CYPRESS WOODS CARE CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 resident (#46) of 2 residents reviewed for catheter care in that:<BR/>CNA A did not clean Resident #46's indwelling urinary catheter tubing when she performed catheter care for the resident.<BR/>CNA A raised Resident #46's indwelling urinary catheter bag filled with urine above her bladder and to the other side of the bed when she assisted the LVN B with Resident #46's wound care.<BR/>These deficient practices could affect residents with indwelling urinary catheters and could result in urinary tract infections.<BR/>The findings were:<BR/>Review of Resident #46's electronic face sheet dated 09/23/2022 revealed she was admitted to the facility on [DATE] with diagnoses of anemia (low red blood cell count), diabetes (blood sugar abnormality) and neurogenic bladder (loss of bladder control).<BR/>Review of Resident #46's Quarterly MDS assessment with an ARD of 8/17/22 revealed she scored a 15/15 on her BIMS which indicated she was cognitively intact. She required extensive assistance with her ADL's and she had an indwelling urinary catheter.<BR/>Review of Resident #46's comprehensive person-centered care plan revised date 05/24/2022 revealed has indwelling catheter .position catheter bag and tubing below the level of the bladder.<BR/>Review of Resident #46's Order Summary Report .Active Orders As Of: 09/23/2022 revealed <BR/>Foley catheter care with soap and water every shift .start date 04/16/2021.<BR/>Observation on 09/22/2022 at 10:53 a.m. of CNA A as she performed catheter care for Resident #46, she wiped the groin and labia of Resident #46 and did not wipe the Residents' catheter tubing.<BR/>Observation on 09/22/2022 at 11:20 a.m. of LVN B providing wound care for Resident #46 as CNA A assisted revealed CNA A raised Resident #46's urinary drainage bag above the level of Resident #46's bladder. Resident #46 was lying on her back in bed. CNA A raised the urinary drainage bag approximately 1 and one half feet above Resident #46's body and over to the other side of the bed. Urine was observed to be flowing back down the catheter tubing toward Resident #46's bladder.<BR/>Interview on 09/22/2022 at 11:00 a.m. with CNA A, she stated she was nervous and forgot to wipe Resident #46's indwelling urinary catheter tubing when she performed catheter care. She stated she was trained to wipe the tubing because it was necessary to help to prevent infections.<BR/>Interview on 09/22/2022 at 11:40 a.m. with CNA A, she stated she was nervous and was not aware she raised Resident #46's urinary catheter drainage bag above the level of the resident's bladder. She stated she knew she should not have raised the bag that high because of the risk of infection.<BR/>Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that CNA A was agency staff but they come to the facility with the training. She stated CNA A should have wiped Resident #46's catheter tubing because that was part of catheter care to prevent infection. She stated that Resident #46's urinary drainage bag should not have been raised above the resident's bladder level because the urine that was sitting could go back down the tubing into Resident #36's bladder which is sterile and could cause a urinary tract infection.<BR/>Review of the facility policy and procedure titled Catheter Care, Urinary dated 2009 revealed 17. Use a clean wash cloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward .Maintaining Unobstructed Urine Flow .3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen storage and sanitation in that: <BR/>Cook D used the facility phone 3 times during meal service without washing her hands afterwards.<BR/>This deficient practice could place residents who received meals from the main kitchen at risk for food borne illness.<BR/>The findings were:<BR/>Observation on 09/22/2022 at 11:52 a.m. revealed [NAME] D was plating food for the residents for lunch. Observation revealed after she placed the food on a plate, she would place the plates on trays which were on a cart used to deliver the food to each hall. When the cart was completed, the kitchen staff would notify staff per facility phone in the kitchen that their carts were ready to be retrieved.<BR/>Observation on 09/22/2022 at 11:56 a.m. revealed [NAME] D realized the staff had not retrieved the cart so she used the facility phone in the kitchen to notify the staff over the intercom the cart was ready, and then returned to the steam table to plate food without washing her hands.<BR/>Observation on 09/22/2022 at 12:04 p.m. revealed [NAME] D had completed plating food for the 2nd cart. The cook then used the facility phone and called over the intercom to notify staff the next cart was ready. The cook then returned to the steam table to plate food without washing her hands. <BR/>Observation on 09/22/2022 at 12:21 revealed [NAME] D had completed plating food for the 3rd cart. The cook then used the facility phone and called over the intercom to notify staff the next cart was ready. The cook then returned to the steam table to begin cleaning the steam table.<BR/>Interview on 09/22/2022 at 03:31 p.m. with the Food Service Supervisor, after the surveyor notified the Supervisor the cook had not washed her hands between meals, revealed she spoke to [NAME] D who reported she was nervous and that cook knows she should wash her hands between tasks. <BR/> Interview on 09/23/2022 at 10:40 a.m. with [NAME] D she revealed she had made a mistake by not washing her hands between tasks and that she knows she was supposed to.<BR/>Review of an in-service dated 09/22/2022, no time noted, presented by the Food Service Supervisor revealed, Practicing hand hygiene is an effective way to prevent infections and Always wash your hands when: changing gloves, after bathroom use, after leaving the service line, touching face/body, touching trash, etc.<BR/>Review of the facility policy, Food Preparation and Service, under the heading, Food Preparation Area, revised October 2017 revealed, 5. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to obtain laboratory services to meet the needs of 1 of 5 residents (Resident #31) reviewed for laboratory services.<BR/>The facility failed to ensure Resident #31 received lab test that were ordered for lipid panel and thyroid panel to know if the medications of atorvastatin and levothyroxine were at correct levels for administration to resident.<BR/>This failure could place residents at risk for adverse effects of pain, discomfort, increase side effects, not receiving the therapeutic effects of the medication, and a decline in health.<BR/>Findings included:<BR/>Record review of Resident #31's face sheet revealed a [AGE] year-old female admitted on [DATE]. Diagnosis were Cerebral Infarction (occurs when blood flow to the brain was blocked), Hypothyroidism (condition which the thyroid gland does not produce enough thyroid hormone), and Hypertensive Heart Disease (complications from high blood pressure). <BR/>Record review of Resident #31's Quarterly MDS dated [DATE] revealed a BIMS score of 14 indicating cognition was intact.<BR/>Record review of Resident #31's Medication Record for September 2024 revealed:<BR/> Atorvastatin Calcium Oral Tablet 40 MG<BR/>(Atorvastatin Calcium)<BR/>Give 1 tablet by mouth at bedtime for<BR/>Hypercholesterolemia<BR/>And<BR/>Levothyroxine Sodium Tablet 125 MCG<BR/>Give 1 tablet by mouth in the morning for<BR/>low thyroid hormone<BR/>were being given to resident as ordered.<BR/>Record review of Resident #31's pharmacist communication to her physician dated 9/4/24 revealed a suggestion to have a lipid panels new and yearly and thyroid panel now one time. This was signed as agreed by physician on 9/23/24.<BR/>Record review of physician orders reviewed on 1/7/25 for active orders revealed no orders for the labs requested on 9/23/24. <BR/>Interview on 1/7/24 at 3:45 PM with DON and she stated that the order had not been ordered and not followed through from the pharmacist suggestion.<BR/>Attempted interview with physician on 1/8/24 at 12:20 PM. Left a message with answering service because the physician was at lunch. The physician never returned the call.<BR/>Interview on 1/8/25 at 1:05 PM with DON and she stated that the process begins with the pharmacist review and suggestion. This was then emailed or given to the MDS nurse. The MDS nurse sends to medical records. The person there ensures to get the form signed by the physician on if the physician agrees or disagrees. Once signed, she sends it back to the MDS nurse to order. After ordered, Medical Records scans into PCC and files away the form. She was not sure what happened and where the breakdown was. This order was never placed. The signed form was an order and should be followed up on and completed. These were not urgent labs but should have been done since it was an order. The physician would be looking for levels of the medication. There were no recent labs, and it was important to know what the medication levels were to ensure correct medication was being given.<BR/>Interview on 1/8/24 at 1:10 PM with MDS nurse and she stated that she was to follow up on what is required after the papers are signed. The physician signed form from the pharmacist was an order. She did not know what happened with this order. She said it was possible for it to be uploaded into the system before she received it. This should have been completed. It was important to do what the physician ordered.<BR/>Interview on 1/8/24 at 1:20 PM with Medical Records and she stated she did not know anything that was done on the medical side. She said she received the pharmacist form and she either put them out for the physician to sign or sent them to the physician to sign. After I receive the form back, I give them to the MDS nurse. She was then responsible for doing what was needed medically. They then were returned, and she would upload and file away.<BR/>Record review of facility policy titled, Lab and Diagnostic test Results - Clinical Protocol revised November 2018 read in part, .The physician will identify and order diagnostic and lab testing .The staff will process test requisitions and arrange for tests

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the residents environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 8 of 59 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #8 and Resident #9) reviewed for accidents and supervision. <BR/>1. <BR/>The facility failed to ensure 8 residents were able to evacuate in the event of an emergency due to plywood bolted down to the exterior door that barricaded the exit on Hall A.<BR/>2. <BR/>The facility failed to ensure 8 residents on Hall A had two exits available in an event of an emergency due to the dead-end corridor.<BR/>An immediate jeopardy (IJ) was identified on 6/4/2024 at 5:37 p.m. The IJ template was provided to the facility on 6/4/2024 at 5:37p.m. While the IJ was removed on 6/5/2024 at 12:01p.m., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure placed residents at risk of physical and psychological harm, and possible death, due to the exit door creating a dead-end corridor in an emergency.<BR/>Findings Included :<BR/> Resident #1<BR/>Record review of Resident #1's face sheet dated 6/5/2024 revealed a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of Emphysema (type of lung disease), unspecified, unspecified abnormalities of gait and mobility (change in walking pattern), other lack of coordination, and cognitive impairment (a condition in which there is a decline in memory and thinking). <BR/>Record review of Resident #1's MDS dated [DATE] revealed Section C0500 had a brief interview of mental status score of 00, which indicated severe cognitive impairment. Section GG- Functional Abilities and Goals -Roll left and right, sit to lying, lying to sitting side of bed, sit to stand, transfer (toilet/shower) and walk 10, 50 and 150 feet were all scored a6 which represented he was independent. <BR/>Record review of Resident #1's care plan revised on 4/28/2023 revealed Resident #1 had a slightly limited physical mobility r/t use of cane when ambulating, goal- Resident #1 will demonstrate the appropriate use of adaptive device to increase mobility.<BR/>Resident #2<BR/>Record review of Resident #2's face sheet dated 6/5/2024 revealed a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of dementia (a loss of thinking, remembering and reasoning), hypertensive heart disease (a change in left ventricle, atrial and arteries as a result of chronic blood pressure), unspecified abnormalities of gait and mobility (change in walking pattern), unspecified lack of coordination and cognitive communication deficit.<BR/>Record review of Resident #2's MDS dated [DATE] revealed Section C-0500 brief interview of mental status was unscored (00), which indicated severe cognitive impairment. Section C-1310 Onset of mental status change (B) Inattention and (C) Disorganized thinking were coded as a 1 for behavior continuously present and did not fluctuate. Section GG Functional abilities GG-0115 notated Upper extremity (shoulder, elbow, wrist and hand) coded as a 2 which indicated impairment on both sides. Section GG-0170 reflected lying to sitting on side of bed was coded as a 03 which indicated partial assistance needed by staff. Sit to stand, chair to bed, toilet transfer and tub/shower transfers were coded as (02) which represented substantial assistance needed by staff. Walk 10 feet was coded an88 which indicated not attempted due to safety concerns.<BR/>Record Review of Resident #2's care plan dated 5/26/2021 and revised on 9/29/2023 revealed Resident #2 had impaired cognitive function r/t forgetfulness, diagnoses of dementia, BIMs indicated severe impairment. Resident #2 had a communication problem r/t/ hearing loss, he was HOH. <BR/>Resident #3<BR/>Record review of Resident #3's face sheet 6/7/2024 revealed an [AGE] year-old female that was admitted to the facility on [DATE] and with diagnoses of cerebral infarction(stroke caused by disrupted blood flow to the brain), other lack of coordination, unspecified abnormality of gait (change in walking pattern), hypertensive heart disease (a change in left ventricle, atrial and arteries as a result of chronic blood pressure), unspecified dementia, and cognitive communication deficit.<BR/>Record review of Resident #3's quarterly MDS dated [DATE] revealed C0500- brief interview of mental status was unscored (00) which indicated severe impairment. Section GG Functional Abilities indicated Upper Extremities and lower extremities (1) indicated impairment on one side. Mobility Devices reflected (C) Wheelchair was used. Roll left and right, sit to lying, lying to sitting on side of bed was coded a 03 which indicated partial/moderate staff assistance was needed. Sit to stand, chair/bed to chair transfer, tub/shower and toilet transfers were coded a 02 which indicated substantial assistance required by staff.<BR/>Record review of Resident #3's care plan dated 9/21/2023 revealed the resident had a physical functioning deficit. Goal: Resident will maintain current ROM through next review. Interventions: Monitor for safety.<BR/>Resident #4<BR/>Record review of Resident #4's face sheet dated 6/7/2024 revealed a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of Cognitive communication deficit, cerebral infarction, difficulty in walking, unspecified osteoarthritis, and Type 2 diabetes.<BR/>Record review of Resident #4's annual MDS dated [DATE] revealed Section C0500- Brief interview of mental status was codes as 13, which indicated cognitively intact. Section GG Functional abilities and goals indicated sit to stand, chair/bed-to chair transfers were coded as a (01) which indicated the resident was dependent on staff for assistance. Walk 10 feet was coded as an (88) which indicated not attempted due to safety concerns.<BR/>Record review of Resident #4's care plan dated 8/22/2023 revealed Resident #4 was at risk for falls. Goal: Resident #4 will demonstrate the appropriate use of adaptive device to increase mobility, and free from minor injury. Intervention: Remind Resident #4 to call for assistance when trying to transfer.<BR/>Resident #5<BR/>Record review of Resident #5's face sheet dated 6/5/2024 revealed a [AGE] year-old female that was admitted on [DATE] with diagnoses of Hypertensive heart disease without heart failure (a change in left ventricle, atrial and arteries as a result of chronic blood pressure), falls, attention and concentration deficits, senile (degeneration of brain), Dementia, and cognitive communication deficit and altered mental status.<BR/>Record review of Resident #5's MDS dated [DATE] revealed section C500- BIMS was unscored (00) indicating severe impairment. Section GG- Functional Abilities and Goals indicated roll left and right, sit to lying, lying to sitting were coded (2) for substantial assistance required by staff. Sit to stand, chair/bed-to-chair transfer, toilet and shower transfer were coded as (1) Dependent- helper did all of the effort. Mobility device was coded a 1 which indicated a manual wheelchair was used.<BR/>Record review of Resident #5's care plan dated 4/5/2021 and revised on 4/24/2024 revealed Resident #5 self-care deficit needed total assistance of one staff with ADL's. Interventions: Resident #5 transfers with one-person total assist. <BR/>Resident #6<BR/>Record review of Resident #6's face sheet dated 6/7/2024 revealed she was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, hypertensive heart disease without heart failure (a change in left ventricle, atrial and arteries as a result of chronic blood pressure), atherosclerosis of native arteries of right leg with ulceration of ankle and peripheral vascular disease. <BR/>Record review of Resident #6's annual MDS dated [DATE] revealed section C0500- brief interview of mental status was not coded(blank). Section C1000- Cognitive skills for daily decisions was coded as (3)- which meant severely impaired (never made decisions). Section GG- Functional Mobility checked C. Wheelchair was used for mobility. GG0170- Roll left and right and lying to sitting on side of bed were coded a 02 which indicated substantial/maximal assistance. Sit to stand and chair/bed-to-chair transfer were coded a 01 which indicated dependent- helper did all effort.<BR/>Record review of Resident #6's care plan dated 9/26/2023 revealed Resident #6 had impaired cognitive function/Alzheimer. Goal: Resident #6 will maintain current level of cognitive function. Resident #6 required assistance with her ADL's. Intervention: Resident requires max 2 staff participation with transfers. <BR/>Resident #8<BR/>Record review of Resident #8 face sheet dated 6/7/2024 revealed she was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (progressive disease that destroys memory), unspecified dementia without behavioral disturbance, hypertensive heart disease a change in left ventricle, atrial and arteries as a result of chronic blood pressure), muscle weakness and other lack of coordination.<BR/>Record review of Resident #8's MDS dated [DATE] revealed Section C0500 brief interview of mental status score was 05 indicating severe cognitive impairment. Section GG- Functional Abilities and goals reflected roll left and right, sit to lying, chair/bed-to-chair transfer, walk 10 feet were all coded as a 6 which indicated the resident was independent. <BR/>Record review of Resident #6's care plan dated 8/21/2023 revealed she had cognitive impairment. Goal: Resident #8 will maintain current cognitive function. <BR/>Resident #9<BR/>Record review of Resident #9's face sheet dated 6/7/2024 revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of hypertensive heart disease with heart failure (a change in left ventricle, atrial and arteries because of chronic blood pressure), muscle weakness, and Type 2 Diabetes and unsteady on feet.<BR/>Record review of Resident #9's MDS dated [DATE] revealed Section C0500-brief interview of mental status was 15, which indicated cognitively intact. The MDS reflected for GG0120-mobility devices (C) Wheelchair is used for mobility. <BR/>Record review of Resident #9's care plan dated 12/8/2023 revealed she had physical functioning deficit related to: Mobility impairment. Goal: Resident will maintain current level of physical functioning through next review. Interventions: Use of overhead trapeze to assist with bed mobility. <BR/>Observation on 6/4/2024 at 10:11am of the exit door at the end of the Hall A near resident rooms 101-106 revealed the exit door was physically barricaded with plywood that was secured with a bolt to the exterior door frame. The residents in rooms 101-106 had only 1 exit path. The door had an EXIT sign above it.<BR/>Record review of resident daily census dated 6/4/2024, listed 8 residents in rooms 101-106. Rooms 102B, 103B and 105A were empty. <BR/>An interview with the Administrator on 6/4/2024 at 10:49 a.m., revealed the air conditioning systems in the facility had not been working well. He said there were 5 to 7 total units throughout the facility. He said the unit in the back of the building where Nursing station 2 was located was leaking freon, another unit in the back unit needed a compressor and Hall A unit needed a blower motor replaced. He stated the plywood that replaced the exit door was put in place because the portable air conditioning ducts had to go through that door to cool Hall A. He stated the portable air conditioning inserted through the plywood in the exit door was done on 6/2/2024 by a local contractor. He stated the plywood had been there for only two days. He said the Maintenance Director oversaw this project. He was asked why the residents on Hall A were not moved to another hall where the exit door was not barricaded, and he stated the interviewable residents were asked about moving to other rooms and they said they were fine remaining in their rooms. He did not recall which residents were asked specifically. He stated if there was an emergency, they would have evacuated the residents on Hall A through the front entrance door . He stated the evacuation routes were posted at the nursing stations and near each exit door. <BR/>An interview with Resident # 8 on 6/4/2024 at 11:18 a.m., she stated that it had been warm in her room. She was unaware of the temperature. She stated she did not recall maintenance or the ADM coming in to check the temperature prior to today. She said the temperature was bearable because she had her fans. She said she had both fans on to ensure she was cool. She used a small personal fan that sat on her nightstand and a floor fan. She said she did not notice plywood covering the exit door on Hall A. She said she did not know what would have happened in an emergency because the door near her was closed off. She said she guessed staff would have to bring her through another door. <BR/>An interview with the FM of Resident #6 on 6/4/2024 at 11:25 a.m., revealed he was not aware of the plywood on the exit door on hall A. He stated he visited Resident #6 once a week and said the plywood was not there when he visited on last Wednesday (5/29/24). He said the facility was usually cool and there were no issues. The FM stated Resident #6 was not verbal. He said she was cold-natured and not sure if she was affected by the air conditioning not working well. He stated he noticed the plywood over the door today (6/4/2024). He stated he asked himself, Are they allowed to have that there? He said Resident #6 would need help in an evacuation as she required total care by staff. He said he guessed they would have to evacuate her through another door in an emergency. <BR/>An interview with RN B on 6/4/2024 at11:56 a.m. revealed she had been employed with the facility for a few months. She stated she normally worked the morning shift. She stated the air conditioning had been out for about two weeks. She stated a family member had inquired about the air conditioning not working and about the exit door in Hall B. She said the thermostat on Hall A read 83 degrees Fahrenheit a few days before the yellow portable was placed. She said it really got warm in the front of the building. She said she saw the plywood covering the door but was more concerned the residents had cool air and figured the Administrator or maintenance must have given the okay for the contractor to install it. She did not ask any questions about it. She said in an emergency they would have evacuated the residents on Hall A out the front door which was the closest exit. <BR/>An interview with CNA B on 6/4/24 at 12:21pm, she stated she had been employed since 2023. She stated she normally worked the 6a-6p shift. She stated she normally worked Hall A. She stated that the air conditioning had been an issue since the end of May 2024. She said she mentioned to the Maintenance Director that it was warm down that hall. He said the air conditioning was flipping the breaker at first then the unit went out. She stated she saw the plywood but was happy the residents had cooler air. She said they would have had to move the residents through another exit or the front door in the event of an emergency. She said she knew boarding that exit door on with wood was a bad idea.<BR/>An interview with the DON on 6/4/2024 at 2:01p.m., she stated she did not work between 5/25/24-6/3/2024. She said she was on vacation and returned to work on today (6/4/24) and although she did see the plywood, she was going to ask questions about it in the morning meeting, but the Investigator entered the facility, so they did not have a morning meeting. She said her backup while she was off was the MDS Nurse. She stated she was not made aware of the plywood barricading the exit door prior to observing it on 6/4/24. She said she did not know that was considered a dead-end corridor. She said in an emergency they could have gotten the residents out of the windows. She said the nurse on duty could have made the decision to move the residents to another hall. She said she was not sure why the residents down Hall A were not moved to another hall with two exit doors. <BR/>An interview with the Medical Records Coordinator on 6/4/2024 at 2:35 p.m., revealed she had been employed at the facility for nine years. She stated the plywood had been setup by a local contractor to run the portable air conditioning ducts through to help cool Hall A. She stated she did notice the plywood replaced the exit door. She stated she only thought about the residents getting cool air and did not think it was a hazard. She said the air conditioner on Hall A went out on or about 5/25/2024 and the portable was setup on 6/2/2024.<BR/>In a subsequent interview with the Administrator on 6/4/2024 at 3:27 p.m. revealed him to state the air conditioning blower motor on Hall A unit was being repaired right now and the Maintenance Director would remove the plywood from the exit door. He was asked why residents on Hall A were not moved to another hall since that door had been replaced with plywood and he stated he was not aware that created a dead-end corridor. He said in an emergency like a fire, the residents might have been harmed or burned from not having an exit closest to them to get out. He said having that door barricaded could have caused a delay in exiting the building, smoke inhalation, and bodily harm could have happened to residents and staff. <BR/>An interview with the Maintenance Director on 6/5/24 at 1:08 p.m. He has been employed at the facility for about 6 months. He stated this was his first maintenance job. He said he had no experience working with air conditioning. He stated the only complaints about the facility being warm came from staff, not residents. He stated he had kept a temperature log and took temperatures in areas with portables. No rooms or hallways were over 78 degrees Fahrenheit. He stated he did not know the plywood bolted down to the door frame created a dead-end corridor. He said he was not aware of that. He said in an emergency staff could have evacuated the residents out the front door, which was the nearest exit. He said he received an in-service on door egress and blocking the exit doors. He said the Regional Maintenance Director had trained him and he was in-serviced by the Administrator as well. <BR/>An interview with the MDS Nurse on 6/7/24 at 10:01am, revealed she had been employed at the facility for 19 years. She worked the Friday before (5/24/24) the holiday and returned on 6/3/24. She stated she did not work weekends. She said she saw the portable air conditioning units down Hall A but she did not notice the plywood. She stated she did not go down Hall A. She said generally she did not go down that hall unless she had an assessment. She said staff did not inform her about the plywood being installed on Hall A. She said the residents could have perished in an emergency. She said as far as she knew the evacuation route was not changed due to the barricaded door. She said she was in-serviced by the maintenance director and DON on door egress. She said she was informed about door egresses and doors should not be blocked. She said also if she noticed a change in the temperature in the building to notify both the Administrator and Maintenance right away. <BR/>An interview on 6/7/24 at 11:58 a.m., LVN B stated she had been employed at the facility about 1 year and usually worked the day shift, 6a-6p. She said she did not work on Hall A. She said she was at work when Hall A air conditioning portables were installed and lots of staff had asked her what was going on. She said she wondered if they could do that (board up the exit door). It was being installed in the later part of her shift like 4pm or so. She said she did not give it much thought. She said residents on Hall A would have needed to be rerouted through another exit door in an emergency. She said residents on Hall A could have been injured by fire, or harmed from not being evacuated in a timely manner. She stated she had been in-serviced on reinforcing access to all exit doors, evacuation routes, and nursing stations evacuation routes were pointed out. <BR/>Record review of safety and supervision of resident policy revised on July 2017, reflected the facility strives to make environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. <BR/>An immediate jeopardy (IJ) was identified on 6/4/2024 at 5:37 p.m. The Administrator and traveling DON were notified. The Administrator was provided with the IJ template on 6/4/2024 at 5:37 p.m. A Plan of Removal was requested at that time. <BR/>The following Plan of Removal was submitted by the facility was accepted on 6/5/2024 at 12:01pm and included:<BR/>6/4/2024 - F689<BR/>PLAN OF REMOVAL<BR/>Date: 6/04/24<BR/>Summary of details which leads to outcomes.<BR/>On 6/4/24 an investigation on a priority 1 was initiated at 5:37 pm, a surveyor provided an IJ Template notification that the Survey Agency has determined that has determined that the condition at the center constitute immediate jeopardy to resident health.<BR/>The Immediate Jeopardy findings were identified in the following areas:<BR/>F689 Free of accidents and hazards/ Supervision/ Devices. <BR/> The facility failed to ensure that 8 residents could evacuate due to a barricade at the end of a corridor. The barricade consisted of plywood which was bolted down. <BR/>Immediate Corrective Actions For Removal Of Immediate Jeopardy<BR/>The plywood physically barricading the exit door at the end of the 101-106 hall near resident rooms 101-106 was immediately removed by the Maintenance Assistant. The exit door is no longer barricaded. 6/4/2024 at 3:45 pm. <BR/>The facility reviewed the system for ensuring that all exits are not blocked. Ad Hoc QAPI meeting was completed with the IDT, Administrator, DON, and Medical Director on 6/4/24 at 9:00 pm.<BR/>Facility Plan to ensure compliance quickly: <BR/>1. <BR/>The Administrator checked all exits to ensure these areas were not blocked.<BR/>2. <BR/>Education provided to the administrator by the Regional Maintenance Director regarding Exit and Means of Egress. 6/4/2024 at 6:30 p.m. <BR/>3. <BR/>Education provided to Maintenance Director by the Administrator on ensuring exits are not blocked and Exit and Means of Egress. 6/4/2024 at 6:40 p.m. <BR/>4. <BR/>Education initiated on 6/4/24 at 7:52pm, to all department staff by the Administrator and Maintenance Director; related to means of egress must remove free from any blockage and evacuation routes. Staff will not be able to work their scheduled shifts without prior in-service on egress. <BR/>Whoever discovers a blocked exit shall clear the exit, if possible, and the report the finding to his or her immediate supervisor or to a supervisor or manger in the building, if the immediate supervisor is not present. If no supervisor is on the building is present staff has been educated to call the Administrator or Maintenance Director. The Administrator and/or Maintenance Director will make sure it is immediately corrected. <BR/>5. <BR/>Facility will be in compliance by 6/5/24 by noon.<BR/>Monitoring of the plan of removal from 6/4/2024 to 6/7/2024 included:<BR/>Observation on 6/4/2024 at 5:50pm revealed the plywood and portable air conditioning ducts had been removed from Hall A's exit door.<BR/>Interviews on 6/5/24 at 12:38pm, with the DON, Administrator and Social Services Coordinator revealed the Administrator stated the Regional Maintenance Director in-serviced him, the DON, Maintenance Director and Social Services on door egress. He stated the egress was not to be blocked. He said he also in-serviced the Maintenance Director about not putting anything to block the exit doors. If someone saw anyone put boxes or anything in front of the doors everyone was responsible for moving it immediately or report to the Administrator or Maintenance Director for help moving. There was a consensus with that group that they understood the plywood barricaded the door on Hall A and made it a dead-end corridor. It created a hazardous situation for residents down that hall. <BR/>Record Review of the ad hoc QAPI meeting reflected that on 6/4/24 at 9:00 p.m., the IDT, DON/MDS /ADM- once compliance is established the Administrator and maintenance will monitor to make sure no exit door is blocked to ensure continuation of resident's care is safe. <BR/>Record review of exit or means of egress huddle sign-in sheet dated 6/4/2024 revealed the Maintenance Director and the Administrator were trained by Regional Maintenance Director on exit and means of egress. <BR/>Record Review of exit and egress log dated 6/5/2024 revealed the maintenance director had checked all exit doors to ensure nothing blocked the doors.<BR/>Interviews were completed between 6/5/2024-6/7/2024 with 3 CNAs on 6am-6pm and 2 CNAs on 6pm-6am shifts, 2 RNs, 3 charge nurses, the Social Services Coordinator, Dietary Manager, Activity Director and 2 LVNs on night shift revealed they were aware of the exits not being blocked, reporting any blocked exits and evacuation route locations . <BR/>The Administrator was informed the Immediate Jeopardy was removed on 6/7/24 at 2:30 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for care plans in that: <BR/>The facility failed to implement a comprehensive care plan intervention for Resident #1 which addressed her fall risk which included a fall mat at Resident #1's bedside. <BR/>The facility failed to implement a comprehensive care plan intervention for Resident #1 which addressed her fall risk which included her bed should have been placed in the lowest position<BR/>This failures placed the resident at risk for injury.<BR/>Finding included: <BR/>Record review of the admission sheet for Resident #1 revealed an [AGE] year-old female admitted on [DATE] and re-admitted [DATE]. Her diagnoses included: diagnosis of muscle weakness, abnormal gait/mobility, cerebrovascular accident (loss of blood flow to a part of the brain) and dementia (group of symptoms that affects memory, thinking and interferes with daily life).<BR/>Record review of Resident #1's Significant Change MDS assessment, dated 2/28/2024, revealed a BIMS score of 13 out of 15 which indicated her cognition was intact. Resident #1 used a wheelchair for mobility. Resident #1 required total dependence from two-person physical assist from staff for bed mobility and transfer. <BR/>Record review of Resident #1's care plan, initiated 3/8/2024 revealed the following:<BR/>Focus: (Resident #1) is at risk for falls/injuries related to CVA weakness. Goal: (Resident #1) will have no falls/injuries daily through next 90 day review. Interventions: .Fall mat in place (date initiated 5/6/2024) Keep bed in low position (date initiated 11/21/22 and revised 8/29/23).<BR/>Record review of Resident #1's Fall assessment dated [DATE] revealed Resident #1 had a score of 17 which indicated a High Risk for falls.<BR/>Observation on 5/8/2024 at 10:07 a.m., revealed Resident #1 awake in bed with her bed not in the low position, and there was no fall mat at bedside or in the room.<BR/>Observation on 5/8/2024 at 10:39 a.m., revealed Resident #1 awake in bed with her bed not in the low position, and there was no fall mat at bedside or in the room. <BR/>Observation on 5/8/2024 at 10:59 a.m., revealed Resident #1 awake in bed with her bed not in the low position and there was no fall mat at bedside or in the room. <BR/>Interview on 5/8/2024 at 11:00 a.m. with CNA A, who was assigned to Resident #1, revealed the nurses would tell her if there were any interventions that the resident needed. She was aware that the resident had falls in the past but was not aware of the fall mat intervention for Resident #1. She was not able to say why the bed was not in the lowest position. She said care planned interventions should be in the [NAME] (system that organizes resident information). CNA A said she had been trained on reviewing the documentation system at the beginning of the shift, but she relied on the nurses to update her on intervention changes. <BR/>Observation on 5/8/2024 at 11:15 a.m. of Resident #1 in her bed without a mat on the side of her bed and not in the low position was observed by CNA B and the ADMIN.<BR/>Interview on 5/8/2024 at 11:16 a.m. with CNA B revealed Resident #1's bed was not in the lowest position and there was not a mat at the bedside. She said the bed was in a mid-position. She said it put the resident at risk for injury since she was a fall risk. She said it was the CNA's and Nurses responsibility to ensure interventions were in place. <BR/>Observation on 5/8/2024 at 1:46 p.m., revealed Resident #1 awake in bed with her bed not in the low position and there was no fall mat at bedside or in the room. <BR/>Interview on 5/8/2024 at 2:10 pm with LVN A revealed she had been off for two days and this was her first day back, and she did not realize that the fall mat intervention was started. She said she should have looked at the [NAME]. She said it was all staff's responsibility to ensure fall interventions are in place. <BR/>Interview on 5/8/2024 at 1:41pm with the DON, revealed Resident #1's had multiple previous falls they discussed interventions during the morning meetings after the falls and decided to implement the fall mat on 5/6/2024. She said she was not sure what happened and why the fall interventions were not in place for Resident #1. The DON said CNA's had been trained to refer to the [NAME] for interventions needed and should read them daily. She said the nurses should have ensured the fall mat and the low bed intervention was in place for Resident #1. She said Central Supply should have initially placed the mat in the room on 5/6/2024. She said Central Supply should have been updated when the intervention was updated.<BR/>Interview on 5/8/24 at 1:57 pm with Central Supply, revealed she was responsible for supplies needed for interventions like fall mats. She said she was not told Resident #1's needed a fall mat. She said she was told approximately 20 minutes prior to that interview (1:37pm).<BR/>Interview on 5/8/24 4:40 p.m. with, the Admin. revealed Resident #1 was supposed to have a fall mat and her bed should have been in a low position. He said the staff should have followed the care plans. He said the Nurses and CNA's were responsible for ensuring fall interventions are in place. He said it is the DON's responsibility and should have ensured the intervention was in place for Resident #1. He said the new interventions should have be communicated to the charge nurses. The charge nurses should have informed CNA's about Resident #1's interventions were in place. <BR/>Record review of facility's policy, Care Plans Comprehensive Person-Centered (revised December 2016) revealed the following in part:<BR/>A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 10. Identifying problems areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.<BR/>Record review of facility's policy, Fall Prevention Program not dated, revealed the following in part: <BR/> .The Interdisciplinary Team will review fall risk assessments completed by the nursing department, as well as completing the Fall Resident Assessment Protocol and if appropriate, a fall prevention protocol will be initiated . Purpose: To ensure consistency in the implementation of preventive measures to assist with the reduction of falls . Procedure: 4. All resident receiving a score of ten (10) or more will be considered at risk for falls .6. The Director of Nursing/designee will be responsible for ensuring that residents who have been identified at risk or who have experienced recent falls have all recommended interventions in place .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for care plans in that: <BR/>The facility failed to implement a comprehensive care plan intervention for Resident #1 which addressed her fall risk which included a fall mat at Resident #1's bedside. <BR/>The facility failed to implement a comprehensive care plan intervention for Resident #1 which addressed her fall risk which included her bed should have been placed in the lowest position<BR/>This failures placed the resident at risk for injury.<BR/>Finding included: <BR/>Record review of the admission sheet for Resident #1 revealed an [AGE] year-old female admitted on [DATE] and re-admitted [DATE]. Her diagnoses included: diagnosis of muscle weakness, abnormal gait/mobility, cerebrovascular accident (loss of blood flow to a part of the brain) and dementia (group of symptoms that affects memory, thinking and interferes with daily life).<BR/>Record review of Resident #1's Significant Change MDS assessment, dated 2/28/2024, revealed a BIMS score of 13 out of 15 which indicated her cognition was intact. Resident #1 used a wheelchair for mobility. Resident #1 required total dependence from two-person physical assist from staff for bed mobility and transfer. <BR/>Record review of Resident #1's care plan, initiated 3/8/2024 revealed the following:<BR/>Focus: (Resident #1) is at risk for falls/injuries related to CVA weakness. Goal: (Resident #1) will have no falls/injuries daily through next 90 day review. Interventions: .Fall mat in place (date initiated 5/6/2024) Keep bed in low position (date initiated 11/21/22 and revised 8/29/23).<BR/>Record review of Resident #1's Fall assessment dated [DATE] revealed Resident #1 had a score of 17 which indicated a High Risk for falls.<BR/>Observation on 5/8/2024 at 10:07 a.m., revealed Resident #1 awake in bed with her bed not in the low position, and there was no fall mat at bedside or in the room.<BR/>Observation on 5/8/2024 at 10:39 a.m., revealed Resident #1 awake in bed with her bed not in the low position, and there was no fall mat at bedside or in the room. <BR/>Observation on 5/8/2024 at 10:59 a.m., revealed Resident #1 awake in bed with her bed not in the low position and there was no fall mat at bedside or in the room. <BR/>Interview on 5/8/2024 at 11:00 a.m. with CNA A, who was assigned to Resident #1, revealed the nurses would tell her if there were any interventions that the resident needed. She was aware that the resident had falls in the past but was not aware of the fall mat intervention for Resident #1. She was not able to say why the bed was not in the lowest position. She said care planned interventions should be in the [NAME] (system that organizes resident information). CNA A said she had been trained on reviewing the documentation system at the beginning of the shift, but she relied on the nurses to update her on intervention changes. <BR/>Observation on 5/8/2024 at 11:15 a.m. of Resident #1 in her bed without a mat on the side of her bed and not in the low position was observed by CNA B and the ADMIN.<BR/>Interview on 5/8/2024 at 11:16 a.m. with CNA B revealed Resident #1's bed was not in the lowest position and there was not a mat at the bedside. She said the bed was in a mid-position. She said it put the resident at risk for injury since she was a fall risk. She said it was the CNA's and Nurses responsibility to ensure interventions were in place. <BR/>Observation on 5/8/2024 at 1:46 p.m., revealed Resident #1 awake in bed with her bed not in the low position and there was no fall mat at bedside or in the room. <BR/>Interview on 5/8/2024 at 2:10 pm with LVN A revealed she had been off for two days and this was her first day back, and she did not realize that the fall mat intervention was started. She said she should have looked at the [NAME]. She said it was all staff's responsibility to ensure fall interventions are in place. <BR/>Interview on 5/8/2024 at 1:41pm with the DON, revealed Resident #1's had multiple previous falls they discussed interventions during the morning meetings after the falls and decided to implement the fall mat on 5/6/2024. She said she was not sure what happened and why the fall interventions were not in place for Resident #1. The DON said CNA's had been trained to refer to the [NAME] for interventions needed and should read them daily. She said the nurses should have ensured the fall mat and the low bed intervention was in place for Resident #1. She said Central Supply should have initially placed the mat in the room on 5/6/2024. She said Central Supply should have been updated when the intervention was updated.<BR/>Interview on 5/8/24 at 1:57 pm with Central Supply, revealed she was responsible for supplies needed for interventions like fall mats. She said she was not told Resident #1's needed a fall mat. She said she was told approximately 20 minutes prior to that interview (1:37pm).<BR/>Interview on 5/8/24 4:40 p.m. with, the Admin. revealed Resident #1 was supposed to have a fall mat and her bed should have been in a low position. He said the staff should have followed the care plans. He said the Nurses and CNA's were responsible for ensuring fall interventions are in place. He said it is the DON's responsibility and should have ensured the intervention was in place for Resident #1. He said the new interventions should have be communicated to the charge nurses. The charge nurses should have informed CNA's about Resident #1's interventions were in place. <BR/>Record review of facility's policy, Care Plans Comprehensive Person-Centered (revised December 2016) revealed the following in part:<BR/>A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 10. Identifying problems areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.<BR/>Record review of facility's policy, Fall Prevention Program not dated, revealed the following in part: <BR/> .The Interdisciplinary Team will review fall risk assessments completed by the nursing department, as well as completing the Fall Resident Assessment Protocol and if appropriate, a fall prevention protocol will be initiated . Purpose: To ensure consistency in the implementation of preventive measures to assist with the reduction of falls . Procedure: 4. All resident receiving a score of ten (10) or more will be considered at risk for falls .6. The Director of Nursing/designee will be responsible for ensuring that residents who have been identified at risk or who have experienced recent falls have all recommended interventions in place .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to have an accurate MDS assessment for 3 residents (#26, #50 and #54) out of 24 residents reviewed for accurate MDS assessments in that:<BR/>1. The facility did not have Resident #26's pacemaker coded on the MDS.<BR/>2. The facility did not have Resident #50's pacemaker coded on the MDS.<BR/>3. The facility active diagnosis of heart failure was not coded on his Resident #54's MDS assessment.<BR/>This deficient practice could affect residents who required assessments at the facility and result in resident needs not being met.<BR/>The findings were:<BR/>1. Review of Resident #26's face sheet dated 9/26/2022 revealed he was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease with heart failure, hemiplegia (paralysis on one side of the body) and hemiparesis (mild weakness or loss of strength to one side of the body) following cerebral infarction (a disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, hyperlipidemia (a condition in which there are high levels of fat particles/lipids in the blood) and presence of automatic (implantable) cardiac defibrillator (a device that sends an electric pulse or shock to the heart to restore a normal heart beat). <BR/>Review of the Quarterly MDS dated [DATE] revealed there was no diagnoses for pacemaker on the MDS. <BR/>Review of Resident #26's Physician Orders dated 9/1/2022 revealed, Resident has a pacemaker check every six months dated 4/8/2021.<BR/>Review of an undated list of residents that had pacemakers, provided by the facility, revealed Resident #26 had a pacemaker.<BR/>Interview on 9/23/2022 at 12:22 p.m. with Resident #26 he confirmed he had a pacemaker, reported he has had it for a while and that he was seeing his physician for follow up in coming weeks. <BR/>Interview on 9/23/2022 at 12:06 p.m. with the MDS Coordinator she reported she should have documented the pacemaker on the MDS. She reported, I have no answer why it did not get documented on the MDS.<BR/>2. Review of Resident #50's face sheet dated 9/21/2022 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and chronic respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood but carbon dioxide levels are close to normal).<BR/>Review of resident #50's MDS dated [DATE] revealed there was no pacemaker listed in the resident's diagnoses.<BR/>Review of an undated list of residents that had pacemakers, provided by the facility, revealed Resident #50 had a pacemaker.<BR/>Interview on 9/23/2022 at 12:48 p.m. with Resident #50 revealed he had a pacemaker. The resident reported he had the pacemaker for 4 or 5 years.<BR/>Review of Resident #50's physician orders dated 9/2/22 did not reveal information about the resident's pacemaker.<BR/>Interview on 9/23/2022 at 11:56 a.m. with the MDS Coordinator she reported she usually uploaded the resident's diagnoses in the resident's electronic record. The MDS Coordinator reported because she missed putting the pacemaker as a diagnosis on the resident's face sheet was probably why she missed it on the MDS. The MDS Coordinator reported she was usually told in the department head morning meeting if a resident had a pacemaker.<BR/>In an interview on 9/23/2022 at 1:23 p.m. with the DON she reported pacemakers should be coded on the MDS. The DON reported they discuss which resident's had pacemakers in their morning meetings. <BR/>3. Review of Resident #54's electronic face sheet dated 09/23/2022 revealed he was admitted to the facility on [DATE] with diagnoses of hypertensive heart disease with heart failure (high blood pressure and dysfunction of the heart), depression (mood disorder), atherosclerotic heart disease (plaque buildup in heart arteries), peripheral vascular disease (blood flow impairment of extremities) and arthritis (inflammation of joints causing pain).<BR/>Review of Resident #54's admission MDS assessment dated [DATE] revealed under Section I - Active Diagnoses that he did not have section 10600. Heart Failure (e.g., congestive heart failure (CHF) ) checked off as a diagnosis. He scored a 14/15 on his BIMS which indicated he was cognitively intact and he could understand and be understood.<BR/>Review of Resident #54's comprehensive care plan which was completed in place of the baseline dated 08/24/2022 revealed he did not have heart failure or cardiac issues addressed. His care plan reflected he wished to be treated as a full code for advanced directives.<BR/>Review of Resident #54's Order Summary Report .Active Orders As Of: 09/23/2022 revealed he was ordered Furosemide (diuretic) Tablet 40 MG, give one tablet by mouth two times a day for CHF.<BR/>Observation on 09/23/2022 at 1:30 p.m. of Resident #54 revealed he was sitting in the hallway in his wheelchair. <BR/>Interview on 09/23/2022 at 1:30 p.m. with Resident #54 revealed he had a cardiac pacemaker a few months earlier related to heart failure. He stated that he had an appointment to get another one in October 2022. <BR/>Interview on 09/23/2022 at 2:00 p.m. with the MDS nurse revealed that she was out sick with COVID-19 for awhile and that she did not know why Resident #54's heart failure was not coded on his admission MDS assessment. She stated that with the medications he was on, and his diagnosis, heart failure needed to be coded. She stated it was important to have accurately coded MDS's because it was a reflection of the care required for the resident and triggered areas for the care plan.<BR/>Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that Resident #54's heart failure needed to be coded on his admission MDS, and that staff was not aware that he had a pacemaker until they caught him going out to an appointment. She stated his medications and history should have provided them with the information to ensure the MDS was coded accurately, but it was missed, and that impacted his care plan and focused area's for needs being met.<BR/>Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 revealed: 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to have an accurate MDS assessment for 3 residents (#26, #50 and #54) out of 24 residents reviewed for accurate MDS assessments in that:<BR/>1. The facility did not have Resident #26's pacemaker coded on the MDS.<BR/>2. The facility did not have Resident #50's pacemaker coded on the MDS.<BR/>3. The facility active diagnosis of heart failure was not coded on his Resident #54's MDS assessment.<BR/>This deficient practice could affect residents who required assessments at the facility and result in resident needs not being met.<BR/>The findings were:<BR/>1. Review of Resident #26's face sheet dated 9/26/2022 revealed he was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease with heart failure, hemiplegia (paralysis on one side of the body) and hemiparesis (mild weakness or loss of strength to one side of the body) following cerebral infarction (a disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, hyperlipidemia (a condition in which there are high levels of fat particles/lipids in the blood) and presence of automatic (implantable) cardiac defibrillator (a device that sends an electric pulse or shock to the heart to restore a normal heart beat). <BR/>Review of the Quarterly MDS dated [DATE] revealed there was no diagnoses for pacemaker on the MDS. <BR/>Review of Resident #26's Physician Orders dated 9/1/2022 revealed, Resident has a pacemaker check every six months dated 4/8/2021.<BR/>Review of an undated list of residents that had pacemakers, provided by the facility, revealed Resident #26 had a pacemaker.<BR/>Interview on 9/23/2022 at 12:22 p.m. with Resident #26 he confirmed he had a pacemaker, reported he has had it for a while and that he was seeing his physician for follow up in coming weeks. <BR/>Interview on 9/23/2022 at 12:06 p.m. with the MDS Coordinator she reported she should have documented the pacemaker on the MDS. She reported, I have no answer why it did not get documented on the MDS.<BR/>2. Review of Resident #50's face sheet dated 9/21/2022 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and chronic respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood but carbon dioxide levels are close to normal).<BR/>Review of resident #50's MDS dated [DATE] revealed there was no pacemaker listed in the resident's diagnoses.<BR/>Review of an undated list of residents that had pacemakers, provided by the facility, revealed Resident #50 had a pacemaker.<BR/>Interview on 9/23/2022 at 12:48 p.m. with Resident #50 revealed he had a pacemaker. The resident reported he had the pacemaker for 4 or 5 years.<BR/>Review of Resident #50's physician orders dated 9/2/22 did not reveal information about the resident's pacemaker.<BR/>Interview on 9/23/2022 at 11:56 a.m. with the MDS Coordinator she reported she usually uploaded the resident's diagnoses in the resident's electronic record. The MDS Coordinator reported because she missed putting the pacemaker as a diagnosis on the resident's face sheet was probably why she missed it on the MDS. The MDS Coordinator reported she was usually told in the department head morning meeting if a resident had a pacemaker.<BR/>In an interview on 9/23/2022 at 1:23 p.m. with the DON she reported pacemakers should be coded on the MDS. The DON reported they discuss which resident's had pacemakers in their morning meetings. <BR/>3. Review of Resident #54's electronic face sheet dated 09/23/2022 revealed he was admitted to the facility on [DATE] with diagnoses of hypertensive heart disease with heart failure (high blood pressure and dysfunction of the heart), depression (mood disorder), atherosclerotic heart disease (plaque buildup in heart arteries), peripheral vascular disease (blood flow impairment of extremities) and arthritis (inflammation of joints causing pain).<BR/>Review of Resident #54's admission MDS assessment dated [DATE] revealed under Section I - Active Diagnoses that he did not have section 10600. Heart Failure (e.g., congestive heart failure (CHF) ) checked off as a diagnosis. He scored a 14/15 on his BIMS which indicated he was cognitively intact and he could understand and be understood.<BR/>Review of Resident #54's comprehensive care plan which was completed in place of the baseline dated 08/24/2022 revealed he did not have heart failure or cardiac issues addressed. His care plan reflected he wished to be treated as a full code for advanced directives.<BR/>Review of Resident #54's Order Summary Report .Active Orders As Of: 09/23/2022 revealed he was ordered Furosemide (diuretic) Tablet 40 MG, give one tablet by mouth two times a day for CHF.<BR/>Observation on 09/23/2022 at 1:30 p.m. of Resident #54 revealed he was sitting in the hallway in his wheelchair. <BR/>Interview on 09/23/2022 at 1:30 p.m. with Resident #54 revealed he had a cardiac pacemaker a few months earlier related to heart failure. He stated that he had an appointment to get another one in October 2022. <BR/>Interview on 09/23/2022 at 2:00 p.m. with the MDS nurse revealed that she was out sick with COVID-19 for awhile and that she did not know why Resident #54's heart failure was not coded on his admission MDS assessment. She stated that with the medications he was on, and his diagnosis, heart failure needed to be coded. She stated it was important to have accurately coded MDS's because it was a reflection of the care required for the resident and triggered areas for the care plan.<BR/>Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that Resident #54's heart failure needed to be coded on his admission MDS, and that staff was not aware that he had a pacemaker until they caught him going out to an appointment. She stated his medications and history should have provided them with the information to ensure the MDS was coded accurately, but it was missed, and that impacted his care plan and focused area's for needs being met.<BR/>Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 revealed: 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to develop and implement a baseline care plan for 3 (Resident's #54, #110 and #113) out of 3 residents reviewed for baseline care plans in that:<BR/>1. Resident #54's heart failure and cardiac issues were not addressed in his baseline care plan.<BR/>2. Resident #110's code status was not addressed in his baseline care plan.<BR/>3. Resident #113's code status was not addressed in her baseline care plan.<BR/>This deficient practice could affect newly admitted residents and could result in inaccurate care provided.<BR/>The findings were:<BR/>1. Review of Resident #54's electronic face sheet dated 09/23/2022 revealed he was admitted to the facility on [DATE] with diagnoses of hypertensive heart disease with heart failure (high blood pressure and dysfunction of the heart), depression (mood disorder), atherosclerotic heart disease (plaque buildup in heart arteries), peripheral vascular disease (blood flow impairment of extremities) and arthritis (inflammation of joints causing pain.<BR/>Review of Resident #54's admission MDS assessment dated [DATE] revealed under Section I - Active Diagnoses that he had active diagnoses of coronary artery disease and atherosclerotic heart disease. He scored a 14/15 on his BIMS which indicated he was cognitively intact and he could understand and be understood.<BR/>Review of Resident #54's baseline care plan dated 08/24/2022 revealed he did not have cardiac issues addressed. His care plan reflected he wished to be treated as a full code for advanced directives.<BR/>Review of Resident #54's Order Summary Report .Active Orders As Of: 09/23/2022 revealed he was ordered Aspirin Tablet Chewable 81 MG (blood thinner for cardiac issues) give one tablet daily order start dated 08/24/2022, Clopidogrel Bisulfate Tablet 75 MG (blood clot prevention) give one tablet by mouth one time a day .start date 08/24/2022 and Furosemide (diuretic) Tablet 40 MG, give one tablet by mouth two times a day for CHF.<BR/>Observation on 09/23/2022 at 1:30 p.m. of Resident #54 revealed he was sitting in the hallway in his wheelchair. <BR/>Interview on 09/23/2022 at 1:30 p.m. with Resident #54 revealed he had a cardiac pacemaker a few months earlier related to heart failure. He stated that he had an appointment to get another one in October 2022. <BR/>Interview on 09/23/2022 at 2:00 p.m. with the MDS nurse revealed that she was out sick with COVID-19 for awhile and that she did not know why Resident #54's heart conditions were not on his baseline care plan and they needed to be to show the care he required. <BR/>Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that Resident #54's heart conditions needed to be on his baseline care plan, and stated his medications and history should have provided them with the information to ensure the baseline care plan was accurate, but his cardiac issues were missed, and that could impact his medical needs from being met.<BR/>2. Review of Resident #110's electronic face sheet dated 09/22/2022 revealed he was admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke to brain), diabetes (blood sugar disorder), hypertensive heart disease (cardiac dysfunction related to high blood pressure) and peripheral vascular disease (low blood flow to extremities).<BR/>Review of Resident #110's 48 HOUR INITIAL CARE PLAN dated 09/20/2022 only addressed his risk for falls, altered skin integrity and self care deficit and did not reflect his full code status.<BR/>Review of Resident #110's Order Summary Report .Active Orders As Of 09/23/2022 revealed Resident #110 was ordered to have full code status with a start date of 09/19/2022.<BR/>Interview on 09/23/2022 at 2:00 p.m. with the MDS nurse revealed that she was out sick with COVID-19 for awhile and that she did not know why Resident #110's full code status was not on his baseline care plan and they needed to be to show what he wished for advance directives.<BR/>Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that Resident #110's full code status should have been on his baseline care plan, and stated his medications and history should have provided them with the information to ensure the baseline care plan was accurate.<BR/>3. Review of Resident #113's electronic face sheet dated 09/22/2022 revealed she was admitted on [DATE] with diagnoses of cerebral infarction (stroke to brain), hypothyroidism (malfunction of thyroid gland, low), bipolar disorder (mood imbalance), anxiety (nervousness), hypertensive heart disease (heart malfunction related to high blood pressure) and hemiplegia and hemiparesis of left side (partial paralysis). <BR/>Review of Resident #113's 48 HOUR INITIAL CARE PLAN dated 09/17/2022 only addressed her risk for falls and self care deficit and did not reflect her full code status.<BR/>Review of Resident #113's Order Summary Report .Active Orders As Of 09/23/2022 with a start date of 09/15/2022 revealed Resident #113 was ordered to have full code status.<BR/>Interview on 09/23/2022 at 2:00 p.m. with the MDS nurse revealed that she was out sick with COVID-19 for awhile and that she did not know why Resident #113's full code status was not on her baseline care plan and they needed to be to show what she wished for advance directives.<BR/>Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that Resident #113's full code status should have been on her baseline care plan, and stated her medications and history should have provided them with the information to ensure the baseline care plan was accurate.<BR/>Review of the facility policy and procedure titled Care Plans - Baseline revised December 2016 revealed 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate needs including but not limited to: a. initial goals based on admission orders; b. Physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for care plans in that: <BR/>The facility failed to implement a comprehensive care plan intervention for Resident #1 which addressed her fall risk which included a fall mat at Resident #1's bedside. <BR/>The facility failed to implement a comprehensive care plan intervention for Resident #1 which addressed her fall risk which included her bed should have been placed in the lowest position<BR/>This failures placed the resident at risk for injury.<BR/>Finding included: <BR/>Record review of the admission sheet for Resident #1 revealed an [AGE] year-old female admitted on [DATE] and re-admitted [DATE]. Her diagnoses included: diagnosis of muscle weakness, abnormal gait/mobility, cerebrovascular accident (loss of blood flow to a part of the brain) and dementia (group of symptoms that affects memory, thinking and interferes with daily life).<BR/>Record review of Resident #1's Significant Change MDS assessment, dated 2/28/2024, revealed a BIMS score of 13 out of 15 which indicated her cognition was intact. Resident #1 used a wheelchair for mobility. Resident #1 required total dependence from two-person physical assist from staff for bed mobility and transfer. <BR/>Record review of Resident #1's care plan, initiated 3/8/2024 revealed the following:<BR/>Focus: (Resident #1) is at risk for falls/injuries related to CVA weakness. Goal: (Resident #1) will have no falls/injuries daily through next 90 day review. Interventions: .Fall mat in place (date initiated 5/6/2024) Keep bed in low position (date initiated 11/21/22 and revised 8/29/23).<BR/>Record review of Resident #1's Fall assessment dated [DATE] revealed Resident #1 had a score of 17 which indicated a High Risk for falls.<BR/>Observation on 5/8/2024 at 10:07 a.m., revealed Resident #1 awake in bed with her bed not in the low position, and there was no fall mat at bedside or in the room.<BR/>Observation on 5/8/2024 at 10:39 a.m., revealed Resident #1 awake in bed with her bed not in the low position, and there was no fall mat at bedside or in the room. <BR/>Observation on 5/8/2024 at 10:59 a.m., revealed Resident #1 awake in bed with her bed not in the low position and there was no fall mat at bedside or in the room. <BR/>Interview on 5/8/2024 at 11:00 a.m. with CNA A, who was assigned to Resident #1, revealed the nurses would tell her if there were any interventions that the resident needed. She was aware that the resident had falls in the past but was not aware of the fall mat intervention for Resident #1. She was not able to say why the bed was not in the lowest position. She said care planned interventions should be in the [NAME] (system that organizes resident information). CNA A said she had been trained on reviewing the documentation system at the beginning of the shift, but she relied on the nurses to update her on intervention changes. <BR/>Observation on 5/8/2024 at 11:15 a.m. of Resident #1 in her bed without a mat on the side of her bed and not in the low position was observed by CNA B and the ADMIN.<BR/>Interview on 5/8/2024 at 11:16 a.m. with CNA B revealed Resident #1's bed was not in the lowest position and there was not a mat at the bedside. She said the bed was in a mid-position. She said it put the resident at risk for injury since she was a fall risk. She said it was the CNA's and Nurses responsibility to ensure interventions were in place. <BR/>Observation on 5/8/2024 at 1:46 p.m., revealed Resident #1 awake in bed with her bed not in the low position and there was no fall mat at bedside or in the room. <BR/>Interview on 5/8/2024 at 2:10 pm with LVN A revealed she had been off for two days and this was her first day back, and she did not realize that the fall mat intervention was started. She said she should have looked at the [NAME]. She said it was all staff's responsibility to ensure fall interventions are in place. <BR/>Interview on 5/8/2024 at 1:41pm with the DON, revealed Resident #1's had multiple previous falls they discussed interventions during the morning meetings after the falls and decided to implement the fall mat on 5/6/2024. She said she was not sure what happened and why the fall interventions were not in place for Resident #1. The DON said CNA's had been trained to refer to the [NAME] for interventions needed and should read them daily. She said the nurses should have ensured the fall mat and the low bed intervention was in place for Resident #1. She said Central Supply should have initially placed the mat in the room on 5/6/2024. She said Central Supply should have been updated when the intervention was updated.<BR/>Interview on 5/8/24 at 1:57 pm with Central Supply, revealed she was responsible for supplies needed for interventions like fall mats. She said she was not told Resident #1's needed a fall mat. She said she was told approximately 20 minutes prior to that interview (1:37pm).<BR/>Interview on 5/8/24 4:40 p.m. with, the Admin. revealed Resident #1 was supposed to have a fall mat and her bed should have been in a low position. He said the staff should have followed the care plans. He said the Nurses and CNA's were responsible for ensuring fall interventions are in place. He said it is the DON's responsibility and should have ensured the intervention was in place for Resident #1. He said the new interventions should have be communicated to the charge nurses. The charge nurses should have informed CNA's about Resident #1's interventions were in place. <BR/>Record review of facility's policy, Care Plans Comprehensive Person-Centered (revised December 2016) revealed the following in part:<BR/>A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 10. Identifying problems areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.<BR/>Record review of facility's policy, Fall Prevention Program not dated, revealed the following in part: <BR/> .The Interdisciplinary Team will review fall risk assessments completed by the nursing department, as well as completing the Fall Resident Assessment Protocol and if appropriate, a fall prevention protocol will be initiated . Purpose: To ensure consistency in the implementation of preventive measures to assist with the reduction of falls . Procedure: 4. All resident receiving a score of ten (10) or more will be considered at risk for falls .6. The Director of Nursing/designee will be responsible for ensuring that residents who have been identified at risk or who have experienced recent falls have all recommended interventions in place .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to review and revise the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments for 4 residents (#21, #31, #44, #48) out of 20 residents reviewed for comprehensive care plan revision in that:<BR/>1. Facility failed to ensure Resident #21's comprehensive care plan was revised after her Significant Change MDS assessment to reflect here DNR status.<BR/>2. Facility failed to ensure Resident #31's comprehensive care plan was revised to address the change in code status from DNR (Do Not Resuscitate) to Full code. <BR/>3. Facility failed to ensure Resident #44's comprehensive care plan was revised to address the change in code status from Full code to DNR (Do Not Resuscitate). <BR/>4. Facility failed to ensure Resident #48's comprehensive care plan was revised to address the change in code status from Full code to DNR (Do Not Resuscitate). <BR/>The findings were:<BR/>1. Review of Resident #21's electronic face sheet revealed she was admitted to the facility on [DATE] after being in the hospital with diagnoses of cellulitis of right and left lower limbs (swelling and inflammation of lower limbs), repeated falls, atherosclerotic heart disease (plaque in heart arteries obstructing blood flow) and major depressive disorder (mood changes).<BR/>Review of Resident #21's Significant Change MDS assessment dated [DATE] revealed she scored a 15/15 on her BIMS which indicated she was cognitively intact. She required extensive assistance with her ADL's.<BR/>Review of Resident #21's person-centered comprehensive care plan dated [DATE] revealed is a full code.<BR/>Review of Resident #21's Order Summary Report .Active Orders As Of: [DATE] revealed she had no code status ordered.<BR/>Review of Resident #21's Nurse Practitioner progress note dated [DATE] revealed the resident was DNR status.<BR/>Review of Resident #21's OOH DNR order revealed it was signed on [DATE].<BR/>Observation on [DATE] at 1:10 p.m. Resident #21 revealed she was lying in bed. <BR/>Interview on [DATE] at 1:11 p.m. with Resident #21 revealed Right now I would say I'm a DNR. The facility already knows I'm a DNR, I don't want CPR because they break your chest and put you on a ventilator. I know because I was a Respiratory Therapist.<BR/>Interview on [DATE] at 2:00 p.m. with the MDS nurse revealed that she was out sick with COVID-19 for awhile and that she did not know why Resident #21's DNR status was not on her person-centered comprehensive care plan and it should have been revised after her Significant Change MDS assesmeent because that was a part of her wishes.<BR/>Interview on [DATE] at 2:10 p.m. with the DON revealed that Resident #21's DNR status should have been in her physician orders and her comprehensive person-centered care plan revised when she returned from the hospital. She stated it slipped through the cracks and was missed. <BR/>2. Record review of Resident #31's face sheet, dated [DATE], revealed she was readmitted to the facility on [DATE] (original admission on [DATE]) with diagnoses which included: type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar (glucose) as a fuel) with hyperglycemia (high blood sugar (glucose) level), chronic embolism and thrombosis of unspecified vein (diseases of the circulatory system), bipolar disorder (mental health condition that causes extreme mood swings) and chronic kidney disease stage 3 (gradual loss of kidney function). <BR/>Record review of Resident #31's Significant Change MDS, dated [DATE], revealed the resident's BIMS score was 15, which indicated intact cognition. <BR/>Record review of Resident#31's physician order summary dated [DATE] revealed the following order Code Status: Full Code with an order date of [DATE]. <BR/>Record review of Resident #31's care plan printed [DATE] revealed had not been revised to reflect Resident #31's Full Code status. Care plan further revealed Focus: Code Status: Do Not Resuscitate . Interventions/Task: Code status will be reviewed with change of condition and at least quarterly. <BR/>Record review of Resident #31's physician progress note dated [DATE] revealed Code Status: Attempt resuscitation (CPR). <BR/>During an interview on [DATE] at 2:07 p.m. Resident #31 stated she did want CPR (cardiopulmonary resuscitation) and no longer wanted her DNR in place. Resident #31 further stated she had wanted her DNR retracted.<BR/>During an interview on [DATE] at 11:02 a.m. SW coordinator stated Resident #31 had voiced the desire to revoke her Texas OOHDNR and change code status to full code. SW coordinator further stated the care plan had not been revised with her request for resuscitation. SW coordinator stated it should have been revised and the MDS coordinator was responsible for the revision of care plans. SW coordinator further stated the MDS coordinator is informed during care plans and when the SW coordinator receives the request from a resident. <BR/>During an interview on [DATE] at 11:22 a.m. MDS coordinator stated she was responsible for the revision of the code status care plans. MDS coordinator further stated they would try to do this when they spoke with the resident or the family/RP. MDS coordinator stated she would write down what was discussed in the care plan then go back to her computer to change the care plan. MDS coordinator further stated the SW coordinator would inform her sometimes and it would also be discussed in the facility morning meetings. MDS coordinator stated Resident #31's care plan had not been revised to reflect Full Code status for resuscitation. <BR/>3. Review of Resident #44's face sheet dated [DATE] revealed he was admitted to the facility on [DATE] and had diagnoses that included dementia without behavioral disturbance, mild protein calorie malnutrition and hypertensive heart disease (heart problems that occur because of high blood pressure over a long time) without heart failure.<BR/>Review of Resident #44's [DATE] Consolidated Physician Orders revealed an order for DNR (Do Not Resuscitate) dated [DATE].<BR/>Review of Resident #44's Care Conference Summary dated [DATE] revealed a Social Services note revealed an Out of Hospital DNR had been signed and awaiting physician signature.<BR/>Review of Resident #44's care plan date initiated [DATE] revealed the resident was a full code.<BR/>In an interview on [DATE] at 11:10 a.m. with the Social Work Coordinator revealed she discussed code status with the resident and/or families during the care plan conference. The Social Work Coordinator reported the MDS Coordinator revised the care plans when there was a change in code status. <BR/>In an interview on [DATE] at 11:24 a.m. with the MDS Coordinator revealed generally the Social Work Coordinator informs her at the morning meeting if a resident's code status had changed. The MDS Coordinator reported when care plan meetings were held quarterly they review the resident's code status. She reported she had no idea how she missed the resident changed the code status to DNR.<BR/>In an interview on [DATE] at 1:02 p.m. with the DON reported it was necessary for the resident's code status to be accurate on the care plan because if the nurse was not able to locate a resident's code status the care plan was another option to review what the resident's code status was. <BR/>4. Record review of Resident #48's face sheet, dated [DATE], revealed she was readmitted to the facility on [DATE] (original admission on [DATE]) with diagnoses which included: presence of cardiac pacemaker (includes a number of complications of high blood pressure that affect the heart), hypertensive heart disease without heart failure, and pulmonary hypertension (high blood pressure that affects the arteries in the lungs and the right side of the heart).<BR/>Record review of Resident #48's Annual MDS, dated [DATE], revealed the resident's BIMS score was 03, which indicated severe cognitive impairment.<BR/>Record review of Resident#48's physician order summary dated [DATE] revealed the following order Code Status: DNR/DNI with an order date of [DATE]. <BR/>Record review of Resident #48's Texas Out of Hospital DNR (form instructs emergency medical personnel and other health care professionals to forgo resuscitation attempts) revealed signed and completed on [DATE].<BR/>Record review of Resident #48's care plan printed [DATE] revealed had not been revised to reflect Resident #48 DNR code status. Care plan further revealed Focus: code status: Full code .Interventions/Task: review code status with each care plan meeting and change of condition with a revision date of [DATE]. <BR/>Record review of Resident #48's Care Plan Conference Summary dated [DATE] revealed, Discussed resident's code status resident and family requested to remain under DNR status. <BR/>During an interview on [DATE] at 10:46 a.m. SW coordinator stated she would complete her section of the care plan summary, by discussing a resident's code status with the resident or the family/RP during a care plan meeting. SW coordinator further stated the MDS coordinator was responsible for the completion of the code status care plan and the revision. Revision usually would occur when the code status is discussed in the care plan meeting or once a Texas OOHDNR (out of hospital do not resuscitate) form was completed. SW coordinator stated she would inform the MDS coordinator of any changes. <BR/>During an interview on [DATE] at 11:22 a.m. MDS coordinator stated she was responsible for the revision of the code status care plans. MDS coordinator further stated they would try to do this when they spoke with the resident or the family/RP. MDS coordinator stated she would write down what was discussed in the care plan then go back to her computer to change the care plan. MDS coordinator further stated the SW coordinator would inform her sometimes and it would also be discussed in the facility morning meetings. MDS coordinator stated Resident #48's care plan had not been revised to reflect the DNR code status. <BR/>During an interview on [DATE] at 12:56 p.m. the DON stated MDS coordinator is responsible for the writing of the care plans and care plans were necessary to have a resident's code status (lets the patient's medical team know what they want and do not want in the event of a medical emergency such as their heart stopping). The DON further stated the care plan being revised was important so staff can identify the care the resident requires and for the continuity of care. <BR/>Review of the facility policy and procedure titled Care Plans, Comprehensive Person-Centered revised [DATE] revealed 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change .14. The Interdisciplinary Team must review and update the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly in conjunction with the MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 2 residents (#56 and #111) of 6 residents reviewed for oxygen therapy in that:<BR/>1. Resident #56's oxygen tubing was not dated and his nebulizer mask was not in a bag.<BR/>2. Resident #111's oxygen tubing was not dated and his nasal cannula was not bagged when he was not in his room.<BR/>This deficient practice could affect residents on oxygen therapy and could result in respiratory compromise.<BR/>The findings were:<BR/>1. Review of Resident #56's electronic face sheet dated 09/23/2022 revealed he was admitted to the facility on [DATE] with diagnoses of COPD (lung disease, difficulty breathing), bronchitis (inflammation of the bronchial's in lung) and allergic rhinitis (allergies).<BR/>Review of Resident #56's Quarterly MDS assessment with an ARD of 08/24/2022 revealed he was coded under active diagnoses to have COPD. He scored a 15/15 on his BIMS which indicated he was cognitively intact, and he required moderate assistance with his ADL's.<BR/>Review of Resident #56's comprehensive person-centered care plan dated 06/23/2022 revealed Focus .impaired gas exchange r/t COPD .Interventions .continue O 2 as needed.<BR/>Review of Resident #56's Order Summary Report .Active Orders As Of: 09/23/2022 revealed he was ordered O 2 at 2 L/NC for SOB titrate sat &gt; 93%. The order start date was 08/28/2021. Change the nebulizer mask, reservoir and tubing every Sunday night with a start dated of 03/13/2022.<BR/>Review of Resident #56's MAR dated September 23, 2022 revealed change tubing and humidifier bottle on oxygen concentrator on Sunday Night every night shift every Sunday and was initialed off by the night shift nurse for Sunday September the 18th.<BR/>Observation on 09/21/22 at 01:23 PM Resident #56 had oxygen on at 2 L/NC, tubing not dated, humidifier bottle had 9/19 written on it. Oxygen mask hanging on dresser drawer knob, tubing not labeled, mask not bagged. <BR/>Observation on 09/23/2022 at 11:00 a.m. with the DCO revealed that Resident #56's oxygen tubing was not dated and his nebulizer mask was unbagged and hanging on the dresser drawer knob.<BR/>2. Review of Resident #111's electronic face sheet dated 09/23/2022 revealed he was admitted to the facility on [DATE] with diagnoses of hypertensive heart disease with heart failure (heart dysfunction caused by high blood pressure), and chronic ischemic heart disease (cardiac dysfunction related to lack of oxygen to heart muscle).<BR/>Review of Resident #111's Quarterly MDS assessment with an ARD of 08/10/2022 revealed he scored a 15/15 on his BIMS which indicated he was cognitively intact. He was coded under active diagnoses for anemia, coronary artery disease and heart failure. He required moderate assistance with his ADL's.<BR/>Review of Resident #111's comprehensive person-centered care plan dated revised 07/26/2022 revealed Focus .impaired gas exchange r/t chest congestion .Interventions .O 2 per order.<BR/>Review of Resident #111's Order Summary Report .Active Orders As Of: 09/23/2022 revealed he was ordered O 2 at 3 L/NC prn SOB or respiratory distress with a start date of 02/14/2022.<BR/>Observation on 09/21/22 at 01:28 PM Resident #111 had oxygen on at 3 L/NC, tubing not dated, humidifier bottle had 9/19 written on it. <BR/>Observation on 09/23/2022 at 11:03 a.m. with the DCO revealed that Resident #111's oxygen tubing was not dated and his nasal cannula was lying on his bed unbagged.<BR/>Interview on 09/23/2022 at 11:15 a.m. with the DCO revealed that recommendation of oxygen tubing was usually to change it out every 7 to 10 days to prevent dust, dirt or other particles to get into the tubing. She stated in order to know it was changed out the nursing staff dated the tubing, and both Resident #56's and #111's tubing was not dated. She stated both needed their oxygen nasal cannula's protected in bags when not in use and Resident #54's nebulizer mask needed to be bagged and it wasn't.<BR/>Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that Resident #56's and #111's oxygen tubing needed to be dated. She stated it was their standard of care to prevent breathing complications due to dust, allergens or dirt particles was to make sure the oxygen tubing and nebulizer masks, etc., were changed out weekly and the masks or nasal cannula's placed in plastic bags when not in use. She stated usually the administrative nursing staff did rounds and checked it on Mondays, but it was missed somehow. <BR/>Review of the facility policy and procedure titled Oxygen Administration dated 2020 revealed Purpose .to provide guidelines for safe oxygen administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were assessed and had consents for bed rails for 1 of 1 resident (#35) reviewed for bed rails in that:<BR/>Resident #35 did not have an assessment or informed consent for the use of bed rails. <BR/>This deficient practice could affect residents who utilized some type of bed rails in the facility and could place the residents at risk for potential and avoidable injuries.<BR/>The findings were:<BR/>Review of Resident #35's electronic face sheet dated 09/22/2022 revealed she was admitted to the facility on [DATE] with diagnoses of chronic systolic (congestive) heart failure (heart dysfunction), diabetes mellitus (blood sugar abnormality) and atheroscerosis of coronary artery (plaque build up in heart artery causing diminished blood flow).<BR/>Review of Resident #35's admission MDS assessment dated [DATE] revealed she scored a 9/15 on her BIMS which indicated she was moderately cognitively impaired and was understood and was able to usually understand and required extensive assistance with her ADL's.<BR/>Review of Resident #35's comprehensive care plan dated 08/17/2022 revealed she had impaired physical mobility r/t end stage disease, but the interventions did not reflect she had a 1/2 side bed rail on both sides of her bed.<BR/>Review of Resident #35's electronic record on 09/22/2022 revealed she did not have a consent form or assessment for bed rails.<BR/>Observation on 09/19/22 at 10:45 a.m. revealed Resident #35 was lying in bed with 1/2 length siderails up X 2.<BR/>Observation on 09/23/2022 at 10:35 a.m. of Resident #35 accompanied by the Director of Clinical Operations (DCO) revealed Resident #35 had 1/2 side rails up X 2. <BR/>Interview on 09/23/2022 at 10:45 a.m. with Resident #35 revealed the bed rails came with the bed, and she did not use them and did not know why she had them.<BR/>Interview on 09/23/2022 at 10:40 a.m. with the DCO, she stated that the facility did not even use those types of bed rails any longer and they must have been brought in by Hospice services. She stated that she could not locate a consent or an assessment for Resident #35's bed rails.<BR/>Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that Resident #35 should have been assessed for the 1/2 length bed rails and that there needed to be a consent done which described the risks of side rails.<BR/>Review of the facility policy and procedure titled Proper Use of Side Rails (undated) revealed An assessment will be made to determine the residents symptom's, risk of entrapment and reason for using side rails. When used for mobility, and assessment will include a review of the resident's: bed mobility, ability to change positions .risk of entrapment, bed's dimensions are appropriate for the resident's size and weight. The use of side rails as an assistive device will be addressed in the resident care plan. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide a therapeutic diet, in the appropriate form as prescribed by a physician for 1 of 20 residents (Resident #48) observed for therapeutic diets.<BR/>The facility failed to provide Resident #48 a pureed diet, as ordered by the physician.<BR/>This failure could affect residents with physician orders for therapeutic diets and could result in consumption of inappropriate textured food items which could cause choking or aspiration and a decline in health. <BR/>The findings were:<BR/>Record review of Resident #48's face sheet, dated 09/21/2022, revealed she was readmitted to the facility on [DATE] (original admission on [DATE]) with diagnoses which included: dysphagia oropharyngeal phase (small pouch that forms and collects food particles in your throat, often just above your esophagus, leads to difficulty swallowing), cerebral infarction due to occlusion or stenosis of small artery (pathologic process that results in an area of necrotic tissue in the brain), dysphagia following cerebral infarction (difficulty swallowing after a stroke), and dementia (loss of cognitive functioning). <BR/>Record review of Resident #48's Annual MDS, dated [DATE], revealed the resident's BIMS score was 03, which indicated severe cognitive impairment, functional status while eating being supervision (oversight, encouragement or cueing) with meal set up and while a resident nutritional approaches mechanically altered diet (require change in texture of food or liquids). <BR/>Record review of Resident#48's physician order summary dated 09/23/2022 revealed the following order Regular diet Dysphagia Level 1 Puree texture . with a start date of 04/15/2021. <BR/>Record review of Resident #48's care plan printed 09/23/2022 revealed Focus: Potential for or presence of altered nutrition needs requires mechanically altered diet Intervention: Diet and food texture provide as tolerated with a revision date of 07/26/2022. <BR/>Observation on 09/20/2022 at 12:30 p.m. Resident #48 was observed sitting upright in her bed eating a regular bowl of pinto beans with her pureed meal on a divided plate to the side. <BR/>During an interview on 09/20/2022 LVN C stated Resident #48 was not supposed to have the regular pinto beans, then further stated the beans should have been pureed. LVN C further stated she was not sure who had given Resident #48 the pinto beans. <BR/>During an interview on 09/20/2022 the DON stated the ST was working with Resident #48 and on occasion she might have ordered her something different. The DON further stated the ST should be present while she was eating the regular pinto beans. The DON stated it could put Resident #48 at risk for aspiration or choking by not giving her the ordered diet.<BR/>During an interview on 09/23/2022 at 1:45 p.m. the ST stated Resident #48 should not be eating unsupervised anything not pureed. ST stated usually speech therapy will due 3 trials of a different texture and then if the resident tolerated it then speech would change the diet in the system, however Resident #48 was not ready for the change. ST stated by not serving resident her ordered pureed diet it would put her at risk of choking, aspiration, weight loss. <BR/>Record review of the facility's Therapeutic Diets policy, Quarter 3, 2021, revealed Policy Statement: Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Policy Interpretation and Implementation: 4. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example .d. Altered consistency diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for 2 residents (#21 and #50) of 24 residents reviewed for code status in that:<BR/>1. Resident #21 did not have a physician's order for her code status.<BR/>2. Resident #50 did not have a physician's order for a pacemaker<BR/>1. Review of Resident #21's electronic face sheet revealed she was admitted to the facility on [DATE] with diagnoses of cellulitis of right and left lower limbs (swelling and inflammation of lower limbs), repeated falls, atherosclerotic heart disease (plaque in heart arteries obstructing blood flow) and major depressive disorder (mood changes).<BR/>Review of Resident #21's Significant Change MDS assessment dated [DATE] revealed she scored a 15/15 on her BIMS which indicated she was cognitively intact. She required extensive assistance with her ADL's.<BR/>Review of Resident #21's person-centered comprehensive care plan dated [DATE] revealed is a full code.<BR/>Review of Resident #21's Order Summary Report .Active Orders As Of: [DATE] revealed she had no code status ordered.<BR/>Review of Resident #21's Nurse Practitioner progress note dated [DATE] revealed the resident was DNR status.<BR/>Review of Resident #21's OOH DNR order revealed it was signed on [DATE].<BR/>Observation on [DATE] at 1:10 p.m. Resident #35 revealed she was lying in bed. <BR/>Interview on [DATE] at 1:11 p.m. with Resident #35 revealed Right now I would say I'm a DNR. The facility already knows I'm a DNR, I don't want CPR because they break your chest and put you on a ventilator. I know because I was a Respiratory Therapist.<BR/>Interview on [DATE] at 2:00 p.m. with the MDS nurse revealed that she was out sick with COVID-19 for awhile and that she did not know why Resident #21's DNR status was not picked up on admission for her physician orders.<BR/>Interview on [DATE] at 2:10 p.m. with the DON revealed that Resident #21's DNR status should have been in her physician orders and comprehensive person-centered care plan. She stated it slipped through the cracks and was missed. <BR/>2. Review of Resident #50's face sheet dated [DATE] revealed the resident was admitted to the facility on [DATE] and had diagnoses that included chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and chronic respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood but carbon dioxide levels are close to normal).<BR/>Review of an undated list of residents that had pacemakers, provided by the facility, revealed Resident #50 had a pacemaker.<BR/>Interview on [DATE] at 12:48 p.m. with Resident #50 revealed he had a pacemaker. The resident reported he had the pacemaker for 4 or 5 years.<BR/>Review of Resident #50's physician orders dated [DATE] did not reveal information about the resident's pacemaker.<BR/>Interview on [DATE] at 11:56 a.m. with the MDS Coordinator she reported she usually uploaded the resident's diagnoses in the resident's electronic record. The MDS Coordinator reported she was usually told in the department head morning meeting if a resident had a pacemaker, but she was not aware the resident had a pacemaker.<BR/>In an interview on [DATE] at 1:23 p.m. with the DON she reported they discuss which resident's had pacemakers in their morning meetings. She reported it was important to know what diagnoses the residents had in order to know how to care for them. <BR/>Review of the facility policy and procedure titled Medication Orders dated [DATE] revealed A current list of orders must be maintained in the clinical record of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 resident (#46) of 2 residents reviewed for wound care and catheter care in that:<BR/>CNA A did not sanitize her hands when she changed her gloves after taking off the dirty brief when she performed catheter care for Resident #46.<BR/>LVN B did not sanitize her hands when she changed her gloves after taking off the dirty dressing, when she performed wound care for Resident #46.<BR/>These deficient practices could affect residents with wound treatments and incontinent care and could result in cross contamination.<BR/>The findings were: <BR/>Review of Resident #46's electronic face sheet dated 09/23/2022 revealed she was admitted to the facility on [DATE] with diagnoses of anemia (low red blood cell count), diabetes (blood sugar abnormality) and neurogenic bladder (loss of bladder control).<BR/>Review of Resident #46's Quarterly MDS assessment with an ARD of 8/17/22 revealed she scored a 15/15 on her BIMS which indicated she was cognitively intact. She required extensive assistance with her ADL's and she had an indwelling urinary catheter.<BR/>Review of Resident #46's comprehensive person-centered care plan revised date 05/24/2022 revealed has indwelling catheter .position catheter bag and tubing below the level of the bladder.<BR/>Review of Resident #46's Order Summary Report .Active Orders As Of: 09/23/2022 revealed Foley catheter care with soap and water every shift .start date 04/16/2021.<BR/>Observation on 09/22/2022 at 10:53 a.m. of CNA A as she performed catheter care for Resident #46, she wiped the groin and labia of Resident #46. She took off her dirty gloves, and put on clean gloves without hand hygiene.<BR/>Observation on 09/22/2022 at 11:20 a.m. of LVN B providing wound care for Resident #46. LVN B took off the dirty dressing, took off her dirty gloves and put on clean gloves without sanitizing her hands and then continued to pull the clean linen up and provide care.<BR/>Interview on 09/22/2022 at 11:00 a.m. with CNA A, she stated she was nervous and forgot to sanitize her hands between glove changes. She stated she knew it was important to prevent the spread of infection.<BR/>Interview on 09/22/2022 at 11:40 a.m. with LVN B, she stated that she forgot to sanitize her hands between glove changes, and she knew it was important on order to prevent cross contamination.<BR/>Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that CNA A and LVN B was agency staff but they come to the facility with the training. She stated that CNA A and LVN B needed to sanitize their hands between glove changes to minimize the change of cross contamination.<BR/>Review of the facility policy and procedure titled Hand/Hand Hygiene dated 2018 revealed 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: m. After removing gloves.<BR/>Review of the facility policy and procedure titled Infection Control Guidelines for All Nursing Procedures dated 2018 revealed 4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub .j. after removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to conduct an inspection of all bed frames, mattresses, and bed rails for 1 resident (#21) of 1 resident reviewed for bedrails in that:<BR/>Resident #21 had 1/2 length side rails on her bed which had not been inspected or assessed.<BR/>This deficient practice could affect residents who have beds with siderails and could result in entrapment.<BR/>The findings were:<BR/>Review of Resident #35's electronic face sheet dated 09/22/2022 revealed she was admitted to the facility on [DATE] with diagnoses of chronic systolic (congestive) heart failure (heart dysfunction), diabetes mellitus (blood sugar abnormality) and atheroscerosis of coronary artery (plaque build up in heart artery causing diminished blood flow).<BR/>Review of Resident #35's admission MDS assessment dated [DATE] revealed she scored a 9/15 on her BIMS which indicated she was moderately cognitively impaired and was understood and was able to usually understand and required extensive assistance with her ADL's.<BR/>Review of Resident #35's comprehensive care plan dated 08/17/2022 revealed she had impaired physical mobility r/t end stage disease, but the interventions did not reflect she had a 1/2 side bed rail on both sides of her bed.<BR/>Observation on 09/19/22 at 10:45 a.m. revealed Resident #35 was lying in bed with 1/2 length siderails up X 2.<BR/>Observation on 09/23/2022 at 10:35 a.m. of Resident #35 accompanied by the Director of Clinical Operations (DCO) revealed Resident #35 had 1/2 side rails up X 2. <BR/>Interview on 09/23/2022 at 10:40 a.m. with the DCO, she stated that the facility did not even use those types of bed rails any longer and they must have been brought in by Hospice services. She stated that regular inspections needed to be completed by the Maintanance Director of bed rails on beds.<BR/>Interview on 09/23/2022 at 10:45 a.m. with Resident #35 revealed the bed rails came with the bed, and she did not use them and did not know why she had them.<BR/>09/23/22 10:46 AM Interview with the Maintenance Director revealed that he was the only maintenance person and had that position since July 2022. He stated he did not check the side rails out on the bed or do measurements. He stated he understood why he needed to because of entrapment issues. <BR/>Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that Resident #35 should have been assessed for the 1/2 length bed rails and that there needed to be regular inspections done by the Maintenance Director to enusre bedrails meet compliance and are safe.<BR/>Review of the facility policy and procedure titled Proper Use of Side Rails (undated) revealed An assessment will be made to determine the residents symptom's, risk of entrapment and reason for using side rails. When used for mobility, and assessment will include a review of the resident's: bed mobility, ability to change positions .risk of entrapment, bed's dimensions are appropriate for the resident's size and weight. The use of side rails as an assistive device will be addressed in the resident care plan. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol.

Based on observation, interview, and record review the facility failed to provide food prepared by methods, which conserved nutritive value, flavor, and appearance for 1 of 1 meal (dinner) observed, in that:<BR/>Cook D pureed egg salad and macaroni salad with water for the lunch meal on 09/21/22, diluting the nutritive value.<BR/>This failure could place residents who receive pureed meals from the kitchen at risk for malnutrition and/or weight loss due to decreased nutritive value of the food. <BR/>The findings were:<BR/>Observation on 09/21/2022 at 11:06 a.m. [NAME] D was preparing the pureed food for lunch. [NAME] D put 4 large scoops of egg salad into mixer and blended the mixture. While the food was blending the cook added 13 teaspoons of water to the egg salad in the mixer. When the food was blended to desired consistency the cook poured the puree egg salad into a small metal pan.<BR/>Observation on 9/21/2020 at 11:15 a.m. [NAME] D put 4 large scoops of macaroni salad into the mixer. [NAME] D then slowly added 25 teaspoons of water to the macaroni salad while it blended. When the food was blended to desired consistency the cook poured the macaroni salad into a small metal pan.<BR/>Interview on 9/21/22 at 11:25 am. with [NAME] D and the Food Service Supervisor the cook revealed sometimes the cook adds broth or milk to puree the food, depending on what the cook was preparing. The cook reported there was no specific reason why she chose to use water to add to the pureed food to reach the proper consistency. When discussed using water to puree the foods, [NAME] D and the Food Service Supervisor reported they did not realize the food was losing some of its nutritive value. <BR/>Review of the Corporate Recipe, #4809, Egg Salad provided by the facility did not specify what type of fluid to add when purifying the egg salad, revealing, Add liquid if product needs thinning.<BR/>The Food Service Supervisor provided a copy of the recipe for macaroni salad but reported there were no instructions on how to prepare the macaroni salad.<BR/>

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen storage and sanitation in that: <BR/>Cook D used the facility phone 3 times during meal service without washing her hands afterwards.<BR/>This deficient practice could place residents who received meals from the main kitchen at risk for food borne illness.<BR/>The findings were:<BR/>Observation on 09/22/2022 at 11:52 a.m. revealed [NAME] D was plating food for the residents for lunch. Observation revealed after she placed the food on a plate, she would place the plates on trays which were on a cart used to deliver the food to each hall. When the cart was completed, the kitchen staff would notify staff per facility phone in the kitchen that their carts were ready to be retrieved.<BR/>Observation on 09/22/2022 at 11:56 a.m. revealed [NAME] D realized the staff had not retrieved the cart so she used the facility phone in the kitchen to notify the staff over the intercom the cart was ready, and then returned to the steam table to plate food without washing her hands.<BR/>Observation on 09/22/2022 at 12:04 p.m. revealed [NAME] D had completed plating food for the 2nd cart. The cook then used the facility phone and called over the intercom to notify staff the next cart was ready. The cook then returned to the steam table to plate food without washing her hands. <BR/>Observation on 09/22/2022 at 12:21 revealed [NAME] D had completed plating food for the 3rd cart. The cook then used the facility phone and called over the intercom to notify staff the next cart was ready. The cook then returned to the steam table to begin cleaning the steam table.<BR/>Interview on 09/22/2022 at 03:31 p.m. with the Food Service Supervisor, after the surveyor notified the Supervisor the cook had not washed her hands between meals, revealed she spoke to [NAME] D who reported she was nervous and that cook knows she should wash her hands between tasks. <BR/> Interview on 09/23/2022 at 10:40 a.m. with [NAME] D she revealed she had made a mistake by not washing her hands between tasks and that she knows she was supposed to.<BR/>Review of an in-service dated 09/22/2022, no time noted, presented by the Food Service Supervisor revealed, Practicing hand hygiene is an effective way to prevent infections and Always wash your hands when: changing gloves, after bathroom use, after leaving the service line, touching face/body, touching trash, etc.<BR/>Review of the facility policy, Food Preparation and Service, under the heading, Food Preparation Area, revised October 2017 revealed, 5. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.