Every finding on record at Admiral at the Lake, The

Based on observation, interview and record review, the facility failed to ensure that total body mechanical lifts were in safe operating condition and failed to ensure the lifts maintained an adequate battery charge before use which affected 4 residents (R1, R3, R5, R7) of 4 residents reviewed for mechanical lift transfers in a total sample of 7 residents and has the potential to affect all residents who utilize mechanical lifts for transfers.Findings include:On [DATE] at 10:30am, V3 (Resident Care Services) submitted a list of residents that require a total body mechanical lift for transfer which included R1, R3, R5 and R7.During initial tour of the 9th floor skilled unit on [DATE] at 10:45am, it was noted that there was one total body mechanical lift and two sit to stand machines.On [DATE] at 11:37am, V10 (CNA-Certified Nurse Assistant) stated, We have three batteries and when we come in the morning, they are not charged. V10 indicated that the total body mechanical lifts and the sit-to-stand machines can share batteries. V10 walked to a storage room where there were two battery chargers affixed to the wall. Each charger had one battery in them. V10 was asked where the third battery was and she indicated that it was in the total body mechanical lift.On [DATE] at 11:42am, V10 attempted to demonstrate that the battery in the total body mechanical lift was functional. V10 turned the total body mechanical lift on, and a message immediately displayed on the screen which read, SERVICE with a black wrench. V10 was asked what the message meant and V10 stated, It may stop in the air if I use this machine. This might mean that the battery is already done. At 11:43am, V10 retrieved the two batteries from their chargers to check their functionality. At 11:44am, V10 placed one battery into the total body mechanical lift. V10 turned on the machine and attempted to maneuver the lift. V10 stated, This battery is not charged because the machine is not moving. At 11:45am, V10 placed the second battery in the machine, and a message was immediately displayed which read, SERVICE and a black wrench. V10 stated, This happens very often. V10 placed both batteries back on the chargers. V10 indicated that these are the only batteries for the mechanical lifts on the floor and does not know if there are anymore stored elsewhere. V10 confirmed that of the three batteries for the three mechanical lifts on the 9th floor, only one battery was partially charged. On [DATE] at 12:05pm, V7 (CNA) and V10 (CNA) transferred R3 from the bed to the wheelchair using the total body mechanical lift transfer that had previously displayed the message SERVICE with a black wrench when checked with this surveyor. At 12:05pm, when V10 turned on the total body mechanical lift in R3's room, the same message displayed. V7 and V10 proceeded to use the machine for R3's transfer. R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 6 which denotes that R3 is severely impaired cognitively. On [DATE] at 1:37pm, the 8th floor skilled unit had one total body mechanical lift and two sit to stand machines. V19 (CNA) stated that there are three batteries for three mechanical lifts on the 8th floor. V19 stated that there is no other back up battery other than going to the 9th floor. V19 stated, I have not had any issues with the battery not working, as long as it is charged. V19 walked to the one total body mechanical lift on the unit and turned the machine on. V19 was able to maneuver the machine up and down. V19 stated, This battery is working. V19 walked to a storage room that had two battery chargers and each one had a battery in place. V19 was asked to bring both batteries to the total body mechanical lift to check if they were charged. V19 placed one battery in the machine and the screen immediately displayed a red blinking battery. V19 stated, This battery is not charged. V19 placed the second battery in the total body mechanical lift and the machine did not move. V19 stated, This battery is also dead and not charged. V19 confirmed that of the three batteries for the three mechanical lifts on the 8th floor, only one battery was functional.On [DATE] at 1:45pm, R7 was noted out of bed and is listed as requiring a mechanical lift for transfers. R7 stated that staff use the machine to transfer her out of bed but that it scares her because the machine moves very slow.R7's MDS dated [DATE] documents a BIMS score of 11, which denotes that R7 is moderately cognitively impaired. V19 (CNA), V20 (CNA), V21 (CNA) and V22 (LPN - Licensed Practical Nurse) were the staff scheduled on the day shift for the 8th floor on [DATE]. On [DATE] during interviews conducted with all 8th floor staff from 1:37pm to 1:55pm, V19, V20, V21 and V22 all indicated that none of them placed the two batteries on the chargers. They all confirmed that the night shift had placed the batteries on the chargers for the day shift, yet they were not charged at 1:37pm.During the course of the complaint survey, staff indicated that they have had or heard of issues with the total body mechanical lifts stopping when in use due to the batteries not being charged. On [DATE], V9 (RN - Registered Nurse) stated that she had an instance when R1 was in the middle of being transferred and the battery was not charged. On [DATE] at 11:34am, V7 (CNA) stated that she was present when R1's battery died. R1 was not moved too far off the bed when it happened so R1 was lowered to the bed, manually.V7 and V9 could not confirm the date that the incident occurred. There was no progress note regarding the incident, no grievance report and no other clinical staff or administrative staff that was aware of the situation. On [DATE] at 2:15pm, V17 (Social Worker) stated that she was unaware of this incident.At the time of this complaint investigation, R1 was out to the hospital and could not be interviewed.However, while reviewing the facility's grievance binder, there was a grievance form on file for R1 which was dated [DATE]. This form documented, (R1's spouse) reports that (R1) never got out of bed due to (total body mechanical lift) battery not being charged. (R1) still in bed at 2:50pm. Asked if there was a back up lift in case the (total body mechanical lift) malfunctions.R1 is listed as requiring a total body mechanical lift for transfers. On [DATE] at 9:32am, R5 stated, Heck yeah, I have had problems when being transferred with that machine. You don't want to be in the air when the battery dies. They had to go and find a battery while I was in the air. It happened once to me about six months ago. I was in the air for about one minute. They were able to lower me down since I didn't get far. But that has always been my fear with those machines. It scared the heck out of me. They only have one battery. They had to look all over for one. They ended up getting one from another floor.R5 is listed as requiring a total body mechanical lift for transfers. R5 was unable to state the date of the incident, the shift or the staff members that were transferring him.R5's MDS dated [DATE] documents a BIMS score of 10, which denotes that R5 is moderately cognitively impaired. On [DATE] at 1:45pm, R7 stated that she is transferred out of bed with a total body mechanical lift. R7 stated, The machine does scare me though because it moves really very slow.On [DATE] at 1:04pm, V2 (Assistant Administrator) indicated that he was in charge of overseeing the maintenance of medical equipment. V2 stated, The batteries can be interchanged between the (total body) mechanical lifts and the sit to stand machines. I have four total batteries between the 8th and 9th floor and one new battery in the 6th floor office and one new battery in the 8th floor office. V2 was asked who has access to the 6th and 8th floor offices if they need another battery. V2 stated that the clinical team was in charge of ensuring that the staff was aware. V2 was made aware that none of the staff knew that there were additional batteries other than the ones on the units. V2 stated that he started investigating and purchased new chargers and batteries. V2 indicated that he thought the issue was the batteries. V2 then stated that it may be something else that is causing the issues with the lifts. V2 was asked if he called for the service technician to come and assess the total body mechanical lifts to find out the root cause of the issues. V2 stated, No, there were no maintenance calls made to look specifically at the mechanical lifts.On [DATE] at 10:41am, V24 (Service Technician) stated, A service message with a wrench means that the machine should be serviced or at least checked to make sure it's okay. V24 further stated that a blinking battery means the battery is low and that battery should not be used. V24 stated, If battery was charging and then placed in the lift and lift is not working, it means that the battery is not holding a charge. Battery should be taken out of circulation. I should have been called in for a maintenance check.A facility policy with a revision date of [DATE] and titled, Lifting, Mechanical Policy and Maintenance documents, in part: The purpose of this policy is to establish the general principles of safe lifting using a mechanical lifting device. Steps in the Procedure: 5. Make sure the battery is charged. Mechanical Lift Maintenance: 1) Mechanical lifts and related equipment shall be maintained in safe working condition and in accordance with the manufacturer's recommendations. 3. Any lift or related equipment identified as damaged, malfunctioning, or unsafe shall be removed from service until it has been evaluated and, when necessary, repaired or serviced.

Based on observation, interview and record review the facility failed to label and date opened food stored in the refrigerator and freezer, failed to discard expired food, failed to use hair nets while working in the kitchen. Failed to store food off the floor. This failure has the potential to affect all residents that receive oral diets.Findings include:On 03/02/26 at 9:28am observed facility's walk-in refrigerator with open containers of mixed fruit, muffin mix, hamburger patties, [NAME] slaw, hot dogs, sliced American cheese, egg mix all with no open or discard date. Observed plastic wrapped containers with tomatoes, carrots, lettuce, cucumber and watermelon with a use by date of 03/01/26.On 03/02/26 at 9:28am V19 (Sous Chef) stated that it is important to date the food so that the staff know when it expires. V19 stated that the food that is expired is garbage.On 03/02/26 at 9:42am observed facility's walk-in freezer with 6 buckets of ice-cream, a tray of veggie burgers and a tray of chicken patties with no date. Observed 3 trays of meatballs with use by date of 10/25/25, tray of bacon with used by date of 12/07/25, tray of chicken parmesan with use by date of 02/14/26, tray of sausage patties with use by date of 12/07/25, Shepards meat with use by date of 01/04/26, turkey meat with use by date of 01/07/26.On 03/02/26 at 9:58am observed V21 (Kitchen Utility) with no beard net on.On 03/02/26 at 9:58am V21 (Kitchen Utility) stated that he forgot to put a beard net on. V21 stated that he forgets to put a beard net on sometimes but not every day. V21 stated that he should wear a beard net so that hair doesn't get into the food.On 03/02/26 at 9:58am V19 (Sous Chef) stated that everyone knows to put on hair nets before coming into the kitchen.On 03/02/26 at 10:07am observed multiple boxes of food sitting directly on the floor in the kitchen.On 03/02/26 at 10:16am V28 (Dietary Manager) stated that the food was delivered by the food delivery company. V28 stated that they shouldn't have placed the food on the floor. V28 stated that placing the food on the floor is not proper storage and the food can become contaminated.On 03/04/26 at 1:32pm V28 (Dietary Manager) stated that it is the expectations of the facility not to have expired food. V28 stated that all food should be labeled and dated. V28 stated that food with a use by date should be discarded before the use by date. V28 stated that if expired food is given to a resident, it could make the resident sick. V28 stated that there needs to be more accountability with checking for expired food. V28 stated that food that is open should have an open date and a use by date and having those dates are for safe food handling. V28 stated that everyone is the kitchen should have hair and beard nets and without them there is a potential risk for contamination.Facility's policy titled Freezer Food Storage reviewed 02/2025 documents in part, Purpose: To be sure all frozen food products are served in a timey manner and are of the highest quality. Policy: Establish a standard on all items stored in freezer, according to how long they may be frozen. Following USDA guidelines. Procedure: 2. Rotate frozen food using the FIFO (First In First Out) method. 3. Store food in its original package when possible, if taken out of original package should be labeled and dated and tightly wrapped.Facility's policy titled Receiving Deliveries revision date 10/2025 documents in part, Purpose: To establish procedures for receiving deliveries for safe food handling. Policy: Establish a standard for all delivered food goods. Purpose:. 6. All items will be stored at least 6 inches off of the floor and eighteen inches from the ceilingFacility's policy titled Refrigerated Storage revision date 02/2025 documents in part, Purpose: To ensure all food products are safe ad to prevent foodborne illnesses. Policy: Establish a standard for all items stored in refrigerator. Procedure:. 7. All food is labeled, if taken out of original packages, food will be labeled and dated.

Based on observation, interview and record review the facility failed to perform hand hygiene between passing dining trays, failed to clean multi use equipment after use for two residents (R2 and R11), failed to perform hand hygiene after caring for one resident (R6), failed to wear PPE (Personal Protective Equipment) while caring for one resident (R17) on EBP (Enhanced Barrier Precautions), failed to perform hand hygiene during resident ADL (activities of daily living) care for one resident (R20), failed to store clean and soiled linen in a way to prevent the spread of infection. This failure affected five residents (R2, R6, R11, R17, R20) and has the potential to affect all residents that reside in the facility. Findings include: R17's medical diagnoses include but are not limited to major depressive disorder, paraplegia, neuromuscular dysfunction, type 2 diabetes. R17's care plan revised 01/13/26 documents in part, R17 is placed on EBP per facility's protocol d/t (due to) indwelling urinary device. R17 will be free from acute signs and symptoms of infection while on EBP through the next review date. EBP: wear gowns and gloves during direct high contact resident's care such as dressing, bathing/showering, personal hygiene, changing linens, wound care and toileting. R17's physician order dated 12/1825 documents in part, On enhanced based precaution d/t suprapubic catheter. On 03/02/26 at 11:17am observed V23 (Care Partner) making the bed of R17 with no PPE gown on. On 03/02/26 at 11:17am V23 (Care Partner) stated that she never had a PPE gown on while taking care of R17, but she should have. V23 stated that she should have a gown on while taking care of R17 because R17 has an indwelling urinary catheter and the gown protects R17 from the staff's bacteria. On 03/02/26 at 12:34pm observed V24 (Care Partner) deliver lunch tray to R13 then touch the foot or R13's bed. V24 observed leaving R13's room without performing hand hygiene and going directly into R18's room and assist R18 with removing lids from food items. V24 observed leaving R18's room without performing hand hygiene and taking R21's food tray into R21's room. On 03/02/26 at 12:40pm V24 stated that she should have performed hand hygiene after touching R13. V24 stated that she touched R13 bed and not R13's feet. V24 stated that she should have performed hand hygiene because not performing hand hygiene can spread infection. V24 stated that she should have performed hand hygiene after assisting R18 with her meal tray. V24 stated that she doesn't know why it is important to not spread infection. On 03/03/26 at 10:15am observed 9th floor laundry room with two closed plastic bags sitting in the corner on the floor with multiple loose items on top of the bags. Observed multiple loose clothing items on top of the laundry rooms dryer. Observed soiled linen in soiled linen bins without bags. Observed clean linen room with multiple bags of clean linen on the floor On 03/03/26 at 10:15am V25 (Housekeeping Manager) stated that she doesn't know if the piles of clothes are clean or dirty. V25 stated that the staff may have brought the clothes into the laundry area and are waiting on the washer to become available. V25 stated that soiled linen should be bagged. V25 then placed items that were on top of the plastic bags on the floor. V25 stated that soiled linen should not be placed on the floor. V25 stated that the items on top of the dryer should not be there and she doesn't know if the items are clean or dirty. V25 stated that soiled linen should be in a bag because of contamination. V25 stated that soiled linen could have blood or stool on it and it could make everyone sick. On 03/03/26 at 10:39am observed 8th floor laundry room with multiple loose items on top of the washer and dryer. Observed clean linen area with multiple bags of clean linen on the floor. On 03/03/26 at 10:39am V25 (Housekeeping Manager) stated that the staff think that because the linen is in a bag it is okay to place the items on the floor. V25 stated that the clean items that are stored on the floor are now contaminated and can't be used. V25 stated that storing items on the floor can cause contamination from possible pipes busting, bugs or anything. On 03/04/26 at 2:34pm V15 (Infection Preventionist) stated that EBP is used for any resident that has a device that goes inside of them. V15 stated that gowns and gloves should be worn during daily care of the residents. V25 stated that changing a resident's bed is considered high contact and PPE should be worn. V25 stated that staff should perform hand hygiene before entering and leaving a resident's room and during care. V15 stated that if a staff member assists a resident with their meal tray, hand hygiene should be performed after. V15 stated that staff should perform hand hygiene just in case there are hidden infections or secretions on the resident's table or trays.V15 stated that if staff don't perform hand hygiene, they could spread infection. V15 stated that soiled linen should be contained in a bag and there is a possibility that if touch it they could be exposed to whatever is on the linen. V15 stated that both clean and dirty linen should not be on the floor. V15 stated that germs from the soiled linen could get on the staff's shoes and the germs can be spread from their shoes. Facility's undated job description titled Care Partner' documents in part, Position Summary: The Care Partner is responsible, under the direct supervision of the Charge Nurse and in accordance with prescribed procedures and established quality care standards, for providing direct personal and restorative nursing care to an assigned number of residents, while at all times ensuring the safety and well-being of all our residents. Essential Functions: Provides and/or assists residents with all aspects of personal hygiene and activities of daily living in accordance with established care procedures and standards. Safely and efficiently moves between resident rooms, units and floors, around bathhouses, utility rooms and other areas within the facility and grounds. Facility's undated job description titled Housekeeper documents in part, Position Summary: Housekeepers are responsible for maintaining the budling's interior by providing cleaning services and ensuring sanitary conditions in resident apartments, patient rooms and assigned area. Essential Functions: Performs tasks in assigned areas using appropriate equipment and chemicals, including but not limited to: dusting, scrubbing, shining, vacuuming, making beds, washing linen. Oversees supply storage room to assist in organization of items, proper storage and well-maintained stock. Facility's policy titled Laundry Services revised 04/08/25 documents in part, Purpose: To ensure that all facility and resident personal laundry is handled, processed and stored in a sanitary manner that prevents the transmission of infection and complies with IDPH (Illinois Department of Public Health) and CMS (Centers for Medicare and Medicaid Services) regulatory requirements. Policy: The facility shall provide laundry services that: Maintain a clean, sanitary, and safe environment, Prevent cross-contamination between soiled and clean linens, Protect residents' personal belongings, Comply with applicable Illinois and federal regulations. Nursing staff are permitted to perform laundry services when necessary to meet resident care needs, provided infection control and safety standards are followed. Facility's policy titled Enhanced Barrier Precaution: revised 12/2025 documents in part, Policy Statement: This policy implements Enhanced Barrier Precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDROs). Policy Interpretation and Implementation: 1. Enhanced Barrier Precautions (EBP) are an infection control intervention to reduce transmission of multidrug-resistant organisms (MDROs) in our facility. It is implemented during high-contact resident care activities for residents known to be colonized, infected or who are at risk of contracting MDROs. 2. This intervention is used in conjunction with standard precautions. 3. High-Contact Residents care activities include:. d. Changing Linens. E. Providing hygiene. Procedure:. 2. Gowns and gloves will be available immediately near or outside of the resident's room. 8. Enhanced Barrier Precautions should be used for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at a higher risk. General Considerations: 1. Staff are provided with training and education on Enhanced Barrier precautions including but not limited to the use of Personal Protective Equipment (PPE) monthly and are expected to comply with precautions. 3. Enhanced Barrier Precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for Contact Precautions, even with no history of MDRO colonization. This is because devices and wounds are risk factors that place these residents at higher risk for carry or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized. Facility's policy titled Handwashing/Hand Hygiene reviewed 12/2025 documents in part, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infection. Policy Interpretation and Implementation: Administrative Practices to Promote Hand Hygiene: 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. immediately before touching a resident; d. after touching a resident; e. after touching the resident's environment. 2. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situation. On 3/2/2026 at 11:29 AM, V6 (Care Partner, Certified Nursing Assistant, CNA) observed donning gloves in R20's room and assisting with R20's one person transfer from the bed to the wheelchair. V6 wheeled R20 into the bathroom, and R20 stood using the grab bars then R20 pulled down R20's pants and brief. After R20 voided in the toilet and wiped R20's perineal area, V6 flushed the toilet with a gloved hand, and V6 started to pull up R20's pants by the waistband, but R20 said that R20 can do it. V6 let go of R20's pants, and R20 pulled up R20's brief and pants. R20 next pivoted to the wheelchair, and V6 wheeled R20 to the sink where R20 washed R20's hands with soap and water. While still wearing the same gloves, V6 wheeled R20 to the reclining chair in R20's room, and V6 assisted R20 in standing by pulling up R20's waist band (back of the pants) and R20 pivoted to sit in the reclining chair. V6 arranged the call light next to R20, straightened up R20's bed linens and arranged personal items on R20's bed side table. V6 then doffed V6's gloves and washed V6's hands with soap and water in the sink in R20's bathroom for 7 seconds (11:42:28 AM to 11:42:35 AM). On 3/3/2026 at 10:58 AM, V4 (Licensed Practical Nurse, LPN) responded to R20's activated call light and entered R20's room without performing hand hygiene. R20 stated that R20 must go to the bathroom, and V4 donned gloves (without performing hand hygiene) to assist R20 to walk to the bathroom with R20's walker (assist x 1). R20 pulled down R20's pants and brief, and R20 sat on the toilet while V4 remained in the bathroom. R20 stated that R20 was having a bowel movement in the toilet. After R20 was finished toileting, R20 stood up and was wiping R20's perineal area with tissue paper (3 times). With V4's gloved hands, V4 assisted in wiping R20s' perianal area after R20's bowel movement. V4 discarded the soiled tissue paper in the toilet and flushed the toilet with the same gloved hand. R20 then pulled up R20's brief and pants. V4 assisted in snapping R20's waist button with the soiled gloves. R20 walked over to the sink, and V4 pushed up R20's shirt arm sleeves with V4's soiled gloved hands. R20 observed washing R20's hands with soap and water. V4 then activated the sensor for the paper towel dispenser and handed the clean paper towel to R20 while V4 is still wearing the same soiled gloves. R20 then dried R20's newly washed hands with this contaminated paper towel. R20 walked back utilizing the walker to R20's recliner chair in the room, and V4 adjusts R20's pillows in the recliner chair still wearing the same soiled gloves prior to R20 sitting down in the reclining chair. V4 then doffs gloves and uses antibacterial hand sanitizer as V4 is walking out of the room. On 3/4/2026 at 1:00 PM, V2 (DON) stated that nursing staff must perform hand hygiene before and after direct resident care. V2 stated that nursing staff must wash their hands for at least 20 seconds with soap and water, and this time frame is the standard practice to sanitize or kill germs from the staff members' hands to prevent spreading of germs or bacteria to the next resident. V2 stated that if a nurse or CNA performs direct care with gloved hands, like wiping a resident for perineal care after a bowel movement, the staff member must change their gloves and wash their hands for 20 seconds before going to the next area of care for the resident. V2 stated that this prevents spreading of germs or bacteria to other areas on the resident or surrounding objects in a resident's environment. R20's admission Record (Face Sheet) documents, in part, diagnoses of dementia, acquired absence of lung, depression, hypertension, acute ischemic heart disease, unsteadiness on feet, anxiety disorder, diverticulitis, low back pain and atrial fibrillation. R20's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 5 which indicates that R20 has severe cognitive impairment. R20's Care Plan, dated 2/15/2026, documents, in part, a focus that R20 has an ADL (activities of daily living) self-care performance deficit with interventions of R20 requiring assistance from the staff for toileting and R20 requiring assistance from the staff to move between surfaces and as necessary. Facility policy titled Handwashing/Hand Hygiene dated December 2025 documents, in part, that hand hygiene is indicated immediately before touching a resident; after contact with blood, body fluids, or contaminated surfaces; after touching a resident; after touching the resident's environment; and before moving from work on a soiled body site to a clean body site on the same resident, and the use of gloves does not replace hand washing/hand hygiene. This policy procedure for washing hands is to wet hands first with warm water; then apply an amount of product recommended by the manufacturer to hands; rub hands together vigorously for at least 15 seconds, coverall all surfaces of the hands and fingers; rinse hands with water and dry thoroughly with a disposable towel; and use towel to turn off the faucet. Facility policy titled Residents' Rights for People in Long-term Care Facilities dated August 2021 documents, in part, You have the right to.Safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction. Facility job description (undated) for Care Partner (CNA) documents, in part, that the Care Partner is responsible, under the direct supervision of the Charge Nurse and in accordance with prescribed procedures and established quality care standards, for providing direct personal and restorative nursing care to an assigned number of residents, while at all times ensuring the safety and well-being of all our residents. The Care Partners' essential functions are documented, in part, as the Care Partner provides and/or assists residents with all aspects of personal hygiene and activities of daily living in accordance with established care procedures and standards. Facility job description (undated) for Licensed Practical Nurse documents, in part, that the LPN is responsible for promoting and restoring residents' quality of life by providing nursing care as determined by the needs of the residents' and their individual plan of care. The LPN's essential functions are documented, in part, as assessing and identifying individual needs; identifies issues and develops appropriate, person-centered plan in collaboration with all health care disciplines; and provides confident, efficient and complete care within established scope of practice as permitted by licensure and outlined in individual care plan of resident; supervises nursing staff (care partners) to ensure appropriate, person-centered care is always being delivered; and adheres to infection control policies. On 3/2/2026 at 9:31 AM, facility presented a census of 30 residents living at the 8th and the 9th floor units. On 3/2/2026 at 12:34 PM, observed V4 putting wrist blood pressure cuff on R11 to measure R11's blood pressure and after completion of R11's the blood pressure measurement V4 removed the cuff of R11 's wrist and V4 placed the cuff directly on V4's wrist, without disinfecting the cuff or the monitor. On 3/2/2026 at 12:47 PM, observed EBP (Enhanced Barrier Precautions) sign on R6's room with hand sanitizer attached on the wall on the inside of R6's room. Observed V4 administering medication to R6 without using hand hygiene, gloves or gown. V4 was observed touching R6's water cup and administered medication mixed with yogurt using a spoon . After completion of the medication administration, V4 walked out of R6's room without performing hand hygiene and holding R6's water cup and spoon and carrying both items with bare hand through the hallway of the unit. No hand hygiene, observed after discarding the cup and spoon in the trash. On 3/2/2026 at 12:48 PM, V4 (LPN) stated that V4 uses same wrist blood pressure monitor for all the residents and that V4 did not clean the blood pressure monitor or the cuff, because it was easier to place on V4's wrist and V4 would clean the monitor and cuff when returned to the nursing station where the disinfectant wipes are located. V4 stated that V4 should disinfect the blood pressure monitor immediately after using and between each resident. V4 also affirmed that V4 did not perform hand hygiene after leaving R6's room and that V4 was going to wash hands at the nurse's station. V4 stated that V4 should have use the room's sanitizer located at the exit of R6's room and perform hand hygiene after exiting R6's room instead of waiting until getting to nurse's station. V4, after reading posted EBP sign on R6's room stated that V4 should have perform hand hygiene before and after exiting room and should wear gloves and gown to perform direct care and when touching R6's objects. V4 stated that hand hygiene and disinfecting equipment between use is important to prevent infection spreading to other residents, visitors and to staff members. On 3/3/2026 at 12:07 PM, observed V4 (LPN) measuring blood glucose for R2. Observed V4 using the blood glucose monitor on R2 and after completion of measurement, V4 placed the glucose monitor directly on top of medication cart. V4 did not clean and disinfect the blood glucose monitor or the top of the cart. On 3/3/2026 at 12;08 PM, V4 (LPN) stated that V4 should wipe and disinfect the blood glucose monitor and the cart immediately after use and before using on another resident. On 3/3/2026 at 12:51 PM, V2 (Director of Nursing/DON) stated that Standard and EBP precautions should be followed, and the staff should wear gown and gloves, when performing direct resident care in EBP rooms. V2 said that nursing staff should perform hand hygiene and wash hands before and after resident care, between each room. when administering medications and using the hand sanitizer that is provided. V2 stated that equipment used on the resident should be immediately cleaned with disinfecting wipes, and between different resident using and must be cleaned after each use. V2 stated that hand hygiene, equipment cleaning and using proper personal protective equipment (PPE) is very important to help prevent infection spreading to residents or staff members. On 3/4/2026 at 12:08 PM, V18 (Certified Nursing Assistant) stated that is important to wear gown and gloves when providing direct care in EBP rooms to help prevent infection spreading and that shared equipment should be cleaned and disinfected between each residents use to prevent contamination and infections spreading to other residents, visitors or staff members. On 3/4/2026 at 12:17 PM, V16 (LPN) stated that before administering medication or providing care for resident, a nurse should wash hand, perform proper hand hygiene and disinfect all equipment such as blood pressure monitor and cuff, blood glucose monitor, and thermometer to promote infection control and prevention of bacteria spreading to other residents or to the staff members. On 3/4/2026 at 12;28 PM, V8 (Restorative Aide) stated that when working with EBP residents and directly touching residents, the staff should perform hand hygiene and wear gowns and gloves to help prevent infection spreading. On 3/4/2026 at 12:40 PM, V15 (Infection Preventionist) stated that when the nurse is providing direct touch care in the EBP rooms, the expectation is to perform proper hand hygiene and don gown and gloves before entering room and perform hand hygiene after care. V15 stated that standard precautions apply to all the staff and nursing staff should always wash hands and perform proper hand hygiene before entering and after exiting resident rooms. V15 stated that the expectations are to wipe and disinfect all equipment shared between residents after each use and between residents and wait for it to properly dry before using again. V15 stated that proper hand hygiene and following standard infection control precautions is important to protect residents, visitors, staff members and to protect self from spreading infection. R2's Face sheet showed in part diagnosis including but not limited to Diabetes Mellitus due to underlying condition; Acute on chronic systolic congestive heart failure; Chronic Kidney disease; Bradycardia; Essential Hypertension; Hyperlipidemia; left bundle branch block; Methicillin susceptible Staphylococcus Aureus infection; History of Transient ischemic attack (TIA) and thrombosis of Atrium; Acute Pulmonary Edema; and Dysphagia. R6's Face sheet showed in part diagnosis including but not limited to Cellulitis of right lower limb; Cervical disc disorder; Gastro-esophageal reflux; Major Depressive disorder; Myalgia; Urgency of urination; Cerebral Palsy; Hyperlipidemia; and muscle weakness. R11's Face sheet showed in part diagnosis including but not limited to open Atherosclerotic heart disease; Displaced fracture of right ulna; Fracture of one rib; History of falling; Mild persistent asthma; Paroxysmal atrial fibrillation; Chronic kidney disease; Essential hypertension; Generalized anxiety disorder; Hypothyroidism; Metabolic encephalopathy; Orthostatic hypotension and syncope. Facility's document titled Policy: Enhanced Barrier Precautions (Revised 12/2025) showed in part that the purpose it to implement Enhanced Barrier precautions (EBP) to prevent of transmission of multidrug-resistant organisms and that high contact residents include residents with wounds with skin opening and that gowns and gloves should be involved. Facility's document titled Handwashing/Hand hygiene (reviewed 12/2025), showed in part that the facility considers hand hygiene as the primary prevention tool of spreading of healthcare-associated infections and that all personnel should adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, resident or visitors. Document also showed in part, that hand hygiene is indicated immediately before and after touching a resident or resident's environment and after glove removal; Alcohol-based hand rub or soap and water should be used to perform hand hygiene. Facility's document titled Policy: Cleaning and Disinfection of Resident-Care Items and Equipment (Revised 12/2025), showed in part, that blood pressure cuffs and other non-critical items should be decontaminated and reusable items cleaned and disinfected between residents. Policy also showed in part that durable medical equipment must be cleaned before reused by another resident according to manufacturer's instructions and could include cleaning with Ethyl or isopropyl alcohol and other low level disinfectants. Facility's document titled Isolation-Categories of Transmission-Based precautions (Reviewed 12/2025), showed in part that Standard precautions should be used when caring for residents at all times regardless of suspected or confirmed infection status. Facility's document titled Standard Precautions (Reviewed 12/2025), showed in part that standard precautions should be used while caring for all residents in all situations regardless of diagnoses, suspected or confirmed infection status and that standard precautions include but not limited to hand hygiene, use of gloves and gowns and reusable resident's equipment should not be used on another resident until properly cleaned. Facility's document titled Infection Preventionist Nurse Job Description (Undated) showed in part that the Infection Preventionist Nurse is responsible for maintaining an infection prevention and control program in the facility and provide safe and sanitary environment and help prevent the development and transmission of communicable diseases and infection by coordinating, implementing, monitoring and evaluating facility's infection control program. Document showed in part one of the essential functions to educate healthcare teams and develop policies and procedures that address residents, staff, visitors and contracted staff issues related to infection control. Facility's document titled Licensed Practical Nurse Job Description (Undated), showed in part that Licensed practical nurse adheres to infection prevention policies; Possible for promoting and restoring residents' quality of life by providing nursing care as determined by the resident's needs and the plan of care and should identify and report equipment's concerns immediately and should maintain proper training. Facility's document titled Director of Nursing Job Description (Undated), showed in part that the director of nursing should provide clinical and management leadership for the nursing department and ensure that standards of quality care are followed. Doctor of nursing is responsible for holding staff accountable for standard care and should demonstrate commitment to continuous quality improvement towards achieving the highest quality care results.

Based on observations, interviews and record review, facility failed to follow their policy and failed to properly label and marked open medications with opened date and failed to remove expired insulin from the medication cart. These failures affected five residents (R2, R9, R19, R28 and R30) residing on the 8th floor of the facility and have the potential to affect all 14 residents residing on the 8th floor unit of the facility.Findings include:On [DATE] at 9:31 AM, facility presented a census of 30 residents living at the 8th and the 9th floor units. Census showed 14 residents residing on the 8th floor unit.On [DATE] at 11:58 AM, observed 8th floor unit's medication room with V4 (Licensed Practical Nurse/LPN). Found the following in the 8th floor unit medication room refrigerator:R9's Lorazepam oral concentrate solution, 30ml bottle 2mg/ml, opened with no open date marked. R19's Lorazepam oral concentrate solution, 30ml bottle 2mg/ml, opened with no open date marked.On [DATE] at 12:59 PM, observed 8th floor unit's medication cart with V4 (Licensed Practical Nurse/LPN) and V4 stated that the cart serves all residents residing on the 8th floor unit of the facility. Found in the 8th floor unit medication cart the following:R2's Insulin Lispro 100units/ml multi dose vial injection , opened, with labeled expiration date of [DATE] and opened date marked of [DATE].R9's Latanoprost 0.005% ophthalmic solution, opened, with no open date labeled, no shortened expiration date marked.R19's Morphine Sulfate oral solution 100mg/per 5ml opened with no open date labeled or marked expiration date.R28's Morphine Sulfate oral solution 100mg/per 5ml opened with no open date labeled or marked expiration date.R30's Aluminum Hydroxide, Magnesium Hydroxide and Simethicone 400-400-40mg/5ml) oral suspension, opened with no open date marked, no shortened expiration date marked.House Stock of Chest Congestion relief DM oral solution, opened with no open date labeled/marked. On [DATE] at 1:02 PM V4 (LPN) stated that oral solutions and ophthalmic solutions after opening, should be labeled with an open date and new shortened expiration date. V4 stated that expired insulin should be not used, must be discarded and new insulin reordered form the pharmacy. V4 also said that usually, open ophthalmic solutions, and other multidose vials, are stable for 28 days after opening and therefore all opened medications should be labeled with an open date and marked with new shortened expiration date. On [DATE] at 12:51 PM, V2 (Director of Nursing/DON) stated that ophthalmic solutions are usually good for 30 days from the opened date and that all liquids and multidose vials should be dated with an open date. V2 stated that a good nursing practice is to label medications with an open date, so the following nurse would be aware of when the item was opened, and then the nurse would know when to discard the opened medications. V2 stated that all liquids, multi dose vials and ophthalmic solutions should have a new shortened expiration date labeled after the medication was opened. V2 stated that multi dose Insulin vials must be marked with an open date and a new shortened expiration date of 30 days after the insulin was opened , to ensure the correct date for proper discarding. V2 also stated that any expired insulin should be immediately removed from the medication cart, insulin should be reordered and replaced with a new vial. V2 stated that expired insulin should not be administered to resident.On [DATE] at 5:25 PM, V14 (Pharmacy Director of Operations) stated that the nursing staff should label all solutions and multi dose vials with an open date after opening. V14 stated that the new shortened expiration date of 30 days after opening an ophthalmic solution, or other oral solution should be written on the label. V14 stated that insulin should be labeled with an open date and shortened expiration date of 28 days after opening. V14 stated that insulin should be discarded after 28 days. V14 stated that is very important to mark an open date on multi dose vials because the medication would be less effective when used after recommended expiration dated.On [DATE] at 12:17 PM, V16 (LPN) stated that all medications when opened, should be labeled with an open date and a new shortened expiration date. V16 said that insulin should be marked with open date and new expiration date which is 28 days after opening. V16 stated that expired insulin should be discarded, and new insulin should be ordered from the pharmacy.R2's Order Summary Report showed in part an active order ([DATE]) for Insulin Lispro 100units/ml inject per sliding scale before meals.R9's Order Summary Report showed in part an active order ([DATE]) for Latanoprost Ophthalmic Solution 0.005% to instill one drop in both eyes one time a day for eye dryness.R9's Order Summary Report showed in part two active orders ([DATE]) for Lorazepam Intensol oral concentrate 2mg/ml to give 0.25ml or 0.5ml sublingually every four hours as needed for restlessness/anxiety. R19's Order Summary Report showed in part two active orders ([DATE]) for Lorazepam oral concentrate 2mg/ml to give 0.25ml or 0.5ml by mouth every 2 hours as needed for mild/severe anxiety/nausea.R28's Order Summary Report showed in part an active order ([DATE]) for Morphine sulfate 20mg/5ml to give 0.25ml sublingually every 2 hours as needed for severe pain or shortness of breath (SOB).R30's Order Summary Report showed in part an active order ([DATE]) for Alum & Mag Hydrox-Simethicone 400-400-40mg/5ml to give 30ml by mouth every 24 hours as needed for stomachache.Facility's document titled Medication Labeling and Storage Policy (Revised [DATE]), showed in part that the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner and if the facility has outdated medications the pharmacy is contacted for instructions related to destruction. Policy further showed that labeling of medications should be consistent with applicable federal and state requirements and that opened multi-dose vials should be dated and discarded within 28 days.Facility's document titled Destroying Medication Policy, (Revised [DATE]/2025), showed in part policy statement that Medications that cannot be returned to the pharmacy should be dispose of in accordance to federal, state and local regulations.

Based on observation, interview and record review, the facility failed to identify, document, and report a new skin alteration (bruise) which affected one resident (R20) reviewed for skin conditions in the total sample of 30 residents. Findings include:On 3/2/2026 at 11:29 AM, V6 (Care Partner, Certified Nursing Assistant, CNA) observed in R20's room and assisting R20 (one person assist) from the bed to the wheelchair. V6 wheeled R20 into the bathroom, and R20 stood using the grab bars for assist and pulled down R20's pants and brief with V6 standing next to R20. This surveyor visibly observed a bruise on R20's left lateral thigh, purple in color, and approximately 3 inches by 2 inches in size. On 3/3/2026 at 10:55 AM, R20 stated that R20 doesn't know about the bruise on R20's left lateral thigh and said, I (R20) always bump into things. R20 gave permission for this surveyor to view R20's skin assessment from the nurse, and R20 pressed R20's call light.On 3/3/2026 at 10:58 AM, V4 (Licensed Practical Nurse, LPN) responded to R20's activated call light and entered the room. This surveyor requested for a skin assessment of R20, and V4 stated that R20 has no skin impairment. R20 stated that R20 must go to the bathroom, and V4 assisted R20 to walk to the bathroom with R20's walker. R20 pulled down R20's pants which exposed R20's purple, left lateral leg bruise, approximately 3 inches by 2 inches in size. R20 sat on the toilet. When asked about R20's bruise, V4 stated that V4 noticed it last week, and V4 never received in report of anything. V4 stated that when V4 noticed R20's new bruise last week, V4 asked fellow nursing staff about it, and V31 (Care Partner, CNA) said that R20 had it (bruise). V4 stated, I (V4) didn't report it to no one. V4 then touched R20's bruise saying that R20 is not complaining of pain to this area, but the bruise is kind of big. V4 assisted with R20's perineal care and transfer back to R20's reclining chair in the room. This surveyor and V4 exited R20's room, and V4 stated that on an unknown date last week, V4 documented R20's new left lateral leg skin bruise in the progress notes, and V4 did not report R20's new bruise to V2 (DON), the doctor or family representative. V4 stated that the CNAs are supposed to let the nurses know when they see something new, like a bruise. V4 stated that when V4 asked V31 about this bruise last week when V4 first noticed R20's bruise, and V31 said that V31 saw it too. On 3/4/2026 at 11:50 AM, this survey requested from V1 (Administrator), V2 (Director of Nursing, DON) and V3 (Assistant Administrator) for R20's skin assessment/evaluation/report documented by V4 in R20's progress notes (for R20's left lateral leg bruise viewed by this surveyor during this survey). On 3/4/2026 at 1:00 PM, when asked for previously requested documentation by V4 for R20's left lateral leg bruise, V2 stated, I (V2) think she (V4) didn't do it. I didn't see any documentation. V2 stated that if V4 observed a new skin alteration, like a bruise, then V4 must document it in an incident report. V2 stated that R20 has no current incident report for a new bruise. V2 stated that nurses perform skin assessments twice weekly, and nurses are to document skin changes or abnormalities in the resident's electronic health record. V2 stated that upon identifying a new skin alteration, like a bruise, the nurse must notify V2 (DON), the resident's doctor, and the resident's family representative. V2 stated that prior to this surveyor requesting for documentation on 3/4/2026 for R20's left leg bruise, V2 received no report from the nursing staff about R20's bruise. V2 stated that after this surveyor requested for R20's bruise documentation on 3/4/2026, V2 went to assess R20's skin and observed a small bruise on R20's left lower leg. When asked about the large purple bruise, approximate size of 3 inches by 2 inches, on R20's left lateral thigh, V2 stated, I didn't see that one. V2 stated that V2 was not made aware of R20's left lateral thigh bruise, and V2 will go back with the nurse on duty to perform a full skin assessment to ensure an incident report is generated. V2 stated that the purpose of identifying a new skin alteration and then the nurse making the appropriate notifications is this is the safe way for the resident to see if anything happened to cause the bruise. V2 stated that the incident report is utilized so staff can review and check the last time when the resident's skin was without the new bruise and to determine the cause of the bruise. V2 stated that CNAs assess resident's skin during bathing and ADL care and must notify the nurse right away if there is a new skin bruise. V2 stated that this is standard nursing practice.R20's admission Record (Face Sheet) documents, in part, diagnoses of dementia, acquired absence of lung, depression, hypertension, acute ischemic heart disease, unsteadiness on feet, anxiety disorder, diverticulitis, low back pain and atrial fibrillation and admission date of 2/13/2026.R20's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 5 which indicates that R20 has severe cognitive impairment. R20's Skin Conditions (section M) indicate that R20 has no pressure ulcer/injury, other ulcer, wound or skin problem. R20's Skin Only Evaluation, dated 2/13/2026 (admission date), documents, in part, that R20's skin baseline is skin warm and dry, within normal limits skin color, mucous membranes moist, turgor normal and that R20 does not have a current skin issue. Review of R20's Skin Only Evaluations in R20's electronic health record (EHR) from admission date to 3/3/2026 show only one additional Skin Only Evaluation, dated 2/21/2026, which was blank (no documentation) and no nurse signature. R20's Care Plan, dated 2/15/2026, documents, in part, a focus that R20 is on anticoagulant therapy with an intervention to monitor, document and report whenever needed (PRN) adverse reactions of anticoagulant therapy such as bruising. R20's Progress Notes reviewed from February to March 4, 2026 (at 2:20 PM) which show no documentation of R20's left lateral leg bruise by V4 (LPN) or any other staff.Facility policy titled Skin Assessment Policy dated March 2017 documents, in part, Policy Statement: In accordance with federal regulations under 42 CFR 483.25 (Quality of Care) and guidance issued by the Centers for Medicare & Medicaid Services (CMS), the facility will ensure that each resident receives timely, comprehensive skin assessments to identify existing skin conditions and changes in condition. Assessments will be sufficient to determine risk factors and to accurately document the presence, absence, or progression of skin impairment, including pressure injuries. Purpose: To ensure consistent, thorough, and timely evaluation of each resident's skin condition in order to identify alterations in skin integrity and support regulatory compliance. Procedure: 1. admission Assessment: A licensed nurse will complete and document a comprehensive head-to-toe assessment upon admission. The assessment will: Identify and describe all existing skin conditions, including pressure injuries, skin tears, rashes, surgical wounds, and discolorations; Include objective description of location, size, and characteristics of any alteration in skin integrity; Clearly distinguish pre-existing conditions present on admission. 2. Routine Skin Assessments (as needed or as ordered). A licensed nurse will perform and document ongoing skin assessments: Weekly for the first four (4) weeks following admission; At least monthly thereafter; More frequently for residents identified as at risk for impaired skin integrity. Observations made during routine care that indicate a potential change in skin condition must be reported promptly to licensed nursing staff for assessment. 3. Significant Change in Condition: A comprehensive skin assessment will be completed when there is a significant change in the resident's physical, cognitive, nutritional, mobility, or medical status, including but not limited to: Return from hospitalization; Decline in mobility; Changes in incontinence; Acute illness; Any newly identified area of skin concern. 5. Documentation Standards: All skin assessments must be: Timely and completed by licensed nursing staff; Accurate, objective, and descriptive; Reflective of the resident's current condition; Consistent with medical record documentation and required federal reporting.Facility policy titled Change in Condition Policy dated 4/8/2025 documents, in part, Policy Statement: Our facility notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident b. discovery of injuries of an unknown source c. adverse reaction to medication d. significant change in the resident's physical/emotional/mental condition . Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source b. there is a significant change in the resident's physical, mental, or psychosocial status . 4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 5. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments . 7. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Facility policy titled Residents' Rights for People in Long-term Care Facilities dated August 2021 documents, in part, You have the right to.Safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction.Facility job description (undated) for Care Partner (CNA) documents, in part, that the Care Partner is responsible, under the direct supervision of the Charge Nurse and in accordance with prescribed procedures and established quality care standards, for providing direct personal and restorative nursing care to an assigned number of residents, while at all times ensuring the safety and well-being of all our residents. Essential functions include that the Care Partner provides and/or assists residents with all aspects of personal hygiene and activities of daily living in accordance with established care procedures and standards.Facility job description (undated) for Licensed Practical Nurse documents, in part, that the LPN is responsible for promoting and restoring residents' quality of life by providing nursing care as determined by the needs of the residents' and their individual plan of care. The LPN's essential functions are documented, in part, to assess and identify individual needs; identifies issues and develops appropriate, person-centered plan in collaboration with all health care disciplines; and provides confident, efficient and complete care within established scope of practice as permitted by licensure and outlined in individual care plan of resident; supervises nursing staff (care partners) to ensure appropriate, person-centered care is always being delivered; and reports concerns and/or changes in resident's physical conditions to RN (Registered Nurse) or DON (Director of Nursing).

Based on observations, interviews and record review, facility failed to implement their policy and failed to ensure that oxygen equipment was properly contained when not in use for two residents (R8 and R24); Failed to properly label and date one resident's (R13) oxygen equipment and failed to discard/replace unused expired oxygen tubing for one resident (R8). These failures affected three residents reviewed for respiratory care in the final sample of 30 residents.Findings include: On [DATE] at 9:31 AM, facility presented a census of 30 residents living at the 8th and the 9th floor units. On [DATE] at 10:45 AM, observed in R8's room unused oxygen machine positioned next to R8's bed. Observed next to oxygen machine an oxygen tubing stuck in R8's dresser drawer sticking out and hanging down, all the way to the floor. The connecting end portion of the tubing was coiled on the floor, completely resting on the floor with labeled date on the tubing of [DATE]. R8 stated that R8 used oxygen in the past, but currently using oxygen only as needed for shortness of breath but did not need to use for a while. On [DATE] at 10:35 AM, observed in R8's room the same oxygen tubing stuck in the dresser, hanging down to the floor, coiled on the floor in the same exact position as the observation from previous day ([DATE]) with the same date of [DATE] labeled on the tubing. On [DATE] at 11;30 AM, during medication pass with V4 (Licensed Practical Nurse/LPN), observed in R24's room oxygen nasal cannula tubing resting inside of a metal basket of respiratory treatment machine, not contained properly, labeled with a date of [DATE]. On [DATE] at 11:40 AM, observed with V4(LPN) in R8's room, oxygen tubing laying on the floor and labeled with date of [DATE]. On [DATE] at 11:40 AM, V4 (LPN) stated that oxygen tubing should have been properly contained in the plastic bag and that usually changing and labeling of the oxygen tubing is a nursing responsibility, but the night shift nurse performs the task and changes oxygen tubing weekly. V4 also said that the oxygen tubing should be properly contained in a plastic bag and should not be touching the floor. V4 additionally said that if resident is not using oxygen and oxygen tubing for more than a week, the tubing should be discarded and that the oxygen tubing should not be used after a month from labeled opened date. V4 affirmed that R8's oxygen tubing expired and should be discarded immediately, and a new tubing should be placed in the room if R8 needed to use oxygen again. V4 said that keeping oxygen tubing properly contained in a plastic bag is important to prevent infection spread to the resident. On [DATE] at 12:51 AM, V2 (Director of Nursing/DON) stated that oxygen tubing should be always contained in a plastic bag when not in use and that the oxygen tubing should be changed weekly and labeled with an open date. V2 said that the oxygen tubing should not be laying on the floor, touching the floor or other equipment when not in use, because the oxygen tubing could contaminate and cause infection. V2 said that properly contained oxygen tubing prevents infection spread to the residents. On [DATE] at 12:17 PM, V16 (LPN) stated that oxygen tubing that is not actively used should not be touching or laying on the floor, should be contained inside plastic bag and dated. V16 also said that oxygen tubing should be changed weekly and discarded after expired date, which is 30 days after opening. On [DATE] at 12:40 PM, V15 (Infection Preventionist) stated that oxygen equipment and tubing should be dated when opened. V15 stated that unused oxygen tubing should be stored in a plastic bag and should never touch the floor because that could spread germs and cause infection spread to the resident, staff and other residents. V15 stated that expired oxygen tubing should not be used, should be discarded. R8's Face sheet showed in part diagnosis include but is not limited to Other Sarcomas of Liver; Generalized Anxiety disorder; Fusion of spine in Lumbar region; Low back pain; Muscle weakness, Asthma, Atrial fibrillation, Essential Hypertension, Urinary Incontinence; Migraine; Right hip pan; Postprocedural hemorrhage of a circulatory system organ or structure following other procedure and Spinal stenosis. R8's Minimum Data Sheet (MDS) ([DATE]) in section C for Cognitive patterns showed a Brief Interview for Mental Status (BIMS) score of 15, which indicates intact cognition. R8's Care plan ([DATE]) showed in part that R8 was admitted to hospice and comfort focused care at this time and that has liver disease related to Cancer of liver. R8's care plan also showed in part that R8 has altered respiratory status related to history of Obstructed Sleep Apnea (OSA) and Asthma and should have oxygen settings at 2L via nasal cannula as needed for shortness of breath (SOB) for comfort. R8's active order ([DATE]) showed in part, an active order for Oxygen at 2L as needed for shortness of breath for comfort. R24's Face sheet showed in part diagnosis include but is not limited to Type 2 Diabetes Mellitus; Hyperlipidemia; Unspecified Dementia; Essential Hypertension; Nonrheumatic tricuspid insufficiency; Left ventricular failure; Cardiomegaly; Venous Insufficiency (chronic, peripheral); Pleural Effusion and Anemia. R24's Order Summary Report showed in part an Active order ([DATE]) for AVAPS machine for sleep apnea at bedtime and in the morning and in the morning switch mask to nasal cannula and connect to oxygen concentrator. R24's Care plan focus ([DATE]), showed in part that R24 has altered respiratory status and difficulty breathing related to sleep apnea and interventions using AVAPS machine. Facility's document titled Oxygen Administration Policy, (Revised [DATE]), showed in part the purpose to provide safe oxygen administration for residents and that oxygen is administered via oxygen mask, nasal cannula and may have humidifier bottle necessary when administering. Document also showed in part, that used supplies should be discarded into designated container. Facility's document titled Oxygen Equipment Storage Policy (Revised [DATE]), showed in part that the purpose is to ensure safe storage of oxygen equipment which includes but not limited to concentrators, tubing, and humidifiers) in compliance with state licensure requirements and federal Conditions of Participation and life safety standards. Policy showed in part, that The facility shall store oxygen-related equipment in a clean, organized, and safe manner that prevents fire hazards, protects residents and staff, and maintains equipment integrity. Policy also documented in part that the unused oxygen tubing, cannulas and humidifiers should be stored in original package or containers (plastic bags) and that opened and not used supplies must be handled per infection control guidelines; equipment must be cleaned, should comply with federal requirements and should not be stored on the floor and that nursing staff is responsible for proper cleaning and returning of equipment after use. R13's medical diagnoses include but are not limited to traumatic subdural hemorrhage, fracture of base of skull, cerebral edema, atrial fibrillation, heart failure, presence of prosthetic heart. On [DATE] at 11:28am R13 observed lying in bed connected to oxygen via nasal cannula and connected to humidifier bottle. No date observed to R13 nasal cannula tubing or humidifier bottle. On [DATE] at 11:33am V22 (Registered Nurse/RN) stated that she does not see a date on R13's oxygen tubing or humidifier bottle. V22 stated that there should be a date on the nasal cannula and the humidifier bottle. V22 stated that oxygen tubing is usually changed once a week on Saturdays. On [DATE] at 2:34pm V15 (Infection Preventionist/IP) stated that oxygen tubing should have a date on it so that everyone knows when it was placed on the resident. V15 stated that oxygen tubing must be replaced weekly. V15 stated that not changing the oxygen tubing can cause infection. R13's physician order dated [DATE] documents in part, On continuous O2 (oxygen) regulated to 4 lpm (liters per minute). R13's physician order start date [DATE] documents in part, Change and replace oxygen tubing every Saturday evening. R13's care plan with admission date of [DATE] documents in part, R13 has oxygen therapy in place r/t (related to) ineffective gas exchange and shortness of breath.change tubing per facility protocol.

Based on observations, interviews and record review, facility failed to follow their policy and federal regulations and failed to ensure the Daily Nurse Staffing Posting information forms were posted daily in a prominent place readily accessible to residents, staff and visitors. These failures have the potential to affect all 30 residents residing in the facility. Findings include:On 3/2/2026 at 9:31 AM, facility presented a census of 30 residents living at the 8th and the 9th floor units.On 3/2/2026 at 10:30 AM, surveyor observed main lobby of the facility and the 8th floor unit. Observed nursing station, posting boards at the nurse's station and announcements and information posted on the walls of the 8th floor unit. The Daily Nurse Staffing Posting sheet was not observed displayed prominently anywhere on the 8th floor unit or main lobby of the facility.On 3/3/2026 between 11:40AM and 11:57 AM, surveyor observed main lobby , 8th floor unit and 9th floor unit of the facility and did not observe the Daily Nurse Staffing Posting sheets prominently displayed on any surface of the facility's used bulletin boards or other display areas.On 3/3/2026 at 12;07 PM, V4 (Licensed Practical Nurse/LPN) stated that V4 is not aware of prominently posted sheet that would contain the daily nurse staffing posting information. V4 said that the only sheet the unit has at the nurse's station is the daily schedule that shows the staff caring for certain residents.On 3/3/2026 at 12:51 PM, V2 (Director of Nursing/DON) stated that the facility makes sure that there is continuing nursing coverage 24 hours per day, 7 days a week and that V2 is a full time in the role of DON. V2 stated that the daily staffing schedules are posted at each nurse's station, but V2 is not sure where the Daily nursing staffing posting sheet would be located. V2 said that V2 thinks the Daily nursing staffing posting sheet should be posted on each unit. V2 stated that V13 (Scheduler/CNA) is the scheduler for the facility and is responsible for filling out the Daily nursing staffing postings and that V2 assists V13 with the responsibilities.On 3/3/2026 at 2:41 PM, V13 (Scheduler/CNA) stated that the Daily schedules are located at each nurse's station, and that V13 fills out Daily nursing staffing posting sheets, but has the sheets located at V13's office in a binder. V13 said that V13 was not aware that the Daily nursing staffing posting sheets should be prominently displayed for all residents, staff and visitors to easily locate and said I did not know that it was supposed to be posted, I update them daily . V13 did not know that the Daily nursing staffing posting sheets should be clearly displayed and visible and V13 said that V13 can bring the sheets from V13's office and present to the surveyor. V13 stated that the Daily nursing staffing posting sheets should include the name of the facility, date, census and total number of hours worked per shift for nurses and nursing assistants.On 3/3/2026 at 2:55 PM, V13 (Scheduler/CNA) presented Daily nursing staffing posting sheets and stated that V13 went to obtain the sheets from V13's office from a binder. V13 stated that V13 has been in a role of scheduler for about a year and had training for the role of scheduler but was not told that the Daily nursing staffing posting information should be prominently posted.On 3/3/2026 at 3:19 PM, V1 (Administrator) stated that the Daily nursing staffing posting sheets were located inside of staffing binders at each nurse's station and that binders are easily accessible to residents or visitors. V1 stated that, starting immediately, the facility will start posting the Daily nursing staffing posting sheets on each nurse's station bulletin boards.Facility's document titled Staffing Sufficient Nursing Policy(Revised 5/13/2025), showed in part that direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care for residents) should be posted in the facility for every shift.Facility's document titled Facility Wide Assessment, (December 2025), showed in part in section Policies and Procedures for Provision of Care that the care needs of the residents, and the requirements of regulations, rules and laws govern the needed policies and procedures.Facility's document titled Nursing Scheduler/Care Partner Job Description (Undated), showed in part that The Scheduler is responsible for coordinating, creating, maintaining, and monitoring staffing schedules for the nursing department to ensure adequate coverage and compliance with staffing requirements. Document showed in part that Essential functions include but are not limited to monitoring daily staffing; Ensuring schedules comply with applicable staffing regulations and Maintaining accurate scheduling records and reports.Facility's document titled Director of Nursing Job Description (Undated), showed in part that the director of nursing should provide clinical and management leadership for the nursing department and ensure that standards of quality care are followed. Doctor of nursing is responsible for holding staff accountable for standard care and should demonstrate commitment to continuous quality improvement towards achieving the highest quality care results.

Based on interview, and record review facility failed to perform accurate fall risk assessment for a resident with a known fall history, develop and implement post fall interventions to prevent future falls and failed to monitor, document, and send resident to hospital in a timely manner post fall incident for one resident (R2) out of four residents reviewed for accident and supervision. This failure led to R2 falling in the facility sustaining multiple acute fractures. Findings Include: R2's Minimum Data Set (MDS) dated [DATE] shows he is cognitively impaired. R2's electronic medical record (EMR) revealed R2 was initially admitted to the facility on [DATE] and was [AGE] years old with diagnoses of, but not limited to unspecified fall, subsequent encounter, malignant neoplasm of bladder, heart failure, unspecified atrial fibrillation, hypertension, unsteadiness on feet, muscle weakness generalized, chronic kidney disease, diverticulitis of intestine with perforation and abscess with bleeding. On 6/3/25 at 1:53 PM, via telephone interview, V11 (Licensed Practical Nurse/LPN) stated that he observed R2 in a sitting position on the floor in his room on 5/12/25 at about 1:15 AM, he denied pain, or hitting his head, the vital signs were stable, he is not aware that R2 was on Eliquis, but the doctor ordered lab and to monitor since he did not hit his head. V11 also stated that there should be seventy-two hours post fall documentation every shift to monitor the resident for any changes and to prevent medical complication, but he did not work with R2 after the incident. R2's fall investigation summary form documents At around 1:15 AM resident observed on the floor, sitting position, by the bedside and call light is within reach. Resident verbalized I lost my balance while trying to get out of bed. On 6/3/25 at 3:30 PM, V2 (Director of Nursing/Fall Coordinator) stated that she has been in the facility since August 2024, she completes the fall risk assessment based on the root cause of the fall and collaborate with the care plan coordinator to update the care plan with new interventions to prevent further falls. V2 also stated that there should be seventy-two hours post fall documentation every shift to monitor R2 for any changes, to provide timely care and to prevent complication. On 6/4/25 at 2:44 PM, V2 stated that R2 was sent to the hospital on 5/16/25 due to neck pain with diagnosis of multiple acute fracture, he is at high risk for fall due to the history of fall prior to admission because he had a fall on 2/18/25. The fall risk assessment of 3/5/25 shows a score of 65, and on 4/9/25 with a score of 80 shows that R2 continues to be at an increased high risk for falls. He should be accurately documented and care planned to prevent further falls, but the readmission falls risk assessment of 4/21/25 shows a score of 3 (low risk). V2 stated that R2 was not accurately assessed to prevent the fall of 5/12/25 which resulted to multiple neck fractures, and when fall risk assessment is not accurately done, appropriate intervention will not be in place and resident safety will be compromised. On 6/4/25 at 12:15 PM, V14 (Minimum Data Set/MDS/Care Plan Coordinator) stated that she has been working in the facility since 2022, she does the care plan for the diagnoses, medications, readmission, admission, quarterly, significant change, and helps with the fall care plan. The purpose of care plan is to set goals for the resident and for the staff to know how to care for the resident. Care plan should be updated post fall with appropriate interventions, R2 is at high risk for fall, his fall assessment should reflect high risk, inaccurate fall assessment will lead to ineffective care plan and potentially another falls. On 6/4/25 at 1:16 PM, V15 (Medical Director) stated that he has been taking care of R2 for two years, he was substantially getting weaker, dependent on staff for activity of daily living, he is at high risk for fall, he had a big fall on 4/5/25, and another fall on 5/12/25. R2 was on Eliquis but according to the nurse report R2 denied hitting his head so there was no need to send him to the hospital on 5/12/25, however it is his expectation that nurses will continue to monitor him every shift and document to rule out any complication. Documents reviewed but are not limited to the following: R2' Face Sheet, POS, Section C, GG, and of MDS. R2's progress notes document on 5/16/25 at 1:30PM care partner and (NOD-nurse on duty) were assisting the care, the resident was screaming when the resident was moving in bed. (Physician) notified, per MD send (R2) out for further evaluation. Resident admitted with diagnosis of multiple acute fracture at C4, C5 and C6. R2's clinical records had no documentation showing that 72 hours post fall monitoring/supervision was done post fall of 5/12/25. R2's Fall risk assessment dated [DATE] with a score of 65 = high risk R2's Fall risk assessment dated [DATE] with a score of 80 =high risk R2' Fall risk assessment dated [DATE] with a score of 3 =low risk. Safety and supervision of residents' policy dated 12/2024, documents read in part: Resident supervision is a core component of the systems approach to safety. Fall Risk Prevention Policy dated 4/4/2025, documents read in part: Staff will try attempt interventions, based on the assessment.

Based on interviews, and record reviews, the facility failed to review and revise the comprehensive resident-centered care plan for one resident (R2) out of four residents reviewed for care plan revision. Findings Include: R2's Minimum Data Set (MDS) dated [DATE] shows he is cognitively impaired. R2's electronic medical record (EMR) revealed R2 was initially admitted to the facility on [DATE] and was [AGE] years old with diagnoses of, but not limited to unspecified fall, subsequent encounter, malignant neoplasm of bladder, heart failure, unspecified atrial fibrillation, hypertension, unsteadiness on feet, muscle weakness generalized, chronic kidney disease, diverticulitis of intestine with perforation and abscess with bleeding. On 6/3/25 at 3:30 PM, V2 (Director of Nursing/Fall Coordinator) stated she has been in the facility since August 2024, she collaborates with the care plan coordinator to update the care plan with new interventions to prevent further falls. On 6/4/25 at 2:44 PM, V2 state if a resident falls once that resident is at high risk for fall, R2 had two falls prior, so he is at high risk, and a resident centered care plan should be updated accordingly to prevent further falls. Surveyor showed V2 that R2's falls of 2/18/25 and 4/5/25 were both initiated on 6/2/25, she stated she expects the care plan coordinator to update but she is planning to review all care plans. On 6/4/25 at 12:15 PM, V14 (Minimum Data Set/MDS/Care Plan Coordinator) stated that she has been working in the facility since 2022, she does the care plan for the diagnoses, medications, readmission, admission, quarterly, significant change, and helps with the fall care plan. The purpose of care plan is to set goals for the resident and for the staff to know how to care for the resident. Care plan should be updated post fall with appropriate interventions, R2's care plan should have been updated with the interventions to prevent further fall. Documents reviewed are not limited to the following: R2' Face Sheet, POS, Section C, GG, and of MDS. R2's fall care plan was initiated on 6/2/25 for fall of 2/18/25 and 4/5/25. Care Plan-Comprehensive Policy dated 1/2024, documents read in part: assessments of resident are ongoing, and care plans are revised as clinical information about the residents and if the residents' conditions change.

Based on observation, interview, and record review the facility failed to follow their policies and implement safe food preparation and services to ensure the food conserves a safe temperature. This failure has the potential to affect all residents that receive nutrition from the kitchen. Findings include: On 1/21/2025 at 9:38 AM, this surveyor reviewed facility dated 1/21/2025 titled Hot holding (main kitchen) temperature log does not document a temperature was taken for the breakfast food (scrambled eggs, scrambled eggs puree, breakfast meat, breakfast meat puree, oatmeal, oatmeal puree, cheese omelet, cheese omelet puree). On 1/21/2025 at 9:39 AM, V6 (Director of Culinary Services) states that it should be filled out before the food goes out. V6 states that it is important to know the temperature of the food because they won't know if they need to make corrections and have proper holding temperatures. V6 it's important for the residents' health and avoiding food-related illnesses. On 1/21/2025 at 12:32 PM, V8 (Supervisor for dining) states that there is a steamer on each floor, and V8 states but this floor's (8th floor) steamer is not working currently, and there is a work order for it. V8 report that the holding food temperature should be about 130 to 135 degrees Fahrenheit. V8 states that the food is being microwaved prior to being served to the resident. This surveyor asked V8 to check the temperature for the barbeque beef and V8 utilized the facility's thermometer to properly measure the temperature. V8 states and this surveyor observed the temperature read 90 degrees Fahrenheit. V8 states that the food should be covered also to prevent dust or insects from entering to the food. On 01/22/2025 at 10:08 AM, with V6 (Director of Culinary Services) states that staff are not supposed to remove the hot food out of the hot boxes (insulated food carriers). V6 continues to state the servers are supposed to serve form the insulated food carriers. V6 states that this is the process that is being done as of now due to the steamer table is not working currently and there is a work order. V6 states that she is just waiting to hear back on the quote to fix it. V6 states that V8 (Supervisor for Dining) is responsible to monitor during the dining services. Facility document not dated documents in part the mealtimes for the skilled floors, breakfast is from 8:00 AM to 9:30 AM. Facility document dated January 2021 documents in part Recording Temperatures, purpose: to ensure all food is prepared at appropriate temperatures and served at correct holding temperatures. The cook is responsible for checking the cooking temperature of each food item: meat, starch, vegetable, etc. The temperature will be taken with calibrated thermometer. The cook will determine if final temperature of each food is at a safe temperature to serve. Facility document dated 11/2010 documents in part Critical Food Temperature Guide, food storage temperatures. Food held in the danger zone temperatures range may cause illness. Danger zone temperatures are from 40 degrees Fahrenheit through 140 degrees Fahrenheit.

Based on observation, interview, and record review the facility failed to observe proper PPE (Personal Protective Equipment) protocols. This failure has the potential to affect all residents residing in the facility. Findings include: 1. On 1/21/25, at 12:30 PM, observed a sign posted on R19's door frame. The sign had two STOP signs pictured and the CDC (Centers for Disease Control and Prevention) emblem on it. The sign read in part: Contact Precautions. Providers and staff must also: put on gloves before room entry. Put on gown before room entry. V24 (R19 Private Care Giver) was observed inside of R19's room with no PPE (Personal Protective Equipment), gown, gloves worn. On 1/21/25, at 12:33 PM, V24 (R19 Private Care Giver) stated R19 is a two-person assist. V24 cleans R19's face, brushes R19's teeth, puts clothes on R19 and helps the Care Partners-CNA's change R19. V24 works weekdays and sits inside R19's room for companionship and to monitor. V24 stated V24 only wears PPE (Personal Protective Equipment), gown, gloves when V24 changes R19 after a bowel movement. V24 stated a nurse told R19 that R19 has to be on quarantine for ten days for something dealing with the bowel. V24 stated that V24 was told PPE was not needed just to be inside of the room, only to change the adult brief. On 1/21/25, at 2:10 PM, V3 (Director of Nursing) stated on contact precaution, you wear the necessary PPE to go into the room which includes gown and gloves. This includes everybody that goes into the room. The caregiver should have on a gown and gloves when they are in the room even if just sitting. They are touching things in the room so they should have on PPE. On 1/21/25, at 3:10 PM, V12 (Infection Control Prevention Nurse-RN) stated R19 is on contact precaution for CDIFF (Clostridioides difficile). R19 has been on contact precaution since 1/13/25, and is due to come off 1/22/25. Contact precaution is for infections passed by touching. CDIFF can be transferred to objects in the room such as the bedside table, call light, television remote control. Staff are supposed to gown and glove whenever they change (change adult brief, clean up after a bowel movement) the resident. If any nurse, CNA (Care Partner) and care giver have any contact (touching, changing adult brief, any contact with bodily fluids) with R19 then they should gown and glove up. If anyone is not touching the resident, then they do not need to gown and glove. If a care giver is just sitting in the room they do not need to gown and glove. If the care giver is touching the resident, then they gown and glove. It is possible for the care giver and anyone else that goes into the room to come into contact with the bedside table, call light, television remote control, etc. and thereby come into contact with CDIFF. The reason for contact precaution is to protect others from the infection. The PPE is to protect the staff and others from the infection of the contact precaution. If the staff or anyone else is not wearing PPE while in the room for any reason they are at risk to contact CDIFF. R19 progress note, 1/13/2025, 3:21 PM, reads in part: Resident tested positive for C-diff. (Physician) notified with order to start vanco 125mg (milligrams) Q (every) 6 PO (by mouth) times 10 days. Order carried out, isolation precautions set up and POA (power of attorney) notified of isolation precautions . R19 progress note, 1/14/2025, 6:35 PM, reads in part: Positive for c-diff. On contact isolation (until 48 hrs after last episode of diarrhea resolution) Facility policy Isolation-Categories of Transmission-Based Precautions, no date, documents in part: Contact precautions are implemented for residents known or suspected to be infected with microorganism that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors wear gloves (clean, non-sterile) when entering the room. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. 45111 2. On 01/23/2024, at 10:36 AM, V26 (Housekeeping) was observed on her phone going from the eighth floor to the elevator wearing disposable gloves, and did not have a cleaning cart. V26 used her gloved hands to choose the floor she was going to. V26 stated she was in a rush and forgot to remove her disposable gloves and got off the elevator on the seventh floor. On 01/23/2025, at 11:17 AM, V26 stated she had gloves on because she was in a hurry to assist two temporary workers and they kept calling her to assist them. V26 stated she was trained to wear gloves only in the residents' rooms then take them out before leaving the resident room then wear clean ones in the next room. V26 stated wearing gloves outside the resident's room posed a risk of spreading germs and is risk for contamination. V26 stated she had infection control in-service last year but she does not remember when. On 01/23/2025, at 1:01 PM, V28 (Assistant Director of Nursing-ADON) stated staff are not supposed to walk around wearing disposable gloves because that would be spreading germs throughout the facility. V28 stated house keepers should be wearing gloves inside the resident's rooms while cleaning and take them out before leaving the residents room and not wear them while walking in the hallways and in the elevator to prevent spread of germs. V28 stated staff are provided in-services to make sure they are aware of how to prevent spread of germs. On 01/23/2025, at 1:17 PM, V12 (Infection Control Nurse-LPN) stated staff, including housekeepers are not supposed to walk in the hallways, elevators and other floors wearing disposable gloves to prevent the spread of germs and diseases in the facility, and the germs can spread around the units which can spread to residents. On 01/23/2025, at 1:41 PM, V29 (Environmental Service Housekeeping Manager) stated house keepers are not supposed to walk around wearing disposable gloves in the units and hallways because they can spread germs which can affect the residents. V29 stated housekeepers are supposed to remove disposable germs once they are done with a resident room and put the dirty gloves in the garbage bin. V29 stated she trains her staff once a year on infection control. V29 stated in-service is provided by an outside vendor but she does not have the information or sign in sheet for staff who attended from the last time the class was provided. Personal Protective Equipment -Using Gowns dated 2001 documents: -After completing the treatment or procedure, gowns must be discarded in the appropriate container located in the room.

Based on observation, interview, and record review the facility failed to store and label food items in accordance with professional standards for food service safety and follow proper sanitation and food handling. This failure has the potential to affect all residents that receive nutrition from the kitchen. Findings include: On [DATE] at 9:53 AM in the refrigerator with V6 (Director of Culinary Services), was approximately 20 slices of cheese slices dated ,d+[DATE] use by ,d+[DATE], approximately 15 slices of turkey dated ,d+[DATE] use by ,d+[DATE], the tail end of cured Italian meat prepared [DATE] with use by [DATE]. A Three 5-pound containers of cottage cheese that expired on [DATE]. On [DATE] at 10:10 AM in the walk-in freezer with V6 was a blue cheese butter labeled [DATE] use by [DATE], approximately 12 pieces of prepared chicken on a silver tray covered with plastic cover, labeled [DATE] use by [DATE]. V6 states these food items should have been discarded. V6 states that she is working on in-servicing the kitchen staff. On [DATE] at 11:26 AM there were several pieces of zucchini on a cart, uncovered, and no staff around the pieces of zucchini. V6 continues to state if the staff took it out, it should be covered due to potential for contamination. With V6, 12 slices of lemon bars uncovered and no staff around the slices of lemon bars. On [DATE] at 9:55 AM there were 6 large soup containers on a table with ice, uncovered, no lids noted in the area. On [DATE] at 12:28 PM V9 (server) was serving a lunch tray that is being prepared to be delivered to a resident. V9 was not wearing a hairnet. Three pans noted on the steam table, without lids or plastic covering the food. One pan was barbeque beef, another pan was peas and carrots. Facility document dated [DATE]/2020 documents in part Refrigerated Storage. Purpose to ensure all food products are safe and to prevent foodborne illnesses. All food is labeled, if taken out of original packages, food will be labeled and dated. Facility document dated [DATE]/2024 documents in part Freezer Food Storage. Purpose to be sure all frozen food products are served in a timely manner and are of the highest quality. Store food in its original package, when possible, if taken out of original package should be labeled and dated and tightly wrapped.

Based on observation, interview, and record review the facility failed to ensure a safe, hazard free environment for 15 residents residing on the eighth floor of the 29 residing in the facility. Findings include: On 1/21/25, at 9:54 AM, while touring the 8th floor, writer observed four screws on the floor in the hallway. Writer observed two staff members, V20 (Live Enrichment) and V21 (Care Partner/Certified Nursing Assistant-CNA) walk past the screws on the floor without picking them up. On 1/21/25, at 10:07 AM, V22 (Maintenance) was observed picking up the four screws from the floor in the hallway. V22 verified to writer that they are screws. V22 stated I picked them up, so no one has an accident. Someone could step on them and slip and fall. They should not have been on the floor. I don't know who left them there. There have been no calls to me to pick them up. Staff should have picked them up to prevent a hazard. On 1/23/25, at 2:50 PM, V3 (Director of Nursing) stated we keep the supply room with medication and supplies locked. Anything hazardous to the resident is locked, especially in the kitchen. Anything harmful to the resident is kept out of reach. To be free of hazards, we make sure no clutter is on the floor, no loose carpet. The passageway is clear of anything to make trip, we have adequate lighting. There should not be anything in the hallway to make the resident trip. Equipment should be kept on one side of the hallway. There should not be screws on the floor of the hallway. If there is they should be picked up by any staff member. The resident can easily slip on them, harm themselves, poke themselves. If I see a screw on the floor, I have to pick it up. According to facility daily census 1/22/2025, provided by facility, there are 15 residents that reside on the eighth floor. According to 10 Fall Prevention Tips for Seniors posted on the 8th and 10th floors of the facility, the first tip is to remove tripping hazards such as books and papers, shoes, and boxes from stairs and hallways, and secure rugs. Facility policy Safety and Supervision of Residents, 12/2024, documents in part: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing bases through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.

Based on interview and record review the facility failed to have a person-centered care plan that is consistent with the resident's current condition, goals, and services for one (R3) resident reviewed in a total sample of 12 residents. Findings include: On 01/21/25, at 12:53 PM, R3 states that she is under hospice care, and she does not know how long she has received hospice services. R3 states she cannot recall what services they provide to her. On 01/23/25, at 10:48 AM, Reviewed R3's active physician order set and documents in part: admitted to Journey Care Hospice 11/16/2024. On 1/23/25, at 1:11 PM, V31 (Licensed Practical Nurse) states R3 is a 2-person assist for ADL (activities of daily living) care, it can take 45-60 minutes to care for because of her behaviors. Sometimes she is very agitated and cursing. She has no wounds. The hospice has provided R3 with the comfort kit. V31 states that hospice comes in every week. Sometimes if there is abnormality and resident is not comfortable, we inform hospice too. On 1/23/2025, at 2:04 PM, via telephone V32 (Licensed Practical Nurse/Minimum Data Set nurse) states that she takes care of developing the residents' nursing care plans. V32 states care plans should be updated and as needed, but at least quarterly (every 3 months). V32 states that it's important to have an updated care plan because it shows what are resident's current needs, goals, and interventions. This surveyor asked V32 what kind of specialized services should be care planned? V32 states if the resident is under palliative care or hospice care. R3's face sheet documents R3 is a [AGE] year-old individual admitted to the facility on [DATE], with the following diagnoses but not limited to secondary Parkinsonism, unspecified, chronic obstructive pulmonary disease, unspecified. R3's Minimum Data Set (MDS) Section C, dated 06/07/2023 documents R3 is cognitive intact. R3's current physician order documents in part: admitted to Hospice 11/16/2024. R3's care plan does not document that R3 is receiving hospice care. Facility document dated 12/2024, title Care Plans, Comprehensive Person-Centered documents in part the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview and record review, the facility failed to follow their restorative care policy and provide restorative therapy for one (R18) in a total sample size of 12 resident. Findings include: On 01/21/25, at 1:10 PM, R18 sitting on his wheelchair, in the activity room, and in no apparent distress. R18 unable to be interviewed. R18's left hand constricted. On 01/21/25, at 1:11 PM, V10 (certified nursing assistant) states that R18 tends to flinch his hands and makes fists. On 1/23/2025, at 2:04 PM, via telephone V32 (Licensed Practical Nurse/Minimum Data Set nurse) states that some common Parkinson's disease signs and symptoms can include tremors, they can decline functionally. V32 states that some interventions that can be put in place for a resident with Parkinson's disease can include- monitor for tremors, if they have side effects of the medication, PT/OT (physical therapy/occupational therapy) when we think they need help, doing range of motion for them to maintain the current function to prevent contractures. On 1/23/25, at 3:17 PM, V30 (Director of Rehab) states that she has not worked for the facility long (since December 10th, 2024). V30 reports that R18 is not being followed by therapy. On 1/23/2025, at 4:24 PM, V3 (Director of Nursing) states that V32 is covering for the restorative therapy since the previous nurse is on vacation. V3 states that the purpose of restorative program is to maintain the resident at their baseline. V3 states that a resident with a primary diagnosis of Parkinson's Disease will benefit from a restorative program because it can slow the decline. V3 states that a restorative program is specific for whatever the resident is assessed for and there are specific goals. V3 states that residents are referred to restorative when they get discharged from rehabilitation services such as physical therapy. V3 states but they will have all residents try to do some restorative program. V3 states that a patient diagnosed with Parkinson's disease can develop contractures especially if they are not able to move around anymore. V3 states I think he (R18) absolutely will benefit from restorative therapy. V3 states that she cannot tell this surveyor the rationale as to why R18 is not being provided with restorative therapy services. R18's face sheet documents R18 is an [AGE] year-old individual admitted to the facility on [DATE] with the following diagnoses but not limited to secondary Parkinsonism, unspecified, muscle weakness, dementia. R18's Minimum Data Set (MDS) Section C, dated 1/5/2025, documents R18 is rarely/never understood. R18's Minimum Data Set (MDS) Section I, dated 1/5/2025, documents R18 has diagnosis of Parkinsonism, unsteadiness on feet, repeated falls, muscle weakness. R18's MDS section O Special Treatments, procedures, and programs, dated 1/5/2025, documents in part that R10 received 0 days of restorative nursing programs. R18's current care plan does not document restorative therapy interventions. R18's physician order set does not document an order for restorative therapy. Facility document undated, titled Restorative Program notes a list of residents that are on a restorative program, and R18 is not noted on the list of residents that are on a restorative program. Facility document dated 12/2024 titled Restorative Nursing Services documents in part residents will receive restorative nursing care as needed to help promote optimal safety and independence.

Based on observation, interview, and record review the facility failed to accurately secure controlled substance medications for two residents (R7 and R14) in a sample of 12 reviewed for medication/controlled substance storage. Findings include: 1/21/25, at 10:43 AM, reviewed 8th floor medication cart and medication room with V23 (Licensed Practical Nurse-LPN). Observed V23 open the refrigerator and narcotic lock box without using a key or entering a code or any other unlocking method. Observed the refrigerator to have no locking mechanism. Observed the narcotic lock box inside of the refrigerator to have a coded locking mechanism. V23 verified to writer the narcotic lock box was not locked with the coded locking mechanism. Inside of the unlocked narcotic lock box was Lorazepam Intensol Oral Concentrate 2mg (milligrams) per ml (milliliter) for R7 and R14. 1/21/25, at 11:30 AM, V23 (Licensed Practical Nurse-LPN) stated narcotics should be locked so accessible only to the nurse; to keep them safe. 1/23/25, at 2:50 PM, V3 (Director of Nursing) stated narcotics need to be double locked. The narcotic box should be locked, and the medication cart is locked when unattended. In the medication room, the medication room should be locked and the narcotic box inside of the refrigerator should be locked. The refrigerator is not locked. The narcotics are locked because they are controlled substances. We keep it locked to keep them from going missing, so residents can't get to them and overdose. R7 physician order summary reads in part: Lorazepam Oral Concentrate 2mg/ml Give 0.25 milliliter by mouth every 2 hours as needed for mild to moderate anxiety, active order status, start date 11/11/2024. Lorazepam Oral Concentrate 2mg/ml Give 0.25 milliliter by mouth one time a day for anxiety, active order status, start date 11/11/2024. Lorazepam Oral Concentrate 2mg/ml Give 0.5ml by mouth every 2 hours as needed for severe anxiety, active order status, start date 11/11/2024. R14 physician order summary reads in part: Lorazepam Intensol Oral Concentrate 2mg/ml Give 0.25 milliliter by mouth every 2 hours as needed for anxiety or nausea for 14 days, active order status, start date 1/22/2025, end date 2/5/2025. Lorazepam Intensol Oral Concentrate 2mg/ml Give 0.5ml sublingually every 2 hours as needed for moderate to severe anxiety or nausea for 14 days, active order status, start date 1/22/2025, end date 2/5/2025. Facility policy Controlled Substances, 11/2022, documents in part: Controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Based on observations, interviews, and record reviews, the facility failed to a.) ensure kitchen staff wore beard covering in the kitchen during meal preparation, b.) food items were properly labeled, dated, and stored, c.) discard expired foods. These failures have the potential to affect all 31 residents receiving food prepared in the facility's kitchen. Findings include: On [DATE] at 9:21 AM, during initial kitchen tour observed V8 (Cook) placing carrots in the steamer and then pulling carrots out of the steamer. V8 had a beard with hair extending past V8's jaw line. V8 was not wearing a beard protector. On [DATE] at 9:22 AM, V7 (Director of Culinary Services) stated that everyone entering the kitchen should be wearing a hairnet and beards should also be covered. V7 stated the purpose of the hair nets and beard coverings is so that hair does not fall into the food and cause contamination. V7 saw that V8 was not wearing a beard covering and told V8 to go put a beard covering on. On [DATE] at 9:26 AM, V8 stated my beard is a little long right now and it should be covered and I'll go and cover it now. On [DATE] at 9:27 AM, observed V8 leave the cook station and returned wearing a beard covering. V8 stated V8 got the beard covering from a box of beard coverings stored by the lockers. On [DATE] at 11:12 AM, observed V8 preparing food with a disposable face mask on. The disposable face mask did not cover V8's facial hair from V8's beard. Surveyor could view V8's facial hair hanging below the face mask toward V8's neck. All V8's facial hair was not fully covered. V8 was not wearing a beard protector. Surveyor asked V8 to put on a beard protector and V8 left the kitchen and returned wearing a beard protector covering all of V8's facial hair. On [DATE] at 9:30 AM, V7 stated everything in the refrigerators needs to be labeled and dated using a sticker. V7 stated on the sticker the staff are expected to write the preparation (or open date) and the use-by-date (or shelf-life date). On [DATE] at 9:42 AM, observed in walk-in dairy cooler opened package of hamburger buns dated with prep date [DATE] and use-by-date [DATE]. Observed nickel sized circle of green fuzzy material on one of the hamburger buns. V7 viewed the hamburger buns and stated that has mold on it and it's old moldy bread and that the bread was past the expiration date and should not be served to the residents. On [DATE] at 9:45 AM, observed opened 1 gallon container labeled as Mustard, Dijon [NAME] without a label. The container was not labeled with a manufacturer use by date. V7 opened the lid of the mustard to show the surveyor that the container had been opened and stated that the item should be labeled and dated indicating an open and use-by-date so staff would know when to discard the item. On [DATE] at 9:55 AM, toured dry storage area and observed opened hard plastic container labeled as pastry flour. The lid of the hard plastic container was not closed tightly so that one corner of the lid was lifting upward. The hard plastic container was not fully closed. V7 stated opened items and storage containers should be sealed tightly so there is no contamination from bugs or leaky water pipe. On [DATE], V7 provide surveyor with list of residents and diet order. V7 stated all of the residents receive food from the kitchen, none of the skilled nursing residents receive NPO (Nothing by Mouth). Kitchen policy titled, Hygiene dated [DATE] documents in part, every employee has a role in reducing the potential for food contamination by following food hygiene practices and all hair must be covered, and facial hair exceeding half an inch must be covered. Kitchen policy titled Food Labeling dated [DATE] documents in part, all dry goods must be labeled with a date received, date opened and use by date and all items opened and out of original packaging should be stored in tightly sealed bag or container. Kitchen policy titled Food Storage dated [DATE] documents in part, plastic containers with tight fitting covers must be used for flour.

Based on interview and record review, the facility failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations for 5 residents (R10, R23, R25, R27 and R28), Failed to assess eligibility and offer pneumococcal vaccinations to 4 (R10, R25, R27 and R28) residents and Failed to administer Pneumococcal vaccine for one (R23) resident eligible to receive the vaccine. These failures affect 5 (R10, R23, R25, R27 and R28) of eight residents reviewed for immunization. The findings include: R10 health record showed admitted on 10/15/23, [AGE] years of age with diagnoses not limited to Type 2 Diabetes mellitus, Essential Hypertension, Fracture superior rim of right pubis, Hypothyroidism, History of falling, Depression, Atherosclerotic heart disease, Anemia, Paroxysmal atrial fibrillation. R23 health record showed admitted on 10/18/23, [AGE] years of age with diagnoses not limited to Other toxic encephalopathy, Epilepsy, Essential Hypertension, Atrial fibrillation, Gastro-esophageal reflux disease, Hyperlipemia, Obstructive sleep apnea, Acute embolism and thrombus deep vein lower extremity, Non traumatic intracranial hemorrhage, Dysphagia. R25 health record showed admitted on 1/12/24, [AGE] years of age with diagnoses not limited to Covid 19, Altered mental status, Essential hypertension, Chronic atrial fibrillation, Hyperlipidemia, Benign prostatic hyperplasia, Multiple sclerosis, Other seizures. R27 health record showed admitted on 2/9/23, [AGE] years of age with diagnoses not limited to Unspecified displaced fracture of 2nd cervical vertebra, Unspecified fall, Hyperlipidemia, Depression, Generalized anxiety disorder, Rhabdomyolysis, Covid 19. R28 health record showed admitted on 5/23/23, [AGE] years of age with diagnoses not limited to Parkinson's disease, Cardiomyopathies, Pain in left hip, Unilateral primary osteoarthritis. On 2/07/24 at 11:08am V4 (Infection Preventionist/IP Nurse) stated that all residents are screened for vaccination eligibility and education should be provided regarding risk and benefits of the vaccines. V4 said Pneumococcal vaccine is given every 5 years if eligible to receive and they are following CDC (Center for Disease Control and Prevention) guidelines. Reviewed immunization record of the following residents with V4: 1. V4 said R10 received PCV13 (Pneumococcal Conjugate) on 10/30/2015. PPSV23 (Pneumococcal Polysaccharide Vaccine) on 2/19/14. She said no screening for Pneumococcal vaccine was done and no education provided. V2 said Pneumococcal vaccine is given every 5 years. R10 was due to receive the vaccine on 10/2020. Per CDC recommendation (Pneumorecs Vax Advisor App), decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. 2. V4 said R23 received PPSV13 on 6/22/15. Pneumonia screening done on 5/15/23 and consented to receive the vaccine but no pneumococcal vaccine was not given. Per CDC recommendation (Pneumorecs Vax Advisor App), give one dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of which vaccine is used (PCV20 or PPSV23), their pneumococcal vaccinations are complete. However, if PPSV23 is administered, decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. 3. V4 said R25 received PVC13 on 10/30/2015. Pneumococcal PPSV23 on 2/8/10. No screening was found for pneumococcal vaccine and no education provided. Per CDC recommendation (Pneumorecs Vax Advisor App), decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. 4. V4 said R27 received Pneumococcal PPSV23 on 01/01/11 and PCV13 on 8/21/18. No screening was found and no education provided regarding pneumococcal vaccine. Per CDC recommendation (Pneumorecs Vax Advisor App), decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. 5. V4 said R28 received PCV13 on 6/17/2016 and PPSV23 on 12/27/2001. No screening and education was found regarding pneumococcal vaccine. Per CDC recommendation (Pneumorecs Vax Advisor App), decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. V4 stated that pneumonia screening is important to determine if resident is eligible to receive the vaccine and education should be provided to either resident / family / representative regarding the risk and benefits of the vaccine. V4 stated that vaccine will prevent serious or severe complications and resident will not easily get the infection or virus. Facility's Pneumococcal vaccine policy dated February 2024 documented in part: - Residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. - Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. - Pneumococcal vaccine will be administered to residents per facility's physician-approved pneumococcal vaccination protocol. - Administration of the pneumococcal vaccines will be made in accordance with current CDC recommendations at the time of the vaccination. Review of the CDC's Pneumococcal Vaccination: Summary of Who and When to Vaccinate, published online on [DATE] and again reviewed on September 22, 2023 revealed, Adults [AGE] years or Older CDC recommends pneumococcal vaccination for all adults [AGE] years or older .For adults [AGE] years or older who have only received PCV13, CDC recommends you either Give 1 dose of PCV20 at least 1 year after PCV13 or Give 1 dose of PPSV23 at least 1 year after PCV13 . Received PCV13 at any age and PPSV23 after age [AGE] years use shared clinical decision-making to decide whether to administer PCV20. If so, the dose of PCV20 should be administered at least 5 years after the last pneumococcal vaccine.

Based on observation, interview, and record review the facility failed to serve food as planned on the pureed and mechanical soft menu, and failed to ensure standardized recipes were followed during food preparation. This failure has the potential to affect five residents (R2, R6, R20, R22, R184) receiving mechanically altered diets prepared in the facility's kitchen. Findings Include: On 02/06/24 at 12:04 PM, V14 (Kitchen Server) stated all food is prepared in the main kitchen and sent up in bulk to the unit kitchen/dining room for V14 to serve. V14 stated residents receiving a regular diet will be receiving for lunch soup, a barbeque pulled pork sandwich on a bun, cauliflower, macaroni salad and a soft cookie. V14 stated residents on a mechanical soft diet are being served for lunch soup, pulled pork with barbeque sauce, ground cauliflower, and mashed potatoes. V14 stated residents on mechanical soft diets are not receiving a bun, or macaroni salad or a cookie. V14 stated for dessert the mechanical soft diets will either receive applesauce or yogurt or gelatin, not the soft cookie. V14 stated residents on a pureed diet will be receiving pureed soup, pureed pork, mashed potatoes. V14 stated the main kitchen did not send up any pureed cauliflower or pureed bun for V14 to serve. V14 stated only the regular diets are receiving macaroni salad and that the mechanical soft and pureed diets are receiving mashed potatoes instead. V14 stated residents on pureed diets will either receive applesauce or yogurt or gelatin for dessert. V14 stated pureed cookies were not sent up by the main kitchen for V14 to serve. On 02/06/24 at 1:12 PM, V17 (Cook) stated V17 is the cook who prepared the food for lunch today including regular, mechanical soft and pureed food. V17 stated V17 did not prepare pureed bun, or pureed macaroni or pureed cookie or soft macaroni for the mechanical soft diets. At 1:17 PM, V17 stated the mechanical soft and pureed diets did not get macaroni salad because it has raw vegetables in it, they can only get cooked vegetables. At 1:23 PM, V17 stated, I don't follow any recipes when preparing the pureed or mechanical soft diets. I didn't follow any recipes this morning when preparing the food for lunch. At 1:52 PM, V17 stated V17 did not make ground pulled pork at lunch and that the regular and mechanical soft diets received the same pulled pork. On 02/06/24 at 1:28 PM, V19 (Dining Supervisor) stated pureed and mechanical soft diets do not get cookies at lunch and that those diets always get either pudding or applesauce, or ice cream at lunch because it's available from the unit dining room. V19 stated those diets get the same dessert as the regular diets in altered consistency form for dinner only, not lunch. V19 stated, I've been working here for two months, and I've never seen any cookies pureed for the pureed diets at lunch. On 02/06/24 at 1:36 PM, V7 (Director of Culinary Services) stated the kitchen prepares everything listed on the production sheets. V7 stated recipes are in the binder in the production area and the cooks should be following recipes for everything they make. V7 stated based on the menu mechanical soft diets received soup, pulled pork (ground) on a bun with barbeque sauce, roast cauliflower, buttered cooked macaroni (chopped) and cookie if soft. V7 stated pureed diets received pureed soup, pureed pork, pureed bun, pureed cauliflower, pureed buttered cooked macaroni salad, and pureed cookie. V7 stated it is important that the residents on pureed and mechanical soft diets get the same food as everyone else except in altered texture form because this is a dignity issues and shows respect to the residents. On 02/07/24 at 11:01 AM, observed V17 prepare pureed food for lunch. V17 stated there are three residents on pureed diets. Observed V17 take a cooking spoon (not measured) and scooped out seven spoonfuls of an unmeasured amount of Chicken a La King and place into a blender. V17 then added 2- 8-ounce ladles of vegetable broth to the same blender and then turned on the blender to puree the Chicken A La King. The pureed mixture looked very thin. V17 then stated V17 needed to add thickener to make the mixture thicker because otherwise it is too thin. Observed V17 add 1/2 cup food thickener to the pureed Chicken a La King mixture. The final product was smooth but still appeared thin. V17 then divided up the pureed Chicken a La King between three containers without measuring the amount going into each container. V17 stated the pureed portion of Chicken a La King served to the residents for lunch will be 4 ounces. On 02/07/24 at 11:13 AM, V17 took cooking spoon (not measured) and scooped out six unmeasured spoonfuls of green beans and placed into a blender. V17 then added 3- 8-ounce ladles of vegetable broth to the blender and then 2-1/2 cups of food thickener and pureed in blender. V17 then divided up pureed green beans between three containers in unmeasured amounts. V17 stated the pureed portion of green beans served to the residents for lunch will be 4 ounces. On 02/07/24 at 11:20 AM, V17 stated, I don't follow a recipe. V17 pointed to the paper on the wall on a clip board and stated they made this recipe yesterday for V17 to follow. V17 stated V17 usually just takes the regular food V17 makes for the regular diets and puree it in a blender with some broth and thickener as needed. V17 stated V17 knows from experience how much broth and thickener V17 needs to use. On 02/08/24 at 11:17 AM, V9 (Executive Chef) provide the recipe the cook followed for yesterday's lunch meal to surveyor. V9 reviewed recipe. Surveyor asked what utensil the cook should have used to portion out 8 ounces of Chicken a La King as stated in the recipe. V9 showed the surveyor a 8 ounce scoop. Surveyor showed V9 the regular spoon (unmeasured) that the cook used to portion out the Chicken a La King based on observations conducted on 02/07/24. V9 stated that the regular spoon is a cooking utensil and does not contain a measured amount and does not provide a controlled portion. V9 stated the cook needs to use the measured scoop to portion out food when following the recipe in order to make sure the residents are hitting their required dietary needs to keep them healthy and well fed. V9's expectation is that the cook purees the item and then gradually add a small amount of liquid at little at a time instead of adding too much liquid all at once and then having to use a lot of thickener thicken it up. On 02/09/24 at 8:05 AM, V20 (Consulting Registered Dietitian) stated menus are created to make sure they hit the major food groups and give the correct servings for fruit/vegetables/starch/protein. TV20 stated the production sheets and recipes are then based off the menus and there are specific serving sizes for each item which should be followed based on what the recipe says. V20 stated it is important for the menus and recipes to be followed so that they are giving the right portion size, so residents get the correct amount of calorie and protein because it important for the residents to get the right amount of nutrition. Residents may be on a pureed diet due to dysphagia or swallowing issues, poor dentition, or lack of teeth and being on a pureed diet places residents at a higher nutritional risk for decreased oral intake, and weight loss because most residents on a pureed diet do not care for the taste and texture of the pureed foods. V20 stated if too much liquid is added, then the texture could be too liquidly, and it could potentially affect the amount of nutrients the resident is getting from the product. V20 stated residents receiving a pureed diet should receive the same food as residents on regular diets except in pureed form assuming the item can be pureed. V20 stated for example, instead of serving cold macaroni salad they could have pureed hot macaroni. V20 stated we try to make the pureed diet as similar to the regular diet as we can. V20 stated the cook should be following the spreadsheets/recipes across all consistencies. V20 stated the cook should be following the menu as printed and if they are missing an item, they would need to reach out to a manager or myself. V20 stated V20 was not called this week about any missing items or substitutions. V20 stated it is important to provide a variety of foods to reduce redundancy, and V20 does not want residents receiving the same thing every day as this could potentially have an effect on their meal intake. R2's diet order per Physician Orders dated 02/07/24 documented as pureed texture with nectar thickened liquid ordered 01/25/24. R6's diet order per Physician Orders dated 02/07/24 documented as Mechanical Soft with nectar thickened liquids ordered 03/01/22. R20's diet order per Physician Orders dated 02/07/24 documented as Pureed Diet ordered 10/24/22 with honey thickened fluids ordered 12/29/22. R22's diet order per Physician Orders dated 02/07/24 documented as Mechanical Soft ordered 12/02/21 and nectar thickened liquid ordered 01/27/24. R184's diet order per Physician Orders dated 02/07/24 documented as Mechanical Soft with nectar thickened fluids ordered 01/21/23. Kitchen Production Summary Worksheet with Temperature dated 02/06/24 for lunch meal documents in part the following items to be prepared: buttered macaroni (chopped), buttered macaroni (pureed), pulled barbeque pork on bun (ground), roasted cauliflower (pureed). Kitchen recipe provided titled Pork Shoulder to yield 160 portions. Kitchen recipe provided titled How To Make THE BEST Macaroni Salad to yield 50 servings. Kitchen recipe provided titled Roasted Cauliflower to yield 4-6 servings. Kitchen document provided titled Puree - Chicken a La King documents in part, place 8 ounces Chicken a La King in Vitamix. Kitchen document titled Puree - Sauteed Green Beans documents in part, place 8 ounces Green Beans in Vitamix. Kitchen policy titled Dining Service in the Health Center dated 2/2020 documents in part menus are planned in accordance with the Recommended Dietary Allowances of the Food and Illinois Department of Public Health and menus are prepared in advance and food is prepared in a form designed to meet individual resident needs, including mechanical alteration of food as required. Kitchen policy titled Job Description for Cook dated July 2021 documents in part essential functions include to assist with all meals by correctly portioned and following the production sheet and preparing all foods as stated on the production sheet and serve quality products by following and extending recipes. 44103 On 2/06/24 at 12:40 PM, V6 (Certified Nursing Assistant) was assisting R20 for lunch in the 9th floor dining room. R20 received pureed soup, pureed meat, pureed cauliflower, mashed potato, and thickened water. R20 did not receive the pureed macaroni salad and pureed cookie that were listed on the menu. On 2/07/24 at 12:16 PM, V39 (Certified Nursing Assistant) was assisting R20 for lunch in the 9th floor dining room. R20 received pureed soup, pureed biscuit, pureed chicken, pureed green beans, and thickened water. At 12:41 PM, R20 finished eating lunch, and did not get any dessert. R20's clinical records show R20 has a diagnosis of Dementia. R20's Minimum Data Set (MDS) dated [DATE] shows R20 has severely impaired cognitive skills for decision making and has short- and long-term memory problems. R20's physician orders show R20's diet order of pureed diet with honey thickened fluids. 47304 On 2/6/24 at 12:28 PM, R184's lunch plate was observed with a scoop of mashed potatoes, ground cauliflower and pulled pork that did not appear ground. Observed staff provided Nectar Thick Liquid (lemon water).

Based on interview and record reviews, the facility failed to establish an antibiotic stewardship program that includes a protocol and a system to monitor antibiotic use and failed to use an infection assessment tool to determine if the antibiotic is indicated or needs to be adjusted for four (R15, R23, R25, R27) of four residents reviewed for antibiotic use in a sample of 14. The findings include: R15 health record showed admitted on 1/24/23 with diagnoses not limited to Multiple Sclerosis, Presence of right artificial shoulder joint, Hyperlipidemia, Non ST elevation (NSTEMI) myocardial infarction, Major depressive disorder, Polyneuropathy, Type 2 diabetes mellitus, Hypothyroidism, Morbid obesity, Other specified disorders of bladder, Acute respiratory failure with hypoxia. R23 health record showed admitted on 10/18/23 with diagnoses not limited to Other toxic encephalopathy, Epilepsy, Essential Hypertension, Atrial fibrillation, Gastro-esophageal reflux disease, Hyperlipemia, Obstructive sleep apnea, Acute embolism and thrombus deep vein lower extremity, Acute cystitis, Non traumatic intracranial hemorrhage, Dysphagia. R25 health record showed admitted on [DATE] with diagnoses not limited to Covid 19, Altered mental status, Essential hypertension, Chronic atrial fibrillation, Hyperlipidemia, Benign prostatic hyperplasia, Generalized muscle weakness, Repeated fall, Multiple sclerosis, Other seizures. R27 health record showed admitted on 2/9/23 with diagnoses not limited to Unspecified displaced fracture of 2nd cervical vertebra, Unspecified fall, Hyperlipidemia, Depression, Generalized anxiety disorder, Rhabdomyolysis, Covid 19, UTI. On 2/6/24 at 02:06pm V4 (Infection Preventionist/IP nurse) stated that she is using an assessment tool which is McGreer criteria for residents on antibiotic and makes sure that resident is meeting criteria. V4 stated that she is also checking signs and symptoms of infection. V4 showed December 2023 tracker for residents on antibiotic but unable to provide assessment tool / McGreer criteria assessment for residents on antibiotic use. V4 stated that she is using McGreer criteria as a guide but not completing the assessment. V2 (DON/Director of Nursing) and V4 said that standard of nursing practice if it was not documented it was not done. V4 unable to provide January and February tracker for residents on antibiotic use. V4 stated that she did not do January and February antibiotic tracker yet, unable to identify who are the residents on antibiotic. On 2/8/24 at 9:47am V4 stated that if antibiotic use is not monitored or tracked on an ongoing basis, not able to determine if antibiotic is appropriate or necessary for the resident. Stated that McGreer assessment tool is important to assess signs and symptoms of infection and to determine if resident is meeting criteria for antibiotic use. R15 Physician order sheet (POS) dated 2/8/24 with order not limited to: Bactrim DS 800mg-160mg (milligrams) by mouth twice a day for 12 days. R23 POS dated 2/8/24 with order not limited to: Doxycycline hyclate 100mg by mouth once a day for UTI (urinary tract infection) prophylaxis. R25 POS dated 2/8/24 with order not limited to: Meropenem 1gram intravenous solution every 8 hours x 7 days. R27 POS dated 2/8/24 with order not limited to: Doxycycline hyclate 100mg by mouth twice a day ongoing staph infection. Facility's Antibiotic stewardship policy dated February 2024 documented in part: - Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. - Antibiotic stewardship policy is a commitment on a the part of the nursing care centers to optimize the treatment of infections, minimizing the emergence of antibiotic resistance while reducing the adverse events associated with the antibiotic use. - The DON will with the clinical staff to ensure proper standards for assessing, monitoring and communicating changes in resident's condition regarding current or potential infection and antibiotic use. The DON will review patients weekly for appropriateness and resident improvement. - Tracking: The antibiotic stewardship committee will determine what will be reviewed and tracked on a monthly basis during the committee meeting. Items tracked can include number and types of antibiotic, type of infectious agents, effectiveness and outcomes of treatment and appropriateness of medication prescribed.

Based on document review and interview the facility failed to ensure that 2 person staff assist was provided during the use of a mechanical lift for 1 of 3 (R1) residents reviewed for safe transfers. This failure resulted in R1 falling to the floor and sustaining a Periprosthetic [MEDICAL CONDITION] femur. Findings include: Facility incident report of 5/1/18 states R1 was with a one to one private caregiver in residents room after dinner. Caregiver (V3) yelled for help from the residents bedroom. Arriving there V4 (Nurse) observed R1 kneeling on the floor close to the bed with caregiver standing close and holding the resident. Called for more help ( ADON and Care partner) Caregiver stated I was transferring the resident from her wheelchair to the bed , but resident started sliding from the edge of the bed. I eased the resident to the floor in a kneeling position. Resident was transferred to bed with three staff at this time. Head to toe assessment completed. Resident is unable to describe what happened. No complaint of pain or discomfort at this time noted. No bruise , nor skin tear noted , range of motion is within normal range with some contracture to upper extremity. Lower extremity range of motion within normal limits , vital signs : BP-118/63 HR-62 , SPo2-97% RA. Educated care giver to seek staff for assist during transfer at all times. Night nurse to monitor. Interdisiplinary note dated 5/5/18 includes statements Called by resident private caregiver to see left hip of R1 noted with discoloration , which is tender to the touch , and mild swelling . Recieved report from AM NOD RE: Swelling & discoloration on left leg , and for X-ray to r/o FX. X Ray results -DON notified. Spoke with NP and relayed X-Ray results - Impression : Left hip Arthroplasty with acute periprosthetic fracture of proximal femure. R1 was sent to the hospital emergency room [DATE]. Hospital document dated 5/8/18 states [DIAGNOSES REDACTED]. Procedure performed open reduction internal fixation periprosthetic proximal femur fracture. R1 was readmitted to the facility on [DATE]. R1s Minimum (MDS) data set [DATE] ( MDS in effect at time of incident) states 3/3 for transfer of resident ( two plus persons physical assist). R1s care plan includes staff to utilize mechanical lift X 2 staff assist. Educate private caregivers to seek staff for all ADLs care every shift and prn. Transfers strictly staff procedure with 2 staff assist using mechanical lift. This care plan was in effect at time of incident with a start date of 10/31/17. 10/10/18 10:40AM V2 (Director Of Nursing ) stated R1 had [MEDICAL CONDITION] due to improper transfer. The care giver transferred R1 unauthorized. We do not allow care givers to transfer the resident.

Based on interview and record review, the facility failed to implement a plan for monitoring and prevention of constipation and a potential fecal impaction for a resident with a known history for one of one resident (R2) reviewed for constipation and fecal impaction in the sample of 10. This failure resulted in R2 experiencing pain and being sent out to the hospital for evaluation and assessed with [REDACTED]. Findings include: On R2's Profile Face Sheet lists a [DIAGNOSES REDACTED]. On 1/15/17 at 5:00 PM, R2 was transferred to the hospital for evaluation. Facility nursing notes indicate R2 had a Fever of 100.2 *F (degrees Fahrenheit), lethargy and weak, loss of appetite, congestion. R2's hospital Admission History and Physical Form, dated 1/16/17, notes on page one of four: had abdominal pain in ED (emergency department). Page four of four reads in part: Clinical investigation available at time of admission - Constipation with impacted fecal material in the rectum. A hospital consultation report dated 1/16/17 reads in part: Of substance, the patient also was found to have constipation with impacted fecal material in the rectum. The rectal measured 9.5 cm (centimeters) in diameter. CT (computerized tomography) scan as described, I reviewed the images and it appears that mild Hydro[DIAGNOSES REDACTED] which (R2) has bilaterally extends to the level of the pelvic brim where there is a large amount of stool sitting in (R2's) colon. Plan: 2. Rigorous bowel regimen to evacuate (R2's) large amount of stool. R2 was readmitted to the facility on [DATE] at 8:30 PM. A review of R2's January Physician order [REDACTED]. The order was dated and active 3/11/16 - 1/15/17 and was reauthorized at readmission 1/28/17. No other orders were present for other medications, scheduled or as needed, or for other interventions to prevent constipation/impaction and monitor R2's bowel activity. Daily charting logs of R2's bowel movements (BM) indicate R2 had no BM on 1/28/17, a medium BM the evening of 1/29/17 and 1/30/17 and no BM 1/31/17. No documentation on the care partner logs or nursing notes indicates if the stools reported 1/29/17 and 1/30/17 were hard, soft or loose/liquid. On 2/1/17, R2's nursing interdisciplinary note created at 2:54 AM reads in part: Resident complains of epigastric/mid-epigastric region discomfort, states not being able to sleep due to discomfort. Denies pain/discomfort to other area of abdomen. Bowel sounds hyperactive, abdomen soft none distended. Fecal impaction of hard stool noted. Z1 (Physician) notified with order to administer Tylenol 650 mg (milligrams), [MEDICATION NAME] 30 ml (milliliters) one time only, urinalysis and culture/sensitivity, Sennosides [MEDICATION NAME] Sodium one tablet twice daily and fleet enema one time only. Z1's charting on 2/4/17 notes Found to have fecal impaction which was addressed. Following the second impaction on 2/1/17, R2's POS included a continuing order for [MEDICATION NAME]-S 8.6 mg - 50 mg one tablet by mouth twice daily. On 2/13/17 at 6:07 PM, results of an abdominal X-ray, ordered due to charted complaints of abdominal discomfort, notes Fecal balls in the distribution of the colon would suggest a degree of dehydration. On 2/17/17 at 10 39 PM, R2's blood pressure was 96/65 and R2 was sent to the hospital for evaluation of lethargy. Facility nursing notes 2/18/17 at 7:48 AM read in part: (R2's) admitting [DIAGNOSES REDACTED]. On 2/19/17, R2 was readmitted to the facility. Hospital discharge records indicate [DIAGNOSES REDACTED]. On 2/23/17, physician orders [REDACTED]. As of 2/28/17, R2 has no care plans addressing a [DIAGNOSES REDACTED]. On 2/28/17 at 11:40 AM, Z1 stated R2's fecal impaction did not cause, but may have contributed to R2's [MEDICAL CONDITION] and Hydro[DIAGNOSES REDACTED]. Z1 stated that, after R2's episodes of fecal impaction, Z1 discussed with facility management the need to be sure care partners understand the importance of monitoring and charting bowel movements accurately. On 3/2/17 at 9:50 AM at a morning feedback presentation, E2 (Director of Nursing) stated being unaware that R2 had a fecal impaction. E2 stated no policy or procedure for bowel regimens could be located, but stated staff record the number and volume (small, medium, large) of resident bowel movements and would notify physicians if residents have not had a bowel movement in two to three days as a standard. No other elements of a bowel regimen were described.

Based on observation, interview and record review, the facility failed to follow the pressure sore prevention policy/protocol and conduct a weekly skin assessment and failed to apply wound treatment as ordered by the physician and failed to follow the plan of care pressure sore prevention interventions for one of one resident (R2) reviewed for pressure ulcers in the sample of 10. This failure resulted in R2 having redness noted on the sacral area then assessed 9 day later with an unidentified open stage 2 pressure sore to sacral area. Findings include: On [DATE], R2 was readmitted to the facility from the hospital. R2's initial skin assessment on [DATE] reads, in part: Redness to sacral area - moisture barrier cream applied. R2's Braden Scale for predicting pressure sore risk was scored as follows, with a score of 14 or less indicating at risk for pressure ulcer development: [DATE] = 11, [DATE] = 13. No Braden assessments were recorded between [DATE] and [DATE]. Prior scores were: [DATE] = 16, [DATE] = 14, [DATE] = 14, [DATE] = 13. Nursing interdisciplinary (ID) notes on [DATE] read barrier cream applied with each incontinence episode to redness on sacral area. No other description of R2's sacral/coccyx area was charted and no wound assessment of R2's sacral/coccyx skin condition was recorded until [DATE]. Nurse ID notes created [DATE] at 7:43 PM read in part: Brought to my attention by care partner that resident skin to buttock area is open, writer attended and noted Stage 2 pressure ulcer to coccyx, 2.5 x 0.5 cm (centimeters) beefy red. Right sacral Stage 1 pressure measure 2 cm x 1 cm reddish bluish discoloration, right and left groin reddened macerated skin. E2 (Director of Nursing) notified and assessed sacral/coccyx. Z6 (Nurse Practitioner) called with order for ([MEDICATION NAME]) dressing every 72 hours and as needed, [MEDICATION NAME] powder to left/right groin twice daily and reposition every two hours when in bed. Skin Evaluation Forms completed by E3 (Assistant Director of Nurse/Wound Care Nurse) note the following: [DATE] - Coccyx - 2.5 cm x 0.5 cm - Stage 2 with moderate (serosanguinous) drainage noted, surrounding redness noted. [DATE] - Coccyx - 3.0 cm x 2.0 cm x 0.2 cm - Stage 2 pressure ulcer with moderate drainage (purulent) noted, resident readmitted from hospital. [DATE] - Coccyx - 3.0 cm x 2.0 cm x 0.1 cm - Stage 2 pressure ulcer with moderate purulent drainage, surrounding skin with redness and excoriation, wound bed with slough and noted dark black and yellow in color. R2's POS includes an order dated [DATE] to start on [DATE]: Cleanse area with normal saline, apply nickel thick layer of Santyl ointment to wound bed, apply zinc oxide to surrounding redness, cover with sacral size (self-adherent absorbent foam) dressing daily at 6:00 AM. Document appearance of wound in ID notes. On [DATE] at 1:30 PM, E4 (Nurse) removed R2's coccyx dressing and the wound was observed to be mostly covered with slough with a small darkened/black area at the base. After cleansing the wound with normal saline, E4 changed gloves and dispensed Santyl cream directly from the tube onto the gloved fingertip, then used the fingertip to apply the Santyl to the wound. E4 patted and spread the Santyl onto the area; unable to determine if a nickel thick layer was applied as ordered. E4 again changed gloves without hand hygiene and dispensed Zinc oxide from the tube directly onto a gloved fingertip and applied zinc oxide in an arch approximately one half inch wide to half of the wound perimeter, then used another fingertip to obtain zinc oxide from the tube and applied it to the other half of the wound perimeter. E4 did not apply zinc oxide to the entire reddened area as directed in the treatment order, leaving approximately a two inch band of redness untreated around the perimeter. E4 did not perform handwashing or use hand gel after each observed glove removal and prior to donning new gloves. On [DATE] at 1:53 PM, E3 stated Braden assessments should be done on admission and quarterly. E3 stated R2's sacral/coccyx wound was initially charted as redness on readmission [DATE], but that E3 might have seen more. E3 stated she was not informed about R2's wounds to assess them before [DATE]. E3 stated the air mattress is usually put at the highest setting unless the resident requests something else for comfort. E3 stated The Static setting is what is usually used so it stays flat; otherwise it would be alternating. On [DATE] at 11:40 AM, Z1 (Physician) stated that R2's initial skin redness would be manageable ideally with barrier cream and proper turning and cleaning. Hospital records listed R2's weight at 132 lbs (pounds) at discharge and Z1 reported R2 had swallowing issues while in the hospital that were improving. Z1 described working with dietary and sacrificed glycemic control to get calories, and adjusted [MEDICATION NAME] to allow (R2) more intake. Facility weights for R2 were 137.4 lbs on [DATE], 133 lbs on [DATE], 135 lbs on [DATE], 137.2 lbs on [DATE] and 136.8 lbs on [DATE]. R2's Physician order [REDACTED]. On [DATE] at 1:40 PM, E4 completed wound care and left R2's room. R2 was in bed on an air mattress with the pressure setting dial fully turned toward Firm and the Static light on. On [DATE] after wound care at 8:22 AM, R2 was again in bed with the air mattress set to Firm and Static. E17 (Nurse) stated It's always set like that. The operating manual for the low air loss mattress instructs that the pressure-adjust knob should be set based on the Hand-check procedure: Check if the pressure is properly adjusted by sliding one hand between the air mattress and the foam base to feel the patient's buttock. Users should be able to feel the space in between, and the acceptable range is 25 to 40 mm (millimeters). This hand check procedure is issued by AHCPR (Agency for Health Care Policy and Research). The facility's policy, Pressure Ulcer Prevention, revised [DATE], reads: 1. Pressure ulcer risk assessments are completed for each resident on admission and weekly for three weeks after the admission utilizing the Braden Scale. 2. After the initial assessments, pressure ulcer risks will be assessed quarterly, annually and for a significant change if needed. 9. Each resident will have a pressure reducing mattress. If nursing or therapy assess that a resident is at greater risk when he/she is in bed, the mattress will be upgraded to an alternating pressure mattress.