Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to privacy as evidenced by a resident who was visible on a video that was posted to a staff member's personal social media account without her consent for one (1) of four (4) sampled residents. Resident #1. Findings include: Review of the facility's policy, Resident Photographs/Videos, revised 2/14/23, revealed, Policy: Taking photographs and/or videos of residents or their personal belongings is a violation of residents' rights to privacy and confidentiality. Policy Explanation and Compliance Guidelines: 1. All photographs or videos of residents will only be taken by an employee having written authorization from the Administrator as indicated below .3. No employees will post pictures, videos, comments, etc., on social media that pertains to anyone within this facility . A record review of the Activity Photograph/Outing Release, dated 5/3/22, revealed Resident #1 signed an Activity Photograph Release which indicated, .For the use of photos, names and/or social information for TV, radio, newspaper articles, facility newsletter, etc . each Resident or Responsible Party will be required to sign a consent form or give verbal consent per phone for each occasion . On 7/1/24 at 11:12 AM, during an interview with Resident #1, she was able to communicate using a note pad. She wrote that to her knowledge the facility had not posted any photos or videos of herself on social media. She indicated she had not signed any recent consents allowing pictures or videos other than the one she signed when she was admitted to the facility in 2022. Resident #1 also indicated that she would not like it much if the facility staff posted a video on their personal social media in which she was in the background. On 7/1/24 at 1:00 PM, during an interview with the Business Office Manager (BOM), she confirmed on 5/15/24, a video was taken of two staff members dancing during nursing home week. Resident #1 was in the background, and she posted it on personal social media. She said she did not realize Resident #1 was visible in the background because when she posted the video, she was more concerned about the staff members being so cute in the video dancing. The BOM stated that she knew posting residents on social media was against facility policy because of resident rights and confidentiality. On 7/1/24 at 1:15 PM, during an observation of the video posted to the BOMs social media, there were two (2) facility staff members dancing and Resident #1 was visible in the background. The video was approximately 5 seconds long. On 7/2/24 at 10:33 AM, during an interview with the Administrator, he confirmed there was a video on the BOM's social media in which Resident #1 was visible in the background. He said it occurred during nursing home week and it was an accident because the staff should have been the only ones to be recorded, but the resident rolled by in her wheelchair into the view of the camera. The Administrator revealed that it was not the facility's policy to have residents on facility staff members personal social media pages and that all residents have the right to privacy and confidentiality. A record review of the admission Record revealed the facility admitted Resident #1 on 05/03/2022 and she had current diagnoses including Deaf Nonspeaking. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact.

Based on interview and record review the facility failed to accurately code the Minimum Data Set (MDS) related to a resident who was discharged to home but was coded as discharging to another facility for one (1) of 17 sampled residents. Resident #58 Findings include: A record review of the Physician's Telephone Orders revealed Resident #58 had a Physician's Order, dated 2/7/24, for May discharge home with home health and medication. A record review of the Discharge MDS with an Assessment Reference Date (ARD) of 2/7/24 revealed Resident #58 had an unplanned discharge to an Intermediate Care Facility. A record review of the Face Sheet revealed the facility admitted Resident #58 on 2/6/24 and he was discharged on 2/7/24. He had diagnoses including Altered Mental Status. On 5/9/24 at 8:50 AM, in an interview with Registered Nurse (RN) #1/MDS nurse, she acknowledged Resident #58 was coded as being discharged to an intermediate care facility in error because he was discharged to home. On 5/9/24 at 9:00 AM, in an interview with the Director of Nursing (DON), she acknowledged the MDS was inaccurately coded to reflect Resident #58 had an unplanned discharge to a facility when he had a discharge to home. The DON reported her expectation was for the MDS to be accurate.

Based on interviews, record review, and facility policy review the facility failed to ensure residents quality of life was maintained as evidenced by the facility's failure to provide a clean and comfortable homelike environment, including clean, blood free linens for one (1) of 17 sampled residents. Resident # 32 Findings include: A record review of the facility's policy Safe and Homelike Environment, revised 2/12/2023 revealed . In accordance with resident's rights, the facility will provide a safe, clean, comfortable, and homelike environment .Policy Explanation and Compliance Guidelines .4. The facility will provide and maintain bed and bath linens that are clean and in good condition . On 5/6/24 at 11:30 AM, in an interview, Resident #32 complained he had gotten blood on his bed sheets and gown when he had a procedure for an intravenous (IV) line. He said he had to sleep on sheets and in a gown that had blood on them. On 5/6/24 at 12:40 PM, during an interview with Licensed Practical Nurse (LPN)#1, she explained she did not remember Resident #32's sheets and gown having blood on them, but she only took off the black compression wrap and did not go back into the resident's room that evening. On 5/6/24 at 3:20 PM, during an interview with Certified Nurse Aide (CNA) #4, she reported she did not remember what time it was, but when she went to obtain Resident #32's vital signs, she saw some blood on his bed sheet and gown. She stated she was not assigned to care for Resident #32 that evening and she forgot to tell his aide or nurse about the blood on the sheets. She said she thought someone would see it. On 5/7/24 at 1:00 PM, during an interview with the Ombudsman, she explained Resident #32 complained to her today that he had to lay in a bloody gown and bloody sheets overnight this past weekend until a nurse came in to change the midline dressing and changed his sheets and gown. On 5/8/24 at 9:00 AM, during an interview with Registered Nurse (RN) #2, she explained she worked on 5/4/24 and 5/5/24 as the weekend supervisor the past weekend. She reported on 5/4/24, Resident #32 had a line inserted around 3:00 PM. She left at 3:30 PM and did not observe the resident after the procedure was completed. She stated on the morning of 5/5/24, she observed Resident #32 and changed the dressing for the line. She confirmed the resident's draw sheet and gown had dried blood and she had to change his sheets and his gown. She explained his sheets and gown should have been changed when they became soiled with blood. Resident #32 reported to her that he had asked a LPN and CNA to change his sheets and gown because of the blood, but no one changed them. At 1:00 PM on 5/9/24, during an interview with the Director of Nursing (DON), she explained she expected staff to change resident's sheets and gown and to not allow a resident to lay in soiled linens overnight. At 4:00 PM on 5/9/24, during an interview with the Administrator, he explained he expected all linens to be clean for residents. A record review of the Face Sheet revealed the facility admitted Resident #32 on 12/3/19 with current diagnoses including Hemiplegia Following Cerebral Infarction Affecting Left Nondominant Side. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 2/22/24 revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. A record review of the Departmental Notes revealed Resident #32 had a Nurse Notes, dated 5/5/24 10:58 AM for . Resident had midline insertion done as ordered on 05/04/24 . Dressing to midline insertion site soiled with blood due to procedure .Dressing changed per sterile technique .

Based on interviews, record review, and facility policy review, the facility failed to implement the use of a sign language interpreter during clinical appointments for a resident who was deaf, which increased the risk of not having the resident's needs met and experiencing a possible decline in the physical and psychosocial well-being and quality of life for one (1) of 17 sampled residents. Resident #40 Findings include: A record review of the facility's document A Matter of Rights A Guide to Your Rights and Responsibilities as a Resident with a copyright date of 2020, revealed . No Discrimination: You have the right to fair and equal treatment . we will not treat residents differently based on .their medical diagnosis .We will meet all applicable rules requiring that we make available free communication aids and services, for example, by providing translation services or other language assistance . On 05/07/24 at 10:30 AM, Resident #40 attended the resident council meeting and the facility's Speech Therapist (ST) assisted her with communication during the meeting. Resident #40 complained she had missed medical and dental appointments because she did not have an interpreter to assist her with communicating with the providers at the clinics. She was unsure if the facility had rescheduled the appointments at this time. The ST reported that if she were made aware in advance, she would attend the appointments with the resident to assist in communicating with the providers. A record review of the Departmental Notes revealed Resident #40 had a Nurse Notes dated 4/18/24 at 8:39 PM for (Proper Name) office from Gastroenterology .called to reschedule a follow up appointment for resident. He was unaware she is deaf and needs an interpreter. He stated he will call us back with a time once he has an interpreter scheduled . A Nurse Notes, dated 4/16/24 at 11:14 AM, revealed, . Called for an update on referral sent to (Proper Name) for teeth extraction . This nurse informs . that resident is deaf and will need an interpreter available . will get in contact with that service and states that when an interpreter is required that the clinic is at the mercy of them . A Nurse Notes, dated 4/6/24, revealed, . late entry 4/5/24: Resident left for cardiology appt (appointment) on 4/5/24 at 1100 (11:00 AM) and returned at 15:30 (3:30 PM). Resident was unable to see cardiologist D/T (due to) no interpreter for resident .New appt scheduled for 4/25/2 at 1300 (1:00 PM) .A translator has been schedule for that appt . At 11:50 AM on 05/09/24, during an interview with the facility's Nurse Practitioner (NP), she stated she was unaware Resident #40 had missed gastroenterology, dental, and cardiology appointments. She explained the appointments were very important for Resident #40's health and well-being and she should not have missed appointments due to not having an interpreter. At 12:00 PM on 05/09/24, during an interview with the Director of Nursing (DON), she explained she was unaware Resident #40 had missed appointments due to not having an interpreter and stated the facility's transportation driver knew sign language and could have assisted with communication during the appointments. The DON said she thought Resident #40 had an application (app) on her phone to help with interpretation and was unaware she could or would not use the phone app when she went to appointments. The DON also stated she thought the clinics provided their own interpreters for appointments and was not aware it was the facility's responsibility. The DON reviewed the departmental notes that were documented by the nurses in the medical record and confirmed she was not aware Resident #40 had missed appointments for gastroenterology, dental, and cardiology due to not having an interpreter. The DON commented that she had not thought about the resident needing an interpreter for appointments. At 12:15 PM on 05/09/24, during an interview with Licensed Practical Nurse (LPN) #3, she explained she was not aware it was the facility's responsibility to provide an interpreter for appointments. LPN #3 stated Resident #40 had mouth pain, was treated for an abscessed tooth, completed antibiotics, and went to the dentist for a tooth extraction. However, the provider could not communicate with the resident and the tooth was not extracted. She said Resident #40's daughter was notified that the resident needed an interpreter before she could have the tooth extracted. LPN #3 confirmed Resident #40 had a dental appointment rescheduled for a tooth extraction on 5/30/24 and there was no indication that appointments had been rescheduled for cardiology and gastroenterology. At 1:00 PM on 05/09/24, during an interview with Certified Nurse Aide (CNA) #2, she explained she was the transportation aide and assisted with driving and attending appointments. CNA #2 confirmed Resident#40 had not been seen at appointments because there was no interpreter available. She explained she had not been asked to perform sign language for the resident and stated that although she knew a little sign language, she did not feel she knew it well enough to communicate with providers at appointments. She stated Resident #30 had not used her phone app while at appointments. At 3:30 PM on 05/09/24, during an interview with the Administrator, he explained he expected residents to attend scheduled appointments and the staff to ensure residents had everything in place prior to the appointment. Record review of the Face Sheet revealed the facility admitted Resident #40 on 5/3/22 with current diagnoses including Deaf Nonspeaking. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/24 revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Section B indicated Resident #40 was coded for No speech-absence of spoken words. Review of the medical record revealed there was no documentation that Resident #40 attended the rescheduled appointment for the cardiologist on 4/25/24 at 1:00 PM.

Based on resident and staff interviews, record review, and the facility policy review, the facility failed to secure a resident in the facility van during transport for one (1) of two (2) residents reviewed for accidents. (Resident #43) Findings Include: Review of the facility's policy, Incident and Accidents, dated 5/13/2023, revealed, .It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur . Review of the facility's Fall Prevention Policy, dated 2/20/23, revealed, .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . Review of the Resident Incident Report for Resident #43, dated 10/4/23, revealed the facility investigated the incident and the Narrative of incident and description of injuries indicated the transporter stated that resident was strap in place in wheelchair and upon taking off in the van the resident chair flipped over backwards and resident stated he hit his head no injuries noted except where resident stated he hit his head but no ap-preat (sic) injury noted on head . An interview with Resident #43 on 5/6/24 at 12:41 PM, revealed his wheelchair had overturned in the facility's transportation van on the return trip from a doctor's office visit last year. Resident #43 stated he must not have been strapped down properly because his wheelchair turned over backwards as the driver put her feet on the gas. He said that he did not touch the straps. He explained the van driver had connected the strap to the wheelchair wheels, but he was unable to see exactly what was going on at the bottom of the wheelchair. He stated that he did not want to go to appointments in the van since the fall occurred, so the facility took him to appointments in the company car with a different driver. During an interview on 5/7/24 at 11:30 AM, with Certified Nursing Aide (CNA) #2, she stated that on 10/4/23, she had strapped Resident #43 into the facility's van and had checked to ensure he was secure. CNA #2 said she had accelerated the gas and the resident's wheelchair overturned and he fell backward onto the floor of the van. CNA #2 explained that she immediately stopped the van to check on the resident and noted the front right belt and the seat belt were not connected. CNA #2 was unsure how the belts could have come apart unless the resident had released them. CNA #2 stated that she notified the facility immediately, assisted the resident back in the wheelchair, and made sure the straps were connected. When the resident arrived at the facility, he was checked by the nurses. During an interview on 5/8/24 at 12:45 PM, with the Director of Nursing (DON), she confirmed Resident #43 had a fall in the transportation van in October 2023. The DON confirmed she had completed the investigation and had interviewed CNA #2 who indicated that she had checked the straps in the van to ensure the resident was secured prior to leaving the doctor's office. The DON stated CNA #2 said the wheelchair overturned when she accelerated the gas to leave the doctor's office. CNA #2 brought the resident back to the facility where he was assessed and found to have no injuries. During the investigation, the DON interviewed Resident #43 and he stated he had hit his head, but he was fine and the resident confirmed the CNA had secured the straps to his wheelchair. The DON and the Maintenance Tech checked the straps on the van to ensure they were working properly, and they found no issues. The DON explained that she and the previous Administrator did not suspect negligence regarding securing the straps to the wheelchair and she believed Resident #43 may have removed the seat belt and the right front strap from the wheelchair himself. During an interview on 5/09/24 at 02:32 PM, with the Maintenance Tech, he confirmed he had checked the straps on the transportation van when the resident returned after he had fallen in October and did not find any faulty equipment. A record review of the Face Sheet' revealed the facility admitted Resident #43 on 7/25/23 with current diagnoses including Cerebral Palsy. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/17/24 revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively Intact

Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to have sufficient staff to assemble meal trays timely to prevent meals from being served late and cold for three (3) of four (4) days of survey. Findings include: Review of the facility's policy, Dietary Services-Staffing, revised 7/21/23, revealed, .The facility employs sufficient staff with the appropriate competencies in skill sets to carry out the functions of the Food and Nutrition Services, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment .Policy Explanation and Compliance Guidelines for Staffing .6. The facility will provide sufficient support personnel to carry out the supportive functions of the Food and Nutrition Services. These functions include .a. Safe and timely meal preparations . During an observation of the kitchen on 5/6/24 at 10:00 AM, the Dietary Manager (DM) and a Dietary Aide were present in the kitchen. The DM explained she was working as the cook today because the kitchen was short-staffed, and she had around half the staff out that was required to operate the dietary department. This was due to staff sickness and staff resignations. The DM said that although the kitchen was short of staff, all the functions of the kitchen services were expected to be carried out by the two members that were working and they were doing their best but could only do so much with little staff. During an observation and interview on 5/7/24 at 07:30 AM, the DM was the only staff member working in the kitchen and was cooking lunch and washing the breakfast dishes. The DM explained the Dietary Aide that was scheduled to work had called in due to sickness, but Dietary Aide #1 was coming in at 9:00 AM to assist. During an observation of the kitchen on 5/7/24 at 11:45 AM, there were two (2) nurses assisting in the kitchen by drying the trays and wrapping the silverware in napkins. Dietary #1 began plating the food according to the dietary slips and all the food was on the trays at 12:00 PM. The DM added the drinks to the trays, and they were ready at 12:15 PM. The meal trays were passed out to the residents at 12:25 PM. While trays were being served, there were several residents who asked the kitchen to re-warm their food. The last meal cart for the hall trays was sent out at 12:35 PM. The nurse checked the trays and dietary slips and the cart arrived at the hall at 12:45 PM. The last tray was delivered to a resident at 12:55 PM. During an observation and interview on 5/8/24, the hall trays arrived at F-hall arrived at 6:30 PM. The residents complained the food was cold. Resident #109 complained the Mexican rice was cold and the hamburger meat on the taco salad was cold. Resident #109 said she does not like cold hamburger meat or cold rice. Review of the facility's, Mealtimes revealed Breakfast was served from 7:30 AM to 7:45 AM, Lunch 11:30 AM to 11:45 AM and Dinner 5:30 PM to 5:45 PM. During an interview on 5/6/24 at 11:00 AM, Certified Nursing Aide (CNA) #1 stated that the residents complained most of the time that the food was cold. She explained to the residents that the kitchen had one (1) person working several times a week. During the resident council meeting on 5/7/24 at 10:00 AM, the residents stated the food was cold most of the time because the facility did not have enough staff working in the kitchen. The residents also complained the food was late being served, especially at dinner. During an interview on 5/8/24 at 9:00 AM, Dietary #2 stated the facility needed to hire more dietary aides because it was difficult setting up meals and washing dishes and she had been working a lot of hours trying cover for not having staff. During an interview on 5/8/24 at 9:30 AM, Dietary #3 stated the facility was short-staffed and the current staff had to work extra hours until the facility could get some help. During an interview on 5/8/24 at 9:45 AM, the DM said she had openings for three (3) cooks and four (4) dietary aides. She confirmed the residents had been complaining that the food was cold. During an interview on 5/8/24 at 10:00 AM, the Administrator confirmed the facility had been short of kitchen staff and he was trying to recruit cooks and dietary aides.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide resident meals at an appetizing temperature for two (2) of two residents reviewed for food. Resident #32 and Resident #109. This had the potential to affect all residents who receive meals from the kitchen. Findings include: A record review of the facility's policy, Food and Nutrition Services, revised 10/2017, revealed . Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs .Policy Interpretation and Implementation: . 7. Food and nutrition services staff will inspect food trays to ensure .the food .is served at a safe and appetizing temperature . Resident #32 On 05/06/24 at 11:35 AM, during an interview with Resident #32, he complained the food was served cold daily at all meals. On 5/07/24 at 12:15 PM, during an observation, the facility staff were in the dining room with the meal tray carts and were reviewing trays. One (1) cart had six (6) trays and one (1) cart and nine (9) trays. The carts were open carts and the trays had insulated plate covers used on the plates. The first cart with nine (9) trays went to the floor at 12:19 PM for the A and B hall. A cart with three (3) trays went to the floor at 12:20 PM for E hall. A cart with six (6) trays went to A and B hall at 12:22 PM and the last tray was removed at 12:27 PM. At 12:29 PM Resident #32 received his lunch tray and he had a fork in his silverware. He asked Certified Nurse Aide (CNA) #6 to bring him a spoon and since she was still delivering trays, she asked a nurse to provide him with a spoon. Resident #32 received a spoon at 12:35 PM, and complained the food was cold and requested staff to take the food back and warm it up. Resident #32's meal included chopped meat, green beans, and a baked potato on his meal tray. On 5/07/24 at 2:00 PM, during an interview with CNA #6, she explained residents had complained about cold food for several months and some residents had requested food to be rewarmed. She confirmed Resident #32 had asked for his food to be rewarmed. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 2/22/24 revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Resident #109 During an interview on 5/6/24 at 10:36 AM, Resident #109 complained the food was cold and explained that she often had to ask the staff to warm it up. In an interview on 5/6/24 at 11:00 AM, with CNA #1, she stated the residents complain most of the time about the food being cold. She said she explained to the residents that the kitchen only had one person working several times a week. An observation of a test tray and interview with the Dietary Manager (DM) on 5/7/24 at 1:00 PM, revealed temperature of the baked potato was 118, the meat was 103, and the green beans were 101, and the food was lukewarm when tasted. The DM reported she had problems with residents complaining the food was cold and explained it took the staff a long time to get the food to the residents. She confirmed she currently had staffing challenges in the kitchen, and she was training a new cook. She also confirmed she had attended resident council meetings where there had been complaints about cold food, and she was working to correct the situation. On 5/8/24, in an observation, the meal trays arrived on F-hall at 6:30 PM. The residents complained the food was cold. Resident #109 complained the Mexican rice was cold and the hamburger meat to go on the taco salad was cold. Resident #109 said she does not like cold hamburger meat or cold rice. During an interview on 5/09/24 at 10:51 AM, with the DM she confirmed the food that was served for dinner on 5/8/24 was cold because the new cook in training, Dietary #1, had placed the hamburger meat in with the lettuce and tomato and put it into the refrigerator because she thought the salad and meat should be cold. On 5/9/24 at 3:30 PM, during an interview with the Administrator, he confirmed residents had complained about cold food and on 5/07/24 it had taken a long time for staff to get the trays on the floor and he confirmed he heard about the cold taco salad served on 5/08/24 for dinner. He expected residents to be served food that is palatable, attractive, and at a safe and appetizing temperature.

Based on interview, record review, and facility policy review, the facility failed to provide care and services consistent with professional standards of practice as evidenced by not completing weekly wound assessments to include wound measurements for one (1) of one (1) pressure injuries reviewed. Resident #1 Findings include: Review of the facility policy, Prevention of Pressure Ulcers/Injuries, revised July 2017, revealed, .The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors . A record review of a facility letter signed by the Director of Operations (DOO), dated 2/17/23, revealed, Leakesville Rehabilitation and Nursing Center measures and records wounds weekly or as needed per the standards of care . A record review of the Face Sheet revealed the facility admitted Resident #1 on 7/21/21 and she had a current diagnosis of Pressure Ulcer of Right Heel, Unstageable. A record review of the facility's Wound Healing Progress Report, for Resident #1, dated 2/16/23, revealed, Type of Wound/Location as Pressure Ulcer Right Heel. The dates in which measurements were recorded were 12/14/22, 12/21/22, and 1/26/23. There were no recorded measurements for 12/28/22, 1/4/23, 1/11/23, or 1/23/23. There was only one (1) measurement documented for January 2023 (1/26/23) and there were no measurements documented for February 2023 prior to the State Agency (SA) entry on 2/15/23. On 2/15/23 at 1:33 PM, in an interview with Registered Nurse (RN) #1, she confirmed that she works at the facility on weekends as the RN Supervisor. She stated that she had not been completing weekly wound assessments or measuring the wounds and the previous Director of Nursing (DON) was aware that the wounds were not being assessed or measured. On 2/16/23 at 10:39 AM, in an interview with the Nurse Practitioner (NP), she confirmed that she expected the facility to assess the wounds weekly as per the standards of care, to be notified of any changes, and updated weekly on her rounds. The NP stated that she thought the facility was assessing the wounds because there had not been any negative outcomes. On 2/16/23 at 12:09 PM, in an interview with the DOO, she stated that the facility had undergone staff changes. She also stated that RN #1 had been instructed to perform the weekly wound assessments and measurements. The DOO confirmed that it was her responsibility to oversee that the wounds were being assessed weekly. On 2/16/23 at 12:39 PM, in an interview with the current Interim DON, she confirmed that the weekly wound assessments were not completed weekly. She stated that it was the responsibility of the DON to track the wounds at the facility and to make sure they are assessed and measured to ascertain if the wounds are deteriorating.

Based on staff interview, record review, and facility policy review, the facility failed to revise the Comprehensive Care Plan for two (2) of three (3) sampled residents. Resident #1 and Resident #2. Findings include: A review of the facility's policy Care Plans - Comprehensive, revised May 2014, revealed, .Policy Interpretation and Implementation 1. Our facility's Care Planning/Interdisciplinary Team .maintains a comprehensive care plan for each resident .8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change . Resident #1 A record review of the Face Sheet revealed the facility admitted Resident #1 on 7/21/21 and she had a current diagnosis of Pressure Ulcer of Right Heel, Unstageable. A record review of Physician's Telephone Orders, dated 1/13/23, revealed Resident #1 had a Physician's Order to . (2) D/C (Discontinue) current tx (Treatment) to R (Right) heel (3) Cleanse pressure ulcer to R heel with NS (Normal Saline), pat dry, apply hydrogel to wound bed, cover with ABD (Abdominal) pad and secure with roll gauze and tape daily and prn (as needed) . A record review of Comprehensive Care Plan for Resident #1 with the Care Plan Description of (Proper Name of Resident #1) has a pressure ulcer to right heel . revealed an Intervention with a start date of 12/13/2022 of Right heel pressure area cleanse with wound cleanser pat dry apply Collagen Sheet/Powder cover with border gauze dressing daily. Remove dressing at HS (Bedtime) and leave OTA (Open to Air). The care plan was not revised to discontinue the previous Physician Order and add the current Physician Order dated 1/13/23. Resident #2 A record review of the Face Sheet revealed that the facility admitted Resident #2 on 4/7/21 with a diagnosis of Type 2 Diabetes Mellitus. A record review of the Physician Orders for Resident #2 For the month of : January 2023 revealed an order with an order date of 1/13/23 to Cleanse diabetic ulcer to 2nd toe right foot daily with NS, Pat Dry, Apply Hydrogel to wound bed and cover with dry dressing. Change daily and PRN. A record review of Comprehensive Care Plan for Resident #2 with a Care Plan Description of (Proper Name of Resident #2) has ulcer to right foot second toe . revealed an Intervention with a start date of 10/25/22 to Cleanse diabetic ulcer to right foot 2nd toe with wound cleanser, pat dry apply Collagen Sheet/Powder, cover with border gauze drsg (Dressing) daily and prn. The care plan was not revised to include the current Physician Order that was dated 1/13/23. On 2/16/23 at 12:09 PM, an interview with the Director of Operations (DOO) revealed that the facility's Care Plan Coordinator had recently resigned. The DOO confirmed that during this transition of staffing, she should have provided the oversight to ensure that resident care plans were current and reflected changes in physician orders. She confirmed that the care plan for Resident #1 and Resident #2 were not revised to reflect the current physician orders for wound care. On 2/16/23 at 12:39 PM, in an interview with the Interim/Director of Nursing (DON), she confirmed that since the facility does not currently have a Care Plan Coordinator, the DON was responsible for completing and revising the comprehensive care plans to include new physician's orders that are written for residents.

Based on interview and record review the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place in 12/2/22. The facility's continued failure during this and the previous survey in November 2022 on an annual recertification survey indicates a pattern of the facility's inability to sustain an effective QAPI Committee. Findings include: Review of the facility's policy, Quality Assurance and Performance Improvement (QAPI) Committee, dated July 2016, revealed, The facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program . The primary goals of the QAPI Committee are to: 1. Establish, maintain and oversee facility systems and processes to support the delivery of quality of care and services . 6. Coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals . F657: Based on staff interview, record review, and facility policy review, the facility failed to revise the Comprehensive Care Plan for two (2) of three (3) sampled residents. Resident #1 and #2. On 02/16/23, at 12:50 PM, in an interview and record review of the facility's Quality Assurance Program, the Administrator explained the team had been meeting monthly and the previous care plan citation had been on the agenda. The Administrator revealed, she was unaware of ongoing issues related to care plan revisions and thought the facility was in compliance.

Based on staff interview, record review, and facility policy review, the facility failed to revise the Comprehensive Care Plan for one (1) of 14 sampled residents. Resident #43 Findings Include: A review of the facility's policy, Care Plans-Comprehensive, revised May 2014, revealed, .Policy Interpretation and Implementation 1. Our facility's Care Planning/Interdisciplinary Team maintains a comprehensive care plan for each resident .8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change . A record review of the Face Sheet revealed the facility admitted Resident #43 on 1/18/22 with diagnoses including Generalized Anxiety Disorder and Type 2 Diabetes Mellitus. A record review of the Quarterly Minimum Data Assessment (MDS) with an Assessment Reference Date (ARD) of 10/11/2022 revealed Resident #43 had an active diagnosis of Diabetes Mellitus. A record review of the Physician's Telephone Orders, dated 10/25/22, for Resident #43, revealed, .Jardiance 10 mg (milligrams) 1 tab(tablet) po (by mouth) q (every) day . A record review of the Comprehensive Care Plan for Resident #43 with the Category of High risk for hyperglycemia/hypoglycemia revealed it was not revised to include the Physician's Order for Jardiance 10 mg. On 11/08/22 at 11:19 AM, in an interview with Registered Nurse (RN) #1/Care Plan Coordinator, she stated that she is responsible for completing care plans. She confirmed that Resident #43's care plan was not revised to reflect the Physician's Order for Jardiance. On 11/08/22 at 11:05 AM, in an interview with the Director of Nursing (DON), she stated that RN #1 is responsible for completing the comprehensive care plans and any new Physician's Orders that are written for residents should be entered into the resident's care plan.

Based on interview, record review, and facility policy review, the facility failed to revise the Care Plan for Resident #22; one (1) of eighteen (18) Care Plans reviewed. Findings include: The facility's policy, Care Plans-Comprehensive, revised June 2017, revealed the resident Care Plans are ongoing and are revised as information about the resident and the resident's condition change. Review of Resident #22's current Care Plan revealed no revision for contact isolation that was ordered 10/4/2019. As a result, the Direct Care staff were not provided written interventions in the Care Plan to address contact isolation. Review of Resident #22's October 2019 Physician's Orders revealed a new order for Contact Isolation, that began on 10/4/19. In an interview on 10/24/2019 at 2:15 PM, Registered Nurse (RN) #1 and RN #2 both confirmed the Care Plan was not revised to include interventions for the new order for contact isolation for Resident #22.

Based on observation, interview, record review, and facility policy review, the facility failed to prevent the possible spread of infection during the administration of one (1) of 38 medications administered for Resident #48. Findings Include: Review of the facility's, Procedure for Instillation of Eye Drops, policy, undated, revealed that the proper technique when administering ophthalmic medication is to replace the cap immediately after use. Review of the facility's, Infection Control policy, revised July 2017, revealed the Infection Control Policies are intended to help prevent and manage transmission of diseases and infections. During an observation on 10/24/2019 at 8:56 AM, of an eye drop administration, Licensed Practical Nurse (LPN) # 1 placed the uncapped eye drops bottle onto Resident # 48's bed covers. LPN # 1 then re-capped the eye drop bottle without cleaning the tip. LPN #1 placed the bottle back into the package and then returned it to the inside of the medication cart. In an interview on 10/24/19 at 9:00 AM, Licensed Practical Nurse (LPN) #1 confirmed she placed the uncapped eye drop bottle on the resident's bed. LPN #1 stated, I knew as soon as I did it, that I messed up. LPN #1 confirmed she let the uncapped eye drop bottle touch a contaminated surface and this could have the potential to cause an eye infection to the resident. In an interview on 10/24/2019 at 4:25 PM, the Director of Nursing (DON) confirmed she considered the tip of the eye drop bottle to be contaminated if it touched the bed linen and should be discarded. In a review of the, Nursing Competence Self-Assessment Tool, signed and dated 7/9/19, by LPN #1, revealed that she was knowledgeable in the administration of eye drops.

Resident #22 Review of the Notice of Transfer or Discharge, revealed Resident #22 was sent to the emergency room (ER) on 8/25/19 and 9/9/19. There was no documented evidence of notification, in writing, of the bed hold agreement. On 10/24/19 at 4:33 PM, the Administrator confirmed Resident #22 or the RP was not provided written notification of a bed hold agreement/policy at the time of transfer to an acute care facility on 8/25/19 and 9/9/19. Resident #54 Review of the Notice of Transfer or Discharge, revealed Resident #54 was transferred to the hospital 9/25/19, and on 10/18/19. On 10/24/19 at 4:33 PM, the Administrator confirmed Resident #54 or Resident #54's RP was not provided written notification of the bed hold agreement/policy at the time of transfer to an acute care facility on 9/25/2019, and again on 10/18/2019. Based on record review and staff interviews, the facility failed to provide the bed hold policy/agreement to the resident and/or the Responsible Party (RP) at the time of transfer to an acute care facility for three (3) of six (6) hospitalizations reviewed for Resident #22, Resident #5, and Resident #54. Findings include: Interview with the Facility's Administrator on 10/24/2019 at 4:33 PM, revealed the facility did not have a policy on bed holds, but is developing a policy at this time. Resident #5 Record review of the facility's, Notice of Transfer, revealed Resident #5 was hospitalized three (3) times. The facility failed to send a bed hold letter to the RP or resident when Resident #5 was sent to the hospital on 7/31/2019, 8/16/2019, and 9/15/2019. In an interview on 10/24/19 at 4:33 PM, the Administrator revealed it is the responsibility of the Social Worker (SW) to send out the bed hold letters when the resident is transferred to the hospital. The Administrator stated the Social Worker is out on Family Medical Leave of Absence (FMLA). The Administrator confirmed the bed hold letters were not sent for Resident #5. The Administrator stated he was responsible for the bed hold letters while the Social Worker was out and stated he missed it.