Every finding on record at Whispering Springs Rehabilitation and Healthcare C

Based on observation, interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 11 (Resident #1) residents whose records were reviewed for assessments. The facility nursing staff failed to code Resident #1 had recent fall with injury on her MDS assessment. This deficient practice could place residents at risk of not identifying care areas and result in residents not receiving needed care and services.The findings included: Record review of Resident #1's admission Record, dated 09/22/2025, revealed a [AGE] year-old female admitted [DATE] and re-admitted on [DATE]. Resident #1 was not listed as her own responsible party with her [family member] listed as Emergency Contact #1. Resident #1 was admitted to the hospital and discharged on 07/28/2026. Record review of Resident #1's Medical Diagnoses, undated and accessed 07/28/2026 at 11:29 a.m., revealed diagnoses including congestive heart failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), chronic kidney disease (occurs when the kidneys are damaged and cannot filter waste, toxins, and excess fluids from the blood effectively), diabetes mellitus (condition that occurs when the body cannot properly use blood sugar), protein-calorie malnutrition (severe form of undernutrition caused by insufficient intake of both protein and calories, leading to muscle wasting, fat loss, and impaired body function), unspecified dementia (refers to cases where a person shows clear signs of cognitive decline, such as memory loss, confusion, and difficulty performing daily tasks, but the underlying cause has not been definitively determined), and cognitive communication deficit (occurs when cognitive processes such as attention, memory, reasoning, and executive function are impaired, affecting how a person organizes, processes, and expresses thoughts in communication). Record review of Resident #1's care plan, undated and accessed 07/28/2026 at 11:30 a.m., revealed Resident #1 was at risk for falls/History [and] require supervision-minimal assistance with ADL's. The interventions included .Call light within reach.Visual checks every 1-2 hrs [hours] and prn [as needed]. The care plan focus was created and initiated on 03/18/2020 and revised on 01/04/2024.Record review of Resident #1's significant change MDS, dated [DATE] and signed 05/29/2026 as completed, reflected cognitive patterns, code of 03, indicating severely impaired. Resident #1 was documented as having no falls since admission/entry or reentry or prior assessment, including number of falls documented no entries. Resident #1's functional abilities for self-care and mobility were documented as requiring dependent or substantial/maximal assistance.Record review of Resident #1's SABR dated 04/16/2026 19. Other relevant information, Noted the resident on the floor lying on her left side due to an unwitnessed fall. Hematoma noted to the left side of her forehead. with orders from MD [Medical Director] Transfer to the hospital.Record review of Resident #1's Unwitnessed Fall report, dated 04/16/2026, revealed Incident Description, Noted the resident on the floor lying on her left side due to an unwitnessed fall. Hematoma noted to the left side of her forehead.During an observation and interview on 07/28/2026 at 1:00 p.m., the MDS Coordinator revealed that the purpose of the MDS assessment is to gather information on a resident, to conduct an assessment on resident's needs, allowing NF staff to look at the whole picture of a resident and their functional abilities and cognition. She stated that not accurately completing the MDS assessments would impact the residents and their care, it would delay developing care plans and delay communication with nurses on resident reports and their continued care. The MDS Coordinator was observed to review Resident #1's Medicare - 5 Day MDS admission dated 05/01/2026 and Resident #1's significant change MDS dated [DATE] and stated section J1700. Fall History on Admission/Entry or Reentry that asked, Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? was coded as No and stated it should have been coded as yes to reflect the fall with injury on 04/16/2026.During an interview on 07/28/2026 at 4:31 p.m., the Administrator stated that she was not sure of policy and procedures regarding MDS assessments, but that the NF was responsible for establishing the level of care needed for each resident and stated that not accurately documenting MDS assessments could impact resident's care.Record review of policy titled, MDS Coding, date last reviewed 07/16/2026, revealed, that the facility utilized the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately.Record review of policy titled, Care Plans, Comprehensive Person-Centered, date last reviewed 07/16/2026, revealed, 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 11 (Resident #1) residents reviewed for care plans. The facility nursing staff failed to revise Resident #1's care plan with a fall with injury requiring hospital admission on [DATE] and fall interventions following significant change of condition. This failure could have placed residents at risk of not having their needs identified and met. The findings included: Record review of Resident #1's admission Record, dated 09/22/2025, revealed a [AGE] year-old female admitted [DATE] and re-admitted on [DATE]. Resident #1 was not listed as her own responsible party with her [family member] listed as Emergency Contact #1. Resident #1 was admitted to the hospital and discharged on 07/28/2026. Record review of Resident #1's Medical Diagnoses, undated and accessed 07/28/2026 at 11:29 a.m., revealed diagnoses including congestive heart failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), chronic kidney disease (occurs when the kidneys are damaged and cannot filter waste, toxins, and excess fluids from the blood effectively), diabetes mellitus (condition that occurs when the body cannot properly use blood sugar), protein-calorie malnutrition (severe form of undernutrition caused by insufficient intake of both protein and calories, leading to muscle wasting, fat loss, and impaired body function), unspecified dementia (refers to cases where a person shows clear signs of cognitive decline, such as memory loss, confusion, and difficulty performing daily tasks, but the underlying cause has not been definitively determined), and cognitive communication deficit (occurs when cognitive processes such as attention, memory, reasoning, and executive function are impaired, affecting how a person organizes, processes, and expresses thoughts in communication).Record review of Resident #1's care plan, undated and accessed 07/28/2026 at 11:30 a.m., did not reveal mention of fall with injury on 04/16/2026, Interdisciplinary Team review, or fall interventions.Record review of Resident #1's NSG [nursing]: Morse Fall Scale Evaluation, dated 04/27/2026, revealed, Reason for Morse Fall completion: 2. Readmission. History of Falling. 2. YesRecord review of Resident #1's SABR dated 04/16/2026 19. Other relevant information, Noted the resident on the floor lying on her left side due to an unwitnessed fall. Hematoma noted to the left side of her forehead. with orders from MD Transfer to the hospital.Record review of Resident #1's Unwitnessed Fall report, dated 04/16/2026, revealed the following Incident Description, Noted the resident on the floor lying on her left side due to an unwitnessed fall. Hematoma noted to the left side of her forehead.Record review of Resident #1's care plan, undated and accessed 07/28/2026 at 11:30 a.m., revealed Resident #1 was at risk for falls/History [and] require supervision-minimal assistance with ADL's. The interventions included .Call light within reach.Visual checks every 1-2 hrs [hours] and prn [as needed]. The care plan focus was created and initiated on 03/18/2020 and revised on 01/04/2024.During an interview on 07/28/2026 at 10:40 a.m. the Director of Nursing stated that care plans discuss anything going on with the residents. She stated the nursing staff relies on care plans and it was to help them know what type of care is needed for the residents and was a tool of communication between departments. She stated care plans not being updated affects residents and causes an inconsistency of care.During an observation and interview on 07/28/2026 at 1:00 p.m., the MDS Coordinator revealed that delays in developing or updating care plans could delay communication with nurses on resident reports and their continued care. She stated care plans are updated as you go, if not she would fall behind. The MDS Coordinator stated that significant items added to the care plan should include falls and interventions. She stated every fall should be listed on the care plan. She stated she was responsible for care plans and updates and the ADON and DON will update them when she is out on leave. She stated she tries to keep up with all resident falls when she can. She will obtain fall details and dates, what were interventions for that date, and patient care. She stated she was responsible with updating care plans in a timely manner, needs to put interventions in place to ensure the resident does not sustain another fall, determines if the interventions are appropriate for the resident if not needs to evaluate again and if not working needs to change the intervention. The MDS Coordinator was observed to review Resident #1's electronic medical record and stated the unwitnessed fall with injury on 04/16/2026 was not documented on the care plan and she probably missed it. She stated it was not an excuse but Resident #1 was probably admitted to the hospital and she completed a discharge and readmission assessment and she thought she had documented the fall.During an interview on 07/28/2026 at 2:04 p.m., CNA C stated that care plans document important resident care, are constantly updated with important resident care. She stated falls and interventions would be listed on care plans. She stated that high risk fall residents will have interventions for fall mats, wheelchairs with footrest, keep constant eyes on them, not to be left alone in their room and all these important changes and interventions need to be documented on the care plans to help avoid falls, concussion, or hospital transport. She stated that not updating care plans frequently could impact resident care.During an interview on 07/28/2026 at 2:28 p.m., CNA B stated that care plans provide specific care for residents and stated that falls and behaviors would be documented on a care plan, and impact of not documenting falls could keep nursing staff from looking for signs or precautions for falls with high-risk fall residents. During an interview on 07/28/2026 at 2:43 p.m., LVN F stated falls are documented on care plans. He stated that not updating care plans with falls and interventions could impact residents in how the aides approach residents and could cause delayed care or cause them injury. During an interview on 07/28/2026 at 3:02 p.m., CNA A stated resident care plans tells staff what type of care was required for a resident. She stated it was important for care plans to include resident falls and interventions if the resident was a high-risk for falls. She stated if care plans are not updated or accurate residents could be hurt from a fall and not knowing their care they could be hurt.During an interview on 07/28/2026 at 4:31 p.m., the Administrator stated that care plans should be updated with falls. She stated it was important to be able to provide a plan of care for an individual, individualized plan, care plan was for staff to follow and to be able to provide specific care. She stated it depended on the situation if failing to update a care plan would impact a resident. She stated that the care plan for Resident #1 should have been updated to include falls with injury and stated there could be a negative impact to the care received and it should have been updated to include interventions and follow-up.Record review of policy titled, Fall Prevention Program, reviewed and revised 03/04/2026, revealed, The facility maintains an interdisciplinary fall prevention and management program designed to identify resident-specific fall risk factors and implement individualized, least restrictive interventions that support safety while promoting mobility, independence, dignity, and quality of life. The program focuses on risk identification, mitigation, monitoring, and reassessment as resident conditions change. A fall is defined as an unintentional change in position resulting in a resident coming to rest on the floor, ground, or other lower level. Each event will be evaluated based on the circumstances present at the time of the occurrence. Screening results will be reviewed as part of the overall nursing assessment and used to guide fall prevention interventions and care planning. Residents identified as at risk will have individualized interventions incorporated into the interdisciplinary plan of care.Record review of policy titled, Care Plans, Comprehensive Person-Centered, date last reviewed 07/16/2026, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems. m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and o. Reflect currently recognized standards of practice for problem areas and conditions. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition. c. When the resident has been readmitted to the facility from a hospital stay.

Based on observation, interview and record review the facility failed to ensure resident use hot water was reliably controlled, by thermostatic or mixing valves, and did not exceed 110 degrees Fahrenheit and not less than 100 degrees Fahrenheit at each fixture for 4 of 4 shower rooms (Hall 1, 2, 3, and 4) reviewed for environment. 1. The facility failed to ensure the Hall 1 shower temperature did not exceed 110 F and read 116.2 F.2. The facility failed to ensure the Hall 2 shower temperature did not exceed 110 F and read 112.2 F.3. The facility failed to ensure the Hall 3 shower temperature was not less than 100 F and read 89.4 F.4. The facility failed to ensure the Hall 4 shower temperature did not exceed 110 F and read 114.4 F. These failures could result in a decrease in residents' quality of life and hot water temperatures could lead to resident skin discomfort or burns.The findings include:Record review of Resident #1's face sheet, dated 6/5/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or partial loss of movement) following cerebral infarction (stroke), abnormalities of gait and mobility, and COPD (difficulty breathing). Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of zero indicative of severe impairment in cognition. The ADLs for toileting was listed as 1 staff assistance. Record review of Resident #1's Skin Assessments revealed: 2/12/26; skin intact. Record review of Resident #1's Nurse Note, dated 2/12/26, authored by the DON revealed resident voiced concerned over shower water being too hot when assisted by CNA A. During an observation and interview on 6/4/26 from 1:15 p.m. to 1:30 p.m. revealed water temperatures of 4 shower rooms were:Hall 1=116.2 F [temps were taken with use of ambient thermometer and confirmed by the Maintenance Director]Hall 2=112.2 FHall 3=89.4 FHall 4=114.4 FDuring an interview on 6/4/26 at 1:30 p.m., the Maintenance Director stated the above readings were correct and he was present when the readings were taken. The Maintenance Director stated he had no explanation for the above readings. The Maintenance Director stated he measured H20 temps using a common temperature gauge. The Maintenance Director stated his readings taken about a week ago revealed: shower temps were within range. The Maintenance Director stated he was aware by regulation residents use water temperature for the shower room had to range from a low of 100 F to a high of 110 F. Also, the Maintenance Director stated he had no explanation for the Hall 4 shower temperature reading on the facility temp log listed as 112 F, dated 5/26/26, exceeding the maximum allowed hot water temp of 110 F. The Maintenance Director stated that hot water temperatures above 100 F could lead to resident skin burns.During observation and interview on 6/4/26 at 2:22 p.m., Resident #1 was in his room sitting in a W/C watching TV. The resident did not reveal any signs of injuries, bruises, skin tears or skin burns. The resident stated he had had a stroke. The resident stated he was showered every 2 days, but his shower days were W, F, M. The resident stated the shower water might have been hot in the past, but he could not remember any details; but no skin burns resulted. During an interview on 6/4/26 at 2:36 p.m., CNA B stated she provided ADL care to Resident #1for the past 6 months. CNA B stated the resident's shower days were W, F, M and she showered the resident on Wednesday 6/3/26. Her procedure was to check the H20 heat by hand and determine whether the H20 was hot or cold. Then she would check with the resident on the comfort level of the water by the resident touching the water with his hands. CNA B remembered in February 2026 an in-service was given on shower temps because Resident #1 complained of the water being too hot and not comfortable. No other residents complained about hot showers.During an interview on 6/4/26 at 2:45 p.m., CNA C stated she provided ADLs to Resident #1, which included showers. CNA C stated she last showered the resident on Monday 6/1/26. CNA C stated the water temperature was comfortable and the resident did not complain. Her procedure was to check the H20 heat by hand and determine whether the H20 was hot or cold. Then she would check with the resident on the comfort level of the water by the resident touching the water with his hands. CNA C remembered in February 2026 an in-service was given on shower temps because Resident #1 complained of the water being too hot. CNA C stated no other residents complained about hot showers. CNA C stated Resident #1 was showered in Hall 4. During an interview on 6/4/26 at 3:02 p.m., RN D stated she was told in February 2026 that Resident #1 complained about the shower water being too hot when he was showered by CNA A. RN D stated, Resident #1 did not experience any skin burns; and no other residents complained about cold/hot showers. RN D stated she attended an in-service on water temps, and the highlight was to check the H20 temp before showering a resident. The RN stated hot showers beyond 110 F could lead to first degree burns based on exposure time. RN D stated Resident #1 used the shower room in Hall 4. During an interview on 6/4/26 at 3:02 p.m., RN E stated she was told in February 2026 Resident #1 complained about the shower water being too hot when he was showered by CNA A. RN E stated the resident did not suffer any skin burns and no other residents complained about shower water temps. RN E stated highlight of the in-service of water temps in February 2026, was to check the water temps before showering a resident. RN E stated based on exposure and temps being 110 F or above the resident could experience 3rd to first degree; at 120 F for 30 seconds the resident could experience 2nd degree burns. RN E stated Resident #1 used the shower room in Hall 4. During an interview on 6/4/26 at 3:32 p.m., the DON stated Resident #1 complained to her during mealtimes on 2/12/26 that he received a shower that was too hot by CNA A. Resident #1 reported the hot shower by CNA A, the previous day (2/11/26), was hot. The DON stated after the resident complained of a hot shower interventions included: assessment of resident; no skin issues. In-service staff on water temps (100 % completion rate) for nursing staff. The DON stated there were not any other incidents after the 2/12/26 allegation of hot water made by Resident #1. The DON stated, when she interviewed CNA A stated Resident #1 voiced no complaints during shower activity. CNA A was competent to give showers to residents. The DON stated based on exposure time and the temperature of the water above 110 F a resident could suffer burns. The DON stated nursing staff were required to check on CNAs' shower sheet and respond appropriately; no incidents of burns or water being hot were reported to her. During an interview on 6/4/26 at 4:00 p.m., the Administrator stated he investigated the allegation of hot water made by Resident #1 on 2/12/26 and his finding was unfounded because CNA A stated the water was lukewarm and it might have been hotter than the resident wanted. The Administrator added when he spoke to Resident #1 the resident denied being burned by the hot water and stated it was hotter than what he wanted. The Administrator stated, at morning meeting incident reports were reviewed and no other incidents surfaced with residents complaining of hot water. The Administrator stated he had no explanation why on 6/4/26 the temperature readings in the 4 shower rooms were out of range based on the readings witnessed by the Maintenance Director. The Administrator stated every shower room had an independent water heater (Hall 1 and 2 shared the same water heaters and Halls 3 and 4 had their own water heaters.) The Administrator stated he had no explanation why the shower reading on 5/26/26 taken by the facility revealed Hall 4's Main Shower was at 112 F out of the acceptable maximum of 110 F. Attempted phone interview on 6/4/26 at 4:54 p.m. and 6/5/26 at 8:44 a.m., with CNA A who no longer was employed by the facility was unsuccessful, a message could not be left. During an interview on 6/5/26 at 8:10 a.m., the Regional Maintenance Director stated: he saw the temp reading for Hall 4, dated 5/26/26, and the temp was out of range for hot limits. The Regional Director had no explanation for Hall 4 not meeting temp standards on 5/26/26, but the facility Maintenance Director should have re-checked the range and attempted a solution. The Regional Maintenance Director stated the temp readings on 6/4/26 of the shower rooms were not within limits and he could not explain the results. The Regional Maintenance Director stated, the facility Maintenance Director adjusted the mixing valves and the thermostats which resulted in the 4 water heaters meeting temp standards. During interviews on 6/5/26 Resident #3 (2:31 p.m.) and Resident # 4 (2:40 p.m.) stated the shower hot water temperature were comfortable on the days they received a shower. Record review of facility's Water Temps log, dated 5/26/26, revealed Hall 4 Main Shower hot water temp was 112 [F].Record review of facility's grievance log dated April 1, 2026, to June 5th, 2026, revealed no grievances involving hot water in the showers or the water not being comfortable.Record review of the facility's, undated, Water Temps policy, read: .Many states have even stricter standards that set maximum temperatures lower than 120 degrees Fahrenheit. Although 100 degrees Fahrenheit is considered a safe water temperature for bathing.

Based on observation, interview and record review the facility failed to ensure that their posted nurse staffing information had all required components, in that: The facility failed to ensure the nurse staffing posting information had the current date of 7/15/25. This failure could place the residents at risk of inaccurate staffing levels, poor care, or regulatory violations. Findings included: During an observation on 7/15/25 at 11:45 a.m. revealed the nurse staffing 24-hour posting was dated for 7/14/25. No other nurse staffing postings were observed at that time. During an observation and interview on 7/15/25 at 12:24 p.m. the DON pulled the nurse staffing posting off the wall and stated the date was 7/14/25, and that the night shift must have put the wrong date on it. The DON stated the risk of not having a current date on the posting was the residents and family not knowing if it was the correct information on the posting. Record review of the facility's policy titles Posting Direct Care Daily Staffing Numbers, and dated September 2022 and last revised in March 2023, reflected the following: Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include the following. b) The date for which the information is posted.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to ensure partial loaf with over half of loaf used was dated with the opened date. 2. The facility failed to ensure opened bagged elbow pasta was dated with the opened date. 3. The facility failed to ensure twenty-five-pound opened bag of corn meal was sealed and dated with opened date. 4. The facility failed to ensure staff with facial hair was covered by a hair restraint. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on [DATE] at 11:20 a.m. during the initial tour of the kitchen the pantry revealed a partial loaf of bread with over half the loaf used. The end of the bread bag was tied off in a knot without an open date. The pantry further revealed an opened bag of elbow pasta in a large zip lock bag with a received date of [DATE], but no opened date. A twenty-five-pound bag of corn meal was observed open on the bottom shelf of pantry with top of bag open to air without an opened date. During an interview on [DATE] at 11:36 a.m. [NAME] A stated the bread in the pantry should have been dated when it was opened and placed back in the pantry. She further stated it was used for sandwiches that morning. [NAME] A stated she was not sure when the pasta had been opened but an opened date should have been placed on the bag with a use by date. She further stated the corn meal usually was placed in a container after it was opened and dated. [NAME] A stated the corn meal being opened and not sealed could have allowed bugs to get in it and it could have caused cross contamination. [NAME] A stated dates are necessary so they know when something was opened and how long it had before it should be used. Observation and interview on [DATE] at 4:57 p.m. of the kitchen revealed [NAME] B and the DA with facial hair restraints not worn properly. [NAME] B was observed with his mustache exposed and the right side of his beard not totally restrained while he demonstrated the preparation of the pureed meal. DA was observed with his mustache exposed and the facial hair restraint only covering his chin while he prepared drinks for dinner meal. [NAME] B stated the purpose of facial hair restraints were to keep hair from getting in the food and basically kept the food from being infected by hair or contaminated. The DA stated beard guards (facial hair restraints) were used to keep his hair from going into the food. The DA further stated it kept food from being contaminated. [NAME] B then asked the DS if it was necessary for the hair restraint to be over his mustache of which the DS replied yes. [NAME] B further stated he honestly did not know the beard guard (facial hair restraint) needed to be over his mustache. During an interview on [DATE] at 9:52 a.m. the DS stated regarding items in the pantry found not dated or properly sealed during the initial tour of the kitchen that the pasta should have been in a closed zip lock bag, the used bread should have been dated with an open date and the corn meal should have been put in a container with an opened date all of which should have been done by kitchen staff. The DS further stated all items should have been dated by the kitchen staff with open dates and use by dates. The DS stated by sealing food items it kept bugs from going in the food and dust. The DS stated dating items when they are opened or dating with use by dates was so the kitchen did not serve something expired and so they would know when it had been opened. The DS further stated by serving expired foods it could cause residents to get sick. The DS stated the importance of beard restraints (facial hair restraints) was to keep food from being cross contaminated and it kept hair from going in the food. The DS further stated hair restraints should be worn entire time staff were in the kitchen. Review of facility's policy Food Receiving and Storage, dated approved [DATE], read Policy Statement: Food shall be received and stored in a manner that complies with safe food handling practices., Policy Interpretation and Implementation: #7 Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date) Such foods will be rotated using a first in - first out system. Review of facility's policy Dietary Employee Dress Code Policy, date revised 10.22 and reviewed [DATE], read Protocol: All employees will wear approved attire in order to perform their assigned duties., Procedure: 1. All staff will have their hair off the shoulders, confined in a hairnet or cap-facial hair covered properly. a. According to the Food Code, food service staff must wear hairnets when cooking, preparing, or assembling food, such as stirring posts or assembling the ingredients of a salad. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, ,d+[DATE].11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, ,d+[DATE] Hair Restraints, ,d+[DATE].11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on observation, interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices were complete, accurately documented, readily accessible and systematically organized for 1 of 12 residents (Resident #20) reviewed for accuracy of medical records, in that: The facility failed to obtain a physician's order for Resident #20's code status. This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors in care and treatment. The findings were: Record review of Resident #20's face sheet, dated 5/5/23 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] and 3/9/23 with diagnoses that included orthopedic aftercare following surgical amputation, diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), heart failure and acquired absence of right leg above the knee. Record review of Resident #20's most recent Significant Change MDS, dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and required two-person physical assist with bed mobility and transfers. Record review of Resident #20's comprehensive care plan, revision date 4/23/23 revealed the resident was a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) with interventions that included to review advanced directive options quarterly and as needed and obtain a copy of full code status physician's order. Record review of Resident #20's Order Summary Report, dated 5/3/23 revealed there were no physician's orders for code status. During an observation and interview on 5/4/23 at 1:44 p.m., LVN A revealed a resident's code status could be determined by looking in the resident's electronic record under the resident profile which included a picture of the resident, the code status, admission information and date of birth. LVN A revealed she believed Resident #20 had a DNR code status. LVN A logged into Resident #20's profile in the electronic record and revealed, the subheading under code status was blank. LVN A revealed a physician's order for code status was required but did not know the reason why. LVN A revealed she believed the SW oversaw obtaining code status for the resident and the nurses were tasked with obtaining the order from the doctor. During an observation and interview on 5/4/23 at 1:58 p.m., the DON revealed, the first-place nursing staff would look for a resident's code status would be in the electronic record under the resident's profile. The DON revealed she believed Resident #20 had a DNR code status. The DON logged into Resident #20's profile in the electronic record and revealed, the subheading under code status was blank. The DON stated it was necessary to have a physician's order for code status in case something happened to the resident, such as if the resident should code (slang for a cardiopulmonary arrest, when the heart suddenly and unexpectedly stops pumping) so staff would know how to treat the resident and respect their rights and the resident's/family's wishes. The DON revealed since there was no active order for code status, Resident #20 would have to be considered to have had a full code status until a physician's order could be obtained. The DON revealed it was the nurse's responsibility to obtain the physician's order for code status. Record review of the facility policy and procedure titled, Physician Services, revision date February 2021 revealed in part, .A physician must recommend in writing that an individual be admitted to the facility. This can be accomplished through .d. a physician's admission orders for the resident's immediate care .Once a resident is admitted , orders for the resident's immediate care and needs can be provided .6. Physician orders and progress notes are maintained in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations and facility policy .

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #20) reviewed for infection control practices, in that: LVN A did not perform hand hygiene between glove changes when providing wound care to Resident #20 These failures could place residents with wounds at risk for infection, slow wound healing and or a decline in health. The findings were: Record review of Resident #20's face sheet dated 5/5/23 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] and 3/9/23 with diagnoses that included orthopedic aftercare following surgical amputation, diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), heart failure, acquired absence of right leg above the knee and peripheral vascular disease (a slow and progressive circulation disorder. Narrowing, blockage or spasms in a blood vessel.) Record review of Resident #20's most recent Significant Change MDS, dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and required two-person physical assist with bed mobility and transfers. Record review of Resident #20's comprehensive care plan, revision date 5/3/23 revealed the resident had developed pressure ulcers due to immobility with interventions that included to administer treatments as ordered and follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Resident #20's Order Summary Report, dated 5/3/23 revealed the following: -Cleanse Stage I to right buttock with normal saline and 4x4 gauze. Pat dry with 4x4 gauze. Apply Duoderm dressing to affected area and change every 72 hours and as needed until healed with order date 5/2/23 and no end date. -Cleanse Stage II to left buttock with normal saline and 4x4 gauze. Pat dry with 4x4 gauze. Apply Duoderm dressing every 72 hours and as needed until healed every night shift every 3 days with order date 5/2/23 and no end date. -Wound #12 cleanse arterial wound (also known as an arterial ulcer, a painful injury in the skin caused by poor dicrulation) to top of left great toe with normal saline, pat dry, apply skin prep every shift with order dated 3/15/23 and no end date. -Wound #13 cleanse arterial wound to left toe (2nd digit) with normal saline, pat dry, paint with betadine, leave open to air every day and evening every shift with order date 4/4/23 and no end date. Observation on 5/4/23 at 9:48 a.m., during wound care revealed LVN A, after applying the Duoderm dressing to Resident #20's wound to the right buttock, removed her gloves, did not perform hand hygiene and put on a new pair of gloves. LVN A then took a second Duoderm dressing and applied it to Resident #20's wound on the left buttock. LVN A then removed her gloves, did not perform hand hygiene, put on a new pair of gloves and assisted Resident #20 onto her back, fastened the incontinent brief on the resident and took a blanket and covered the resident. LVN A then continued with wound care to Resident #20's lower extremities. LVN A, after pulling back Resident #20's blanket to expose her lower extremities then removed the resident's offloading boot and then removed the resident's sock to the left foot. LVN A then removed her gloves, did not perform hand hygiene, put on a new pair of gloves and cleaned the resident's left great toe and 2nd toe with normal saline. LVN A then removed her gloves, did not perform hand hygiene and put on a new pair of gloves. LVN A then applied betadine to Resident #20's left great toe, then removed her gloves but did not perform hand hygiene, put on a new pair of gloves and placed the resident's sock and boot back on the left foot. During an interview on 5/4/23 at 10:28 a.m., LVN A revealed she thought she had done well during wound care but then stated, Now that I think about it, I skipped (not performing hand hygiene between glove changes) that once or twice. LVN A revealed, hand hygiene was necessary between gloves changes to prevent cross contamination and was considered an infection control issue. LVN A revealed not performing hand hygiene between gloves changes could cause Resident #20 to get an infection or sepsis (condition resulting from presence of harmful microorganisms in the blood or other tissues and the body's response to their presence) from cross contamination. During an interview on 5/4/23 at 2:07 p.m., the DON revealed it was best practice to perform hand hygiene, either by sanitizing the hands or washing with soap and water, during glove changes. The DON revealed, hand hygiene would be performed before and after changing gloves to prevent cross contamination. The DON revealed, if there was cross contamination the resident could get sick. Record review of the facility's In-Service Training Report, dated 12/1/22 revealed LVN A had satisfied the requirements for proper hand hygiene protocol. Record review of the facility policy and procedure, titled Handwashing/Hand Hygiene, revision date was illegible, revealed in part, .This facility considers hand hygiene the primary means to prevent the spread of infections .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .before donning .gloves .i. After contact with a resident's intact skin .m. after removing gloves .

Based on observations and interviews the facility failed to ensure all patient care equipment was in safe operating condition for one (Residents #1) of 10 resident reviewed for safe operating equipment. The facility failed to properly maintain bed controls for Residents #1. The bed control had exposed wiring on the bed controller. This failure could place residents at risk of electrical shock. Findings included: Observation on 6/22/2022 at 11:00 AM revealed Resident #1's bed control had exposed wiring where the outer protective casing of the cord was cracked and opened. The control's wiring was visible through the openings in the cord's outer casing for nearly the entire length of the cord. Attempted interview with Resident #1 on 6/22/2022 at 11:00 AM was not completed due to resident not wanting to or did not answer questions asked. Interview on 6/22/2022 at 11:30 AM, Maintenance Director (MD) revealed that nursing or the department head for that room would alert him when there was a concern for anything in a resident's room. MD stated he was not made aware of any damaged cords in the resident's room and reported no entry into the facility's TELS systems which would have created a work order for him. Interview on 6/22/2022 at 1:30 PM, Administrator (ADMN) she was not made aware of the damaged bed remote cord for Resident #1. ADMN stated the facility follows a system for staff rounding called Nexion Neighbors that requires the facility's department heads to make daily checks on the rooms that they have been assigned to. ADMN stated the assigned staff are required to report any issues to include but are not limited to cleanliness, lack of supplies, resident complaints/concerns, and general maintenance issues. ADMN said if staff find a maintenance issues, they are responsible for reporting it to maintenance via verbal, cellular, or TELS system communication. ADMN stated the Human Resources Manager (HRM) was assigned to Resident #1's room. ADMN reported the facility has no written policy on requirements for maintenance of the facility and only use the verbal process for Nexion Neighbors rounding. Interview on 6/22/2022 at 2:10 PM, HRM stated she is assigned rounding for Resident #1's room and is required to report any found issues to include maintenance concerns. HRM said she reports maintenance issues like leaks, holes in walls, non-functioning equipment, etc. HRM stated she never noticed there was an issue with the bed remote since it was working. HRM stated she did not notice the cord's casing was cracked and opening causing the wires inside to become exposed. HRM said the last time she looked at Resident #1's room was about two weeks ago. HRM stated the requirement for rounding is once a week but she was not able to do it during the last two weeks due to being occupied with other tasks. Record review of undated TELS work order log for the month of June 2022 revealed no work order for Resident #1's bed remote. Record review of undated Nexion Neighbors rounding process revealed: Any issues are reported to the Maintenance Director via TELS, Phone Call, and/or during morning meetings. Staff is aware to report any room maintenance issues to their immediate supervisor Record review of Position Description for Maintenance dated 01/2022 revealed: Job Responsibilities - Maintains furniture and equipment appropriate to individuals needs and abilities.

Based on interview and record review the facility failed to ensure the notice to residents was provided when changes in coverage were made to items and services covered by Medicare as soon as reasonably possible was provided to 1 of 2 residents (Resident #20) reviewed for Medicare/Medicaid in that: Resident# 20 was not given a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could affect residents who use skilled services and could place them at risk of not being aware of changes to provided services. The findings were: Record review of Resident #20's face sheet, dated 02/24/2022, revealed the resident was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . · Hesitancy or difficulty starting to urinate. · Frequent urination), intervertebral disc degeneration lumbar region (refers to a syndrome in which age-related wear and tear on a spinal disc causes low back pain), and unspecified cataract (condition in which the lens of the eye becomes cloudy). Record Review of the Notice of Medicare Non-Coverage (NOMNC) for Resident #20 revealed it had been completed with signature confirmation of understanding from Resident #20 on 01/26/2022, with services ending on 01/29/2022. However the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) was not completed which would have informed Resident #20 of the option to continue services at a private pay rate. During an interview on 02/23/2022 at 4:26 PM the MDS Coordinator stated that she was responsible for the completion of NOMNC (Notice of Medicare Non-Coverage) forms when a resident came off Medicare A skilled services. The MDS Coordinator further stated she was not aware the SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice) was to be completed when a resident came off Medicare A skilled services and then stayed at the facility. The MDS Coordinator confirmed the SNFABN form was not completed. During an interview on 02/24/2022 at 1:32 PM the BOM confirmed that the SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice) forms were not completed further stating that they were not aware of the need for SNFABN forms needing to be completed. During record review of the Advance Beneficiary Notice of Noncoverage (ABN) that was provided by the facility's BOM revealed The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case The ABN must be verbally reviewed with the beneficiary or his/her representative and any question raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. Further record review provided by BOM of the SNF Notices of Non-Coverage Cheat Sheet Proprietary and Confidential Version 2.0 by WPS Medicare modified 08/26/2010, Section Scenario, Beneficiary drops to a non-skilled level of care, benefits have not exhausted, beneficiary remains in the facility (Medicare certified bed or non-Medicare certified bed). Section, What Notices to Give stated SNFABN or SNF Denial Letter required no later than 2 days before covered services end.

Based on interviews and record reviews, the facility failed to ensure that a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 (Resident #11) of 6 residents reviewed for in that: Resident #11's comprehensive person-centered care plan was not updated to reflect he no longer received [MEDICATION(S)] (anti-anxiety medication) and [MEDICATION(S)] (dietary supplement sleep-aid). This deficient practice could affect residents with comprehensive person-centered care plans by not keeping staff updated on their required care and result in missed or inaccurate care provided. The findings were: Record review of Resident #11's face sheet, dated 02/24/2022, revealed the resident was readmitted to the facility on [DATE] (original admission 01/16/2020) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #11's Quarterly MDS assessment dated [DATE] revealed she had not received antianxiety or hypnotics in the last seven days prior to the MDS completion. Record review of Resident #11's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #11's comprehensive person-centered care plan dated 02/23/2022 was not updated to reflect Resident #11 was no longer receiving antianxiety or hypnotic medication. Further review revealed the comprehensive person-centered care plan last revised on 10/15/2021 and last care plan review completed on 01/06/2022. During interview on 02/24/2022 at 10:07 a.m. the DON confirmed the comprehensive person-centered care plan for [MEDICATION(S)] and [MEDICATION(S)] should have been revised when the order for the medications were discontinued. The DON further stated the MDS Coordinator, ADON, or herself were responsible for revising the comprehensive care plan when the changes occurred. During interview on 02/24/2022 at 12:19 p.m. the DON confirmed that Resident 11's [MEDICATION(S)] was discontinued 06/02/2021. During an interview on 02/24/2022 at 1:07 p.m. the MDS Coordinator stated it was her responsibility to revise the comprehensive person-centered care plan when care changes occur. Further confirming that Resident #11 was not receiving [MEDICATION(S)] or [MEDICATION(S)] of which both were care planned. She states that when a medication was discontinued the care plan should be revised. The MDS Coordinator also confirmed that the [MEDICATION(S)] had been discontinued on 01/14/2021, further stated that she had probably overlooked it, and this was why the care plan was not revised to reflect the change. During an interview on 02/24/2022 at 2:09 p.m. the ADM stated that it was the MDS Coordinator who was responsible for revising the care plans when significant changes occur. She further confirmed medication changes or discontinuation would have been a significant change enough to have required revising the care plan. Record review of the facility's Care Plan, Comprehensive Person-Centered policy, revised December 2016, revealed Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation .13. Assessments of resident are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review the facility failed to ensure residents were assessed for bed rails for 1 of 6 residents (Resident #21) reviewed for bed rails in that: Resident #21 has not had an evaluation (assessment) for bed rail/assist bar since 12/22/2020. This deficient practice could affect residents who utilized bed rails/assist bars in the facility and could put the residents at risk for potential injuries. The findings were: Record review of Resident #21's face sheet, dated 02/24/2022, revealed the resident was readmitted to the facility on [DATE] (original admission on 01/13/2020) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The damage from the injury creates arthritis quickly in the affected joint), unilateral primary [CONDITION(S)] right knee (commonly known as wear-and-tear arthritis, is a condition in which the natural cushioning between joints -- cartilage - wears), pain in right knee, and unsteadiness on feet. Record review of Resident #21's significant change MDS, dated [DATE], revealed the resident with long- and short-term memory problem, and the resident required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing support) by one-person physical assist for transfers and bed mobility. Record review of Resident #21's Care Plan, initiated 12/18/2020 and revised on 01/29/2022 revealed a focus being The resident has had an actual fall with due to poor balance, poor communication/comprehension, unsteady gait. and intervention being assist handle x1 to aide in turning and repositioning. Record review of Resident #21's clinical record revealed there was a bed rail/assist bar evaluation dated 12/20/2020 that documented the use of bed mobility and transfers without a quarterly, annual or significant change evaluations for the assist bar. Observation on 02/23/2022 at 11:34 a.m. revealed an assistance handle attached to the upper part of the bed frame near the head of Resident #21's bed. During an interview on 02/24/2022 at 12:23 p.m. the DON confirmed the last evaluation for Resident #21's assist handle was completed 12/22/2020. Further stated that an evaluation was to be completed quarterly and stated that nursing is responsible for the evaluation along with getting the consent for them. Interview on 02/24/2022 at 2:20 p.m. with ADM confirmed that assist handles were to be reviewed and evaluated quarterly and as needed. Record review of the facility's policy titled Facility Policy on Physical Restraints and Involuntary Seclusion, revised December 2019, revealed under Enablers, revealed Intent The facility will use enablers whenever possible in lieu of restraints to assist the resident to obtain, maintain and enhance his/her functional status, it revealed Definition: An enabler is defined as any method, device or procedure that provides the means, opportunity , or power for the patient/resident to reach his/her highest practicable well-being. Protocol revealed 6. Interdisciplinary Team will reassess at least quarterly and prn (ex. With significant change), and revise as needed.

Based on observation, interviews, and record review, the facility failed to ensure that menus were followed for 5 meals over a 3 day period in that: During lunch on 10/22/19, during breakfast, lunch and dinner on 10/23/19, and during lunch on 10/24/19, substitutions required were not provided due to the facility being out of the product listed on the menu in that: This deficient practice could affect residents who receive meals from the kitchen by contributing to dissatisfaction, poor intake, and/or weight loss. The findings were: Observation on 10/22/2019 the facility was on day 3 of the Fall/Winter menu cycle for 2019-20 the lunch menu called for pumpkin pie. The facility utilized a substitution of pudding citing on their menu substitutions list that they were out of pie crust. Observation on 10/23/2019 the facility was on day 4 of the menu and breakfast was scheduled to have an iced cinnamon roll and the facility substituted a muffin stating on their menu substitutions log that they were out of product. Observation on 10/23/19 the facility was on day 4 of the menu and the lunch menu called for Sopapilla with honey and a cookie was substituted due to the facility not having enough of the product. Observation on 10/23/19 the facility was on day 4 of the menu and the Supper menu called for scalloped potatoes and butterscotch bars. The scalloped potatoes had a substitution of mashed potatoes due to the facility being out of the product. The butterscotch bars were substituted with a butterscotch pudding due to the facility not having enough product. Observation on 10/24/19 the facility was on day 5 of the menu and the lunch menu called for apple stuffing and frosted cake. The apple stuffing was substituted with yams and the frosted cake was substituted with fruit cobbler. The reason noted on the menu substitution list was due to the facility not having enough product. During an interview with Dietary Supervisor I on 10/24/19 at 2:00 p.m. she stated she had been having to utilize a lot of substations because they were going to start a new menu cycle and they had not purchased items to where she could utilize what she currently had on hand. During an interview with Registered Dietician P on 10/24/19 at 4:10 p.m. she stated that she was not aware of the facility utilizing substitutions.

Based on observation, interview, and record review the facility failed to store and prepare food in accordance with professional standards for food service safely in 1 of 1 kitchen in that: 1. On 10/22/2019 at 10:00 a.m., juice and thickened liquids were discovered in glasses in the refrigerator with no plastic wrap covering them. Chocolate syrup and 2 gallons of milk were found opened in the refrigerator with no open dates. 2. A pan of dirty water was left on the bottom shelf of the steam table. 3. The Kitchen was dirty . The drain area under the dishwashing sink had a dried white and black muddy substance with food particles dried on the drain. A small juice glass was observed under the cabinet in the dishwashing area. The glass had a dried thick milky substance on the bottom of the glass. These deficient practices could place residents who ate meals/snacks prepared in the kitchen at risk for cross contamination and/or foodborne illness. The findings were: 1. Observation of the Kitchen at 10:00 a.m. on 10/22/19 revealed juice and thickened liquids in glasses in the refrigerator with no plastic wrap covering them. Further observation revealed chocolate syrup and 2 gallons of milk were found opened in the refrigerator with no open dates. 2. Observation of the Kitchen on 10/22/19 at 11:05 a.m. revealed staff placing food on the steam table. Surveyor questioned Dietary Supervisor I as to what the pan of dirty water was that was sitting on the bottom shelf of the steam table. Dietary Supervisor I stated it was drained last night and they forgot to empty it and it was too heavy for her so the staff were going to get it in a little bit. When asked if it was sanitary to have dirty water sitting under the table with food, Dietary Supervisor I stated no. 3. Observation of the Kitchen on initial tour conducted on 10/22/19 at 10:00 a.m. to 1:00 p.m. revealed areas on the kitchen floor that had dried black dirt. Further observation revealed the drain areas in the floor with dried caked on food substances adhered to the drain. Onion skins, paper and other dirt noted under shelving in the dry storage area. Three large dead roaches observed under the bread freezer. The second large freezer in the dry storage room had a broken hinge preventing it from sealing correctly. Interview conducted with Dietary Supervisor I on 10/22/2019 at 10:00 a.m. confirmed that items in the refrigerator and dry goods on the shelf in the storage room should have been dated. Interview conducted with Dietary Supervisor I on 10/22/2019 at 10:45 a.m. regarding the cleanliness of the kitchen revealed that the kitchen had not had a deep cleaning in two weeks.

Based on interviews and record review the facility failed to ensure Residents received their mail on Saturdays for 5 of 12 Residents reviewed for weekend mail delivery during the group interview. The facility failed to ensure Resident's Saturday mail was delivered on the day it was received. This failure could affect Residents in the facility and place them at risk of not receiving mail in a timely manner which could result in a decline in Residents' psychosocial well-being and quality of life. The findings were: During a group interview on 10/23/19 at 10:30 a.m., 5 of 12 Residents identified by the facility as being alert, oriented and interviewable, revealed that mail was only delivered during week days and not on weekends. During an interview on 10/24/19 at 8:08 a.m. Activity Director H confirmed that the mail was not delivered to the facility on Saturday and that mail was received Monday through Friday by the Business office and then distributed to the Residents. During an interview on 10/24/19 at 8:31 a.m. Business Office Manager A confirmed that mail delivery was stopped on Saturdays because the facility office was closed on weekends. During an interview on 10/24/19 at 9:03 a.m. the Administrator revealed that she assumed that mail is delivered on Saturdays, I don't know because I'm not here. Review of the facility policy titled Statement of Resident Rights, revision date 7/2006, revealed in part .You, the resident do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. You have all the rights, benefits, responsibilities, and privileges granted by the constituion and laws of this state .

Based on observation, interview, and record review, the facility failed to provide based on the comprehensive assessment and careplan and the preference of each Resident an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each Resident for 5 of 12 Residents reviewed for activities in that: The facility did not provide outings for Residents based on activity preference. This deficient practice could place Residents with activity preferences at risk for isolation, low self-esteem and decline in mental status. The findings were: During a group interview on 10/23/19 at 10:30 a.m., 5 of 12 Residents identified by the facility as being alert, oriented and interviewable revealed that the facility had not provided activities outside of the facility because the facility van was broken. During an interview on 10/23/19 at 10:30 a.m., during the group meeting Ombudsman K revealed that Residents had complained that there were no outings provided by the facility because the facility van had been broken more than 6 months. During an interview on 10/24/19 at 8:08 a.m., Activity Director H confirmed that the facility van had been broken for almost a year and could accommodate 13 people. Activity Director H further revealed that Residents had used the van for outings to the casino, the mall, eating out at restaurants, going to the movies, fishing and dancing. Review of the activity calendar provided by Activity Director H revealed that the last scheduled outing was in (MONTH) 2019 to a restaurant. During an interview on 10/24/19 at 9:03 a.m. the Administrator revealed that the facility van had not been working since last summer and that an alternative means of transportation for outings was requested from corporate only last month. Review of the facility policy titled Statement of Resident Rights, revision date 7/2006, revealed in part .You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights .To participate in activities of social, religious, or community groups .

Based on observations, interviews and record review, the facility failed to assure that residents receive and consume foods in appropriate forms and/or the appropriate nutritive content as prescribed by a physician for 2 residents (Residents #23 and #30) of 5 residents observed for therapeutic diets in that: 1. Resident #23 had a diet order for small portions and NSOT and received regular portions and used the salt on the table. 2. Resident #30 had a diet order for small egg and meat portions and NSOT and received regular portions and used the salt on the table. These deficient practices could affect residents on therapeutic diets and could result in weight loss, gain or nutritional deficiencies. The findings were: 1. Review of Resident #23's electronic face sheet (undated) revealed he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #23's Physician order [REDACTED]. Review of Resident #23's comprehensive plan of care dated reviewed 4/6/19 revealed Problem .Nutritional Status, is on a therapeutic or altered diet as evidenced by regular, LCS/NSOT small portions .Approach .encourage dietary/fluid intake within dietary limits. Observation on 10/22/19 at 11:29 a.m. revealed Resident #23 had regular portions and there was salt on the table which he used. Observation on 10/23/19 at 11:40 a.m. revealed Resident #23 had regular portions and there was salt on the table which he used. Observation on 10/24/19 at 12:00 p.m. revealed Resident #23 had regular portions instead of small portions and there was salt on the table. Interview on 10/24/19 at 12:10 p.m. with RN B revealed that NSOT means No salt on table and she confirmed that the salt was on the table. 2. Review of Resident #30's electronic face sheet (undated) revealed she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #30's Physician order [REDACTED]. Review of Resident #30's comprehensive plan of care dated 10/10/19 revealed Nutritional Status .is on a therapeutic or altered consistency diet .regular, LCS, NSOT,small egg/meat entree at all meals .Approach .serve diet regular LCS, NSOT small egg/meat entree at all meals. Observation on 10/22/19 at 12:00 p.m. revealed Resident #30 had regular portions and salt on the table which she used. Interview on 10/22/19 at 12:05 p.m. with Resident #30 revealed she used the salt shaker, but did not like the one she used because the salt came out too fast. Observation on 10/23/19 at 12:15 p.m. Resident #30 had regular portions of food and salt was on the table. Observation on 10/23/19 at 12:20 p.m. with the DON confirmed that Resident #30 had regular portions and that salt was on the table. Interview on 10/24/19 at 12:30 p.m. with RN B revealed that NSOT means No salt on table and she confirmed that the salt was on the tables. Interview on 10/24/19 at 2:00 p.m. with the Dietician revealed that therapeutic diets are recommended by her and ordered by the physician. She stated that nutrition and weight management are the goals of having a therapeutic diet. Review of http://www.imedpub.com/scholarly/therapeutic-diet-journals-articles-ppts-list.php, (November 2019) Journal of Clinical Nutrition and Dietetics, Therapeutic Diet revealed Therapeutic diets are formulated by doctors or dietitians. Some examples of common therapeutic diets are gluten-free diet, clear liquid diets, full liquid diets, no concentrated sweet diet, diabetic (calorie controlled) diet, renal diet, low fat diet, high fiber diet, no added salts diet etc. Diabetic diet is one of the most common therapeutic diets which involve limiting high sugar foods to help blood sugar levels.

Based on observation, interview and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infection to include hand hygiene for 1 of 1 Resident (Resident #27) who received catheter care, 1 of 2 Residents (Resident #34) who received incontinent care, 1 of 5 Residents (Resident #37) who received medications, in that: 1. CNA G did not sanitize her hands or change gloves after she wiped the back side of Resident #27 during catheter care, and proceeded to apply a clean brief with soiled gloves. 2. During incontinent care CNA L placed soiled wipes between Resident #34's legs. CNA L and CNA M did not wash or sanitize their hands after removing their soiled gloves. 3. MA C placed her left hand in the trash on her medication cart when throwing away an empty pill pack, did not sanitize her hand prior to finishing setting up her medications, and pulled one plastic water cup with her fingers on the rim of the cup and inside the inner cup to pull them apart. 4. The annual Infection Control Policy and Procedure had not been updated since (YEAR). These deficient practices could place Residents at risk for infections. The findings were: 1. Review of Resident #27's face sheet (undated) revealed he was admitted on [DATE] with [DIAGNOSES REDACTED].>Spinal bifida, Pressure Ulcer of sacral region, [MEDICAL CONDITION] and Chronic [DIAGNOSES REDACTED]. Review of Resident #27's Comprehensive plan of care dated 1/3/19 revealed Category: Indwelling Catheter .Problem .I use a Foley catheter, I have [DIAGNOSES REDACTED].Approach .Foley Catheter Care q shift. Observation on 10/24/19 at 01:29 p.m. of Resident #27's catheter care revealed CNA G cleaned the Resident's catheter tubing, removed her soiled gloves, did not wash or sanitize her hands and donned clean gloves. CNA G then cleaned Resident #27's buttock area, did not change gloves or clean hands prior to putting on Resident #27's clean brief. Interview on 10/24/19 at 1:40 p.m. with CNA G confirmed that she should have taken off gloves, sanitized hands and put on clean gloves prior to applying Resident #27's clean brief. 2. Review of Resident #34's Face Sheet, dated 10/24/19, revealed an admission date of [DATE], and re-admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #34's most recent Significant Change MDS, dated [DATE], revealed a BIMS score of 3 which indicated that the Resident was severely cognitively impaired for daily decision-making skills. Further review revealed Resident #34 was always incontinent of bowel and bladder. Observation of CNA L and CNA M on 10/24/19 at 9:49 a.m. during incontinent care for Resident #34 revealed CNA L wiped the Resident's vaginal area with 4 separate wipes and placed the soiled wipes between the Resident's thighs. Further observation revealed CNA L removed her soiled gloves, did not wash or sanitize her hands, placed her ungloved hand into a zip lock bag and withdrew a pair of clean gloves. CNA M gathered Resident #34's soiled linens and placed them in a trash bag. CNA M then removed her soiled gloves, did not wash or sanitize her hands, and proceeded to cover the Resident with a clean sheet and used the crank handle to adjust the Resident's bed. During an interview on 10/24/19 at 10:08 a.m. CNA L confirmed that she had placed the soiled wipes between Resident #34's thighs instead of in a trash bag and that she had not washed or sanitized her hands between glove changes. CNA L revealed that she had received training on incontinent care last month. During an interview on 10/24/19 at 10:08 a.m., CNA M confirmed that she had not washed or sanitized her hands after removing her soiled gloves and touched Resident #34's clean bed sheet and before she touched the crank handle on the bed. CNA M revealed that she had received monthly training on infection control. During an interview on 10/25/19 at 7:53 a.m., the DON revealed that it was the expectation of the Staff to wash or sanitize their hands between glove changes or when providing care to a Resident to prevent cross contamination. The DON further revealed that the CNA should have placed the Resident #34's soiled wipes into a trash bag and not between the Resident's legs as it may lead to a chance of infection. 3. Review of Resident #37's face sheet (undated) revealed he had [DIAGNOSES REDACTED]. Review of Resident #37's Comprehensive Plan of Care dated 4/14/19 revealed Alteration in thought process related to Dementia and Alzheimer's .Approach .Administer [MEDICATION NAME] 5 mg po bid. Observation on 10/24/19 at 09:49 a.m. with MA C and Resident #37 revealed MA C placed part of an empty medication card in the trash and her left hand entered the trash container. Then using the same hand she finished setting up her medications and pulled two plastic water cups apart with her fingers placed on the rim and inside one of the cups without sanitizing her hands. Interview with MA C on 10/24/19 at 09:50 a.m. revealed that she should have sanitized her hands after putting the empty pill pack into the trash. MA C stated she should have not handled the inside or rim of the cups used for water during the medication pass with her fingers or hands. Review of the facility policy and procedure for Infection Control-Prevention and Control Program revised date 3/2012 revealed It is the policy of this organization that hand hygiene will be performed consistent with accepted standards of practice to prevent the spread of infection. Review of the facility policy and procedure on Medication Administration revised date 4/2018 revealed Procedure .supplies and equipment .hand-washing materials. 4. Review of the facility policies and procedures on infection control revealed they were not reviewed annually by the Medical Director and Department personnel as required. The signature page for the Infection Control policy and procedures was last signed in (YEAR), with (YEAR) and 2019 being blank. Interview with the DON revealed the nursing policies and procedures for infection control were on-line and reviewed and the antibiotic stewardship program was in a separate binder and reviewed. However, the DON confirmed that generic infection control policy and procedures did not have a review process. Review of the facility policy titled Incontinent Care/Perineal Care With or Without a Catheter, revision date 8/2017, revealed in part .Procedure: Discard soiled gloves along with the soiled brief and/or wipes .Wash clean to dirty .remove soiled gloves, wash hands and apply clean gloves . Review of the facility policy titled Infection Control-Prevention and Control Program, revision date 3/2012, revealed in part .The intent of this program is to assure that the home develops, implements, and maintains an Infection Prevention and Control Program in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility .2. Program oversight including planning, organizing, implementing, operating, monitoring, and maintaining all of the elements of the program and ensuring that the facility's interdisciplinary team is involved in infection prevention and control . Review of the facility policy titled Hand Hygiene, revision date 2/2018, revealed in part .Hand hygiene will be performed consistent with accepted standards of practice to prevent the spread of infection .Clean your hands: before and after having direct contact with a patient's intact skin .if hands will be moving from a contaminated-body site to a clean-body site during patient care .after glove removal .Wearing gloves is not a substitute for hand hygiene. Dirty gloves can soil hands .Always clean your hands after removing gloves .

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary and comfortable environment for 3 of 3 Residents (Resident #22, #32, #36) in that: 1. Resident #22's left armrest cover on her wheelchair was torn and exposed the padding underneath. 2. Resident #32's left armrest cover on her wheelchair was cracked and torn exposing the padding underneath. 3. Resident #36 had a cracked and torn cover on both armrests of his wheel chair. These deficient practices could affect residents that used a wheelchair and could result in scratches and infection to the skin while residents propel their wheelchairs. The findings were: 1. Review of Resident #22's electronic face sheet (undated) revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #22's comprehensive plan of care dated 7/8/19 revealed she required extensive assistance with ADL's. Observation on 10/22/19 at 12:00 p.m. Resident #22's left wheel chair arm rest had torn vinyl. Observation and interview on 10/25/19 at 12:10 p.m. with the DON confirmed the left wheel chair arm rest vinyl covering was torn. 2. Review of Resident #32's Face Sheet, dated 10/25/19, revealed an admission date of [DATE], and re-admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #32's most current Quarterly MDS, dated [DATE], revealed that the Resident was moderately cognitively impaired for daily decision-making skills. Further review of the Quarterly MDS revealed Resident #32 used a mobility device, wheelchair, for mobility. Observation on 10/22/19 at 10:58 a.m. revealed Resident #32 sitting up in her wheelchair and the left armrest was cracked and torn exposing the foam padding underneath. Further observation of Resident #32's wheelchair revealed a tear on the inner inseam of the armrest that measured approximately 6 inches in length. During an interview on 10/25/19 at 12:06 p.m., Resident #32 revealed that she did not know how long the left armrest on her wheelchair had been torn. During an interview on 10/25/19 at 12:08 p.m., the DON confirmed that the wheelchair that Resident #32 was seated in belonged to the Resident and further revealed that the left armrest was cracked and torn. 3. Review of Resident #36's electronic face sheet (undated) revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #36's comprehensive plan of care dated 9/26/19 revealed he required extensive assistance with his care. Observation on 10/22/19 at 10:45 a.m. revealed Resident #36 lying in bed sleeping and the arm rests on his wheelchair cover was torn and cracked During an interview on 10/25/19 at 12:25 p.m., the DON confirmed that the wheelchair that Resident #36 was seated in belonged to the Resident and further revealed that both covers on the armrests were cracked and torn exposing the foam padding underneath. Review of the facility policy titled Statement of Resident Rights, revision date 7/2006, revealed in part .You, the resident do not give up any rights when you enter a nursing facility .You have a right to: 3. Safe, decent and clean conditions .

Based on interview and record review, the facility failed to ensure Residents have the right to formulate an advance directive for 1 of 15 Residents (Resident #42) reviewed for advanced directives in that: The facility failed to obtain a signed out of hospital, do not resuscitate (OOHDNR) as ordered by the physician. This deficient practice could affect residents and place them at risk of having cardiopulmonnary resuscitation (CPR) performed against their wishes. The findings were: Record review of Resident #42's face sheet dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #42's clinical record revealed a cover sheet on the front of the chart that read, GO FULL CODE PR[NAME]EED TO RESUSCITATE, however a physican's order dated [DATE] read DNR. Further review of the record revealed no out of hospital do not rescuitate form (OOHDNR) signed by the Resident's representitive, the physician and two witnessess on the record. Review of Resident #42's care plan dated [DATE], under the problem category: Code Status revealed do not resuscitate orders were in place. Review of the Physician Order report dated [DATE]-[DATE], revealed an order for [REDACTED]. During an interview with LVN N at 5:00 p.m on [DATE] revealed that if a Resident had a code situation in the building the Resident's medical record would be obtained and their code status would be determined by a sheet on the front of the chart that would either be a red paper that read STOP, DNR STATUS or a green sheet of paper that would read GO, FULL CODE, Proceed with CPR. LVN N confirmed that Resident #42 had a green sheet on the record that read GO, full Code which indicated Resident #42 would receive CPR. LVN N reviewed Resident #42's Care Plan against the Physician's orders and stated we have a problem, something on this chart is wrong but I do not know which order is correct. I will have to get with the DON for clarification. During an interview with ADON O and the DON at 5:20 p.m. on [DATE] both acknowledged that the chart was incorrect and that no signed DNR paperwork could be located. Both the DON and ADON O revealed that although the Physican's orders read DNR status and Resident #42's care plan read DNR and the front sheet read Full Code they confirmed there was no signed Out of Hospital DNR with the required witnesses on the medical record. ADON O stated this would cause a lot of confusion but that Resident #42 would have to be considered as a Full Code because the paperwork in the chart was incorrect. Review of the facility policy titled Advance Directive-General Information, dated (MONTH) 2014, revealed in part .Out-Of-Hospital DNR .This is a form to instruct Emergency Medical Personnel and other health care professionals to forgo resuscitation attempts and to permit the resident to have a natural death with peace and dignity .Directive to Physicians .Your Directive to Physicians must be signed in the presence of two witnesses, who must also sign it .

Based on observation, interview and record review, the facility failed to develop a baseline care plan that included the instructions needed to provide effective and person-centered care for 1 (Resident #100) of 3 residents reviewed for baseline care plans in that: Resident #100's baseline care plan did not reflect his indwelling urinary catheter. This deficient practice could affect residents with baseline care plans and could result in required care being missed. The findings were: Review of Resident #100's Face Sheet (undated) revealed he was admitted to the facility on [DATE] after he had a cardiac catheter procedure. Further review revealed he had the [DIAGNOSES REDACTED]. Review of Resident #100's Physician Orders dated 10/14/19 revealed Change 16 French with 10 cc Foley catheter monthly on the 14th and as needed. Observation on 10/24/19 at 09:10 a.m. revealed Resident #100 lying in bed with an indwelling urinary catheter. Interview on 10/24/19 at 09:12 a.m. with Resident #100 revealed that he had the indwelling urinary catheter since the hospital and had it when he was admitted to the facility. Review of Resident #100's Admission Baseline Care Plan dated 10/14/19 did not reflect that he had an indwelling urinary catheter. Review of Resident #100's Skilled Nursing Notes dated 10/15/19 reflected that he had an indwelling urinary catheter. Interview on 10/24/19 at 10:00 a.m. with the DON confirmed that the indwelling urinary catheter for Resident #100 was not reflected on his baseline care plan. Review of the facility policy and procedure titled Care Plan-Resident revised date 12/2016 revealed staff must develop a comprehensive care plan to meet the needs of the resident.