dated 3/1/2025-3/31/2025 revealed monitoring of behaviors for crying, agitation, or refusing of care. No behaviors were noted during the month of 3/2025. Review of the MAR dated 4/1/2025-4/15/2025 revealed monitoring of behaviors for crying, agitation, or refusing of care. No behaviors were noted from 4/1/2025-4/15/2025. Review of the Consultant Pharmacist Communication to the Physician form for Resident #26 dated 3/2024 revealed .prn [as needed] lorazepam-Under CMS regulations that started November 2017, PRN psychoactive medications. including anxiolytics FOR ANY INDICATION are initially limited for 14 days. NO EXCEPTIONS ARE GIVEN FOR HOSPICE OR SEIZURES. AFTER 14 DAYS, THE ORDER MUST BE DISCONTINUED and the resident must be re-evaluated for continued need of therapy. The results of the evaluation should be documented in the resident's medical record, with any behaviors warranting continued use documented by the nursing staff. Please discontinue order and reevaluate this resident by 3/29/24 [3/29/2024] . Observation on 4/15/2025 at 8:19 AM, Resident #26 was noted to be drowsy sitting in the dining area and leaning to the left side of her wheelchair. Observation on 4/15/2025 at 8:25 AM, Resident #26 nodded off sitting in her wheelchair and awakened when her head nodded down. Observation on 4/15/2025 at 8:28 AM, Resident #26 was served her breakfast, and a staff member was feeding her. The staff member had to pull her over to help the resident to sit upright in the wheelchair since Resident #26 continued to slump over to her left side. Observation on 4/15/2025 at 8:32 AM, the staff member continued to prop Resident #26 up for her to sit upright in his wheelchair. A telephone call was placed to the Pharmacist on 4/16/2025 at 12:09 PM. No return call was received from the Pharmacist prior to exiting the facility. During an interview on 4/16/2025 at 12:15 PM, the Director of Nursing (DON) was asked about Resident #26's prn Lorazepam order. The DON stated, .her Lorazepam is prn and it should not be ordered no longer than 14 days. Yes, it has been ordered since 1/2025 .all prn antianxiety meds should have a stop date of 14 days .I usually go in and check for this, but I missed it .we do discuss this with the hospice agency and they know our process for ordering these medications for only 14 days prn .

Based on facility policy review, medical record review, observation and interview, the facility failed to accommodate dietary preferences for 2 of 2 (Resident #33 and #42) sampled residents reviewed for dietary preferences. The findings include: 1. Review of the undated facility policy titled, RESIDENT FOOD PREFERENCES, revealed .Food preferences will be honored unless contraindicated .The facility will offer residents food choices and preferences to include .personal preferences .The Food Service Manager or designee will interview the resident and obtain their food preferences .Food preferences will be updated accordingly and will be noted in the resident's tray card .The staff may follow the list of resident's food choices and preferences . 2. Review of the medical record revealed Resident #33 was admitted on [DATE], with diagnoses which included Muscle Wasting and Atrophy, Chronic Pain Syndrome, Need for assistance with personal care, and Anorexia. Review of the Nutritional Risk Quarterly Review dated 6/17/2024, revealed no discussion with Resident #33 related to his food preferences. Review of the Nutritional Risk Quarterly Review dated 9/11/2024, revealed no discussion with Resident #33 related to his food preferences. Review of the Nutritional Risk Quarterly Review dated 12/4/2024, revealed no discussion with Resident #33 related to his food preferences. Review of the Nutritional assessment dated [DATE], revealed food preferences for French toast and pancakes. Continue review revealed .List any Food/Beverage Dislikes See Tray Card . Review of the Annual Minimum Data Set assessment (MDS) dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review revealed Resident #33 required setup or clean-up assistance with eating. Further review revealed Resident #33 had no significant weight loss in the last month or 6 months. Review of the current comprehensive care plan revealed, .My history indicates that I have experienced serious trauma during my lifetime. Specifically, trauma related to .Homelessness, living through depravation, going without food . Review of Resident #33's printed tray card dated 4/15/2024 revealed no area for likes or dislikes. During an interview on 4/14/2025 at 9:15 AM, Resident #33 was asked if breakfast was good. Resident #33 stated, .I haven't seen a good breakfast, pancakes and french toast is what I like but oatmeal is what I got . Observation in the dining room on 4/15/25 07:49 AM, residents were noted to have pancakes on their breakfast tray. During an interview on 4/15/25 at 8:36 AM, Resident #33 was asked how his breakfast was this am. Resident #33 stated, .got to go with what they cook .just take what you can get . Resident #33 had eaten his eggs and half of his oatmeal. 3. Review of the medical record revealed Resident #42 admitted to the facility on [DATE], with diagnoses which included Rhabdomyolysis, Dementia, Essential Hypertension, and Dehydration. Review of Resident #42's admission Progress Note dated 2/27/2025 revealed, .The resident has a good appetite but does not like to drink tea . Review of the Admission MDS dated [DATE], revealed Resident #42 had a BIMS score of 8 which indicated moderate cognitive impairment. Continued review revealed Resident #42 required setup or clean-up assistance with eating. Further review revealed Resident #42 had weight loss noted prior to his admission. Review of the current comprehensive care plan revealed, .At possible risk for dehydration with signs and symptoms R/T [related to]: history of dehydration poor po [by mouth] intake at times . Review of Resident #42's Nutritional assessment dated [DATE] revealed the Food Preferences were not marked, list of food/beverage dislikes was blank, and comments related to food preferences noted .See tray card . Further review revealed RD [Registered Dietician] Summary noted Resident #42 remains at risk for compromise in nutrition and hydration status related to altered nutrition related lab values and being on meds that may have nutritionally significant side effects. Observation on 4/14/2025 at 12:14 PM, Resident #42 was noted to have tea on his tray. Continued review revealed Resident #42 had eaten 100% (percent) of his meal and had not touched his tea. Review of Resident #42's printed tray card dated 4/15/2024 revealed no area for likes or dislikes. During an interview on 4/15/2025 at 3:10 PM, the Dietary Manager was asked about the 3/6/2025 Nutritional Assessment being blank for beverage dislikes. The Dietary Manager stated, .I don't do the preferences in [Named Computer system], I don't have access to it .I do them on paper . The Dietary Manager searches through her filed papers and stated, .I haven't done a preference on him. I usually do it when they admit .No he shouldn't have received tea on his tray . During an interview on 4/15/2025 at 3:15 PM, the Dietary Manager was asked if Resident #33's food preferences noted he enjoyed pancakes and french toast should he receive those foods at breakfast. The Dietary Manager stated, .he never has said he wanted them daily . The Dietary Manager was asked to show this surveyor his tray card. Review of the tray card with the Dietary Manager revealed no likes or dislikes noted on the tray card. The Dietary Manager stated, .It's not going to show the likes and dislikes . The Dietary Manager was asked if staff prepare the trays by the review of the tray cards. She stated, yes. The Dietary Manager and Regional Dietary Manager was asked how the staff members who prepare the trays on the tray line would know what foods the resident prefers. The Dietary Manager stated, .I see what you are saying but the Certified Nursing Assistants would come back and get something else if they didn't like it .If he liked pancakes, he should receive them when we have them . During an interview on 4/15/2025 at 4:00 PM, the Administrator was asked if the food preference policy should be followed. She stated, Yes, it should be followed. The Administrator was shown Resident #33 and Resident #42's tray card which revealed no likes or dislikes. The Administrator stated, .usually tray cards show the likes and dislikes I will have to check with [Named Dietary Company] to see why the cards are not showing that .

Based on policy review, record review, observations and interviews the facility failed to ensure staff followed hand hygiene guidelines during wound care for 1 of 1 (Resident #13) reviewed for wound care. The findings include: 1. Review of the facility policy titled, Dressing Change, Clean, dated 1/1/2024, revealed .Procedure Purpose .To prevent infection and spread of infection .Perform hand hygiene .put on .disposable gloves .Cleanse wound .Apply prescribed medication .Apply dressings .Remove gloves .Wash hands . 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Muscle Weakness, Abnormal Posture, Hemiplegia and Hemiparesis, and Low Back Pain. Review of Care Plan dated 1/28/2025, revealed .Skin .has disruption of skin surface .to labia .disruption of skin surface will remain free from infection . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 1, which indicated that Resident #13 was severely cognitively impaired. Review of the Physician's orders dated 3/13/2025, revealed .Clean sacrum with wound cleanser. Pat dry. Apply zinc oxide paste and apply non pressure dressing to sacrum daily and PRN [as needed]. every day shift for pressure injury healing AND every 12 hours as needed for pressure injury healing . Review of the Physician's orders date 4/15/2025, revealed .Apply layer of Dermaphor to right labia Q [every] shift and PRN every shift for protection AND as needed for protection . During observation in Resident #13's room on 4/16/2025 at 9:22 AM, revealed Licensed Practical Nurse (LPN) D touched the paper towel dispenser after washing hands, then preceded to resident's bedside to begin wound treatment. LPN D reached into uniform pocket with gloved hand to retrieve a marker, used the marker on clean dressing, and laid marker on bedside table without a barrier, applied dressing to sacral wound, changed gloves and then preceded to address the next wound. LPN D removed the marker from bedside table and placed into uniform pocket, then exited the resident's room and applied Alcohol Based Hand Rub (ABHR) to hands. LPN D failed to perform proper hand hygiene after touching paper towel dispenser, after reaching in pocket, between wound care treatments, and after completing all wound care. LPN D failed to sanitize marker prior to exiting room to prevent cross contamination. During an interview on 4/16/2025 at 11:27 AM, LPN D confirmed that staff should not touch the paper towel dispenser after washing hands, staff should not reach into uniform pocket with gloved hand, proper hand hygiene should be performed between wounds, and multiuse items should be sanitized after use. During an interview on 4/16/2025 at 11:53 AM, the Director of Nursing (DON) confirmed that staff should not touch the paper towel dispenser after washing hands, staff should not reach into uniform pocket with gloved hand, proper hand hygiene should be performed between wounds and at end of wound care treatment, and multiuse items should be sanitized after use. 51670

Based on policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to formulate an Advance Directive to residents or the residents' responsible parties for 3 of 16 sampled residents (Resident #13, #17, and #35) reviewed for Advanced Directives. The findings include: Review of the facility's policy titled, Advance Directives Policy and Procedure, dated 1/1/2017, revealed .The facility provides the resident's the right to accept or refuse medical and surgical treatment, and at the resident's option, formulate an advance directive .Determine upon admission whether the resident/legal representative has an advanced directive and if not, determine whether the resident/legal representative wishes to formulate an advance directive .Upon admission, the facility will provide written information to resident/legal representative concerning the resident's rights to make decisions regarding medical care including the right to accept/refuse medical treatment and the right to formulate advance directives .the facility must determine if the resident executed an advance directive or has given other instructions to indicate what care is desired in case of subsequent incapacity .If the resident has not executed advance directives or is incapacitated, the facility will advise the resident/legal representative regarding the right to establish an advance directive . Review of the medical record, revealed Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 had a Brief Interview For Mental Status (BIMS) of 3, which indicated severe cognitive impairment. Review of Resident #13's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change MDS assessment dated [DATE], revealed Resident #17 had a BIMS of 12, which indicated moderate cognitive impairment. Review of Resident 17's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #35 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the annual MDS assessment dated [DATE], revealed Resident #35 had a BIMS score of 0, which indicated severe cognitive impairment. Review of Resident #35's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. During an interview on 8/2/2022 at 8:29 AM, the Administrator confirmed the facility was unable provide documentation that Resident #13, #17, and #35 or their responsible parties were given a right to formulate an Advance Directive.

Based on policy review, medical record review, and interview the facility failed to ensure Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's undated policy titled, PHYSICIANS ORDERS-(FOLLOWING PHYSICIAN ORDERS), revealed .It is the policy of the facility to follow the orders of the physician . Review of the facility's undated policy titled, BLOOD GLUCOSE MONITORING, revealed .Blood sugars found to be below 70 or above 400 will be reported immediately to the physician and resident's representative . Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .If BS [Blood Sugar] 60 or > [greater than] 400 notify MD/NP [Medical Doctor/Nurse Practitioner] .TYPE 2 DIABETES MELLITUS WITH [CONDITION(S)] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated severe cognitive impairment. Review of the Care Plan dated 7/12/2022, revealed, .Potential for signs of hypo/[CONDITION(S)] [decreased/increased blood sugar] related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .pallor, diaphoresis, shakiness, change in mental status .assess blood sugar via [by way of] accucheck [blood glucose monitoring] and notify physician if abnormal . Review of the Progress Notes dated 7/31/2022, revealed .Resident is alert and able to make needs known. Resident has been up and propelling self in wheelchair . During an interview on 8/1/2022 at 3:42 PM, revealed Resident #26 confirmed last week his blood sugar was 430, he received 12 units of insulin and his blood glucose dropped to 50 during the night. Review of the Nurses' Progress Notes dated 7/27/2022, revealed .Resident wife called voicing concerns regarding HS [hour of sleep] insulin of 25 units and ssi [Sliding Scale Insulin] for BS over 400. This nurse explained that insulin was given per orders and MD [Medical Doctor] was aware . There was no documentation on 7/27/2022 of the hypoglycemic episode. During an interview on 8/2/2022 at 3:15 PM, the Director of Nursing (DON) and Registered Nurse (RN) #1 confirmed Resident #26's blood glucose was 50 on 7/27/2022, and LPN #2 failed to document, notify the physician, and follow the facility policy, and a one on one in-service was done with LPN #2 today. During a telephone interview on 8/3/2022 at 11:00 AM, LPN #2 confirmed she was working on 7/26/2022 and Resident #26's blood sugar was 50. LPN #2 confirmed she did not document in his chart and failed to notify the doctor that his blood sugar had dropped to 50.

Based on policy review, medical record review, observation, and interview, the facility failed to document treatments and provide treatment orders for pressure ulcers for 2 of 3 (Resident #3 and #27) sampled residents reviewed with pressure ulcers. The findings include: 1. The facility's Wound Prevention and Management Program policy, revised 5/17 documented, .To identify Residents at risk of developing pressure ulcers and conduct appropriate interventions to maintain intact skin .Write a separate treatment order for each wound site .D. MANAGEMENT OF WOUND INFECTION: The purpose of this procedure is to prevent wound deterioration, and other complications .provide local management that optimizes healing potential . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Care Plan dated 7/24/19 documented, .I am at risk for skin breakdown .non-compliance with being off load at times .choosing not to receive incontinence care at times .I have areas of skin breakdown now on my buttocks .Please treat areas of my skin that are broken down according to my doctors (doctor's) orders . A Physician's Order dated 6/3/19 documented, .Site: left buttock / Topical Every Shift (day shift 7 AM-7 PM, night shift 7 PM-7AM) .Treatment: Clean with W/C (wound cleanser), apply skin prep, and leave OTA (open to air) . Review of the (MONTH) 2019 Treatment Administration Record (TAR) revealed there was no treatment documented for the night shift on 6/20/19. A Physician's Order dated 6/21/19 documented, .Site: left buttock / Topical Every Shift .Treatment: Clean with W/C, air dry, skin prep around wound, and cover with moisture-balancing dressing . Review of the (MONTH) 2019 TAR revealed there was no treatment documented for the night shift on 6/23/19. Review of the (MONTH) 2019 TAR revealed there was no treatment documented for the night shift on 7/2/19, 7/3/19, 7/7/19, 7/16/19, and on both shifts on 7/20/19. A Physician's Order dated 8/30/19 documented, .Site: left buttocks .day shift .clean w/ (with) W/C, apply skin prep to intact peri-wound, and cover wound-bed with hydrogel dressing . A Physician's Order dated 9/23/19 documented, .Site: left buttocks every Night and Day Shift .apply skin prep and leave OTA . Review of the (MONTH) 2019 TAR revealed there was no treatment documented on 9/4/19 and 9/13/19, and no treatment documented for the night shift on 9/24/19. A Physician's Order dated 9/29/19 documented, .Site: left buttocks .Day Shift .apply skin prep and leave OTA . Review of the (MONTH) 2019 TAR revealed there was no treatment documented on 10/3/19. Observations in Resident #3's room on 10/7/19 at 2:07 PM, revealed Resident #3 had a Stage 2 pressure ulcer to the left buttock, the wound bed was 0.5 centimeters (cm) length (L), 1.3 cm width (W), and less than 0.1 cm depth (D). Interview with the Director of Nursing (DON) on 10/10/19 at 9:03 AM, in the DON office, the DON was asked if there was documentation the pressure ulcer treatments were performed as ordered on [DATE], 6/23/19, 7/2/19, 7/3/19, 7/7/19, 7/16/19, 7/20/19, 9/4/19, 9/13/19, 9/24/19, and 10/3/19. The DON stated, No . 3. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented Resident #27 was cognitively intact, and had (2) stage 4 pressure ulcers upon admission and (4) unstageable pressure ulcers upon admission. The Care Plan dated 8/28/19 documented, .I am at risk for skin breakdown related to my history of wounds, decreased mobility, current wounds, [MEDICAL CONDITION] status and protein-calorie malnutrition .with interventions .treat any areas that breakdown according to my doctors (doctor's) orders .9/19/19 Podus boots bilaterally while in bed as allows . Review of the facility's WEEKLY PRESSURE WOUND LOG dated 9/30/19-10/6/19 documented, .Facility Acquired Right pad of foot DTPI (Deep Tissue Pressure Injury) .Size (cm) Lx (by) W 3x1.0 .Depth (cm) 0 .Treatment Apply w (with)/Skin Prep . Review of the facility's WEEKLY PRESSURE WOUND LOG dated 10/7/19-10/13/19 documented, .Facility Acquired Right pad of foot DTPI .Size (cm) LxW 2.5x0.9 .Depth(cm) 0 .Treatment Apply w/Skin Prep . Review of the facility's Week 1 Assessment of the DTPI to the right pad of the foot dated 9/30/19 documented, .Length in cm: 3. Width in cm: 1. Depth in cm: 0 .Physician response: No new orders .Initial assessment . Review of the facility's Week 2 Assessment of the DTPI to the right pad of the foot dated 10/7/19 documented, .Length in cm: 2.5 Width in cm: 0.9 Depth in cm: 0 .Yes .Physician response: No new orders . Medical record review revealed there were no physician's orders for the pressure ulcer to the right pad of the foot. Review of the (MONTH) and (MONTH) 2019 TAR, revealed no treatments documented for the right pad of the foot pressure ulcer. Observations in Resident's #27's room on 10/8/19 at 3:06 PM, revealed Resident #27's wound care was performed by RN #1, skin prep was applied to right foot pad DTPI. Interview with the DON on 10/9/19 at 4:42 PM, in room [ROOM NUMBER], the DON was asked if Resident #27 had an order for [REDACTED].

Based on policy review, medical record review, observation, and interview, the facility failed to ensure accurate documentation related to insulin administration for 1 of 5 (Resident #25) sampled residents reviewed for unnecessary medications and failed to ensure medical information was kept private and confidential for 1 of 13 (Resident #24) sampled residents. The findings include: 1. The facility's Medication Administration Subcutaneous Insulin policy, reviewed 1/14 documented, .Check prescriber's order for insulin .Determine the correct amount of insulin to be withdrawn . 2. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The (MONTH) 2019 physician's orders [REDACTED].=0, 201-250=2u, 251-300=4u, 301-350=6 u, 351-400=8 (u), > (greater than) 400 call MD (Medical Doctor) The Medication Administration Record [REDACTED] a. 9/3/19 at 6:00 AM the blood glucose was 283 and 54 units of insulin was documented as administered. 4 units of insulin was ordered to be administered. b. 9/3/19 at 8:30 PM the blood glucose was 388 and 73 units of insulin was documented as administered. 8 units of insulin should have been administered. c. 9/4/19 at 6:00 AM the blood glucose was 284 and 54 units of insulin was documented as administered. 4 units of insulin was ordered to be administered. d. 9/4/19 at 8:30 PM the blood glucose was 378 and 12 units of insulin was documented as administered. 8 units of insulin was ordered to be administered. e. 9/9/18 at 6:00 AM the blood glucose was 194 and 65 units of insulin was documented as administered. Resident #25 should not have received any insulin. f. 9/12/19 at 8:30 PM the blood glucose was 390 and 73 units of insulin was documented as administered. 8 units of insulin was ordered to be administered. g. 9/1719 at 8:30 PM the blood glucose was 486 and 73 units of insulin was documented as administered. 8 units of insulin was ordered to be administered. h. 9/18/19 at 8:30 PM the blood glucose was 367 and 6 units of insulin was documented as administered. 8 units of insulin was ordered to be administered. The (MONTH) 2019 physician's orders [REDACTED].[MEDICATION NAME] U/1 ML Solution (Insulin [MEDICATION NAME], Recombinant) 70 units Subcutaneous Twice a day 09:00 (9 AM), 21:00 (9 PM) . There was no documentation on the Medication Record (MAR) the insulin was administered on 9/28/19 at 9:00 PM and on 9/29/19 at 9:00 AM. Interview with Regional Nurse Consultant and the Informatics Nurse on 10/10/19 at 9:35 AM, at the 100/200 Hall Nurses' Station, the Regional Nurse Consultant confirmed the inaccurate documentation of the insulin administered. The Informatics Nurse stated, I feel it is a data entry issue. The Regional Nurse Consultant confirmed his statement. The Regional Nurse Consultant was asked about the documentation of the [MEDICATION NAME]. The Regional Nurse Consultant confirmed the [MEDICATION NAME] was not documented as ordered on the MAR. 3. The facility's HIPAA (Health Insurance Portability and Accountability Act) - General policy, revised 5/14 documented, .It shall be the policy of the facility to protect and safeguard the protected health information (PHI) created . Random observations on the 300 Hall outside the Janitor's Closet on 10/8/19 at 4:02 PM, revealed Resident #24's Electronic Health Record (EHR) was open, with personal information that included her Medication Administration Record [REDACTED]. No staff were present. Interview with Licensed Practical Nurse (LPN) #1 on 10/8/19 at 4:08 PM, on the 300 Hall by the Janitor's Closet, LPN #1 was asked if personal information on the EHR was left in view of the public. LPN #1 confirmed the EHR was open to the public and stated, .No .it should have been closed down. Interview with the Director of Nursing (DON) on 10/10/19 at 12:11 PM, in the DON office, the DON was asked if the resident's EHR should be left opened and unattended on the computer in public view. The DON stated, No.

Based on medical record review and interview, the facility failed to ensure physician orders [REDACTED].#25) sampled residents reviewed for unnecessary medications. The findings include: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The (MONTH) 2019 physician's orders [REDACTED].=0, 201-250=2u, 251-300=4u, 301-350=6u, 351-400=8 (u), > (greater than) 400 call MD (Medical Doctor) . The (MONTH) 2019 Medication Administration Record [REDACTED]. Interview with the Regional Nurse Consultant on 10/10/19 at 9:25 AM, at the 100/200 Hall Nurses' Station, the Regional Nurse Consultant was asked if the doctor had been notified of the blood sugar > 400. The Regional Nurse Consultant confirmed the MD had not been notified of the blood glucose results.

Based on policy review, observation and interview, the facility failed to ensure food was maintained at a proper holding temperature for 15 of 26 residents receiving a meal tray. The findings included: The facility's Holding Foods policy dated 3/27/17 documented, .Temperatures must meet or exceed 135 degrees F (Fahrenheit) .for hot foods . Observations in the kitchen on 12/11/18 beginning at 11:30 AM, after 15 meal trays had already been served, revealed the following: a. smothered pork chops: 100 degrees F b. pureed cabbage: 112 degrees F c. pork chop without gravy: 110 degrees F Interview with the cook on 12/11/18 at 12:10 PM, in the kitchen, the Cook was asked what is the holding temperature for hot foods. The Cook stated, .above 130 . The Cook was then asked are the smothered pork chops, pureed cabbage, and pork chops without gravy at the proper temper holding temperature. The Cook stated, No. Interview with the Dietary Manager on 12/11/18 at 3:00 PM, in the dietary manager office, the Dietary Manager was asked what the holding temperature for hot food should be. The Dietary Manager stated, .at least 135 or greater. The Dietary Manager was then asked should the temperature for the smothered pork chops be 100 degrees Fahrenheit, the pureed cabbage at 112 degrees Fahrenheit, and the pork chops without gravy be at 100 degrees Fahrenheit. The Dietary Manager stated, .No .

Based on policy review, medical record review, and interview, the facility failed to revise the care plan related to antianxiety medication use, weight loss, and anticoagulant use for 4 of 12 (Resident #7, 9, 17, and 18) residents. The findings include: 1. The facility's Care Plans policy dated 7/14 documented, .10. Care Plans will be updated as changes occur. New problems will be added as they occur . 2. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] (antianxiety) 5 mg .enteral tube twice a day . Review of the current care plan dated 3/26/18 and last reviewed 12/3/18 was not revised related to Antianxiety medication use. Interview with with the Minimum Data Set (MDS) Coordinator on 12/12/18 at 7:46 AM, in the MDS Coordinator's office, the MDS Coordinator was asked if there should be a care plan addressing the resident's use of antianxiety medication use. The MDS Coordinator stated, .she (Resident #7) should have a care plan for the antianxiety medication . 3. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current plan of care dated 9/21/18 and last reviewed 12/1/18 was not revised to reflect weight loss. A physician's orders [REDACTED].Juven (supplement) .1 packet oral twice a day . A physician's orders [REDACTED].[MEDICATION NAME] .5 ml (milliliter) oral one time daily .for .abnormal weight loss . Interview with the MDS Coordinator on 12/11/18 at 2:20 PM, in the MDS office, the MDS Coordinator was asked should this resident have a care plan for his nutritional status. The MDS Coordinator stated, .yes, he should have . 4. Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current plan of care dated 7/27/18 and last reviewed 11/30/18 was not updated to reflect the significant weight loss and interventions implemented for the dates of 10/9/18 through 12/10/18. Interview with the Director Of Nursing (DON) on 12/12/18 at 9:45 AM, in room [ROOM NUMBER], the DON was asked if Resident #17 was care planned for weight loss. The DON stated, No, I didn't see it . 5. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] (anticoagulant) .40 mg/0.4 ml sol (solution) .sq (subcutaneous) .at bedtime . Interview with the DON on 12/11/18 at 1:27 PM, in room [ROOM NUMBER], the DON confirmed that Resident #18 was not care planned for anticoagulant use. The DON stated, .the MDS Coordinator realized the resident didn't have a care plan for anticoagulants and created one today .

Based on policy review, observation and interview the facility failed to ensure food was maintained at a proper holding temperature. The facility had a census of 28 with 26 of those residents receiving a meal tray from the kitchen. The findings included: Review of the facility's Food Temperature Control policy documented, .Hot foods are held at a minimum of 140 F (Fahrenheit) or higher . Observations in the kitchen on 3/5/18 beginning at 11:30 AM, revealed the following: a. chicken: 128 F degrees b. scalloped potatoes: 112 F degrees c. chopped chicken: 80 F degrees d. black eye peas: 130 F degrees Interview with the Dietary Manager on 3/5/18 at 2:30 AM, in the Dietary Manager office, the Dietary Manager confirmed the temperature of the chicken, scalloped potatoes, chopped chicken and black eye peas were below acceptable holding temperatures.

Based on policy review, observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by open food items with no date, expired food, and the stove not properly cleaned. The facility had a census of 28 with 26 of those residents receiving a meal tray from the kitchen. The findings included: 1. Review of the facility's Cold Storage Areas policy documented, .Date and label all products removed from original containers .Store cold foods until their use by date, expiration date . Observations in the kitchen on [DATE] beginning at 9:40 AM, revealed the following: a. an undated and unlabeled container of baked beans b. an unsealed and undated container of link sausage c. an undated and unlabeled container of grape jelly d. an undated opened package of American cheese e. an unsealed container of pimento cheese f. an unsecurely wrapped and undated pat of butter g. 2 undated loaves of bread in the freezer h. a zip lock bag of ham with a date to throw away by [DATE] i. an undated opened bag of chicken nuggets j. an opened and undated bag of french fries Interview with the Dietary Manager on [DATE] at 2:30 PM, in the Dietary Manager's office, the Dietary Manager was asked if it was acceptable to have food products unsealed, opened undated, and expired food stored in the refrigerator and freezer. The Dietary Manager stated, No. 2. Review of the facility's Cleaning & Sanitation policy documented, .develops, implements and monitors a cleaning schedule to include all areas of the kitchen and equipment . Observations in the kitchen on [DATE] at 9:40 AM, revealed a golden, yellow, sticky substance along the edges and the side of the cook stove. Interview with the Dietary Manager on on [DATE] at 2:30 PM, in the Dietary Managers office, the Dietary Manager was asked if it was acceptable to have a golden, yellow, sticky substance on the cook stove. The Dietary Manager stated .No.

Based on policy review, medical record review, observation and interview, the facility failed to ensure 1 of 1 (Licensed Practical Nurse (LPN) #1) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 5 medication errors were observed out of 34 opportunities for error, resulting in a medication error rate of 14.71%. The findings included: 1. Review of the facility's Providing Care and Services . policy dated 5/17 documented, This facility will provide effective care, treatment and services .in compliance with current regulations and physician's orders [REDACTED]. 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].CRANBERRY 450 MG (milligram) CAPSULE .2 (tablets) Oral . Observations in Resident #16's room on 3/5/18 beginning at 10:21 AM, revealed LPN #1 administered one Cranberry 450 Mg tablet to Resident #16. Interview with the Assistant Director of Nursing (ADON) on 3/5/18 beginning at 3:45 PM, at the medication cart near the nurses station, the ADON was asked how many Cranberry tablets Resident #16 should have received. The ADON reviewed the physician's orders [REDACTED].should have gotten 2 . 3. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].SAVAYSA 30 MG .1 TAB Oral . Observations in Resident #19's room on 3/5/18 beginning at 9:55 AM, revealed LPN #1 administered Resident #19's morning medications and failed to administer the scheduled Savaysa. Interview with LPN #1 on 3/5/18 at 3:55 PM, at the medication cart near the nurses station, LPN #1 was asked about Resident #19's Savaysa. LPN #1 reviewed the orders and confirmed it had not been administered as ordered and scheduled. LPN #1 stated, .maybe I just forgot . 4. Medical record review revealed Resident #278 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED].Oral . Observations in Resident #278's room on 3/5/18 beginning at 10:49 AM, revealed LPN #1 administered Resident #278's morning medications. LPN #1 failed to administer the scheduled Myrbetriq, [MEDICATION NAME], and [MEDICATION NAME]. Interview with LPN #1 on 3/5/18 at 4:00 PM, at the medication cart near the nurses station, LPN #1 was asked about Resident #278's [MEDICATION NAME], Myrbetriq, and [MEDICATION NAME]. LPN #1 reviewed the orders and confirmed the medications had not been administered as ordered and scheduled. LPN #1 stated, I had quite a mess going on up here. Interview with the ADON on 3/6/18 at 10:42 AM, in the RAI (Resident Assessment Instrument) office, the ADON was asked if medications should be administered to residents as ordered by the physician. The ADON stated, Yes, Ma'am.