Does THE SPRINGS BATESVILLE have any serious inspection findings?

Yes, THE SPRINGS BATESVILLE has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 31 total deficiencies from recent inspections.

What are the staffing levels at THE SPRINGS BATESVILLE?

THE SPRINGS BATESVILLE has a three-star staffing rating from CMS with 0.34 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is THE SPRINGS BATESVILLE located?

THE SPRINGS BATESVILLE is located in BATESVILLE, AR. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does THE SPRINGS BATESVILLE have?

THE SPRINGS BATESVILLE has 150 certified beds.

Who owns THE SPRINGS BATESVILLE?

THE SPRINGS BATESVILLE is a for profit - corporation facility and is part of the THE SPRINGS ARKANSAS chain.

What questions should families ask when visiting THE SPRINGS BATESVILLE?

Families visiting THE SPRINGS BATESVILLE should ask about staff retention and training programs, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does THE SPRINGS BATESVILLE compare to other nursing homes?

THE SPRINGS BATESVILLE has a 2-star overall rating, which is below average compared to other nursing homes in AR. Families should carefully review inspection findings and consider alternatives.

THE SPRINGS BATESVILLE

Name: THE SPRINGS BATESVILLE
Address: 1975 WHITE DRIVE, BATESVILLE, AR, 72501, US
Telephone: (870) 698-1853
Rating: 2.0

1975 WHITE DRIVE, BATESVILLE, AR 72501 · (870) 698-1853

For profit - Corporation 150 Beds THE SPRINGS ARKANSAS Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

33/100

#175 of 218 in AR

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THE SPRINGS BATESVILLE nursing home in BATESVILLE, AR - Photo 1 of 4

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Photo by Julie Hill

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Last Inspection: May 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

The Springs Batesville has a Trust Grade of F, indicating a poor facility with significant concerns about care quality. It ranks #175 out of 218 in Arkansas, placing it in the bottom half of state facilities, and #2 out of 3 in Independence County, meaning only one local option is better. While the facility's situation is improving, having gone from 13 issues in 2024 to just 1 in 2025, it still faces serious challenges, including a concerning staffing turnover rate of 64%, which is higher than the state average of 50%. On the positive side, the facility has not incurred any fines, which is a good sign, and it maintains average RN coverage, providing essential oversight. However, there are worrisome incidents, such as failing to follow COVID-19 isolation precautions, which could have endangered residents, and issues with food safety and kitchen cleanliness, both of which raise the potential for health risks. Overall, while there are some strengths, families should carefully consider these significant weaknesses before making a decision.

Trust Score: F
In Arkansas: #175/218
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 64% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most Arkansas facilities.
Skilled Nurses: Each resident gets only 20 minutes of Registered Nurse (RN) attention daily — below average for Arkansas. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 31 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★★

5.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 13 issues

2025: 1 issues

The Good

5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

2-Star Overall Rating

Below Arkansas average (3.1)

Below average - review inspection findings carefully

Staff Turnover: 64%

18pts above Arkansas avg (46%)

Frequent staff changes - ask about care continuity

Chain: THE SPRINGS ARKANSAS

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (64%)

16 points above Arkansas average of 48%

The Ugly 31 deficiencies on record

1 life-threatening

Feb 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure staff followed the Care Plan of a resident who was at risk for falls, as evidenced by intervention of a fall mat not being on the floor beside resident's bed to prevent injury for 1 (Resident # 1) of 3 sampled residents. The findings are: A review of an admission Record indicated the facility admitted Resident #1 with diagnoses that included dementia with behavioral disturbances, restlessness and agitation, atrial fibrillation [heart condition where the heart beats rapidly and the upper and lower chambers beat out of sync causing poor blood flow], hypertension [high blood pressure] and history of falling. Review of an admission Minimum Data Set (MDS) with an ARD dated 03/21/24, revealed Resident #1 had a Staff Assessment for Mental Status (SAMS) which indicated the resident was severely impaired for their daily decision making. Review of Resident #1's Care Plan initiated 03/15/2024, revealed Resident #1 was at risk for falls r/t (related/to) weakness, muscle wasting and atrophy, impulsivity, Alzheimer's disease, dementia, seizure activity, restlessness and agitation, will roll out of bed onto floor, and was an unavoidable fall risk. Interventions included: a fall mat next to bed. Review of a Fall Assessment dated 11/13/2024, revealed Resident #1 had a score of 9, where summary of fall risk indicated a score of 10 or higher was considered At Risk. Review of a Fall Assessment dated 11/19/2024, revealed Resident #1 had a score of 9, where summary of fall risk indicated a score of 10 or higher was considered At Risk. Review of a Fall Assessment dated 11/30/2024, revealed Resident #1 had a score of 7, where summary of fall risk indicated a score of 10 or higher was considered At Risk. A review of a Nsg (Nursing) I&A (Incident & Accident) Note dated 11/13/2024 at 3:52 PM, revealed, Incident Description: A nurse walking by the room heard the resident moaning and looked into room and saw the resident's upper torso was on the floor with the forehead on the floor and legs still on the bed. There was no fall mat beside the bed. Immediate Intervention (to prevent reoccurrence): assisted from the floor to the bed and assessed for injuries with a red mark to left side of forehead noted, fall mat placed beside bed. During an interview on 02/05/2025 at 11:30 AM, the Director of Nursing (DON) said if a resident was at risk for falls, and was care planned for a fall mat beside the bed, then there should be a fall mat beside the bed. The DON stated she was familiar with Resident #1 and there had been a fall mat beside Resident #1's bed at all times. Review of a facility policy titled Care Plans, Comprehensive Person-Centered revised March 2022, indicated The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Oct 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly transfer a resident using a mechanical lift and failed to investigate and educate to prevent possible injury for one (Resident #2) sampled resident who was transferred via mechanical lift. The findings are: Review of an electronic Medical Diagnosis Chart revealed Resident #2 had a diagnosis of paraplegia. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/19/2024 indicated Resident #2 understands and is understood, had a Brief interview of Mental Status (BIMS) score of 14 (13-15 cognitively intact), ambulated via wheelchair, and had no falls since their last assessment. Review of Resident #2's Care Plan showed the resident required a mechanical lift with assistance of 2 staff members for transfers. Review of Resident #2's Electronic Medical Record (EMR) did not document a fall on 06/10/2024. On 10/01/2024 at 8:49 AM, during an interview Resident #2 relayed that on the evening of 06/10/2024, while being transferred from the wheelchair to the bed via mechanical lift, they began to slide out of the lift sling. Resident #2 stated they tried to tell the two Certified Nursing Assistants (CNAs) they were sliding but the CNAs continued with the transfer and the resident slid out of the lift sling onto the floor with the lift sling under their arms holding their upper body up. Resident #2 said the two female CNAs got the assistance of two male CNA's and were able to use a sheet to lift the resident's lower body and position the lift sling under the resident and safely transfer them into the bed. Resident #2 denied any injury. On 10/01/2024 at 8:56 AM, during an interview CNA #1 said they were asked to come to room [ROOM NUMBER] to help with something, and that when they arrived, Resident #2 was sitting on the floor with mechanical lift pad slid up on back and under arms holding them up. They confirmed there was no in-service, retraining. or witness statements taken following this incident. On 10/01/2024 at 9:44 AM, during an interview LPN #2 stated the incident was not reported to her, but she remembered someone talking the next day about Resident #2 sliding out of the lift pad and onto the floor. On 10/01/2024 at 9:57 AM, during an interview LPN #3 stated she was unaware of an incident involving Resident #2 until the next day at approximately 6:30 AM. She stated she reported the incident to the Treatment nurse (LPN #4) who then reported it to the Director of Nursing (DON) and Assistant Director of Nursing (ADON). LPN #3 stated she questioned Resident #2's CNA (CNA #6), who reported that Resident #2 did not hit the floor. LPN #3 said the treatment nurse went and preformed a body audit and questioned the resident. LPN #3 did not know if a formal in-service was initiated but stated she educated her CNAs on proper transfer with a lift. On 10/01/2024 at 10:04 AM, during a phone interview CNA #7 stated he was not in the room when Resident #2 slid out of lift pad, and the CNA working that hall came and got him to help transfer a resident. He stated when he got the room, he saw Resident #2's lower body had slid out of the lift pad and onto the floor, the resident was sitting with their back to the wheelchair. He stated he and 3 other CNAs got the resident back onto the lift pad using a sheet and then resident #2 was lifted into wheelchair. When asked if he knew what time this was, CNA #7 replied, he was pretty sure it was before lunch. On 10/01/2024 at 10:07 AM, during a phone interview with CNA #5, who is no longer employed at this facility, she stated she had helped CNA #6 transfer Resident #2 from wheelchair to the bed. When they began lifting the resident up with the mechanical lift, the resident began to slide out of lift pad. She stated, Resident #2 never touch the floor. When asked if she reported this event, she replied, she didn't think it needed reporting. On 10/01/2024 at 10:10 AM, CNA #6, who no longer works at this facility, was contacted by phone for an interview. CNA #6 stated she did not remember the event that took place. CNA #6 called back at 10:11 AM and recalled she was transferring Resident #2 from the wheelchair to bed using a mechanical lift, when the resident slipped out of lift pad and slid down to the floor. She went on to say the resident did not touch the floor because they landed on pillows that were on the foot of the wheelchair. CNA#6 stated it was her , a nurse and another CNA in the room. When asked if she reported the incident to anyone stated she did not since the nurse was in the room at the time. On 10/01/2024 at 10:14 AM, during an interview with the Director of Nursing (DON) regarding the events of the evening of 06/10/2024, she stated she knew nothing about the incident, she was in the hospital at the time and does not recall knowing anything about incident. When questioned regarding staff training on operating the mechanical lift, she reported new hires are trained during orientation and staff re-trained yearly. When asked if an in-service had been performed after Resident #2 had slid from the lift seat, she replied not that she was aware of as she was just finding out about it. On 10/01/2024 at 10:33 AM, during an interview the Assistant Director of Nursing (ADON) stated she had also been in the hospital at the time of the incident, but when she found out about it later had questioned CNA #7 who told her the resident had never touched the floor. Review of CNA #1, #5, #6, and #7 employee files indicated training and check off of mechanical lift usage during new hire orientation. Review of the facility policy, Accidents and Incidents - Investigating and Reporting indicated, all accidents and incidents regarding residents or staff will be investigated and reported to the Administrator. The charge nurse, supervisor, or department head will initiate and document the investigation and any action taken. Review of the facility policy Lifting Machine, Using a Mechanical specified to ensure the lift sling is properly balanced, make sure the head, neck and back are properly supported and make sure the lift sling is properly balanced.

May 2024 12 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

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The facility failed to ensure a comprehensive, accurate assessment of the resident's side rail use was completed quarterly for 01 (Resident #06) of 01 sample mix residents. The findings are: On 05/20/2024 at 2:14 PM, the Surveyor observed Resident #06 lying in bed on their right side with eyes closed. Both half side rails were up at top of bed with the right side rail padded on top and sides with what appears to be a black foam pool noodle. The Care Plan dated 10/22/2020 for Resident #06 revealed the resident has an (activity of daily living) ADL self-care performance deficit with an intervention of quarter side rails to promote independence. Resident #06's Side Rail(s) Usage Assessment dated 12/11/2023 revealed Side Rail(s) Usage- Is the use of side rails(s) being considered? No. Are side rail(s) currently in use? Yes. If yes, what type- [quarter] side rail. Resident #6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 03/13/2024 revealed 'Physical Restraints'- bed rail not used, and an active diagnosis of seizure disorder or epilepsy. On 05/22/2024 at 3:01 PM, the Surveyor took Certified Nursing Assistant (CNA) #10 to Resident #06's room. Resident #06 was observed sitting up on the side of the bed with the right leg leaning up against the half side rail that was up. CNA #10 confirmed she was familiar with Resident #06 ' s care. CNA #10 confirmed both half rails were up on the bed but did not know why they were both up. On 05/22/2024 at 3:21 PM, the Surveyor took Licensed Practical Nurse (LPN) #12 to Resident #06's room. The resident was observed sitting up on the side of the bed with the right leg leaning up against the half side rail that was up. LPN #12 confirmed she was familiar with Resident #06's care. LPN #12 confirmed both half side rails were up on the bed. LPN #12 confirmed that Resident #06's care plan focus area self-performance deficit showed quarter rails. LPN #12 stated she had started back working for the facility on May 6, 2024, and confirmed the two half rails have been up since she has worked here. LPN #12 confirmed the resident walks unassisted. LPN #12 confirmed the side rail assessment revealed the resident was assessed for quarter side rail use. On 05/22/2024 at 03:27 PM, the Surveyor took the Director of Nursing (DON) to resident #06's room and resident was observed sitting up on the side of the bed with the right leg leaning up against the half side rail that was up. The DON confirmed she was familiar with Resident #06's care. The DON confirmed the two half side rails were up on Resident #06's bed. The DON confirmed Resident #06 wanders into rooms with empty beds. On 05/23/2024 at 9:34 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator, and she confirmed that Resident #06's side rail assessment should be completed quarterly and that resident #06 had her most recent quarterly side rail assessment dated for 03/11/2024 when it was due, but it was actually completed on 05/22/2024 at 15:11. She also confirmed that when assessments are completed it should be at the bedside for observation purposes, so the assessment is accurate. On 05/23/2024 at 09:46 AM the Surveyor interviewed the Director of Nursing (DON) and she confirmed Resident #06's side rail assessment should have been conducted quarterly and was due on 03/11/2023 but was actually completed on 05/22/2024 at 15:11 and was not completed timely. The DON confirmed that if a resident is able to sit up on the side of their bed unassisted that does not indicate the resident is unable to support their trunk, and that if the resident is able to ambulate down the hall unassisted that means they independently ambulate, and the assessment is inaccurate. The facility provided a policy titled Proper Use of Side Rails with a revision date of 2016 revealed General Guidelines 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's- a. bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; d. That the bed's dimensions are appropriate for the resident's size and weight. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. The facility provided a policy titled Use of Restraints with a revision date of April 2017 that revealed Policy Interpretation and Implementation revealed, 6. Prior to placing a resident in restraints there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Deficiency Text Not Available

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Deficiency Text Not Available

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected multiple residents

Deficiency Text Not Available

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Deficiency Text Not Available

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to ensure residents individualize plan of care was revised to reflect the current needs of the resident and updated to include falls for 02 (Resident #06, #31) of 02 sample mix resident, and to include half side rail use for 01 (Resident #06) of 01 sample mix residents. The findings are: 1. On 05/20/2024 at 2:14 PM, the surveyor observed Resident #06 lying in bed. Both half side rails were up at top of bed with the right side rail padded on top and sides with what appears to be a black foam pool noodle. a. Review of Resident #06's Progress Notes dated 01/31/2024 revealed the resident was found on the floor beside the bed with lacerations to the top and bottom lip. b. Resident #06's Patient Registration Form [named medical center] dated 01/31/2022 revealed a maxillary closed fracture from a fall from the bed. Chief Complaint revealed resident stated, I fell off my bed and hit my nose. Computed tomography (CT) Scan revealed comminuted fracture of the anterior/lateral/ posterior right and left maxillary sinuses. 'Final Diagnoses' revealed fall with lip laceration repair, maxillary sinus fracture. c. The Care Plan dated 10/24/2022 for Resident #06 did not reveal falls on 01/18/2022; 10/21/2022; 10/31/2022; or use of half side rails. d. Resident #6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 03/13/2024 revealed 'Physical Restraints'- bed rail not used, and an active diagnosis of seizure disorder or epilepsy. e. Resident #06's Order Summary Report revealed no order for half side rails. f. On 05/22/2024 at 3:01 PM, the Surveyor took Certified Nursing Assistant (CNA) #10 to Resident #06's room. The resident was observed sitting up on the side of the bed with their right leg leaning up against the half side rail that was up. CNA #10 confirmed she was familiar with resident's care, and she was not aware of any fall the resident may have had. CNA #10 confirmed both half rails were up on the bed but did not know why they were both up. g. On 05/22/2024 at 3:21 PM, the Surveyor took Licensed Practical Nurse (LPN) #12 to Resident #06's room. The resident was observed sitting up on the side of the bed with their right leg leaning up against the half side rail that is up. LPN #12 confirmed she was familiar with Resident #06's care and was sure the resident had a fall during her admission to the facility. LPN #12 confirmed both half side rails were up on the bed. LPN #12 confirmed that Resident #06's care plan focus area self-performance deficit showed quarter rails. h. On 05/22/2024 at 03:27 PM, the Surveyor took the Director of Nursing (DON) to Resident #06's room and resident was observed sitting up on the side of the bed with her right leg leaning up against the half side rail that is up. The DON confirmed she was familiar with resident #06's care and she was aware the resident had fallen previously. The DON confirmed the two half side rails were up on resident #06's bed. The DON confirmed the use of the two half side rails for Resident #06 were for bed boundaries and the two half side rails have been in use for a while. DON confirmed that Resident #06 had falls on 10/18/2022 with neuros started no injuries; 10/21/2022 with the resident found on the floor beside the bed no injuries observed; and on 01/31/2022 sent to the emergency department (ED). i. On 05/23/2024 at 09:34 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator, and she confirmed that if a resident has and fall or a fall with injury in the facility should be on the care plan along with any interventions. She confirmed that Resident #06's care plan did not document falls on 01/31/2022; 10/18/2022; and 10/21/2022. She confirmed Resident #06's care plan did not accurately reflect half side rail use. 2. On 05/21/2024 at 10:48 AM, the Surveyor interviewed Resident #31 and asked if they had experienced a fall since being in the facility. Resident #31 confirmed a fall in the shower room with no injuries on 05/20/2024. a. Review of Resident #31's Progress Notes dated 05/20/2024 revealed and incident and accident (I&A) report noting resident #31's fall in the shower room with no injuries and immediate intervention for resident to ask for assistance and ensure that staff is there to assist. b. Review of Resident #31's Progress Notes dated 05/22/2024 revealed and I&A (Incident and Accident) follow up note that documented a long term intervention to educate staff for shower safety. c. Review of the care plan date 04/24/2024 does not document Resident #31's fall on 05/20/2024. d. On 05/23/2024 at 9:34 AM, the Surveyor interviewed the MDS Coordinator, and she confirmed that Resident #31's care plan did not document a fall on 05/20/2024. e. On 05/23/2024 at 9:46 AM, the Surveyor interviewed the Director of Nursing (DON) and she confirmed that Resident #06 had falls on 10/18/2022 with neuros started no injuries; 10/21/2022 with the resident found on the floor beside the bed no injuries observed; and on 01/31/2022 sent to the emergency department (ED) and those falls were not documented on the care plan. f. On 05/23/2024 at 9:46 AM, the Surveyor interviewed the DON, and she confirmed Resident #31 had a fall on 05/20/2024 that is not documented on the care plan. g. The facility provided a policy titled, Care Plans, Comprehensive Person-Centered with a revision date of March 2022 that documented, Policy Interpretation and Implementation .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan- a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0687 (Tag F0687)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and interview, the facility failed to ensure residents who required assistance with foot care were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure toenails were kept clean and trimmed for 1 (Resident #68) of 1 sampled resident. The findings are: Review of the Order Summary revealed that Resident #68 has diagnoses of paraplegia, venous insufficiency, and type 2 diabetes. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/09/2024 revealed that Resident #68 scored a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of the Care Plan reveals that Resident #68 has these interventions in place, Nail Care: I require substantial assistance with nail care. I am a diabetic. Check nail length, clean, trim and file on shower days and as needed. On 05/20/2024 at 11:04 AM, the Surveyor observed Resident #68 ' s feet were dry with skin peeling off. There was skin material observed on the pillow below the feet. The left great toenail was thick, half of the toenail was yellow. Around the edges of the nail bed there was a brownish black color observed. The second toenail was thick, yellow, with dry skin buildup around the nail area. A flesh colored area was observed in the middle of the toe. The third toenail was long, curving inwards towards the second toe, yellow, with a scabbed sore observed below the nail bed. The fourth toenail was curved under the third. The toenail was thick and yellowing. The fifth toe was thick with dry skin buildup around the nail bed. The Surveyor observed the toes on the left foot were close together, with dry skin buildup in between each one. The Surveyor observed the right foot, the right great toenail was thick, yellowing, with dry skin buildup around the nail bed. A scabbed sore was located above the nail bed. The second toenail was thick, yellow, with dry skin buildup around the nail. Three scabbed sores were observed on the toe. The third toenail was thick, yellowing, and in the corner was a brownish, black area. The toenail was curving under the second toe. The fourth toenail was long, thick, yellowing and the nail was curving. The fifth toenail was yellowing, and thick. The Surveyor observed the toes on the right foot were close together, with dry skin buildup in between each one. Both heels were observed to be dry and scaly. The Surveyor asked Resident #68 about the toenails. Resident #68 said the newer areas on the toes were from the mechanical lift during a transfer in the hospital. Resident #68 said they have mentioned podiatry coming into the building before, but it had been a while now, and they would like something done about my feet they are pretty rough looking. On 05/20/2024 at 2:40 PM, the Surveyor observed nail care or wound care had not been completed for Resident #68's feet. On 05/23/2024 at 10:28 AM, the Surveyor asked Certified Nursing Assistant (CNA) #15 to describe Resident #68's toes. CNA #15 said that she was not sure if Resident #68 was diabetic, the way the toes are it could cause infections or sores. The Surveyor asked what the process for reporting toenails was if the resident is diabetic. CNA #15 said to report to the nurse to make a podiatry appointment. On 05/23/2024 at 10:36 AM, the Surveyor asked Licensed Practical Nurse (LPN) #15 to describe Resident #68's toenails. LPN #15 stated the resident was a diabetic, the resident could lose those toes, for sure definitely needs interventions. LPN #15 stated the resident was compliant with heel protectors. The Surveyor asked if Resident #68 had ever refused toenail care. LPN #15 said from her experience the resident has not refused it. The Surveyor asked what interventions could be put in place for Resident #68. LPN #15 said to ensure heel protectors, assess daily, notify the treatment nurse immediately. A review of the facility policy Fingernails/Toenails Care of revealed, Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and interview, the facility failed to ensure interventions were utilized to prevent worsening of contractures in one of one sampled resident (Resident #8). The findings are: A review of the Order Summary revealed that Resident #8 had diagnoses of bipolar disorder, osteoarthritis, and left-hand contracture. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/12/2024 revealed that Resident #8 scored a 12 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Section GG reveals that Resident #8 has Function Limitation Range of Motion; Upper Extremity 2. Impairment on both sides. A review of the Care Plan reveals that Resident #8 has Interventions: contractures: The resident has contractures of the left hand. Provide skin care as needed to keep clean and prevent skin breakdown. On 05/20/2024 at 2:30 PM, the Surveyor observed Resident #8 sitting up on the side of the bed, the left hand was contracted with the middle and ring finger digging into the palm of the resident's hand. The index finger and the pinky finger were curved, no interventions were in place. The Surveyor asked about the contracture of the left hand and if it bothered the resident in any way. Resident #8 said that it did bother the resident, it hurts the resident's hand, and it stinks. The Surveyor asked Resident #8 if they would like a washcloth or a hand cone with a strap to help. Resident #8 said a washcloth usually falls out when the resident gets up and would prefer something with a strap to hold it into place. On 05/21/2024 at 10:28 AM, the Surveyor observed Resident #8 did not have any interventions in place for the left hand contracture. On 05/23/2024 at 10:00 AM, the Surveyor asked Certified Nursing Assistant (CNA) #10 if Resident #8 had any interventions in place for the left hand contracture. CNA #10 said that the resident had a brace, and it was here one day and gone the next day. The Surveyor asked what could happen with no interventions in place of contractures. CNA #10 said it could contract all the way and the resident would have no use of it. The Surveyor asked CNA #10 if they could smell Resident #8's contracted hand. CNA #10 put on a glove and put a finger in the contracted hand. The Surveyor observed Resident #8 grimacing. CNA #10 said that it had a small stench, the nails are digging into the palm, and it hurt the resident to mess with contracture. On 05/23/2024 at 10:15 AM, the Surveyor asked Licensed Practical Nurse (LPN) #12 if Resident #8 had any interventions for left hand contracture. LPN #12 said sometimes the resident does, sometimes the resident doesn't. The Surveyor asked what could happen with no interventions in place. LPN #12 said it could contract worse. A review of the facility policy, Resident Mobility and Range of Motion stated, .3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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2. A review of the Order Summary revealed that Resident #294 had diagnoses of Huntington's disease and abnormal involuntary movements. A review of the Progress Notes revealed that Resident #294 N Adv [Abnormal Involuntary Movement Scale (AIMS)] - AIMS Evaluation: Muscles of Facial Expression: e.g. movements of forehead, eyebrows, periorbital area, cheeks, including frowning, blinking, smiling, grimacing: Severe. Lips and Perioral Area: e.g. puckering, pouting, smacking: Severe. Jaw: e.g. biting, clenching, chewing, mouth opening, lateral movement: Severe. Tongue: Rate only increases in movement both in and out of mouth. NOT inability to sustain movement. Darting in and out of mouth: Severe. Upper (arms, wrists, hands, fingers). Include chorei movements (i.e. rapid objectively purposeless, irregular, spontaneous) athetoid movements, DO NOT INCLUDE TREMOR (i.e. repetitive, regular, rhythmic): Severe. Lower (legs, knees, ankles, toes) Lateral knee movement, foot tapping, heel dropping, foot squirming, inversion, and eversion of foot: Severe. Neck, shoulders, hips, e.g. rocking, twisting, squirming, pelvic gyrations. Include diaphragmatic movements: Severe. Severity of abnormal movements overall: Severe. Incapacitation due to abnormal movements: Severe. Resident's awareness of abnormal movements. Rate only Resident's report: Aware, severe distress. Resident does not currently have problems with teeth and/or dentures. Resident does not usually wear dentures. Edentulous: No. Movements do not disappear in sleep. Resident cooperation level: Full. N Adv - AIMS Total score: 28.0 05/13/2024 at 13:41 [1:41 PM]. A review of the Progress Notes indicated Resident #294 BIMS Evaluation: Brief Interview for Mental Status should be conducted. Number of words repeated after first attempt: Three. Record Response: sock blue bed Able to report correct year. Record response (year): 2024 Able to report correct month: Missed by > 1 month or no answer. Record response (month): December Able to report correct day of the week: Incorrect or no answer. Record response (day): Thursday Able to recall sock: No, could not recall. Able to recall bed: No, could not recall. Able to recall blue: Yes, no cue required. N Adv - BIMS Summary score: 8.0 A review of the Care Plan revealed these interventions for Resident #294, Focus: The resident is at risk for falls r/t involuntary extremity movements, Interventions: Anti-tippers to wheelchair due to thrashing. On 05/20/2024 at 11:45 AM, the Surveyor observed Resident #294 in Dayroom, both brakes were locked, the back of the wheelchair had anti tippers in place. The Surveyor observed Resident #294 had involuntary movements causing the wheelchair to move. On 05/20/2024 at 12:40 PM, the Surveyor observed Resident #294 in the wheelchair in the dining area. The Surveyor observed Certified Nursing Assistant (CNA) #11 lock the brakes on the wheelchair while setting up the tray. The Surveyor observed Resident #294 was eating lunch, having involuntary movements and the wheelchair was moving back and forth still. On 05/23/2024 at 10:20 AM, the Surveyor asked CNA #13 if Resident #294's wheelchair had both brakes locked in the dayroom. CNA #13 said, yes both brakes were locked, they usually are. The surveyor asked what could happen to the resident with both brakes being locked. CNA #13 said with Resident #294's involuntary movements it could cause (the resident) to go backwards. The Surveyor asked what other interventions could be considered for the resident other than locking the brakes. CNA #13 said a different chair with foot pedals or an anti-roll back. On 05/23/2024 at 10:38 AM, the Surveyor showed Licensed Practical Nurse (LPN) #15 that both brakes were locked on wheelchair, and asked what could happen to the resident with both brakes being locked. LPN #15 stated that it is a restraint the resident cannot move. The Surveyor asked what interventions could be in place. LPN #15 stated that the resident is a newer admission, and they agree that the resident needs to be reassessed for a different chair. LPN #15 then stated that the resident needed more padding as well to prevent injury with involuntary movements. Based on observation, record review, and interview, the facility failed to ensure residents were free from potential accidents from half side rail use for 1 (Resident #06) and failed to ensure bed side rails were properly padded for a resident with a seizure disorder for 1 (Resident #06) of 1 sampled resident, and failed to ensure a wheelchair was left unlocked to prevent an injury for 1 (Resident #294) of 1 sample mix resident. The findings are: 1. On 05/20/2024 at 2:14 PM, the Surveyor observed Resident #06 lying in bed on their right side with eyes closed. Both half side rails were up at the top of bed with the right side rail padded on top and sides with what appears to be a black foam pool noodle. The Care Plan dated 10/22/2020 for Resident #06 revealed the resident had an (activity of daily living) ADL self-care performance deficit with an intervention of quarter side rails to promote independence. No seizure precautions were noted on the care plan. Resident #06's Patient Registration Form [Hospital Name]' dated 01/31/2022 revealed a maxillary closed fracture from a fall from the bed. Chief Complaint revealed resident stated, I fell off my bed and hit my nose. Computed tomography (CT) Scan revealed comminuted fracture of the anterior/lateral/ posterior right and left maxillary sinuses. Final Diagnoses revealed fall with lip laceration repair, maxillary sinus fracture. The Care Plan dated 10/24/2022 for Resident #06 did not reveal falls on 01/18/2022; 10/21/2022; 10/31/2022; or use of half side rails. The Annual Minimum Data Set (MDS) with an Assessment Reference Date of 10/26/2022 revealed Resident #06 had a fall in the facility. Resident #06's Side Rail(s) Usage Assessment dated 12/11/2023 revealed, Side Rail(s) Usage- Is the use of side rails(s) being considered? No. Are side rail(s) currently in use? Yes. If yes, what type- [quarter] side rail. Resident #6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 03/13/2024 revealed 'Physical Restraints'- bed rail not used, and an Active Diagnosis of Seizure Disorder or Epilepsy. Resident #06's Order Summary Report dated 05/21/2024 revealed no order for half side rails. On 05/20/2024 at 2:14 PM, the Surveyor observed Resident #06 lying in bed on their right side with eyes closed. Both half side rails up with the right side rail padded on top and sides with what appears to be a black foam pool noodle. On 05/21/2024 at 11:44 AM, the Surveyor observed Resident #06's bilateral side rails up at the top of the bed with the right side rail padded on top and sides with what appears to be a black foam pool noodle. On 05/22/2024 at 9:00 AM, the Surveyor observed Resident #06 lying in bed on the right side with eyes closed. Bilateral half side rails up at the top of bed with the right side rail padded on top and sides with what appears to be a black foam pool noodle. On 05/22/2024 at 2:56 PM, the Surveyor went to Resident #6's room and observed the resident sitting up on the side of the bed with their right leg leaning up against the half side rail that is up. On 05/22/2024 at 3:01 PM, the Surveyor took Certified Nursing Assistant (CNA) #10 to resident #06's room. The resident was observed sitting up on the side of the bed with their right leg leaning up against the half side rail that is up. CNA #10 confirmed she was familiar with Resident #10's care and that she was not aware of any fall the resident may have had. CNA #10 confirmed both half rails were up on the bed but did not know why they were both up. CNA #10 confirmed the resident walks around the facility and is limited assistance of one. On 05/22/2024 at 3:21 PM, the Surveyor took Licensed Practical Nurse (LPN) #12 to Resident #06's room. The resident was observed sitting up on the side of the bed with the right leg leaning up against the half side rail that is up. LPN #12 confirmed she was familiar with Resident #06's care and was sure the resident had a fall during her admission to the facility. LPN #12 confirmed both half side rails were up on the bed. LPN #12 confirmed that resident #06's care plan focus area self-performance deficit showed quarter rails. LPN #12 stated she had started back working for the facility on May 6, 2024, and confirmed the two half rails have been up since she has worked here. LPN #12 confirmed the risks of half side rails hinder resident independence, are restraint, and resident safety. LPN #12 confirmed the resident walks unassisted. LPN #12 confirmed the residents side rail assessment noted the resident had previously had a fall with fracture. On 05/22/2024 at 3:27 PM, the Surveyor took the Director of Nursing (DON) to Resident #06's room. The resident was observed sitting up on the side of the bed with the right leg leaning up against the half side rail that was up. The DON confirmed she was familiar with Resident #06's care and that she was aware the resident had fallen previously. The DON confirmed the two half side rails were up on Resident #06's bed. The DON confirmed Resident #06 wanders into rooms with empty beds. The DON confirmed the use of the two half side rails for Resident #06 were for bed boundaries and the two half side rails have been in use for a while and that a waiver should be in place for their use, or they should not be in use. The DON confirmed having two half side rails up could cause resident #06 to fall. The DON confirmed quarter rails are the only ones that were supposed to be used. The DON confirmed Resident #06's side rail assessment noted quarter side rail on both sides and that the resident had a previous fall with fracture. The DON confirmed that Resident #06 had falls on 10/18/2022 with neuros (neurological signs) started, no injuries; 10/21/2022 with the resident found on the floor beside the bed no injuries observed; and on 01/31/2022 sent to the emergency department (ED). On 05/23/2024 at 9:34 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator who confirmed that Resident #06's Quarterly MDS with an ARD of 03/13/2024 was coded that the resident does not use a restraint even though half side rails have been in use and therefore the quarterly assessment is inaccurate. She confirmed that Resident #06's care plan did not document falls on 01/31/2022; 10/18/2022; and 10/21/2022. She confirmed Resident #06's care plan did not accurately reflect half side rail use. On 05/23/2024 at 09:46 AM, the Surveyor interviewed the Director of Nursing (DON) and she confirmed that Resident #06 had falls on 10/18/2022 with neuros started no injuries; 10/21/2022 with the resident found on the floor beside the bed no injuries observed; and on 01/31/2022 sent to the emergency department (ED) and those falls were not documented on the care plan. On 05/23/2024 at 11:24 AM, the Surveyor interviewed the Maintenance Director and he confirmed that he didn't install the half side rails on Resident #06's bed and that they have been there since his employment started two (02) months ago. He confirmed there is to be quarterly assessment completed for an entrapment report, but it was not completed for resident #06. On 05/23/2024 at 1:55 PM, the Surveyor interviewed the Assistant Director of Nursing (ADON) who confirmed that Resident #06 had a diagnosis of seizure disorder and should be on seizure precautions. The ADON confirmed resident #06's bed was not adequately padded to prevent injury in the event of a seizure.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure bed rail assessments were performed before the use of bed rails for 1 (Resident #06) of 1 sampled resident reviewed for accidents. The findings are: Review of Resident #06's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 03/13/2024 revealed 'Physical Restraints'- bed rail not used, and an Active Diagnosis of Seizure Disorder or Epilepsy. Review of Resident #06's Side Rail(s) Usage Assessment dated 12/11/2023 indicated resident #06 did not use bed rails. On 05/21/2024 at 11:44 AM, the Surveyor observed both of Resident #06's side rails up at the top of the bed with the right side rail padded on top and sides with what appeared to be a black foam pool noodle. On 05/22/2024 at 9:00 AM, the Surveyor observed Resident #06 lying in bed on the resident's right side with eyes closed. Both half side rails up at the top of bed with the right side rail padded on top and sides with what appeared to be a black foam pool noodle. On 05/22/2024 at 2:56 PM, the Surveyor went to Resident #06's room and observed the resident sitting up on the side of the bed with the resident's right leg leaning up against the half side rail that was up. On 05/22/2024 at 3:01 PM, the Surveyor took Certified Nursing Assistant (CNA) #10 to Resident #06's room. The resident was observed sitting up on the side of the bed with the resident's right leg leaning up against the half side rail that was up. CNA #10 confirmed she was familiar with Resident #06's care. CNA #10 confirmed both half rails were up on the bed but did not know why they were both up. On 05/22/2024 at 3:21 PM, the Surveyor took Licensed Practical Nurse (LPN) #12 to Resident #06's room and the resident was observed sitting up on the side of the bed with her right leg leaning up against the half side rail that is up. LPN #12 confirmed she was familiar with Resident #06's care. LPN #12 confirmed both half side rails were up on the bed. LPN #12 stated she had started back working for the facility on May 6, 2024, and confirmed the two half rails have been up since she has worked at the facility. On 05/22/2024 at 03:27 PM, the Surveyor took the Director of Nursing (DON) to Resident #06's room. The resident was observed sitting up on the side of the bed with the resident's right leg leaning up against the half side rail that was up. The DON confirmed she was familiar with Resident #06's care. The DON confirmed the two half side rails were up on Resident #06's bed. On 05/23/2024 at 9:34 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator who confirmed that Resident #06's side rail assessment should be completed quarterly, and that Resident #06 had their most recent quarterly side rail assessment dated for 03/11/2024 when it was due, but it was actually completed on 05/22/2024 at 15:11 (3:11) PM. She also confirmed that when assessments are completed it should be at the bedside for observation purposes, so the assessment is accurate. On 05/23/2024 at 09:46 AM, the Surveyor interviewed the Director of Nursing (DON) who confirmed Resident #06's side rail assessment should have been conducted quarterly and was due on 03/11/2023 but was actually completed on 05/22/2024 at 15:11 PM and was not completed timely. On 05/23/2024 at 11:24 AM, the Surveyor interviewed the Maintenance Director who reported that he didn't install the half side rails on Resident #06's bed and that they have been there since his employment started two months ago. He confirmed there is to be a quarterly assessment completed for an entrapment report, but it was not completed for Resident #06. On 05/23/2024 at 9:34 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator, and she confirmed Resident #06's side rail assessment should be completed quarterly and that Resident #06 had her most recent quarterly side rail assessment dated for 03/11/2024 when it was due, but it was actually completed on 05/22/2024 at 15:11 PM. She also confirmed that when assessments are completed it should be at the bedside for observation purposes, so the assessment is accurate. Review of the facility policy tilted, Proper Use of Side Rails, with a revision date of December 2016 noted, General Guidelines .An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rail. When used for mobility or transfer, an assessment will include a review of the resident's- a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight . 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol . 13. When side rail use is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation, interview and policy review, the facility failed to ensure controlled medications were stored in a permanently affixed container in the medication room. The findings are: On 05/23/2024 at 1:00 PM, the Assistant Director of Nursing (ADON) toured the medication room with the Surveyor. The refrigerator used to store medications was not locked. Once opened a black safe-style box with a combination lock was observed sitting on a glass shelf in the refrigerator. The Surveyor pulled on the narcotics box, which came out of the refrigerator and was not permanently affixed in the refrigerator. On 05/23/2024 at 1:10 PM, the ADON was asked why the narcotics box should be permanently affixed. The ADON indicated so that you can't take it out and carry it off. On 05/23/2024 at 1:16 PM, the Surveyor spoke with the Administrator regarding the narcotics box not being affixed in the refrigerator. The Surveyor asked why the narcotics box must be permanently affixed. The Administrator indicated because it has controlled substances in it. On 05/23/2024 at 1:37 PM, the Administrator provided a Storage of Medications policy, which read, .Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and policy review, the facility failed to ensure 5 sampled residents who have a physician's order for a pureed diet received food which was smooth, lump free consistency to minimize the threat of choking or other complications. The findings are: On 05/21/2024 at 11:49 AM, a pureed meal was observed being plated for a resident with an order for a pureed diet for the lunch meal. A scoop of the pureed baked ham was observed to be placed on the plate. The mixture was observed to be textured with bits of unprocessed ham remaining in the mixture. Water, which was escaping from the ham, was observed to run across the plate and form puddles around the cornbread and peas. What was identified as pureed cornbread was observed to be placed on the plate. The cornbread mixture was observed to not hold its form. What was identified as pureed black-eyed peas was observed to be placed on the plate and did not hold its form. At 11:51 AM, a second pureed lunch meal was observed to be placed on a tray to be served. The food items were observed to have the same issues with consistency and the unblended food particles as the first observation. On 05/21/2024 at 12:15 PM, the Dietary Manager (DM) was observed placing several pieces of ham in the bowl of a food processor as additional servings were needed. After processing the meat mixture was placed into the steam table pan for serving. At 12:21 PM, pureed items were placed on a plate for serving. The ham mixture was observed to consist of small ham bits. There was no part of the substance that appeared to be of a smooth consistency. The cornbread on the plate did not hold its form. The plate did not contain peas. The water escaping from the ham encapsulated the pureed bread and the potato mixture. The water on the plate was 1/8th to 1/4th inches deep. On 05/22/2024 at 9:10 AM, the DM verbalized that therapeutic diet, such as pureed is often ordered for a resident who has chewing or swallowing problems when asked the purpose of a therapeutic diet. The correct consistency was verbalized as somewhere between applesauce and pudding, that the pureed food item should hold its form. When asked to describe the ham that was served on 05/21/2024, the DM verbalized that the mixture was a little grainy. She continued that the mixture did not appear smooth and had water escaping from it. The cornbread mixture was described as not holding its form. The black-eyed peas were described as not so runny but surrounded by water from the ham. The DM reported that the facility has multiple machines, but none that will produce a smooth meat mixture. On 05/22/2024 at 9:25 AM, the Administrator provided a policy concerning therapeutic diets which revealed a therapeutic diet is ordered by the physician to support the treatment plan of care. A diet with an altered consistency is considered as one form of a therapeutic diet. On 05/22/2024 at 11:35 AM, Certified Nursing Assistant (CNA) #1 was asked to describe the pureed lunch meal. CNA #1 described the ham mixture as lumpy with dark specs that are either pepper or the rim of the ham slice. The word mush was used to describe the cornbread. CNA #2 was asked to describe the ham mixture. CNA #2 reported that the mixture looked chunky, not smooth, with particles of meat that were not processed. The cornbread was described as runny and floating in water which came from the ham.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and interview, the facility failed to ensure a resident's preferences or allergies for a diet was implemented for 1 (Resident #79) of 1 sampled resident. The findings are: A review of the Order Summary revealed Resident #79 had diagnoses of dementia, functional intestinal disorder, and lactose intolerance. A review of the Order Summary revealed an order that stated, Regular Diet, Regular texture, Regular consistency, enhanced food all meals, offer high calorie lactose free snack TID [three time per day] (i.e. peanut butter sandwich); food served in bowls at meal times for Lactose Intolerant Do Not Send Milk. A review of the Food Dislikes/Likes stated, Resident is to receive soy milk. A review of the Progress Notes stated, Note Text: Ate 50% or less for 2 or more meals in the day. Offered [Nutritional Supplement Brand] supplement at hs [bedtime]. Consumed 237mL [milliliters] A review of the Certified Nursing Assistant Task Snacks states that for Resident #79 Task Nutrition-Snacks-Offer and encourage high protein low lactose free three times a day. A review of the Care Plan revealed Focus-Resident has potential for nutritional deficits related to dementia and lactose intolerance causing GI upset when consumed. Resident may require verbal cues to stay on task to complete eating, Interventions-Avoid dairy based foods/beverage. A review of the Care Plan revealed Focus-At risk for potential allergic reaction to known/unknown drugs/food. Allergies: Lactose Intolerant. Goal-Risk for allergic reaction to Drugs/Food will be minimized through review date. Interventions-If adverse side effect/allergic reaction or signs and symptoms of allergic reaction such as hives, rash, itching, difficulty breathing occur, Notify MD/Practitioner; Review allergies to foods when preparing diet/meals. On 05/20/2024 at 12:56 PM, the Surveyor observed dining on secure unit. Resident #79 was observed during lunch drinking whole milk. A review of the meal ticket revealed that Resident #79 had Allergies: Lactose, Dislike/Intolerances: Cheese; Notes: Enhanced; No Lactose, No Milk, No, Cheese; Sandwich Each Meal. The Surveyor observed that the resident had drank 50% of the liquid. On 05/20/2024 at 01:00 PM, the Surveyor asked Certified Nursing Assistant (CNA) #11 to review Resident #79's meal ticket for lunch. CNA #11 said it says that Resident #79 is lactose intolerant and the resident received milk. CNA #11 said that she was not aware Resident #79 was lactose intolerant, and that Resident #79 had received milk for lunch several times. The Surveyor asked what could be the issue for the resident to be drinking milk products. CNA #11 said well they are allergic to it and it could cause the resident to have diarrhea. On 05/23/2024 at 09:43 AM, the Surveyor asked the Dietary Manager why is it important to follow resident allergies for meals. The Dietary Manager said because they are allergic to the item, it's important that they do not receive that item as it could cause harm. A review of the facility policy, Food Allergies and Intolerances stated, For example, lactose intolerance is the inability to digest milk sugars due to a deficiency in the enzyme lactase. Lactose intolerance causes gas, bloating, cramping, and diarrhea. Assessment and Interventions: 5. Residents with food intolerances and allergies are offered appropriate substitutions for foods they cannot eat.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, record review, and interview, the facility failed to ensure food items were discarded by their use by date; food items were stored and served in a manner to prevent cross contamination; and hair covering for the face and head were worn at all times in 1 of 1 kitchen. The findings are: On 05/20/2024 at 10:35 AM, Dietary Aide #5 was observed with facial hair which was uncovered. On 05/20/2024 at 10:45 AM, a previously opened package containing tortillas was observed on the top shelf of the bread rack. The use by date was 05/14/2024. On 05/20/2024 at 10:50 AM, a one-pound bag of diced onion was observed on the shelf of the walk in refrigerator. The use by date was 05/13/2024. A 5-pound container of cottage cheese which was 3/4 full was observed on a shelf in the walk-in refrigerator. The use by date was 05/19/2024. On 05/20/2024 at 10:52 AM, the Maintenance Director was observed to be working in the kitchen without a covering for facial hair. The Dietary Manager was asked if an individual in the kitchen with facial hair should have a face covering. The Dietary Manager confirmed a facial hair covering should be worn at all times in the kitchen. On 05/20/2024 at 10:55 AM, two pitchers of iced tea were observed in the drink refrigerator with the lids turned to open exposing the contents to air and contamination. On 05/20/2024 at 11:15 AM, the following items were observed in the dry storage area: a. A one pound bag of marshmallows, half full, with a use by date of 04/21/2024. b. A one pound bag of marshmallows with a use by date of 05/14/2024. c. A 50 pound bag of rice, 1/2 full, unsealed, and open to air and contaminates. d. A 50 pound bag of cake mix, 1/2 full, unsealed, and open to air and contaminates. On 05/20/2024 at 11:58 AM, Dietary Aide #6 was observed to enter the kitchen through the door in the dining room. Dietary Aide #6 walked through the entire length of the kitchen prior to arriving at the Dietary Manager's office where he put a covering over his head. On 05/20/2024 at 12:41 PM, a nourishment refrigerator on Hall 200 was observed to contain the following items: a. 2 plastic bags containing half a sandwich each. The bags were not dated. b. A 1/2 bottle of water, not labeled with a name or a date. c. A floral lunch container. CNA #7 confirmed that the lunch container was hers, however she was unaware of who the water belonged to, just that she was sure it belonged to an employee. On 05/21/2024 at 10:40 AM, a 20 ounce bottle of water, 1/3 full, was observed in the nourishment refrigerator on Hall 200. The bottle had no name or date. CNA #7 identified the water as belonging to her partner, CNA #9. On 05/21/2024 at 11:41 AM, Dietary Aide (DA) #3 was observed at the beginning of the tray line. DA #3's fingers and/or thumb were placed on the surface of the plate when the plate was picked up and the thumb remained in the plate as the plate was filled. DA #3 was also observed to place her fingers inside the bowls which were filled for a resident who required the meal be served in bowls. At 12:07 PM, DA #3 was observed to place her fingers inside a bowl and a cup prior to filling. On 05/21/2024 at 12:02 AM, DA #6 was observed to enter the kitchen through the door located in the dining room. The employee was observed to cross the length of the kitchen before obtaining and putting on a hair covering. On 05/22/2024 at 9:00 AM, the Dietary Manager was asked how long foods are kept after they are opened. The Dietary Manager described how the length depended on the food item; refrigerated foods are considered good after 5 days. When asked how dishes/utensils should be handled to prevent cross contamination, the Dietary Manager reported that nothing that enters the mouth should be touched. The Dietary Manager also confirmed that the inside of a plate, cup or bowl should not be touched. When asked when a hair covering should be applied, the Dietary Manager expressed that coverings for face and head should be applied prior to entering the kitchen. On 05/22/2024 at 9:25 AM, the Administrator supplied a policy concerning food storage titled, Food Receiving and Storage, which described that dry foods are stored in bins and will be removed from original packaging, all food in the refrigerator or freezer will be covered, labeled, and dated with a use by date. A policy titled, Preventing Foodborne Illness revealed hair nets or caps and or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.

Apr 2023 5 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure 1 (Resident #40) of 1 sampled resident received a trapeze bar to assist with positioning as ordered by the Physician. The findings are: Resident #40 had a diagnosis of Morbid (Severe) Obesity due to Excess Calories, and Type 2 Diabetes Mellitus with Unspecified Complications. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS) and required extensive two plus persons physical assistance with bed mobility and transfers. a. A Physician Order dated 12/20/22 documented, .Trapeze Bar . b. A Care Plan with a revision date of 11/10/22 documented, .The resident has limited physical mobility r/t [related to] morbid obesity . Provide supportive care, assistance with mobility as needed . A history of trauma from falling, being bedbound, and unable to care for myself affects me negatively. Triggers are delayed care, being bedbound, and the Hoyer lift . The Care Plan does not address the use or need for a Trapeze Bar. c. On 04/03/23 at 1:10 PM, Resident #40 was in a bariatric bed. He stated, I've been waiting for a trapeze bar on my bed. I've been waiting since October of last year. d. On 04/07/23 at 8:34 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, Can you tell me when the trapeze bar was ordered for [Resident #40]? She stated, I don't know when it was specifically ordered. We went to put it on the bed, but it wouldn't fit probably. They said they had to order another one. The Surveyor asked, Can you tell me when the trapeze bar was put in his room? She stated, It would have had to be within the last 2 days. It was not there on Tuesday. The Surveyor asked, Can you tell me why [Resident #40] didn't have the trapeze bar in his room on Monday when we entered? She stated, I'm not sure. The Surveyor asked, Can you tell me why the trapeze bar was ordered for him? She stated, He requested it. e. On 04/07/23 at 8:39 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1, Can you tell me when the trapeze bar was ordered for [Resident #40]? She stated, I do not know. The Surveyor asked, Can you tell me when the trapeze bar was put in his room? She stated, Wednesday. The Surveyor asked, Can you tell me why [Resident #40] didn't have the trapeze bar in his room on Monday when we entered? She stated, I'm not aware. The Surveyor asked, Can you tell me why the trapeze bar was ordered for him? She stated, So he can pull up his upper body. f. On 04/07/23 at 9:10 AM, the Surveyor asked the Director of Nursing (DON), Can you tell me when the trapeze bar was ordered for [Resident #40]? She stated, I will have to look for that date. The Surveyor asked, Can you tell me when the trapeze bar was put in his room? She stated, It was sometimes this week I know that. The Surveyor asked, Can you tell me why [Resident #40] didn't have the trapeze bar in his room on Monday when we entered? She stated, I didn't know anything about him wanting one until this week. The Surveyor asked, Can you tell me why the trapeze bar was ordered for him? She stated, Repositioning himself in bed.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure residents feet were kept clean for 1 (Resident #28) of 8 (Residents #16, #17, #21, #28, #40, #57, #66 and #130) sampled residents who required assistance or were dependent on staff for activities of daily living (ADL) and/or bathing. The findings are: Resident #28 had a diagnosis of Huntington's Disease, Senile Degeneration of Brain, Not Elsewhere Classified. The Quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 03/13/23 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive two plus person physical assistance for personal hygiene and in part of bathing activity. a. A Care Plan with a revision date of 01/04/22 documented, .The resident has an ADL self-care performance deficit r/t [related to] Huntington's Chorea Disease. Resident will be clean and well-groomed daily throughout review date . Bathing: Requires extensive assistance with bathing . Personal Hygiene: The resident requires extensive assistance with personal hygiene . b. On 04/03/23 at 2:07 PM, Resident #28 was lying in bed in a fetal position. The soles of his feet were black and dirty. c. On 04/04/23 at 1:09 PM, Resident #28 was lying in bed in a fetal position. The soles of his feet were black and dirty. d. On 04/06/23 at 4:30 PM, Resident #28 was lying in bed in a fetal position. The soles of his feet were clean. e. On 04/05/23 at 11:15 AM, the Surveyor asked the Treatment Nurse, How often does [Resident #28] get a bath? She stated, I think it's three times a week, but I'm not 100% sure. The Surveyor asked, Can you tell me why the bottom of [Resident #28's] feet are black and dirty? She stated, No I cannot. f. On 04/05/23 at 11:24 AM, the Surveyor asked Certified Nursing Assistant (CNA) #4, How often does [Resident #28] get a bath or shower? She stated, Three times a week, but I'm not always here on his bath days. The Surveyor asked, Can you tell me why the bottom of [Resident #28's] feet are black and dirty? She stated, I'm not sure. g. On 04/07/23 at 8:34 AM, the Surveyor asked Licensed Practical Nurse (LPN) #3, Can you tell me why the soles of [Resident #28's] feet were black and dirty on Monday and Tuesday? She stated, It's been several months since I worked on the 200 Hall. h. On 04/07/23 at 8:45 AM, the Surveyor asked CNA #5, Can you tell me why the soles of [Resident #28's] feet were black and dirty on Monday and Tuesday? She stated, We tried to keep socks on him, but he takes them off. He fights us on keeping his feet clean. He fights us on everything. i. On 04/07/23 at 9:12 AM, the Surveyor asked LPN #4, Can you tell me why the soles of [Resident #28's] feet were black and dirty on Monday and Tuesday? She stated, We tried to keep socks on him, but he takes them off. He fights us on keeping his feet clean. He fights us on everything. j. On 04/07/23 at 9:22 AM, the Surveyor asked the Director of Nursing (DON), Can you tell me why the soles of [Resident #28's] feet were black and dirty on Monday and Tuesday? She stated, We tried to keep socks on him, but he takes them off. He fights us on keeping his feet clean. He fights us on everything.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of the 8:00 AM and 12:00 PM medication passes on [DATE], record review, and interview, the facility failed to maintain a medication error rate of less than 5% to prevent potential complications for 2 (Residents #1 and #18) of 3 (Residents #1, #3 and #18) residents observed during the medication pass, resulting in medication errors. Medication errors were made by 2 Licensed Practical Nurses (LPN #1 and LPN #2) who were observed administering medications in the facility. The medication error rate was 5.88% based on the observation of 34 medication opportunities and 2 errors detected. The findings are: 1. Resident #1 had diagnoses of Parkinson's Disease, Urinary Tract Infection (UTI) and Alzheimer's Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. The Physicians Orders dated [DATE] documented, .Primaxin IV Intravenous Solution Reconstituted 500-500 MG (Imipenem-Cilastatin) Use 500 mg intravenously every 6 hours for UTI bacteria Proteus Mirabils related to URINARY TRACT INFECTION, SITE NOT SPECIFIED . until [DATE] 23:59 [11:59 PM] . b. The [DATE] MAR documented, .Primaxin IV Intravenous Solution Reconstituted 500-500 MG (Imipenem-Cilastatin) Use 500 mg intravenously every 6 hours for UTI bacteria Proteus Mirabils related to URINARY TRACT INFECTION, SITE NOT SPECIFIED . until [DATE] 23:59 [11:59 PM] . c. On [DATE] at 11:40 AM, Resident #1 was in the Common Area of the Unit. LPN #2 arrived on the unit with an intravenous (IV) tubing, a syringe labeled, Heparin, a bag of Saline, and a vial of medication. LPN #2 moved an IV pole with an attached infusion pump near Common Area. She used a laptop on the Medication Cart to verify the medication was to be administered to Resident #1. She used the bag of saline to reconstitute the vial of medication and shook it to mix it thoroughly. She spiked the bag of fluid with the IV tubing and hung the bag on the IV pole. She primed the tubing with the fluid and inserted the tubing into the infusion pump. She removed the cap from the peripheral IV port located on the resident's right forearm, cleaned the port with an alcohol wipe, and flushed the port with the syringe of heparin before attaching the primed tubing. She powered on the pump and set it to run at 200 milliliters per hour (ml/hr) for a 100 milliliter (ml) bag of fluid. The label identified the contents as Primaxin IV 500-500 MG. The bag contained 100 ml of fluid. The medication label on the bag of fluid did not specify a flow rate for the medication to be administered. The Surveyor asked LPN #2 how she knew what rate to administer the medication. She stated, I just set it at 30 minutes because he moves a lot. He's already pulled his IV out once this morning. The Surveyor asked LPN #2 to attempt to locate the medication flow rate on the laptop located on the Medication Cart. LPN #2 was not able to locate the flow rate on the laptop. The Surveyor asked if IV medications were often missing a flow rate in the orders. She stated, Yes, they leave it up to us. d. On [DATE] at 2:16 PM, the Surveyor asked the DON if orders for intravenous medication administration should include an administration rate. She stated, It should. The Surveyor asked the DON to pull up Resident #1's Physician Orders in the [Facility Computer Software]. She pulled up the Physician Orders and studied them for several minutes. She stated, That should be in there, I'll get the APN [Advanced Practice Nurse] to fix that right now. e. On [DATE] at 2:30 PM, the DON asked the Surveyor to look in [Facility Computer Software] and check to see if the flow rate for the Primaxin was in the order. The Physicians Order documented, Infuse 500mg (1 bag) IV over 60 minutes every 6 hours until [DATE] at 23:59 [11:59 PM]. The DON asked, Did she run it over an hour? The Surveyor stated he had observed it run over thirty minutes. She stated, Ok, and left the room. f. On [DATE] at 2:40 PM, the DON reentered the room and provided the Surveyor with a copy of Resident #1's orders. The Physicians Order documented, Use 500 mg intravenously every 6 hours for UTI bacteria Proteus Mirabils related to URINARY TRACT INFECTION, SITE NOT SPECIFIED . until [DATE] 23:59 Run at 200 mls/hr [milliliters per hour]; give over 30 mins. [minutes] . g. On [DATE] at 4:38 PM, the Interim Administrator provided a bottle of Resident #1's medication with a label attached. The label documented, Infuse 500mg (1 bag) IV over 60 minutes every 6 hours until [DATE] 23:59 [11:59 PM] . h. On [DATE] at 9:45 AM, the Surveyor asked the DON if IV medications should be administered at the ordered rate. She stated, Yes. The Surveyor asked the DON what the outcome of administering IV medications at an incorrect rate might be. She stated, An adverse reaction.2. Resident #18 had diagnoses of Osteoarthritis of Knee, Gout, and Morbid Obesity. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. A Physician's Order dated [DATE] documented, .Acetaminophen ER [extended release] Tablet Extended Release 650mg Give 650mg [milligrams] by mouth two times a day for CPPD [Calcium pyrophosphate deposition disease] in left knee . b. The [DATE] Medication Administration Record (MAR) documented, .Acetaminophen ER Tablet Extended Release 650 MG Give 650 mg by mouth two times a day for CCPD in left knee -Start Date- [DATE] 2000 . c. On [DATE] at 8:30 AM, during the 8:00 AM medication pass, the Surveyor observed LPN #1 preparing medication for Resident #18. LPN #1 retrieved 2 round tablets from an over the counter bottle. The label read, .Acetaminophen 325mg [milligram] tablets . d. On [DATE] at 9:10 AM, the Surveyor returned to the medication cart after verifying the medications given by LPN #1 with the MAR. The Surveyor asked LPN #1 to show the Surveyor the bottle of Acetaminophen she had given out of earlier during the medication pass. The Surveyor looked at the bottle and it was not extended release. The Surveyor asked, Is that extended release? LPN #1 looked at the bottle and stated, It doesn't say that. The Surveyor asked LPN #1 to pull up the Physicians Order for the scheduled dose and verified with LPN #1 that the order was for extended release. LPN #1 stated, That's all we ever get in our stock medications, so what are we supposed to do? e. On [DATE] at 9:54 AM, the Surveyor accompanied the Director of Nursing (DON) to the medication cart for the 100 and 600 Halls. The Surveyor asked the DON to review the label on the Acetaminophen bottle used during the 0800 [8:00 AM] medication pass on [DATE] at 8:30 AM and to review the Resident #18 ' s Physicians Orders. The Surveyor asked what the difference was between the medication given and the medication ordered. The DON stated, This one is not extended release. The Surveyor asked what this meant for the medication that was given. The DON responded, This one has a shorter life of 4 to 6 hours. The Surveyor asked what the duration was on the extended-release version of Acetaminophen. The DON stated, Up to 8 hours. 3. The facility policy titled, Administering Medications, provided by the Interim Administrator on [DATE] at 4:27pm documented, .Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders, including any required time frame . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 6 residents who received pureed diets and 17 residents who received mechanical soft diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 04/06/23. The findings are: 1. On 04/05/23, the menu for the lunch meal documented residents who received pureed diets were to receive 2 inch x 4 inch servings of pureed carrot cake and residents on mechanical soft diets were to receive ground herb chicken. 2. On 04/05/23 at 11:45 AM, Dietary Employee (DE) #2 placed nine 1 inch x 2 inch servings of carrot cake with frosting into a blender, added milk and pureed to be served to the residents who received a pureed diet, instead of a 2 inch x 4 inch serving for each resident. There was no ground herb chicken prepared as documented on the menu for the residents who were to receive a mechanical soft diet. 3. On 04/05/23 at 11:58 AM, the Surveyor asked DE #1 the reason mechanical ground meat was not prepared. He stated, We give them diced meat. At 12:20 PM, the residents on mechanical soft diets were served diced chicken, with gravy, instead of ground herb chicken. At 12:30 PM, the Surveyor asked the Dietary Supervisor the reason residents on mechanical soft diets were served diced chicken. She stated, We use diced chicken for the mechanical soft diets.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, and interview, the facility failed to ensure the kitchen floor was maintained in clean, sanitary condition for food preparation to prevent the potential for food borne illnesses for residents who received meals from 1 of 1 kitchen; the refrigerator temperature and dairy products stored in the refrigerator were maintained at 41 degrees Fahrenheit or below; food items stored in the freezer were sealed or covered to prevent the potential for cross contamination or freezer burn, employees washed their hands and changed gloves when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1 kitchen and the ice machine was maintained in clean condition to prevent the potential contamination of residents' beverages. These failed practices had the potential to affect 79 residents (total census: 81) who received meal trays from the kitchen as documented on a list provided by the Dietary Supervisor on 04/06/23 at 1:50 PM. The findings are: 1. On 04/03/23 at 11:31 AM, the following observations were made during the initial tour of the kitchen with the Dietary Manager: a. In the refrigerator, there were 12 eggs in an egg carton that were cracked. b. In the walk-in freezer, there was an opened box with 30 corndogs in it that was not dated. c. In the walk-in freezer, there was a bag of French fries with 3 puncture holes in the bag. d. The kitchen floor was dirty and had a lot of debris on it. 2. On 04/05/23 at 10:45 AM, the following observations were made in the refrigerator and the walk-in freezer: a. An opened box of cookies was on a shelf in the refrigerator. There was no opened or received date on the box. b. An opened box of corn dogs was on a shelf in the walk-in freezer. The box was not covered or sealed. There was no opened date on the box. c. An opened bag of pancakes was on a shelf in the walk-in freezer. The box was not covered or sealed. 3. On 04/05/23 at 10:55 AM, DE #1 turned on the hand washing sink faucet and washed his hands. He turned off the faucet with his bare hands. He pulled out tissue papers and dried his hands. He removed gloves from the glove box and placed them on his hands, contaminating the gloves. He used his gloved hand to attach a clean blade to the base of the blender to be used in pureeing food items to be served to the residents who received pureed diets for lunch. 4. On 04/05/23 at 11:01 AM, DE #1 was wearing gloves on his hands. He picked up a cup that contained thickener and placed it on the counter. He removed the gloves from his hands and threw them away. Without washing his hands, he picked up a pan with his thumb inside the pan and placed it on the counter. At 11:02 AM, he poured the pureed chicken into a pan and placed it in the food warmer to be served to the residents who receive pureed diets for lunch. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? He stated, I should have removed the gloves and washed my hands. 5. On 04/05/23 at 11:08 AM, the ice machine located in the Dining Room had an accumulation of wet brown/rusty sediment on the panel of the ice machine. The area had condensation that could possibly drip onto the ice. The Surveyor asked the Dietary Supervisor to wipe the accumulation of wet rusty sediment from the panel of the ice machine. She did, and the wet brown/rusty colored residue easily transferred to the tissue. The Surveyor asked the Dietary Supervisor, How often do you clean the ice machine? She stated, I think the Maintenance Man cleans it. At 12:31 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1, Who uses the ice from the ice machine? He stated, We use it for the water pitchers in the residents' rooms. 6. On 04/05/23 at 2:38 PM, DE #4 was wearing gloves on her hands. She opened the refrigerator door and closed it back. Without changing gloves and washing her hands, she picked up glasses and placed them on the trays with her gloved fingers inside the glasses. On 04/05/23 at 2:44 PM, DE #4 poured punch into the glasses to be served to the residents with their supper meal. At 2:46 PM, the Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have removed the gloves and washed my hands. 7. On 04/06/23 at 7:53 AM, the Surveyor asked CNA #2, Who uses the ice from the ice machine? He stated, We use it to fill the water pitchers in the residents' rooms. 8. On 04/06/23 at 12:57 PM, the Surveyor asked CNA #3, Who uses the ice from the ice machine? He stated, We use it to fill the water pitchers in the residents' rooms. 9. On 04/06/23 at 1:38 PM, the Surveyor asked the Maintenance Director, How often do you clean the ice machine and who uses the ice from the ice machine? He stated, I clean it out once every 3 months and check on it every week. 10. The facility policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, provided by the Interim Administrator on 04/06/23 at 1:41 PM documented, .Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness . 6. Employees must wash their hands: .f. after handling soiled equipment or utensils; g. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or h. after engaging in other activities that contaminate the hands .

Nov 2022 2 deficiencies

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and interview, the facility failed to ensure the resident's representative was promptly notified of changes in the resident's condition and status for 1 (Resident #4) of 3 (Residents #4, #5 and #6) sampled residents who required contact isolation and a room change. The findings are: 1. Resident #4 had diagnoses of Dementia and Bipolar Disorder. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/28/22 documented the resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS) and required supervision of one person assistance for bed mobility and transfers and had no skin problems. a. The Physician order dated 10/05/22 documented, .Contact Isolation . b. The Infection Note dated 10/5/222 at 1:22 PM documented, .Resident was removed from (Resident #4's Room Number) and directly taken to shower in only a clean linen gown to be showered and assessed for any bites or other bugs . She was placed on contact isolation for 72 hours in room (Room Number) to be monitored while room (Resident #4's Room Number) . treated by pest control . c. The Infection Note dated 10/10/22 at 2:48 PM documented, .Resident has been removed from Contact isolation and returned to her original room (Resident #4's Room Number). Quarantine completed . d. The Nurse's Notes from 10/05/22 to 10/25/22 contained no documentation where the daughter was notified of the Resident's room changes or Contact Isolation due to bed bugs. e. The Nursing General Note dated 10/15/22 at 1:25 PM documented, .staff found bed bug in residents' bed, resident was bathed and moved to another room, infection control and ADON [Assist Director of Nursing] aware . f. The (Pest Management Company) Invoices provided by the Administrator on 11/15/22 at 4:36 PM documented the following visits: i.Time In: 10/6/22 . Bed Bug Infestation in one room . (Room Number). Prevention treatment on (Room Number), (Room Number) (office) . Baby Bed bugs in room (Room Number) only. Bags need to be threw away . ii.Time In: 10/19/22 .Bed Bug recall .Room (Room Number). Finished bedbug treatment. Didn't find any live bed bugs. Treated both beds .chair .floor . g. The Resident's Census documented on 10/05/22 the resident was moved to room (Room Number), on 10/10/22 moved back to room (Resident #4's Room Number). On 10/15/22 the resident was moved to (Room Number), on 10/17/22 to room (Room Number). Then on 10/26/22 back to room (Resident #4's Room Number). h. On 11/16/22 at 8:01 AM, Resident #4 was resting in bed. The Surveyor asked if her room had bed bugs. She stated, Yes, my roommate's husband came to visit, and he brought in the bed bugs.They did not even notify my daughter that I had bed bugs twice and had to be on isolation twice. i. On 11/18/22 at 9:59 AM, the Surveyor asked the Director of Nursing (DON), When [Resident #4] was placed on Contact Isolation for bedbugs and moved to another room was her daughter notified? The DON stated, Yes. The Surveyor asked if there was any documentation that the daughter was notified. The DON stated, No, I could not find any documentation that the daughter was notified. The Surveyor asked, How many times was the resident on Isolation? The DON stated, One time. j. The facility policy titled, Change in a Resident's Condition or Status, received by the Administrator on 11/18/22 at 12:35 PM documented.Our facility promptly notifies . the resident representative of changes in the resident's medical . and/or status . a nurse will notify the resident's representative when; .there is a need to change the resident's room assignment . notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical . condition or status . The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate and complete to facilitate the ability to plan and provide necessary care and services for 2 (Residents #1 and #2) of 3 (Residents #1, #2 and #3) sampled residents who wandered and resided in the facility. The findings are: 1. Resident #1 had diagnoses of Dementia with Behavior Disturbances. The admission MDS with an Assessment Reference Date (ARD) of 10/03/22 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had no behaviors of wandering, was independent of transferring, walking and locomotion, and had no mobility devices. a. The admission assessment dated [DATE] documented, .Elopement Risk . Exit seeking . History of wandering prior to nursing home placement . at risk for elopement . b. The Care Plan with an initiated date of 10/03/22 documented, .The resident is an elopement risk/wanderer r/t [related to] dementia and active exit seeking behaviors . Distract resident from wandering . Identify pattern of wandering . MEN'S SECURE UNIT UPON admission . c. The Progress Note dated 10/01/22 at 3:05 PM documented, .resident pacing hallway . cont [continue] to monitor and more precautions advised to staff when entering and exiting r/t resident is attempting to elope. d. The Nursing General Note dated 10/02/22 at 5:51 PM documented, .resident noncompliant with quarantine . ambulates self to dr [dining room] area, up/down hallway . e. On 11/19/22 at 11:04 AM, the Surveyor asked MDS Coordinator #2, Who completes section E of the MDS? MDS Coordinator #2 replied, I do. The Surveyor asked, The admission MDS for [Resident #1] under Wandering, is it coded correctly? She replied, No, I will modify that MDS. 2. Resident #2 had diagnoses of Dementia with Behavior Disturbances and Psychosis. The Quarterly MDS with an ARD of 09/21/22 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a BIMS and had no behaviors of wandering, required supervision with transferring, walking and locomotion, and had no mobility devices. a. The admission assessment dated [DATE] documented, .Elopement Risk . History of wandering . Exit seeking . risk for elopement. Behaviors . Wandering behavior: Yes, looking for his mother, constantly . b. The Care Plan with an initiated date of 03/28/22 documented, .The resident is an elopement risk/wanderer r/t dementia with behaviors and psychosis . Distract resident from wandering . Identify pattern of wandering . secure unit for men . c. The Progress Noted dated 3/29/2022 at 9:58 PM documented, .resident does have exit seeking and wondering behaviors . d. The admission MDS dated [DATE] documented, .Wandering - Behavior not exhibited . e. The Interdisciplinary Team (IDT) Meeting Notes dated 06/27/22 at 10:50 PM documented, .The resident has exhibited wandering behaviors at this frequency . Behavior of this type occurred 4 to 6 days . f. The Quarterly MDS dated [DATE] documented, .Wandering - Behavior not exhibited . g. On 11/19/22 at 10:54 AM, the Surveyor asked the MDS Coordinator #1, Who completes section E of the MDS? MDS Coordinator #1 replied, Social, but she is not here anymore, but I have to make sure it's accurate. The Surveyor asked, The admission MDS on 04/04/22 and the Quarterly MDS on 07/01/22 for [Resident #2] under Wandering is it coded correctly? She replied, No. h. The facility policy titled, Resident Assessments, received from the Administrator on 11/18/22 at 12:35 PM documented, .A comprehensive assessment of every resident's needs is made at intervals .All persons who have completed any portion of the MDS resident assessment form must sign the documentation attesting to the accuracy of such information .

Jan 2022 10 deficiencies 1 IJ (1 affecting multiple)

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Infection Control (Tag F0880)

Someone could have died · This affected multiple residents

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A. Based on observation, record review, and interview, the facility failed to ensure implementation of infection prevention and control practices to prevent the potential transmission of COVID-19, as evidenced by failure to ensure COVID-19 isolation precautions were followed and personal protective equipment (PPE) was readily available for staff caring for COVID-positive residents for 4 (Residents #3, 4, 5, and 6) of 4 sampled residents who resided on the 500 Hall Dementia Unit and were COVID-positive The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to 8 COVID-negative residents who resided on the 500 Hall Dementia Unit, according to a list provided by the Director of Nursing (DON) on 1/26/22 at 10:30 AM. The Administrator was informed of the Immediate Jeopardy condition on 1/24/22 at 5:45 p.m. The findings are: 1. A list of COVID-19 positive residents provided by Registered Nurse #1, the Infection Preventionist, on 1/24/22 at 3:30 PM was compared to the Midnight Census provided by the Administrator on 1/24/22 From the lists that were provided by the Infection Preventionist and the Administrator, it was determined that a COVID-19 positive resident (Resident #3) and a COVID-19 negative resident were housed in the same room. Additionally, a COVID-19 negative resident (Resident #7) in one room on the 500 Hall was sharing a bathroom with a COVID-19 positive resident in the adjacent room, and both residents were ambulatory. Based on a review of the vaccine records and COVID test results, Resident #3 tested positive for COVID-19 on 1/18/22 and was not separated from his COVID-negative roommate until 1/24/22 during the complaint survey. 2. The facility's policy titled, Isolation Precautions, provided by the Administrator on 1/24/22 at 4:20 p.m. documented, .Maintain an adequate supply of isolation supplies (gloves, gowns, masks, as needed) at the entrance of the isolation room so that appropriate personal protective equipment can be easily used. Post an isolation sign on the room entrance door instructing staff and visitors to report to the nursing station before entering room. Place a container for laundry and container for waste in the isolation room. 3. The facility's policy titled Infection Control and Prevention Plan for COVID-19 Positive Test Results for Residents, provided by the Assistant Director of Nursing on 1/26/22, documented, In the event a resident test positive for COVID-19, the resident will don a mask and be moved to the COVID-19 designated unit. The resident will remain in droplet isolation times 10 days following a positive test .residents who are symptomatic will have screening increased to every 8 hours. 4. Resident #3 had diagnoses of Atrial Fibrillation, Altered Mental Status, Vascular Dementia, and COVID-19. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/21 documented the resident scored 5 (0-7 indicates cognitively impaired) on a Brief Interview for Mental Status (BIMS), used a wheelchair for mobility, and required limited assistance of one person for locomotion. a. The Plan of Care dated 8/6/21 documented, .Resident is at risk for exposure and contracting the Coronavirus . Observe for signs and symptoms of COVID-19 such as fever, coughing, shortness of breath, fatigue . b. The COVID-19 Positive Resident list provided by the Infection Preventionist on 1/24/22 documented the resident tested positive for COVID-19 on 1/18/22. c. The January 2022 Physician Orders had no documented orders for isolation for this resident. 5. Resident #4 had diagnoses of Alzheimer's Disease and COVID-19. The admission MDS with an ARD of 12/22/2 documented the resident scored 7 (0-7 indicates severely impaired) on a BIMS and required supervision of 1 person with walking and locomotion. a. The Plan of Care dated 12/27/21 documented, .Resident is at risk for exposure and contracting the Coronavirus . Observe for signs and symptoms of COVID-19 such as fever, coughing, shortness of breath, fatigue . b. The COVID-19 Positive Resident list provided by the Infection Preventionist on 1/24/22 documented the resident tested positive for COVID-19 on 1/18/22. c. The January 2022 Physician Orders had no documented orders for isolation for this resident. 6. Resident #5 had diagnoses of Alzheimer's and COVID-19. The Quarterly MDS with an ARD of 12/2/21 documented the resident scored 4 (0-7 indicates severely impaired) on the BIMS, was independent with transfer and required supervision of 1 person for walking and locomotion. a. The Plan of Care dated 12/27/21 documented, .Resident is at risk for exposure and contracting the Coronavirus . Observe for signs and symptoms of COVID-19 such as fever, coughing, shortness of breath, fatigue . b. The COVID-19 Positive Resident list provided by the Infection Preventionist on 1/24/22 documented the resident tested positive for COVID-19 on 1/14/22. c. The January 2022 Physician Orders had no documented . orders for isolation for this resident. 7. Resident #6 had diagnoses of Dementia and COVID-19. The Quarterly MDS with an ARD of 11/30/21 documented the resident scored 2 (0-7 indicates severely impaired) on a BIMS, used a wheelchair for mobility, and required supervision and set-up only for locomotion. a. The Plan of Care dated 12/27/21 documented, .Resident is at risk for exposure and contracting the Coronavirus . Observe for signs and symptoms of COVID-19 such as fever, coughing, shortness of breath, fatigue . b. The COVID-19 Positive Resident list provided by the Infection Preventionist on 1/24/22 documented the resident tested positive for COVID-19 on 1/14/22. c. The January 2022 Physician Orders had no documented orders for isolation for this resident. 8. On 1/24/22 at 3:00 PM, rounds were made on the 500 Hall, which housed the Dementia Unit on the back half of the hall. The doors were locked but, had no signage to let staff or visitors know that there were positive residents on the unit. After the surveyor entered the unit, there was a plastic sheet that was hanging from the ceiling in the back half of the hall. The sheet of plastic was attached to the ceiling and both walls on the side with a split in the middle. The residents on the hall pushed the plastic sheeting aside and wandered freely from the front to the back of the unit. There were no isolation bins with personal protective equipment for staff located on the hallway. 9. On 1/24/22 at 3:15 PM, Certified Nursing Assistant (CNA) #1 wore a KN95 mask as she walked out of a resident's room and was asked, Are there any COVID-positive residents on this hallway? She stated, Yes, we consider them all COVID-positive. She was asked, Do all the residents have COVID? She stated, I really don't know. She was asked, Do you wear gown and gloves when you do personal care? She stated, No, they just told us we had to wear these masks. She was asked, Have they told you that any resident on this unit was positive for COVID? She stated, No, I just returned today. I have had COVID and been at home. 10. On 1/24/22 at 3:25 PM, Nursing Assistant (NA) #1 was asked, Do any of the residents on this unit have COVID? She stated, I really am not sure; this is my third day here as a Nurse Aide. She was asked, What kind of personal protective equipment do you wear when taking care of the residents on this unit? She stated, They gave us these masks to wear. She was asked, Do you wear a gown and gloves when you do resident care? She stated, No, they didn't say we had to. 11. On 1/24/22 at 4:20 PM, Licensed Practical Nurse (LPN) #1 was asked, What hall are you working on? She stated, I work 500 Hall. She was asked, Are there any residents on the 500 Hall unit that are COVID-positive? She stated, Yes. She was asked, Which residents are positive? She stated, We have a list on our 24-hour report. The 24-hour report documented 10 residents on the unit were COVID-19 positive. She was asked, How are you keeping the positive residents and negative residents separated? She stated, We aren't, we are considering them all positive. 12. On 1/24/22 at 4:26 PM, LPN #2 was asked, Should the 500 Hall unit have personal protective equipment for the staff to use? She stated, I'm not sure. She was asked, Are there COVID-positive residents on the 500 Hall unit? She stated, Yes. She was asked, Who is responsible for making sure personal protective equipment is accessible to the staff? She stated, It's a group effort. She was asked, How are the staff made aware of the residents who are COVID-positive? She stated, It's on the 24-hour report. 13. On Monday, 1/24/22 at 5:00 PM, the Assistant Director of Nursing (ADON) and the Administrator were asked, Should staff have on personal protective equipment when on a hall with COVID [positive residents]? She stated, Yes. They were asked, Should personal protective equipment be accessible to staff on a hall with COVID-positive residents? She stated, Yes. They were asked, If a unit has COVID positive residents, should there be a sign indicating that? Both replied, Yes. They were asked, Are there COVID-positive residents on the 500 Hall unit? They stated, Yes. They were asked, Why is there no sign to indicate that? They both stated, There was on Friday [1/21/22]. They were asked if they had checked for signage today and, the Administrator stated, No. The Administrator and ADON accompanied the surveyors to the 500 Hall unit and observed that no signs were in place and there was no PPE available for the staff . 14. On 1/24/22 at 5:20 PM, Personal Protective Equipment was delivered to the 500 Hall unit, and bins to dispose of used PPE were placed on the unit behind the barrier. 15. The immediate jeopardy was removed, and the scope reduced to E on 1/24/22 at 6:15 PM when the facility implemented the following plan of removal: IJ - Plan of Removal: Step #1 Corrective Action: 500 Hall - a. On 1/24/2022, the administrator placed appropriate isolation signage on the entrance of 500 hall to alert of COVID positive residents. b. On 1/24/2022, the IP [Infection Preventionist] stocked appropriate and sufficient PPE on 500 hall unit to include gowns, gloves, KN95, goggles/face-shield. c. On 1/24/2022 at 5:30 p.m., the Maintenance Director replaced plastic barrier on 500 hall to clearly separate COVID negative and COVID positive residents to include securing barrier to the floor. d. Positive and negative residents on 500 hall were separated on 1/24/2022 by nursing staff and verified by Administrator. e. On 1/25/2022, the MDS coordinator supplied a list of active COVID positive, negative, recovered and vaccination status and placed on each unit for staff . Step #2 Identification of others with the potential to be affected: On 1/24/2022, the Administrator verified a census of 95 residents in house. The facility identified 40 positive residents, 11 recovered COVID positive residents, and 44 negative residents. The Administrator made observation rounds to ensure all COVID negative residents were separated from COVID positive residents. Step #3 To ensure deficient practice does not occur: On 1/24/2022, the Administrator initiated inservices for the following for all staff: a. Appropriate isolation signage for COVID units. b. Appropriate PPE for use by employees for COVID isolation and ensuring PPE is available. c. Ensuring COVID negative and COVID positive residents are not co-mingled [sic]. d. Ensuring residents are not brought off COVID units onto non COVID units. e. The MDS coordinator will maintain a current list of residents COVID status and vaccination status and will be updated as needed. Step 4 Monitoring: Administrator / designee will monitor all COVID units daily 7 days/week x 2 weeks, 5 days/week x 2 weeks, 3 days/week x 2 weeks, then weekly thereafter to ensure: a. Appropriate signage for COVID units. b. Appropriate PPE for use by employees and available. c. Ensuring COVID negative and COVID positives are no co-mingled. d. Ensuring residents are not brought off COVID units into non COVID units. e. Ensuring a current list of residents COVID status and vaccination status is posted and current. Monitoring will be documented on monitoring calendar and negative findings will be corrected immediately by Administrator / designee. Step 5 QA [Quality Assurance]: Administrator / designee will present findings to the monthly QA committee x 1 quarter for further review and recommendations. B. Based on observation, record review and interview, the facility failed to ensure signage for isolation precautions was posted to inform staff / visitors of the need for precautions to prevent the potential spread of infection for 1 (Resident #64) of 1 sampled resident who was on isolation precautions as of 1/3/2022. The findings are: Resident #64 had diagnoses of Anemia, Hip fracture, Alzheimer's Disease, Dementia and Schizophrenia. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/21 documented the resident scored 7 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS). a. The Care Plan dated 12/22/21 documented, Resident is at risk for exposure and contracting the Corona Virus. Check temperature at least daily and as needed. Report any abnormal result to MD [Medical Doctor] and Nurse Management. Respiratory assessment for COVID-19 as indicated. Lab testing for COVID-19 as MD orders. Report all results to the MD. Observe for signs and symptoms of COVID-19 such as fever, coughing, shortness of breath, fatigue, etc. [et cetera] Initiate E-Interact if S/S [signs/symptoms] are noted. Consult with MD and Nurse Management if any signs/symptoms of COVID-19 are observed. b. The January 2022 Physicians Orders documented, Administer PCR [Polymerase Chain Reaction] COVID-19 test at frequency recommended by CMS [Centers for Medicare and Medicaid Services] and Arkansas Department of Health. Administer PRN [as needed] Antigen COVID-19 test in the presence of COVID-19 symptoms .for Potential COVID-19 PRN per CMS/DOH [Department of Health] recommendations, or as needed for symptoms . Vital signs and COVID 19 monitoring daily for residents not requiring quarantine every night shift . c. Nursing Progress Notes dated 1/3/22 documented a specimen for, SARS-COV-2 [Severe Acute Respiratory Syndrome Coronavirus 2] by PCR was collected on Resident #64 on 01/3/22 at 6:45 AM. The specimen was received by a local hospital laboratory at 11:36 AM and the result was verified at 12:40 PM and documented, CoV-2 Negative. d. On 1/03/22 at 11:14 PM, a Personal Protective Equipment (PPE) container was noted outside a resident's room / door; no name was posted. Licensed Practical Nurse (LPN) #2 was walking by was asked, Is there a resident in that room? She replied, Yes there is a resident in this room; it's [Resident #64]. She was moved from the next room; she started having signs and symptoms this morning and was tested for COVID. The test was inconclusive, so we moved her to this room. Her roommate tested negative, no signs or symptoms, and is fully vaccinated. She was asked, What kind of isolation is she on? The LPN replied, Contact. The LPN was asked, Should there be isolation and PPE signs on the resident's door indicating she is on isolation and what type of PPE is required? She replied, Yes. e. The Hot Rack Charting dated 1/3/22 documented, .resident is on hot rack r/t [related to] elevated temp [temperature] on day shift . resident was tested for COVID . f. On 1/5/22 at 10:39 AM, the Director of Nursing (DON) was asked, When a resident is placed on quarantine or isolation, should the resident's door have signage that indicates the type of isolation and what PPE is required? She replied, Yes. She was asked, What was the resident's temperature and when was the resident moved to isolation? She replied, I do not know; there is no documentation found on her elevated temperature or when she was moved.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure a written discharge summary was completed which included a recapitulation of the resident's stay and information regarding the disposition of the resident's medications to ensure necessary information was provided to the receiving care provider for 1 (Resident # 91) of 1 sampled resident whose record was reviewed for discharge documentation. The findings are: Resident #91 had diagnoses of Unspecified Dementia with Behavioral Disturbance, Postherpetic Polyneuropathy, Anxiety Disorder and Essential Hypertension. The admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/25/21 documented the resident scored 5 (0-7 indicates severe impairment) on a brief interview for mental status. a. The Care Plan dated 09/01/2021 documented, Resident / representative wishes to be discharged to (Specify: Home, Community, another facility [no location was specified]) . Resident will be discharged to (Specify). Arrange discharge planning conference with resident / representative to discuss potential discharge options. Resolved date 09/01/2021 . b. The Minimum Data Set with an ARD of 11/01/2021 documented, Discharge assessment - return not anticipated . discharge date : 20211101 [11/01/2021] . Discharge Status: Another nursing home or swing bed . c. As of 01/06/21 at 1:00 PM, there was no documentation in the electronic health record of a discharge summary that included the disposition of the resident's medications and a summation of the resident's stay. d. On 01/07/21 at 8:45 AM, the Director of Nursing was asked Who is responsible for the completion of discharge summaries? She stated, Let me check . Upon return, she stated, Nursing . e. The facility's policy for Transfer and Discharge provided by the Administrator on 1/6/22 documented, For a transfer to another provider, the following information must be provided to the receiving provider: Contact information of the practitioner responsible for the care of the resident. Resident representative information including contact information. Advance Directive information. All special instructions or precautions for ongoing care, as appropriate. Comprehensive care plan goals. Other necessary information, including a copy of the resident's discharge summary, as applicable, to ensure a safe and effective transition of care .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure housekeeping services were provided to maintain a sanitary comfortable interior and improve the quality of life for the residents, as evidenced by failure to ensure floors and walls were clean, and baseboards were free from dirt build-up on 4 of 4 halls. The findings are: 1. On 01/03/22 at approximately 2:05 pm, the floors on the 600 Hall had dried liquids and trash on the floor. The baseboards were stained and dirty, and the walls between the handrails and floors were stained and had scuff marks. 2. On 01/03/22 at approximately 2:40 pm, in room [ROOM NUMBER]-B, there was enteral formula dried on the wall above the bed. There were dried liquid stains and trash on the floor and under the bed. 3. On 01/04/22 at approximately 10:00 am, the floors in the day room, next to the nursing station had dried liquid stains and the baseboards were stained and dirty. 4. On 01/06/22 at approximately 1:07 pm, the covering of an electrical box located on the main hall was loose, with a gap greater than ½ inch. 5. On 01/06/22 at 9:38 am, Certified Nursing Assistant (CNA) #1 was asked, Should the floors be stained with dried liquid and dirty, with trash on the floor? She stated, No, we work together with housekeeping and try to clean up spills and pick up the trash. She was asked, Should there be dried enteral feeding on the wall? She stated, No ma'am, it should not. 6. On 01/06/22 at 9:45 am., CNA #2 was asked, Should the floors be stained with dried liquid and dirty, with trash on the floor? She stated, No, we are supposed to clean it up when we see it and housekeeping is supposed to follow up. She was asked, Should there be dried enteral feeding on the wall? She stated, No, it should not. 7. On 01/06/22 at 9:53 am, Licensed Practical Nurse (LPN) #1 was asked, Should the floors be stained with dried liquid and dirty, with trash on the floor? She stated, No, the floors should be kept clean; anything could affect the residents' walking or gait. She was asked, Should there be dried enteral feeding on the wall? She stated, No, it should have been cleaned up. 8. On 01/06/22 at 10:00 am., Housekeeper (HK) #1 was asked, Should the floors be stained with dried liquid and dirty, with trash on the floor? She stated, No, the floors should be kept clean; it depends on how many people are working, how many halls each person has. She was asked, Should there be dried enteral feeding on the wall? She stated, No, it should have been cleaned up. 9. On 01/06/22 at 10:05 am., HK #2 was asked, Should the floors be stained with dried liquid and dirty, with trash on the floor? He stated, No, I work the scrubber and usually do one hall per day; if I have time, I go back with a mop and check. He was asked, Should there be dried enteral feeding on the wall? He stated, No, but once it's dried you can't hardly get it off of the concrete. 10. On 01/06/22 at 10:10 am., the Assistant Director of Nursing (ADON) was asked, Should the floors be stained with dried liquid and dirty, with trash on the floor? She stated, No, not to the point you can see it. She was asked, Should there be dried enteral feeding on the wall? She stated, No, it should have been cleaned up. 11. On 01/06/22 at 1:10 pm, the Administrator was asked, Should the floors be stained with dried liquid and dirty, with trash on the floor? She stated, No, housekeeping will clean it up as they come through; they start in the common areas and then work toward the rooms.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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2. Resident #83 had diagnoses of Chronic Obstructive Pulmonary Disease, Unspecified Atrial Fibrillation and Atherosclerotic Heart Disease of Native Coronary Artery. The quarterly MDS with an ARD of 12/14/2021 documented the resident scored 12 (8-12 indicates moderately impaired) on a BIMS and required extensive assistance of 1 person a. The Care Plan dated as revised 9/21/20 documented, The resident has an ADL self-care performance deficit . Goal Resident will be clean and well-groomed daily . Personal Hygiene: The resident requires extensive assistance with personal hygiene . b. On 01/5/21 at 1:30 p.m., the resident participated in a resident council meeting. When asked about the provision of nail care, the resident lifted her hands to show her fingernails to the surveyor. Her nails were uneven, some with jagged edges, and there was a brownish-black substance under her nails. Resident #33 was also present at the meeting and raised his hands to show his nails to the surveyor. His fingernails were long, extending 1/4 to 1/3-inch past the tips of his fingers and stated, I'd like to have mine cut. I don't like them this long . When asked if nail care was provided regularly, Resident #33 and the other group members described the nail care as, .hit or miss. (Note: Per the MDS with an ARD of 10/22/21, Resident #33 scored 15 on a BIMS (13-15 indicates cognitively intact). 3. On 01/07/22 at 09:18 a.m., CNA #1 was asked, How often is nail care provided for residents? She stated, During showers unless they refuse. 4. On 01/07/22 at 09:19 a.m., CNA #6 was asked, How often is nailcare provided for residents? She stated, Once weekly. 5. On 01/07/22 at 09:20 a.m., CNA #7 was asked, How often is nailcare provided for residents? She stated, Every Sunday or when residents ask. Based on observation, record review and interview, the facility failed to ensure a resident was promptly assisted to change out of soiled clothing and with removal of facial hair to promote good hygiene and grooming for 1 (Resident #80); and failed to ensure nail care was regularly provided to maintain good hygiene and grooming for 2 (Residents #83 and #33) of 5 (Residents #80, #33, #48, #83 and #47 sampled residents reviewed for activities of daily living (ADLs). The findings are: 1. Resident #80 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Muscle Weakness, and Unspecified Dementia without Behavioral Disturbance. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/2021 documented the resident scored 11 (8-12 indicates moderately intact) on a Brief Interview for Mental Status (BIMS), required extensive assistance of one person for dressing and personal hygiene, and was always incontinent of bowel and bladder. a. The Care Plan dated as revised 12/14/21 documented, The resident has an ADL self-care deficit r/t [related to] COPD, malnutrition and weakness . Goal: Resident will be clean and well-groomed daily throughout review date . Dressing: Requires extensive assistance with dressing . Personal Hygiene: The resident requires extensive assistance with personal hygiene . b. On 1/3/22 at 2:03 p.m., Resident #80 was sitting in a Broda chair in her room. Her shirt was soiled from dried foods and liquids, and she had facial hair greater than ½ inch long on her chin. c. On 1/5/22 at 1:30 p.m., the resident was in her room, dozing in her chair. She had on a different shirt, and it was soiled with dried liquids and the facial hair remained unchanged from 1/3/22. d. On 1/6/22 at 9:30 a.m., the resident was sitting in the day room next to the nursing station. Her shirt was soiled with dried liquids and the long hairs remained on her face. e. On 1/6/22 at 9:38 a.m. to 9:50 a.m., during, staff interviews, Certified Nursing Assistant (CNA) #1 and #2 were asked, about clothing changes and female resident' facial hair. Their responses were as follows: .we change them after meals if their clothes are dirty. I shave them when I give showers. They should have on clean clothes anytime they are out of their room. .there are a couple that refuse [to have facial hair removed]. f. On 1/6/22 at 9:53 a.m., Licensed Practical Nurse (LPN) #1 was asked, Should residents have soiled clothes on? She stated, No, they should always have on clean clothes. She was asked, Should the ladies have facial hair? She stated, No, not unless they refuse. g. On 1/6/22 at 10:00 a.m. the Assistant Director of Nursing (ADON) was asked, Should residents have soiled clothes on? She stated, No, they should be taken to their room and cleaned up. She was asked, Should the ladies have facial hair? She stated, No, not to the point that you can see them.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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2. Resident #32 had diagnoses of Coronary Artery Disease Transient Ischemic Attack Hemiplegia or Hemiparesis and Psychotic Disorder. A Quarterly Minimum Data Set with an Assessment Date of 10/20/21 documented the resident scored 11 (8-12 indicates moderate impairment) on a Brief Interview for Mental Status and required extensive assistance of 2 plus persons for bed mobility and transfer. a. The Care Plan dated as revised 8/18/21 documented, The resident is at risk for falls r/t [related to] impaired mobility, hemiplegia to left side, cognitive deficit, and psychotropic medications . Keep personal items within reach . Anticipate and meet the resident's needs . b. On 01/03/22 at 11:13 am, during initial rounds, 4 power cords were hanging out of drawers and plugged into a power strip in the resident's room. The power strip was plugged into a wall outlet. A white television cable was attached to the wall and was wadded up with the other cords. A Karaoke machine sitting on the floor had the power cord wrapped around it and the microphone cord was running across the floor in front of the bathroom door and hanging from the foot of the roommate's bed. c. On 01/03/22 at 12:30 pm, the resident was lying in bed. He was asked what all the power cords were. He stated, My phone, my television and the Christmas tree. He was asked what the black thing in the floor was and he stated, My Karaoke machine. I guess that cord running across the floor is an accident waiting to happen. d. On 01/03/22 at 1:00 pm, the Maintenance Director was asked if he would accompany the surveyor to the resident's room. He was asked if the extension cords hanging down were a hazard. He stated, Yes, and that Karaoke cord is a tripping hazard. I'll fix that right away. e. A policy and procedure from the Emergency Preparedness Book, provided by the Administrator on 01/06/22 at 3:03 pm, documented, .d. Electrical receptacles and circuits will not be overloaded . Based on observation, record review, and interview, the facility failed to ensure medication was not left unsecured and unattended to prevent potential access by cognitively impaired residents for 1 (Resident #69) of 7 (Residents #64, #69, #240, #24, #60, #68, and #45) sampled residents who received medications from Licensed Practical Nurse (LPN) #2. The facility also failed to ensure the walkway in a resident's room was free of electrical cords to prevent potential falls and the power outlets in the room were not overloaded to prevent potential fire for 1 (Resident #32) of 1 case mix resident who had multiple electrical cords in his room. The findings are: 1. Resident #69 had diagnoses of Parkinson's Disease and Generalized Muscle Weakness. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of 10/28/21 documented the resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status. a. A physician order dated 10/19/21 on the January 2022 Physician Orders list documented, Calcium Carbonate 200 mg [milligram] calcium (500 mg) Oral chewable tablet Give 1 tablet by mouth two times a day . b. On 01/04/22 at 8:39 AM, the resident was resting in bed, eyes closed. A white medication cup was sitting on the resident's bedside table with 2 dime-sized, cream-colored tablets in it. c. On 1/04/22 at 9:49 AM, Licensed Practical Nurse (LPN) #3 accompanied the surveyor to the resident's room. The resident was resting in bed with his eyes closed, the medication cup with the tablets were on the bedside table, next to the resident's bed. The LPN was asked, What's in the medication cup? She replied, It appears to be Tums. The LPN was asked, Should medication be left unattended on the resident's bedside table? She replied, No. She was asked, Why? The LPN replied, Because there's the risk of another resident getting it and taking that medication. d. The January 2022 Medication Administration Record documented, Calcium Carbonate 200 mg calcium (500 mg) Oral chewable tablet give 1 tablet by mouth two times a day. The 8:00 a.m. dose for 1/4/22 was initialed as administered by LPN #2. e. On 1/5/22 at 10:33 AM, the Director of Nursing (DON) was asked, When nurses are administering medications to the residents, is it permitted to leave the medication unattended on the resident's bedside table? She stated, No, there's a risk for other residents to take it. f. On 1/7/22 at 8:15 AM, LPN #2 was asked, On 1/4/22, did you administer 8:00 AM medications to [Resident #69]? She replied, Yes, I did. The LPN was asked, Did you leave medication in a cup on his bedside table? She replied, Yes. The LPN was asked, What was the medication? She stated, Tums. The LPN was asked, Should medication be left unattended on the resident's bedside table? She replied, No. She was asked, Why? The LPN replied, Other residents will have access to the medication and may take it. g. The facility's Medication Administration Policy, provided by the Assistant Director of Nursing on 1/6/22, documented, .Remain with resident/patient until all medication is taken .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets, as documented on a list provided by the Dietary Supervisor on 1/6/2022. The findings are: 1. On 1/05/22 at 3:58 PM, Dietary Employee #2 used a #8 scoop (4 ounces) to place 8 servings of carrots into a blender to puree, then poured the pureed carrots into a pan. The consistency of the pureed carrots was not formed. It was runny. 2. On 1/05/22 at 4:17 PM, Dietary Employee #1 used a #8 scoop to place 7 single servings of lasagna into a blender to puree. She poured the pureed lasagna into a pan, covered the pan with foil and placed it in the oven. The consistency of the pureed lasagna was lumpy and not smooth. 3. On 01/05/22 at 4:47 PM, Dietary Employee #3 placed 10 servings of dinner rolls into a blender, added warm milk and pureed. She poured the pureed dinner rolls into a pan. The consistency of the pureed dinner rolls was thick and not smooth. There were pieces of bread still visible in the mixture. 4. On 1/05/22 at 6:47 PM, Dietary Employee #2 was asked to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, Pureed lasagna needs to be pureed more. It was gritty. Pureed bread was thick 5. On 1/05/22 at 7:07 PM, Dietary Employee #3 was asked to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, You can see bread through it. It needs to be pureed more. Pureed carrots have liquid in it. It could have been a little thicker and pureed lasagna was gritty. It needs to be pureed more.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0885 (Tag F0885)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to ensure residents and their representatives were informed of a COVID-19 positive resident by 5:00 p.m. the next calendar day following positive COVID-19 tests for 4 (Residents #3, #4, #5 and #6) of 4 sampled residents who tested positive for COVID-19. The failed practice had the potential to affect all 95 residents, as documented on the Alphabetical Census provided by the Clinical Consultant on 1/24/22 at 2:00 PM. The findings are: 1. A COVID-19 positive residents list provided by the Infection Preventionist on 1/24/22 at 3:30 PM documented Resident #5, Resident #6 and 11 other residents tested positive for COVID-19 on 1/14/22; and Resident #3, Resident #4 and 16 other residents tested positive on 1/18/22. 2. On 1/26/22 at 11:15 AM, the Administrator was asked, What method do you use to inform residents, their representatives, and families of COVID-positive residents? She stated, We use [Notification Software]; it sends out messages to all the families and then Social tells all the residents. She was asked, When are these notifications sent out? She stated, When we have positive residents. She was asked, How often do you send updates? She did not answer. She was asked, On 1/14/22, you had an outbreak with 13 residents testing positive. Were the families notified? After looking at computer, she stated, No. She was asked if the families were notified after the outbreak on 1/18/22 when 18 residents tested positive. She stated, I was out; apparently not.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected most or all residents

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Based on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. These failed practices had the potential to affect 6 residents who received pureed diets, 24 residents who received mechanical soft diets and 59 residents who received regular diets from the kitchen (total census: 91), according to a list provided by the Dietary Supervisor on 1/6/2022. The findings are: 1. On 1/5/2022, the menu for the supper meal documented the residents on regular diets and mechanical soft diets were to receive a slice of lasagna and residents on pureed diets were to receive 8 ounces (oz) of lasagna each. a. On 1/05/22 at 5:43 PM Dietary Employee #2 used a #8 (4-ounce) scoop to serve a single portion of pureed lasagna to the residents on pureed diets. At 6:51 PM she was asked how many residents received pureed diets. She stated, We have 5 residents, but I used a #8 scoop (4 ounces) to put 7 servings of lasagna in the blender and pureed. She was asked, What scoop size did you use to serve pureed lasagna? She stated, I used a #8 scoop and I gave a single serving of pureed lasagna to every resident on a pureed diet. I should have used an 8-ounce spoon. She was asked how many servings of pureed lasagna were left in the pan at the end of the meal service. She stated, There were 3½ left in the pan. b. On 1/05/22 at 6:38 PM, the kitchen ran out of lasagna for the residents on regular and mechanical soft diets. Dietary Employee #1, who was sorting tray cards, was asked how many residents were left to be served. She stated, We have 7 residents left to be served. At 7:04 PM, seven residents were served baked chicken, macaroni salad and vegetable blend. On 01/05/22 at 7:05 PM, Dietary Employee #2 was asked, How many residents receive meal trays from the kitchen. She stated, We feed 90 residents. She was asked, How many servings of lasagna did you prepare for supper? She stated, I made 3 pans. I thought I did enough lasagna for everybody.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure food was prepared by methods that maintained flavor and meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 2 meals observed. The failed practices had the potential to affect 89 residents who received meal trays from the kitchen (total census: 91), as documented on a list provided by the Dietary Supervisor on 1/6/2022 at 11:10 AM. The findings are: 1. Resident #27 had diagnoses of Bipolar Disorder, Unspecified Dementia with Behavioral Disturbance, Delusional Disorders and Anxiety Disorder. The quarterly Minimum Data Set, dated [DATE] documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). On 01/03/22 at 12:09 pm, Resident #27 stated, The food is always cold, especially in the mornings. This morning I had 2 runny eggs, yuck! Even the plates are cold. 2. Resident #32 had diagnoses of Coronary Artery Disease Transient Ischemic Attack, Hemiplegia or Hemiparesis and Psychotic Disorder. A Quarterly MDS with an ARD of 10/20/21 documented the resident scored 11 (8-12 indicates moderate impairment) on a BIMS. On 01/03/22 at 12:12 pm, Resident #32 was asked how the food tastes. He stated, The food is bland and doesn't have any taste to it. Lunch and supper are the worst; in fact, for supper last night, I don't even know what to call what we had. 3. Resident #82 had diagnoses of Type 2 Diabetes Mellitus with Hyperglycemia, Hypo-Osmolality and Hyponatremia. The admission MDS dated [DATE] documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS. and was independent with eating. On 1/03/22 at 2:52 pm, Resident #82 was asked how the food tastes and she stated, The food is horrible and cold. In the dining room, it's warm, but if you eat in your room then the food is always cold. They serve the same thing, rice, corn, green beans over and over. We get soup over and over. I never receive a menu, so I don't know what we are having or what the alternatives are, if we even have alternatives. I never receive salt and pepper or condiments with sandwiches. It's hard to eat a plain sandwich. 4. Resident #33 had diagnoses of Human Immunodeficiency Virus (HIV), Cirrhosis of the Liver, Unspecified Protein-Calorie Malnutrition and Anxiety Disorder. The quarterly MDS dated [DATE] documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS. On 1/5/21 at 1:30 PM during the resident council meeting, the resident described the food as ice cold and stated, The food is cold if you eat in the dining room or if you eat in your room . 5. On 01/06/22 at 07:26 AM, an unheated cart that contained 13 breakfast trays for the 100 and 400 Halls was delivered to the 100 Hall by Nursing Assistant (NA) #4. At 7:35 AM, the cart was delivered to the 400 Hall by NA #4. At 7:43 AM, immediately after the last resident received a tray in their room on the 400 Hall, the temperatures of the food items on a test tray from the cart were checked and read by the Dietary Supervisor with the following results: a. Milk: 50 degrees Fahrenheit. b. Sausage patty: 80 degrees Fahrenheit. 6. On 1/06/22 at 7:42 AM, an unheated cart that contained 13 trays for breakfast was delivered to the 200 Hall. At 7:56 AM immediately after the last resident received a tray from the 200 Hall cart, the temperatures of the food items on a test tray from the cart were checked and read by the Dietary Supervisor with the following results: a. Milk: 45 degrees Fahrenheit. b. Scrambled eggs: 100 degrees Fahrenheit. c. Sausage patty: 94 degrees Fahrenheit. d. Ground sausage: 96 degrees Fahrenheit. e. Pureed bread with milk: 95 degrees Fahrenheit. 7. On 1/06/22 at 7:55 AM, an unheated cart that contained 10 trays for breakfast was delivered to the 300 Hall. At 8:29 AM, immediately after the last resident received a tray in their room on 300 Hall, the temperatures of the food items on a test tray from the cart were checked and read by the Dietary Supervisor with the following results: a. Milk: 52 degrees Fahrenheit. b. Pureed sausage: 88 degrees Fahrenheit. c. Oatmeal: 105 degrees Fahrenheit. d. Scrambled eggs: 108 degrees Fahrenheit. e. Sausage patty: 88 degrees Fahrenheit. 8. On 1/06/22 at 08:00 AM, an unheated cart that contained 10 trays for breakfast was delivered to the front 500 Hall. At 8:20 AM, immediately after the last resident received a tray in their room on the front 500 Hall, the temperatures of the food items on a test tray from the cart were checked and read by the Dietary Supervisor with the following results: a. Scrambled eggs: 105 degrees Fahrenheit. b. Oatmeal: 99 degrees Fahrenheit. 9. On 1/06/22 at 8:28 AM, an unheated cart that contained 15 trays for breakfast was delivered to the back 500 Hall by Certified Nursing Assistant (CNA) #5. At 8:45 AM, immediately after the last resident received a tray in their room on the back 500 Hall, the temperatures of the food items on a test tray from the cart were checked and read by the Dietary Supervisor with the following results: a. Milk: 48 degrees Fahrenheit. b. Pureed sausage: 109 degrees Fahrenheit. c. Regular sausage: 109 degrees Fahrenheit. d. Pureed bread with water: 91 degrees Fahrenheit. e. Sausage patty: 88 degrees Fahrenheit. 10. On 1/06/22 at 08:58 AM, an unheated cart that contained 30 trays for breakfast was delivered to the 600 Hall by CNA #1. At 9:09 AM, immediately after the last resident received a tray in their room on the 600 Hall, the temperatures of the food items on a test tray from the cart were checked and read by the Dietary Supervisor with the following results: a. Milk: 52 degrees Fahrenheit. b. Scrambled eggs: 109 degrees Fahrenheit. c. Ground sausage: 108 degrees Fahrenheit. d. Sausage patty: 104 degrees Fahrenheit.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 89 residents who received meals from the kitchen (total census: 91), as documented on a list provided by the Dietary Supervisor on 1/6/2022. The findings are: 1. On 1/05/22 at 3:09 PM, Dietary Employee #1 was wearing gloves on her hands when she pushed a cart out of the way in the dishwashing room. Without changing gloves and washing her hands, she picked up clean dishes and stacked them on a cart on the clean side of the dishwashing machine. 2. On 1/05/22 at 3:15 PM, Dietary Employee #2 had gloves on her hands when she opened the refrigerator door and removed a bag of shredded cheese and then closed the refrigerator door. She untied the bag of cheese and placed it on the counter. She removed shredded cheese from the bag with the same gloved hands and sprinkled the cheese on top of the lasagna in a pan on the counter. At 3:18 PM, she placed the pan of lasagna in the oven to be served to the residents for the supper meal. 3. On 1/05/22 at 3:34 PM, Dietary Employee #2 turned on the sink faucet, obtained water in a pitcher and poured it into a pan on the stove. She then turned off the faucet with her bare hand. Without washing her hands, she removed gloves from a glove box and placed them on her hands, contaminating the gloves in the process. She picked up vegetable blend from the original box and placed them in a pan of water on the stove to cook for the supper meal. 4. On 1/05/22 at 3:43 PM, Dietary Employee #2 wore mittens over the gloves on her hands. She opened the oven with mittens on her hands, removed a pan of lasagna and placed it on the counter. She removed the mittens from her hands and put them away. With the same gloves on her hands, she removed shredded cheese from the bag of cheese and sprinkled it on top of the lasagna to be served to the residents for the supper meal. She then placed the pan of lasagna in the oven. 5. On 1/ 05/22 at 3:50 PM, Dietary Employee #1 had gloves on her hands when she opened the refrigerator door and removed pitchers that contained tea and punch and placed them on the counter. Without changing gloves and washing her hands, she picked up glasses by the rims and placed them on the counter. She poured beverages in the glasses to be served to the residents with their supper meal. 6. On 1/05/22 at 3:59 PM, Dietary Employee #1 pushed a cart that contained 3 pitchers towards the sink. She turned on the water faucet with her bare hand and filled the pitchers with water, then turned off the faucet. She picked up gloves and placed them on her hands, contaminating the gloves in the process. She picked up glasses by the rims and poured beverages to be served to the residents for the supper meal. Dietary Employee #1 was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 7. On 1/05/22 at 4:02 PM, Dietary Employee #2 used a dish towel to wipe off particles of food items that spilled on the cart. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets for the supper meal. When she was ready to place foods into the blender to puree, she was stopped and was asked what she should have done after touching dirty objects and before handling clean equipment. She stated, Wash my hands. The Dietary Supervisor instructed her to wash the blender and blade.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No fines on record. Clean compliance history, better than most Arkansas facilities.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
• 31 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• Grade F (33/100). Below average facility with significant concerns.
• 64% turnover. Above average. Higher turnover means staff may not know residents' routines.

Bottom line: Trust Score of 33/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is The Springs Batesville's CMS Rating?

CMS assigns THE SPRINGS BATESVILLE an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Arkansas, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is The Springs Batesville Staffed?

CMS rates THE SPRINGS BATESVILLE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 64%, which is 18 percentage points above the Arkansas average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 60%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at The Springs Batesville?

State health inspectors documented 31 deficiencies at THE SPRINGS BATESVILLE during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 30 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates The Springs Batesville?

THE SPRINGS BATESVILLE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by THE SPRINGS ARKANSAS, a chain that manages multiple nursing homes. With 150 certified beds and approximately 94 residents (about 63% occupancy), it is a mid-sized facility located in BATESVILLE, Arkansas.

How Does The Springs Batesville Compare to Other Arkansas Nursing Homes?

Compared to the 100 nursing homes in Arkansas, THE SPRINGS BATESVILLE's overall rating (2 stars) is below the state average of 3.1, staff turnover (64%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting The Springs Batesville?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.

Is The Springs Batesville Safe?

Based on CMS inspection data, THE SPRINGS BATESVILLE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Arkansas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at The Springs Batesville Stick Around?

Staff turnover at THE SPRINGS BATESVILLE is high. At 64%, the facility is 18 percentage points above the Arkansas average of 46%. Registered Nurse turnover is particularly concerning at 60%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was The Springs Batesville Ever Fined?

THE SPRINGS BATESVILLE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is The Springs Batesville on Any Federal Watch List?

THE SPRINGS BATESVILLE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 150
Avg. Residents: 94
Occupancy: 62.7%
Ownership: For profit - Corporation
Chain: THE SPRINGS ARKANSAS
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
High Turnover: -5
1 Immediate Jeopardy citation: -12
31 Deficiencies: -10
Final Score: 33/100

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 045203