CHEROKEE ROSE NURSING AND REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess residents for risk of entrapment from bed rails prior to installation and/or review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of 1 of 4 (Resident # 3) reviewed for the use of bed rails. The facility failed to ensure that a bed rail assessment and bed rail consent was completed for Resident # 3 or Resident # 3's family representative. This failure could have placed residents at increased risks for entrapment in bed rails and for lack of informed consent regarding the risks associated with use of bed rails. The findings included:Record review of Resident #3's face sheet dated 8/6/2025 revealed Resident #3 was an [AGE] year-old female admitted on [DATE] with a readmission on [DATE] with the following diagnoses fracture of right femur, high blood pressure, heart disease and weakness.Record review of Resident #3's admission MDS dated [DATE] revealed: Section C- Cognitive Patterns revealed Resident # 3 had a BIMS score of 13 (cognitively intact).Record review of physician orders dated 08/06/2025 revealed: start date 07/14/2025 1/4 side rails up x2 while in bed for mobility every shift.Record review of Resident #3's care plan dated 07/08/2025 revealed interventions of side rails: quarter rails up as per doctor order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN to avoid injury. Date Initiated: 07/14/2025Record review of Resident #3's electronic medical chart on 08/05/2025 revealed no evidence of a completed bed rail assessment or bed rails consent. Observation and interview on 08/05/2025 at 1:35 PM Resident #3 was sitting in his wheel chair in the doorway of his room. Resident #3's bed had 1/4 bed rails on both of sides. Resident #3 stated he used the bed rails to move around in his bed. Observation on 08/06/2025 at 11:20 AM Resident #3 was lying in his bed in his room sleeping, bed rails were on both sides of his bed. During an interview on 08/06/2025 at 11:35 AM Resident #3's Representative stated she did not remember signing a consent for Resident #3 to have bed rails on his bed. Resident #3's Representative stated there was no problem with Resident #3 having bed rails on his bed. During an interview on 08/06/2025 at 3:30 PM the ADON stated she had only been at the facility as the ADON for a week. The ADON stated consents for bed rails and bed rail assessments should have been completed before bed rails were placed on bed. The ADON stated the consents and assessments should have been completed and in the resident's electronic medical chart. During an interview on at 08/06/2025 at 4:00 PM the ADMN stated her expectation was for there to have been a bed rail consent and a bed rail assessment prior to bed rails being placed on a bed. The ADMN stated the charge nurse would have been responsible to complete the assessment and the consent, but the ultimately the DON would be responsible to ensure they were done. The DON was responsible to monitor the completion of bed rail consent and bed rail assessments were completed. The ADMN stated the effect on residents could have been unnecessary injury or a restraint. The ADMN stated what led to the failure of consents and assessment not being completed was there had been turnover in the DON position. Record review of facility policy titled, Bed Rails dated November 8, 2016, revealed: Assess the resident for risk or entrapment from bed rails prior to installation. Review the risks and benefits of bed rails with the resident or resident representative and obtained informed consent prior to installation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accommodate residents' needs and preferences for 3 of 19 (Resident #8, Resident # 21, and Resident #37) residents reviewed for accommodation of needs.<BR/>The facility failed to ensure Resident #8, Resident #21, and Resident #37 call lights were within reach. <BR/>This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.<BR/>Findings included:<BR/>Resident #8<BR/>Review of Resident #8's electronic face sheet dated 12/13/2024 revealed a [AGE] year-old female admitted on [DATE] and most recently admitted on [DATE] with following diagnosis: dementia, senile degeneration of brain (mental deterioration that is associated with old age), difficulty walking, unsteadiness on feet, lack of coordination, history of falling, and muscle weakness. <BR/>Review of Resident #8's significant change MDS dated [DATE] revealed: BIMS score of 01 which indicated severe cognitive impairment. Section GG: Functional Abilities revealed Resident #8 needed partial to moderate assistance of staff for bed mobility, sitting to standing, and bed to chair transfer.<BR/>Review of Resident #8's most recent comprehensive care plan reviewed on 12/13/2024 revealed: Resident #8 had a risk for falls with interventions that included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 07/02/2021. <BR/>During an observation and attempted interview on 12/10/2024 at 8:30 a.m., Resident #8 was lying in bed. She did not answer questions, and no discomfort or distress observed. The call light was not in reach of the resident's bed and was on the other side of the room's privacy curtain. <BR/>Resident #21<BR/>Review of Resident #21's electronic face sheet revealed an [AGE] year-old female admitted on [DATE] and most recently admitted on [DATE] with the following diagnosis: muscle weakness, abnormalities of gait and mobility, and unsteadiness on feet.<BR/>Review of Resident #21's quarterly MDS dated [DATE] revealed: BIMS score of 09 which indicated moderate cognitive impairment. Section GG: Functional Abilities revealed Resident #21 was dependent on staff for chair to bed transfers and for sitting to standing.<BR/>Review of Resident #21's most recent comprehensive care plan reviewed on 12/13/2024 revealed: Resident #21 was at continued risk for falls with interventions that included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 05/25/2022.<BR/>During an observation and interview on 12/10/2024 at 7:55 a.m., Resident #21 was lying in bed with the head of bed elevated and breakfast sitting on over the bed table. Resident #21 stated she would like more coke. She stated she did not think she had call light. The call light was hanging from the over the bed light down between headboard and mattress of bed and not within arm's length of resident. <BR/>Resident #37<BR/>Review of Resident #37's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] with the following diagnosis: dementia, weakness, unsteadiness on feet, and abnormalities of gait and mobility.<BR/>Review of Resident #37's significant change MDS dated [DATE] revealed: BIMS score of 00 which indicated severe cognitive impairment. Section GG: Functional Abilities revealed Resident #37 was dependent on staff for chair to bed transfers and for sitting to standing.<BR/>Review of Resident #37's most recent comprehensive care plan reviewed on 12/13/2024 revealed: Resident #37 was at risk for falls with interventions that included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 06/26/2022.<BR/>During an observation and attempted interview on 12/11/2024 at 10:24 a.m., Resident #37 was lying in bed. She did not speak, and no distress observed. Resident breathing easily. The call light was not in reach of the resident's bed and was on the other side of the room's privacy curtain. <BR/>During an interview on 12/13/2024 at 9:18 a.m., CNA F stated all residents should have a call light in reach. She stated Resident #8, Resident #21, and Resident #37 could not exit the bed safely without assistance of staff. She stated CNAs were responsible for making sure call lights were within reach and the charge nurses monitor that call lights were in reach. She stated not having call light in reach could cause residents to not be able to call for help.<BR/>During an interview on 12/13/2024 at 9:22 a.m., RN G stated all residents should have a call light in reach. She stated Resident #8, Resident #21, and Resident #37 could not exit bed safely without assistance of staff. She stated CNAs were responsible for making sure call lights were within reach. She stated nurses monitored that CNAs were keeping call lights in residents' reach. She stated not having call light in reach could cause residents to not be able to call for help.<BR/>During an interview on 12/13/2024 at 9:35 a.m., the DON stated her expectation would be for all residents to have call lights in reach. She stated in reach meant within residents' arm length, so residents were able to reach call light. She stated Resident #8 and Resident #37 would not be able to reach a call light that was across the room when they were lying in bed. She stated Resident #21 would not be able to reach a call light that was in between her mattress and headboard. She stated she felt residents being moved from another hall for unplanned construction may have led to call lights not being in reach. She stated everyone in the building were responsible for ensuring residents had access to call lights. She stated the CNAs, nurses, and department heads monitored call lights were within reach of residents. She stated not having a call light in reach could lead to resident not being able to call for assistance. <BR/>During an interview on 12/12/2024 at 11:05 a.m., the ADMN stated her expectation would be for all residents to have call lights in reach. She stated in reach meant within arms distance. She stated that Resident #21 would not be able to reach a call light that was handing in between her mattress. She stated Resident #8 and Resident #37 would not be able to reach a call light on the other side of their room when they were in bed. She stated she did not know why call lights were not in reach but may have been due to unexpected construction and relocation of some residents. She stated that CNAs were responsible for making sure call lights were in reach and nurses were responsible for monitoring that call lights were in reach. She stated not having call light in reach could lead to residents not being able to call for help. She stated the facility did not have call light policy.<BR/>Record review of the facility policy titled Resident [NAME] of Rights no date revealed: Dignity/Self Determination and Participation. You have the right to receive care from the facility in a manner and in an environment that promotes, maintains, or enhances your dignity and response in full recognition of your individually. You have the right to: a. Choose activities, schedules, and health care consistent with your interests, assessments and plans of care. b. Interact with members of the community both inside and outside the nursing facility. C. Make choices about aspects of your life in the nursing facility that is significant to you.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a residents significant change in physical or mental condition was determined for 1 of 19 residents (Residents #47) reviewed for significant change.<BR/>The facility failed to ensure Resident # 47 had a Significant Change Assessment completed after his admission to hospice.<BR/>This failure could contribute to providing an inaccurate assessment of resident's most current medical condition and could lead to failure to not provide necessary care. <BR/>Findings include:<BR/>Record review of Resident #47's electronic face sheet revealed an [AGE] year-old male admitted to the facility 9/13/2024 with a most recent admission on [DATE] with the following diagnosis: Traumatic subdural hemorrhage with loss of consciousness (head injury from trauma with brain bleed), sepsis (infection that has spread to the blood), respiratory failure, and Type 2 diabetes. <BR/>Record review of Resident #47's admission assessment dated [DATE] revealed: Section C-Cognitive Patterns revealed Resident #47 had a BIMS score of 0 meaning severe cognitive impairment; Section O- Special Treatments and Programs revealed no evidence of hospice.<BR/>Record review of Resident #47's hospice records revealed a physician order with a start date of 11/15/2024 after admit Resident #47 to hospice. <BR/>Record review of Resident #47's electronic record on 12/12/2024 revealed no evidence of a Significant Change Assessment completed for Resident #47 when he was admitted to hospice; and no order to admit to hospice.<BR/>During an interview on 12/12/24 at 2:10 PM the DON stated her expectation was a Significant Change Assessment should have been completed within after 14 days of Resident #47 being admitted to hospice. The DON stated the MDS nurse was responsible to complete the Significant Change and nursing was responsible to notify MDS with the change. The DON stated the affect on residents could have received incorrect services. The DON stated she did not know why the Significant Change was not completed stated possible miscommunication. The DON stated they did not have a policy for Significant Change Assessment that they followed the CMS's RAI Manual. <BR/>During an interview on 12/12/2024 at 2:45 PM the RRN stated the MDS nurse was out of office on sick leave for the last 2 days, and she was responsible to complete the Significant Change Assessment. The RRN stated hospice should have triggered for a Significant Change Assessment to be completed and should have been completed when the order for hospice was completed. The RRN stated the MDS nurse was responsible to complete the MDS and the DON and the RRN monitors the completion. The RRN stated the effect on residents could have been plan of care not being updated and loss of revenue. The RRN stated what led to the failure was miscommunication, the nurse that received the order should have entered the order which would have triggered the Significant Change to be completed. <BR/>Review of CMS'S RAI Version 3.0 Manual version 1.17.1 dated October 2019 revealed:<BR/>The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that<BR/>(1) the assessment accurately reflects the resident's status<BR/>(2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals<BR/>(3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.<BR/>Nursing homes are left to determine<BR/>(1) who should participate in the assessment process<BR/>(2) how the assessment process is completed<BR/>(3) how the assessment information is documented while remaining in compliance with the requirements of the Federal regulations and the instructions contained within this manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to 2 (Hall C Med Cart and Hall D Med Cart) of 4 medication carts reviewed for security.<BR/>The facility failed to ensure Hall C and Hall D Medication Cart with prescription medications and biologicals were not left unlocked, unsecured, and unattended.<BR/>These failures could place residents at risk of harm or decline in health due to lack of potency of supplies, medications/biologicals or misappropriation of medications, or drug diversions. <BR/>The findings included:<BR/>Observation on 08/28/22 at 9:55 AM revealed Hall D Med Cart was left unattended and unlocked. Hall D Med Cart was sitting against the wall beside the door to room [ROOM NUMBER]. RN A was in room [ROOM NUMBER] talking with residents, her back was to the hallway. Hall D Med Cart was not in line of site of RN A. Residents were observed walking past the open Hall D Med Cart. <BR/>Observation on 08/28/22 at 10:10 AM of Hall D Med Cart contained the following: eye drops, Nitro, Sertraline, Buspirone, Carbidopa-Levodopa, Hydralazine, Amlodipine, Lisinopril, Lithium, Metoprolol, Lamotrigine, Trazadone, Keppra, Wellbutrin, Duloxetine, Paroxetine, Carvedilol, Isosorbide, Clopidogrel, Losartan, Diltiazem, Milk of Magnesium, Robitussin, Pepto-Bismol, Mylanta, Nystatin, Lactulose, and Nose sprays. The following controlled medications were not under double lock: Morphine, Lorazepam, Nitrofurantoin, Norco, Lyrica, Clonazepam, Oxycodone, and Tramadol. <BR/>Observation on 08/30/22 at 2:05 PM revealed Hall C Med Cart was left unattended and unlocked. Hall C Med Cart was parked on the outside wall of the nurse's station. LVN B walked away from Hall C Med Cart without locking cart and entered medication room, no other nursing staff was observed at nurse's station. Residents were observed walking down hall passing the unlocked Hall C Medication Cart.<BR/>Observation on 08/28/22 at 2:10 PM of Hall C Med Cart contained the following: eye drops, Lasik, Levetiracetam, Losartan, Sertraline, Risperidone, Lisinopril, Tamsulosin, Baclofen, Trazadone, Mirtazapine, Fluoxetine, Fluphenazine, Divalproex, Metoprolol, Sucralfate, Gabapentin, Olanzapine, Bicalutamide, Eliquis, Rosuvastatin, Ranolazine, Buspar, Desmopressin, Albuterol, Mucinex, and Nasal Spray. The following controlled medications were not under double lock: Alprazolam, Modafinil, Clobazam, Hydrocodone, and Tramadol.<BR/>During an interview on 08/28/22 at 10:10 AM with RN A, she stated medication carts should be locked whenever unattended. RN A stated she had entered resident's room and must have forgotten to lock the cart. RN A stated if a resident were to get into and unlocked med cart it would not be good. RN A stated resident could have adverse reactions, which could lead to minimal or server harm. RN A stated she was trained on securing medication in nursing school. <BR/>During an interview on 08/30/22 at 11:19 AM with the ADMN, she stated her expectation was that medication carts were to be locked at all times and never be left unattended while unlocked. The ADMN stated the nurse assigned to cart for the shift was responsible to ensure medication cart was not left unattended when unlocked. The ADMN stated the DON, ADON and the ADMN were ultimately responsible to ensure carts were locked. The ADMN stated she monitored carts frequently when she was on the floor, by looking at carts and pulling drawers. The ADMN stated unlocked med carts could affect residents by a resident could take medications that were not theirs, which could have interfered with their medications causing side effects with a potential for minimal to severe harm. The ADMN stated what led to failure of medication carts left unattended and unlocked was the weekend RN A supervisor had to work the floor (because a nurse called in) and got distracted. <BR/>During an interview on 08/30/22 at 12:58 PM with the DON, she stated medication carts were to be always locked, medication carts should not be left unattended while unlocked. The DON stated nurses should have eye contact with cart when it is unlocked. The DON stated the nurse or medication that had keys to medication cart was responsible to ensure cart not left unlocked and unattended. The DON stated she monitored medication cart when she was out on the floor, she would look to see if carts were unlocked by pulling on drawers and reeducate staff if she found an unlocked cart. The DON stated the affect to residents was a resident could take a medication that was not theirs, which could have caused a negative impact to resident, or another resident's medication could be lost. The DON stated what led to failure of carts left unlocked and unattended was staff not realizing unlocked cart needed to be in line of sight, needed reeducation for securing medication carts. <BR/>During an interview on 08/30/22 at 2:18 PM with LVN B, she stated she thought she had pushed the button to lock cart, that she was always good about locking cart. LVN B stated the effect on residents could have been resident get sick or worse. LVN B stated securing medications was common nurse training. <BR/>Record review of facility's policy titled, Storage of Medication, dated 2003 revealed: Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medication (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked and attended by persons with authorized access.<BR/>Record review of facility's policy titled, Storage and Documentation of Schedule II Controlled Medications, dated 2003 revealed: All Schedule II controlled medications will be stored under double lock

Based on observation, interviews, and record review, the facility failed to ensure the menus met the nutritional needs of residents in accordance with established guidelines and were followed for 1 of 1 meal (lunch meal on 12/10/2024) reviewed for menus being followed.<BR/>The facility did not prepare or serve the posted items included on the menu as recommended by the licensed dietician.<BR/>This failure could affect all residents who ate the food prepared for the lunch meal on 12/10/2024, by placing them at risk of not receiving adequate nutritive value and calorie intake needed to promote and maintain good health. <BR/>Findings include:<BR/>During an observation on 12/10/2024 at 8:10 a.m., the menu on the bulletin board posted in the dining room outside the kitchen door was set up in cycles which set the meals in five-week rotation of meals. The menu for the lunch meal dated 12/10/2024 was: Grilled steak with onions, baked potatoes, saut&eacute;ed broccoli, honey kissed rolled, margarine, sour cream, cheese, cheesecake with fruit topping and tea. <BR/>During an interview on 12/10/2024 at 10:25 a.m., [NAME] I said she said she did not follow or use recipes because<BR/>the facility did not have the item that was on the menu. She said she was substituting Grilled steak with onions with Salisbury steak, and she was not sure if she was serving baked potatoes. [NAME] I said the facility did not have broccoli so she was substituting mixed vegetables and thought she would serve garlic, parmesan mashed potatoes. She said the kitchen would serve green Jell-O with fruit instead of cheesecake. [NAME] I said when the kitchen did not have an item, she would substitute a dish as close as possible to the item she was substituting. <BR/>During an interview on 12/10/2024 at 10:29 a.m., the Regional Certified Dietary Manager said the staff should follow the menu because substitutions would change the overall calorie intake of the meal and have a negative effective on the resident's diet. The Regional Certified Dietary Manager said [NAME] I did not follow the facility's policy and the change could have affected the resident's negatively by changing the overall daily nutritional value and intake. <BR/>During a follow-up interview on 12/10/2024 at 1:18 p.m., the Regional Certified Dietary Manager said the reason the facility did not serve steak was because the facility had an abundant supply of beef patties. The Regional Certified Dietary Manager said prior to the new facility Dietary Manager, who started her position three (3) weeks prior, no one completed inventory. The Regional Certified Dietary Manager said [NAME] I, who had prepared the lunch meal, was defiant and the fact that she did not follow the menu did not meet her expectations. <BR/>During an interview on 12/12/2024 at 1:20 p.m., [NAME] H said knew she was required to follow the menu and if she needed to substitute any item, she would ask the manager. <BR/>During an interview on 12/12/2024 at 1:35 p.m., the Dietary Manager said her expectations were for the cooks to follow the menu. The Dietary Manager said the substitution log was blank and the previous logs were missing. The Dietary Manager said she was responsible to ensure the menu items were ordered and available and to provide oversight and supervision of the dietary staff. The Dietary Manager said she was responsible to ensure dietary staff followed the menu.<BR/>Record review of the substitution logs for December 2024 revealed the logs were blank.<BR/>Record review of the facility's policy, Resident Menus, dated 2012, revealed the facility will strive to assure the resident's nutritional needs are provided based on the RDA. The standard menu will ensure nutritional adequacy of all diets, offer a variety of food in adequate amount at each meal, and standardize food production. Alternates for noon and evening meal will be planned and recorded. Alternates shall be of comparable nutritive value and the alternate food shall come from the same food group. If any meal served varies from the planned menu, the change and reason for the change shall be noted on the substitution log.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. <BR/>The Facility failed to ensure foods were sealed and/or labeled properly in dry food storage area, the kitchen refrigerators, and the freezers.<BR/>These failures could place residents that eat out of the kitchen at risk for food borne illnesses.<BR/>Findings included: <BR/>During an observation on 08/28/2022 from 10:15AM to 10:40AM of the kitchen revealed:<BR/>Dry Storage Area: <BR/>1. One large bag of elbow macaroni in bag not sealed and no date on bag.<BR/>2. Four jars of pickled Okra with no date<BR/>3. One box of butterscotch pudding on the floor with six other boxes containing canned goods stacked on top.<BR/>Chest freezer: <BR/>1. One large bag of frozen squash round in orginal labeled or dated<BR/>2. One bag frozen of chicken wing not labeled or dated. <BR/>3. One bag frozen of chicken leg not labeled or dated<BR/>4. Three bags frozen of chicken breasts not labeled or dated<BR/>Refrigerator #1 with top freezer:<BR/>1. One opened bag celery stalk not sealed or dated<BR/>2. Three opened bags celery stalks not labeled or dated<BR/>3. One bag cucumber not sealed or dated<BR/>4. One silver container with lid, double compartment with gel-like food product with no label or date.<BR/>Refrigerator # 2: <BR/>1. Two bags of yellow liquid with no date and not labeled<BR/>2. One gallon container of ice cream with no date and not labeled<BR/>Freezer #2 revealed:<BR/>1. One bag of tortellini with no date or label<BR/>2. One bag of pot pie filling with no date or label<BR/>3. One bag of Brussel sprouts with no date or label<BR/>4. One bag of mini taco with no date or label<BR/>During an interview on 08/28/2022 at 10:35 AM, [NAME] A stated the boxes had been on the floor since 08/25/2022. She stated they should be stored on the racks. She stated she did not know why this happened, she stated she had been off.<BR/>During an Interview on 08/28/22 at 11:30 AM, DM stated all dietary staff were responsible for labeling products the date received. She stated if the product was leftovers the date to be removed was three days after product was made. She stated in dry storage the canned goods were in boxes on the floor due to a leak in the wall area that had to be fixed and sheetrock replaced. She stated there were no other place to store the canned goods during this process. She stated all products should be stored at least 6 inches off the floor.<BR/>During an interview on 08/30/2022 at 08:30 AM, DM stated she was responsible for monitoring that all products are labeled and stored properly. She stated staff was also responsible for labeling and storing products when they are delivered. She stated she did not know why the failure occurred. She stated the dietary staff was trained on storage and labeling upon hire and as needed. She stated the effect on the residents could be if the food product was out of date and not good it could cause the resident to get a food born illness. <BR/>During an interview on 08/30/2022 at 10:29 AM, ADMIN stated her expectations was that all items were dated and labeled as they come into the kitchen. She stated she did not know why the failure occurred. She stated she made rounds in kitchen for monitoring of storage of products and labeling. She stated the canned goods stored on the floor had only been there for two days due to a pipe bursting and needing to replace sheetrock in dry storage area. She stated the failure to properly label could place residents at risk for food borne illness. She stated that all dietary staff were trained on how to label and store all products for the kitchen.<BR/>Review of DM employee file revealed training on storage and labeling on 05/01/2022<BR/>Review of facility policy titled: Dry Storage and Supplies dated 2012<BR/>All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects.<BR/>Procedure:<BR/>1. <BR/> Storerooms are to be well lighted, ventilated and temperature controlled.<BR/>b. All food and supplies and supplies are to be stored six (6) inches above the floor on surfaces which facilitate thorough cleaning.<BR/>4. Open packages of food are stored in closed containers with tight l covers and dated as to when opened.<BR/>Review of facility policy titled: Storage Refrigerators dated 2012<BR/>All storage refrigerators shall be maintained clean and have proper temperature for food storage and to ensure a proper environment and temperature for food storage.<BR/> 5. Food must be covered when stored with a date label identifying what is in the container.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program to prevent the development and transmission of communicable diseases and infections for 3 of 3 (Resident #94,6, #14) residents on the warm unit with unknown Covid status/hot unit Covid positive, reviewed for infection control. <BR/>CNA-A was passing lunch meal trays on the warm/hot resident hall and did not wear eye protection upon entering resident room for 2 of 2 persons with unknown Covid status and 1 of 1 Covid positive residents.<BR/>This failure placed all residents at risk for exposure by staff to Covid 19. <BR/>Findings included:<BR/>Record review of Resident #94 Facesheet dated 8/30/22 revealed: A [AGE] year-old female with an admission date of 8/24/22. Her diagnosis list included: Cerebral infarction (Primary), Celiac disease, Malnutrition, Atrial fibrillation, Contact with and suspected exposure to other viral communicable diseases, Hemiplegia.<BR/>Record review of Resident #94 Vaccination Status revealed: Refusal for Covid-19, Flu, Pneumonia vaccinations. <BR/>During an observation on 08/28/22 at 12:20 PM, CNA-A failed to don eye protection when CNA-A went into Resident #94 room to deliver a meal tray that was unknown covid status due to hospital stay.<BR/>Record review of Resident #6 Facesheet dated 08/30/22 revealed: A [AGE] year-old male admitted to the facility 7/30/04 with a diagnosis list that included: Dementia, Malnutrition, Covid-19 (11/12/20), Schizophrenia, Glaucoma, Communicating hydrocephalous, Exposure to other viral communicable diseases.<BR/>Record review of Resident #6 Vaccination status revealed: 1 dose of Covid-19 10/01/21.<BR/>During an observation on 08/28/22 at 12:23 PM, CNA-A failed to don eye protection when CNA-A went into Resident #6 room to deliver a meal tray that was unknown covid status due to exposure to Covid.<BR/>Record review of Resident #14 Facesheet dated 8/30/22 revealed: A [AGE] year-old male admitted to the facility on [DATE] with a diagnosis list that included: Alzheimer's disease, Gastrointestinal hemorrhage, Covid-19 (08/18/22), Pneumonia, Malnutrition. <BR/>Record review of Resident #14 Vaccination status revealed: Historical 2nd dose Covid-19 04/02/21.<BR/>During an observation on 08/28/22 at 12:25 PM CNA-A failed to don eye protection when CNA-A went into Resident #14 room to deliver a meal tray that was Covid positive.<BR/>During an interview on 08/26/22 at 12:27 PM, DON said any of the residents that are on the warm unit for PUI for Covid or hot unit because of Confirmed Covid, the staff should have on either a face shield or goggles to protect their eyes. Prescription glasses does not constitute eye protection. She said there were boxes of supplies in the room midway down that hall that were full of face shields, the staff can use those and store them in that room on the table with their name on them. Staff is supposed to clean the shield each time they leave a resident room on the warm/hot unit with the bleach sani wipes.<BR/>During an interview on 08/28/22 at 12:29 PM, CNA-A said the staff was supposed to change all PPE each time on the warm/hot unit. PPE included a N95 mask, gown, gloves and with the hot Covid positive resident rooms a face shield was included. CNA-A said he was not aware that a face shield was required with a resident on the warm unit. He said the reason for a face shield was to protect the person from small particles that could include spit. He said that even when a resident talked, they could emit small particles of spit. CNA-A said he was an agency aide that worked every weekend for the past 6 months and he was usually the only person that worked on the warm/hot unit on the weekends. He said that residents on the warm unit were either exposed in the facility through a roommate to Covid or they were a new admission from the hospital, where there was a very real chance, they could have contracted Covid and just not showing positive yet. CNA-A said he did not wear the face shield for the 2 residents that were on the warm unit as PUI because he thought he did not have to. CNA-A said he did not wear a face shield for the resident that was Covid positive because that resident was due to leave the quarantine area the next day as this was day 10 of quarantine for that resident. He said he had been trained by the facility with ICP that included donning and doffing of PPE.<BR/>During an interview on 08/28/22 at 12:42 PM, DON said all agency had to do an orientation for the facility before they started working with the residents. She said donning and doffing PPE was a part of the orientation training. DON said the reason CNA-A did not wear the face shield could have been because it had been a while since he did the training and maybe he just forgot. <BR/>During an interview on 08/28/22 at 03:00 PM, DON said that any resident that tested positive for Covid 19 were quarantined for 10 full days. Any resident that was exposed through a roommate testing positive for Covid was quarantined for 10 days. She said any resident that was a new admission was quarantined for 5 days if they were fully vaccinated or 10 days if they were unvaccinated. In the case of the residents on the warm unit, Resident # 94 was a new admission on [DATE] and she was unvaccinated. Resident # 6 was exposed through a roommate on 8/10/22, then had a roommate on the warm unit that tested positive on 8/18/22 and Resident # 14 tested positive for Covid on 8/18/22. DON and ADON provided CNA-A orientation training and check off training for donning/doffing PPE.<BR/>Record review of CNA-A orientation training was signed by CNA-A and DON was dated 07/01/22 by CNA-A and 07/12/22 by DON. It included orientation training on donning/doffing PPE.<BR/>Record review of CNA-A donning/doffing competency training was signed by ADON but was undated It included determining and assembling appropriate PPE, donning goggles or face shield and doffing goggles/face shield. ADON checked that yes, CNA-A showed competency with these tasks.<BR/>Record review of ICPP Manual dated 2018 revealed: SARS precautions to use as follows airborne precautions preferred droplet if AIIR precautions unavailable; N95 or higher respiratory protection; surgical mask if N95 unavailable; eye protection (goggles, face shield); aerosol generating procedures and Supershedders highest risk for transmission via small droplet nuclei and large droplets 93, 94, 96. Vigilant environmental disinfection.<BR/>Record review of Facility Policy labeled Positive Resident in Facility Protocol undated revealed: Hot zone-residents with active Covid-19. Warm zone- new admissions/readmissions who are not fully vaccinated, residents with exposure to Covid-19, ie their roommate was positive . Place any resident who is positive in the Hot Zone. Place any negative roommates of the positive resident or other residents exposed in the Warm Zone . Place PPE (gloves, gowns, N95, eye protection) carts at the entrance of each resident who is on the Warm or Hot Zone . Staff caring for a Warm or Hot Zone resident should don all appropriate PPE when entering room and doff PPE when exiting the room . Re-inservice on contact/droplet precautions.<BR/>Record review of CDC Precautions Guidelines accessed at https://www.cdc.gov/sars/guidance/i-infection/healthcare.html on 9/1/22 revealed: Gloves, gown, respiratory protection, and eye protection . should be donned before entering a SARS patient's room or designated SARS patient-care area . Healthcare workers should wear gown, gloves, respiratory protection, and eye protection . Droplet Precautions: Make sure eyes, nose, mouth are fully covered before room entry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #31) reviewed for accidents and supervision. <BR/>The CNA and NA failed to lock the Hoyer lift (a patient lift used by caregivers to safely transfer patients) during a transfer of Resident #31. <BR/>This failure could place residents at risk of injuries.<BR/>Findings included:<BR/>Record Review of Resident #31's electronic face sheet revealed the resident was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses to include: Abnormalities of the gait and mobility, Disorders of the bone in the upper arm, and Stiffness of the right and left arm. <BR/>Review of Resident #31's Quarterly MDS assessment dated [DATE], revealed: Section C: Cognitive Patterns: BIMS score (08) indicating moderate cognitive impairment. Section G: Transfer: Extensive assistance with two-person physical assist.<BR/>Review of Resident's #31's electronic comprehensive care plan initiated 08/27/2023, revealed: Problem: Self-care deficit: requires assistance. Focus: The resident has had an actual fall related to weakness. [Resident #31] is a Hoyer Lift for transfers and requires staff assistance for ADL care. Goals: The resident will resume usual activities without further incident through the review date. <BR/>During an observation on 10/24/2023 at 9:24 AM revealed the CNA and the NA did not lock the Hoyer Lift prior to lifting resident and did not lock the wheelchair prior to transferring Resident #31 from his wheelchair to his bed. <BR/>During an interview on 10/24/2023 at 9:40 AM the CNA stated the wheelchair and Hoyer Lift should have been locked before lifting Resident #31. She stated once at the bed and before lowering the resident, the Hoyer Lift should also have been locked. The CNA stated she had not locked the resident's wheelchair or Hoyer Lift at any time during the transfer and in not doing so, the Hoyer could have rolled resulting in the resident falling .<BR/>During an interview on 10/24/2023 at 10:42 AM the DON stated she and therapy staff had performed staff in-services for transfering residnets with a a Hoyer Lift every quarter but had no documentation to show it had been completed. She stated the procedures for the mechanical Hoyer lift was a two person transfer with one staff to operate and the other staff to monitor the resident and transfer. The staff were to always lock the wheelchair as well as the Hoyer lift before transferring a resident. The DON stated once the Hoyer lift was at the resident's bed, the Hoyer was to again be locked before the resident was lowered. The DON stated she and the ADON were to monitor in-services with staff for transgering with a Hoyer lift, but had not documented them in the in-service logs. The DON stated the negative affect could have been a possible injury to the resident. The DON stated the lack of sufficient monitoring and training of staff led to the failure. The DON stated her expectation was staff were to lock the wheel chair and the hoyer lift when transferring residents. She stated her expectations were to monitor staff thoroughly with proper in-services, making sure they understood the policies and procedures. <BR/>Record Review of personnel files for CNA and NA revealed no evidence of training for the Hydraulic Hoyer Lift.<BR/>Record Review of the facility policy titled Hydraulic Lift not dated, revealed:<BR/>Goals<BR/>1. <BR/>The resident will achieve safe transfer to bed or chair via a mechanical lift device. <BR/>2. <BR/>The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair <BR/>Procedure<BR/> 6. <BR/> Lock the wheel chair or Geri chair<BR/> 8. Lock or unlock the base wheels according to the lift manufacturer's recommendation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure CNA's and NA's were able to demonstrate appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 of 2 (CNA, NA) staff reviewed for Hoyer Lift transfers. <BR/>The facility failed to ensure the CNA and NA had competency in skills and techniques necessary to care for residents' needs. <BR/>This failure could place residents requiring incontinent care at risk for the spread of infections, skin breakdown, and decreased quality of life. <BR/>Findings include:<BR/>Record Review of Resident #31's electronic face sheet revealed resident was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses to include: Abnormalities of the gait and mobility, Disorders of the bone in the upper arm, and Stiffness of the right and left arm. <BR/>Review of Resident #31's Quarterly MDS assessment dated [DATE], revealed: Section C: Cognitive Patterns: BIMS score (08) indicating moderate cognitive impairment. Section G: Transfer: Extensive assistance with two-person physical assist.<BR/>Review of Resident's #31's electronic comprehensive care plan initiated 08/27/2023, revealed: Problem: Self-care deficit: requires assistance. Focus: The resident has had an actual fall related to weakness. Resident #31 is a Hoyer Lift for transfers and requires staff assistance for ADL care. Goals: The resident will resume usual activities without further incident through the review date. <BR/>During an observation on 10/24/2023 at 9:24 AM the CNA and the NA did not lock the Hoyer Lift while transferring Resident #31 from his wheelchair to his bed. <BR/>During an interview on 10/24/2023 at 9:40 AM the CNA stated the wheelchair and Hoyer Lift should have been locked before lifting Resident #31. She stated once at the bed and before lowering the resident, the Hoyer Lift should also have been locked. The CNA stated she had not locked the resident wheelchair or Hoyer Lift at any time during the transfer and in not doing so, the Hoyer could have rolled resulting in the resident falling. The CNA stated she had been trained she should have locked the wheels to Hoyer Lift and wheelchair prior to transferring the resident.<BR/>During an interview on 10/24/2023 at 10:42 AM the DON stated her expectation was that staff are trained and know how to correctly use a Hoyer Lift. The DON stated herslef and therapy staff had performed staff in-services every quarter for resident transfers with Hoyer Lift, but had no documentation of in-services being completed. She stated the procedures for the mechanical Hoyer lift was a two person transfer with one staff to operate and the other staff to monitor the resident and transfer. The Staff were to always lock the wheelchair as well as the Hoyer lift before transferring all resident. The DON stated once the Hoyer lift were at the resident bed, the Hoyer was to again be locked before the resident was lowered. The DON stated herself and ADON were to monitor staff and provide in-services for transferring residents with [NAME] lift. The DON stated she was not able to provide documentation of completion of in-services for Hoyer Lifts. The DON stated the negative affect could have been a possible injury to residents. The DON stated the lack of sufficient monitoring and training of staff led to the failure. The DON stated her expectation was staff were to lock the wheel chair and the hoyer lift when transferring residents. She stated her expectations were to monitor staff thoroughly with proper in-services, making sure they understood the policies and procedures. <BR/>Record Review of personnel files CNA and NA revealed no evidence of training for the Hydraulic Hoyer Lift.<BR/>Record Review of facility policy titled Hydraulic Lift not dated, revealed:<BR/>Goals<BR/>1. <BR/>The resident will achieve safe transfer to bed or chair via a mechanical lift device. <BR/>2. <BR/>The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair <BR/>Procedure<BR/> 6. <BR/> Lock the wheel chair or gerichair<BR/> 8. Lock or unlock the base wheels according to the lift manufacturer's recommendation.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. <BR/>The Facility failed to ensure foods were sealed and/or labeled properly in dry food storage area, the kitchen refrigerators, and the freezers.<BR/>These failures could place residents that eat out of the kitchen at risk for food borne illnesses.<BR/>Findings included: <BR/>During an observation on 08/28/2022 from 10:15AM to 10:40AM of the kitchen revealed:<BR/>Dry Storage Area: <BR/>1. One large bag of elbow macaroni in bag not sealed and no date on bag.<BR/>2. Four jars of pickled Okra with no date<BR/>3. One box of butterscotch pudding on the floor with six other boxes containing canned goods stacked on top.<BR/>Chest freezer: <BR/>1. One large bag of frozen squash round in orginal labeled or dated<BR/>2. One bag frozen of chicken wing not labeled or dated. <BR/>3. One bag frozen of chicken leg not labeled or dated<BR/>4. Three bags frozen of chicken breasts not labeled or dated<BR/>Refrigerator #1 with top freezer:<BR/>1. One opened bag celery stalk not sealed or dated<BR/>2. Three opened bags celery stalks not labeled or dated<BR/>3. One bag cucumber not sealed or dated<BR/>4. One silver container with lid, double compartment with gel-like food product with no label or date.<BR/>Refrigerator # 2: <BR/>1. Two bags of yellow liquid with no date and not labeled<BR/>2. One gallon container of ice cream with no date and not labeled<BR/>Freezer #2 revealed:<BR/>1. One bag of tortellini with no date or label<BR/>2. One bag of pot pie filling with no date or label<BR/>3. One bag of Brussel sprouts with no date or label<BR/>4. One bag of mini taco with no date or label<BR/>During an interview on 08/28/2022 at 10:35 AM, [NAME] A stated the boxes had been on the floor since 08/25/2022. She stated they should be stored on the racks. She stated she did not know why this happened, she stated she had been off.<BR/>During an Interview on 08/28/22 at 11:30 AM, DM stated all dietary staff were responsible for labeling products the date received. She stated if the product was leftovers the date to be removed was three days after product was made. She stated in dry storage the canned goods were in boxes on the floor due to a leak in the wall area that had to be fixed and sheetrock replaced. She stated there were no other place to store the canned goods during this process. She stated all products should be stored at least 6 inches off the floor.<BR/>During an interview on 08/30/2022 at 08:30 AM, DM stated she was responsible for monitoring that all products are labeled and stored properly. She stated staff was also responsible for labeling and storing products when they are delivered. She stated she did not know why the failure occurred. She stated the dietary staff was trained on storage and labeling upon hire and as needed. She stated the effect on the residents could be if the food product was out of date and not good it could cause the resident to get a food born illness. <BR/>During an interview on 08/30/2022 at 10:29 AM, ADMIN stated her expectations was that all items were dated and labeled as they come into the kitchen. She stated she did not know why the failure occurred. She stated she made rounds in kitchen for monitoring of storage of products and labeling. She stated the canned goods stored on the floor had only been there for two days due to a pipe bursting and needing to replace sheetrock in dry storage area. She stated the failure to properly label could place residents at risk for food borne illness. She stated that all dietary staff were trained on how to label and store all products for the kitchen.<BR/>Review of DM employee file revealed training on storage and labeling on 05/01/2022<BR/>Review of facility policy titled: Dry Storage and Supplies dated 2012<BR/>All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects.<BR/>Procedure:<BR/>1. <BR/> Storerooms are to be well lighted, ventilated and temperature controlled.<BR/>b. All food and supplies and supplies are to be stored six (6) inches above the floor on surfaces which facilitate thorough cleaning.<BR/>4. Open packages of food are stored in closed containers with tight l covers and dated as to when opened.<BR/>Review of facility policy titled: Storage Refrigerators dated 2012<BR/>All storage refrigerators shall be maintained clean and have proper temperature for food storage and to ensure a proper environment and temperature for food storage.<BR/> 5. Food must be covered when stored with a date label identifying what is in the container.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program to prevent the development and transmission of communicable diseases and infections for 3 of 3 (Resident #94,6, #14) residents on the warm unit with unknown Covid status/hot unit Covid positive, reviewed for infection control. <BR/>CNA-A was passing lunch meal trays on the warm/hot resident hall and did not wear eye protection upon entering resident room for 2 of 2 persons with unknown Covid status and 1 of 1 Covid positive residents.<BR/>This failure placed all residents at risk for exposure by staff to Covid 19. <BR/>Findings included:<BR/>Record review of Resident #94 Facesheet dated 8/30/22 revealed: A [AGE] year-old female with an admission date of 8/24/22. Her diagnosis list included: Cerebral infarction (Primary), Celiac disease, Malnutrition, Atrial fibrillation, Contact with and suspected exposure to other viral communicable diseases, Hemiplegia.<BR/>Record review of Resident #94 Vaccination Status revealed: Refusal for Covid-19, Flu, Pneumonia vaccinations. <BR/>During an observation on 08/28/22 at 12:20 PM, CNA-A failed to don eye protection when CNA-A went into Resident #94 room to deliver a meal tray that was unknown covid status due to hospital stay.<BR/>Record review of Resident #6 Facesheet dated 08/30/22 revealed: A [AGE] year-old male admitted to the facility 7/30/04 with a diagnosis list that included: Dementia, Malnutrition, Covid-19 (11/12/20), Schizophrenia, Glaucoma, Communicating hydrocephalous, Exposure to other viral communicable diseases.<BR/>Record review of Resident #6 Vaccination status revealed: 1 dose of Covid-19 10/01/21.<BR/>During an observation on 08/28/22 at 12:23 PM, CNA-A failed to don eye protection when CNA-A went into Resident #6 room to deliver a meal tray that was unknown covid status due to exposure to Covid.<BR/>Record review of Resident #14 Facesheet dated 8/30/22 revealed: A [AGE] year-old male admitted to the facility on [DATE] with a diagnosis list that included: Alzheimer's disease, Gastrointestinal hemorrhage, Covid-19 (08/18/22), Pneumonia, Malnutrition. <BR/>Record review of Resident #14 Vaccination status revealed: Historical 2nd dose Covid-19 04/02/21.<BR/>During an observation on 08/28/22 at 12:25 PM CNA-A failed to don eye protection when CNA-A went into Resident #14 room to deliver a meal tray that was Covid positive.<BR/>During an interview on 08/26/22 at 12:27 PM, DON said any of the residents that are on the warm unit for PUI for Covid or hot unit because of Confirmed Covid, the staff should have on either a face shield or goggles to protect their eyes. Prescription glasses does not constitute eye protection. She said there were boxes of supplies in the room midway down that hall that were full of face shields, the staff can use those and store them in that room on the table with their name on them. Staff is supposed to clean the shield each time they leave a resident room on the warm/hot unit with the bleach sani wipes.<BR/>During an interview on 08/28/22 at 12:29 PM, CNA-A said the staff was supposed to change all PPE each time on the warm/hot unit. PPE included a N95 mask, gown, gloves and with the hot Covid positive resident rooms a face shield was included. CNA-A said he was not aware that a face shield was required with a resident on the warm unit. He said the reason for a face shield was to protect the person from small particles that could include spit. He said that even when a resident talked, they could emit small particles of spit. CNA-A said he was an agency aide that worked every weekend for the past 6 months and he was usually the only person that worked on the warm/hot unit on the weekends. He said that residents on the warm unit were either exposed in the facility through a roommate to Covid or they were a new admission from the hospital, where there was a very real chance, they could have contracted Covid and just not showing positive yet. CNA-A said he did not wear the face shield for the 2 residents that were on the warm unit as PUI because he thought he did not have to. CNA-A said he did not wear a face shield for the resident that was Covid positive because that resident was due to leave the quarantine area the next day as this was day 10 of quarantine for that resident. He said he had been trained by the facility with ICP that included donning and doffing of PPE.<BR/>During an interview on 08/28/22 at 12:42 PM, DON said all agency had to do an orientation for the facility before they started working with the residents. She said donning and doffing PPE was a part of the orientation training. DON said the reason CNA-A did not wear the face shield could have been because it had been a while since he did the training and maybe he just forgot. <BR/>During an interview on 08/28/22 at 03:00 PM, DON said that any resident that tested positive for Covid 19 were quarantined for 10 full days. Any resident that was exposed through a roommate testing positive for Covid was quarantined for 10 days. She said any resident that was a new admission was quarantined for 5 days if they were fully vaccinated or 10 days if they were unvaccinated. In the case of the residents on the warm unit, Resident # 94 was a new admission on [DATE] and she was unvaccinated. Resident # 6 was exposed through a roommate on 8/10/22, then had a roommate on the warm unit that tested positive on 8/18/22 and Resident # 14 tested positive for Covid on 8/18/22. DON and ADON provided CNA-A orientation training and check off training for donning/doffing PPE.<BR/>Record review of CNA-A orientation training was signed by CNA-A and DON was dated 07/01/22 by CNA-A and 07/12/22 by DON. It included orientation training on donning/doffing PPE.<BR/>Record review of CNA-A donning/doffing competency training was signed by ADON but was undated It included determining and assembling appropriate PPE, donning goggles or face shield and doffing goggles/face shield. ADON checked that yes, CNA-A showed competency with these tasks.<BR/>Record review of ICPP Manual dated 2018 revealed: SARS precautions to use as follows airborne precautions preferred droplet if AIIR precautions unavailable; N95 or higher respiratory protection; surgical mask if N95 unavailable; eye protection (goggles, face shield); aerosol generating procedures and Supershedders highest risk for transmission via small droplet nuclei and large droplets 93, 94, 96. Vigilant environmental disinfection.<BR/>Record review of Facility Policy labeled Positive Resident in Facility Protocol undated revealed: Hot zone-residents with active Covid-19. Warm zone- new admissions/readmissions who are not fully vaccinated, residents with exposure to Covid-19, ie their roommate was positive . Place any resident who is positive in the Hot Zone. Place any negative roommates of the positive resident or other residents exposed in the Warm Zone . Place PPE (gloves, gowns, N95, eye protection) carts at the entrance of each resident who is on the Warm or Hot Zone . Staff caring for a Warm or Hot Zone resident should don all appropriate PPE when entering room and doff PPE when exiting the room . Re-inservice on contact/droplet precautions.<BR/>Record review of CDC Precautions Guidelines accessed at https://www.cdc.gov/sars/guidance/i-infection/healthcare.html on 9/1/22 revealed: Gloves, gown, respiratory protection, and eye protection . should be donned before entering a SARS patient's room or designated SARS patient-care area . Healthcare workers should wear gown, gloves, respiratory protection, and eye protection . Droplet Precautions: Make sure eyes, nose, mouth are fully covered before room entry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of admission and failed to provide a summary of a baseline care plan to the resident or representative for three (Resident #23, Resident #34, Resident #94) of five residents reviewed for baseline care plans.<BR/>1.The facility failed to ensure that Resident #23 had baseline care plan developed 48 hours after being admitted to the facility on [DATE] and failed to provide a copy of a baseline care plan to the resident or representative. <BR/>2.The facility failed to ensure that Resident #34 had a baseline care plan developed 48 hours after being admitted to the facility on [DATE] and failed to provide a copy of a baseline care plan to the resident or representative.<BR/>3.The facility failed to ensure that Resident #94 had a baseline care plan developed 48 hours after being admitted to the facility on [DATE] and failed to provide a copy of a baseline care plan to the resident or representative.<BR/>These failures place the residents at risk of not having continuity of care to safeguard against adverse events that are most likely to occur right after admission. <BR/>Findings included:<BR/>Record review of Resident #23's electronic face sheet dated 08/30/2022 revealed resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Dementia, COVID-19, muscle weakness, and breast cancer. <BR/>Record review of Resident #23's admission MDS dated [DATE] revealed a BIMS score of 06 which indicated severe cognitive impairment. <BR/>Record review of Resident's #23's electronic medical record revealed no evidence of a baseline care plan. Further review revealed no evidence of the summary given to the resident. <BR/>Record review of Resident #23's Baseline Care Plan Acknowledgment assessment dated [DATE] revealed: A copy of the baseline care plan was provided to the resident and a copy of the baseline care plan was provided to the resident representative on 07/05/2022 at 15:00. Further review revealed assessment was signed by the DON. <BR/>Record review of Resident #23's electronic Comprehensive Care Plan dated 07/19/2022 revealed no evidence of any Focus initiated prior to 07/11/2022. <BR/>During an interview on 08/30/2022 at 2:20 PM Resident #23 stated she never received a copy of her baseline care plan, and she was unaware of what a care plan was. <BR/>Record review of Resident #34's face sheet dated 08/30/2022 revealed resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of Alzheimer's, COVID-19, urinary tract infection, and diabetes.<BR/>Record review of Resident #34's Quarterly MDS dated [DATE] revealed a BIMS score of 06 which indicated severe cognitive impairment. <BR/>Record review of Resident's #34's electronic medical record revealed no evidence of a baseline care plan. Further review revealed no evidence of the summary given to the resident. <BR/>Record review of Resident #34's Baseline Care Plan Acknowledgment assessment dated [DATE] revealed: A copy of the baseline care plan was provided to the resident and a copy of the baseline care plan was provided to the resident representative on 07/07/2022 at 13:00 (1:00 PM). Further review revealed assessment was signed by the DON. <BR/>During an interview on 08/30/2022 at 2:30 PM Resident #34 stated she never received a copy of her baseline care plan, and she was unaware of what a care plan was. <BR/>Record review of Resident #94's electronic face sheet dated 08/29/2022 revealed resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of stroke, malnutrition, high blood pressure, irregular heart rate, and arthritis. <BR/>Record review of Resident #94's MDS revealed no evidence of MDS submitted or accepted. <BR/>Record review of Resident #94's BIMS assessment dated [DATE] revealed a BIMS score of 14 which indicated no cognitive impairment. <BR/>Record review of Resident's #94's electronic medical record revealed no evidence of a baseline care plan. Further review revealed no evidence of the summary given to the resident. <BR/>Record review of Resident #94's Baseline Care Plan Acknowledgment assessment dated [DATE] revealed: A copy of the baseline care plan was provided to the resident representative on 08/25/2022 at 10:00. Further review revealed assessment was signed by the DON. <BR/>Record review of Resident #94's electronic Comprehensive Care Plan dated 08/24/2022 revealed: Focus: Contact Precautions. Resident is a new admit to facility unvaccinated from covid. Date Initiated: 08/24/2022. Further review or comprehensive care plan revealed no evidence of any other Focus and no interventions initiated prior to 08/28/2022. <BR/>During an interview on 08/30/2022 at 11:21 AM, the MDS nurse stated the admission nursing assessment triggered care plan areas in the comprehensive care and then the facility began to initiate the care plans. She stated the nurse who did the admission printed out the nursing assessment as the baseline care plan and the comprehensive care plan with the triggered focus areas, reviewed the assessment and the care areas with the residents and representative, and provided the resident and representative with the printed copy. She stated all baseline care areas were addressed with the focus, goal, and interventions within 48 hours. She stated the facility was not aware of there being a failure and she felt the baseline care plans were being done correctly. She stated not having a baseline care plan within 48 hours could put the residents at risk of not receiving adequate care. <BR/>During an interview on 08/30/2022 at 11:45 AM, the DON stated comprehensive care plans are triggered when the admission nursing assessment is completed and used as the baseline care plan, which was done immediately upon admission. She stated she printed a copy of the admission assessment and the triggered care areas, reviewed it with the resident and representative, and provided a copy. She stated the facility did not keep of copy of what documentation was provided. She stated she was responsible for ensuring that the baseline care plan information was entered and reviewed within 48 hours. She stated she was unaware that there was a failure. <BR/>Record review of facility policy titled Base Line Care Plans, not dated revealed: Completion and implementation of the bassline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan .The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to: Initial goals based on admission orders, Physician orders, Dietary orders, Therapy services, Social services, and PASARR recommendations, if applicable .This facility will provide the resident and their representative with a summary of the baseline care plan that includes but not limited: The initial goals of the resident, A summary of the resident's medications and dietary instructions, Any services and treatments to be administered by the facility and personnel acting on behalf of the facility, and Any updated information based on the details of the comprehensive care plan, as necessary. The medical record will contain evidence that the summary was given to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to 2 (Hall C Med Cart and Hall D Med Cart) of 4 medication carts reviewed for security.<BR/>The facility failed to ensure Hall C and Hall D Medication Cart with prescription medications and biologicals were not left unlocked, unsecured, and unattended.<BR/>These failures could place residents at risk of harm or decline in health due to lack of potency of supplies, medications/biologicals or misappropriation of medications, or drug diversions. <BR/>The findings included:<BR/>Observation on 08/28/22 at 9:55 AM revealed Hall D Med Cart was left unattended and unlocked. Hall D Med Cart was sitting against the wall beside the door to room [ROOM NUMBER]. RN A was in room [ROOM NUMBER] talking with residents, her back was to the hallway. Hall D Med Cart was not in line of site of RN A. Residents were observed walking past the open Hall D Med Cart. <BR/>Observation on 08/28/22 at 10:10 AM of Hall D Med Cart contained the following: eye drops, Nitro, Sertraline, Buspirone, Carbidopa-Levodopa, Hydralazine, Amlodipine, Lisinopril, Lithium, Metoprolol, Lamotrigine, Trazadone, Keppra, Wellbutrin, Duloxetine, Paroxetine, Carvedilol, Isosorbide, Clopidogrel, Losartan, Diltiazem, Milk of Magnesium, Robitussin, Pepto-Bismol, Mylanta, Nystatin, Lactulose, and Nose sprays. The following controlled medications were not under double lock: Morphine, Lorazepam, Nitrofurantoin, Norco, Lyrica, Clonazepam, Oxycodone, and Tramadol. <BR/>Observation on 08/30/22 at 2:05 PM revealed Hall C Med Cart was left unattended and unlocked. Hall C Med Cart was parked on the outside wall of the nurse's station. LVN B walked away from Hall C Med Cart without locking cart and entered medication room, no other nursing staff was observed at nurse's station. Residents were observed walking down hall passing the unlocked Hall C Medication Cart.<BR/>Observation on 08/28/22 at 2:10 PM of Hall C Med Cart contained the following: eye drops, Lasik, Levetiracetam, Losartan, Sertraline, Risperidone, Lisinopril, Tamsulosin, Baclofen, Trazadone, Mirtazapine, Fluoxetine, Fluphenazine, Divalproex, Metoprolol, Sucralfate, Gabapentin, Olanzapine, Bicalutamide, Eliquis, Rosuvastatin, Ranolazine, Buspar, Desmopressin, Albuterol, Mucinex, and Nasal Spray. The following controlled medications were not under double lock: Alprazolam, Modafinil, Clobazam, Hydrocodone, and Tramadol.<BR/>During an interview on 08/28/22 at 10:10 AM with RN A, she stated medication carts should be locked whenever unattended. RN A stated she had entered resident's room and must have forgotten to lock the cart. RN A stated if a resident were to get into and unlocked med cart it would not be good. RN A stated resident could have adverse reactions, which could lead to minimal or server harm. RN A stated she was trained on securing medication in nursing school. <BR/>During an interview on 08/30/22 at 11:19 AM with the ADMN, she stated her expectation was that medication carts were to be locked at all times and never be left unattended while unlocked. The ADMN stated the nurse assigned to cart for the shift was responsible to ensure medication cart was not left unattended when unlocked. The ADMN stated the DON, ADON and the ADMN were ultimately responsible to ensure carts were locked. The ADMN stated she monitored carts frequently when she was on the floor, by looking at carts and pulling drawers. The ADMN stated unlocked med carts could affect residents by a resident could take medications that were not theirs, which could have interfered with their medications causing side effects with a potential for minimal to severe harm. The ADMN stated what led to failure of medication carts left unattended and unlocked was the weekend RN A supervisor had to work the floor (because a nurse called in) and got distracted. <BR/>During an interview on 08/30/22 at 12:58 PM with the DON, she stated medication carts were to be always locked, medication carts should not be left unattended while unlocked. The DON stated nurses should have eye contact with cart when it is unlocked. The DON stated the nurse or medication that had keys to medication cart was responsible to ensure cart not left unlocked and unattended. The DON stated she monitored medication cart when she was out on the floor, she would look to see if carts were unlocked by pulling on drawers and reeducate staff if she found an unlocked cart. The DON stated the affect to residents was a resident could take a medication that was not theirs, which could have caused a negative impact to resident, or another resident's medication could be lost. The DON stated what led to failure of carts left unlocked and unattended was staff not realizing unlocked cart needed to be in line of sight, needed reeducation for securing medication carts. <BR/>During an interview on 08/30/22 at 2:18 PM with LVN B, she stated she thought she had pushed the button to lock cart, that she was always good about locking cart. LVN B stated the effect on residents could have been resident get sick or worse. LVN B stated securing medications was common nurse training. <BR/>Record review of facility's policy titled, Storage of Medication, dated 2003 revealed: Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medication (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked and attended by persons with authorized access.<BR/>Record review of facility's policy titled, Storage and Documentation of Schedule II Controlled Medications, dated 2003 revealed: All Schedule II controlled medications will be stored under double lock

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. <BR/>The Facility failed to ensure foods were sealed and/or labeled properly in dry food storage area, the kitchen refrigerators, and the freezers.<BR/>These failures could place residents that eat out of the kitchen at risk for food borne illnesses.<BR/>Findings included: <BR/>During an observation on 08/28/2022 from 10:15AM to 10:40AM of the kitchen revealed:<BR/>Dry Storage Area: <BR/>1. One large bag of elbow macaroni in bag not sealed and no date on bag.<BR/>2. Four jars of pickled Okra with no date<BR/>3. One box of butterscotch pudding on the floor with six other boxes containing canned goods stacked on top.<BR/>Chest freezer: <BR/>1. One large bag of frozen squash round in orginal labeled or dated<BR/>2. One bag frozen of chicken wing not labeled or dated. <BR/>3. One bag frozen of chicken leg not labeled or dated<BR/>4. Three bags frozen of chicken breasts not labeled or dated<BR/>Refrigerator #1 with top freezer:<BR/>1. One opened bag celery stalk not sealed or dated<BR/>2. Three opened bags celery stalks not labeled or dated<BR/>3. One bag cucumber not sealed or dated<BR/>4. One silver container with lid, double compartment with gel-like food product with no label or date.<BR/>Refrigerator # 2: <BR/>1. Two bags of yellow liquid with no date and not labeled<BR/>2. One gallon container of ice cream with no date and not labeled<BR/>Freezer #2 revealed:<BR/>1. One bag of tortellini with no date or label<BR/>2. One bag of pot pie filling with no date or label<BR/>3. One bag of Brussel sprouts with no date or label<BR/>4. One bag of mini taco with no date or label<BR/>During an interview on 08/28/2022 at 10:35 AM, [NAME] A stated the boxes had been on the floor since 08/25/2022. She stated they should be stored on the racks. She stated she did not know why this happened, she stated she had been off.<BR/>During an Interview on 08/28/22 at 11:30 AM, DM stated all dietary staff were responsible for labeling products the date received. She stated if the product was leftovers the date to be removed was three days after product was made. She stated in dry storage the canned goods were in boxes on the floor due to a leak in the wall area that had to be fixed and sheetrock replaced. She stated there were no other place to store the canned goods during this process. She stated all products should be stored at least 6 inches off the floor.<BR/>During an interview on 08/30/2022 at 08:30 AM, DM stated she was responsible for monitoring that all products are labeled and stored properly. She stated staff was also responsible for labeling and storing products when they are delivered. She stated she did not know why the failure occurred. She stated the dietary staff was trained on storage and labeling upon hire and as needed. She stated the effect on the residents could be if the food product was out of date and not good it could cause the resident to get a food born illness. <BR/>During an interview on 08/30/2022 at 10:29 AM, ADMIN stated her expectations was that all items were dated and labeled as they come into the kitchen. She stated she did not know why the failure occurred. She stated she made rounds in kitchen for monitoring of storage of products and labeling. She stated the canned goods stored on the floor had only been there for two days due to a pipe bursting and needing to replace sheetrock in dry storage area. She stated the failure to properly label could place residents at risk for food borne illness. She stated that all dietary staff were trained on how to label and store all products for the kitchen.<BR/>Review of DM employee file revealed training on storage and labeling on 05/01/2022<BR/>Review of facility policy titled: Dry Storage and Supplies dated 2012<BR/>All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects.<BR/>Procedure:<BR/>1. <BR/> Storerooms are to be well lighted, ventilated and temperature controlled.<BR/>b. All food and supplies and supplies are to be stored six (6) inches above the floor on surfaces which facilitate thorough cleaning.<BR/>4. Open packages of food are stored in closed containers with tight l covers and dated as to when opened.<BR/>Review of facility policy titled: Storage Refrigerators dated 2012<BR/>All storage refrigerators shall be maintained clean and have proper temperature for food storage and to ensure a proper environment and temperature for food storage.<BR/> 5. Food must be covered when stored with a date label identifying what is in the container.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program to prevent the development and transmission of communicable diseases and infections for 3 of 3 (Resident #94,6, #14) residents on the warm unit with unknown Covid status/hot unit Covid positive, reviewed for infection control. <BR/>CNA-A was passing lunch meal trays on the warm/hot resident hall and did not wear eye protection upon entering resident room for 2 of 2 persons with unknown Covid status and 1 of 1 Covid positive residents.<BR/>This failure placed all residents at risk for exposure by staff to Covid 19. <BR/>Findings included:<BR/>Record review of Resident #94 Facesheet dated 8/30/22 revealed: A [AGE] year-old female with an admission date of 8/24/22. Her diagnosis list included: Cerebral infarction (Primary), Celiac disease, Malnutrition, Atrial fibrillation, Contact with and suspected exposure to other viral communicable diseases, Hemiplegia.<BR/>Record review of Resident #94 Vaccination Status revealed: Refusal for Covid-19, Flu, Pneumonia vaccinations. <BR/>During an observation on 08/28/22 at 12:20 PM, CNA-A failed to don eye protection when CNA-A went into Resident #94 room to deliver a meal tray that was unknown covid status due to hospital stay.<BR/>Record review of Resident #6 Facesheet dated 08/30/22 revealed: A [AGE] year-old male admitted to the facility 7/30/04 with a diagnosis list that included: Dementia, Malnutrition, Covid-19 (11/12/20), Schizophrenia, Glaucoma, Communicating hydrocephalous, Exposure to other viral communicable diseases.<BR/>Record review of Resident #6 Vaccination status revealed: 1 dose of Covid-19 10/01/21.<BR/>During an observation on 08/28/22 at 12:23 PM, CNA-A failed to don eye protection when CNA-A went into Resident #6 room to deliver a meal tray that was unknown covid status due to exposure to Covid.<BR/>Record review of Resident #14 Facesheet dated 8/30/22 revealed: A [AGE] year-old male admitted to the facility on [DATE] with a diagnosis list that included: Alzheimer's disease, Gastrointestinal hemorrhage, Covid-19 (08/18/22), Pneumonia, Malnutrition. <BR/>Record review of Resident #14 Vaccination status revealed: Historical 2nd dose Covid-19 04/02/21.<BR/>During an observation on 08/28/22 at 12:25 PM CNA-A failed to don eye protection when CNA-A went into Resident #14 room to deliver a meal tray that was Covid positive.<BR/>During an interview on 08/26/22 at 12:27 PM, DON said any of the residents that are on the warm unit for PUI for Covid or hot unit because of Confirmed Covid, the staff should have on either a face shield or goggles to protect their eyes. Prescription glasses does not constitute eye protection. She said there were boxes of supplies in the room midway down that hall that were full of face shields, the staff can use those and store them in that room on the table with their name on them. Staff is supposed to clean the shield each time they leave a resident room on the warm/hot unit with the bleach sani wipes.<BR/>During an interview on 08/28/22 at 12:29 PM, CNA-A said the staff was supposed to change all PPE each time on the warm/hot unit. PPE included a N95 mask, gown, gloves and with the hot Covid positive resident rooms a face shield was included. CNA-A said he was not aware that a face shield was required with a resident on the warm unit. He said the reason for a face shield was to protect the person from small particles that could include spit. He said that even when a resident talked, they could emit small particles of spit. CNA-A said he was an agency aide that worked every weekend for the past 6 months and he was usually the only person that worked on the warm/hot unit on the weekends. He said that residents on the warm unit were either exposed in the facility through a roommate to Covid or they were a new admission from the hospital, where there was a very real chance, they could have contracted Covid and just not showing positive yet. CNA-A said he did not wear the face shield for the 2 residents that were on the warm unit as PUI because he thought he did not have to. CNA-A said he did not wear a face shield for the resident that was Covid positive because that resident was due to leave the quarantine area the next day as this was day 10 of quarantine for that resident. He said he had been trained by the facility with ICP that included donning and doffing of PPE.<BR/>During an interview on 08/28/22 at 12:42 PM, DON said all agency had to do an orientation for the facility before they started working with the residents. She said donning and doffing PPE was a part of the orientation training. DON said the reason CNA-A did not wear the face shield could have been because it had been a while since he did the training and maybe he just forgot. <BR/>During an interview on 08/28/22 at 03:00 PM, DON said that any resident that tested positive for Covid 19 were quarantined for 10 full days. Any resident that was exposed through a roommate testing positive for Covid was quarantined for 10 days. She said any resident that was a new admission was quarantined for 5 days if they were fully vaccinated or 10 days if they were unvaccinated. In the case of the residents on the warm unit, Resident # 94 was a new admission on [DATE] and she was unvaccinated. Resident # 6 was exposed through a roommate on 8/10/22, then had a roommate on the warm unit that tested positive on 8/18/22 and Resident # 14 tested positive for Covid on 8/18/22. DON and ADON provided CNA-A orientation training and check off training for donning/doffing PPE.<BR/>Record review of CNA-A orientation training was signed by CNA-A and DON was dated 07/01/22 by CNA-A and 07/12/22 by DON. It included orientation training on donning/doffing PPE.<BR/>Record review of CNA-A donning/doffing competency training was signed by ADON but was undated It included determining and assembling appropriate PPE, donning goggles or face shield and doffing goggles/face shield. ADON checked that yes, CNA-A showed competency with these tasks.<BR/>Record review of ICPP Manual dated 2018 revealed: SARS precautions to use as follows airborne precautions preferred droplet if AIIR precautions unavailable; N95 or higher respiratory protection; surgical mask if N95 unavailable; eye protection (goggles, face shield); aerosol generating procedures and Supershedders highest risk for transmission via small droplet nuclei and large droplets 93, 94, 96. Vigilant environmental disinfection.<BR/>Record review of Facility Policy labeled Positive Resident in Facility Protocol undated revealed: Hot zone-residents with active Covid-19. Warm zone- new admissions/readmissions who are not fully vaccinated, residents with exposure to Covid-19, ie their roommate was positive . Place any resident who is positive in the Hot Zone. Place any negative roommates of the positive resident or other residents exposed in the Warm Zone . Place PPE (gloves, gowns, N95, eye protection) carts at the entrance of each resident who is on the Warm or Hot Zone . Staff caring for a Warm or Hot Zone resident should don all appropriate PPE when entering room and doff PPE when exiting the room . Re-inservice on contact/droplet precautions.<BR/>Record review of CDC Precautions Guidelines accessed at https://www.cdc.gov/sars/guidance/i-infection/healthcare.html on 9/1/22 revealed: Gloves, gown, respiratory protection, and eye protection . should be donned before entering a SARS patient's room or designated SARS patient-care area . Healthcare workers should wear gown, gloves, respiratory protection, and eye protection . Droplet Precautions: Make sure eyes, nose, mouth are fully covered before room entry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 1 (Resident #47) of 19 residents reviewed for resident records.<BR/>The facility failed to ensure Resident #47's clinical record included an order to admit to hospice. The order was only located in the hospice records. <BR/>This failure could place residents at risk of having errors in care and treatment.<BR/>The Findings included: <BR/>Findings included: <BR/>Record review of Resident #47's electronic face sheet revealed an [AGE] year-old male admitted to the facility 9/13/2024 with a most recent admission on [DATE] with the following diagnosis: Traumatic subdural hemorrhage with loss of consciousness (head injury from trauma with brain bleed), sepsis (infection that has spread to the blood), respiratory failure, and Type 2 diabetes. <BR/>Record review of Resident #47's admission assessment dated [DATE] revealed: Section C-Cognitive Patterns revealed Resident #47 had a BIMS score of 0 meaning severe cognitive impairment; Section O- Special Treatments and Programs revealed no evidence of hospice.<BR/>Record review of Resident #47's hospice records revealed a physician order with a start date of 11/15/2024 after admit Resident #47 to hospice. <BR/>Record review of Resident #47's Comprehensive Care Plan last updated on 11/07/2024 revealed no evidence of hospice. <BR/>Record review of Resident #47's electronic records revealed no evidence of a physician order to admit to hospice. <BR/>During an interview on 12/12/24 at 2:10 PM the DON stated her expectation was that the nurse that received a physician order was to enter the order into the electronic medical records when it was received. The DON stated the effect on residents could have been residents received incorrect services or had services missed. The DON stated she did not know why the comprehensive care plan was not updated with hospice. The DON stated what led to the failure was the charge nurse forgot to transcribe the record. <BR/>Record review of facility policy titled, Physician Orders dated 2015 revealed Written orders by the Physician or Nurse Practitioner 1. Nurse will review the order and if needed contact the prescriber for any clarifications. 2. The nurse will enter the order into {electronic charting system} for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #47) of 19 residents reviewed for comprehensive person-centered care plans. <BR/>The facility failed to ensure Resident #47's comprehensive care plan addressed Resident #47 being on hospice. <BR/>This failure could affect the residents by placing them at risk for not receiving care and services to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being.<BR/>Findings included: <BR/>Record review of Resident #47's electronic face sheet revealed an [AGE] year-old male admitted to the facility 9/13/2024 with a most recent admission on [DATE] with the following diagnosis: Traumatic subdural hemorrhage with loss of consciousness (head injury from trauma with brain bleed), sepsis (infection that has spread to the blood), respiratory failure, and Type 2 diabetes. <BR/>Record review of Resident #47's admission assessment dated [DATE] revealed: Section C-Cognitive Patterns revealed Resident #47 had a BIMS score of 0 meaning severe cognitive impairment; Section O- Special Treatments and Programs revealed no evidence of hospice.<BR/>Record review of Resident #47's hospice records revealed a physician order with a start date of 11/15/2024 after admit Resident #47 to hospice. <BR/>Record review of Resident #47's Comprehensive Care Plan last updated on 11/07/2024 revealed no evidence of hospice. <BR/>Record review of Resident #47's electronic records revealed no evidence of a physician order to admit to hospice. <BR/>During an interview on 12/12/24 at 2:10 PM the DON stated her expectation was care plans should have been updated when there was a Significant Change Assessment completed. The DON stated admission to hospice should have been updated in the care plan. The DON stated the MDS nurse was responsible to update the comprehensive care plan when the significant change assessment was completed. The DON stated the effect on residents was they could have received incorrect services. The DON stated she did not know why the comprehensive care plan was not updated with hospice. The DON stated what led to failure was the Significant Change assessment was not completed. The DON stated they did not have a policy for Significant Change Assessment that they followed the CMS's RAI Manual. <BR/>During an interview on 12/12/2024 at 2:45 PM the RRN stated the MDS nurse was out of office on sick leave, and she was responsible to complete the Comprehensive Care Plan. The RRN stated hospice services should have been updated in care plan after the Significant Change Assessment was completed. The RRN stated the MDS nurse was responsible to complete the comprehensive care plan and the DON and the RRN were responsible to monitor the completion. The RRN stated the effect on residents could have been the plan of care not being updated and loss of revenue. The RRN stated what led to failure was miscommunication, the nurse that received the order should have entered the order which would have triggered the Significant Change to be completed which would have triggered the comprehensive care plan to be updated. <BR/>Record review of facility policy titled, Comprehensive Care Planning without a date revealed, The comprehensive care plan will describe the following- The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . Any specialized services .