Every finding on record at Westminster at Lake Ridge

Based on observations, interviews and facility document review, the facility staff failed to maintain a safe environment for one of thirty-seven residents in the survey sample (Resident #1). Four oxygen cylinders were observed unsecured constituting the identification of immediate jeopardy (IJ) at Level Four, Isolated scope and severity and substandard quality of care. Upon verification of the removal of the IJ, the scope and severity were lowered to Level Two, Isolated. The findings include:On 1/20/26 at 12:46PM, during initial rounds, four oxygen e-tanks were observed stored freestanding in an upright position, not contained in a stand or holder in Resident #1's room on the secured Memory Care Unit. (An E tank (or E-cylinder) is a common medical oxygen cylinder, typically holding around 680 liters (about 23-24 cubic feet) of oxygen, with dimensions of roughly 4.4 inches in diameter and 24-28 inches in height, weighing around 10 lbs. empty, and used for home, travel, and emergency oxygen needs.) On 1/20/26 at 1:00PM, a second observation of Resident #1 was conducted by the survey team. The oxygen cylinder tanks were observed freestanding approximately 3 inches from the wall immediately to the left side of the door as you enter the room. Resident #1 was sitting in his wheelchair, with the cylinders approximately 2 1/2 feet directly behind his chair. Resident #1's wife was observed visiting him in the room.Resident #1, whose room the oxygen cylinders were observed in, was admitted to the facility Health Care Center on 12/18/25 with diagnoses including but not limited to acute respiratory failure with hypoxia (dangerously low supply of oxygen), hypertensive heart disease, chronic obstructive pulmonary disease, pneumonia and atrial fibrillation (irregular heart rhythm). Resident #1 was admitted to Hospice services on 12/19/25 for hypertensive heart disease. Resident #1's most recent MDS (Minimum Data Set) Assessment with ARD (Assessment Reference Date) 12/31/25 was coded in Section C. Cognitive Pattern with a score of 2 out of 15 indicating severe cognitive impairment and impaired safety awareness. Resident #1 had a physician order for oxygen 2 liters per minute via nasal cannula.On 1/20/26, at approximately 1:15PM, a third observation was conducted and again the cylinder tanks were observed stored unsecured, to the left of the door as you entered the room. An interview was conducted with LPN-B. According to LPN-B, the oxygen tanks had been there over a week or so and they had called Hospice to come and pick them up. LPN-B was interviewed on how oxygen cylinder tanks should be stored and she stated, the tanks should be stored in rolling stands. Further interview with LPN-B on why they should be stored in rolling stands she replied, so that they don't fall over and so the resident can move about the unit with his family.On 1/20/26 at 1:45PM, an observation and interview were conducted with the Director of Nursing and Assistant Director of Nursing. The observation again revealed four oxygen cylinder tanks freestanding approximately 3 inches from the wall immediately to the left side of the door as you enter the room. The Director of Nursing (DON) indicated that the oxygen tanks were not stored properly and should be secured in a stand or holder and stated the tanks could fall over or accidentally be knocked over by staff or visitors causing the cylinder to propel and/or explode, potentially inflicting harm to residents and staff. According to the DON, the tanks had been delivered by Hospice, and the facility nurse had called last week to have them come and pick them up. The Director of Nursing and the Assistant Director of Nursing immediately removed the four-cylinder oxygen tanks from Resident #1's room and stored them in the facility's oxygen storage area in stands and racks.On 1/20/26 at 3:15PM, the survey team conducted a sweep of the entire facility and there were no other unsecured oxygen tanks found in the facility. An inspection of the facility's oxygen storage area was conducted where seventy-two (72) cylinder tanks were observed securely stored in stands and/or racks.On 1/20/26 at 4:00PM, a meeting was conducted with the Administrator and the Director of Nursing to inform them of Immediate Jeopardy due to the observation of four (4) oxygen cylinder tanks stored unsecured in Resident #1's room on the secured Memory Unit. The risk of these unsecured tanks posing an imminent risk of safety for residents, visitors and staff is high due to the resident population on the secured unit consisting of residents with cognitive impairments and impaired safety awareness.A review of the facility's policy Oxygen Administration dated, October 2024 read in part:Paragraph entitled, Equipment and Supplies: The Following will be necessary when performing this procedure. 1. Portable oxygen cylinder (strapped to the stand).On 1/20/26 at 6:04PM, the Administrator submitted an Immediate Jeopardy (IJ) Removal Plan. The IJ Removal Plan was reviewed by the survey team, sent to the State Agency for review and the IJ Removal Plan was accepted.The facility's IJ Removal Plan read: 1. Immediate action taken for the residents to have been affected:Tanks were immediately removed from residents' room.Hospice notified not to deliver oxygen tanks, only to provide concentrators to residents.Identification of other residents having the potential to be affected was accomplished by:The facility identified potential residents of 10 residents on oxygen at risk.Actions taken/systems put into place to reduce the risk of future occurrence include:Audit of all residents on oxygen for placement of concentrators and removal of oxygen tanks if identified on 1/20/26 by 5:00PM.Education provided to all current staff and prior to assigned scheduled shift on oxygen safety - storage/handling by 1/21/26 by 10:00AM.All staff unassigned will be educated via phone and will be required to sign acknowledgement of education upon next scheduled shift.All contracted Hospice companies to be notified of providing only concentrators to SNF (skilled nursing facility) Hospice residents.Alleged compliance 1/21/26 by 10:00AM.On 1/21/26 from 10:30AM to 3:45PM, interviews were conducted with multiple staff of varying departments related to the storage of oxygen. All staff interviewed confirmed they had received education on storage of oxygen tanks on 1/20/26 and/or 1/21/26 and could verbalize proper storage of oxygen tanks that all portable oxygen tanks are to be in a secure carrier such as a stand or rolling holder, never free standing.In addition to interviewing staff on receiving education on proper oxygen storage, education attendance records were reviewed and verified to confirm all staff working had received education. Rounds were conducted to verify no other oxygen tanks were observed unsecured. A review of email confirmations to the two Hospice providers to verify they had received a call from the facility administration regarding no further delivery of oxygen tanks to the facility. After verifying completion of all components of the IJ Removal Plan, the immediacy was removed effective 1/21/26 at 11:30AM. The Administrator, Director of Nursing and the Director of Clinical Operations were made aware that the IJ Removal Plan was verified and IJ removed.On 1/20/26 at approximately 3:15PM, a phone call was placed to the facility's contracted Hospice company (name redacted) who was providing Hospice services to Resident #1 regarding when the oxygen tanks were delivered to Resident #1 and their expectations of proper oxygen storage. According to the Hospice provider's Regional Director (Other-F), portable oxygen tanks should be stored securely in a holder/carrier/dolly or stand, the oxygen was delivered for Resident #1 on 12/30/25, at which time the IJ began.On 1/21/26 at 4:00pm, the Administrator produced a delivery receipt from the Hospice company's oxygen supplier (name redacted) dated 12/30/25 confirming the oxygen was delivered to Resident #1 on 12/30/25 at 11:44AM.On 1/22/26, a list of residents on the Memory Care unit was requested to include their BIMS score (Brief Interview of Mental Status), a short, mandatory cognitive screening tool used in long-term care facilities to assess resident's cognitive, attention and memory. The list included 8 out of 9 residents residing on the Memory Care Unit with a BIMS score of 9 or less, indicating significant cognitive impairment (1 out of the 9 residents was coded as 99 indicating the resident was unable to complete the interview).On 1/22/26 during end of day meeting, with the Administrator, Director of Nursing, Assistant Director of Nursing and Director of Clinical Operations, the facility team was asked if any residents residing on the Memory Care Unit had impaired safety awareness. The Director of Clinical Operations (Employee-D) responded, Yes, I would say all of them, due to their cognitive impairment potentially affecting their safety awareness. No further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to ensure there was a written transfer agreement with a local hospital which had the potential to affect all residents residing on 3 of 3 units. Findings included:On 1/21/2026 at 1:15 p.m. as a part of the extended survey, an interview was conducted with the Administrator who was asked provide evidence of a transfer agreement with the hospital. The Administrator stated he would look for a copy of the agreement. On 1/22/2026 at 9:20 a.m., the Administrator stated he could not find any evidence of a transfer agreement with the hospital. He stated he was sure the facility would have an agreement but could not find it. There was no evidence of a transfer agreement in the facility's documentation.On 1/22/2026 at 10:30 a.m., an interview was conducted with the Clinical Nurse Consultant who stated the Administrator had checked but could not find a transfer agreement. She stated a transfer agreement was necessary and the hospital had been contacted. During the end of day debriefing on 1/22/2026, the facility Administrator, Director of Nursing, Director of Informatics and Corporate Clinical Nurse Consultant were informed of the findings. The Administrator stated he did not see any transfer agreements with a hospital He stated he had reached out to the hospital administrative staff but had not received any information. No further information was provided.

Based on staff interview, and facility documentation review, the facility staff failed to develop a procedure for unvaccinated and vaccinated staff who refuse or are unable to be tested for COVID-19 in accordance with the Centers for Disease Control and Prevention (CDC) guidance. The findings included: There were no COVID positive staff nor Residents present in the facility during the course of the survey, from 6-21-22 through 6-23-22. Staff were observed wearing eye protection and face masks during the survey in accordance with community transmission rates, and according to CDC guidance. Staff were interviewed and asked what the procedure was for those staff who are unable or unwilling to be tested . Two direct care staff members, and one house keeping staff member, were interviewed. Each of them stated they did not know, and would ask the Director of Nursing (DON). On 6-22-22 at 10:00 a.m., the DON was asked for policies regarding testing of staff. The document title was Universal COVID-19 Testing Policy. The policy was reviewed and revealed under General Considerations, Staff who decline COVID-19 testing will not be allowed to continue to work, removed from the work calendar and sent home immediately to self-quarantine for 14 days. This is the only mention of refusal or inability to test staff in all of the COVID-19 facility policies. On 6-22-22 at the end of day debriefing at 5:00 p.m., the Administrator and DON were asked what happened at the end of the 14 day quarantine? Was the staff member allowed to return to work? The DON stated I see what you mean. We need a contingency plan for staff refusals and those staff which can't be tested , for them to be able to return safely to work, or not to return. This will include what PPE to wear and what areas they may safely work in. We will be fixing this policy this week. On 6-23-22 at 2:00 p.m., the Administrator and DON were made aware of the facility need for a contingency plan for testing refusals. No further information was provided by the facility.

Based on observation, Resident interview, clinical record review and staff interview, the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed within 30 days of admission (prior to admission is being waived due to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency) for 1 resident (Resident #11) in a sample of 19 residents. For Resident #11, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed within 30 days of admission. The Findings included: Resident #11 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6-22-22 an observation, Resident interview, and review of Resident #11's record was conducted. Resident #11 was noted to have diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Geriatric psychiatry notes, resident history, and admission information revealed that the illnesses were long standing. No previous to admission PASARR was found in the Electronic Health Record (EHR). The facility staff were asked to locate Resident #11's PASARR. On 6-23-22, an interview was conducted with the Director of Nursing (DON). The DON stated there was no PASARR completed for Resident #11, and stated that this error would be corrected. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 6-23-22. The Administrator stated, we will correct this immediately and indicated they would be auditing all residents' PASARRs. No further documents were provided.

Based on facility documentation review and staff interview, the facility staff failed to implement their abuse policy for screening employees for 8 employees (Employee#1, Employee #4, Employee #5, Employee #8, Employee #9, Employee #10, Employee #16, Employee #23) in a sample size of 25 employees. The findings included: On [DATE], the facility staff provided a copy of their policy entitled, Abuse Prevention Program. In Section 2(a), it was documented, Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has (a) been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law . Section 2(b) documented, .had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at approximately 10:45 A.M., this surveyor and Employee E, the Human Resources Manager, reviewed 25 employee files which revealed the following: Employee #1, a housekeeper with a hire date of [DATE], did not have a criminal background check on file. Employee #4, a Licensed Practical Nurse (LPN) with a hire date of [DATE], had a license verification completed on [DATE]. The LPN license had an expiration date of [DATE]. There was not another license verification until [DATE], nearly 4 months after the license had expired. There was no evidence the license was verified to be renewed or evaluated for findings. Employee #5, a Certified Nursing Assistant (CNA) with a hire date [DATE], had a license verification completed on [DATE], over 4 months after the date of hire. Employee #8, a Certified Nursing Assistant (CNA) with a hire date of [DATE], had a license verification completed on [DATE]. The CNA license had an expiration date of [DATE]. The next license verification to verify active status was not completed until [DATE], nearly 3 months after the license was due to expire. Employee #9, a CNA with a hire date of [DATE], had a license verification on [DATE], one month after the date of hire. Employee #10, a CNA with a hire date of [DATE], had a certification verification on [DATE], nearly one month after the date of hire. Employee #16, a CNA with a hire date of [DATE], had a certification verification completed on [DATE]. The CNA license had an expiration date of [DATE]. The next license verification to verify active status was not completed until [DATE] months after the license was due to expire. Employee #23, a certified physical therapy assistant with a hire date of [DATE], had a license verification on [DATE], over one year after the date of hire. On [DATE] at approximately 11:30 A.M., when asked why many of the license/certification verifications were performed late, Employee E stated that licenses used to be checked prior to hire but due to a time crunch with the implementation of a new process and electronic system, some licenses did not get verified timely. On [DATE] at approximately 1:15 P.M., the administrator and Director of Nursing were notified of findings. The administrator indicated there was no further information or documentation to submit.

Based on observation, staff interview, clinical record review, facility documentation review, and in the course of an investigation, the facility staff failed to implement wound treatment orders for 2 residents (Resident #2, Resident #3) in a sample size of 5 residents. The findings included: For Resident #2: 1a) the facility staff failed to ensure wound treatments were in place for an unstageable pressure wound observed on 03/11/2021. 1b) the facility staff failed to perform hand hygiene between glove changes. 1c) and applied santyl directly to a wound with a contaminated cotton-tipped applicator on 03/11/2021 increasing the risk of wound infection. Resident #2, a [AGE] year-old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #2's admission Minimum Data Set was not completed. 1a) On 03/11/2021 at approximately 12:50 P.M., an interview with Registered Nurse A (RN A) was conducted outside Resident #2's room near the treatment cart. When asked about Resident #2's wound, RN A stated that (Resident #2) was admitted to the facility with an unstageable wound to his coccyx region. This surveyor and RN A entered Resident #2's room. Resident #2 was observed awake in his bed, wearing a hospital gown. The head of the bed was elevated approximately 45 degrees and Resident #2 was watching TV. RN A called another staff member for assistance to turn Resident #2 for the wound observation. RN A and the other staff member, Licensed Practical Nurse A (LPN A), assisted Resident #2 to turn to his left side. RN A removed Resident #2's brief. There was no dressing on the wound or in the brief or in the bed. There was approximately 70% eschar and slough in the wound bed. RN A measured the wound as 10cm length x 5cm width. When asked about the absence of a dressing, RN A stated he changes the dressing every morning and that Maybe it fell off. When asked if the certified nursing assistant (CNA) caring for Resident #2 RN A talked to him about the dressing, RN A stated that the CNA did not tell him the dressing was off. On 03/11/2021 at approximately 1:35 P.M., an interview with Certified Nursing Assistant A (CNA A) was conducted. CNA A verified she was assigned to care for Resident #2 today. When asked if she had performed incontinence care on Resident #2 today, CNA A stated, Twice. When asked if Resident #2 had a bowel movement today, CNA A stated that Resident #2 had a bowel movement the second time she changed the brief. When asked what Resident #2's wound looked like, CNA A stated that the wound was pink and red and a little bit open. When asked if Resident #2 had a dressing over the wound, CNA A stated that Resident #2 did have a dressing on but with the second time she changed his brief, the dressing was messy and coming off so she removed it. When asked what she did next, CNA A stated that she cleaned the skin and the wound with the skin wipes and put a clean brief on. When asked what she did next, CNA A stated she then told the nurse (RN A) that she cleaned the area and that the dressing was off. On 03/12/2021 at approximately 9:00 A.M., the clinical record was reviewed. A physician's orders [REDACTED].) - 1 unit cleanse sacral wound with NSS (normal saline solution), apply santyl, and calcium alginate to sacral wound QD (every day), cover with foam dressing. Topical once daily for changes in skin texture. This order on the Treatment Administration Record was signed off as administered 03/05/2021 through 03/11/2021. On 03/12/2021 at approximately 10:40 A.M., the administrator and Director of Nursing (DON) were notified of findings. When asked about expectations for wound treatments, the DON stated that there should've been a wound treatment in place and (Resident #2) should've had a dressing on the wound. A copy of their policy on wound care was requested. On 03/15/2021, the facility staff provided a copy of their policies associated with pressure injuries entitled, Pressure Injuries Overview, Prevention of Pressure Injuries, and Pressure Injury Risk Assessment. The policies did not address providing wound treatments as ordered by the physician to promote wound healing. 1b) On 03/11/2021 at approximately 12:50 P.M., this surveyor observed RN A gather supplies from the treatment cart outside Resident #2's room. RN A stated that Resident #2 was admitted to the facility with an unstageable wound to his coccyx region. RN A stated that the wound doctor ordered Santyl and [MEDICATION NAME] dressing for a wound treatment. RN A then filled a medicine cup with santyl ointment, and gathered the following supplies: a chux, gauze packs, [MEDICATION NAME] dressing, and a cotton tip applicator (not in wrapper). This surveyor and RN A entered Resident #2's room. Resident #2 was observed awake in his bed, wearing a hospital gown. The head of the bed was elevated approximately 45 degrees and Resident #2 was watching TV. RN A washed the tray table with a wipe and placed supplies on the tray table. RN A balanced the cotton-tipped applicator across the top of the medicine cup. RN A then called another staff member for assistance to turn Resident #2 for the wound observation. RN A and the other staff member, Licensed Practical Nurse A (LPN A), assisted Resident #2 to turn to his left side. RN A removed Resident #2's brief. There was no dressing on the wound or in the brief or in the bed. There was approximately 70% eschar and slough in the wound bed. RN A measured the wound as 10cm length x 5cm width. RN A then sprayed the wound with [MEDICATION NAME]. RN A then removed his gloves and donned a new pair of gloves without washing his hands. RN A then opened a gauze package with his gloved hands and patted the wound dry. 1c) The cotton tip applicator had rolled off the top of the medicine cup and unto the tray table. RN A picked up the cotton tipped applicator, placed it into the santyl and applied santyl over the wound bed. RN A then applied the [MEDICATION NAME] dressing. On 03/12/2021 at approximately 10:40 A.M., the administrator and Director of Nursing (DON) were notified of findings. When asked about expectations for wound care, the DON stated that staff are expected to wash their hands between glove changes. The DON also stated that the cotton-tipped applicator that rolled onto the table should not have been used because it was contaminated. The DON stated it's an infection control issue. 2) For Resident #3, the facility staff failed to: 2a) ensure wound treatments were in place for bilateral posterior thigh pressure wounds on 03/11/2021. 2b) the facility staff failed to perform hand hygiene between glove changes. Resident #3, [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #3's most recent Minimum Data Set with an Assessment Reference Date of 02/15/2021 was coded as an admission assessment. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicative of intact cognition. Functional status for bed mobility, transfers, toileting, dressing, and personal hygiene were coded as requiring extensive assistance from staff. 2a) On 03/11/2021 at approximately 12:00 P.M., this surveyor and Registered Nurse A (RN A) entered Resident #3 room to perform a wound observation. Prior to entering the room, RN A stated that Resident #3 had a DTI (deep tissue injury to her right heel and wounds on her posterior thighs. When asked about the cause of the wounds to her thighs, RN A stated that Resident #3 sits in her wheelchair for a long time and recently he noted that Resident #3 had blisters on the back of thighs which had since opened. RN A also stated that Resident #3 has a cushion for her wheelchair and an air mattress on her bed. Upon entering the room, Resident #3 was observed dressed in a hospital gown, seated in her wheelchair watching TV. RN A assisted Resident #3 to stand to visualize posterior thigh wounds. There was an elongated open wound on each posterior thigh. Each wound bed was reddened with no drainage noted. There was no dressing on either wound. When asked to describe the wounds, RN A stated, They're stage 2. This surveyor asked Resident #3 if staff apply dressings to her wounds, Resident #3 stated that the nurse puts dressings on every evening before she goes to bed. This surveyor asked RN A about the missing dressings and RN A stated that every morning when getting into the chair, the dressings fall off. RN A stated that they are waiting for the wound doctor to arrive to do the wound treatment and dressing. On 03/12/2021 at approximately 8:00 A.M., the clinical record was reviewed. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The Treatment Administration Record for these physician orders [REDACTED]. A care plan problem entitled, (Resident #3's name) has an open area on back of L (left) thigh, and blister on back of right posterior thigh . The goal associated with this problem documented, (Resident #3's name) will have no new open areas caused by pressure or friction. An intervention associated with this problem included but was not limited to Tx (treat) daily as per MD's (medical doctor) ordered (sic). On 03/12/2021 at approximately 10:40 A.M., the administrator and Director of Nursing (DON) were notified of concerns. When asked about the expectation for wound treatments, the DON stated that We don't wait for the wound doctor to do a dressing. The DON stated that the expectation is the wound will be covered. The DON also stated that what happened yesterday was unacceptable. On 03/15/2021, the facility staff provided a copy of their policies associated with pressure injuries entitled, Pressure Injuries Overview, Prevention of Pressure Injuries, and Pressure Injury Risk Assessment. The policies did not address providing wound treatments as ordered by the physician to promote wound healing. 2b) On 03/11/2021 at approximately 12:25 P.M., RN A gathered his supplies from the treatment cart to change the dressing on Resident #3 right heel. RN A assisted Resident #3 back to bed in preparation to change right heel dressing. Resident #3 was lying in supine position and the undressed wounds on Resident #3's posterior thighs were in contact with the fitted sheet on the bed. In the course of removing the old right heel dressing and applying the new dressing, RN A did not wash his hands when changing gloves. RN A then assisted Resident #3 back to her wheelchair. On 03/12/2021 at approximately 8:00 A.M., the clinical record was reviewed. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The Treatment Administration Record for these physician orders [REDACTED]. A care plan problem entitled, (Resident #3's name) has an open area on back of L (left) thigh, and blister on back of right posterior thigh . The goal associated with this problem documented, (Resident #3's name) will have no new open areas caused by pressure or friction. An intervention associated with this problem included but was not limited to Tx (treat) daily as per MD's (medical doctor) ordered (sic). On 03/12/2021 at approximately 10:40 A.M., the administrator and the Director of Nursing were notified of findings. When asked about expectations for wound care, the Director of Nursing stated the expectation is to wash hands between glove changes.

Based on observation, staff interview, and clinical record review, and in the course of an investigation, the facility staff failed to maintain an accurate clinical for 1 resident (Resident #2 ) in a sample size of 5 residents. For Resident #2, there was conflicting information about the stage and location of a pressure wound upon admission to the facility on [DATE] and in the subsequent days. The findings included: Resident #2, a [AGE] year-old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 03/11/2021 at approximately 12:50 P.M., an interview with Registered Nurse A (RN A) was conducted outside Resident #2's room near the treatment cart. When asked about Resident #2's wound, RN A stated that (Resident #2) was admitted to the facility with an unstageable wound to his coccyx region. This surveyor and RN A entered Resident #2's room. Resident #2 was observed awake in his bed, wearing a hospital gown. The head of the bed was elevated approximately 45 degrees and Resident #2 was watching TV. RN A called another staff member for assistance to turn Resident #2 for the wound observation. RN A and the other staff member, Licensed Practical Nurse A (LPN A), assisted Resident #2 to turn to his left side. RN A removed Resident #2's brief. There was no dressing on the wound or in the brief or in the bed. There was approximately 70% eschar and slough in the wound bed. RN A measured the wound as 10cm length x 5cm width. On 03/12/2021 and 03/15/2021, the clinical record was reviewed. A Care Plan problem entry dated 02/26/2021 (date of admission) documented, (Resident #2's name) has unstageable in the buttocks. An excerpt of an admission nurse's note dated 02/26/2021 at 11:36 P.M. documented, On assessment .stage 2 pressure ulcer to sacrum . A physician's orders [REDACTED]. This order on the Treatment Administration Record for February 2021 is not signed off as administered. The physician's History & Physical dated 03/01/2021 did not address any pressure wounds. Under the header, Skin there were no narrative comments and the option No rashes, [MEDICAL CONDITION], or nodules was selected. A Minimum Data Set nursing note dated 03/05/2021 at 12:42 P.M. documented, Spoke with the nurse about the wound, stated the wound is unstageable, slough . A physician's orders [REDACTED].) - 1 unit cleanse sacral wound with NSS (normal saline solution), apply santyl, and calcium alginate to sacral wound QD (every day), cover with foam dressing. Topical once daily for changes in skin texture. This order on the Treatment Administration Record was signed off as administered 03/05/2021 through 03/11/2021. A Skin Evaluation Form dated 03/06/2021 at 1:01 P.M. under the header, Description documented, Stage 2 pressure ulcer on admission. A nurse's note dated 03/08/2021 at 5:03 P.M. documented, Wound round with (physician's name) 03/04/2021: Coccyx measures 9 x 3.2 x UTD (unable to determine) with 90% slough, [MEDICATION NAME] tissue and scant amount of serous drainage. Treatment: continue to cleanse with wound cleanser, pat dry, apply Santyl, and cover with dry dressing daily. In summary, based on observation, staff interview, and clinical record review, there was conflicting information regarding the stage and location of Resident #2's pressure wound on admission on 02/26/2021 and in subsequent days resulting in an inaccurate clinical record.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure pain management was provided for one resident (Resident # 3) in a survey sample of 5 residents. Findings included: For Resident # 3, the facility staff did not assess and offer pain medication prior to wound care treatment and when the resident expressed pain during the treatment. Resident #3, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but were not limited to [MEDICAL CONDITIONS], [DIAGNOSES REDACTED], and muscle weakness. Resident #3's most recent Minimum Data Set with an Assessment Reference Date of 02/15/2021 was coded as an admission assessment. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicating no cognitive impairment. Functional status for bed mobility, transfers, toileting, dressing, and personal hygiene were coded as requiring extensive assistance from staff. Review of Resident # 3's electronic clinical record was conducted on 3/11/2021 and 3/12/2021. Review of Physicians Orders revealed an order for [REDACTED]. Review of the Care plan revealed entry of problem which read: Problem was listed as (Resident #3) has alteration in comfort pain level related to (no [DIAGNOSES REDACTED]. Pain level will be decreased in number and/or severity or absent (see pain flow sheet or observations/documentation x 90 days) Goal date 5/11/2021 Approaches with Start date 2/10/2021 read: Monitor pain every shift and as needed. Administer [MEDICATION NAME] as ordered and assess effectiveness. Note trending in pain relief and notify MD (medical doctor) of results, Provide non medication prior to adding pain medications such as Monitor for indicators of pain, documented reevaluated ongoing as needed Utilize pain scale to determine intensity of pain Assess location and duration of pain and any contributing factors or precipitating events, Complete pain assessment per facility protocol. Observation conducted by Surveyor A: On 03/11/2021 at approximately 12:25 P.M., RN A gathered his supplies from the treatment cart to change the dressing on Resident #3's right heel. RN A did not assess the quality or severity of Resident #3's pain. RN A did not offer Resident #3 pain medication in preparation for a dressing change. RN A assisted Resident #3 back to bed. Resident #3 was lying in supine position and the undressed wounds on Resident #3's posterior thighs were in contact with the fitted sheet on the bed. RN A sprayed the alginate dressing with [MEDICATION NAME] wound spray then removed the alginate dressing. RN A looked at the area and pulled away dead skin. There was a small purple spot on the lateral heel. RN A pushed on the spot and immediately Resident #3 recoiled her right leg and let out a moan. Surveyor A asked Resident #3 if that hurt and she said, Yes. RN A did not assess the quality or severity of Resident #3's pain. After removing the alginate dressing, RN A removed his gloves and put on a new pair of gloves. RN A then assisted Resident #3 back to her wheelchair. On 03/12/2021 at approximately 12:15 P.M., an interview with the Director of Nursing (DON) was conducted. When asked about the expectation for pain management associated with dressing changes,the DON stated that even before touching the Resident, she would offer pain medication. The DON also stated she expects staff to wait 30-45 minutes after medication administration and assess effectiveness before continuing with a wound treatment. When informed of Resident #3's expression of pain during the dressing change, the DON stated she expects her staff to stop, assess pain, and offer pain medication before proceeding. During the end of day debriefings on 3/12/2021 and again on 3/15/2021, the Administrator and Director of Nursing were informed of the findings that RN A did not assess for pain and failed to offer pain medication to Resident # 3 after her expression of pain during the wound treatment. The Director of Nursing stated nurses were expected to assess for pain and offer pain medication prior to treatments. No further information was provided.

Based on observation, staff interview, clinical record review, facility documentation review, and in the course of an investigation, the facility staff failed to ensure environment remains free of potential accident hazards for 2 residents (Resident #2, Resident #3) in a sample size of 5 residents. The findings included: For Resident #2, the facility staff failed to keep bed in lowest position while Resident #2 was in his bed on 03/12/2021 resulting in a potential accident hazard. Resident #2, a [AGE] year-old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 03/12/2021 at approximately 12:30 P.M., this surveyor and the Director of Nursing (DON) observed Resident #2 lying in his bed with the head of bed elevated approximately 45 degrees. The call bell was within Resident #2's reach. Both half rails were up. The bed controller was located on the outer portion of the half rail (not removable) and out of Resident #2's reach. The bed was not in the lowest position. The Director of Nursing entered Resident #2's room and lowered the bed approximately 4 inches to its lowest position. When asked about the expectation for bed positioning, the DON stated she expects the bed to be in the lowest position due to fall risk. When asked if Resident #2 had a history of [REDACTED]. When asked why his bed was up, the DON stated she didn't know why the bed was not in the lowest position. On 03/12/2021, the clinical record was reviewed. A problem on the care plan dated 02/26/2021 entitled, (Resident #2's name) has unstageable in the buttocks. Interventions associated with this problem included but were not limited to: - Answer calls quickly, attempt to anticipate needs for prompt response and decrease in attempts to ambulate without proper assist. - Keep call bell, fluids, and personal items within reach in and out of room. - Keep bed in lowest position at all times when not working at the bedside. The facility staff provided an incident log with the date range of 12/01/2020 through 03/11/2021. Resident #2 was not on the list which indicated Resident #2 did not experience a fall since his admission to the facility. 2) For Resident #3, the facility staff failed to ensure Resident #3's call bell was within her reach to prevent a potential accident hazard on two occasions. Resident #3, [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #3's most recent Minimum Data Set with an Assessment Reference Date of 02/15/2021 was coded as an admission assessment. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicative of intact cognition. Functional status for bed mobility, transfers, toileting, dressing, and personal hygiene were coded as requiring extensive assistance from staff. On 03/11/2021 at approximately 12:00 P.M., this surveyor and Registered Nurse A (RN A) entered Resident #3 room to perform a wound observation. Following the wound observation, RN A then assisted Resident #3 back to her wheelchair, which was beside her bed. This surveyor observed RN A did not place the call light within reach for Resident #3. This surveyor and RN A left Resident #3 seated in her wheelchair next to her bed. This surveyor returned to the room to ask Resident #3 if she could reach her call bell. Resident #3 looked around and stated it is usually on her bed where she can reach it but stated it was not there now. This surveyor went to the hall to notify RN A the call bell was not within reach. RN A stated, Oh. RN A then entered Resident #3 room and put the call bell within her reach. On 03/12/2021 at approximately 8:00 A.M., the clinical record was reviewed. A care plan problem dated 02/10/2021 entitled, (Resident #3's name) is at risk of falls related to weakness and disease process. Interventions associated with this problem included but were not limited to Answer calls quickly, attempt to anticipate needs for prompt response and decrease attempts to ambulate without a proper assist. Keep call bell, fluids, and personal items within reach in and out of room. On 03/12/2021 at approximately 10:40 A.M., the administrator and Director of Nursing were notified of findings. When asked about the expectation for call bell availability, the Director of Nursing stated it is expected that the call bell will be within reach. The Director of Nursing also stated the expectation is that staff will ask residents if they need anything before staff leaves the room and make sure the call light, phone, and anything else they may want is within reach. On 03/12/2021 at approximately 12:45 P.M., this surveyor and the Director of Nursing observed Resident #3 in her bed with the head of the bed elevated approximately 60 degrees. Resident #3's call bell was hanging on her lamp out of reach. The DON put the call bell within Resident #3's reach and stated she didn't know why it was on the lamp out of Resident #3's reach.

Based on staff interviews, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to ensure post-discharge needs and services were in place for 1 resident (Resident #1) in a sample size of three residents. For Resident #1, the facility staff failed to ensure the availability of a caregiver for assistance/supervision with standing/ambulation in her apartment on the day of discharge, 09/30/2020. The findings included: Resident #1 was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date of 09/08/2020 was coded as an admission assessment. The Brief Interview for Mental Status was coded as 15 out of possible 15, indicative of intact cognition. Functional status for transfers was coded as requiring extensive assistance from staff with 2+ persons' physical assistance for support. Walk in Room was coded as limited assistance and one person physical assistance for support. On 11/10/2020, the closed clinical record was reviewed. A social worker note written by Employee D, the social worker, dated 09/29/2020 at 2:40 P.M. documented, Discharge note: Home health care PT/OT (physical therapy/occupational therapy) and nursing has been arranged for (Resident #1) with (agency name). She will return to her apartment tomorrow September 30th. Therapy is conducting a home safety assessment this afternoon. Writer spoke briefly with her daughter (name) and reviewed the above plans with her. The home care company name and number will be provided to (Resident #1). The occupational discharge summary dated 09/29/2020 at 5:22 P.M. under the header, D/C Recs (discharge recommendations), it was documented, Discharge Recommendations: rollator, HHOT (home health occupational therapy), HEP (home education program), AM/PM caregiver. A nurse's discharge note dated 09/30/2020 at 2:33 P.M. documented, Patient was admitted from (hospital name) to (facility name) for rehab, with [DIAGNOSES REDACTED]. Patient received current medication list, left over of (sic) medications, copies of discharged summary from (facility), copies of discharged summary from (hospital name), care plan. Advanced directives sent with resident and will continue to home with HHA (home health aide), PT (physical therapy), OT (occupational therapy), Aide, DME (durable medical equipment). Education provided to patient on disease process, administration of medications, and adverse reactions to medications, patient understood teaching, nurse ask if there is any further questions or clarifications needed, Patient stated no questions, stated that she understood's (sic) what was explained. On 09/30/20 at 14:45hrs (2:45 P.M.) patient was discharged from (facility), departed facility safely accompanied by CNA (certified nurse assistant). The physical therapy discharge summary dated 09/30/2020 at 2:18 P.M. under the header, STG #2.0 (short-term goal #2) - met on 09/17/2020 documented, Patient will perform sit to stand transfers and simulated car transfers with SBA (stand-by assist) demonstrating safe techniques. Under the sub-header, Baseline (09/04/2020), it was documented, Min A/CGA (minimum assist/contact guard assist. Under the header Status/Prior Living/Discharge and sub-header D/C (discharge) Location it was documented, Patient discharged to resident at ILF (independent living facility). Under the sub-header, Assistance/Support to be Provided, it was documented, AM assistance/caregiver available. Under the header, Discharge Recommendations and Status and sub-header, D/C Recs (discharge recommendations), it was documented, D/C to self/family care. Recommended home health or out-patient PT (physical therapy) for continued strengthening in order to achieve PLOF (prior level of function). The physician's discharge summary dated 09/30/2020 under the header Musculoskeletal selected the option unsteady gait. On 11/12/2020 at approximately 12:55 P.M., an interview with Employee D, the social worker, was conducted. When asked how long she had been working at the facility, Employee D stated she had been working at the facility since September 14th (2020). Employee D verified she is the only social worker working at the skilled facility. When asked about her general process for discharge planning, Employee D stated that she ensures they (the Residents) have the services they need. Employee D stated that she'll make arrangements for personal care assistants if that's needed. When asked if she follows up to ensure services are in place, Employee D stated that it is my normal practice to follow up. When asked within what period of time would do a follow-up, Employee D stated that it depends on the situation. When asked about follow up if a resident needed home health services, Employee D stated she would make sure that home health services had come by the following week but usually the day after discharge. When asked about Resident #1, Employee D stated that she vaguely remembers Resident #1. Employee D stated Resident #1 was in the skilled facility and returned to her apartment in independent living. Employee D then referred to her discharge note dated 09/29/2020 and stated that Resident #1 had home health services. When asked why Resident #1 needed home health services, Employee D stated she did not know Resident #1's [DIAGNOSES REDACTED]. When Employee D was asked if she did a follow-up to ensure all equipment and services were in place, Employee D stated I did not follow up. When asked why a follow-up wasn't done, Employee D stated that she thought others were going to do the follow-up. On 11/10/2020 at approximately 1:30 P.M., an interview with Employee E, the Director of Rehab, was conducted. When asked about Resident #1's functional ability, Employee E referred to the clinical record and stated that at baseline, Resident #1 was able to stand and walk 10 feet with contact guard assist. When asked if Resident #1's functional ability improved prior to discharge, Employee E stated yes. Employee E then stated that Resident #1 required stand-by assist to stand and supervision/contact guard assist to ambulate 200 feet with a front-wheeled walker. When asked about therapy recommendations, Employee E stated that therapy recommended home health, physical therapy, occupational therapy, and an A.M./P.M. caregiver. When asked who coordinates the services needed for home, Employee E stated the social worker. When asked how therapy recommendations are communicated, Employee E stated that they verbally tell the resident and the interdisciplinary team. In reference to Resident #1, Employee E stated that she notified the interdisciplinary team of discharge recommendations for Resident #1. When asked who was on the team, Employee E stated the social worker, the MDS Coordinator, and a nursing representative. On 11/10/2020 at approximately 1:55 P.M., an interview with Employee G was conducted. Employee G stated that her role is Director of Clinical Services, the nurse that oversees private pay cases for (outside company name). Employee G stated that she spoke with Resident #1 and Resident #1's son prior to Resident #1's day of discharge (09/30/2020). Employee G stated that Resident #1 and Resident #1's son indicated they would be needing home care services after discharge from the skilled facility. Employee G also stated that the first home visit occurred on 10/01/2020 after Resident #1 called her. When Employee G was asked if she had any communication with the facility social worker pertaining to the day of discharge and what services were needed, Employee G stated no. On 11/10/2020, the facility staff provided a copy of a document entitled, Post Discharge Plan of Care. Under the Section entitled, Therapy Instructions completed by Employee E, the Director of Rehab, dated 09/30/2020 at 11:16 A.M., the following sub-headers and selections included but not limited to: Transfers: Supervision; Toileting: Supervision; Other Precautions: Balance concerns, should have supervision. Under the Section entitled, Services Needed completed by Employee D, the social worker, dated 09/30/2020 at 11:56 A.M., the following sub-headers and selections were documented: Home Health Agency (agency name); Private Duty Care Agency (agency name); Follow-up Appointments: See your Primary Physician within 7-10 days from discharge & take this form with you. Physical therapy, occupational therapy, medical equipment, and physician appointments were not selected/completed. The facility staff provided a copy of their policy entitled, Discharge Summary and Plan. Section 1 documented, When the facility anticipates a resident's discharge to a private residence a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. Under Section 5 entitled, The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include: subpart (b) documented, Arrangements that have been made for follow-up care and services. On 11/10/2020 at approximately 5:30 P.M., the administrator was notified of findings.

Based on observation, staff interview, and facility documentation the facility staff failed to maintain infection control practices in accordance with the Center for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommendations to prevent the spread of COVID-19 in 1 (COVID unit) of 3 areas within the facility. The findings included: The facility staff failed to properly wear personal protective equipment (PPE) to prevent the spread of COVID-19. A staff member was observed entering the COVID unit wearing a surgical mask. On 06/18/2020 at 1:00 PM, an interview with the administrator was conducted by Surveyor A. When asked about the policy and expectation for personal protective equipment for staff to wear while on the south wing (designated the facility's COVID positive unit), the administrator stated staff should wear gown, gloves, N95 mask, faceshield, and shoe covers. On 06/18/2020 at approximately 1:55 PM, Surveyor A and the Assistant Director of Nursing stood outside a set of closed doors on the south wing. The Assistant Director of Nursing (ADON) stated that this was their COVID unit. Signs on the door read Authorized personnel only. Surveyor A and the ADON were wearing personal protective equipment per facility policy and walked the length of the hall which led to a common area room. There was an exit door to the outside on the left side of the room. Surveyor A and the ADON observed a staff member (Employee F) enter the COVID unit common area from the side door and the only personal protective equipment she was wearing was a surgical mask. The ADON approached the staff member (Employee F) and the staff member (Employee F) went back outside. Surveyor A and the ADON met with staff member (Employee F) outside the door and the ADON stated to Employee F that staff need to have their N95 on at all times in the COVID unit. On 06/18/2020 at approximately 1:56 PM, an interview with Employee F was conducted by Surveyor A. Employee F stated she had worked in the Rehab Unit for 3 months. When asked about her workflow process, Employee F stated that she first works in the clean unit and when it's time to work on the COVID unit, she leaves the facility from the main entrance and enters the COVID unit through this side entrance. Employee F stated her N95 is stored in a bag on a table by the door. Employee F stated when she enters the COVID unit, she replaces her surgical mask with the N95 then washes her hands then dons the rest of her PPE. On 6/18/2020 at 3:35 PM, a telephone conference was held by Surveyor B and Surveyor A with the Facility Administrator (Employee A) who stated the facility policy was for N95 masks to be worn on the COVID unit. The Administrator stated the physical therapists were expected to provide and wear their own N95 masks. On 06/18/2020 at 3:38 PM, an interview with rehab director (Employee G) was conducted by Surveyor A and Surveyor B. When asked about the expectation of staff workflow process, rehab director stated that after staff completes assignments on clean unit, the staff should leave the facility through the main entrance and enter the COVID unit from the side door, and then don their PPE. When asked about the distance between the door and the location of their PPE, the rehab director stated about 3 feet. When asked about the distance between that table and the nearest resident room, the rehab director stated approximately 20 to 30 feet. On 06/18/2020 at 3:55 PM, a telephone conference was held by Surveyor B and Surveyor A with the ADON. The ADON confirmed the observations made during the tour with Surveyor A and stated that staff members needed to be compliant with existing facility policy on the use of face masks. The ADON stated she was going to make sure fit testing would be done on all staff members. Facility documents with regard to infection control and the use of face masks were requested and received. On 6/18/2020, review of the facility policy entitled [MEDICAL CONDITION] (COVID-19) Guideline: This guideline is written to provide infection prevention and control measures for residents and staff members during the outbreak of COVID-19. with a revision date of 4/2/2020 read, CDC (Center for Disease Control), CMS (Center for Medicare and Medicaid Services) and specific state guidelines will be followed. regarding the need for employees to wear protective equipment. The facility Administrator and ADON were made aware of the findings during the end of day meeting held on 6/18/2020. The ADON stated she was a new employee of less than one week and was going to conduct inservices with the staff to ensure they understand about COVID-19 and the need to follow the policy to have on the N95 when on the COVID unit. The Administrator stated there was no shortage of PPE at the time of the survey. On 6/22/2020 at 11:34 AM, an interview was conducted with the ADON who stated she had conducted inservices with the staff about the need to wear N95 masks on the COVID Unit.The ADON stated before staff enter the COVID unit, they need to don everything including the N95. Copies of the inservices sign in sheets were provided and reviewed. On 6/22/2020 at 2 PM, an interview was conducted with the Administrator who stated the Therapy Department was following standards about optimizing staff. There were not enough therapists and cases to have only one therapist assigned to the COVID Unit. The Administrator stated the therapy staff were assigned to care for the residents on the clean unit first. Then, toward the end of the workday they would go to the COVID Unit through a separate entrance. The Administrator stated the staff should wear the N95 mask when they enter the COVID unit and after finishing the work there, they would go home after leaving the COVID unit. On 6/22/2020 during the end of day debriefing, the Administrator was again advised of the findings. The Administrator stated the situation was already handled with the Therapy staff. All staff should have on the N95 mask when they enter the COVID unit. No further information was provided.

Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to prevent significant medication errors. The facility failed to administer insulin on 5 separate occasions for 3 of 25 sampled residents. 1. For Resident #7, the facility staff failed to administer 2 consecutive doses of insulin on 05/12/2019 as indicated by sliding scale per physician's orders. 2. For Resident # 190 the facility staff omitted giving insulin at 4:30 PM on two consecutive days. 3. For Resident #5, the facility staff failed to ensure insulin was administered on 5-11-19 as ordered by a physician. The findings included: 1. For Resident #7, the facility staff failed to administer 2 consecutive doses of insulin on 05/12/2019 as indicated by sliding scale per physician's orders. Resident #7, a [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #7's most recent Minimum Data Set with an Assessment Reference Date of 01/30/2019 was coded as an annual assessment. The Brief Interview for Mental Status was coded as 3 out of possible 15 indicative of severe cognitive impairment. Number of days insulin injections were received was coded as 7. On 05/14/2019 at approximately 3:00 PM, the current physician's orders were reviewed. An excerpt of an order dated 01/14/2019 documented, Humalog 100unit/ml subcutaneous solution sliding scale check QID (four times a day) FS (fasting sugar) 200 or less give 0 units; 201-250 give 2 units; 251-300 give 4 units; 301-350 give 6 units; 351-400 give 8 units; greater than 400 give 1 units, call MD, recheck in 1 hour. The Medication Administration Record [REDACTED]. Just below it on the line units, it was documented 0 (units). On the line BfrLunch (before lunch), the blood sugar level was documented as 283. Just below it on the line units, it was documented 0 (units). The meal intake flowsheet was reviewed. It was documented that Resident #7 consumed 51-75% of her meal for dinner on 05/11/2019. For 05/12/2019, Resident #7 consumed 76-100% of her breakfast and 26-50% of her lunch. On 05/15/19 10:24 AM , the findings were shared with the DON. When asked about her expectations for insulin administration, she stated she expects insulin to be administered as ordered. The DON then looked at the electronic health record of Resident #7 and stated she was unable to find a reason why the insulin was not given. The facility staff provided a copy of their policy entitled, Sliding Scale Insulin. The policy documented, A physician protocol for the use of sliding scale insulin will be used in the nursing center. The procedure documented, The following scale will be initiated upon admission for residents of (physician names): Regular human insulin finger sticks AC & HS (before meals and at bedtime) FS (fasting sugar) below 200 - 0 units; 201-250 - give 2 units; 251-300 - give 4 units; 301-350 - give 6 units; 351-400 - give 8 units; Above 400 - give 10 units, call MD, recheck in 1 hour. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they had no further documentation or information to offer. 2. For Resident # 190, the facility staff omitted giving insulin at 4:30 PM on two consecutive days. Resident # 190, a [AGE] year old woman admitted to the facility on [DATE]. The Resident had no (Minimum Data Set) MDS information available as she was a new admission. The Resident was admitted to the facility with [DIAGNOSES REDACTED]. On 5/15/19 during clinical record review, it was noted that Resident #190 had orders for the following insulin : Humalog Mix 75/25 Insulin 100 Units/ (Milliliter) ml subcutaneous suspension (Insulin [MEDICATION NAME]-[MEDICATION NAME]) give 10 Units subcutaneously twice daily HOLD FOR BLOOD SUGAR (LESS THAN) < 125 It was noted that : 5/12/19 at 4:30 PM the Resident's blood sugar was 133 and insulin was not given 5/13/19 at 4:30 PM the Resident's blood sugar was 159 and insulin was not given On 5/15/19 at 1:43 PM, copies of (Medication Administration Record) MAR indicated [REDACTED]. On 5/16/19 at 8:30 AM during an interview with the DON (Director of Nursing), she stated that she checked with the LPN (Licensed Practical Nurse) who gave medications to that resident and that the LPN stated the insulin was refused by the Resident. She then produced another MAR indicated [REDACTED]. She produced nothing to address the insulin on 5/12/19 at 4:30 or 5/13/19 at 4:30 PM. On 5/16/19 during the end of day conference, the Administrator was made aware of the issues with medication administration. No further documentation was provided. 3. For Resident #5, the facility staff failed to ensure insulin was administered on 5-11-19 as ordered by a physician. Resident #5, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #5's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-24-19 was coded as an annual assessment. Resident #5 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #5 was also coded as requiring extensive assistance to total dependence on one to two staff members to perform activities of daily living, such as hygiene, and bed mobility. On 5-14-19 at 12:00 noon, Resident #5 was observed in her room in bed. A Resident interview was conducted, and the Resident stated she did not receive her insulin as she should from staff. Review of the resident's clinical record revealed the resident's current POS (physician order sheet), and MAR (Medication Administration Record) for (MONTH) 2019. Contained was an order for [REDACTED]. On 5-11-19 the Resident's FSBS was 254, and no insulin was given, and was documented as such by the nurse. Review of the medication and nursing notes revealed no documentation as to why the insulin was not given. Review of the facility policy revealed that only trained nurses would administer insulin by the physician's orders. On 5-15-19 at 5:00 p.m., the DON (director of nursing) was notified of above findings. The DON stated, The medication should have been given.

Based on observation, staff interview, facility documentation and clinical record review the facility staff failed to provide care and services in accordance with professional standards of practice for 3 Residents (Residents # 7, # 190, #5) in a survey sample of 25 Residents. 1a. For Resident #190, the facility staff failed to administer medications per physicians order and; 1b. failed to document that an entry was a late entry. 2. For Resident #7, the facility staff failed to administer 2 consecutive doses of insulin on 05/12/2019 as indicated by sliding scale per physician's orders. 3. For Resident #5, the facility staff failed to ensure insulin was administered on 5-11-19 as ordered by a physician. The findings include: 1a. For Resident #190, the facility staff failed to administer medications per physicians order and; 1b. failed to document that an entry was a late entry. Resident # 190, a [AGE] year old woman admitted to the facility on [DATE] the Resident had no (Minimum Data Set) MDS information available as she was a new admission. The Resident was admitted to the facility with [DIAGNOSES REDACTED]. On 5/15/19, the clinical record was reviewed. During review of the (MONTH) 2019 Medication Administration Record [REDACTED] 5/10/19 - 1:00 PM- [MEDICATION NAME] 180 (milligrams) mg 1 capsule by mouth 3 times a day. 5/13/19 - 6:00 AM - Linzess 145 (microgram) mcg capsule- 2 Capsules by mouth every day 5/13/19 - 6:00 AM - Pantoprazole 40 mg. by mouth every day 5/14/19 Lunch- Thrive Gelato (Dietary Supplement) QD with lunch 5/15/19 - 6:00 AM - [MEDICATION NAME] 20 mg by mouth 3 times per day for pain On 5/15/19 at 1:43 PM, copies of (Medication Administration Record) MAR indicated [REDACTED]. On 5/16/19 at 8:30 AM during an interview with the DON (Director of Nursing), she stated that she checked with the LPN (Licensed Practical Nurse) who gave medications to that resident and that the LPN stated the meds were refused by the Resident. She then produced an MAR indicated [REDACTED]. The DON was asked why the document did NOT say LATE ENTRY she said she didn't know. She stated that she told the LPN to put in a late entry. The documents were identical except the new MAR indicated [REDACTED]. When DON was asked how was someone to know by looking at that document that it was a late entry, she stated there was no way to know unless you look at the computer. According to the DON, the facility used Lippincott for Professional Standards. According to Lippincott Manual of Nursing Practice, 10th edition, in Box 2-1 entitled, Common Legal Claims for Departure from Standards of Care it is documented that a departure from standards of nursing care included, Failure to administer medications properly and in a timely fashion or to report and administer omitted doses appropriately. On 5/16/19 during the end of day conference, the Administrator was made aware of the issues with medication administration. No further documentation was provided. 2. For Resident #7, the facility staff failed to administer 2 consecutive doses of insulin on 05/12/2019 as indicated by sliding scale per physician's orders. Resident #7, a [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #7's most recent Minimum Data Set with an Assessment Reference Date of 01/30/2019 was coded as an annual assessment. The Brief Interview for Mental Status was coded as 3 out of possible 15 indicative of severe cognitive impairment. Number of days insulin injections were received was coded as 7. On 05/14/2019 at approximately 3:00 PM, the current physician's orders were reviewed. An excerpt of an order dated 01/14/2019 documented, Humalog 100unit/ml subcutaneous solution sliding scale check QID (four times a day) FS (fasting sugar) 200 or less give 0 units; 201-250 give 2 units; 251-300 give 4 units; 301-350 give 6 units; 351-400 give 8 units; greater than 400 give 1 units, call MD, recheck in 1 hour. The Medication Administration Record [REDACTED]. Just below it on the line units, it was documented 0 (units). On the line BfrLunch (before lunch), the blood sugar level was documented as 283. Just below it on the line units, it was documented 0 (units). The meal intake flowsheet was reviewed. It was documented that Resident #7 consumed 51-75% of her meal for dinner on 05/11/2019. For 05/12/2019, Resident #7 consumed 76-100% of her breakfast and 26-50% of her lunch. On 05/15/19 10:24 AM , the findings were shared with the DON. When asked about her expectations for insulin administration, she stated she expects insulin to be administered as ordered. The DON then looked at the electronic health record of Resident #7 and stated she was unable to find a reason why the insulin was not given. The facility staff provided a copy of their policy entitled, Sliding Scale Insulin. The policy documented, A physician protocol for the use of sliding scale insulin will be used in the nursing center. The procedure documented, The following scale will be initiated upon admission for residents of (physician names): Regular human insulin finger sticks AC & HS (before meals and at bedtime) FS (fasting sugar) below 200 - 0 units; 201-250 - give 2 units; 251-300 - give 4 units; 301-350 - give 6 units; 351-400 - give 8 units; Above 400 - give 10 units, call MD, recheck in 1 hour. According to Lippincott Manual of Nursing Practice, 10th edition, in Box 2-1 entitled, Common Legal Claims for Departure from Standards of Care it is documented that a departure from standards of nursing care included, Failure to administer medications properly and in a timely fashion or to report and administer omitted doses appropriately. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they had no further documentation or information to offer. 3. For Resident #5, the facility staff failed to ensure insulin was administered on 5-11-19 as ordered by a physician. Resident #5, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #5's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-24-19 was coded as an annual assessment. Resident #5 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #5 was also coded as requiring extensive assistance to total dependence on one to two staff members to perform activities of daily living, such as hygiene, and bed mobility. On 5-14-19 at 12:00 noon, Resident #5 was observed in her room in bed. A Resident interview was conducted, and the Resident stated she did not receive her insulin as she should from staff. Review of the resident's clinical record revealed the resident's current POS (physician order sheet), and MAR (Medication Administration Record) for (MONTH) 2019. Contained was an order for [REDACTED]. On 5-11-19 the Resident's FSBS was 254, and no insulin was given, and was documented as such by the nurse. Review of the medication and nursing notes revealed no documentation as to why the insulin was not given. Review of the facility policy revealed that only trained nurses would administer insulin by the physician's orders. On 5-15-19 at 5:00 p.m., the DON (director of nursing) was notified of above findings. The DON stated, The medication should have been given.

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed to have sufficient nursing staff to meet the needs of seven Residents (Resident #20, Resident #190, Resident #28, Resident #189, Resident #12, Resident #15, Resident #6) in a survey sample of 25 Residents. 1. For Resident #20, the facility staff failed to have adequate staff to respond to the Resident's call bell and request for assistance for three hours. 2. For Resident #190, the facility staff failed to ensure adequate staff available to answer call bell in a timely manner. 3. For Resident #28, the facility staff failed to ensure adequate staff available to answer call bell in a timely manner. 4. For Resident #189, the facility staff failed to provide sufficient staff to safely lift Resident using Hoyer. 5. For Resident #12, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 2 of 14 opportunities the call light was activated. 6. For Resident #15, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 3 of 15 opportunities the call light was activated. 7. For Resident #6, the facility staff failed to provide activities of daily living care in a timely manner. The findings included: 1. For Resident #20, the facility staff failed to have adequate staff to respond to the Resident's call bell and request for assistance for three hours. Resident # 20, was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. . Resident #20's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/20/19, was coded as a quarterly assessment. Resident #20 was coded as having a BIMS (brief interview for mental status) score of 15, which indicated being cognitively intact. Resident #20, was also coded as requiring extensive of assistance of staff for bed mobility, transfers, dressing, and personal hygiene. She was coded as being totally dependent upon staff for toileting and bathing. During an interview with Resident #20 on 05/14/19 at 01:33 PM, Resident #20 stated, I have called for help and waited over an hour. When asked how often this occurs, Resident #20 stated, it happens too often and indicated it is an ongoing concern. Resident #20 stated, they need another aide on the unit, they don't have enough staff to help us. Review of the facility call bell response log on 5/15/19 revealed that on 5/8/19, Resident #20 used her call bell at 2:11pm to call for assistance. Three hours later, at 5:11pm her call bell was still sounding and had not been responded to. On 5/15/19 at 10:10am an interview was conducted with Employee J, Information Systems Director. Employee J stated, the system is programmed so when the call bell is pressed it notifies multiple people. If there is no response after 30 minutes, it resets and resends all of the notifications again. When Employee J was asked to interpret the call bell response log for Resident #20 on 5/8/19, Employee J stated, it tells me it wasn't responded to. When Employee J was asked what happens when a resident uses their call bell, Employee J and the DON stated, it activates a notification to the CNA, the supervisor and after a minute the DON and Administrator get a text on their phone. On 5/15/19 the DON (Director of Nursing, Employee B) was asked about the incident on 5/8/19 when Resident #20's call bell went off for 3 hours. The DON stated, I can tell you someone will check- people will come by and pop their heads in. On 5/15/19 the Administrator stated, an acceptable time and my expectation is for call bells to be answered within 15 minutes. We don't know what happened at that time, her care is exceptional. I know they get the care they need. Review of the facility policy titled, Call light with an effective date of (MONTH) (YEAR), read Emergency call system will be made available to all residents in room, bathrooms and other areas as deemed necessary. Residents are to have a method to activate the emergency call system herein referred to as call lights in bedrooms and bathrooms. Review of the facility polity titled, Responding to call light with an effective date of, (MONTH) (YEAR) read, All staff to respond to all lights. 1. Respond to location of call light. 2. Ask resident what assistance is needed. 3. If certified to perform care, render care 4. If not certified to render care, notify a member of the nursing team and/or supervisor 5. Please ensure call light is reset. On 5/15/19 the facility Administrator and DON were made aware of the facility staff's failure to respond to Resident #20's call light for 3 hours. No further information was provided. 2. For Resident #28 the facility staff failed to ensure adequate staff available to answer call bells in a timely manner. Resident #28 is an [AGE] year old woman originally admitted to the facility with [DIAGNOSES REDACTED]. On 3/19/19 Resident was admitted to the facility prior to admission to hospital for planned surgical repair of hardware from prior [MEDICAL CONDITION]. The Resident went out for surgery on 4/6/19 and was readmitted on [DATE]. Residents most recent (Minimum Data Set) MDS was dated 3/31/19 and it was a 14 -Day PPS. According to the most recent MDS Resident # 28 had a (Brief Interview of Mental Status) BIMS score of 15/15 indicating no cognitive impairment. On 5/14/19 at 2:15 PM an interview was conducted with Resident #28 who stated she had no problems with the facility other than the time it took for staff to answer the call bells. She further elaborated by saying If the staff would answer the call bells this place would be great! She relayed and incident where she had put the call bell on because she wanted something for her cough. She stated that someone came in and turned the call bell off and told her she would let the nurse know what she needed. She stated that happened three times and no nurse came. She stated after that I just got up by myself and walked to the nurses' station to tell her. On 5/14/19 at 3:00 P.M. an interview was conducted with Employee J (Information Technology), when asked if this surveyor could have a copy of the call bell response times he replied I don't think I can get that. When asked what company they use he stated Status Solutions and when asked what program he stated Sara. He was then informed by this surveyor that we request these logs from other facilities using the same system and are able to get them, he stated he would try to get them. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated, my expectation is for call bells to be answered within 15 minutes. I know they get the care they need. According to the facility call logs provided by Status Solutions from 5/1/19 through 5/14/19 5/02/19 - Call bell rang from 4:33 PM to 4:56 PM - total 22 min. 21 sec. 50/3/19 - Call bell rang from 7:05 AM to 7:23 AM - total 18 min 10 sec. 5/03/19 - Call bell rang from 7:38 AM to 7:53 AM - total 14 min. 56 sec. 50/3/19 - Call bell rang from 1:33 PM to 1:56 PM - total 22 min 46 sec. 5/04/19 - Call bell rang from 7:59 AM to 8:15 AM - total 16 min. 19 sec. 50/4/19 - Call bell rang from 8:24 PM to 8:50 PM - total 26 min. 5 sec. 5/05/19 - Call bell rang from 8:10 AM to 8:24 AM - total 14 min. 15 sec. 5/05/19 - Call bell rang from 8:43 AM to 9:18 AM - total 34 min 35 sec. 5/06/19 - Call bell rang from 8:03 AM to 8:19 AM - total of 15 min 46 sec. 5/07/19 - Call bell rand from 7:01 AM to 7:30 AM - total 28 min 41 sec. 5/10/19 - Call bell rang from 7:35 AM to 7:53 AM total of 18 min 7 sec. 5/11/19 - Call bell rang from 7:01 AM to 7:44 AM - total 43 min 37 sec. 5/11/19 - Call bell rang from 12:30 PM to 12:50 PM total of 20 min 10 sec. 5/13/19 - Call bell rang from 4:12 PM to 4:52 PM total of 20 min 40 sec. 5/13/19- Call bell rang from 9:10 PM to 9:27 PM total of 17 min 5 sec. On 5/15/19 at 4:30 PM in an interview with CNA A stated that Resident # 98 needs assistance to get up and go to the bathroom and she needs help getting out of bed and to her chair. On 5/16/19 at the end of day meeting the Administrator was made aware of the issues with answering call bells timely and no further information was provided. 3. The facility staff failed to ensure adequate staff available to answer call bells in a timely manner. Resident # 190 a [AGE] year old woman admitted to the facility on [DATE] the Resident has no (Minimum Data Set) MDS information available as she is a new admission. The Resident was admitted to the facility with [DIAGNOSES REDACTED]. On 5/14/19 at 2:25 PM an interview was conducted with Resident #190 who stated the staff take too long to answer call bells. She stated that the facility is nice but if you have to use the bathroom [ROOM NUMBER] minutes is way too long to wait. When asked what type of assistance she requires Resident #190 stated she had a hip replacement surgery but something went wrong and she ended up with foot drop as well so she is unable to ambulate or transfer alone. On 5/14/19 at 3:00 P.M. an interview was conducted with Employee J (Information Technology), when asked if this surveyor could have a copy of the call bell response times he replied I don't think I can get that. When asked what company they use he stated Status Solutions and when asked what program he stated Sara. He was then informed by this surveyor that we request these logs from other facilities using the same system and are able to get them, he stated he would try to get them. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated, my expectation is for call bells to be answered within 15 minutes. I know they get the care they need. According to the facility call logs provided by Status Solutions from 5/1/19 through 5/14/19 5/9/19 - Call bell rang from 7:14 AM to7:31 AM - total 17 min. 18 sec. 5/10/19 Call bell rang from 9:17 AM to 9:37 AM total 19 min 40 sec. 5/10/19 Call bell rang from 12:35 PM to 12:50 PM total 15 min 9 sec. 5/11/19 Call bell rang from 1:38 AM to 1:55 AM total 16 min 42 sec 5/11/19 Call bell rang from 2:30 PM to 3:06 PM total 19 min 32 sec. 5/11/19 Call bell rang from 5:59 PM to 6:15 PM total 15 min 56 sec. 5/12/19 Call bell rang from 1:44 PM to 2:15 PM total 31 min 45 sec. 5/12/19 Call bell rang from 3:02 PM to 3:22 PM total 19 min 32 sec. 5/14/19 Call bell rang from 8:19 AM to 8:42 Am total 23 min 4 sec. On 5/16/19 at the end of day meeting the Administrator was made aware of the issues with answering call bells timely and no further information was provided. 4. For Resident #189 the facility staff failed to provide sufficient staff to safely lift Resident using Hoyer which resulted in an injury. Resident #189 a [AGE] year old woman was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #189's most recent (Minimum Data Set) MDS a quarterly with an ARD date of 3/16/19 codes Resident #189 as having a (Brief Interview of Mental Status) BIMS score of 00/15 which indicates severe cognitive impairment. Resident is also coded as being total assistance for all aspects of (Activities of Daily Living) ADL's. She is coded as requiring 2 or more people to perform her care and the use of Mechanical Lift for transferring from bed to chair or wheelchair. Resident #189 is the subject of a (Facility Reported Incident) FRI that was submitted to the OLC on 1/16/19. The FRI states that on 1/16/19 at approximately 11:30 AM the CNA that was working with Resident #189 reported to the LPN and Nursing supervisor that the resident was crying out in pain when she was touched on her right lower leg. The nurse examined and found swelling to the ankle area. The family and the MD were notified and the MD ordered X-Rays. The FRI also states that at 4:30 PM the X-Ray results arrived with a [DIAGNOSES REDACTED]. The MD and family were notified of the [DIAGNOSES REDACTED]. On 5/15/19 at 2:00 PM an interview was conducted with the DON who stated that once she was told that there was a fracture involved she initiated a Fracture (of unknown cause) Investigation Form The DON submitted all of the statements and results of her investigation and also stated that the cause of the fracture was improper use of the mechanical lift. She elaborated to say that the CNA that was working with Resident #189 failed to obtain help from a coworker. She stated at all times there should be 2 persons operating the mechanical lift. The DON further stated that she did training on all direct care staff after the incident. According to the statement by the CNA who worked with Resident #189 on 1/15/19 from 3:00 PM to 11:00 PM Requested assistance multiple times to help with residents transfer to bed- unable to obtain assistance-transferred via Hoyer lift / mechanical lift to bed. According to facility Policy for Full Body Lift Policy: All CNA's will be trained in safe and appropriate use of the full body lift. Any time the full body lift is used, there must be 2 trained staff members present to ensure staff and resident safety. On 5/16/19 the Administrator was made aware of the issues involving the transfer without adequate number of staff and subsequent injury to Resident #189 and no further information was provided. 5. For Resident #12, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 2 of 14 opportunities the call light was activated Resident #12, an [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Cognitive disorders were not on the list of diagnoses. Resident #12's most recent Minimum Data set with Assessment Reference Date of 02/13/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as a 6 out of possible 15 indicative of severe cognitive impairment. Functional status for bed mobility, dressing, and personal hygiene were coded as requiring extensive assistance from staff. On 05/14/19 at approximately 12:00 PM, an interview with Resident #12 was conducted. Resident #12 was in bed with the head of the bed elevated approximately 45 degrees. When asked if the facility staff answered the call light promptly when he needed assistance, Resident #12 stated, Sometimes it seems like it takes forever for staff to come. Resident #12 stated that sometimes he needs help positioning in the bed and calls for assistance. On 05/14/19 at 2:55 PM, call logs for the past week for the health center were requested from Employee J from the information technology department. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated, my expectation is for call bells to be answered within 15 minutes. She stated that she didn't know why they were longer perhaps staff forgot to cut off the call bell and was in the room doing care. On 05/15/2019 at approximately 9:00 AM, the facility staff provided call logs for Resident #12 with a date range of 05/08/2019 through 05/13/2019. Of the 14 times the call light was activated, there were 2 instances where the duration was longer than 15 minutes. On 05/12/2019 at 7:11 AM, the duration was 21 minutes and 7 seconds. On 05/12/2019 at 10:22 PM, the duration was 30 minutes and 2 seconds. On 05/15/19 at approximately 10:10 AM, an interview with Employee J was conducted. Employee J stated that the system is programmed to do certain things when the button is pushed. Employee J stated that the activated call bell routes to the certified nurse assistant (CNA) pager. If it isn't answered, it flows over to nurse pager. The facility staff provided a copy of their policy entitled, Responding to call light. The listed procedures documented, 1. Respond to location of call light. 2. Ask resident what assistance is needed. 3. If certified to perform care, render care. 4. If not certified to render care, notify a member of the nursing team and/or supervisor. 5. Please ensure call light is reset. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they had no further documentation or information to offer. 6. For Resident #15, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 3 of 15 opportunities the call light was activated. Resident #15, an [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #15's most recent minimum Data set with an Assessment Reference Date of 02/20/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 12 out of possible 15 indicative of moderate cognitive impairment. Functional status for bed mobility, transfers, dressing, and toileting was coded as requiring extensive assistance from staff. On 05/14/19 at approximately 1:55 PM, an interview with Resident #15 was conducted. When asked if the staff answer the call light promptly when she needs assistance, Resident #15 stated, Sometimes it's a long time before they come. Resident #15 stated that she needs help to get into her chair or to get positioned for a nap. Resident #15 also stated, I can't get up by myself. On 05/14/19 at 2:55 PM, call logs for the past week for the health center were requested from Employee J from the information technology department. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated, my expectation is for call bells to be answered within 15 minutes. She stated that she didn't know why they were longer perhaps staff forgot to cut off the call bell and was in the room doing care. On 05/15/2019 at approximately 9:00 AM, the facility staff provided call logs for Resident #12 with a date range of 05/08/2019 through 05/14/2019. Of the 15 times the call light was activated, there were 3 instances where the duration was longer than 15 minutes. On 05/08/2019 at 9:23 AM, the duration was 28 minutes and 43 seconds. On 05/11/2019 at 7:56 PM, the duration was 23 minutes and 24 seconds. On 05/13/2019 at 4:26 PM, the duration was 15 minutes and 31 seconds. On 05/15/19 at approximately 10:10 AM, an interview with Employee J was conducted. Employee J stated that the system is programmed to do certain things when the button is pushed. Employee J stated that the activated call bell routes to the certified nurse assistant (CNA) pager. If it isn't answered, it flows over to nurse pager. The facility staff provided a copy of their policy entitled, Responding to call light. The listed procedures documented, 1. Respond to location of call light. 2. Ask resident what assistance is needed. 3. If certified to perform care, render care. 4. If not certified to render care, notify a member of the nursing team and/or supervisor. 5. Please ensure call light is reset. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they had no further documentation or information to offer. 7. For Resident #6, the facility staff failed to provide activities of daily living care in a timely manner. Resident #6 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #6's [DIAGNOSES REDACTED]. The Minimum Data Set, which was an Annual Assessment, with an Assessment Reference Date of 1/3/19 was reviewed. Resident #6 was coded as having a Brief Interview of Mental Status Score of 8, indicating moderate cognitive impairment. In addition, Resident #8 was coded as not having any mood or behavioral issues. On 5/15/19 at 8:31 A.M., an observation was conducted of Resident #6 in her bed. Resident #6's call bell was on the floor, out of reach. Resident #6 stated that she had no way to let the staff know what she needed. She said that due to the wound on the back of her knee, it was difficult for her to get up and use her walker, when it was time for her to go to the bathroom. Resident #6 stated that she didn't remember the last time that the call bell was within reach. On 5/15/19 a review was conducted of facility documentation. The call bell response log was reviewed. During the previous 7 days, the call bell had not been activated during any shift. On 5/15/19 at 2:30 P.M., a Group Interview was conducted. The group unanimously agreed that their call bells were not routinely answered in a timely manner. They stated that it usually took staff between 30 minutes and one hour to answer the call bell. They further stated that the facility had reduced the number of available Certified Nursing Assistants, and that additional staff were needed to meet their needs. On 5/15/19 at approximately 3:30 P.M., an interview was conducted with the facility Administrator (Employee A). The administrator stated, The resident probably knocked the call bell off the bed. No further information was provided.

Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to follow infection prevention protocols. The dietary manager was observed not wearing personal protective equipment (PPE) in the room of a resident on contact isolation for [MEDICAL CONDITION]. The dietary manager then exited the room without washing hands and entered two other resident rooms without performing hand hygiene. The findings included: On 05/16/19 at 08:35 AM, the dietary manager was observed in the room of Resident #92. There was personal protective equipment stationed outside the room door and a Stop sign posted next to the door. The dietary manager was observed standing inside the room talking with Resident #92 (seated in a chair) and a family member (standing next to Resident #92). The dietary manager and the family member were not wearing PPE. The dietary manager was observed shaking the family member's hand then stooped down next to Resident #92, leg touching the side of the chair, and placed his hand on Resident #92's back/shoulder. LPN A was observed to pass by the room [ROOM NUMBER] times, looked in the room once, then kept walking past the room without comment. The dietary manager then left the room of Resident #92 and entered the room of Resident #91 and spoke briefly to her without making physical contact. The dietary manager then exited Resident #91's room and entered the room of Resident #239. The dietary manager was observed touching the left bedrail as he spoke to Resident #239 who was lying in bed at the time. The dietary manager then exited Resident #239's room, walked down the hall, activated 2 sets of doors by pressing the door plates, touched the doorknob to open the dietary manager's office, then turned around and got on the elevator. The dietary manager did not perform hand hygiene from the time he left Resident #92's room to the time he got on the elevator. On 05/16/19 at 08:49 AM, the DON was asked if Resident #92 was on isolation and she stated she would need to check. On 05/16/19 at 09:03 AM, the ADON was asked if Resident #92 was on isolation and she stated, Yes, he is on contact precautions for[DIAGNOSES REDACTED]. When asked about the process for observing contact precaution, the ADON stated that staff should wash their hands, don PPE before entering room, remove PPE in room, and immediately wash hands before leaving room. When the ADON was updated on the observations made of dietary manager, the ADON stated the dietary staff was supposed to be mindful of that (policy) and report to the nurse first so they will use appropriate PPE when entering a resident's room. On 05/16/2019, an interview with the dietary manager was conducted. When asked about the process for entering a room of a resident on isolation, he stated he normally won't enter an isolation room but if required, he would first stop and ask the nurse what proper equipment to wear before entering room. When shared concerns about not donning PPE before entering Resident #92's room, the dietary manager stated he didn't know Resident #92 was still on isolation because he was scheduled to be discharged today (05/16/2019). The facility staff provided a policy entitled, Handwashing/Hand Hygiene. In Section 5 (e), it was documented, Employees must wash their hands for at least twenty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: Before and after entering isolation precaution settings. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they had no further documentation or information to offer.

Based on observation, resident interviews, staff interviews, clinical record reviews, and facility documentation review, the facility staff failed to accommodate needs and preferences for 7 residents (Resident #12, Resident #15, Resident #5, Resident #28, Resident #190, Resident #20, Resident #6) in a sample size of 25 residents. 1. For Resident #12, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 2 of 14 opportunities the call light was activated. 2. For Resident #15, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 3 of 15 opportunities the call light was activated. 3. Resident #5 was not provided a hoyer lift sling to get out of bed in the morning on 5-14-19 due to lack of equipment. 4. For Resident # 28 the facility staff failed to answer call bells in timely manner for a Resident who requires assistance with transfer and ambulation. 5. For Resident #190 the facility staff failed to answer call bells in a timely manner for a Resident who needs assistance with transfer and ambulation. 6. For Resident #20, the facility staff failed, for three hours to respond to the Resident's call bell and request for assistance 7. For Resident #6, the facility staff failed to ensure that her call bell was within reach. The findings included: 1. For Resident #12, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 2 of 14 opportunities the call light was activated. Resident #12, an [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Cognitive disorders were not on the list of diagnoses. Resident #12's most recent Minimum Data set with Assessment Reference Date of 02/13/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as a 6 out of possible 15 indicative of severe cognitive impairment. Functional status for bed mobility, dressing, and personal hygiene were coded as requiring extensive assistance from staff. On 05/14/19 at approximately 12:00 PM, an interview with Resident #12 was conducted. Resident #12 was in bed with the head of the bed elevated approximately 45 degrees. When asked if the facility staff answered the call light promptly when he needed assistance, Resident #12 stated, Sometimes it seems like it takes forever for staff to come. Resident #12 stated that sometimes he needs help positioning in the bed and calls for assistance. On 05/14/19 at 2:55 PM, call logs for the past week for the health center were requested from Employee J from the information technology department. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated that her expectation is for call bells to be answered within 15 minutes. She stated that she didn't know why they were longer perhaps staff forgot to cut off the call bell and was in the room doing care. On 05/15/2019 at approximately 9:00 AM, the facility staff provided call logs for Resident #12 with a date range of 05/08/2019 through 05/13/2019. Of the 14 times the call light was activated, there were 2 instances where the duration was longer than 15 minutes. On 05/12/2019 at 7:11 AM, the duration was 21 minutes and 7 seconds. On 05/12/2019 at 10:22 PM, the duration was 30 minutes and 2 seconds. On 05/15/19 at approximately 10:10 AM, an interview with Employee J was conducted. Employee J stated that the system is programmed to do certain things when the button is pushed. Employee J stated that the activated call bell routes to the certified nurse assistant (CNA) pager and if it isn't answered, it flows over to nurse pager. The facility staff provided a copy of their policy entitled, Responding to call light. The listed procedures documented, 1. Respond to location of call light. 2. Ask resident what assistance is needed. 3. If certified to perform care, render care. 4. If not certified to render care, notify a member of the nursing team and/or supervisor. 5. Please ensure call light is reset. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they had no further documentation or information to offer. 2. For Resident #15, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 3 of 15 opportunities the call light was activated. Resident #15, an [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #15's most recent minimum Data set with an Assessment Reference Date of 02/20/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 12 out of possible 15 indicative of moderate cognitive impairment. Functional status for bed mobility, transfers, dressing, and toileting was coded as requiring extensive assistance from staff. On 05/14/19 at approximately 1:55 PM, an interview with Resident #15 was conducted. When asked if the staff answer the call light promptly when she needs assistance, Resident #15 stated, Sometimes it's a long time before they come. Resident #15 stated that she needs help to get into her chair or to get positioned for a nap. Resident #15 also stated, I can't get up by myself. On 05/14/19 at 2:55 PM, call logs for the past week for the health center were requested from Employee J from the information technology department. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated that her expectation is for call bells to be answered within 15 minutes. She stated that she didn't know why they were longer perhaps staff forgot to cut off the call bell and was in the room doing care. On 05/15/2019 at approximately 9:00 AM, the facility staff provided call logs for Resident #12 with a date range of 05/08/2019 through 05/14/2019. Of the 15 times the call light was activated, there were 3 instances where the duration was longer than 15 minutes. On 05/08/2019 at 9:23 AM, the duration was 28 minutes and 43 seconds. On 05/11/2019 at 7:56 PM, the duration was 23 minutes and 24 seconds. On 05/13/2019 at 4:26 PM, the duration was 15 minutes and 31 seconds. On 05/15/19 at approximately 10:10 AM, an interview with Employee J was conducted. Employee J stated that the system is programmed to do certain things when the button is pushed. Employee J stated that the activated call bell routes to the certified nurse assistant (CNA) pager and if it isn't answered, it flows over to nurse pager. The facility staff provided a copy of their policy entitled, Responding to call light. The listed procedures documented, 1. Respond to location of call light. 2. Ask resident what assistance is needed. 3. If certified to perform care, render care. 4. If not certified to render care, notify a member of the nursing team and/or supervisor. 5. Please ensure call light is reset. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they had no further documentation or information to offer. 3. Resident #5 was not provided a hoyer lift sling to get out of bed in the morning on 5-14-19 due to lack of equipment. Resident #5, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Resident's neck was bent laterally to the right, so profoundly, that the Resident's right cheek laid on her right clavicle and shoulder. Resident #5's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-24-19 was coded as an annual assessment. Resident #5 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #5 was also coded as requiring extensive assistance to total dependence on one to two staff members to perform activities of daily living, such as hygiene, transferring, and bed mobility. On 5-14-19 at 12:00 noon, Resident #5 was observed in bed, with the head of the bed elevated, during initial tour of the facility. A Resident interview was conducted, and the Resident complained that this morning I couldn't even get up to get my lunch today because they had no strap clean for the hoyer lift for me. She explained that she got up for lunch and went back to bed around 4:00 p.m., which was her choice, because if I didn't go back at 4:00 p.m., I would be up til 9:00 p.m., or 10:00 p.m., and she stated that she could not sit up comfortably that long. She went on to say that today, I won't be able to get out of bed at all. That just makes no sense. Review of the resident's clinical record revealed the resident's current POS (physician order sheet), for (MONTH) 2019. Contained was an order for [REDACTED]. On 5-14-19 at approximately 4:00 p.m., Resident #5 was again interviewed and observed returning to bed from a wheel chair. CNA B was in the room with the Resident and stated the Resident did get up for about 2 hours after they found a hoyer lift sling for her, however, they were only able to get her up from 2:00 p.m., until 4:00 p.m., because there was no lift sling for the hoyer mechanical lift for her. Resident #5's care plan was reviewed and revealed that the document was last revised on 5-2-19, and noted that the resident was dependent on 2 staff members to provide mechanical lift for transferring. On 5-16-19 at end of day debrief the DON (director of nursing), and Administrator were notified of above findings. No further information was provided. 4. For Resident # 28 the facility staff failed to answer call bells in timely manner for a Resident who requires assistance with transfer and ambulation. Resident #28 is an [AGE] year old woman originally admitted to the facility with [DIAGNOSES REDACTED]. On 3/19/19 Resident was admitted to the facility prior to admission to hospital for planned surgical repair of hardware from prior [MEDICAL CONDITION]. The Resident went out for surgery on 4/6/19 and was readmitted on [DATE]. Residents most recent (Minimum Data Set) MDS was dated 3/31/19 and it was a 14 -Day PPS. According to the most recent MDS Resident # 28 had a (Brief Interview of Mental Status) BIMS score of 15 / 15 indicating no cognitive impairment. On 5/14/19 at 2:15 PM an interview was conducted with Resident #28 who stated she had no problems with the facility other than the time it took for staff to answer the call bells. She further elaborated by saying If the staff would answer the call bells this place would be great! She relayed an incident where she had put the call bell on because she wanted something for her cough. She stated that someone came in and turned the call bell off and told her she would let the nurse know what she needed. She stated that happened three times and no nurse came. She stated after that I just got up by myself and walked to the nurses' station to tell her. On 5/14/19 at 3:00 P.M., an interview was conducted with Employee J (Information Technology), when asked if this surveyor could have a copy of the call bell response times he replied I don't think I can get that. When asked what company they use he stated Status Solutions and when asked what program he stated Sara. He was then informed by this surveyor that we request these logs from other facilities using the same system and are able to get them, he stated he would try to get them. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated, my expectation is for call bells to be answered within 15 minutes. I know they get the care they need. According to the facility call logs provided by Status Solutions from 5/1/19 through 5/14/19 5/2/19 - Call bell rang from 4:33 PM to 4:56 PM - total 22 min. 21 sec. 5/3/19 - Call bell rang from 7:05 AM to 7:23 AM - total 18 min 10 sec. 5/3/19 - Call bell rang from 7:38 AM to 7:53 AM - total 14 min. 56 sec. 5/3/19 - Call bell rang from 1:33 PM to 1:56 PM - total 22 min 46 sec. 5/4/19 - Call bell rang from 7:59 AM to 8:15 AM - total 16 min. 19 sec 5/4/19 - Call bell rang from 8:24 PM to 8:50 PM - total 26 min. 5 sec 5/5/19 - Call bell rang from 8:10 AM to 8:24 AM - total 14 min. 15 sec 5/5/19 - Call bell rang from 8:43 AM to 9:18 AM - total 34 min 35 sec 5/6/19 - Call bell rang from 8:03 AM to 8:19 AM - total of 15 min 46 sec. 5/7/19 - Call bell rand from 7:01 AM to 7:30 AM - total 28 min 41 sec. 5/10/19 - Call bell rang from 7:35 AM to 7:53 AM total of 18 min 7 sec 5/11/19 Call bell rang from 7:01 AM to 7:44 AM - total 43 min 37 sec 5/11/19 Call bell rang from 12:30 PM to 12:50 PM total of 20 min 10 sec. 5/13/19 Call bell rang from 4:12 PM to 4:52 PM total of 20 min 40 sec. 5/13/19 Call bell rang from 9:10 PM to 9:27 PM total of 17 min 5 sec. On 5/15/19 at 4:30 PM in an interview with CNA A, CNA A stated that Resident # 98 needs assistance to get up and go to the bathroom and she needs help getting out of bed and to her chair. On 5/16/19 at the end of day meeting, the Administrator was made aware of the issues with answering call bells timely and no further information was provided. 5. For Resident #190 the facility staff failed to answer call bells in a timely manner for a Resident who needs assistance with transfer and ambulation. Resident # 190 a [AGE] year old woman was admitted to the facility on [DATE]. The Resident had no (Minimum Data Set) MDS information available as she was a new admission. The Resident was admitted to the facility with [DIAGNOSES REDACTED]. On 5/14/19 at 2:25 PM an interview was conducted with Resident #190 who stated the staff take too long to answer call bells. She stated that the facility is nice but if you have to use the bathroom [ROOM NUMBER] minutes is way too long to wait. When asked what type of assistance she requires Resident #190 stated she had a hip replacement surgery but something went wrong and she ended up with foot drop as well so she is unable to ambulate or transfer alone. On 5/14/19 at 3:00 P.M. an interview was conducted with Employee J (Information Technology), when asked if this surveyor could have a copy of the call bell response times he replied I don't think I can get that. When asked what company they use he stated Status Solutions and when asked what program he stated Sara. He was then informed by this surveyor that we request these logs from other facilities using the same system and are able to get them. He stated he would try to get them. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated, my expectation is for call bells to be answered within 15 minutes. I know they get the care they need. According to the facility call logs provided by Status Solutions from 5/1/19 through 5/14/19 5/9/19 - Call bell rang from 7:14 AM to 7:31 AM - total 17 min. 18 sec. 5/10/19 Call bell rang from 9:17 AM to 9:37 AM total 19 min 40 sec. 5/10/19 Call bell rang from 12:35 PM to 12:50 PM total 15 min 9 sec. 5/11/19 Call bell rang from 1:38 AM to 1:55 AM total 16 min 42 sec. 5/11/19 Call bell rang from 2:30 PM to 3:06 PM total 19 min 32 sec. 5/11/19 Call bell rang from 5:59 PM to 6:15 PM total 15 min 56 sec. 5/12/19 Call bell rang from 1:44 PM to 2:15 PM total 31 min 45 sec. 5/12/19 Call bell rang from 3:02 PM to 3:22 PM total 19 min 32 sec. 5/14/19 Call bell rang from 8:19 AM to 8:42 Am total 23 min 4 sec. On 5/15/19 at 4:30 PM, an interview was conducted with Employee H who stated that Resident # 98 needed assistance to get up and go to the bathroom and she needed help getting out of bed and to her chair. On 5/16/19 at the end of day meeting, the Administrator was made aware of the issues with answering call bells timely and no further information was provided. 6. For Resident #20, the facility staff failed, for three hours to respond to the Resident's call bell and request for assistance. Resident # 20, was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #20's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/20/19, was coded as a quarterly assessment. Resident #20 was coded as having a BIMS (brief interview for mental status) score of 15, which indicated being cognitively intact. Resident #20, was also coded as requiring extensive of assistance of staff for bed mobility, transfers, dressing, and personal hygiene. She was coded as being totally dependent upon staff for toileting and bathing. During an interview with Resident #20 on 05/14/19 at 01:33 PM, Resident #20 stated, I have called for help and waited over an hour. When asked how often this occurs, Resident #20 stated, it happens too often and indicated it is an ongoing concern. Review of the facility call bell response log on 5/15/19 revealed that on 5/8/19, Resident #20 used her call bell at 2:11pm to call for assistance. Three hours later, at 5:11pm her call bell was still sounding and had not been responded to. On 5/15/19 at 10:10am an interview was conducted with Employee J, Information Systems Director. Employee J stated, the system is programmed so when the call bell is pressed it notifies multiple people. If there is no response after 30 minutes, it resets and resends all of the notifications again. When Employee J was asked to interpret the call bell response log for Resident #20 on 5/8/19, Employee J stated, it tells me it wasn't responded to. When Employee J was asked what happens when a resident uses their call bell, Employee J and the DON stated, it activates a notification to the CNA, the supervisor and after a minute the DON and Administrator get a text on their phone. On 5/15/19 the DON (Director of Nursing, Employee B) was asked about the incident on 5/8/19 when Resident #20's call bell went off for 3 hours. The DON stated, I can tell you someone will check- people will come by and pop their heads in. On 5/15/19 the Administrator stated, an acceptable time and my expectation is for call bells to be answered within 15 minutes. We don't know what happened at that time, her care is exceptional. I know they get the care they need. Review of the facility policy titled, Call light with an effective date of (MONTH) (YEAR), read Emergency call system will be made available to all residents in room, bathrooms and other areas as deemed necessary. Residents are to have a method to activate the emergency call system herein referred to as call lights in bedrooms and bathrooms. Review of the facility policy titled, Responding to call light with an effective date of, (MONTH) (YEAR) read, All staff to respond to all lights. 1. Respond to location of call light. 2. Ask resident what assistance is needed. 3. If certified to perform care, render care 4. If not certified to render care, notify a member of the nursing team and/or supervisor 5. Please ensure call light is reset. On 5/15/19 the facility Administrator and DON were made aware of the facility staff's failure to respond to Resident #20's call light for 3 hours. No further information was provided. 7. For Resident #6, the facility staff failed to ensure that the call bell was within reach. Resident #6 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #6's [DIAGNOSES REDACTED]. The Minimum Data Set, which was an Annual Assessment, with an Assessment Reference Date of 1/3/19 was reviewed. Resident #6 was coded as having a Brief Interview of Mental Status Score of 8, indicating moderate cognitive impairment. In addition, Resident #8 was coded as not having any mood or behavioral issues. On 5/15/19 at 8:31 A.M., an observation was conducted of Resident #6 in her bed. Resident #6's call bell was on the floor, out of reach. Resident #6 stated that she had no way to let the staff know what she needed. She said that due to the wound on the back of her knee, it was difficult for her to get up and use her walker when it was time for her to go to the bathroom. Resident #6 stated that she didn't remember the last time that the call bell was within reach. On 5/15/19 a review was conducted of facility documentation. The call bell response log was reviewed. During the previous 7 days, the call bell had not been activated during any shift. On 5/15/19 at 2:30 P.M., a Resident Group Interview was conducted. The group unanimously agreed that their call bells were not routinely answered in a timely manner. They stated that it usually took staff between 30 minutes and one hour to answer the call bell. They further stated that the facility had reduced the number of available Certified Nursing Assistants, and that additional staff were needed to meet their needs. On 5/15/19 at approximately 3:30 P.M., an interview was conducted with the facility Administrator (Employee A). The administrator stated, The resident probably knocked the call bell off the bed. No further information was provided.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed develop a care plan for 2 of 25 sampled residents. 1. For Resident # 91, the facility staff failed to develop a care plan for a renal diet. 2. For Resident #34, the facility staff failed to develop a comprehensive care plan for hearing deficits. The Findings included: 1. For Resident # 91, the facility staff failed to develop a care plan for a renal diet. Resident #91 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #91's [DIAGNOSES REDACTED]. On 5/14/19 at 3:15 P.M., an interview was conducted with Resident #91 and her son. Resident #91 was concerned that her diet order wasn't being followed. She stated that the facility served her canned peaches that morning, and continued to serve her orange juice for breakfast. She stated, and her son agreed that her potassium level increased and she had to take a new medication the previous night. Resident #91 gave the surveyor her meal ticket, which listed the following prohibited foods: No banana, orange juice, potato, sweet potato, tomato, apricots, peaches, pears, oranges, spinach, asparagus, Brussels sprouts, collard, turnips, deli meat sausage bacon. Resident #91 was dressed appropriately, and was oriented to person place, time and situation. On 5/15/19 at 8:20 A.M., an observation was conducted of Resident #91 eating breakfast. The breakfast tray contained mandarin oranges and orange juice. On 5/15/19, a review was conducted of Resident #91's clinical record. On 5/9/19 the Registered Dietician changed the resident's diet from a regular, no added salt diet, to a renal diet. Resident #91's lab reports were as follows: Potassium on 4/30/19 - 4.6 Potassium on 5/13/19 - 5.6 normal range is 3.5 - 5.1 According to a signed telephone order, on 5/13/19 at 2:23 P.M. the MD ordered [MEDICATION NAME] 30 Grams by mouth x 1 dose (used to decrease elevated potassium). Resident #91's care plan was reviewed. It read, 5/8/19. No added salt diet. On the most recent care plan , dated 5/15/19, The Nutritional status, and Dietary Goals sections were left blank. On 5/14/19 at 2:27 P.M. an interview was conducted with the Registered Dietician (Employee L). She stated, If the potassium is high, she shouldn't get the foods high in potassium. The Regional Dietician (Employee M) was also present, and stated, A person who gets too much potassium, it could cause heart failure. On 5/15/19 at 10:42 A.M., an interview was conducted with the Director of Nursing (Employee B). She was asked to describe how the process works to change a diet order. She stated, the dietician can change the order in the computer system. The Dietician writes their own orders. The kitchen and nursing departments are automatically notified of the diet change. The kitchen staff is supposed to make sure that forbidden foods are not on the tray. The nursing staff should also read the ticket on the resident's tray to ensure that food restrictions are followed. No further information was received. 2. For Resident #34, the facility staff failed to develop a comprehensive care plan for hearing deficits. Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #34's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 3-20-19. Resident #34 was coded with a Brief Interview of Mental Status score of 7, indicating moderate cognitive impairment. Resident #34 was extensively dependant on one staff member for assistance with activities of daily living care, such as bed mobility, transferring, and toileting. On the physician's progress notes, it described the Resident as hard of hearing (HOH). Nursing staff and the Resident's daughter indicated the Resident was very hard of hearing, and this could be a barrier to communication, and understanding instructions. The Resident's current care plan was reviewed and revealed no care plan for hard of hearing deficits. The Administrator and Director of Nursing were notified at the end of day meeting on 5-16-19 at 2:00 p.m. No further information was provided by the facility.

Based on staff interview facility documentation and clinical record review the facility staff failed to ensure one Residents was free from neglect for 1 of 25 sampled Residents (#34). For Resident #34 who had a recent history of falls with fracture, the facility staff left the Resident on the toilet without supervision, neglecting the Resident's known needs, and the Resident fell . The findings included: Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident was also hard of hearing and wore hearing aids. Resident #34's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 3-20-19. Resident #34 was coded with a Brief Interview of Mental Status score of 7, indicating moderate cognitive impairment. Resident #34 was extensively dependant on one staff member for assistance with activities of daily living care, such as bed mobility, transferring, and toileting. On the physician's progress notes, most described the Resident as hard of hearing (HOH). Nursing staff and the Resident's daughter indicated the Resident was very hard of hearing, and this could be a barrier to communication, and understanding instructions. On 2-25-19 the physician's progress notes indicated the Resident had fallen on 2-23-19 while trying to stand from a wheel chair. On 3-5-19 the nursing notes documented that the Resident had been left alone on the toilet and had fallen. On 5-14-19 at approximately 1:00 p.m., Resident #34's daughter was interviewed. The daughter stated I was not aware that mom fell from the toilet unattended. She can't be left alone on the toilet, she will try to get up and fall. She has an immobilizer on her ankle from her fracture, and pain in that leg that she receives pain medication for. She is not supposed to stand on it unassisted, and she doesn't remember that. The Resident's current care plan was reviewed and revealed no revision or update review, since admission on 12-26-18, and had a goal date of 7-5-19. The care plan stated as problems related to falls and fracture, the 3 following areas, and those interventions are below; 1. Falls - at risk for more falls related to recent fall and fracture - observe and anticipate or intervene with factors causing previous or potential for falls. Answer calls quickly, attempt to anticipate needs for prompt response, and decrease in attempts to ambulate without proper assist. 2. Impaired functional status - has impaired functional status with bed mobility, transfer, walking, toileting, etc - weight bear as tolerated with brace when out of bed, stand pivot for transfers with assist of 1 staff. 3. Medical condition Orthopedic - had a recent fracture, requires follow up care. - Assess immobilizer device cast to ensure intact, assess skin under/at edge of immobilizer to ensure no rubbing, friction or pressure is evident. Maintain imposed limitations of non-weight bear right lower extremity educate and remind (Resident) of limitations. At the time of survey no facility reported incident (FRI) or allegation of neglect was forwarded to the state agency, the Virginia Department of Health Office of Licensure and Certification (VDH/OLC). The facility abuse & neglect policy and procedure documents were requested from the administrator, and obtained. Review of the policy revealed that all allegations of abuse or neglect be reported within 24 hours after the (incident) allegation is made. Federal regulations describes neglect as: the failure of the facility , it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. On 5-16-19 at 10:30 a.m. the Director of Nursing (DON) was asked for any FRI's for this Resident. She stated there were none. In summary, the staff were aware of the Resident's fall history with attempts to stand alone, resulting in serious injury, and the Resident was demented, with memory impairment, hard of hearing, and was non-weight bearing. The Resident had a cast device on her left leg which was a fall hazard. she had pain in that leg, poor vision, lack of coordination and weakness. The facility staff placed her on the toilet and left her there alone, and when they returned she was sitting on the floor in the bathroom where she had fallen. Staff did not implement their care plan to intervene with factors causing previous falls or potential for falls, nor attempt to anticipate needs for prompt response, and decrease in attempts to ambulate without proper assist. The Administrator and Director of Nursing were notified at the end of day meeting on 5-16-19 at 2:00 p.m. that the staff was negligent in providing the care and services required by the Resident, and were deficient in investigating and reporting this incident. No further information was provided by the facility.

Based on staff interview and clinical record review, the facility staff failed to notify the ombudsman of transfer to the hospital for two Residents (Resident #339, Resident 89) in a survey sample of 25 Residents. 1. For Resident #339, the facility staff failed to notify the ombudsman of transfer to the hospital on two occasions. 2. For Resident #89, the facility staff failed to notify the ombudsman of transfer to hospital. The findings included: 1. For Resident #339, the facility staff failed to notify the ombudsman of transfer to the hospital on two occasions. Resident #339, was admitted to the facility on [DATE]. The Resident's [DIAGNOSES REDACTED]. Resident #339's most recent MDS (minimum data set) (an assessment tool), was coded as an admission assessment, with an ARD (assessment reference date) of 11/21/18. Resident #339, had a BIMS (brief interview for mental status) score of 9, which indicated moderately impaired cognition. Resident #339 was coded that extensive assistance of two staff members was required for ADL's (activities of daily living) which included, bed mobility, transfers, dressing and personal hygiene. On 5/15/19 during review of Resident #339's clinical record, nursing notes revealed that on 12/13/18, Resident #339 was sent to the hospital. The nursing note dated 12/13/18 at 23:51 read, Resident was found on the floor close to the bed in her room by Aide. A laceration noted on back of head, measured 2cm x 0.5 cm, with depth 0.3cm. Surrounding area appeared swollen and blood draining. In the incident scene there was a clock with front glass in pieces on the floor, blood on the carpet closer to the TV and two chairs on the side wall. She denied pain, no complain of drowsiness, dizziness, or lightheadedness noted. Injury area cleanse with NS, pressure applied to stop bleeding. According to assigned CNA, resident was put to bed after dinner and ADL care had been provided. Resident stated that she lost her balance and hit her head on the side wall while trying to go to the restroom. She believed that the clock fell to the ground resulting from the impact on the wall due to her hitting the wall. Vitals taken x 4 every 15 minutes, pressure applied to stop bleeding, cleanse injured with NS, pat dry and covered with dry gauze. MD notified and ordered to sent to ER for further evaluation and possible sutures to injured area Daughter was notified that walked in shortly after the incident occurred. Pt was sent out via medical transportation, accompanied by daughter. A nursing note dated 12/16/18 at 17:04 read, Patient was sent out per daughter/(name) request: approved by Dr. (Dr. name) d/t s/p fall trauma injury noted to right forearm (redness, swelling, pain, inflammation and warm to touch) and c/o pain to right hip. Pain managed with [MEDICATION NAME]. Review of the clinical record for Resident #339 revealed no indication that the ombudsman was notified of her transfer to the hospital on [DATE] and 12/16/18. On 5/16/19 at approximately 11 am the facility Administrator was interviewed and asked for verification of the ombudsman notification of Resident #339's transfer to the hospital. The Administrator stated, we weren't doing it at that time. The facility administrator was made aware of the facility staff's failure to notify the ombudsman of hospital transfers on 5/16/19. No further information was provided. 2. For Resident #89, the facility staff failed to notify the ombudsman of transfer to hospital. Resident #89, a [AGE] year old female, was admitted to the facility on [DATE] and discharged on [DATE] due to a transfer to the hospital. Therefore, this was a closed record review. [DIAGNOSES REDACTED]. Resident #89's most recent Minimum Data Set with an Assessment Reference Date of 04/20/2018 was coded as an admission assessment. The Brief Interview for Mental Status was coded as a 15 out of possible 15 indicative of intact cognition. On 05/16/2019 at approximately 9:30 AM, the nurse's notes were reviewed. A nursing entry dated 05/01/2018 documented that (Resident #89) was sent to the hospital for [MEDICAL CONDITION] after unsuccessfully attempting to correct levels. On 05/16/2019 at approximately 9:45 AM, documentation of ombudsman notification associated with transfer to hospital on [DATE] was requested. On 05/16/19 at 1:45 PM, the Administrator stated, We have not been notifying ombudsman of transfers. On 05/16/2019, the facility staff provided a policy entitled, Transfer or Discharge, Emergency. In Section 4, it documented, Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's attending physician b. Notify the receiving facility that the transfer is being made c. Prepare the resident for transfer d. Prepare a transfer form to send with the resident e. Notify the sponsor or other family member f. Assist in obtaining transportation g. Others as appropriate or as is necessary. Notifying the ombudsman of hospital transfer was not addressed in the policy. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they have no further documentation or information to offer.

Based on staff interview and clinical record review, the facility staff failed to notify the resident of bed hold policy before transfer to the hospital for one Resident (Resident #339) in a survey sample of 25 Residents. For Resident #339, the facility staff failed to notify the resident of the bed hold policy before transfer to the hospital on two occassions. The findings included: Resident #339, was admitted to the facility on [DATE]. The Resident's [DIAGNOSES REDACTED]. Resident #339's most recent MDS (minimum data set) (an assessment tool), was coded as an admission assessment, with an ARD (assessment reference date) of 11/21/18. Resident #339, had a BIMS (brief interview for mental status) score of 9, which indicated moderately impaired cognition. Resident #339, was coded that extensive assistance of two staff members was required for ADL's (activities of daily living) which included, bed mobility, transfers, dressing and personal hygiene. On 5/15/19 during review of Resident #339's clinical record, nursing notes revealed that on 12/13/18 Resident #339 was sent to the hospital. The nursing note dated 12/13/18 at 23:51 read, Resident was found on the floor close to the bed in her room by Aide. A laceration noted on back of head, measured 2cm x 0.5 cm, with depth 0.3cm. Surrounding area appeared swollen and blood draining. In the incident scene there was a clock with front glass in pieces on the floor, blood on the carpet closer to the TV and two chairs on the side wall. She denied pain, no complain of drowsiness, dizziness, or lightheadedness noted. Injury area cleanse with NS, pressure applied to stop bleeding. According to assigned CNA, resident was put to bed after dinner and ADL care had been provided. Resident stated that she lost her balance and hit her head on the side wall while trying to go to the restroom. She believed that the clock fell to the ground resulting from the impact on the wall due to her hitting the wall. Vitals taken x 4 every 15 minutes, pressure applied to stop bleeding, cleanse injured with NS, pat dry and covered with dry gauze. MD notified and ordered to sent to ER for further evaluation and possible sutures to injured area Daughter was notified that walked in shortly after the incident occurred. Pt was sent out via medical transportation, accompanied by daughter. A nursing note dated 12/16/18 at 17:04 read, Patient was sent out per daughter/(name) request: approved by Dr. (Dr. name) d/t s/p fall trauma injury noted to right forearm (redness, swelling, pain, inflammation and warm to touch) and c/o pain to right hip. Pain managed with [MEDICATION NAME]. Review of the clinical record for Resident #339 revealed no indication that the resident or her responsible representative was notified of the bed hold policy prior to her transfer to the hospital on [DATE] and 12/16/18. On 5/16/18, the facility Administrator was asked where it is noted that Resident #339 was notified of the bed hold policy prior to her transfer and the Administrator stated, we weren't doing it at that time. The facility administrator was made aware on 5/16/19 of the facility staff's failure to notify the resident of the bed hold policy prior to transfer. No further information was provided.

Based on observation, staff and family interview, clinical record and facility documentation review, the facility staff failed to serve hot liquids at a safe temperature to Resident # 397, resulting in Immediate Jeopardy. The facility also failed to serve coffee at a safe temperature for Resident # 21, resulting in harm (second degree burns). 1. The staff allowed unrestricted and unsupervised access to a coffee/hot water machine producing coffee at 177 degrees F (Fahrenheit). Resident #397 was served this coffee immediately after the CNA (certified nursing assistant, Employee A) poured her the coffle. 2. Resident #21 sustained second [MEDICAL CONDITION] spilling hot coffee on herself. There were no temperatures for hot liquids documented. The resident was not assessed for safety with hot liquids prior to or after the burn. The findings included: 1. Resident # 397 was a [AGE] year old female admitted to the facility originally on 4/21/2015 and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a Significant Change Assessment with an Assessment Reference Date (ARD) of 1/7/2018. The MDS coded Resident # 397 with a BIMS (Brief Interview for Mental Status) of 15/15 indicating no cognitive impairment. Resident # 397 required extensive assistance of one staff person to two staff persons with activities of daily living except required total assistance of one staff person for bathing and was coded for supervision and set up only for eating. During tour on 2/5/18 at 2:48 PM, food /temperature logs were reviewed. No hot beverage temperatures were taken. Kitchen manager stated that it was the nursing staff's responsibility to take the coffee temperatures. He said that there were currently no residents who were using special cups with two handles. He further stated that no residents had ever been burned. 02/06/18 4:40 PM: Pantry area near kitchen (south dining room) has two entryways into the pantry (no doors). A coffee maker/hot water machine was on the counter at waist level, accessible by w/c (wheelchair) residents. On palpation, the water was extremely hot with small bubbles and steam evident, painful to touch. Styrofoam cups were on the counter next to the machine. No residents were observed near the pantry at this time. 02/06/18 5:40 PM: A small steam table on the same counter as the coffee maker contained hot soup. The dietary supervisor checked the temperature of the soup, which was 155 degrees Fahrenheit (F). Coffee temperature was checked as well with the temperature of the coffee at 177 degrees F, which was served to Resident #397 immediately by a CNA (certified nursing assistant- employee A). On 2/7/18 at approximately 3:00 PM, Employee (E) was asked for the manufacturer's guidelines for the coffee/hot water machine. The specifications for this machine read as follows (page 43): Internal boiler temperature range, adjustable between 83 degrees Celsius- 97 degrees Celsius (181.4 to 206 degrees Fahrenheit). The Burn Foundation gives the following information on burns: Coffee, tea, soup and hot tap water can be hot enough to cause serious burn injury: Hot Water Causes Third [MEDICAL CONDITION]. .in 1 second at 156º .in 2 seconds at 149º .in 5 seconds at 140º .in 15 seconds at 133º. 2/6/18: Review of the care plan for Resident #397, dated 1/9/18, read as follows: I require extensive assistance with my bathing, grooming, dressing, mobility and eating related to impaired cognition, decreased strength /mobility. 2. Resident #21 sustained a second degree burn from spilling hot coffee on herself on 1/28/18. There were no temperatures for hot liquids documented. The resident was not assessed for safety with hot liquids prior to and after the burn and the facility did not take action to correct the practice of monitoring and adjusting the serving of hot liquids. Resident #21 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #21's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1/3/18 was coded as a significant change in status assessment. The resident was coded as having a BIMS (brief interview of mental status) of 9 out of a possible 15, or moderate cognitive impairment. Resident #21 was also coded as requiring extensive assistance of one staff member to perform activities of daily living (ADL's), but requires supervision of one staff member for eating. On 2/6/18 at approximately 3:00 PM, Resident #21 was observed in her room. She refused an interview. On 2/6/18, review of the clinical record review rev revealed on 1/28/18, the resident had sustained a second degree burn on her abdomen from spilling hot coffee during her breakfast. Treatment to the burn was ordered. The facility documented the resident had no pain on the day of [MEDICAL CONDITION] thereafter. The resident ate her meals in the South dining Room where the coffee container was located. She stated, It could happen to anybody. On 1/31/18, the resident's primary physician noted the following: Patient had poured hot coffee on her abdomen on 1/29/18. [MEDICATION NAME] (burn ointment) started empirically and skin prep on blister every day. On 1/31/18, the skin evaluation form noted the following measurements: 2.4 cm (centimeters) with a width of 8 cm. Johns Hopkins Medicine describes second [MEDICAL CONDITION]: Second-degree (partial thickness)[MEDICAL CONDITION] Second-[MEDICAL CONDITION] the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful. Review of the temperature logs the day of the incident revealed oatmeal/grits temperature was 170 degrees. There were no temperatures of hot liquids such as coffee and tea. 02/06/18 03:28 PM: Interview with Resident #21's son who was present in room. Resident had earlier stated she did not like to talk or be asked questions. The son stated that the facility had called him about the burn. He stated, She had a blister or two, which was painful for a brief period. He went on to state that therapy was looking at a cup that would be appropriate for her. Review of the wound note dated 1/28/18 documented an area of 2.4 cm (centimeters) by 8.0 cm. 02/06/18 5:30 PM: Resident #21 was at the dining room (DR) (South) table with milk and cold water in regular mugs. She had no liquids with her meal. 2/6/18: 5:50 PM: notified supervisor of possible IJ. 2/6/18: 6:00 PM: Called office and notified supervisors and Division Director of possible IJ Immediate jeopardy). At 6:15 PM, the office advised to get more information form the facility. 2/6/18: 6:20 PM: The facility Administrator and acting DON were notified of needed information. The Administrator stated the facility had a mock survey completed and had identified there was no policy for hot liquids and had also reviewed this on their QA (quality assurance meeting) monthly meeting on 1/26/18. 2/6/18: 6:45 PM: Information received from facility. The facility was unable to demonstrate hot liquid safety assessments were completed for Resident #21 or all other residents at risk after Resident #21 was burned. The Program Manager presented facility wide assessments completed on 1/10 and 1/11/18 (prior to the burn) which she stated, We assessed residents for use of adaptive equipment correctly. She went on to state that the screen was not specifically for hot liquid safety. In addition, the facility staff was informed that the continued lack of documentation of hot liquid temperatures and the unrestricted use of the hot coffee/hot water machine may constitute IJ (immediate jeopardy). 2/6/18: 7:30 PM: Information reviewed, called supervisor, agreed with IJ 2/6/18: 7:35 PM: Administrator and team notified to report to conference room. 2/6/18: 7:38 PM: Administrator and team notified of IJ. P[NAME] (plan of correction) requested. 2/6/18: 8:30 PM, P[NAME] reviewed and accepted. The coffee/hot water machine was removed from service (IJ abated). Review of the P[NAME] revealed: 1. The identified resident received a hot liquid assessment. Resident has agreed to use coffee cup with a secure lid for safety. Care plan was updated. All coffee machines were immediately removed from the units. (2/6/18) 2. All residents will receive a hot liquids assessment by 2/7/18. 3. Facility staff will be inserviced on hot liquids policy and procedure by 2/7/18. 4. Dining Services/designee will conduct daily audits to ensure proper temperature of 165-170 hot liquids prior to leaving kitchen. Audits will be conducted for three months and results turned in to QAA committee for review and appropriate action. 5. All actions will be completed by 2/7/18. On 2/6/18 at 4:20 p.m., interviews were conducted with the dietary staff in the main kitchen. The Kitchen Manager (Employee B) was asked about the service of hot beverages. She stated that no hot liquids were served on the meal trays that leave the kitchen. She stated that hot coffee goes into a carafe and is transported on top of the carts that are delivered to the memory unit and the open dining area where the residents requiring assistance eat. The pantry at the South dining area had a machine that dispensed hot liquids. In summary, two of the three dining areas were provided hot liquids in carafes from the main kitchen. Temperatures of the hot liquids in the carafes prepared for the units in the main kitchen were not observed to be taken. On 2/6/18 at 4:30 p.m. three carafes (hot water, coffee and decaf coffee) were observed in the pantry area of the memory care dining area. Diet Supervisor (Employee C) entered the dining area and took the temperatures of all three liquids using a regular thermometer (not digital). Hot water= 130 degrees Fahrenheit (F), coffee= 118 degrees F, decaf= 110 degrees F. On 2/6/18 at 4:40 p.m. no carafes of hot liquid were observed in the south dining hall pantry. This pantry had an automatic hot liquid dispensing machine that could dispense hot water, coffee and decaf coffee. Employee C entered the pantry and took the temperature of the broccoli cheddar soup. The temperature measured 155 degrees F. Employee C was not observed to take the temperatures of the hot liquids available from the automatic dispensing machine. Observations continued in the south dining area. At 5:10 p.m., the dietary aide (Employee A) dispensed a cup of hot liquid from the machine. She added packets of a powdered substance and stirred the liquid for approximately 2- 3 minutes. She served the hot beverage to a resident in the dining room. Employee C was in the dining room at this time and he was asked to take the temperature of the hot beverage just served by Employee A. The temperature was 134 F. Employee A was asked if she ever took the temperature of the hot liquids or soups that she served. Employee A stated no. Employee A was asked if she had a thermometer in the pantry. She stated no. On 2/6/18 at 5:35 p.m., a second Diet Supervisor (Employee D) walked into the south dining area. She was asked to take the temperature of three items in the pantry. The mighty shake, a cold nutritional supplement, was 41.9 degrees F. The broccoli cheddar soup was 155 degrees F. Lastly, Employee D was asked to fill a cup with coffee from the automatic hot liquid dispenser and take the temperature. At this time, Employee A (diet aide) walked up to the machine to fill a cup of decaf coffee for a resident. Employee D took the cup of decaf coffee from Employee A and told Employee A that she would need to fill another cup. Employee D took the temperature of the cup of decaf coffee with a digital thermometer. The temperature measured 177 degrees F. Immediately after the temperature was taken, Employee A, in the presence of Employee D, dispensed a new cup of decaf coffee. Employee A put the cup on a saucer. She took two creamers out of the refrigerator and put them on the saucer. The coffee was steaming. The cup of coffee did not have a lid. She then served the cup of decaf coffee to Resident #397 who was seated at the table. Resident # 397 was a [AGE] year old female admitted to the facility originally on 4/21/2015 and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a Significant Change Assessment with an Assessment Reference Date (ARD) of 1/7/2018. The MDS coded Resident # 3 with a BIMS (Brief Interview for Mental Status) of 15/15 indicating no cognitive impairment; Resident # 397 required extensive assistance of one staff person to two staff persons with activities of daily living except required total assistance of one staff person for bathing and was coded for supervision and set up only for eating. On 2/6/18 at 6:45 p.m. the Administrator and Director of Therapy (Employee F) were interviewed regarding the plan put into place after Resident #21 was burned by the hot coffee. The Administrator stated that all residents were screened by therapy. The Director of Therapy stated that the residents were screened for the need of adaptive equipment during self feeding. She stated that all residents were screened to use a cup without a lid. When asked if the screening she completed was a hot liquid assessment, the Director of Therapy stated no. When asked if her screen was to assess the physical ability versus the cognitive ability of the residents to drink hot liquids, the Director of Therapy stated that her assessment was of physical ability only. The assessments were reviewed by the survey team. They were dated 1/10/18 to 1/11/18, prior to Resident #21's burn. The Administrator also stated that after Resident #21 was burned on 1/28/18, the dietary staff began to monitor the temperatures of the hot beverages served. The Administrator was asked to provide the coffee temperature logs. This surveyor and the Administrator entered the main kitchen on 2/6/18 at 7:05 p.m. to review the hot beverage temperature logs. The Administrator asked the Kitchen Manager (Employee B) for the logs. She stated that the log for the dinner meal that evening had not been returned from the floor yet. She was asked to provide the log and all of the logs since 1/28/18. Employee B stated that the dietary department did not have temperature logs from 1/28/18 because they just started taking the temperatures of hot liquids on 2/5/18 after the survey team asked about hot liquid temperatures during the initial tour of the kitchen. She was asked to provide the temperature log for the dinner meal on 2/6/18 once it was located. As of the conclusion of the survey on 2/8/18, the temperature log for the 2/6/18 dinner meal was not provided. On 2/6/18 at 7:10 p.m., the Director of Dining Services stated that the machine in the south dining pantry dispensed liquids at 160-165 degrees F. He was informed that the machine dispensed a cup of coffee measuring 177 degrees F during the dinner meal service that evening. No temperature logs were provided as documentation that temperatures of the hot beverages served from the machine had been monitored. The Director of Dining Services also stated that the dietary aides were supposed to let the hot liquids sit for three minutes once poured to let the liquid cool down so it is not too hot when served. When asked how the facility defined too hot, the Dining Services Director stated 155 degrees F.