**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders regarding a medication for one resident (Resident #68) that received dialysis (a treatment that filters waste and excess fluid from the blood when the kidneys can no longer do so) out of one sampled resident. The facility also failed to follow oxygen orders for two residents (Residents #14 and #24) out of two sampled residents. The facility census was 70. Review of the facility's policy titled, Medication and Treatment Orders, revised July 2016, showed: - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - Orders for medications must include: name and strength of the drug; number of doses, start and stop dates, and/or specific duration of therapy; route of administration; clinical condition or symptoms for which the medication is prescribed; any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.). Review of the facility's policy titled, Oxygen Administration, revised October 2010, showed: - Verify that there is a physician's order for this procedure. Review physician's orders of the facility protocol for oxygen administration; - Turn on oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute; - Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated; - Notify the supervisor if the resident refuses the procedure; - Report other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #14's medical record showed: - admission date of 06/21/24; - Diagnoses of depression, chronic obstructive pulmonary disease (COPD - a chronic, progressive lung disease that makes it difficult to breathe), anemia (condition where the blood doesn't have enough healthy red blood cells or enough hemoglobin, a protein that carries oxygen), heart failure (condition that develops when the heart doesn't pump enough blood for the body's needs), hypertension (high blood pressure, multidrug resistant organism (MDROs - bacteria that have become resistant to certain antibiotics), pneumonia (lung infection causing inflammation and swelling in the air sacs of the lungs). type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood), and anxiety (feeling of fear, dread, and uneasiness). Review of the resident's Physician Order Sheet (POS), dated April 2025, showed: - An order for oxygen at 2 liters per minute (L/min) per nasal cannula (a tube delivering oxygen to a person's nose) continuously, every shift related to COPD, dated 08/25/24; - An order to change the oxygen tubing and humidifier at bedtime every Sunday night shift, dated 08/25/24. Observations of the resident showed: - On 04/15/25 at 10:45 A.M., 04/17/25 at 1:40 P.M., and 04/18/25 at 11:45 A.M., the resident lay in bed with oxygen on at 3 L/min per a nasal cannula and the oxygen tubing and humidifier dated 04/13/25. During an interview on 04/15/25 at 10:55 A.M., Resident #14 said he/she didn't know the oxygen was on at 3 L/min. It should be on 2 L/min. 2. Review of Resident #24's medical record showed: - admission date of 04/09/24; - Diagnoses of malignant neoplasm of colon (a cancerous tumor or growth in the colon), type II diabetes mellitus with hyperglycemia, atelectasis, (a condition where all or part of a lung collapses, meaning it loses its volume and air), acquired hemolytic anemia (caused by factors outside the red blood cell, such as antibodies from an autoimmune disorder, burns, or medications), anxiety disorder, chronic kidney disease, stage 3, (moderate loss of kidney function, where the kidneys are not filtering waste and fluids effectively), COPD, essential hypertension, atrial fibrillation (an irregular heart rhythm, and major depressive disorder (MDD - mental health condition characterized by persistent sadness, loss of interest, and difficulty functioning in daily life). Review of the resident's POS, dated April 2025, showed: - An order for oxygen at 2.5 L/min per nasal cannula continuously, every shift related to chronic obstructive pulmonary disease, dated 06/21/24; - An order to change the oxygen tubing and humidifier at bedtime every Sunday night shift, dated 06/21/24. Observations of the resident showed: - On 04/15/25 at 11:10 A.M., and 04/17/25 at 1:50 P.M., the resident sat in a wheelchair in the hallway with oxygen on at 3 L/min per nasal cannula. The oxygen tubing was stretched from oxygen concentrator at the resident's bedside in his/her room and the oxygen tubing and humidifier dated, 04/13/25; - On 04/16/25 at 2:30 P.M., the resident lay in bed with oxygen on at 3 L/min per a nasal cannula and the oxygen tubing and humidifier dated 04/13/25. During an interview on 04/16/25 at 11:55 A.M., Resident #24 said he/she didn't know the oxygen rate was increased to 3 L/min from 2.5 L/min which was what he/she thought was on the physician orders. During an interview on 04/18/25 at 02:00 P.M., the DON and the Administrator said they would expect residents' oxygen to be at the rate the physician ordered. 3. Review of Resident #68's April 2025 showed: - admission date of 03/28/25; - Diagnoses of end stage renal disease, (a condition where the kidneys have permanently stopped working), COPD, type II diabetes mellitus with hyperglycemia, anemia in chronic kidney disease, transient cerebral ischemic attack (when the blood supply to part of the brain is briefly blocked), essential primary hypertension, atrial fibrillation, depression (common mental health condition that causes a persistent feeling of sadness and changes in how you think, sleep, eat and act), emphysema (chronic lung disease that causes permanent damage to the air sacs in the lungs), and syncope (a sudden, temporary loss of consciousness due to decreased blood flow to the brain) and collapse; - An order for dialysis three times a week, dated 03/28/25; - An order for sodium polystyrene sulfonate (medication to treat high levels of potassium in the blood) powder one packet by mouth one time a day for hyperkalemia (high potassium levels in the blood), dated 03/29/25. Review of the resident's Medication Administration Records (MAR), dated March and April 2025, showed: - An order for sodium polystyrene sulfonate powder one packet by mouth one time a day for hyperkalemia, dated 03/29/25; - The sodium polystyrene sulfonate powder one packet daily not administered 03/31/25, 04/01/25, 04/02/25, 04/03/25, 04/06/25, 04/07/25, 04/08/25, 04/13/25, 04/14/25, 04/15/25, and 04/17/25; - A total of 12 missed opportunities out of 20 opportunities for the sodium polystyrene sulfonate oral powder one packet to be administered as ordered. Review of the resident's medical record showed: - No documentation the physician was notified the resident's sodium polystyrene sulfonate powder was not administered daily as ordered for 03/29/25 - 04/17/25. Observation on 04/18/25 at 9:00 A.M., of the resident's medication administration showed: - Certified Medication Technician (CMT) D did not administer the resident's sodium polystyrene sulfonate oral powder one packet by mouth one time a day. During an interview on 04/17/25 at 9:15 A M., CMT D said he/she wasn't able to find Resident #68's sodium polystyrene sulfonate oral powder packets in the medication cart or in the medication room. The sodium polystyrene sulfonate oral powder was ordered from the pharmacy on 03/28/25. He/She normally worked evenings and the medication was given in the mornings. CMT D spoke with CMT E about where staff kept the resident's sodium polystyrene sulfonate oral powder and was told by CMT E the medication was sent to the facility by the hospital when the resident was discharged to the facility on [DATE]. The hospital sent the powder and staff were unsure how to measure how much powder to administer to the resident. Resident #68 had not received the medication since he/she was admitted to the facility. During an interview on 04/17/25 at 3:30 P.M., the Director of Nursing Director of Nursing (DON) and the Administrator said that they would expect physician orders to be followed as written. They would expect staff to notify them, the pharmacy, and the physician if orders were not understood.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #68) was free from significant medication errors when staff failed to administer medications as ordered by the physician. The facility census was 70. Review of the facility's policy titled, Medication and Treatment Orders, revised July 2016, showed: - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - Orders for medications must include: name and strength of the drug; number of doses, start and stop dates, and/or specific duration of therapy; route of administration; clinical condition or symptoms for which the medication is prescribed; any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.). 1. Review of Resident #68's April 2025 Physician Order Sheet (POS) showed: - admission date of 03/28/25; - Diagnoses of end stage renal disease, (a condition where the kidneys have permanently stopped working), (COPD - a chronic, progressive lung disease that makes it difficult to breathe), type II diabetes mellitus type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood) with hyperglycemia, anemia (condition where the blood doesn't have enough healthy red blood cells or enough hemoglobin, a protein that carries oxygen) in chronic kidney disease, transient cerebral ischemic attack (when the blood supply to part of the brain is briefly blocked), essential primary hypertension (high blood pressure), atrial fibrillation (an irregular heart rate), depression (common mental health condition that causes a persistent feeling of sadness and changes in how you think, sleep, eat and act), emphysema (chronic lung disease that causes permanent damage to the air sacs in the lungs), and syncope (a sudden, temporary loss of consciousness due to decreased blood flow to the brain) and collapse; - An order for dialysis (a treatment that filters waste and excess fluid from the blood when the kidneys can no longer do so) three times a week, dated 03/28/25; - An order for sodium polystyrene sulfonate (a medication to treat high levels of potassium in the blood) powder one packet by mouth one time a day for hyperkalemia (high potassium levels in the blood), dated 03/29/25. Review of the resident's Medication Administration Records (MAR), dated March and April 2025, showed: - An order for sodium polystyrene sulfonate powder one packet by mouth one time a day for hyperkalemia, dated 03/29/25; - The sodium polystyrene sulfonate powder one packet daily not administered 03/31/25, 04/01/25, 04/02/25, 04/03/25, 04/06/25, 04/07/25, 04/08/25, 04/13/25, 04/14/25, 04/15/25, and 04/17/25; - A total of 12 missed opportunities out of 20 opportunities for the sodium polystyrene sulfonate oral powder one packet to be administered as ordered. Review of the resident's medical record showed: - No documentation the physician was notified the resident's sodium polystyrene sulfonate powder was not administered daily as ordered for 03/29/25 - 04/17/25. Observation on 04/17/25 at 9:00 A.M., of the resident's medication administration showed: - Certified Medication Technician (CMT) D did not administer the resident's sodium polystyrene sulfonate oral powder one packet by mouth one time a day. During an interview on 04/17/25 at 9:15 A M., CMT D said he/she wasn't able to find Resident #68's sodium polystyrene sulfonate oral powder packets in the medication cart or in the medication room. The sodium polystyrene sulfonate oral powder was ordered from the pharmacy on 03/28/25. He/She normally worked evenings and the medication was given in the mornings. CMT D spoke with CMT E about where staff kept the resident's sodium polystyrene sulfonate oral powder and was told by CMT E the medication was sent to the facility by the hospital when the resident was discharged to the facility on [DATE]. The hospital sent the powder and staff were unsure how to measure how much powder to administer to the resident. Resident #68 had not received the medication since he/she was admitted to the facility. During an interview on 04/17/25 at 3:30 P.M., the Director of Nursing Director of Nursing (DON) and the Administrator said that they would expect physician orders to be followed as written. They would expect staff to notify them, the pharmacy, and the physician if orders were not understood. During an interview on 04/25/25 at 12:03 P.M., Pharmacist G said the resident's discharge orders were received on 03/29/25. Documentation at the pharmacy showed there was a note on the resident's discharge order that the pharmacy didn't have the sodium polystyrene sulfonate powder and would need a physician order for the liquid form and an end date which wasn't on the powder form order. Typically the pharmacy would call the facility and speak to a charge nurse and explain if changes were needed. There was no documentation on who called the facility from the pharmacy to notify of the changes needed. During an interview on 04/28/25 at 1:33 P.M., Registered Nurse (RN) F from the dialysis center said all dialysis patient's labs were obtained monthly then sent to an outside lab in another state so the results were received back in a day or two later. RN F said the resident's monthly labs were obtained on 04/10/25, and the final results came back to the dialysis center on 04/12/25. RN F notified the dialysis medical director and the nurse practitioner of the lab results and received order to call the facility to send the resident to the emergency room. During an interview on 04/28/25 at 4:50 P.M., the facility Medical Director said Resident #68 had an elevated potassium level was due to non-compliance with going to his/her scheduled dialysis treatments as ordered. It was uncommon for dialysis patients to take medications to lower potassium to the dialysis treatments maintained the normal potassium levels.

Based on observation, interview, and record review, facility staff failed to wear gloves when administering insulin for two residents (Residents #7, and #49) out of two sampled residents and one resident (Resident #22) out of the sample. The facility also failed to maintain appropriate infection control practices by not following enhanced barrier precautions (EBP) and by not performing proper hand hygiene and glove changing techniques during wound care and catheter care for two residents (Residents #38 and #61) out of sampled residents. The facility's census was 70. Review of the facility's policy titled, Enhanced Barrier Precautions, not dated, showed: - Enhanced barrier precautions will be initiated for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic stasis ulcers) and/or indwelling/implanted medical devices (e.g., central lines, ports, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a multi-drug resistant organism (MDRO); - Personal protective equipment (PPE) for EBP is only necessary when performing high-contact care activities and may not need to be put on prior to entering the resident's room; - High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes), wound care; - EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised October 2023, showed: - Single use disposable gloves should be used prior to: before aseptic procedures; when anticipating contact with blood or body fluids; when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions; - The use of gloves does not replace hand washing/hand hygiene. 1. Review of Resident #7's April 2025 Physician Order Sheet (POS) showed: - An admission date of 12/30/24; - An order for insulin lispro (a fast acting insulin) inject subcutaneously (injection under the skin) before meals per sliding scale for 151-200=3 units, 201-250=5 units, 251-300=7 units, 301-350=9 units, 351-400=11 units, 401-450=13 units, 451-500=15 units, and 501 to notify physician, dated 12/30/24; Observation on 04/17/25 at 10:41 A.M., of the resident's insulin administration showed: - Licensed Practical Nurse (LPN) A performed hand hygiene and did not put on gloves; - LPN A administered the resident's insulin lispro subcutaneously to the right; - LPN A performed hand hygiene. 2. Review of Resident #22's April 2025 POS showed: - An admission date of 03/31/23; - An order for insulin aspart (a rapid-acting insulin) inject 29 units subcutaneously before meals and inject as per sliding scale for 60-150=0 unit, 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units , 401-450=12 units, 451-500=14 units , 501-999 notify physician if over 500, dated 03/31/23. Observation 04/17/25 at 10:51 A.M., of the resident's insulin administration showed: - LPN A performed hand hygiene and did not put on gloves; - LPN A administered the resident's insulin aspart subcutaneously to the left abdomen - LPN A performed hand hygiene. 3. Review of Resident #38's April 2025 POS showed: - An admission date of 02/17/25; - An order to apply Medihoney (type of wound treatment) to the right buttock wound bed then cover with bordered foam dressing daily, dated 04/01/25. Observation on 04/17/25 at 9:21 A.M., of the resident's wound care showed: - EBP signage on the mailbox by the resident's door; - LPN A and Certified Nurse Aide (CNA) B entered the room, did not put on a gown, performed hand hygiene, and put on gloves; - CNA B placed the resident on his/her right side; - LPN A cleansed the right buttock wound with wound cleanser-soaked gauze, did not change gloves, and did not perform hand hygiene; - LPN A applied Medihoney to the wound bed and covered with a bordered foam dressing; - LPN A changed gloves and did not perform hand hygiene;; - LPN A cleansed the resident's catheter tubing from the insertion site outward using a cleansing wipe; - LPN A removed the gloves and performed hand hygiene. 4. Review of Resident #49's April 2025 POS showed: - An admission date of 05/24/24; - An order for insulin aspart inject 7 unit subcutaneously before meals, dated 05/24/24; - An order for insulin aspart inject subcutaneously before meals and at bedtime per sliding scale for 151-200=3 units, 201-250=5 units, 251-300=7 units, 301-350=9 units, 351-400=11 units, 401-450=13 units, 451-500=15 units, and 501 or greater to notify the physician or go to the emergency room, dated 05/24/24. Observation on 04/17/25 at 10:44 A.M., of the resident's insulin administration showed: -LPN A performed hand hygiene and did not put on gloves; - LPN A administered the resident's the resident's insulin aspart subcutaneously to the right abdomen; - LPN A performed hand hygiene. During an interview on 04/17/25 at 11:00 A.M., LPN A said he/she didn't wear gloves when administering insulin subcutaneously. 5. Review of Resident #61's April 2025 POS showed: - An admission date of 04/03/25; - An order to cleanse the gluteal cleft (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks) wound with wound cleanser, apply Santyl (a type of wound treatment) nickel thick to the wound bed and cover with bordered foam dressing daily, dated 04/10/25; - An order to cleanse the left heel wound with facility wound cleanser of choice, apply Santyl to the wound bed, cover with non-bordered foam dressing and secure with Kerlix (a type of dressing) and tape, dated 04/17/25. Observation 04/17/25 at 1:00 P.M., of the resident's wound care showed: - EBP signage on the mailbox by the resident's door; - LPN A and CNA C entered the room, did not put on a gown, performed hand hygiene, and put on gloves; - CNA C positioned the resident on his/her left side; - LPN A cleansed the gluteal fold wound with saline-soaked gauze, did not change gloves, and did not perform hand hygiene; - LPN A applied Santyl to the wound bed and covered with a bordered foam dressing; - LPN A removed the glove from his/her right hand, did not remove the glove from his/her left hand, and did not perform hand hygiene; - CNA C positioned the resident on his/her back; - CNA C held the resident's leg up for the wound care; - LPN A removed the dressing from the left heel wound with the gloved left hand; - LPN A did not perform hand hygiene, did not change the glove to the left hand, and put on new glove to the right hand; - LPN A cleaned the left heel wound with saline-soaked gauze, did not change gloves, and did not perform hand hygiene; - LPN A applied Santyl to the left wound wound bed, covered with a non-bordered foam dressing, wrapped with Kerlix, and taped; - LPN A and CNA C removed the gloves and performed hand hygiene. During an interview on 04/18/25 at 1:28 P.M., LPN A said EBP should be used for residents with wounds or indwelling devices and gloves and gown should be worn during wound care and catheter care. During an interview on 04/18/25 at 2:40 P.M., the Administrator and Director of Nursing (DON) said that they would expect staff to use EBP during high-contact resident care. During an interview on 04/17/25 at 2:35 P.M., the DON said that she would expect staff to wear gloves with insulin injections or coming in contact with any bodily fluids.

Based on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving one resident (Resident #55) out of nine sampled residents exposed during care. The census was 62. Review of the facility's policy titled, Dignity, dated February 2021, showed: - Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; - Residents are treated with dignity and respect at all times; - When assisting with care, residents are supported in exercising their rights; - Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures; - Demeaning practices and standards of care that compromise dignity are prohibited, for example, promptly responding to a resident's request for toileting assistance. Review of the facility's policy titled, Catheter (a tube inserted into the bladder to drain urine) Care, Urinary, revised August, 2022 showed to provide privacy. 1. Review of Resident #55's medical record showed: - admission date of 08/04/23; - Diagnoses included obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow); Review of the resident's Physician Order Sheet (POS), dated February 2024, showed: - An order to place an indwelling Foley catheter, dated 01/04/24; - An order to change the catheter monthly, dated 01/04/24; - An order for catheter care twice a day, dated 01/04/24. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/29/23, showed: - Required partial to moderate assist of staff for dressing, bed mobility, transfers, and toileting; - Frequently incontinent of bladder; - Always continent of bowel. Observation of the resident on 02/29/24 at 9:49 A.M., showed: - The resident lay in bed; - Licensed Practical Nurse (LPN) A entered the room to perform catheter care; - LPN A did not pull the curtain or close the blind to the window; - Through the window, the yard and a road could be seen; - LPN A failed to provide privacy during catheter care for the resident. During an interview on 02/29/24 at 11:00 A.M., LPN A said the curtain or blind should be closed when performing resident care. During an interview on 03/01/24 at 2:40 P.M., the Director of Nursing and Administrator said they expect privacy to be maintained and provided during resident care.

Based on interview and record review, the facility failed to ensure residents and/or responsible parties were notified in a timely manner when a resident's account was within the $200.00 Social Security (SSI) limit ($5,726.00) or when the resident's account was over the SSI limit. This affected two residents (Residents #22 and #47) reviewed who received Medicaid benefits. The census was 62. Review of the facility's policy titled, Resident's Trust Fund Management, revised, June 2022, showed: - Maintain the Trust Funds module of the American Health Tech (AHT) program to track resident trust fund; - Provide for the delivery of a quarterly accounting of the activity of transactions in the resident's account to the resident or the resident's responsible party; - When a resident's account balance exceeds $4800.00 in the resident fund accounts, the bookkeeper will advise the resident or fiduciary, in writing, that the resident may lose eligibility for Medicaid. This balance should include any credit balance held in Accounts Receivable. 1. Review of Resident #22's Resident Trust Statement, dated 02/29/24, showed: - On 11/30/23, ending monthly balance of $6,943.65; - On 12/31/23, ending monthly balance of $7,033.60; - On 01/31/24, ending monthly balance of $6,927.50. Review of the resident's fund documentation showed no resident fund notifications were provided to the resident or his/her representative. 2. Review of Resident #47's Resident Trust Statement, dated 02/29/24, showed: - On 11/30/23, ending monthly balance of $5,496.04; - On 12/31/23, ending monthly balance of $5,694.81; - On 01/31/24, ending monthly balance of $5,940.58. Review of the resident's fund documentation showed no resident fund notifications were provided to the resident or his/her representative. During an interview on 02/29/24 at 1:30 P.M., the Business Office Manager (BOM) said he/she was responsible for identifying when the residents got close to the need of a spend down. A notification letter should be sent to the resident/resident's representative. He/She did not send a letter to Resident #22 or Resident #47, just their quarterly statements. During an interview on 03/01/24 at 2:40 P.M., the Administrator said she expects the residents' accounts to be kept below the limit and notification to be sent when they were close to their limit.

Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for one resident (Resident #22) out of three sampled residents. The facility census was 62. The facility did not provide a policy for SNF ABNs. 1. Review of Resident #22's Advanced Beneficiary Notice (ABN) form showed: - The resident discharged from skilled Medicare services on 12/13/23, and remained in the facility; - The resident received and signed the form on 01/16/24; - The facility failed to provide the correct SNF ABN form to the resident at least two calendar days before the skilled Medicare services ended. During a phone interview on 03/07/24 11:40 A.M., the Director of Nursing said the Social Services Designee (SSD) was responsible for the SNF ABNs. If the SSD was not available, they go to the Business Office Manager. She said it should have been signed prior to 01/16/24. During a phone interview on 03/07/24 at 11:55 A.M., the Business Office Manager said SNF ABNs were completed when the social worker received notification of the resident coming off therapy. If the resident was their own person, the social worker took the SNF ABN and Notice of Medicare Non-Coverage (NOMNC) documents to them to sign. If the resident was not their own person, the social work mailed the documents to the family with a self-addressed envelope to be signed and returned. He/she would expect SNF ABNs and NOMNC to be provided and signed prior to the date of last covered day. He/she would expect Resident #22's to have been signed prior to 01/16/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement care plans with specific interventions to meet individual needs for seven residents (Residents #13, #19, #27, #34, #41, #49, and #63) out of 16 sampled residents. The facility's census was 62. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, showed: - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The comprehensive, person-centered care plan is developed within seven days of the completion of the required Minimum Data Set (MDS) (a federally mandated assessment completed by facility staff) assessment, and no more than 21 days after admission; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - The comprehensive, person-centered care plan includes: measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and reflects currently recognized standards of practice for problems areas and conditions. 1. Review of Resident #13's medical record showed: - An admission date of 05/16/23; - Diagnoses of atrial fibrillation (abnormal heart rhythm), congestive heart failure (CHF) (an inability of the heart to pump sufficient blood flow to meet the body's needs), and chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs); - An order for oxygen tubing change and clean concentrator weekly on Sunday, dated 06/08/24; - An order for oxygen at 2 liters per minute per nasal cannula continuously, dated 06/08/23. Review of the resident's care plan, undated, showed did not address the resident's use of oxygen. Observation of Resident #13 showed: - On 02/28/24 at 11:10 A.M., the resident lay in bed not wearing a nasal cannula and the oxygen concentrator turned off at the bedside; The oxygen tubing, undated, stored coiled in the trash can. The portable oxygen tubing, undated, hung coiled on the brake handle of the wheelchair without a sealed container; - On 02/29/24 at 8:05 A.M., and 02/29/24 at 4:08 P.M., the resident lay in bed not wearing a nasal cannula and the oxygen concentrator turned off at the bedside. The portable oxygen tubing, undated, hung coiled on the brake handle of the wheelchair without a sealed container; - On 03/01/24 at 8:17 A.M., the resident lay in bed not wearing a nasal cannula and the oxygen concentrator turned off at the bedside. The portable oxygen tubing, undated, hung coiled on the brake handle of the wheelchair without a sealed container. The concentrator tubing, undated, was coiled in a bag placed on the concentrator. During an interview on 02/28/24 at 11:10 A.M., Resident #13 said he/she slept with the oxygen tubing on at night and normally could take it off without help, but sometimes it fell off. 2. Review of Resident #19's medical record showed: - An admission date of 12/05/23; - Diagnoses of hypertension (high blood pressure), coronary artery disease (CAD) (a condition causing damage to the major blood vessels that supply the heart with blood, oxygen and nutrients), benign prostatic hyperplasia (BPH) (enlargement of the prostate causing difficulty in urination), gastroesophageal reflux disease (GERD) (stomach acid being forced back into the throat region), falls, sacral (the bottom of the spine, between the bottom of the lumbar spine and tailbone) decubitus (damage to the skin and/or underlying tissue as a result of pressure), impaired mobility, and chronic bladder outlet obstruction (a blockage at the base of the bladder); - No oxygen or oxygen tubing change orders. Review of the resident's care plan, last revised 02/14/24, showed did not address the resident's use of oxygen. Observation of Resident #19 showed: - On 02/27/24 at 9:45 A.M., the resident lay in bed and not wearing the oxygen tubing, dated 02/18/24, but with the oxygen concentrator (a medical device that provides extra oxygen) on 2 liters (L) at the bedside; - On 02/29/24 at 8:10 A.M., the resident lay in bed with the oxygen concentrator on 2 L at the bedside and the resident removed the nasal cannula, dated 02/18/24, from his/her nostril. 3. Review of Resident #34's medical record showed: - An admission date of 12/09/22; - Diagnoses of metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the blood), myocardial infarction (a blockage of blood flow to the heart; heart attack), and seizures; - Smoking assessment, dated 01/14/24, showed resident smoked safely but required staff supervision. Review of the resident's care plan, dated 02/27/23, showed did not address the resident's smoking with specific interventions. 4. Review of Resident #41's medical record showed: - An admission date of 01/12/24; - Diagnoses of dyspnea (shortness of breath), failure to thrive, anemia, diabetes mellitus (DM) (a disease where the body's ability to produce or respond the the hormone insulin is impaired), hypertension, end stage renal disease (ESRD) (when the kidneys are no longer able to work at a level needed for day-to-day life), right lower extremity amputation, and impaired mobility; - Smoking assessment, dated 01/12/24, showed resident smoked safely but required staff supervision. Review of the resident's care plan, revised 02/14/24, showed did not address the resident's smoking with specific interventions. 5. Review of Resident #49's medical record showed: - An admission date of 04/26/22; - Diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), osteoarthritis (degenerative joint disease), DM, muscle weakness, and history of falling; - Risk of Elopement/Wandering review, dated 4/26/22, showed the resident was at risk for elopement/wandering as evidenced by the resident wandered aimlessly in the hallway and in and out of common rooms. Review of the resident's care plan, dated 07/20/22, showed did not address the resident's elopement/wandering with specific interventions. 6. Review of Resident #63's medical record showed: - An admission date of 01/30/24; - Diagnoses of atrial fibrillation, decubitus ulcer (damage to the skin and/or underlying tissue as a result of pressure) to buttocks, weakness, DM, lower extremity pain, bed bound, constipation, asthma (a condition where a person's airways become inflamed, narrow and swell, and produce extra mucus which causes difficulty breathing), hypertension, sacral (the bottom of the spine, between the bottom of the lumbar spine and tailbone) deep tissue injury (a pressure-related injury to subcutaneous tissues under intact skin), and shortness of breath; - No oxygen order. Review of the admission MDS, dated [DATE], showed the resident received oxygen. Review of the resident's care plan, dated 02/12/24, showed did not address the resident's use of oxygen. Observation of Resident #63 showed: - On 02/27/24 at 2:01 P.M., the resident lay in bed with oxygen on at 2 L per nasal cannula, dated 02/18/24; - On 02/28/24 at 8:15 A.M., and 02/29/24 at 9:40 A.M., the resident lay in bed with oxygen on at 3 L per nasal cannula, dated 02/18/24. During an interview on 02/27/24 at 2:01 P.M., Resident #63 said he/she used oxygen a lot. During an interview on 03/01/24 at 2:37 P.M., the MDS Coordinator said that care plans should be individualized. He/She just started in November 2023 and the MDS's had been behind and care plans were not up to date. The care plans were basic for now but he/she was working on them. The care plans should be updated and individualized. During an interview on 03/01/24 at 3:40 P.M., the Administrator and Director of Nursing said that care plans should be individualized and the new MDS Coordinator was working on that. Anything that told the staff how to care for a resident that was specific should be included, such as smoking, oxygen, and wandering.

Based on interview and record review, the facility failed to follow oxygen orders for one resident (Resident #13) out of three sampled residents. The facility also failed to follow physician orders regarding a medication on a resident (Resident #41) that received dialysis (a process for removing waste and excess water from the blood) out of one sampled resident. The facility census was 62. Review of the facility's policy titled, Medication and Treatment Orders, revised, July 2016, showed: - Orders for medications and treatments will be consistent with principles of safe and effective order writing; - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Review of the facility's policy titled, Dialysis Critical Element Pathway, dated, May 2017, showed for residents receiving dialysis at a certified dialysis facility, assess and document vitals, weights and resident's status with the dialysis facility prior to and post dialysis, administer medications or meals before or after dialysis as ordered, and provide direct visual monitoring of the access site before and after dialysis. 1. Review of Resident #13's medical record showed: - admission date of 05/16/23; - Diagnoses of atrial fibrillation (abnormal heart rhythm), congestive heart failure (CHF) (an inability of the heart to pump sufficient blood flow to meet the body's needs), chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of the resident's Physician Order Sheet (POS), dated February 2024, showed; - An order to change the oxygen tubing and clean the concentrator (a machine that produces extra oxygen) weekly on Sundays, dated 06/08/24; - An order for oxygen at 2 liters per minute (L/min) per nasal cannula (a tube delivering oxygen to a person's nose) continuously, dated 06/08/23. Observation of Resident #13's showed: - On 02/28/24 at 11:10 A.M., the resident lay in bed not wearing a nasal cannula and the oxygen concentrator turned off at the bedside; The oxygen tubing, undated, stored coiled in the trash can. The portable oxygen tubing, undated, hung coiled on the brake handle of the wheelchair without a sealed container; - On 02/29/24 at 8:05 A.M., and 02/29/24 at 4:08 P.M., the resident lay in bed not wearing a nasal cannula and the oxygen concentrator turned off at the bedside. The portable oxygen tubing, undated, hung coiled on the brake handle of the wheelchair without a sealed container; - On 03/01/24 at 8:17 A.M., the resident lay in bed not wearing a nasal cannula and the oxygen concentrator turned off at the bedside. The portable oxygen tubing, undated, hung coiled on the brake handle of the wheelchair without a sealed container. The concentrator tubing, undated, was coiled in a bag placed on the concentrator. 2. Review of Resident #41's medical record showed: - admission date of 01/12/24; - Diagnoses of end stage renal disease (ESRD) (when the kidneys are no longer able to work at a level needed for day-to-day life), dyspnea (shortness of breath), failure to thrive, diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), hypertension (high blood pressure), right lower extremity amputation, and impaired mobility. Review of the resident's POS, dated February 2024, showed an order for sodium polystyrene sulfonate (a medication used to remove potassium from the blood) 15 milligram mg/60 milliliters (ml) give 60 ml by mouth daily for 30 days, hold on dialysis days (Tuesdays, Thursdays and Saturdays), dated 01/12/24. Review of the resident's Medication Administration Record (MAR) dated, February 2024, showed: - An order for sodium polystyrene sulfonate 15 mg/60 ml give 60 ml by mouth daily for 30 days, hold on dialysis days (Tuesdays, Thursdays and Saturdays), dated 01/12/24; - A total of 15 missed opportunities out of 16 opportunities for the staff to administer the medication to the resident on non-dialysis days. During an interview on 02/28/24 at 5:38 P.M., Certified Medication Technician (CMT) J said the bottle wasn't in the medication cart with his/her medication. CMT J looked in the other medication cart and found it. He/She said it was located in the wrong medication cart. The medication was not given some days because the resident refused it and didn't get it on the dialysis days anyway. If the resident refused, it should be documented. During an interview on 02/28/24 at 5:45 P.M., the resident said he didn't get offered a liquid medication in the morning, but he/she did refuse the water pill on dialysis days because dialysis was going to get rid of the water for him/her. During an interview on 03/01/24 at 3:40 P.M., the Administrator and Director of Nursing (DON) said they would expect medications not be routinely circled as not given without documentation of the reason. If the bottle was misplaced, it should be found or reordered. If the resident refused it, the medication should be documented and in this case, dialysis and the physician should be notified of the resident's refusal of the medication.

Based on observation, interview, and record review, the facility failed to ensure staff utilized safe transfer techniques for one resident (Resident #7) out of one sampled resident using a sit-to-stand lift (a mechanical lift used to help a person to transfer from a seated position to a standing position or vice versa). The facility census was 62. Review of the facility's policy titled, Sit to Stand Lift, undated, showed the policy did not address the number of staff required to perform the transfer safely. Review of the instructional sticker on the sit to stand lift showed, when possible, use two staff to perform a sit to stand safely. 1. Review of Resident #7's medical record showed: - An admission date of 09/12/22; - Diagnoses of falls, altered mental status, atrial fibrillation (an irregular heart rate), diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), hypertension (high blood pressure), depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), anxiety (persistent worry and fear about everyday situations), and acute metabolic encephalopathy (an alteration of the brain function resulting from other internal organ failure). Review of the resident's quarterly Minimum Data Set (MDS) (a federally mandated assessment completed by facility staff), dated 02/13/24, showed the resident required substantial to maximal assist for transfers. Review of the resident's care plan, revised on 02/13/24, showed the resident required assistance of two staff of all transfers using the sit to stand lift. Observation on 02/29/24 at 10:34 A.M., showed: - Certified Nurse Assistant (CNA) B pushed the sit to stand lift into Resident #7's room; - CNA B put the sling on the resident and lifted the resident into a standing position with the lift; - CNA B pushed the lift with the resident standing up and bearing weight while holding onto the grip bars from the resident's room into the bathroom; - CNA B lowered the resident onto the toilet with the lift; - CNA B failed to transfer the resident with the sit to stand lift with two staff. During an interview on 03/01/24 at 11:24 A.M., Nurse Assistant (NA) D said a sit to stand was always used with two staff. During an interview on 03/01/24 at 11:25 A.M., CNA B said a sit to stand should always be used with two staff. During an interview on 03/01/24 at 12:27 P.M., Registered Nurse (RN) C and Physical Therapist (PT) E said a sit to stand was always used with two staff. During an interview on 03/01/24 at 3:31 P.M., the Administrator and Director of Nursing (DON) said that a sit to stand should be performed with two staff at all times.

Based on observation, interview and record review, the facility failed to ensure staff maintained proper positioning and placement of the indwelling urinary catheter (a tube inserted into the urinary bladder to drain urine) tubing and drainage bags and the facility also failed to ensure documentation of the catheter changes and the catheter care were maintained for two residents (Resident #19 and #55) out of three sampled residents. The facility census was 62. Review of the facility's policy titled, Catheter Care, revised on 02/26/21, showed: - The facility will ensure any resident with a urinary catheter will be maintained to prevent infection; - Staff will make sure urine flows out of the the catheter into the drainage bag; - Staff to keep the urinary drainage bag below the level of the bladder to prevent back flow of the urine; - Staff to make sure the urinary drainage bag and catheter tubing does not touch the floor; - Catheter drainage bags will be placed in privacy bags to promote the resident's dignity. 1. Review of Resident #19's medical record showed: - admission date of 11/05/23; - Diagnoses of hypertension (high blood pressure), coronary artery disease (CAD) (a condition causing damage to the major blood vessels that supply the heart with blood, oxygen and nutrients), benign prostatic hyperplasia (BPH) (enlargement of the prostate causing difficulty in urination), gastroesophageal reflux disease (GERD) (stomach acid being forced back into the throat region), falls, sacral (the bottom of the spine, between the bottom of the lumbar spine and tailbone) decubitus (damage to the skin and/or underlying tissue as a result of pressure), impaired mobility, and chronic bladder outlet obstruction (a blockage at the base of the bladder). Review of the resident's Physician Order Sheet (POS), dated February 2024, showed: - An order to change the Foley (an indwelling catheter) catheter with 16 French every 30 days, dated 01/05/24; - An order to perform Foley catheter care every shift, dated 01/05/24. Review of the resident's Treatment Administration Records (TAR), dated January 2024, and February 2024, showed: - For January 2024, and February 2024, no documentation the Foley catheter was changed; - For January 2024, Foley catheter care every shift showed 10 out of 84 opportunities missed; - For February 2024, Foley catheter care every shift showed 20 out of 70 opportunities missed. Observations on 02/27/24 at 2:07 P.M., 02/28/24 at 8:26 A.M., 02/29/24 at 8:10 A.M., and 02/29/24 at 10:21 A.M., of the resident showed the resident lay in bed with the catheter bag hanging from the bed frame in a privacy bag with an open bottom, touching the floor, and amber colored urine flowed from the tubing into the bag. During an interview on 02/27/24 at 2:07 P.M., Resident #19 said he/she didn't know how often the catheter got changed but he/she didn't like it. The catheter had to hang low to flow correctly. During an interview on 02/29/24 at 3:00 P.M., the Director of Nursing (DON) said Resident #19's catheter had been changed in the hospital recently because they had to use a scope. The doctor's office will continue to change the catheter at this time because of how complicated it was to do so. 2. Review of Resident #55's medical record showed: - admission date of 08/04/23; - Diagnoses of unspecified convulsion (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness), essential hypertension (high blood pressure), hypokalemia (decreased blood level of potassium), unspecified symbolic dysfunctions (language impairment), cognitive communication deficit (difficulty with thinking and how someone uses language), acidosis (a condition in which there is too much acid in the body fluids), acute kidney failure, type two diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), unspecified lack of coordination, difficulty in walking, muscle weakness, abnormal posture, and obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow); - Nurses note, dated 01/04/24, showed the urologist's (a physician that deals with diseases of the male and female urinary tract) office called and requested to place an indwelling catheter due to urinary retention. A 16 French Foley catheter placed per sterile technique. Received 100 milliliters (ml) or amber urine. Review of the resident's POS, dated January, 2024, showed: - An order to place indwelling Foley catheter, dated 01/04/24; - An order to change the catheter monthly, dated 01/04/24; - An order for catheter care twice a day, dated 01/04/24. Review of the resident's TAR, dated January 2024 and February 2024, showed: - For January 2024, catheter care twice a day showed 16 out of 53 opportunities missed; - For February 2024, catheter care and monthly catheter change not addressed. Observation on 02/29/24 at 9:45 A.M., showed the resident to sat in a wheelchair with his/her catheter tubing hanging out of the bottom of his/her pants with the catheter bag hooked under the wheelchair in a privacy bag. The catheter tubing dragged on the floor under the wheelchair. During an interview on 03/02/24 at 12:27 P.M., Registered Nurse (RN) C said the catheter tubing and bags should not touch the floor. Catheter care should be done at least every shift and documented. During an interview on 03/02/24 at 3:50 P.M., the Administrator and DON said the catheter bags and tubing should be kept off of the floor. Catheter care should be done as ordered and documented.

Based on observation, interview and record review, the facility failed to obtain a physician's order for oxygen use and orders for oxygen tubing (a small, flexible tube that contains two open prongs that sit in the nostrils and attaches to an oxygen source) changes for two residents (Resident #19 and #63) out of two sampled residents. The facility census was 62. Review of the facility's policy titled, Physician Medication Orders, revised April 2010, showed: - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses; - Orders for medications must include name and strength of drug, quantity or specific duration of therapy, dosage and frequency of administration, route of administration if other than oral, and reason or problem for which given; - Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the pharmacist on a monthly basis. Review of the facility's policy titled, Oxygen Administration, revised 05/14/20, showed: - Check physician order for liter flow and method of administration; - For the use of reusable humidifiers: Set the flow meter to the rate ordered by the physician, place mask or cannula (a device that delivers extra oxygen through a tube into your nose) on the resident; - Label the humidifier with the date and time opened. Change the humidifier and tubing per facility policy. The facility did not provide a policy that addressed the timing of when to change the oxygen tubing and humidifiers. 1. Review of Resident #19's medical record showed: - An admission date of 12/05/23; - Diagnoses of hypertension (high blood pressure), coronary artery disease (CAD) (a condition causing damage to the major blood vessels that supply the heart with blood, oxygen and nutrients), benign prostatic hyperplasia (BPH) (enlargement of the prostate causing difficulty in urination), gastroesophageal reflux disease (GERD) (stomach acid being forced back into the throat region), falls, sacral (the bottom of the spine, between the bottom of the lumbar spine and tailbone) decubitus (damage to the skin and/or underlying tissue as a result of pressure), impaired mobility, and chronic bladder outlet obstruction (a blockage at the base of the bladder). Review of the resident's Physician's Order Sheet (POS), dated February 2024, showed: - No order for oxygen use; - No order for oxygen tubing or humidifier changes. Review of the resident's care plan, last revised 02/14/24, showed oxygen not addressed. Observation of Resident #19 showed: - On 02/27/24 at 9:45 A.M., the resident lay in bed and not wearing the oxygen tubing, dated 02/18/24, but with the oxygen concentrator (a medical device that provides extra oxygen) on 2 liters (L) at the bedside; - On 02/29/24 at 8:10 A.M., the resident lay in bed with the oxygen concentrator on 2 L at the bedside and the resident removed the nasal cannula, dated 02/18/24, from his/her nostril. During an interview on 01/23/24 at 1:05 P.M., the resident said staff changed the tubing, but he/she wasn't sure how often. 2. Review of Resident #63's medical record showed: - An admission date of 01/30/24; - Diagnoses atrial fibrillation (an irregular heart rate), decubitus ulcer to the buttocks, weakness, type two diabetes mellitus (a disease where the body's ability to produce or respond to the hormone insulin is impaired), lower extremity pain, bed bound, constipation, asthma (a condition where a person's airways become inflamed, narrow and swell and produce extra mucous making it difficult to breathe), hypertension, sacral deep tissue injury, and shortness of breath. Review of the resident's POS, dated February 2024, showed: - An order to check oxygen saturation (a measure of how much oxygen is in the blood) two times a day, dated 07/07/23; - An order for the head of bed to be elevated for shortness of breath, dated 01/30/24; - No order for oxygen use; - No order for oxygen tubing or humidifier changes. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/12/24 showed the resident received oxygen. Review of the resident's care plan, dated 02/12/24, showed oxygen not addressed. Observation of Resident #63 showed: - On 02/27/24 at 2:01 P.M., the resident lay in bed with oxygen on at 2 L per nasal cannula, dated 02/18/24; - On 02/28/24 at 8:15 A.M., the resident lay in bed with oxygen on at 3 L per nasal cannula, dated 02/18/24 ; - On 02/29/24 at 9:40 A.M., the resident lay in bed with oxygen on at 3 L per nasal cannula, dated 02/18/24. During an interview on 02/27/24 at 2:01 P.M., Resident #63 said he/she was on oxygen a lot. During an interview on 03/01/24 at 3:50 P.M., the Administrator and Director of Nursing said they would expect residents who receive oxygen to have an order for oxygen and an order to change the tubing.

Based on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #41) out of two sampled residents. The facility census was 62. Review of the facility's policy titled, Dialysis Critical Element Pathway, dated, May 2017, showed: - Review of Physician's orders to include: dialysis access care; dialysis schedule; and individualized dialysis prescription such as number of treatments per week length, type of dialyzer, specific parameters of the dialysis delivery system, anticoagulation, fluid restrictions, target weight, blood pressure monitoring; - Pertinent diagnosis; - Individualized care plan; - For residents receiving dialysis at a certified dialysis facility, assess and document vitals, weights and resident's status with the dialysis facility prior to and post dialysis, administer medications or meals before or after dialysis as ordered, and provide direct visual monitoring of the access site before and after dialysis. 1. Review of Resident #41's medical record showed: - admission date of 01/12/24; - Diagnoses of end stage renal disease (ESRD) (when the kidneys are no longer able to work at a level needed for day-to-day life), dyspnea (shortness of breath), failure to thrive, diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), hypertension (high blood pressure), right lower extremity amputation, and impaired mobility; - No documentation of the resident's condition before and after dialysis treatments; - Documentation of the communication between the facility and the dialysis center with 15 out of 18 opportunities missed by the facility post dialysis. Review of the resident's Physician Order Sheet (POS), dated February, 2024, showed: - No order for dialysis with the specific days dialysis was received; - No documentation of an order to assess and monitor the resident's dialysis access site; - No documentation of an order to assess and monitor the resident before and after dialysis treatments. Review of the resident's Treatment Administration Record (TAR), dated February 2024, showed: - No documentation of assessments and monitoring of the resident's dialysis access site; - No documentation of assessments and monitoring of the resident before and after dialysis treatments. Review of the resident's care plan, last reviewed on 01/31/24, showed the resident required renal dialysis and monitor the resident's shunt for patency (open and unobstructed). During an interview on 02/28/24 at 5:44 P.M., Resident #41 said the nurses didn't check his/her dialysis port after dialysis. The staff did take his/her vital signs most of the time. He/She went to dialysis on Tuesdays, Thursdays and Saturdays. During an interview on 03/01/24 at 1:30 P.M., Registered Nurse (RN) C said the resident's vital signs and the access site should be assessed upon a resident's return from dialysis. Resident #41 was pretty cognitive so he/she could let the staff know if there was a problem. The dialysis communication form was filled out by dialysis staff with the pre and post weights, but nothing by the facility staff. Resident #41 went to dialysis on Tuesdays, Thursdays and Saturdays. During an interview on 03/01/24 at 3:50 P.M., the Director of Nursing (DON) and the Administrator said the dialysis access site should be checked upon the resident's return from dialysis. There should be an order for it so it can be documented. The communication sheets should be completed by the facility staff as well as the dialysis staff.

Based on interview, and record review, the facility failed to identify, assess and provide supportive interventions for one resident (Resident #21) with a diagnosis of post-traumatic stress disorder (PTSD) (a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of two sampled residents. The facility's census was 62. Review of the facility's policy titled, Trauma-Informed and Culturally Competent Care, revised August 2022, showed: - Perform universal screening of the resident, which includes a brief, non-specialized identification of possible exposure to traumatic events; - Utilize screening tools and methods that are facility-approved, competently delivered, culturally relevant and sensitive; - Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers; - Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate; - Identify and decrease exposure to triggers that may re-traumatize the resident. 1. Review of Resident #21's medical record showed: - admission date of 02/01/17; - Diagnoses of PTSD, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness); - No documentation of a PTSD assessment. Review of the resident's Physician Order Sheet (POS), dated March 2024, showed an order for Lamictal (a seizure medication) 25 milligram (mg) by mouth twice a day for mood stabilization, dated 03/16/17. Review of the resident's Preadmission Screening and Resident Review (PASARR) (a federal program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities), dated 02/03/17, showed: - Seizure disorder; - No behaviors documented. Review of resident's care plan, undated, showed: - Did not identify PTSD as a problem; - Did not address personalized triggers or interventions associated to the resident or triggers. During an interview on 03/01/24 at 1:55 P.M., Resident #21 said PTSD was an issue and some things at the facility were triggers. He/She said the facility didn't do anything to help with the PTSD. The resident became tearful and did not want to speak about it anymore. During an interview on 03/01/24 at 2:00 P.M., the Social Services Designee (SSD) said expectations were that a resident with a diagnosis of PTSD should be assessed for triggers. It was not clear if Resident #21 had an accurate diagnosis of PTSD, but there was a diagnosis of major depressive disorder. It was not clear how a PTSD diagnosis wound up on the resident's POS, but it might have came from the hospital. During an interview on 03/01/24 at 2:04 P.M., the Minimum Data Set (MDS) (a federally required assessment completed by the facility staff) Coordinator said the PTSD diagnosis came in on Resident #21's admission. During an interview on 03/01/24 at 2:43 P.M., the Director of Nursing (DON) said she would expect a resident with a diagnosis of PTSD to be assessed for triggers. Residents with a history of traumatic events were expected to be assessed on admission and monitored for triggers. Resident #21 should have a PTSD assessment, an updated care plan, and a list of triggers. During an interview on 03/01/24 at 3:50 P.M., the Administrator said Resident #21 was admitted to the facility with the diagnosis of PTSD. There should have been a PTSD assessment and care plan that addressed the concerns. All residents with a history of traumatic events were expected to be assessed on admission and monitored for triggers.

Based on interview and record review, the facility failed to ensure an appropriate diagnosis for the use of psychotropic (medications used to treat mental health disorders) medication and to ensure a medication regimen was free from unnecessary medications when the facility failed to implement gradual dose reductions (GDR) for one resident (Resident #27) out of one sampled resident. The facility census was 62. Review of the facility's policy titled, Residents Drug Regimen Review, undated, showed: - The consultant pharmacist shall review the drug regiment of each resident at least monthly or more often if necessary; - The consultant pharmacist will report any irregularities noted in writing to the Director of Nursing (DON), the attending physician, and the facility's medical director; - The attending physician must document in the resident's medical record that the irregularity has been reviewed and what, if any, action has been taken to address it; - If there is to be no change in the medication, the attending physician should document his/her rational in the resident's medical record; - Nursing personnel will take appropriate action on all reports returning from the physicians; - It is the facility's responsibility to make sure the physicians return these reports in a timely manner so as to benefit the resident's health. The facility did not provide a GDR policy. 1. Review of Resident #27's medical record showed: - admission date of 04/08/22; - Diagnoses of major depressive disorder (long-term loss of pleasure or interest in life) and anxiety disorder (persistent worry and fear about everyday situations); - An order for Lexapro (an antidepressant medication) 20 milligrams (mg) by mouth daily, dated 08/09/23; - An order for Lamictal (an anticonvulsant and/or mood stabilizer medication) 25 mg by mouth daily, dated 05/13/23; - An order for Abilify (an antipsychotic (medication used to to treat psychosis (a mental disorder characterized by a disconnection from reality)) medication) 5 mg by mouth daily, for mood disorder (a mental health problem that primarily affects a person's emotional state), dated 05/13/23; - No documentation of an appropriate diagnosis for the Lexapro; - No documentation of an appropriate diagnosis for the Lamictal; - No attempt by the physician for a GDR of the Abilify and Lamictal. Review of thee resident's Pharmacist's Monthly Review Record (MRR) log, dated 11/21/23, showed: - The GDR's requested by the pharmacist for Ability and Lamictal; - No documentation from the physician regarding the GDR's requested for Abilify and Lamictal. During a phone interview on 03/08/24 at 10:20 A.M., the Administrator said she would expect GDR's to be completed on psychotropic medications and a documented rational why a GDR was not attempted by the physician. She said the pharmacist reviews the residents' medications each month, then each physician completed the GDR's. She would expect GDR's to be completed when recommended, and for them to be documented. She would expect residents' medications to have an appropriate diagnosis.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were given. There were 32 opportunities with two errors made, for an error rate of 6.25 %. This affected two residents (Residents #7 and #25) out six sampled residents with the potential to affect all residents. The facility's census was 62. Review of the facility's policy titled, Insulin Administration, revised September 2014, showed the nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Review of NovoLog Flex Pen (insulin in a pen-type device) instructions, revised 06/2023, showed: - Remove the cap; - Attach the needle; - Prime the pen by turning the dose selector to select two units; - Hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top; - Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows zero. The zero must line up with the dose pointer; - A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps (priming), no more than 6 times. If you still do not see a drop of insulin, change the needle and repeat steps (priming); - Check to make sure the dose selector is set at zero; - Turn the dose selector to select the number of units needed to inject; - Insert the needle into the skin; - Press and hold down the dose button until the dose counter shows zero; - Keep the needle in the skin after the dose counter has returned to zero and slowly count to six; - Pull the needle out of the skin, remove the needle from the pen and place in a sharps container. Review of Fiasp (insulin) FlexTouch Pen instructions, revised 02/2023, showed: - Remove the cap; - Attach the needle; - Prime the pen by turning the dose selector to select two units; - Hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top; - Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows zero. The zero must line up with the dose pointer; - A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps (priming), no more than 6 times. If you still do not see a drop of insulin, change the needle and repeat steps (priming); - Check to make sure the dose selector is set at zero; - Turn the dose selector to select the number of units needed to inject; - Insert the needle into the skin; - Press and hold down the dose button until the dose counter shows zero; - Keep the needle in the skin after the dose counter has returned to zero and slowly count to six; - Pull the needle out of the skin, remove the needle from the pen and place in a sharps container. 1. Review of Resident #7's Physician's Order Sheet (POS), dated 02/14/24, showed an order for Novolog subcutaneous (an injection just below the skin) four times daily before meals and hours of sleep per sliding scale for blood sugar of 0 -150 = 0 units, 151-200 = 5 units, 201-250 = 7 units, 251-300 = 10 units, dated 01/30/23: Observation on 02/29/24 at 4:25 P.M., of the resident showed: - Licensed Practical Nurse (LPN) M obtained a blood sugar reading of 164 for the resident; - LPN M administered 5 units of Novolog subcutaneously per order of the sliding scale for a blood sugar of 164 with the resident's Novolog Flex Pen; - LPN M failed to prime the Novolog Flex Pen per the manufacturer's instructions prior to the administration of the insulin to the resident. 2. Review of Resident #25's POS, dated 02/08/24, showed an order for Fiasp insulin subcutaneous four times of day per sliding scale for blood sugar of less than 150 = 0 units, 151 - 200 = 2 units, 201 - 250 = 4 units, 251 - 300 = 6 units, 301 - 400 = 8 units, 351 - 400 = 10 units, 401 - 450 = 12 units, 451 - 500 = 14 units, if more than 500, call physician, dated 02/15/24. Observation on 02/29/24 at 4:10 P.M., of the resident showed: - LPN M obtained the a blood sugar of 302 for the resident; - LPN M administered 8 units of Fiasp subcutaneously per order of the sliding scale for blood sugar of 302 with the resident's Fiasp Flextouch Pen; - LPN M failed to prime the Fiasp Flextouch Pen per the manufacturer's instructions prior to the administration to the resident. During an interview on 02/29/24 at 4:29 P.M., LPN M said he/she turned the dial to pull up the exact amount with an insulin pen and didn't need to prime the insulin pen. During an interview on 03/01/24 at 3:50 P.M., the Director of Nursing said she would expect insulin pens to be primed before each use. During an interview on 03/01/24 at 3:50 P.M., the Administrator said she would expect insulin pens to be primed before each use.

Based on observation, interview and record review, the facility failed to properly monitor the refrigerator temperatures in which medications, including insulin (medication used to lower blood sugar), were stored. This had the potential to affect all residents. The facility census was 62. Review of the facility's policy titled, Medication Labeling and Storage, dated February 2023, showed: - The facility stores all mediations and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys; - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; - Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. Review of the facility's policy titled, Refrigerators and Freezers, revised November 2022, showed monthly tracking sheets for all refrigerators and freezers are posted to record temperatures. Review of Invega (a medication used to treat symptoms of psychosis (a mental disorder characterized by a disconnection from reality)) manufacture's instructions showed to store at room temperature, between 59 degrees Fahrenheit (F) and 86 degrees F. 1. Observation on 03/01/24 at 1:15 P.M., of the medication refrigerator showed: - No documentation of the refrigerator temperature log; - Current temperature 32 degrees Fahrenheit; - Novolog (an insulin) and Lantus (an insulin) in the door; - One unopened box of Invega medication on a shelf; - One opened bottle of ranch dressing in the door; - One cup of applesauce, dated 2/24; - One chocolate health shake; - Ice buildup in and around the freezer; - A 4 inch (in.) x 6 in. freeze pack embedded in ice in the freezer; - An 1 in. brown substance in the middle of the frosted area of the freezer. During an interview on 03/01/24 at 2:15 P.M., Certified Nursing Assistant (CNA) K said the refrigerator temperature was supposed to be checked twice daily. He/She did not know where the log was or why a log had not been completed for this month. During an interview on 03/01/24 at 2:25 P.M., Registered Nurse (RN) L said the refrigerator temperature was supposed to be checked daily but it had not been done. The refrigerator temperature was currently 40 degrees F, but he/she did not know what it should be. During a phone interview on 03/07/24 at 11:40 A.M., the Director of Nursing (DON) said the refrigerator temperatures should be checked and logged daily. The temperature log should be kept on the refrigerator. If the temperature was incorrect, she would expect staff to make sure they were checking the correct area of the refrigerator. If the temperature was out of range, staff should check if the control was set at the right temperature zone and report it to maintenance immediately. No personal items or food should be kept in the medication refrigerator, unless it was the health shakes for a resident that were given with medications. She would expect the refrigerator to be clean, and any frosted freezers to be addressed. The Invega should be kept in the refrigerator if that was what the manufacturer's instructions said to do. The Invega should not be kept in the refrigerator if it said to be stored at 59 to 86 degrees F.

Based on interview and record review, the facility failed to ensure they developed and implemented a Quality Assurance and Performance Improvement (QAPI) plan pertaining to on-going monitoring for correction of identified systemic failures. This deficient practice had the potential to affect all residents. The facility census was 42. Review of the facility's policy titled, QAPI Program, revised 2019, showed: - The primary purpose of the QAPI Program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of the residents. To develop ongoing and comprehensive procedures that ensures the facility identified and corrects facility deficiencies, identifies opportunity for improvement, and addresses failures in systems or processes; - Develop and utilize a systemic approach to determine an in-depth analysis is needed to fully understand a problem, its cause, and implications of change. A thorough, organized, and structured approach in identifying problems that may be caused or exacerbated by the way care and services are organized or delivered will be used along with proficient root cause analysis components utilized to comprehensively evaluate all involved systems to prevent future events and promote sustained improvement and continual learning. Review of the facility's Monthly QAPI/Risk Report, dated November 2023, showed: - Finger stick blood sugar (FSBS) documentation listed as a performance improvement project (PIP); - The concern was improper/incomplete documentation; - The plan of action was to in-service the nurses responsible. Review of the Monthly QAPI/Risk Report, dated December 2023, showed: - No documentation of any PIPs; - No documentation of follow-up monitoring for the November PIP. Review of Monthly QAPI/Risk Report, dated January 2024, showed: - No documentation of any PIPs; - No documentation of follow-up monitoring for the November PIP. During an interview on 03/01/24 at 9:20 A.M., the Administrator said the QAPI committee meets monthly. During an interview on 03/01/24 at 9:30 A.M., the Director of Nursing (DON) said the facility did not currently have any PIPs in process. During an interview on 03/01/24 at 10:15 A.M., the DON said that as a result of the PIP regarding FSBS documentation, an in-service was conducted with all nursing staff and the responsibility for insulin administration was switched from Certified Med Technicians (CMT) to the nurses. She did ongoing medical record audits but that she did not keep a log or other written record of the audits. During an interview on 03/01/24 at 10:20 A.M., the Corporate Nurse said the DON did daily audits of the medical records and any problems found were discussed during the daily stand-up meetings. During an interview on 03/01/24 at 10:25 A.M., the Administrator said that if a problem was identified during the DON's medical record audits, the facility notified the resident's physician and family, then the facility honed in on the problem and fixed it right then.

Based on observation, interview, and record review, the facility failed to maintain adequate infection control practices to prevent the transmission of infection by ensuring a clean barrier for wound care supplies in the resident's room for four residents (Resident #8, #13, #19, and #39) out of five sampled residents. The facility failed to maintain adequate infection control practices during catheter (a tube inserted into the bladder to drain urine) care for two residents (Resident #19 and #55) out of two sampled residents. The facility also failed to maintain adequate infection control practices during incontinent care for two residents (Resident #39 and #63) out of three sampled residents. The facility census was 62. Review of the facility's policy titled, Wound Care, revised October 2010, showed: - Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field; - Wash, dry hands, put on gloves; - Remove dressing. Wash and dry hands, put on gloves. - Pour liquid solutions directly on gauze sponges on the papers; - Wear sterile gloves when physically touching the wound or holding a moist surface over the wound; - Apply treatments as indicated. Review of the facility's policy titled, Handwashing/ Hand Hygiene, revised October 2023, showed: - All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; - All personnel are expected to adhere to hand hygiene polices and practices; - Hand hygiene is indicated: immediately before touching a resident; before performing an aseptic task; after contact with blood, body fluids, or contaminated surfaces; after touching a resident, after touching the resident's environment, before moving to work from a soiled body site to a clean body site and immediately after glove removal. Review of the facility's policy titled, Urinary Continence and Incontinence - Assessment and Management, revised August 2022, showed the management of incontinence will follow relevant clinical guidelines. 1. Review of Resident #8's Physician Order Sheet (POS), dated February 2024, showed an order to clean the posterior (the back of the body) left thigh wound, pat dry, apply Triad (for light-to- moderate levels of wound exudates (fluid that leaks out of blood vessels into nearby tissue). Helps maintain an optimal wound healing environment) paste topically to the wound three times a day until resolved and as needed related to being soiled, dated 01/27/24. Observation on 02/28/24 at 3:04 P.M., for the resident's wound care treatment showed: - Licensed Practical Nurse (LPN) G put on gloves; - LPN G placed the wound care supplies on the bedside table with no barrier; - LPN G performed the wound care treatment. 2. Review of Resident #13's POS, dated February 2024, showed an order to cleanse the wound with normal saline, apply collagen powder (a wound treatment) and Medihoney (a wound treatment), pack the wound with normal saline moist gauze, and cover with border foam (a dressing) everyday and as needed, dated 02/05/24. Observation on 02/28/24 at 10:13 A.M., of the resident's wound care showed: - LPN G entered the resident's room and put the wound supplies on the bedside table with no barrier; - LPN G performed hand hygiene and put on clean gloves; - LPN G removed the dirty dressing and packing from the wound, picked up the wound cleanser bottle with the dirty gloves, and sprayed the wound cleaner directly into the wound; - LPN G twisted a piece of gauze and inserted it into the wound hole and twisted it inside and removed the pink tinged gauze covered with healthy tissue; - LPN G changed gloves but did not perform hand hygiene; - LPN G applied collagen powder and Medihoney to the wound and touched the bedside table with his/her gloved hand; - LPN G did not change gloves and perform hand hygiene; - LPN G packed the wound using a cotton-tipped applicator to push the saline soaked gauze into the wound. 3. Review of Resident #19's POS, dated February 2024, showed an order to clean the coccyx wound with wound cleanser and apply bordered foam every day, dated 02/05/24. Observation on 02/28/24 at 2:09 P.M., of the resident's wound care treatment showed: - LPN G put on gloves; - LPN G placed the wound care supplies on the bedside table with no barrier; - LPN G left the room to get a bag and touched the door knob with his/her gloved hand; - LPN G did not change gloves or perform hand hygiene; - LPN G removed the old dressing and cleansed the wound; - LPN G changed gloves but did not perform hand hygiene; - LPN G put on new gloves and applied the new dressing. Observation on 02/29/24 at 10:21 A.M., of the resident's catheter care showed: - LPN A put on clean gloves and didn't perform hand hygiene; - LPN A lowered the resident's pants below the waist, unfastened the brief, wet a washcloth in a prepared basin of soapy water; - LPN A wiped the catheter from the insertion site with the same area of the wash cloth two times; - LPN A wiped the catheter with the wash cloth and scrubbed the tubing back and forth in a small spot; - LPN A held the tubing up to drain the urine down into the catheter collection bag with the bottom of the bag touching the floor; - LPN A did not change gloves or perform hand hygiene; - LPN A used a clean dry wash cloth to wipe down the catheter and tubing away from the insertion site; - The bottom of the collection bag continued to touch the floor where it hung from the bed frame; - LPN A did not change gloves or perform hand hygiene; - LPN A touched the resident's top sheet, blanket, the resident's shirt, and the outside and inside doorknob of the bathroom door; - LPN A removed his/her gloves but did not perform hand hygiene and touched the resident's call light, the blanket, and the resident's shirt. 4. Review of Resident #39's POS, dated February 2024, showed an order to apply skin prep (forms a barrier between the patient's skin and adhesives to help preserve skin integrity and prevent insult or injury) on the toe and ankle and Triad cream to the resident's bottom, dated 01/30/24. Observation on 02/28/24 at 2:01 P.M., of the resident's wound treatment showed LPN G put the resident's wound supplies on the bedside table with no barrier and beside an unclean urinal. Observation on 02/29/24 at 9:34 A.M., of the resident's incontinent care showed: - Certified Nurse Aide (CNA) B and CNA F performed hand hygiene and put on gloves; - CNA F rolled the resident; - CNA B cleansed the resident of fecal material; - CNA F left while CNA B cleaned the resident and returned with LPN A; - CNA B finished cleaning the resident; - CNA B did not change gloves and perform hand hygiene; - LPN A squirted Triad cream onto CNA B's soiled gloved hand; - CNA B applied the Triad cream to an open area on the resident's coccyx; - CNA B did not change gloves and perform hand hygiene; - CNA B put a new brief and clothes on the resident with the same soiled gloves. 5. Observation on 02/29/24 at 9:49 A.M., of Resident #55's catheter care showed: - LPN A performed hand hygiene and put on gloves; - LPN A wiped from the insertion site of the catheter down; - LPN A did not change gloves and perform hand hygiene; - LPN A, with the same gloves, touched the catheter tubing in different areas down to the collection bag to ensure no kinks in the tubing; - LPN A picked up the catheter collection bag out of the privacy bag and put the bottom of the bag on the floor; - LPN A put the collection bag back in the privacy bag; - LPN A changed gloves but did not perform hand hygiene and emptied the collection bag; - LPN A removed the gloves but did not perform hand hygiene and touched the resident's shirt, pants, a clean wash cloth, the bedside table, the wheelchair, and the door. 6. Observation on 02/27/24 at 2:23 P.M., of incontinent care on Resident #63 showed: - CNA B and CNA H performed hand hygiene and put on gloves; - CNA H rolled the resident while CNA B cleansed the resident of urine and fecal material; - CNA B did not change gloves or perform hand hygiene after cleaning the resident and before touching the resident's clean brief; - CNA B touched the resident's thigh and fecal material transferred from his/her gloves onto the resident's clean brief, pad and sheet; - CNA H rolled the resident toward him/her and removed the dirty brief, pad, and sheet; - CNA H did not change gloves and perform hand hygiene; - CNA B handed the new clean sheet, pad and brief to CNA H who put it under the resident; - CNA B rolled the resident and touched the clean sheet, pad and brief with the same soiled gloves. During an interview on 02/28/24 at 2:20 P.M., LPN G said he/she should have performed hand hygiene between dirty and clean care and between glove changes. During an interview on 03/01/24 at 3:40 P.M., the Administrator and DON said gloves should be changed and hand hygiene performed anytime staff went from dirty to clean in incontinent care, catheter care, or wound care. The catheter collection bag should not be placed on the ground or touching the ground at any time.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility census was 62. Review of the facility's policy titled, Food Preparation and Service, revised November 2022, showed: - Only pasteurized shell eggs are cooked and served when residents request undercooked, soft-served or sunny side up eggs and preparing foods that will not be thoroughly cooked example (e.g.) hollandaise sauce, French toast, ice cream, et cetera (etc); - Unpasteurized eggs are cooked until all parts of the egg (yolk and whites) are completely firm. Review of the facility's policy titled, Food Receiving and Storage, revised November 2022, showed: - Food shall be received and stored in a manner that complies with safe food handling practices; - Food services or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times; - When food is delivered to the facility, it is inspected for safe transport and quality before being accepted; - Non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean; - Other opened containers are dated and sealed or covered during storage. Review of the facility's policy titled, Refrigerators and Freezers, revised November 2022, showed: - Foods kept in the refrigerator/freezer are stored according to the Food Receiving and Storage Policy; - Supervisors inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs; - Necessary repairs are initiated immediately, maintenance schedules per manufacturer guidelines are scheduled and followed; - Refrigerators are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary. 1. Observation on 02/27/24 at 8:55 A.M., and 02/29/24 at 1:59 P.M., of the kitchen showed: - The commercial range with oily film and brown grime build-up along the top surface and black grime build-up on the oven's interior surfaces; - Food debris and oily film build-up on the floor beneath the range; - The floor was damp with scattered food debris in the food prep area; - Two chest type deep freezers with 1 inch (in.) thick frost build up along the upper 6 in. interior surface near the hinged top; - Floor below the reach-in freezer with scattered debris; - Five ceiling diffusers (one of the few visible parts of an air conditioning system) with gray grime and a brown substance on the front exterior surfaces and between the ventilation louvers; - The commercial dishwasher with gray grime build-up and oily film and food debris below; - Black grime build-up on the drain pipes below the dishwashing counter; - The commercial style can opener with a worn cutting edge, oily grime build-up, and base edges with a brown grime build-up; - A 4 foot (ft.) diameter (dia.) wall section with scratched and damaged paint and wallboard beside the reach-in refrigerator; - A 2 ft. dia. wall section with scratched and damaged paint and wallboard beside the commercial fryer. 2. Observation on 02/27/24 at 8:55 A.M., of the walk-in refrigerator showed: - Debris on the floor below the food shelves; - The wall base with a brown substance; - Dust and grime build-up between the ventilation louvers; - Large metal bowl with fruit salad partially covered with parchment paper; - Tray with small individual bowls of mixed fruit partially covered with parchment paper; - Contained one partially full, 15 dozen case box of non-pasteurized eggs, dated 02/21/24. During an interview on 02/27/24 at 9:28 A.M., Dietary Aide I said the residents were served the non pasteurized eggs made to order and they were normally not cooked well done when fried on the griddle. The dietary staff were expected to follow the facility policy on cleaning. There should not be standing water in the dry food storage room, but it was related to a clogged floor drain that was connected to a sump pump outside the facility. During an interview on 02/27/24 at 9:35 P.M., the Dietary Manager (DM) said dietary staff cook eggs to order using the fresh shell eggs that were not pasteurized. The residents that wanted fried eggs, like them medium or over easy, so they were not always cooked well done. During an interview on 02/27/24 at 10:30 A.M., Resident #29 said fried eggs are ordered often and eaten, they are cooked over easy. During an interview on 02/27/24 at 10:54 A.M., Resident #4 said the food is good and eaten daily, usually it is the same order for breakfast, two eggs over easy, oats and two cups of coffee are served. During an interview on 02/27/24 at 2:30 P.M., Resident #1 said staff are helpful and meals are brought to the room. Eggs were eaten last time for breakfast about 5 days ago, they were served over easy. 3. Observation on 02/29/24 at 2:03 P.M., of the walk-in refrigerator showed: - Debris on the floor below the food shelves; - Dust and grime build-up between the ventilation louvers; - The wall base with a brown substance. 4. Observation on 02/27/24 at 9:37 A.M., and 02/29/24 2:05 P.M., of the dry food storage room showed: - Two 3 quart (qt.) dented cans with diced tomatoes, dated received on 02/21/24, and one 3 qt. dented can with baked beans, dated received on 02/16/24, on the canned food rack; - A vertical 1 in. refrigeration polyvinyl chloride (PVC) drainage line dripped above a 2 ft. dia. section with standing water near a 4 in. floor drain in the corner below the stocked food shelves; - Scattered debris below the food storage shelves; - One 2 ft. section of vinyl baseboard missing behind the food shelving. During an interview on 02/27/24 at 3:30 P.M., the Administrator said the fried eggs were expected to be pasteurized. The unpasteurized eggs should have never been stocked and the supplier had been asked to take them off the ordering list, they will be returned. The facility should not stock any eggs that were not pasteurized. The residents enjoyed fried eggs and don't always like them cooked well done. She expected the dietary staff to keep the kitchen clean, report maintenance concerns and follow the facility policy. During an interview on 02/29/24 at 2:15 P.M., the DM said the issue with non-pasteurized eggs in the kitchen should be corrected but were not at the time of initial inspection. Eggs should not be served fried unless they were well done if they were not pasteurized. There should not be standing water in the dry food storage room and dented cans should not have been placed on the rack. Dented cans were supposed to be sent back to the supplier. Maintenance was possibly aware of the water that stands in the dry storage room. The can opener blade should be replaced. The ceiling vents should be clean and not have corrosion. During an interview on 03/01/24 at 12:45 P.M., the Maintenance Director said no one had mentioned the floor drain being clogged in the dry food storage room but it should be fixed. The ceiling vents should be kept clean and will be repainted. Dietary staff were expected to clean the dust from the vents and the refrigerator ventilation. Missing baseboards will be replaced in the kitchen and dry food storage. Inspections should be made, and concerns should be reported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update and revise care plans with specific interventions tailored to meet individual needs for three residents, (Resident #1, #61, and #215) or include the resident and/or the guardian of two residents (Resident #48 and #54) out of 15 sampled residents. The facility census was 58. Record review of the facility's Record Review of the Facility's Care Planning - Interdisciplinary Team policy, dated 9/30/13, showed: - The purpose of care planning shall be to identify problem areas and their causes, and develop interventions targeted and meaningful to the resident; - The assessments of residents will be ongoing and care plans will be revised as information about the residents and their conditions change; - The resident, the resident's family and/or the resident's legal representative/guardian or surrogate will be encouraged to participate in the development of and revisions to the resident's care plan. 1. Record review of Resident #1's nurses notes, dated 6/15/22, showed: - The resident found on the floor on his/her stomach in the dining room in front of the wheelchair; - The resident with a one and a half to two inch laceration above the right eye; - The resident sent to the emergency room for sutures. Record review of the resident's nurses notes, dated 7/20/22, showed: -The resident slid out of the wheelchair with no injuries. Observations of the resident showed: - On 8/2/22 at 9:20 A.M., the resident lay in bed with no fall mat beside the bed; - On 8/3/22 at 10:30 A.M., the resident lay in bed with no fall mat beside the bed; - On 8/4/22 at 3:33 P.M., the resident lay in bed with no fall mat beside the bed. During an interview on 8/4/22 at 11:10 A.M., Certified Nursing Assistant (CNA) A said the resident does not require a fall mat because of the inability of turning self or moving. Record review of the resident's care plan, revised on 7/27/22, showed: - Diagnoses of Alzheimer's disease (progressive mental deterioration), and psychotic disorder (severe mental disorder that causes abnormal thinking and perceptions); - At risk for falls with an intervention of a fall mat at bedside, dated 2019; - The facility failed to revise the resident's care plan after the discontinuation of the intervention of a bedside fall mat; - The facility failed to revise the care plan after the resident's falls on 6/15/22 and 7/20/22. 2. Record review of Resident #48's medical record showed: - Diagnoses of Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves); bipolar depression (a disorder of extreme mood swings which include emotional highs and lows) and schizophrenia (a serious mental disorder in which people interpret reality abnormally); - Moderately impaired cognition, but interviewable; - No documentation the resident attended his/her care plan conferences. During an interview on 8/2/22 at 2:00 P.M., Resident #48 did not believe he/she had ever attended a meeting where his/her care was discussed. Record review of the resident's care plan conference summary, dated 7/13/22, showed: - No documentation the resident attended the meeting. 3. Record review of the Resident #54's medical record showed: - Diagnoses of Alzheimer's Disease, high blood pressure, depression and poliomyelitis (an infection involving the bone); - Moderately impaired cognition, but interviewable; - No documentation the resident attended his/her care plan conferences. Record review of the resident's care plan conference summary, dated 7/6/22, showed; - No documentation the resident and/or the representative attended the meeting. During an interview on 8/3/22 at 10:33 A. M., Resident #54 did not think he/she had ever been to a meeting where his/her care was discussed. 4. Record review of Resident #61's Physician Order Sheet (POS) dated July 2022, showed; - An order to discontinue the wander guard (a wander management system), dated 7/25/22. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, dated 7/25/22 showed; - Wander/elopement alarm used daily. Record review of the resident's care plan, revised on 7/15/22, showed; - Diagnosis of Alzheimer's Disease; - The intervention of the wander guard alarm; - The facility failed to revise the resident's care plan with the discontinuation of the wander guard. During an interview on 8/4/22 at 1:36 P.M., CNA A said the resident did not need a wander guard anymore because of his/her physical decline. 5. Record review of Resident #215's quarterly MDS, dated [DATE], showed: - A fall during the month before the resident's admission or reentry; - Extensive assistance of two or more staff for transfers. Record review of a status change sheet, dated 5/16/22, showed: - Resident found on the floor in the hall with the wheelchair to the side of the resident. Record review of the resident's nurses notes, dated 7/22/22, showed: - Resident slid out of the wheelchair and sat in front of the wheelchair on the floor without injuries. Record review of the resident's care plan, revised on 7/20/22, showed: - Diagnoses of Down Syndrome (a genetic disorder causing developmental and intellectual delays), mental retardation (below average intelligence), Alzheimer's Disease, seizure disorder (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness); - Potential for falls; - Poor safety awareness; - Resident sits self in floor at times; - Activities of daily living (ADL's) with an assist of one staff; - The care plan did not address the falls on 5/16/22 and 7/22/22 or any new interventions for the falls. During an interview on 8/3/22 at 2:11 P.M., the MDS Coordinator said care plans should reflect the MDS and care plans should be updated with falls. During an interview on 8/5/22 at 9:30 A.M., the Social Services Designee (SSD) stated the families were now called and invited to the care plan meeting instead of just sending a letter. The residents were invited, but it wasn't documented any where if the resident refused to attend. The SSD said he/she knows it should be documented if the resident refused to attend. The SSD also said they did not go to the resident for their care plan conference if the resident didn't want to leave their room. During an interview on 8/6/22 at 10:45 A.M., the Director of Nursing (DON) said the care plans should reflect the MDS and be updated with changes.

Based on observation, interview, and record review, the facility failed to provide consistent resident care for activities of daily living (ADL's) for two residents (Resident #19 and #215) out of 15 sampled residents. The facility census was 58. Record review of the facility's Resident Self Determination and Participation policy dated, February 2021, showed: - Each resident allowed to choose their own activities and schedule their health care and healthcare providers consistent with his/her interests, values, assessments and plans of care; - Each resident allowed to choose their own personal care needs, such as bathing methods, grooming styles, and dress. Record review of the residents' scheduled shower sheets showed: - The residents should receive two showers weekly. 1. Record review of Resident #19's admission evaluation showed: - An admission date of 4/6/22; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) and Parkinson's disease (a disease of the central nervous system that affects movement, often including tremors); - Moderately impaired cognition but able to make his/her needs known. Record review of the resident's shower sheets, dated August 2022, showed: - The resident received a shower on 8/2/22; - Documentation the staff did not shave the resident with his/her shower on 8/2/22. Observations of the resident showed: - On 8/2/22 at 12:36 P.M., the resident's face with the start of a beard; - On 8/3/22 at 9:30 A.M., the resident's face with a beard; - On 8/4/22 at 9:02 A.M., the resident's face with a beard. During an interview on 8/2/22 at 12:36 P.M., Resident #19 said he/she had waited for days to be shaved. During an interview on 8/4/22 at 9:02 A.M., Resident #19 said he/she did get a shower today and told the staff he/she wanted to be shaved. The staff said they could not find a razor and he/she did not get shaved. 2. Record review of Resident #215's medical record showed: - An admission date of 10/7/21; - Diagnoses of Down Syndrome (a genetic disorder causing developmental and intellectual delays), mentally retarded, Alzheimer's Disease (progressive mental deterioration), seizure disorder (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness); - Physical assist of one staff for ADL's; - Severely impaired cognition. Record review of the resident's shower sheets, dated August 2022, showed: - On 8/1/22, the resident received a shower. Observations of the resident showed; - On 8/2/22 at 12:27 P.M., the resident's nails extended past the finger tips with the nail of the second finger of the left hand to be broken; - On 8/4/22 at 11:03 A.M., the resident's nails extended past the finger tips with the nail of the second finger of the left hand to be broken. During an interview on 8/4/22 at 11:03 A.M., Certified Nursing Assistant (CNA) A said the staff that gave a shower to the resident, should have shaved him/her. The staff should also trim the resident's nails unless the resident was diabetic (a person with Diabetes Mellitus, a condition that affects the way the body processes blood sugar). Whoever showered Resident #19, did not shave him/her or trim Resident #215's nails. During an interview on 8/4/22 at 10:30 A.M., the Director of Nursing (DON) said residents' nails should be trimmed when showered unless they were diabetic. The nurse trims the nails of the diabetic residents if needed. The staff that showers a resident should shave the resident if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were transferred with safe transfer techniques for three residents (Residents #15, #61, and #215) and smoking safety interventions were followed for one resident (Resident #48) out of 15 sampled residents. The facility census was 58. Record review of the facility's Resident Handling policy, dated 2000, showed: - Mandatory gait belts for handling of all resident with the exception of bed mobility and medical contraindications. Record review of the facility's Sit to Stand Lift procedure evaluation, undated, showed: - Position the sling around the resident's back with approximately two inches above the waistline; - Position the resident's arms outside of the sling; - Fasten the safety belt around the resident's waist; - Instruct and/or assist the resident to place his/her feet on the lift platform and to hold onto the lift handles with his/her hands; - The procedure does not address how many staff would be needed for this procedure. 1. Record review of Resident #15's medical record showed: - Resident admitted on [DATE]; - Diagnoses of spinal stenosis (narrowing of the space inside the backbone), high blood pressure, anxiety, depression and peripheral neuropathy (condition which involves damage to the peripheral nerves); - Total dependence on staff for transfers between the bed and the wheelchair; Record review of the resident's admission care plan, undated, showed: - The resident to be at risk for falls; - The resident to be transferred by a Hoyer lift (a type of transfer device that lifts a resident between the bed and the chair. Observation of Resident #15 on 8/3/22 at 9:45 A.M., showed: - The resident lay in bed; - Nursing Assistant (NA) D assisted the resident to sit up on the side of the bed; - NA D placed the sit to stand lift in front of the resident; - NA D placed the safety strap around the resident and connected it to the sit to stand lift and placed the resident's feet on the sit to stand platform; - NA D proceeded to lift the resident from the bed to a semi-standing position by his/herself; - NA D turned the sit to stand lift with the resident in front of the resident's wheelchair and sat the resident down in his/her wheelchair; - NA D did not fasten the safety strap around the resident; - The safety strap rode up into the resident's axilla and pulled the resident's arms upward; - NA D did this procedure without a second person present. During an interview on 8/4/22 at 2:15 P.M., NA D said he/she thought a sit to stand lift could be used with one person, but he/she later learned there should have been two people with the resident when using the sit to stand. Also, the safety strap should have been fastened around the resident. The strap should not have pulled at the residents underarms. During an interview on 8/5/22 at 9:15 P.M., the Physical Therapist (PT) E said PT evaluates the residents to see which transfer method would be the best for the resident. For Resident #15, the sit to stand lift was used because the resident would get a feeling of standing. If they can bear weight, then the sit to stand lift was best for the resident. The safety strap should have been fastened around the resident. During an interview on 8/5/22 at 1:10 P.M., the Director of Nursing (DON) said she would expect staff to use the sit to stand lift correctly. The safety strap should be fastened when moving the resident from one surface to another. Record Review of the facility's Smoking Policy for Residents, revised 7/2017, showed: - The facility shall establish and maintain safe resident smoking practices; - Smoking shall only be permitted in designated resident smoking areas; - The resident will be evaluated on admission to determine if he or she smokes; - The staff will consult with the attending physician and the DON to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 2. Record review of Resident #48's medical record showed: - The resident smoked. The resident's Smoking Evaluation form, dated 6/16/22, showed: - The resident to wear a smoking apron across the resident's lap when he/she smoked; - The smoking assessment signed by the Activity Director (AD). Record review of the resident's care plan, revised on 4/5/22, showed: - The resident to place a smoking apron folded across his/her lap to protect the lap area in case he/she drops the hemostats (an instrument used to grasp and secure objects) which holds his/her cigarette. Observations of the resident showed: - On 8/3/22 at 9:12 A.M. and at 3:30 P.M., the resident sat outside and smoked without a smoking apron on; - On 8/4/22 at 1:52 P.M., the resident sat outside and smoked without a smoking apron on. During an interview on 8/4/22 at 8:34 A.M., the AD said Resident #48 was to have a smoking apron on when he/she smoked. During an interview on 8/5/22 at 8:33 A.M., Certified Nursing Assistant (CNA) F said he/she didn't know if Resident #48 should have a smoking apron on or not when the resident smokes. He/she was not sure where to find out if a resident needed a smoking apron when the resident smoked. During an interview on 8/5/22 at 10:46 A.M , CNA E said Resident #48 was supposed to have a smoking apron on and used hemostats to hold his/her cigarette when he/she smoked. The AD tells the staff if a resident had any smoking precautions, such as if they needed to wear a smoking apron. 3. Record review of Resident #61's quarterly Minimum Data Set (MDS), a federally mandated assessment required to be completed by the facility staff, dated 7/25/22, showed: - Required supervised assistance of one staff for transfers; - Required extensive assist of one staff for dressing, hygiene and toilet use. Observation of Resident #61 on 8/4/22 at 1:35 P.M., showed: - The resident lay in bed; - CNA A assisted the resident to a sitting position while keeping a hand on the resident's back to keep him/her from falling backwards; - CNA A placed his/her hands under the resident's axilla area and transferred the resident to his/her wheelchair; - The resident did bear weight but did not move his/her feet; -CNA A did not use a gait belt during the transfer. 4. Record review of Resident #215's annual MDS, dated [DATE], showed: - Required extensive assist of one staff for transfers, hygiene, dressing, and toileting. Observation of Resident #215 on 8/2/22 at 2:55 P.M., showed: - The resident sat in his/her wheelchair; - CNA B placed his/her hands under the resident's axilla area to assist the resident to a standing position; - CNA B placed his/her hands under the resident's axilla area to assist the resident to stand; - The resident stood by him/herself during his/her care when needed; - CNA B assisted the resident back into the wheelchair by holding and pulling up on the resident's pants; - The CNA used the resident's pants to hold the resident's weight during the transfer. - CNA B did not use a gait belt during the transfer. During an interview on 8/4/22 at 1:40 P.M., CNA A said a gait belt should be used at all times during transfers. During an interview on 8/2/22 at 2:55 P.M., CNA B said a gait belt should be used during transfers, but he/she did not use it on Resident #215. During an interview on 8/5/22 at 10:30 A.M., the DON said gait belts should be used at all times with transfers. The staff should not use their hands under a resident's axilla area or hold onto their pants.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a proper diagnosis for a psychotropic medication for one resident (Resident #47) out of six sampled residents. The facility census was 58. Record review of Mosby's 2019 Nursing Drug Reference for quetiapine (an antipsychotic medication), showed: - Drug not indicated for use in elderly patients with dementia-related psychosis; - Watch for extrapyramidal (nerves associated with motor activity) effects; - May have a drug-to-drug interaction with the QT interval (a measurement used to assess some of the electrical properties of the heart) prolonging medications. Record review of the facility's Antipsychotic Medication Use policy, revised 12/16, showed: - Residents will only receive antipsychotic mediations, when necessary, to treat specific conditions when indicated and effective; - The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms and risks; - The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications; - The attending physician and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions; - Residents admitted from the community or transferred from a hospital and already receiving antipsychotic medications, will be evaluated for the appropriateness and indications for use; - Diagnosis of a specific conditions for which antipsychotic medications will be necessary to treat, will be based on a comprehensive assessment of the resident; - Antipsychotic medications shall only be used for the conditions/diagnoses as documented in the record, consistent with definitions in the Diagnostic and Statistical [NAME] of Mental Disorders (conditions that affect a person's thinking, feeling, mood, and behavior); - An antipsychotic medication will not be used if only symptoms should be one or more of the following: Wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia, unsociability, inattention to surroundings, fidgeting, uncooperativeness or verbal expressions or behaviors not due to conditions listed under the indications and do not represent a danger to the resident or others. 1. Record review of Resident #47's Physician Order Sheet (POS), dated 8/2022, showed: - An admit date of 6/2/22; - An order for quetiapine 12.5 milligrams (mg) one tablet by percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube placed through the skin and stomach wall, directly into the stomach) at bedtime, dated 6/2/22; - An order for quetiapine 12.5 mg one tablet by PEG tube twice a day as needed, for congestion and agitation, dated 6/2/22; - An order for quetiapine 12.5 mg one tablet by PEG tube at bedtime as needed, for agitation, dated 6/2/22. Record review of the resident's medical record showed: - No documentation of specific, targeted behaviors; - No documentation by the physician as to why the resident received quetiapine with an appropriate diagnosis. Record review of the resident's admission care plan, dated 6/2/22, showed: - No antipsychotic medication use with interventions; - No identification of specific, targeted behaviors with interventions. Record review of the pharmacist recommendations, dated 7/19/22, showed: - The pharmacist asked for the physician to clarify the diagnosis of congestion for the quetiapine and update the POS with the diagnosis; - To make documentation of the symptom being treated; - No documentation or clarification of the diagnosis for usage of the quetiapine by the doctor on the recommendation report and/or in the medical record. Observations of the resident from 8/2/22 - 8/5/22, showed: - The resident lay quietly in bed in his/her room and received the PEG tube feeding infusion; - The resident worked quietly in his/her room with Speech Therapy; - The resident sat quietly up in a wheelchair in his/her room and watched TV or talked on the telephone. During an interview on 8/5/22 at 10:28 A.M., Registered Nurse (RN) G said he/she didn't know why the resident was on quetiapine. The resident was admitted on it. RN G said the resident was to be on the medication for agitation, but that probably wasn't a proper diagnosis for the medication use. During an interview on 8/5/22 at 1:15 P.M., the Director of Nursing (DON) said she would expect all medications to have a proper diagnosis. One of the physicians for the facility did not want the facility to fax him/her. The doctor wanted to wait until his/her next visit to look at things so items could be signed at that time.

Based on observation, interview and record review, the facility failed to follow the recipe for preparing a pureed consistency (food prepared with an applesauce consistency) meal. This affected four residents on a pureed diet. The facility census was 58. Record review of the facility's Standardized Recipes policy, dated 2020, showed: - Standardized recipes will be used for all menu items, including purred and therapeutic diets; - Each recipe will include the name of the product, number of servings or yield, ingredients, measurement and/or weight of ingredients, procedures for assembling/method of production, size of pan needed, serving sizes, modification for therapeutic diets if applicable, recipes will be scaled to the number served; - The Registered Dietitian will approve recipe changes or new recipes utilized for a menu item. Record Review of the recipe for pureed baked chicken showed: - Servings for 50 to be the smallest recipe; - Needed nine pounds (lb.) six ounces (oz.) of baked chicken; - Needed 25 slices of white bread; - Needed two quarts (qt.) and two cups of water with three tablespoons (T) and one teaspoon (tsp) of chicken base; - No recipe for servings less than 50. Observation on 8/4/22 at 9:34 A.M., showed: - [NAME] C placed cooked, diced chicken in the Robot Coup (a device used to prepare altered textured diets) for the mechanical and pureed diets and processed the chicken; - [NAME] C emptied part of the chopped chicken into a metal container and placed it on the steam table; - [NAME] C returned the Robot coup to the stand and pureed the rest of the cooked, diced chicken for the pureed diets; - [NAME] C added five, four oz. ladles of gravy to the chopped chicken to prepare the proper consistency for the pureed diets; - [NAME] C did not measure the cooked, diced chicken before preparing the pureed consistency meal; - [NAME] C failed to follow the recipe for pureed baked chicken. During an interview on 8/4/22 at 10:10 A.M., [NAME] C said he/she had been a cook in the kitchen for 10 years and he/she knew how to fix the meals. He/she knew that one bag of frozen, diced chicken to be five lbs. and it was enough to make the 17 mechanical and four pureed meals, with an extra serving for five pureed meals, which were needed. During an interview on 8/4/22 at 2:00 P.M., the DM said when preparing meals, the recipe should be followed. If the recipe said bread was to be added to the chicken for the pureed diet, then bread should have been added.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affected all residents. The facility census was 58. Record review of the facility's Steam Table Serving Temperatures policy, dated 2011, showed: - A table of safe temperatures for hot and cold foods; - Problems with the steam table heating capability will be reported to the maintenance department immediately; - All hot foods will be kept in steam table pans and placed in steam table carts or in the oven; - Foods will not be placed in the steam table more than 30 minutes before the dining service. Record review of the facility's meal times showed: - Breakfast served at 7:00 A.M., hall trays started and served out at 7:00 A.M.: - Lunch served at 11:45 A.M., hall trays served at 11:45 A.M.; - Dinner served at 5:00 P.M., hall trays served out at 5:00 P.M. Observation of the kitchen on 8/2/22 at 9:55 A.M., showed: - Three floor tiles missing at the entrance to the kitchen; - The chest freezer by the door to the kitchen did not have a handle on it and with a build up of ice, one inch (in.) thick around the top of the freezer; - A build-up of ice, one in. thick on the left door seal of the upright freezer in the back of the kitchen; - The up right freezer in the back of the kitchen with a black substance build up on the left and right door seals; - The seal on the side and the bottom of the left side of the upright freezer in the back of the kitchen to be split; - Four dishwasher racks sat on the floor on a white sheet with black footprints on it in front of the dishwasher. Observation on 8/2/22 from 11:30 A.M., to 12:15 P.M., showed: - Certified Nurse Aide (CNA) B touched the tops of most of the glasses when he/she served them to the residents on the secured unit for lunch. Observation on 8/4/22 at 8:55 A.M., showed: - Ice Machine drain pipe with one and one half in. inside the floor drain; - A white substance on the floor and one in. up the wall behind the ice machine; - Four dishwasher racks sat in the floor on a floor mat in front of the dishwasher; - A four x four in. tile broken and pushed into the wall on the right hand corner of the walk-in refrigerator; - Five flies in the dishwasher area and one fly landed on the tray of clean glasses. Observation on 8/4/22 at 9:34 A.M., showed: - [NAME] C placed the pureed chicken in a metal container and placed the container on the steam table; - Mashed potatoes and gravy present in containers on the steam table; - At 10:03 A.M., [NAME] C placed the prepared broccoli on the steam table; - [NAME] C placed food on the steam table more than 30 minutes before serving the meal. During an interview on 8/4/22 at 10:10 A.M., [NAME] C said they would start to prepare the hall trays at 11:15 A.M., and the food was not to be left on the steam table for more than two hours. During an interview on 8/4/22 at 9:00 A.M. , the Dietary Manager (DM) said he/she did not realize the ice machine drain pipe could not be down inside the floor drain. He/she did not realize there needed to be a one and one half in. air gap between the ice machine drain pipe and the floor drain. The DM said the drain from the hand washing sink also emptied into the same floor drain and the drain had overflowed at one time. There was calcium deposit build up on the floor and the wall since the drain had overflowed in the past. During an interview on 8/4/22 at 2:00 P.M., the DM said food should not be added to the steam table more than 30 minutes before a meal was served. He/she knew ice had built up on the upright freezer in the back of the kitchen, but did not realize the seal was broken or there was a build up of a black substance on the seals. He/she said the dishwashing racks did not belong on the floor. They had rolling carts for those to be placed on. During an interview on 8/5/22 at 1:00 P.M., the Director of Nursing (DON) said staff should not touch the tops of glasses when they serve drinks to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review showed the facility failed to maintain an effective pest control program for five residents (Resident #18, #26, #48, #61 and #63) out of 15 sampled residents and two residents outside of the sample (Residents #33 and #41). This practice had the potential to affect all residents in the facility. The facility's census was 58. Record review of facility's Pest Control policy, revised on May 2008, showed: - The facility maintains an on-going pest control program to ensure the building will be kept free of insects and rodents; - Pest Control Services provided by Orkin Pest Control Services in Sikeston, MO; - Windows will be screened at all times; - Only approved Food and Drug Administration (FDA) (responsible for protecting the public health by assuring the safety, efficacy, and security of human drugs, biological products, medical devices, our nation's food supply, cosmetics and products that emit radiation) and Environmental Protection Agency (EPA) (protects people and the environment from significant health risks, sponsors and conducts research and develops and enforces environmental regulations) insecticides and rodenticides will be permitted in the facility and all such supplies will be stored in areas away from food storage areas; - Garbage and trash will not be permitted to accumulate and will be removed from the facility daily; - Maintenance services assists, when appropriate and necessary, in providing pest control services. Record review of the Work Request Log for Bugs showed: - On 7/22/22, roaches in the memory care dining room with request not addressed; - On 7/27/22, roaches in the room and bathroom of room [ROOM NUMBER], as well as roaches in the memory care shower room and sink area with request not addressed; - On 8/4/22, roaches in the memory unit shower room with request not addressed. Record review of Resident Council Minutes, dated 6/15/22, showed: - New business of too many flies in the facility. Record review of Resident Council Minutes, dated, 7/20/22, showed: - New business of too many flies in the facility. 1. Record review of Resident #18's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 4/15/22, showed: - Cognitively intact. Observation on 8/3/22 at 8:38 A.M., showed: - Two flies flew in Resident #18's face in his/her room. During an interview on 8/3/22 at 8:38 A.M., Resident #18 said he/she keeps a fly swatter because the flies get bad. The staff told him/her not to take the flyswatter into the dining room or the common areas. He/she was not really sure what they can do about the flies, but they keep getting in. During an interview on 8/3/22 at 10:15 A.M., Resident #18 said while in attendance at the Resident Council Meeting, he/she purchased himself/herself and his/her roommate fly swatters to use in their room. The flies get in due to the staff and the residents opening the doors to the outside and they deal with them the best they can. 2. Record review of Resident #26's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment. Observation on 8/4/22 at 8:30 A.M., showed: - One fly flew inside Resident # 26's cup of coffee in the dining room on the memory care unit. 3. Record review of Resident #33's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment. Observation on 8/3/22 at 11:29 A.M., showed: - One fly flew inside Resident # 33's cup of koolaid in the memory care dining room. 4. Record review of Resident #41's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment. Observation on 8/4/22 at 2:25 P.M., showed: - Two large roaches, one medium roach, and two small roaches crawled on the walls and the floor of the memory care unit shower room during Resident #41's shower. One spider crawled out of the shower stall area during Resident #41's shower. One fly sat on the towel used to dry Resident #41 after the shower. 5. Record review of Resident #48's quarterly MDS, dated [DATE], showed: - Moderate cognitive impairment. Observations showed: - On 8/2/22 at 3:00 P.M., Resident #48 swatted at a fly in his/her room; - On 8/4/22 at 3:30 P.M., a fly flew in Resident #48's room and the resident swatted at the fly. During an interview on 8/4/22 at 3:30 P.M., Resident #48 said there were flies in his/her room all the time and the flies were annoying. The flies had also bitten him/her and it hurt. 6. Record Review of Resident #61's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment. Observations showed: - On 8/3/22 at 11:33 A.M.,a fly flew on the top rim of Resident #61's shake glass and a second fly landed on the resident's mashed potatoes in the memory care unit dining room; - On 8/5/22 at 8:40 A.M., one fly sat on Resident #61's arm. 7. Record review of Resident #63's admission MDS, dated [DATE], showed: - Severe cognitive impairment. Observations of Resident #63 showed: - On 8/2/22 at 12:00 P.M., the resident sat in a wheelchair at the bedside table in his/her room with six flies that flew around the resident's plate and landed on the resident's food. - On 8/2/22 at 3:00 P.M., the resident lay in bed with a blanket over his/her head and seven flies flew around and landed on the resident's bed and blanket; - On 8/3/22 at 8:36 A.M., the resident sat on the side of the bed and ate breakfast with six flies that flew around the resident's bed and plate of food; - On 8/5/22 at 08:17 A.M., the resident's breakfast tray sat on the bedside table in the resident's room while the resident lay in bed with his/her eyes closed and two flies sat on the resident's food. Two additional flies flew in the hallway outside of the resident's room. Observations of the facility showed: - On 8/3/22 at 10:15 A.M., a fly flew around the residents that attended the Resident Council meeting in the main dining room; - On 8/4/22 at 1:02 P.M., one small roach crawled on the shower wall in the memory care unit shower room; - On 8/5/22 at 11:23 A.M., a large roach crawled between the mirror and the cabinet in the memory care unit shower room. During an interview on 8/4/22 at 2:30 P.M., Certified Nurse Assistant (CNA) A said he/she had seen roaches in the shower room and sometimes flies. The flies were worse in the dinning room. During an interview on 8/5/22 at 8:44 A.M., the Housekeeping Supervisor said if bugs were seen, it was documented in a log up at the nurse's station and then maintenance notified Orkin to come spray. During an interview on 8/5/22 at 11:40 A.M., the Maintenance Director said staff list areas and types of bugs on the bug log. The list was checked two to three times a day. The list was initialed if the store type pesticide was used. Otherwise it wasn't initialed if Orkin came in. Orkin comes in once a month and will come in as needed. During an interview on 8/5/22 at 1:30 P.M., the Administrator said she would expect the facility to have adequate pest control. She would expect the residents to be able to eat without flies flying around or landing in their food.