Wi Veterans Home-boland Hall

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to identify and document grievances as required by its own policy for a resident with Alzheimer's Disease and dementia, who had an activated power of attorney for healthcare. The resident's power of attorney (POA) voiced concerns to the facility's social worker regarding the resident being put to bed too early and not receiving prescribed eye drop medication. Despite these concerns being communicated multiple times, the social worker did not initiate or document grievances for these issues, as required by the facility's grievance policy. The facility's grievance policy states that any circumstance thought to be unjust and grounds for a complaint, including those related to care and treatment or missing property, should be documented and investigated. The policy also requires that all grievances and concerns be logged and investigated within five business days. However, review of the grievance log revealed that only issues related to missing property were documented, while concerns about care routines and medication administration were not entered as grievances. Interviews with the social worker and interim director of nursing confirmed that the concerns about early bedtime and missed eye drops were not documented as grievances. The social worker acknowledged the oversight, stating that a risk assessment was done for the medication issue and the care plan was updated for the bedtime concern, but no formal grievance was initiated. The interim director of nursing agreed that these concerns should have been documented as grievances according to policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report a resident's unaccounted for narcotic medication to the local police as required by policy and federal regulations. During a review of facility reported incidents, it was found that a tablet of Hydrocodone 5/325 mg prescribed to a resident was discovered missing during an audit. The medication was determined to be missing on a specific date, but the facility's investigation did not document any notification to local law enforcement. Interviews with the Interim Director of Nurses and during the exit meeting with facility leadership confirmed that there was no additional information indicating the police had been contacted regarding the missing narcotic. The facility's policy requires all such incidents to be reported to the appropriate agency, including law enforcement, but this was not done in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a history of Alzheimer's disease, dementia, central corneal ulcer, and conjunctivitis did not receive prescribed ophthalmic medication as ordered by the consulting ophthalmologist. The resident was evaluated by an ophthalmologist, who documented a treatment plan that included continuing polymyxin-trimethoprim eye drops four times daily to the left eye, in addition to starting erythromycin ointment. Despite this clear directive, the facility discontinued the polymyxin-trimethoprim eye drops on the same day as the ophthalmology consult, rather than continuing them for the full prescribed duration. Review of the medication administration record (MAR) showed that the eye drops were administered as ordered for several days but were stopped prematurely, with the discontinue date set before the end of the prescribed course. Nursing notes and order documentation confirmed that the medication was discontinued after the ophthalmology appointment, and the resident did not receive the eye drops after that point, contrary to the physician's orders. The error was later identified and documented as a medication incident, with the facility noting that the medication was discontinued when it should have been continued. Interviews with nursing staff revealed inconsistencies and a lack of clarity regarding the process for handling new or continued orders following a resident's return from a consultation appointment. Staff described varying procedures for transcribing and clarifying orders, and were unable to explain why the eye drops were discontinued despite the physician's explicit instructions to continue them. The deficiency was identified through record review, staff interviews, and confirmation that the resident did not receive the ordered medication as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision to prevent accidents. The resident, who had diagnoses including Alzheimer's disease, dementia, hemiplegia, and hemiparesis, was dependent on staff for activities of daily living and was not interviewable. The care plan for this resident included specific interventions such as the use of non-slip material (Dycem) on the wheelchair and padding with black pool noodle on the sides and lower front bars of the wheelchair to prevent injury and maintain skin integrity. However, multiple observations by the surveyor over two days revealed that these interventions were not in place, as the resident was repeatedly seen without the required non-slip material and padding on the wheelchair, contrary to the care plan directives. Additionally, the resident sustained two separate skin tears. The first was identified during a body check, with no evidence that staff were interviewed to determine how the injury occurred or if staff had observed the resident picking at the area. The second skin tear occurred when the resident's arm came into contact with a sharp area on a shower chair. Although the chair was removed after the incident, there was no documentation of preventative measures to avoid recurrence. Maintenance staff confirmed that shower chairs were not routinely checked for hazards such as jagged edges, and the inspection process focused primarily on mechanical function rather than safety hazards. The facility's policy required that interventions be implemented for any incident causing or potentially causing injury, with appropriate measures to prevent recurrence. Despite this, the investigation into the resident's injuries lacked staff statements or evidence of a thorough inquiry into the causes. Furthermore, staff were observed to be unaware of the care plan requirements regarding the use of non-slip material and padding, and these interventions were not consistently implemented, as evidenced by repeated surveyor observations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its established pharmacy procedures for controlled substances, resulting in an unaccounted-for narcotic medication for one resident. According to the facility's policy, licensed nurses are required to compare the last recorded medication count in the Electronic Health Record with the physical medication package at the time of administration and update the count accordingly. However, during a review of a Facility Reported Incident, it was found that one tablet of Hydrocodone 5/325 mg was missing from a resident's medication supply. The missing tablet was not identified until an audit was conducted, revealing that the medication had been unaccounted for since a previous date. The facility's investigation was unable to determine the root cause of the missing medication. The report indicates that the required shift-to-shift narcotic counts were not consistently performed, which contributed to the delay in identifying the missing medication. The process for monitoring narcotic counts was not included in the facility's Quality Assurance Program Improvement (QAPI) at the time of the incident. Interviews with facility leadership confirmed that there was no additional information regarding the investigation, and the process for narcotic count audits was still under development.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary care and services to promote quality of life and ensure the safety and psychosocial well-being of several residents. One resident experienced fear and developed PTSD after being assaulted by another resident with a history of escalating aggressive behaviors. Despite repeated incidents, the facility did not have an effective plan to monitor or manage the aggressive resident, resulting in further assaults and ongoing fear among other residents. Staff reported difficulty in preventing altercations and providing adequate supervision, and documentation showed that management continued to minimize the level of monitoring required. Another resident, with a history of elopement and significant medical and psychosocial needs, repeatedly expressed dissatisfaction with the facility and planned unsafe ways to leave. The resident experienced a significant sunburn after remaining outside for an extended period due to sadness over the loss of a friend, yet no staff member addressed the underlying emotional distress or implemented proactive interventions in the care plan. The facility did not conduct a root cause analysis or update the care plan to address triggers for the resident's behaviors, and staff were unaware of the resident's cognitive impairments and the need for closer monitoring until after a serious elopement incident occurred. A third resident, with dementia and major depressive disorder, made multiple verbalizations and attempts to leave the facility, including an actual elopement. Despite repeated expressions of distress and high elopement risk scores, the facility did not implement timely or person-centered interventions to ensure safety. There was a lack of documentation of psychosocial support, root cause analysis, or monitoring of the resident's mental health status, and the care plan did not reflect individualized interventions. The facility also failed to provide medically related social services, resulting in a deterioration of the resident's psychosocial well-being.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that multiple residents received adequate supervision and that the environment was free from accident hazards, resulting in repeated falls and elopements. Six out of seven residents reviewed experienced incidents where the facility did not thoroughly investigate falls, failed to determine root causes, and did not consistently implement or revise interventions to prevent recurrence. For example, one resident with Alzheimer's disease and severe cognitive impairment experienced 15 falls over several months, including multiple falls that resulted in serious injuries such as a subdural hematoma, subarachnoid hemorrhage, T12 fracture, and hospitalizations. The facility's investigations into these falls were incomplete, lacking details such as the last time the resident was toileted, whether interventions were in place, and the root causes of the incidents. Care plans were not always updated with new interventions following falls, and staff statements were inconsistently obtained. Other residents assessed as high risk for elopement were able to leave the facility unsupervised. One resident, despite repeated expressions of intent to leave and previous attempts, was able to exit the facility and was found down the road by a family member of another resident, with staff unaware of the elopement. Another resident left the building unattended, resulting in sunburn and blisters, and later traveled nine miles in a wheelchair, nearly reaching a major highway. The facility did not have effective systems in place to monitor these residents or prevent their unsupervised departures. Additional examples of noncompliance included unwitnessed falls that were not thoroughly investigated, lack of root cause analysis, and failure to implement or document appropriate interventions after incidents. In some cases, interventions were not put in place after falls, or when residents refused certain interventions, no alternatives were provided. The facility's own policy required individualized care plans and root cause analysis for falls, but these procedures were not consistently followed, contributing to ongoing risks for residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect two residents from abuse by another resident, resulting in physical harm. One resident with severe cognitive impairment and a history of aggressive behaviors repeatedly entered other residents' rooms and engaged in altercations. Despite documented incidents of aggression, including punching another resident in the head and mouth, the facility only implemented temporary 1:1 supervision, which was discontinued due to staffing limitations. The resident was then placed on 15-minute checks, but continued to display aggressive and wandering behaviors, with staff frequently needing to intervene to prevent escalation. Following the initial incident, the aggressive resident continued to exhibit disruptive behaviors, including entering other residents' rooms and causing distress among both residents and staff. Progress notes indicated that staff found it difficult to manage the resident's behaviors and ensure the safety of others, especially when the resident was not on 1:1 supervision. Despite ongoing behavioral issues and staff concerns, the facility did not maintain the higher level of supervision that had proven effective in preventing further incidents. A subsequent altercation occurred when the same resident entered another resident's room and struck them multiple times with a cane, resulting in serious injuries including a traumatic brain injury, subdural hematoma, and subarachnoid hemorrhage. The injured resident required hospitalization and follow-up with neurosurgery. Interviews with staff and documentation revealed that the facility was aware of the escalating behaviors but did not consistently implement or sustain interventions necessary to prevent resident-to-resident abuse, leading to immediate jeopardy for resident safety.

Removal Plan

• Educate licensed nurses and direct care staff on member to member altercation, abuse education, and managing behaviors.
• Social worker will review members for appropriate placement.
• Educate all staff on member to member altercation policy, member behavior policy, care planning policy, mood assessment, and root cause analysis.
• Social worker and clinical staff will review progress notes for residents exhibiting aggressive behaviors or patterns of escalating behaviors and update care plans accordingly.
• Interdisciplinary team will review policy for member behaviors.
• Staff to review care plan for members exhibiting behaviors for appropriate interventions.
• Provide education to all staff regarding elopement on their first shift in their work unit.
• Provide education on managing aggressive behaviors and providing intervention before there is member to member contact (early detection of escalating behavior) on their first shift in their work unit.
• Provide education to social services on responding to residents' psychosocial needs, behaviors and wishes to be discharged, developing a plan and updating the care plans.
• Provide education to managers on completing a root cause analysis for falls, elopements, and escalated behaviors.
• Social worker to audit progress notes for any residents with increased behaviors. Care plan and interventions to be updated based on audit findings. Findings to be presented to quality assurance and performance improvement committee for review and suggestions. Findings discussed at interdisciplinary team clinical daily stand-up meeting.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide medically-related social services to help residents achieve the highest practicable physical, mental, and psychosocial well-being, as evidenced by multiple incidents involving several residents. One resident with severe cognitive impairment and a history of dementia, mood disturbances, and psychotic disturbances exhibited escalating aggressive behaviors, including multiple physical altercations with staff and other residents. Despite repeated incidents, the facility did not consistently conduct root cause analyses, reassess behavioral interventions, or implement new person-centered strategies to address the resident's psychosocial and behavioral needs. Documentation showed that interventions were not evaluated for effectiveness, and there was a lack of follow-up by social services after significant behavioral events. Other residents were also affected by the facility's deficient practices. For example, one resident repeatedly entered another resident's room, sometimes inappropriately disrobed, causing distress and fear. The intervention of a stop sign banner was inconsistently applied, and there was no evidence of reassessment or follow-up with the affected resident regarding their psychosocial needs after the incidents. Additionally, another resident expressed feeling unsafe following a violent altercation but did not receive any follow-up or assessment from social services. In another case, a resident with a history of elopement and verbalizations of wanting to leave the facility did not have their psychotherapy updated or alternative placement options explored, despite ongoing expressions of frustration and feeling like a prisoner. The facility's own assessment documents indicate an expectation to provide person-centered care, including behavioral and mental health interventions, yet the actions taken did not align with these stated competencies. The lack of timely and thorough social services assessments, failure to update care plans, and insufficient follow-up after behavioral incidents contributed to an environment where residents' psychosocial and safety needs were not adequately addressed. These failures resulted in a pattern of deficient practice affecting multiple residents.

Removal Plan

• NHA educated Social Worker on the following policies: Definition of F745 Medically related social services from CMS, Members Behavior Policy, Member to Member altercation policy, Care planning policy, Trauma informed Care Policy, Root Cause Analysis process, Member mood assessment policy, Member discharge policy, Member at risk for elopement or unsafe wandering policy
• SDC/Designee educated Staff on Member Behavior policy, Member to member altercation policy, care planning policy and member at risk for elopement or unsafe wandering policy
• Social worker attended the Wisconsin Nursing Home Social Workers Association fall conference
• Social Worker/Designee to follow up with members or POA-HC or Guardian in discharge planning per member discharge policy for members wishing to discharge from facility
• Nurse Managers/Designee to complete elopement assessment for members due for quarterly assessment or with current change of condition warranting updated elopement assessment
• Social worker will establish a mentorship relationship with a licensed clinical social worker at the Wisconsin Veterans Home at King with weekly mentorship meetings. Facility will also pursue professional services for social services consulting
• The facility implemented a system/procedure to review every behavior event, resident-to-resident altercations, and elopements during morning clinical which included reviewing assessment and care plan interventions for appropriateness
• Social Worker/Designee will review progress notes in clinical meeting auditing for members with increased behaviors, exit seeking, wishes to discharge and trauma. Those members identified will be adequately assessed and interventions put in place. Findings will be reported to QA for further recommendations
• Social Service Director and Administrator to conduct weekly meeting to review Medically Related Social Services concerns and establish process for addressing concerns

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all staff received the required Effective Communication program training. Upon review of training records for seven staff members, including CNAs, LPNs, and a Food Service Assistant, there was no documentation that these individuals had completed the mandatory training on the facility's Effective Communication program. The training was intended to outline and inform staff of the elements and goals of the program, but records showed that it had not been provided to these staff members within the past year. During the survey, the Nursing Home Administrator and Director of Nursing confirmed that the Effective Communication training had never been included in the facility's training process. Despite attempts to locate documentation or verify completion of the training, it was ultimately acknowledged that the staff in question had not received the required education. This deficiency had the potential to affect all 71 residents who could receive care or services from these staff members.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all staff received the required Quality Assessment and Performance Improvement (QAPI) program training. During a review of training records for seven staff members, including CNAs, LPNs, and a Food Service Assistant, there was no documentation found indicating that these individuals had completed the mandatory QAPI training. The surveyor specifically checked the training records for the past year and found no evidence that the staff had been informed about the elements and goals of the facility's QAPI program. When the surveyor requested documentation of QAPI training, the Nursing Home Administrator and Director of Nursing were unable to provide it and indicated they needed to contact human resources and the education company to locate the missing records. Later, it was confirmed by the Nursing Home Administrator that the staff in question had not received the required QAPI training, as it was never included in the facility's training process. No further explanation was provided for the omission.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly investigate multiple incidents involving potential abuse, neglect, and injuries of unknown origin for several residents. In two separate member-to-member altercations, the facility did not conduct interviews with other residents who may have witnessed the events, nor did they document the root cause or specific interventions for the individuals involved. In one incident, a resident reported being punched, but the facility did not investigate this claim further, despite a CNA's statement indicating possible physical contact. In another case, an allegation of abuse was reported to the State Survey Agency, but the facility did not interview other residents on the same unit to determine if there were additional concerns. The Director of Social Services acknowledged that resident interviews are typically part of the process but could not confirm that they were completed in this instance. Upon review, no resident interviews were found in the facility's documentation for this abuse allegation. Additionally, the facility did not complete a thorough investigation into an injury of unknown origin involving a resident who developed a right clavicle fracture. Multiple witness statements indicated the resident had been experiencing right shoulder pain for several days prior to the discovery of the fracture, but there was no evidence that these statements were followed up on to determine the cause of the injury or to rule out abuse or neglect. The lack of follow-up on these statements and the absence of further investigation into the timeline of the injury contributed to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely physician notification for two residents following significant changes in their condition or incidents. In the first case, a resident with multiple complex diagnoses, including chronic embolism, atrial fibrillation, hypertension, left above knee amputation, dementia, and a history of traumatic brain injury, experienced severe pain after returning from a chiropractor appointment. Nursing documentation indicated that the resident was screaming in pain with minimal movement, and the pain was localized to the right knee. Despite repeated reports of pain and the resident's refusal to be repositioned, the physician was not notified on the day of the incident. The nurse deferred to the resident's POA, who advised that physician notification was unnecessary. The physician was not informed until the following day, after which the resident was sent to the hospital and diagnosed with a femur fracture requiring surgery. In the second case, another resident with dementia, major depressive disorder, chronic respiratory failure, and other comorbidities eloped from the facility. The resident was found outside the facility by a family member of another resident and expressed intentions to travel out of state. The incident report was incomplete, lacking documentation of a registered nurse assessment, vital signs, and mental status evaluation. The physician was not notified of the elopement at the time of the incident, and there was no evidence that the physician was made aware during a subsequent monthly compliance visit. Notification to the medical director and a body check were not completed until six days after the elopement. Both incidents demonstrate a failure to promptly notify the physician of significant changes in resident condition or incidents, as required. In the first case, the nurse relied on the POA's direction rather than clinical judgment and facility policy, resulting in delayed medical intervention. In the second case, the lack of immediate physician notification and incomplete incident documentation following an elopement further contributed to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to provide adequate evidence of a proper discharge for one resident who was reviewed for discharge and transfers. The facility's physician did not document the specific needs of the resident that could not be met at the facility, nor the facility's attempts to meet those needs, or the services available at the receiving facility to meet the resident's needs. The resident in question had a history of violent and aggressive behaviors, was on multiple psychiatric medications, and was sent to the hospital for a mental health evaluation. Despite being medically cleared to return to the facility, the facility declined to readmit the resident, citing inability to provide 1:1 supervision and necessary mental health services. Documentation reviewed by the surveyor showed that the facility issued a 30-day discharge notice to the resident's family member, stating the facility could not meet the resident's care needs due to unpredictable and uncontrollable behaviors. The family member expressed distress and safety concerns about the possibility of the resident returning home, as well as financial concerns regarding bed hold payments. Communication between the facility and the hospital was inconsistent, with the hospital social worker not being informed of the discharge notice while the resident was still hospitalized. The facility's documentation included a physician's verbal order to discharge the resident per the guardian's request, but lacked detailed assessment or rationale regarding the resident's needs and the facility's inability to meet them. Interviews with facility staff confirmed that the facility does not admit residents requiring long-term 1:1 supervision due to staffing limitations, and that the resident was requiring such supervision while hospitalized. The facility's DON and NHA indicated that the plan was to reassess the resident, but ultimately the facility decided not to readmit the resident. The surveyor found no documentation from the facility's physician outlining the specific needs that could not be met, the facility's attempts to address those needs, or the services available at the receiving facility, as required for an appropriate and safe discharge.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident with a history of dementia, cognitive communication deficit, and hearing impairment did not receive proper treatment and assistive devices for hearing. The resident's care plan and physician orders indicated the need for hearing aids, and staff were instructed to ensure hearing aids were in place and stored appropriately. However, observations over multiple days revealed that the resident was not wearing hearing aids, and staff interviews confirmed uncertainty about the existence or location of the hearing aids. The resident was observed watching television at maximum volume and was separated from others, with staff and family members noting ongoing hearing difficulties. Record reviews showed that the resident's hearing aids had previously been lost and, at one point, sent for repair. Documentation indicated that the hearing aids were returned, but subsequent notes stated that no hearing aids were available, and the physician order for hearing aids was discontinued without explanation. Staff interviews revealed a lack of knowledge about the process for replacing or repairing assistive devices, and the facility did not have a policy or procedure for managing assistive devices for hearing, vision, or dental needs. The resident and family both expressed that the resident would benefit from having hearing aids, but no grievance was filed regarding the missing device, and the facility's grievance log only referenced a past incident. Further, the facility's system for storing and tracking hearing aids was reviewed, and it was confirmed that the resident did not have a hearing aid case or device present. The lack of a clear process for replacement or repair, combined with staff turnover and incomplete documentation, contributed to the resident not having access to necessary hearing assistive devices. The deficiency was further highlighted by the resident's continued difficulty hearing, as evidenced by the need for maximum TV volume and social isolation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A female resident with a significant history of PTSD, sexual assault, and other mental health conditions was subjected to inappropriate sexual touching by a male resident with dementia and moderate cognitive impairment. The male resident was known to have a potential for aggressive or threatening behavior, and his care plan included interventions to respect his personal space. The female resident's care plan specified only female caregivers due to her trauma history. On the day of the incident, the male resident grabbed the female resident in the crotch and later in the buttocks as she walked past him in a common area. Multiple staff members witnessed these incidents, and it was noted that the male resident had previously attempted to touch the female resident, though not as successfully or in such a targeted manner. Staff responses to the incidents were inconsistent and delayed. Although staff separated the residents after the first incident, the male resident was able to touch the female resident a second time. Witness statements indicated that staff were aware of previous attempts by the male resident to touch the female resident, and some staff considered these behaviors to be harmless. There was confusion among staff regarding the timing and number of incidents, and discrepancies were found in the facility's investigation and documentation. Not all staff who may have had knowledge of the incident were interviewed, and there was a lack of clarity about the interventions implemented immediately following the events. The facility failed to protect the female resident from further inappropriate contact after the initial incident, despite her vulnerability due to her trauma history. The male resident was not moved to a different unit until two days after the incident, and there was a delay in obtaining a psychiatric evaluation for him. The investigation revealed that the facility did not thoroughly assess or monitor the female resident for psychological or emotional harm following the incidents, and interventions to ensure her safety were not promptly or adequately implemented. The failure to keep the resident free from sexual abuse resulted in a finding of immediate jeopardy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with a documented history of multiple traumas, including sexual assault and combat-related experiences, was admitted with diagnoses of PTSD, major depressive disorder, anxiety disorder, and dementia. The resident's social history and assessment tools clearly indicated significant trauma history, yet the facility failed to develop an individualized, person-centered care plan addressing known triggers and specific interventions related to the resident's PTSD and trauma. The care plan only included a general intervention for female caregivers and did not incorporate detailed information from the resident's social history or trauma assessments. The facility did not have a policy or procedure for trauma-informed care and did not ensure that non-pharmacological interventions were documented or implemented when the resident exhibited targeted behaviors such as behavioral disturbances, crying, restlessness, or anxiety. Staff interviews revealed a lack of awareness regarding the resident's specific triggers, and the social worker had not obtained previous mental health records or communicated critical incident information to the psychiatric nurse practitioner. The facility also failed to involve the psychiatric provider in developing a person-centered care plan after a significant incident. An incident occurred in which another resident made unwanted sexual contact with the resident who had a history of sexual trauma. The facility's response was delayed in moving the offending resident, and staff were aware of ongoing inappropriate behavior but did not implement adequate protective measures. The care plan was only updated after the incident, and there was no evidence of a thorough assessment or individualized interventions to address the resident's trauma-related needs. The facility did not provide appropriate treatment and services to help the resident attain the highest practicable mental and psychosocial well-being.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. The lack of appropriate supervision and the presence of hazards in the area were directly observed by surveyors during their assessment.

Penalty

Fine: $112,60027 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate supervision and accident hazard prevention for two residents, resulting in actual harm. One resident, with a history of elopement, dementia, mood disturbance, and protective placement by court order, repeatedly expressed a desire to leave the facility and had previously left medical appointments early or eloped. Despite these documented behaviors and a prior incident where the resident eloped from a hospital appointment, the facility did not implement a proactive elopement care plan or provide supervision during off-site appointments. The resident was again sent to a hospital appointment unaccompanied, where he eloped and was found at a hotel several hours later. Staff interviews revealed a lack of awareness of the resident's prior elopement history and no clear rationale for allowing the resident to attend appointments alone, despite known risks. Another resident, with diagnoses including repeated falls, cognitive impairment, and dependence on staff for mobility and self-care, was found outside the facility unattended for over an hour on a hot day. The resident was discovered by staff arriving for their shift, exhibiting signs of dehydration, heat exposure, and renal insufficiency, and required hospitalization. Prior to this incident, there was no protocol in place to monitor unsupervised residents who exited the building to go outdoors. Staff interviews indicated that residents considered independent were not routinely checked on when outside, and there was no clear system to track how long a resident had been outside or to ensure their safety while off the unit or building grounds. The facility's lack of proactive assessment, individualized care planning, and supervision for residents at risk for elopement or harm resulted in both residents experiencing actual harm. The absence of effective monitoring protocols and staff awareness contributed to the failure to prevent these incidents, as evidenced by the residents' ability to leave unsupervised and suffer adverse outcomes.

Removal Plan

• Affected resident continues to have periodic onsite checks in alignment with resident rounding policy.
• All Staff will be educated regarding elopement on their very first shift in their work unit.
• R2's care plan has been updated to require attendant at each external appointment/outing.
• Facility has made contact with the Guardian who is agreeable to a care plan meeting to discuss possible placement in the community, as this is what the member expressed a desire to do.
• Facility has reviewed court determined member rights restrictions and has updated R2's care plan to reflect any/all court order rights and/or removals.
• Member's care plan has been updated to include checks whether member is in the building or anywhere on the premises.
• Facility reviewed Member rounds policy and member elopement policy. The policies remain appropriate.
• DON, ADONs and or designated licensed staff will audit member rounding and safety checks on all residents. If no concerns noted, will perform audit every two weeks. If no concerns, will perform audits monthly. If no concerns, random audits will be done.
• All Audits will be reviewed during the facility's QAPI meetings.
• Facility will ensure attendant goes to every off-site appointment the member has, attendant will be identified in the appointment note in the EHR (Electronic Health Record).

Penalty

Fine: $112,60027 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a history of dementia, mood disturbance, and mild cognitive impairment was not provided with adequate medically-related social services to help attain or maintain the highest practicable physical, mental, and psychosocial well-being. The resident had repeatedly expressed a desire to leave the facility and live independently, and these wishes were known to facility staff. Despite this, the resident was not provided with consistent discharge or placement services, and there was a lack of follow-up from the social worker, who had not communicated with the resident or the resident's guardian for approximately six months prior to the incident. The resident had a documented history of elopement and non-compliance with care plans for safety, including previous incidents of leaving scheduled medical appointments without attending them. On multiple occasions, the resident was transported to hospital appointments without an escort, despite prior elopement attempts. During one such appointment, the resident eloped from the hospital and was found several hours later at a hotel. Staff interviews revealed a lack of awareness among nursing and social services staff regarding the resident's elopement risk and previous incidents, and there was no elopement care plan in place until after the most recent event. Documentation showed that the resident's dissatisfaction with the facility and desire for alternative placement were ongoing, but social services did not provide timely or adequate support for discharge planning or placement closer to family, as requested by the resident and the guardian. The social worker acknowledged not following up or providing placement services for an extended period, and there was no evidence of recent attempts to address the resident's expressed needs. This failure to provide necessary social services contributed to the resident's repeated elopement attempts and unmet psychosocial needs.

Penalty

Fine: $112,60027 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify a resident's healthcare Power of Attorney (POA) when there was a change in the resident's medical treatment, specifically the initiation of physical therapy (PT) for balance improvement. The resident in question had significant cognitive impairments, including Alzheimer's disease, dementia with mood disturbance, and a history of repeated falls and difficulty walking. The resident's care plan included PT evaluation and treatment as needed, and a physician's order for PT was placed following a fall. However, there was no documentation that the POA was informed prior to the start of therapy. Interviews with facility staff, including the Rehab Director, PT Assistant, nurses, and the Director of Nursing (DON), revealed inconsistencies and a lack of clarity regarding the process for notifying a resident's POA about new or revised medical orders. Staff members confirmed that the therapy department typically communicates with nursing staff to obtain physician orders, and it is the nurse's responsibility to notify the POA. Despite this, both the therapy and nursing staff acknowledged that the POA was not notified before therapy began, and there was no established process to ensure this notification occurred. The DON and other staff members indicated that while the facility's care app might send notifications about changes in care, this was not considered an appropriate or sufficient method for informing the POA. The Nursing Home Administrator confirmed that the app notification was inadequate and acknowledged that the POA had not been properly notified. The deficiency was identified through interviews and record review, which showed a lack of documentation and direct communication with the POA regarding the initiation of PT for the resident.

Penalty

Fine: $112,60027 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to address and resolve grievances in accordance with its own grievance policy for two residents. One resident, who had diagnoses including Parkinson's, dementia, and diabetes, expressed a concern to the social worker that a CNA told him to get his own water when he requested assistance at approximately 2 AM. The grievance was documented but not investigated or resolved in a timely manner. The Director of Nursing (DON) acknowledged that follow-up had not occurred until prompted by the surveyor, and there was no documentation of resolution or communication back to the resident. Another resident, with Alzheimer's disease, dementia, and impaired cognition, experienced a prolonged delay in having his broken eyeglasses repaired. The glasses were broken and staff documented that they would be sent out for repair, but this did not occur. The resident's family provided old glasses as a temporary solution, but these were not the correct prescription. Despite a grievance being filed and multiple communications among staff, the glasses remained unrepaired for over a month. The social worker admitted to forgetting to send the glasses out for repair, and the grievance remained unresolved beyond the facility's five-business-day policy requirement. Both cases demonstrate that the facility did not follow its grievance policy, which requires prompt investigation, documentation, and resolution of grievances within five business days. In both instances, there was a lack of timely action, incomplete documentation, and insufficient communication with the residents or their representatives regarding the resolution of their concerns.

Penalty

Fine: $112,60027 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report two out of four allegations of abuse or neglect to the Nursing Home Administrator (NHA) and the State Survey Agency within the required timeframe, as outlined in their own policy. In the first incident, a resident with multiple medical conditions, including quadriplegia and major depressive disorder, reported to the charge nurse that a CNA was rough during care and did not respect the resident's request to delay care. The incident occurred on one day, was reported to the NHA the following day, and was not reported to the State Survey Agency until two days after the event. Interviews with staff confirmed the delay in reporting, and there was no clear explanation for the delay from the charge nurse or the DON. In the second incident, a charge nurse discovered that a resident was double briefed, and further investigation revealed that this practice was occurring on other units and shifts. The incident was discovered on one day, reported to the NHA the next day via email, and not reported to the State Survey Agency until nearly two weeks later. Staff interviews indicated that the delay was due to a lack of awareness that double briefing constituted neglect, and the DON confirmed that staff were slow to report because they did not recognize the issue as neglect. Both incidents demonstrate a failure to adhere to the facility's policy, which requires immediate reporting of suspected abuse, neglect, or other reportable incidents to the appropriate authorities. The policy specifies that incidents involving abuse or serious bodily injury must be reported to the state agency within two hours, and all other incidents within 24 hours. In both cases, these timelines were not met, and the required notifications to management and the state agency were delayed.

Penalty

Fine: $112,60027 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly investigate an injury of unknown origin for a resident with significant cognitive impairment and multiple comorbidities, including atrial fibrillation, vascular dementia, and dysphagia. After an unwitnessed fall resulting in a laceration and subsequent bruising to the resident's right forearm, the facility's incident self-report only included statements from staff who worked with the resident on the day the injury was discovered. No statements were obtained from staff who had cared for the resident in the days prior, and the Director of Nursing was unable to provide an explanation for this omission. The investigation did not include a comprehensive review of all potential witnesses or staff who may have been involved in the resident's care during the relevant period. Additionally, the facility did not ensure that all alleged violations involving abuse or neglect were properly addressed for another resident who reported rough care and a lack of respect for their right to refuse care. The resident, who was cognitively intact and had a history of requesting not to be cared for by a specific CNA, reported that the CNA was forceful and did not honor their request to delay care. The investigation into this incident did not result in the removal of the CNA from caring for all residents during the investigation, but only from the care of the reporting resident. Furthermore, there was no evidence that staff education on residents' rights to refuse care was provided to all staff following the incident. Facility policy requires immediate and thorough investigation of all alleged violations, including obtaining statements from all relevant staff, removing accused staff from resident care as appropriate, and providing staff education. In both cases, the facility did not follow its own procedures for investigation and response, resulting in incomplete investigations and insufficient measures to protect residents and prevent further incidents.

Penalty

Fine: $112,60027 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when the facility failed to complete a performance review at least once every 12 months for a Certified Nursing Assistant (CNA). The last documented performance evaluation for the CNA covered the period from November 1, 2022, to October 31, 2023, and was signed as completed on November 14, 2023. During a review of a facility-reported incident related to abuse, the surveyor requested the employee file and found no subsequent performance evaluation for the CNA. When questioned, the Nursing Home Administrator and Director of Nursing acknowledged that a performance evaluation had likely not been completed since 2023, citing administrative changes. The Director of Nursing also noted that the CNA had been on medical leave twice in 2024, but the surveyor clarified that this did not exempt the facility from conducting the required annual review. No further explanation was provided for the lapse in completing the performance evaluation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report two injuries of unknown origin to the state agency, as required by their Abuse Prohibition and Investigation policy. The first incident involved a resident, R25, who was discovered with a 15 cm by 6 cm bruise on the left posterior axilla. The facility assumed the bruise resulted from transferring the resident without a gait belt. Despite the extent of the bruise and the resident's inability to explain the injury due to severe cognitive impairment, the facility did not report the incident to the state agency. The second incident involved another resident, R38, who was found with a 7.5 cm by 4.4 cm bruise on the right upper arm during a routine shower skin check. The facility attributed the bruise to the resident's poor safety awareness and cognitive decline, suggesting the resident may have bumped into a doorway or wall. However, the resident's severe cognitive impairment and inability to explain the injury met the criteria for an injury of unknown origin, which should have been reported to the state agency. In both cases, the facility's Director of Nursing (DON) and Nursing Home Administrator (NHA) failed to provide adequate documentation or justification for not reporting these injuries to the state agency. The surveyor highlighted the facility's non-compliance with their policy, which mandates reporting injuries of unknown origin to the state agency within specified timeframes.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct thorough investigations into three separate incidents involving potential abuse or neglect of residents. In the first case, a resident with severe cognitive impairment and a history of falls was found with a significant bruise on the left posterior axilla. The facility assumed the bruise resulted from staff assisting with transfers without a gait belt, but no comprehensive investigation was conducted to confirm the cause or gather staff and resident statements. In the second incident, another resident with severe cognitive impairment was discovered with a large bruise on the right upper arm. The facility attributed the bruise to the resident's poor safety awareness and ability to ambulate independently, suggesting the resident may have bumped into walls or doorways. However, no thorough investigation was performed, and no statements from staff or residents were collected to substantiate this assumption. The third incident involved an allegation of potential neglect by a CNA who reportedly failed to assist a resident with toileting needs. The facility placed the CNA on administrative leave but did not conduct a comprehensive investigation, including interviews with other residents under the CNA's care or providing staff education on neglect and abuse prevention. As a result, the facility did not adequately address the reported incident or ensure the safety and well-being of the residents involved.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete a PASRR Level II assessment for a resident with a possible serious mental disorder, as required. The resident, identified as R17, was admitted with diagnoses including major depressive disorder, anxiety disorder, PTSD, and dementia. Despite a change in condition that indicated the need for a Level II PASRR, this assessment was not completed. The resident's records showed severe cognitive impairment and the use of psychotropic medications, which should have triggered a Level II PASRR. During an interview, the social worker acknowledged that a Level II PASRR should have been completed for R17, but it was not done due to an oversight. The surveyor noted that the facility's process involves conducting PASRR screens upon admission or when there is a change in the resident's condition, particularly if psychotropic medications are involved. The deficiency was discussed with the facility's administration during the exit conference, but no additional information was provided at that time.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary treatment and services consistent with professional standards of practice for two residents with pressure injuries. Resident R10 was found to have Moisture Associated Skin Damage (MASD) on 8/18/24 by an LPN, but there was no documentation of an RN assessment until 8/21/24. During this period, no skin evaluation documentation was available, and the MASD was later upgraded to a stage 3 pressure injury on 10/23/24. Interviews with facility staff confirmed the lack of timely RN assessment, and no additional information was provided to explain the delay. Resident R40 had a care plan intervention to wear gripper socks due to a pressure injury on the heel but was observed wearing shoes during the survey. The resident's care plan indicated the use of gripper socks except for appointments, but staff interviews revealed that R40 was routinely dressed in shoes and socks. The wound assessments showed an increase in the size and depth of the pressure injury over time, and the dressing on the wound lacked proper labeling to indicate the last treatment date. The facility's policy on wound prevention and treatment was not followed, as evidenced by the lack of prompt assessment and treatment for R10 and the failure to adhere to care plan interventions for R40. The surveyor's observations and staff interviews highlighted deficiencies in the facility's wound care practices, contributing to the inadequate management of pressure injuries for these residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate supervision and intervention to prevent accident hazards for a resident, identified as R7, who experienced a fall resulting in a fracture. R7, who has dementia and moderate cognitive impairment, fell after being startled by a staff member approaching from the right side. The fall resulted in pain and swelling in the left elbow, and an x-ray confirmed a nondisplaced fracture of the radial head. Despite the facility's policy requiring a Registered Nurse (RN) to conduct a head-to-toe assessment after a fall, no such assessment was documented in R7's medical record. The incident occurred when an LPN assessed R7 post-fall, noting pain and swelling, and obtained an order for an x-ray. However, the LPN did not document an RN assessment, and the facility could not provide evidence of an RN assessment being conducted. The facility's policy mandates that an RN should assess the resident before moving them after a fall, but this protocol was not followed in R7's case. The surveyor's investigation revealed that the facility's staff, including the Director of Nursing (DON) and Nursing Educator, could not locate the required RN assessment. The LPN involved in the incident confirmed that the standard procedure is to involve an RN for assessment after a fall, but this was not done. The lack of an RN assessment after R7's fall constitutes a deficiency in the facility's adherence to its own policies and procedures for fall management.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident maintained acceptable nutritional status, as evidenced by a significant weight loss of 4.8% over a period of 7 days. The resident, who has a history of major depressive disorder, anxiety, hypothyroidism, and dysphagia, was on a mechanically altered and therapeutic diet. Despite the resident's care plan indicating the need to monitor and report significant weight changes to a physician, no consultation or assessment was conducted when the weight loss was documented. The resident's care plan also highlighted a history of nutritional problems, yet the facility did not take appropriate action when the weight loss occurred. During interviews, the dietician acknowledged the weight loss and stated that such a change would require notifying the medical doctor and the resident's Power of Attorney, but no notifications had been made. The dietician was out of the office at the time, and the responsibility for noticing weight changes fell to the nursing staff. However, the nursing staff failed to report the weight change to the Director of Nursing or notify the physician. The deficiency was communicated to the facility's administration during the exit meeting, but no further information was provided at that time.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) meetings were held at least quarterly with the required committee members. This deficiency was identified during a surveyor's review of the facility's QAPI attendance sign-in sheets and interviews with the Director of Nursing (DON) and Assistant Nursing Home Administrator (ANHA). The surveyor found that the facility could not provide attendance logs for two out of four quarterly QAPI meetings. During interviews, the DON and ANHA were unable to specify which months the quarterly meetings were held, and the facility was unable to provide complete documentation for the meetings. The absence of consistent upper management and missing attendance logs for certain quarters were noted, indicating a lack of proper documentation and adherence to the required meeting schedule.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report several incidents to the appropriate authorities as required by regulations. In one instance, a physical altercation occurred between two residents, R1 and R8, where R8 kicked R1 in the groin. The facility did not report this incident to local law enforcement, and the current Nursing Home Administrator (NHA) could not locate any documentation or police report regarding the incident. Similarly, another altercation between residents R1 and R2 was not reported to the police. The NHA decided against reporting because R2 did not sustain visible injuries and believed contacting the police would cause further distress to the residents. Additionally, the facility failed to submit a 24-hour report to the State Agency for an incident involving R7, who received a cut on their leg from a CNA using scissors to remove a dressing. This incident was not reported within the required timeframe, and the CNA's actions were outside their scope of practice, resulting in an injury to R7. The facility's administration at the time did not ensure timely reporting, and the current administration could not provide evidence of the required report being submitted. Furthermore, the facility did not report an incident involving R6, who expressed suicidal and homicidal ideations, to the State Agency within the required 24-hour period. Despite the involvement of local law enforcement and a human service agency, the facility failed to submit the necessary Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report. The current NHA acknowledged the responsibility for submitting such reports but could not provide documentation that the report was submitted as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly investigate several alleged violations involving abuse, neglect, exploitation, or mistreatment. In one incident, two residents were involved in a physical altercation, but the investigation did not include resident statements or document any interventions beyond initial checks. Additionally, there was no evidence of staff education following the incident, and the care plans for the residents involved did not specify long-term interventions to prevent future altercations. In another case, a certified nursing assistant (CNA) verbally abused a resident but was not immediately removed from resident care, allowing continued access to vulnerable residents. The facility's policy required immediate intervention and removal of accused staff from direct care, which was not followed. The facility's failure to act promptly potentially affected all residents in the facility. Furthermore, the facility did not conduct a thorough investigation into a resident's suicidal and homicidal ideations. The misconduct incident report lacked a summary of events, root cause analysis, and staff statements. The facility's failure to provide supporting documentation and conduct a comprehensive investigation highlights significant deficiencies in handling serious incidents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food was palatable and served at a safe and appetizing temperature across all four units, potentially affecting 66 of the 67 residents. The facility's policy requires food to be served at specific temperatures, but observations and interviews revealed that staff did not consistently complete and log food temperatures before serving meals. A resident reported that the food was sometimes dry and cold, and a test tray revealed unpalatable vegetables. The surveyor noted multiple instances where food temperatures were not logged, indicating a systemic issue. Interviews with staff, including a Nursing Instructor, Food Service Manager, CNAs, and a Therapy Assistant, highlighted confusion and inconsistency in the responsibility for taking and logging food temperatures. Some staff believed it was the kitchen staff's responsibility, while others indicated that various staff members, including CNAs and activity staff, could take temperatures if needed. However, not all staff were trained to take food temperatures, and there was a lack of clarity about who should perform this task. The facility's policy also required the Dietician to audit the temperature logs weekly, but the Dietician admitted to not performing these audits. The Nursing Home Administrator acknowledged the issue with food temperatures and stated that efforts were being made to address it. Despite this acknowledgment, the report does not provide further information on why the facility failed to ensure food was served at the correct temperature.