Every finding on record at Advanced Rehabilitation & Healthcare of Live Oak

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 facilities reviewed for physical environment.The facility failed to ensure there was adequate working equipment to supply linens and clothing when 1 of the 2 washing machines were not working and the working one was leaking. These failures could place residents at risk of not receiving clean clothing, and linens, and a reduced linen supply that could delay needed care and services making residents uncomfortable and frustrated. Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 facilities, reviewed for physical environment.The facility failed to ensure there was adequate working equipment to supply linens and clothing when 1 of the 2 washing machines were not working and the working one was leaking.This failure could place residents at risk of not receiving clean clothing, and linens, and contribute to a reduced linen supply that could delay needed care and services making residents uncomfortable and frustrated.The findings were:Record review of the resident council minutes revealed a meeting dated 2/10/26 under old business under the laundry section was, 1. Residents reported laundry is not being picked up from their room. Record review of resident council minutes from 1/13/26 did not reveal this listed under old or new business.Record review on 7/17/26 at 4:40 p.m. of 2 washing machine quotes provided by the MD revealed 1 quote dated 6/23/26 and another quote dated 6/25/26.In an observation on 7/14/26 at 2:50 p.m. the linen closet for the north wing was observed to have 11 fitted sheets, 1 flat sheet, 6 pillowcases, 10 towels, 10 washcloths, and no blankets. In an observation on 7/16/26 at 12:09 p.m. the linen closet for the north wing was observed to have 6 fitted sheets, 11 flat sheets, numerous pillowcases, 2 towels, multiple washcloths, and one blanket.In an observation on 7/16/26 at 12:18 p.m. the linen closet for the south wing was observed to have 1 fitted sheet, 1 flat sheet, no towels, no washcloths, multiple pillowcases, 2 blankets, and 2 drawsheets.In an observation and interview on 7/16/26 at 12:20 p.m. the HKS stated they had a 3rd linen closet and showed surveyors a small closet stacked with boxes labeled as different linens. 2 boxes labeled as 10 dozen washcloths were completely empty and 1 unopened box of 10 dozen washcloths was observed. Some boxes were opened and missing items but there were boxes of fitted sheets, flat sheets, towels, pillowcases, and draw sheets. The HKS stated that anyone could get linens if they needed them and that he had a key and the Administrator and not sure who else but that linens were not being saved and staff just need to tell the nurse or Administration they needed linen and if they were not in the linen closets they would get them from this closet.In an observation and interview on 7/16/26 at 12:30 pm the laundry room was observed and 1 washing machine was not working; soiled linens were piled approximately 1 foot out of the top of a large blue container (approximately 2 feet wide by 3 feet long by 3 feet deep) on wheels. All 3 dryers were working and only 1 had linen in it. The HKS stated the other washer was broken for 2 to 4 months, and another washer was being ordered. The HKS then stated it was likely the washer had been broken for 4 months and not two.In an observation and interview on 7/17/26 at 4:20 p.m. in the laundry room, 1 of 2 washers remained not working, and the working washer had linen in it and a blanket on the floor in front of it that was wet. There were two soiled linen containers on wheels, both were approximately 2 feet wide X 3 feet long X 3 feet deep and soiled clothing and linens were piled approximately 1 foot high out of the first container. There were 9 large bags of soiled linens, clothing, mechanical lift slings, and foam wedges piled in this area and 2 resident laundry hampers that were full of clothing. The laundry staff present stated only 1 washer worked and she was mostly Spanish speaking. The HKS stated the laundry staff had only been working for a couple of weeks. The HKS stated the blanket on the floor in front of the washer that was running was due to the washer leaking and maintenance was aware and had ordered the part to fix it. The HKS stated the 1 washer that worked was able to keep up with the facility demand for the 118 residents residing at the facility.In an anonymous family member interview, they stated the facility had been without sheets or towels at different times recently and that their family member had been on a draw sheet blanket as a sheet and even towels when there were no sheets available. The family member stated an anonymous resident had also been told there were no washcloths when they were supposed to receive a shower, but they were uncertain what ended up happening with that situation.In anonymous resident interviews, it was confirmed that they sometimes had no sheets for their beds, towels or washcloths for showers, or pillowcases for their pillows. In anonymous interviews on undisclosed dates at undisclosed times, some residents stated they did not want their names attached to any citations as they feared retaliation and could possibly make someone mad and might be kicked out of the facility. The residents refused to state who exactly they feared retaliation from or answer any questions related to how the environment, cleanliness, laundry, or other services affected them and one resident stated, If I tell you, and you turn it in, they will know who said it.In an interview on 7/17/26 at 4:05 p.m. the Administrator stated they had 2 quotes for a new washing machine and was in process, and that nursing was not having an issue with linens. The Administrator further stated there was no way they were short of linens and the washing machine had only been broken for a few weeks. The Administrator stated the facility did not have an issue with laundry, and the one machine was handling the facility's needs. In an interview on 7/17/26 at 4:40 p.m. the MD stated the washing machine had not been broken for a long time, maybe 2 months, and another 2 months when it was not running right. The MD stated the washing machine would break down, and he would fix it and it would work for a while and then break down again. The MD stated once he was not able to fix it, he notified the Administrator and she began the process of ordering the new washing machine. The MD stated the washing machine that was leaking was a small leak and stated it was a small part he was waiting on and it would be fixed. Review of the facility maintenance policy revised December 2009 indicated, Maintenance service shall be provided to all areas of the buildings, grounds, and equipment in a safe operable manner at all times. Functions for maintenance personnel include but are not limited to: a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. f. establishing priorities in providing repair service.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: The facility failed to store a bag of sausage patties in the walk-in cooler.The facility failed to store a head of lettuce in the walk-in cooler.Cook E failed to remove jewelry on the wrists while preparing food in the kitchen.The DM failed to ensure the thermostat on the dishwasher was in working condition.Cook E failed to ensure the soup bowls were covered and protected from any debris during the cooling off period.Cook E failed to ensure proper hand hygiene during plating of a lunch meal.Dietary Staff failed to ensure the holding temperatures of the food maintained 135 degrees while being distributed to resident rooms.These failures could place residents who received meals and/or snacks from the kitchen at risk for food-borne illness. During observations on 07/14/2026 at 9:03 AM in the kitchen, the [NAME] E, had bracelets on his left wrist and a ring on his fourth finger. The Dietary Aide had a watch on her left wrist. Observations in the walk-in cooler revealed an opened bag of sausage patties in a box that was dated, and a head of lettuce without a bag was placed on top of a box. During an observation in the kitchen on 7/14/2026 at 9:03AM the [NAME] wore 2 bracelets on his left wrist and DA I wore a white watch on her left wrist while they handled food for the breakfast meal. The DM stated they should not wear jewelry. During an observation and interview on 7/14/2026 at 9:10 AM the walk-in cooler, had an open bag of sausage patties in a box. The DM said it should have been closed. Observed a head of lettuce that sat on a box without a bag and the DM let out a sigh and said that should not be there. During an interview on 7/17/2026 at 4:50PM the DM- Interim said it was important for the dietary staff not to wear jewelry because it could come off or pieces of it could come off in the food that could cause a resident to choke. The DM- Interim said wearing jewelry could cause sweating and it could drip in the food causing cross contamination that could lead to food-borne illness for the residents. The facility did not have a specific policy for wearing jewelry and food safety, however an in-service titled, Why Jewelry Is a Food Safey Concern no date, stated Jewelry can harbor bacteria, dirt, and other contaminants that are difficult to remove during handwashing; Fall into food; Interfere with proper hand hygiene and glove use. Jewelry Guidelines stated: Do not wear bracelets, watches, or fitness trackers during food preparation, Staff Responsibilities stated: Every employee is responsible for following the facility's jewelry policy and Maintaining good personal hygiene to protect residents. 4. Observation and interview on 7/16/26 at 11:25 AM during a kitchen tour with DA D and the DM, revealed the sanitation in the dishwasher should measure 100 PPM. DA D ran the dishwasher and tested the sanitization level with a test strip. She stated it read between 50 and 100 PPM. Observation revealed the plastic cover on the thermostat was cloudy and the temperature reading was not clear. The needle on the thermostat did not move when the dishwasher was running and when the cycle ended. DA D stated she noticed the plastic covering on the thermostat was cloudy and she could not read the temperature clearly, but did not notice the needle was not moving. The DM stated she returned to work on 7/15/26 and did not know the thermostat was not working. Observation and Interview on 7/16/26 at 11:45 AM with the MD revealed the thermostat on the dishwasher was not working. He stated the needle on the thermostat did not move when he ran a cycle. He stated the plastic cover was cloudy making it difficult to read the temperature but again stated he was able to see the needle did not move. He stated It stayed in the same position while the dishwasher was running and when the cycle ended. The MD stated he did not know the thermostat was not functional. 5. Observation and interview on 7/16/26 at 11:36 AM revealed 9 individual bowls of chicken soup and 4 puree bowls of chicken soup placed on a prep table underneath the microwave. The soup bowls were not covered and behind the prep table was a trash barrel about 3 1/2 feet away. It had a lid with an opening in the middle. The barrel was completely full and there was trash was lying on top of the lid. Interview with [NAME] E stated he prepared the chicken noodle soup and placed them on the prep table at about 11:10/11:15 AM. He stated he was letting the soup cool off and then would heat them up in the microwave when ready to serve. He stated he did not cover them, and it was not something he usually did while preparing the food. [NAME] E stated he had not thought about it but debris in the air could fall into the soup. 6. Observation on 7/16/26 at 12:16 PM revealed [NAME] E plating the food for the lunch meal which included spaghetti, meat sauce, green beans and one garlic roll. He put gloves on both hands. Observation revealed [NAME] E used his left hand while holding a plate and positioned his fingers on the inside of the plate. [NAME] E served a portion of spaghetti on the plate and then poured a portion of meat sauce on top of the spaghetti with his right hand. He put the plate down on the prep table. [NAME] E then moved a menu ticket closer to him with his left hand and was reading the menu ticket. He picked the plate back up with his left hand placing his fingers inside the rim of the plate and added a portion of green beans and a garlic roll on the plate. He removed the gloves, discarded them in the trash barrel and put on another set of gloves on his hands. He did not wash his hands. Observation on 7/16/26 at 12:19 [NAME] E prepared 2 more lunch plates in the same manner as he did with the previous plate, placing his left fingers inside the rim of the plates. Observation on 7/16/26 at 12:22 PM [NAME] E removed the gloves, washed his hands and put on another clean pair of gloves on his hands. 7. Observation and interview on 7/16/26 revealed the Interim DM taking food temperature of a sample test tray on the 600 hall cart. The spaghetti was 118 degrees, the meat sauce was 120 degrees and the green beans were 135 degrees. Further observation revealed the Interim DM took readings of the sample test tray on the 700 hall. The spaghetti and meat sauce was 119 degrees and the green beans were 115 degrees. Interview with Interim DM stated the holding temperatures should be 135 degrees to ensure plated food did not start developing bacteria which could result in food-borne illness. The Interim DM stated it could make the residents sick. Interview on 7/17/26 at 3:45 PM with the DM revealed she was extended leave and there was an interim-DM in her place. She stated the interim DM reported the thermostat was checked daily and told her that it had been working. The DM stated as seen, the thermostat on the dishwasher was not working, and this would affect the dishwasher temperature reading. She stated it was important the temperature was 120 degrees and the sanitation level was 100 PPM to ensure it killed any bacteria on the dishware. The DM stated that any prepared food waiting to be served (outside the steam table) should be covered to prevent debris from falling into the food. She stated that touching the inside of the plate with the same gloves after handling a menu ticket could contaminate the food. The DM stated the menu ticket was handled by multiple staff and was considered dirty. The DM stated the holding temperatures should reach 135 degrees to prevent the growth of bacteria. She stated that all of these factors could result in the transmission of foodborne illness, and the residents could get sick. Review of facility policy, Food Safety and Sanitation Plan dated 11/15/2017 read It is the policy of this facility to follow effective, proactive food safety program that is based on preventing food safety hazards before they occur. The Hazard Analysis Critical Control Point (HAACCP) Plan is an example of such a program. HACCP is not an exact science but rather tool for creating a better understanding and awareness of the potential for foodborne bacterial contamination of food and how to best control this in a food service operation. Nursing home residents risk serious complication from foodborne illness as a result of their compromised health status. Unsafe food handling practices present a potential source of pathogen exposure for residents. Sanitary condition must be present in health care food service settings to promote safe food handling. 3. Protected During Storage Store raw meat (e.g. beef, pork, lamb, poultry, and seafood) separately and in drip-proof containers and in a manner that prevents cross-contamination of other foods in the refrigerator. Procedure 11. All foods kept in a hot-holding unit must be maintained at 135 degrees or above. 15. Food Handling: Food service employees will minimize bare hand contact with food that is read-to-eat. Review of facility policy, Senior Life+Dining Services Policy and Procedure Manual signed by the Administrator, Culinary Services Director and Regional Manager, dated 6/16/26, read Equipment. Action Steps. 1. The Dining Services Director will ensure that all equipment is routinely cleaned and maintained in accordance to manufacturer directions and training materials. 5. The Dining Services Director will submit requests for maintenance of repair to the Administrator and/or Maintenance Director as needed

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Residents #134) and 3 of 3 resident rooms (rooms #409, 110, 111) reviewed for infection control. 1. Nursing staff failed to properly store a resident's back brace in the resident's closet and discarded a urinated brief in the trashcan in room [ROOM NUMBER]. 2. The facility staff did not wear PPE per the EBP guidelines when providing urinary catheter care for Resident #134.3. room [ROOM NUMBER]'s bathroom shower seat was dirty and had brown and white discolorations.4. room [ROOM NUMBER]'s bathroom shower curtain had mold for approximately 5 inches from the bottom along the entire bottom of the curtain. These failures could place the residents at risk of cross contamination, infection, and illnesses. Observation on 7/14/26 at 2:55 PM in room [ROOM NUMBER] revealed what looked like a back brace placed on the floor by the closet. The closet was positioned along the wall in front of the footboard away from bed b. Observation upon exiting the room revealed a trashcan in the corner of the room by the door. In the trashcan was a soiled brief with urine. Interview on 7/14/26 at 3:04 PM with LVN J revealed she observed the back brace on the floor and the soiled brief with urine in the trashcan in room [ROOM NUMBER]. She stated she was not sure of the name of the device on the floor but stated it should be in the resident's closet and not on the floor. LVN J stated the resident in bed b was dependent on staff for all ADL's and not able to get out of bed on his own. She stated it was unlikely the resident placed the device on the floor. LVN J stated the dirty brief should be discarded in one of the trash barrels in the facility utility room. LVN J stated nursing staff should not place a resident's device on the floor or discard a dirty brief in a resident's room. She stated both examples were a concern related to infection control. She stated the items could spread bacteria, diseases and result in an infection. She stated nursing staff should keep the resident's room clean. 3. Record review of Resident #134's Face sheet, dated 7/17/26, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness and loss of strength on the right side of the body after a stroke), and wedge compression fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing (The front part of the first lumbar vertebra breaks and collapses under pressure into a wedge shape and is healing without major complications). Record review of Resident #134's admission MDS assessment, dated 7/14/26, was in process and the BIMS was not documented yet and the resident had urinary incontinence and an indwelling catheter. Record review of Resident #134's undated care plan revealed a focus initiated on 7/13/26 for EBP related to indwelling urinary catheter with a goal to remain free from infection. The intervention was for direct care staff to follow EBP. In an observation on 7/16/26 at 4:50 p.m. catheter care was completed by CNA B and CNA G for Resident #134. An EBP sign was on the resident's room door and PPE was inside the resident's room. CNA B and CNA G completed catheter care for the resident without donning gowns required for EBP. In a joint interview on 7/16/26 at 5:15 p.m. with CNA B and CNA G, CNA G stated they should have worn a gown per the EBP guidelines and CNA G stated it just slipped her mind and stated the possible consequences could be an infection control issue. CNA B stated they should have worn a gown per the EBP guidelines and she forgot to put it on. Both CNA B and CNA G stated they normally wear PPE and were able to state the presence of an indwelling urinary catheter required EBP to be followed. In an interview on 7/17/26 at 3:47 p.m., the DON stated the staff should have worn PPE per the EBP during Resident #134's catheter care. The DON stated it protected the residents and staff so they do not spread anything. 3. In an observation on 7/16/26 at 12:04 p.m. in room [ROOM NUMBER]'s bathroom shower, the shower seat had a triple section seat bottom and was gray in color and textured. The left and middle sections of the seat had brown discolorations on the seat bottom and the edges of the seat in the creases. The right-side section had white discolorations and peeling on the edge of a layer of something unknown. In an observation and interview on 7/16/26 at 12:24 p.m. in room [ROOM NUMBER]'s bathroom, the MD stated the shower seat should not look like that and he was unsure who cleaned them but would notify staff. 4. In an observation on 7/16/26 at 12:00 p.m. the shower curtain in room [ROOM NUMBER]'s bathroom had black spot stains from the bottom of the curtain along the entire length of the curtain from the bottom to approximately 5 inches high and up to approximately 8 inches high in certain areas. In an observation and interview on 7/16/26 at 12:23 p.m. in room [ROOM NUMBER]'s bathroom, the MD stated the shower curtain should not look like that and he would get it replaced immediately. The MD stated he was unsure of who was in charge of cleaning the shower curtains, but it was not on his list of items and stated again it would be replaced immediately. In anonymous interviews on undisclosed dates at undisclosed times, some residents stated they did not want their names attached to any citations as they feared retaliation and could possibly make someone mad and might be kicked out of the facility. The residents refused to state who exactly they feared retaliation from or answer any questions related to how the environment, cleanliness, laundry, or other services affected them and one resident stated, If I tell you, and you turn it in, they will know who said it. In an interview on 7/17/26 at 4:05 p.m. the Administrator stated the shower curtains were nursing's responsibility. Review of the facility infection control policy, revised 4/12/25, indicated, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.2. All staff are responsible for following all policies and procedures related to the program.c. All staff shall use Personal Protective Equipment (PPE) according to established facility policy.e. environmental cleaning and disinfection is performed routinely with high touch cleaning procedures. F. All staff have responsibilities related to report cleanliness issues in the facility to the Administrator/designee and housekeeping. Review of the facility policy titled, Enhance Barrier Precautions, dated 2001, indicated, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities.3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include. g. device care or use (central line, urinary catheter. 5. EBP's are indicated (when contact precautions do not otherwise apply) for residents with wounds and or indwelling medical devices regardless of MDRO colonization.

Based on observation, interview and record review the facility failed to ensure a safe, clean, comfortable and homelike environment, for 3 of 8 Residents (Resident #61, #77, #118) and 4 resident bathrooms (rooms 110, 111, 112, 113) reviewed for the environment. 1. Nursing staff failed to make Resident #61's bed on 7/15/26. 2. The shower in rooms #202 (Resident #77) and #306 (Resident #118) were left soiled with stool and debris on the floor. 3. The bathroom vents in rooms 110, 111, 112, and 113 had a thick fuzzy layer approximately 1/4 inch thick of debris/dust. These deficient practices could place residents at risk of not having a clean, homelike environment, and could cause anxiety, feelings they do not matter, and a decreased quality of life.Record review of Resident #118's face sheet dated 7/17/2026 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included; spastic quadriplegic Cerebral Palsy, seizures, history of falls. Record review of Resident #118's Care Plan dated 6/12/2026 revealed the resident was care planned for full code, mobile with electric wheelchair, risk for falls related to spastic quadriplegic Cerebral Palsy, epilepsy, and seizure disorder. Record review of Resident #118's comprehensive MDS dated [DATE] revealed the resident had a BIMS score of 13, cognitively in tact. Further review revealed she required minimum to maximum assist with ADLs. Record review of Resident #77's face sheet dated 7/17/2026 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Parkinsonism, major depressive disorder, schizophrenia, and anxiety. Record review of Resident #77's Care Plan dated 6/4/2026 revealed the resident was care planned for dementia, delirium due to disorganized thought process, and resistant to care. Record review of Resident #77's quarterly MDS dated [DATE] revealed a BIMS score was not obtained due to severe cognitive impairment. Further review revealed she required total assistance with all ADLs. During an observation on 7/16/2026 at 12:27 PM Resident #118's shower had an orange body puff for bathing, a broken string from the emergency call light near the toilet, and hair. Next to the toilet was a broken string from the emergency call light but it would not affect the use of the light. There was a raised toilet seat over the toilet. During an observation on 7/16/2026 at 12:31PM Resident #77's shower had no shower curtain, and feces was left on the shower floor. During an interview on 7/16/2026 at 1:16 PM Resident #118 was in the hallway in her electric wheelchair and went to a quiet area for privacy. She was shown the picture of the shower in her room. Resident #118 said sometimes it bothered her when the staff did not clean her shower and the toilet seat. The resident asked for her RP to be called as well. During an interview on 7/16/2026 at 2:45PM CNA H said the shower should be cleaned after they give a resident a shower. She said it was the CNA's responsibility to clean the shower. She said the shower should be cleaned for infection control. During an interview on 7/17/2026 at 11:42 AM the RP for Resident #118 said he found the bathroom less than desirable at times. The RP said there would be things on the floor like a pull up and gloves. The RP said another family member requested a garbage bag, but staff picked up the trash off the floor and removed it from the room. During an interview on 7/17/2026 at 3:59PM the RP for Resident #77 said he had seen the resident's bathroom dirty or trash not picked up. The RP said he noticed they put up a shower curtain because there was none for the duration of her admission. During an interview on 7/17/2026 at 5:07PM ADON A shrugged her arms and said there would be no harm for feces to be left on the shower floor after a shower was given to a resident. She shook her head and shrugged her shoulders again and said, If the shower got cleaned before the next shower and shook her head and shrugged her shoulders. 3. Observations on 7/16/26 from 12:00 p.m. to 12:07 p.m. revealed the bathrooms of rooms 110, 111, 112, and 113 all had an approximate 1/4 inch thick fuzzy layer of dust and debris on the ceiling vents. In the bed areas of these rooms the vents were observed to be clean. In an observation and interview on 7/16/23 at 12:23 p.m. the MD stated they would clean the vents immediately and they should not look like that and must have been missed. The MD got another maintenance worker and he was observed going room to room with a broom cleaning the vents in the bathrooms. The MD stated they would be checking all the bathroom vents in the facility as well. The MD did not state how often the ceiling vents were cleaned. In attempted interviews on 7/16/26 and 7/17/26 at undisclosed times, some residents stated they did not want their names attached to any citations as they feared retaliation and could possibly make someone mad and might be kicked out of the facility. The residents refused to state who exactly they feared retaliation from or answer any questions related to how the environment, cleanliness, laundry, or other services affected them and one resident stated, If I tell you, and you turn it in, they will know who said it. In an interview on 7/17/26 at 4:40 p.m. the MD stated the vents were cleaned monthly and staff just missed those vents in the bathrooms, but they had since been cleaned and all other vents had been checked and there were no issues. In an interview on 7/17/26 at 4:05 p.m. the Administrator stated the vents were cleaned regularly. The Administrator stated she did not believe retaliation was brought up by the residents. Review of facility policy, Home like Environment, dated 4/24/25, read This policy aims to provide comprehensive framework for creating and maintaining a homelike environment in long-term care facilities. A homelike environment is essential for promoting the comfort, dignity, and quality of life of residents. This policy outlines the principles, guidelines, and practices that should be implemented to achieve this goal. Principles: 1. Respect for Individual Preferences. Recognize and honor the personal preferences and choices of each resident, including their daily routines, activities, and living arrangements. Review of the facility maintenance policy revised December 2009 indicated Maintenance service shall be provided to all areas of the buildings, grounds, and equipment in a safe operable manner at all times. Functions for maintenance personnel include but are not limited to : . d. maintaining the heat/cooling system. in good working order. Review of Resident #61's face sheet, dated 6/17/26, revealed she was admitted to the facility on [DATE] with diagnoses including hemiplegia (complete or near-complete paralysis on one side) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (Thrombotic stroke happens when a clot forms in a blood vessel in your brain and blocks it) affecting right dominant side and unspecified abnormalities of gait and mobility (experiences unusual gait or movement issues without a clearly identified cause). Review of Resident #61's quarterly MDS, dated [DATE], revealed her BIMS score was 15 of 15 reflective of being cognitively intact. Resident #61 did not have a mood disturbance or behaviors towards others. Observation and interview on 07/15/2026 12:25 PM revealed Resident #61's bed was not made. The linens were bundled and lying on top of the bed. Interview with Resident #61 revealed she took a shower on 7/14/26 and staff usually changed her linens at that time. She stated staff did not change her linens. She stated sometimes she had to wait for staff to change linens because staff would tell her there was no clean linen available. Resident #61 stated she was up for breakfast and liked her bed made first thing in the morning. She stated she wanted her room to be neat and made up because you never know who will come in. Observation and interview on 7/15/26 at 1:00 PM revealed Resident #61's bed had still not been made. CNA B stated Resident #61's bed was not made. She stated they usually made a resident's bed once the resident was up and out of bed. CNA B stated some of the residents like Resident #61 like their bed made up right away and stated it was their right. CNA B stated it was the CNAs responsibility to ensure they maintained a resident's room neat and clean. She stated not doing so could result in residents' dissatisfaction. Interview on 7/17/26 at 1:35 PM with LVN J. revealed CNA's should make up a resident's bed as soon as they transferred the resident out of bed. She stated this was part of keeping the resident's room neat and clean. LVN J. stated a resident might not be happy and or satisfied if the assigned CNA did not make up their bed especially if it was important to the resident; it was a matter of maintaining their dignity. 07/17/2026 1:47 PM Int with CNA K. revealed she helped Resident #61 out of bed about 11:30 AM today. She stated she sanitized the bed and was going to make it up when it dried, but got busy with passing out lunch trays, feeding residents and then picking up lunch trays. CNA K stated she was going to make it before she left for the day at 2:00 PM. She stated she always made Resident #61's bed and did not make it because she was distracted with other tasks. Review of facility policy, Home like Environment, dated 4/24/25, read This policy aims to provide comprehensive framework for creating and maintaining a homelike environment in long-term care facilities. A homelike environment is essential for promoting the comfort, dignity, and quality of life of residents. This policy outlines the principals, guidelines, and practices that should be implemented to achieve this goal. Principles: 1. Respect for Individual Preferences. Recognize and honor the personal preferences and choices of each resident, including their daily routines, activities, and living arrangements.

Based on observation, interview, and record review, the facility failed to ensure the residents right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 6 residents (Residents #28, #37) reviewed for resident rights. The facility failed to ensure Residents #28 and #37's call lights were in reach when they were sitting in wheelchairs in their rooms. This failure could place residents at risk of not being able to call for assistance when they need it, delays in care and assessment, and meeting the residents needs. Record review of Resident #28's face sheet dated 7/16/2026 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included a break at the base of her neck without separation, cardiac pacemaker, dementia, and anxiety. Record review of Resident 28's Care Plan dated 7/3/2026 revealed the resident was care planned for falls and with an intervention for the call light to be within reach. Record review of Resident #28's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 3, indicative of severe cognitive deficits. Further review revealed she required minimum to maximum assistance with ADLs, and a pacemaker. During an observation and interview on 07/14/2026 at 10:27, AM Resident #28 sat in her wheelchair in her room next to her bed with facial discolorations, four steri-strips(adhesive medical tape) on the bridge of her nose, a C-collar (cervical collar), and she spoke softly. The resident said she fell at home and she had a little pain. Resident #28's call light was attached to the other side of the bed on the blanket, out of reach. The SW entered the room when informed of the call light and placed it within the resident's reach. The SW stated, oh, let me get that right away because she needs that near her. During an interview on 7/17/2026 at 1:45PM the DON said it was important for the residents' call lights to be within reach to ensure the safety of the residents, to prevent them from falls and injuries. She said it was the responsibility of any staff that had contact with a resident to ensure the call lights were within reach. Facility policy dated 1/1/2024 titled: Call Light- Use Of stated in part 12. Be sure call lights are placed near the resident. The findings were: Record review of Resident #37's face sheet dated 7/17/26 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnoses included senile degeneration of the brain not elsewhere classified (neurological diagnosis describing age-related diffuse cerebral atrophy or cognitive decline on imaging, without specific underlying causes), cognitive communication deficit (impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving), lack of coordination (refers to problems with movement, balance, or the ability to perform smooth, controlled motions), muscle weakness (weakness of the muscles), and unsteadiness on feet ( difficulty maintaining balance while standing or walking, leading to an unstable or uncoordinated gait). Record review of Resident #37's quarterly MDS assessment dated [DATE] indicated the resident had clear speech, moderate difficulty hearing, was usually understood by others, and usually understands others. The resident had a BIMS score of 11 out of 15 indicating the resident was moderately cognitively impaired. The resident had functional range of motion limitations to both upper and lower extremities. The resident required substantial/maximal assistance - helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for toileting, and transfers. The resident required supervision or touching assistance to wheel 50feet, and partial/moderate assistance to wheel 150 feet. and the resident was frequently incontinent of bowel and bladder. Record review of Resident #37's undated care plan revealed a focus initiated on 1/19/22 and revised on 6/24/26 for falls related to her diagnoses that included lack of coordination, pain, and muscle weakness and indicated the resident was a high fall risk. Interventions included placing the resident's call light within reach and encouraging the resident to use it for assistance as needed. In an observation and interview on 7/14/26 at 10:30 a.m., Resident #37 was in the bathroom and family members were present in the room. There was a small card table that had an unfinished puzzle on it. An anonymous family member stated the resident had been assisted to the bathroom by staff and the only concern they had was that staff sometimes forget to put the call light in reach when the resident is sitting at her table working on her puzzle. The family member stated the staff just forget to put the call light in reach sometimes and that they worry the resident will fall. In an observation and interview on 7/17/26 at 1:37 p.m., Resident #37 was sitting in her wheelchair at the small table in her room working on her puzzle. The call light was attached to the resident's bed approximately 6 feet away and not within the resident's reach. The resident was being interviewed on something unrelated to the call light. The resident looked around her immediate area and then at the call light on the bedrail when the surveyor mentioned the call light but did not respond. In an observation and interview on 7/17/26 at 2:50 p.m. Resident #37 was no longer in her room and was participating in a group activity. The call light remained attached to the resident's bedrail in the same position as the observation at 1:37 p.m. LVN F stated when the resident was up in her chair at her table the call light should be closer to her and stated it is normally placed on the table or her chair.

Based on observation, interview and record review the facility failed to ensure that residents received proper treatment and care to maintain good foot health in accordance with professional standards of practice for 1 of 8 residents (Resident #1) reviewed for foot care. Nursing staff failed to ensure they clipped Resident #1's toenails resulting in Resident #1's having cracked and long toenails past the nail bed. This deficient practice could place residents at risk for skin tears and infections. The findings were:Review of Resident #1's face sheet, dated 7/16/26, revealed he was admitted to the facility on [DATE] with diagnoses including age related physical debility and need for assistance with personal care. Review of Resident #1's quarterly MDS, dated [DATE], revealed his BIMS score was 12 of 15 reflective of moderate cognitive impairment. Resident #1 required partial to moderate assistance for personal hygiene. Review of Resident #1's Care Plan, dated 12/11/25, revealed he required partial to moderate assistance with personal hygiene. One of the interventions was for staff to assist with personal hygiene as needed. Observation and interview on 7/15/26 at 11:36 AM revealed Resident #1 was lying in bed. His toenails were long and passed the nail bed on both feet. The toenail by the left pinkie toe was cracked. Resident #1 stated his toenails were long and they needed to get cut. He stated he had mentioned to it to nursing staff but they had not cut his toenails. Observation and interview on 7/16/26 at 11:40 with LVN C revealed he started working at the facility about 1 month ago. He stated Resident #1 was alert with some confusion but could make his needs known. LVN C stated Resident #1 required assistance with personal care. He stated Resident #1's toenails were long, passed the nail bed and his left toenail by the pinkie toe was cracked. He stated he had not noticed Resident #1's toenails were long. He stated he was not sure if Resident #1 was Diabetic, but if he was not Diabetic, any of the nurses could cut his toenails. LVN C stated as a result the toenails could cause skin tears and the cracked toenail could become embedded and infected. Interview on 6/17/26 at 8:50 PM with ADON A revealed the nurses were able to cut a resident's toenails unless the resident was diabetic. She stated having cracked and long toenails could cause an ingrown toenail which could become infected. A policy related to foot care/podiatry care was requested and not provided by the end of the survey, 7/17/26.

Based on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as possible in 1 of 1 beauty shop and for 1 of 8 Residents (Resident #91) reviewed for accident hazards. Nursing staff failed to remove a bottle of body wash/shampoo and a razor from Resident #91's bedside table. The facility failed to ensure the beauty shop containing multiple bottles of poisonous, hazardous cleaning and beauty supplies were locked and not accessible to residents on 7/17/26. These deficient practices could result in serious bodily accidents and/ or death. The findings were: 1. Observation and interview on 7/17/26 at 7:42 PM revealed the beauty shop was unlocked. On the countertop of the armoire, there was a 32 oz bottle of shampoo and conditioner, 1 plastic bottle of alcohol and 1 plastic bottle of sanitizer also about 32 ounces. The alcohol bottle was about 1/4 full, and the bottle of sanitizer was almost full; both bottles had the name of the chemical written on the bottle. There was also a 33.8 oz bottle of color care and bottle of volume [NAME]. Observation in a cabinet underneath the countertop contained a gallon of bleach, 1 tub of sanitizer wipes and next to it was a 32 oz bottle of hydrating shampoo and hair volume. In another bottom cabinet there were 4 boxes of hair color. In a separate cabinet there were 4 aerosol aluminum bottles of hairspray and there were 2 32 oz bottles of color cleaner towards the back of the cabinet. Interview with the Corporate nurse revealed they did not have residents who wandered except in the secured unit. However, she stated that all of the cleaning and beauty chemicals would be hazardous to any resident who misused them and could jeopardize their health and safety. Interview at 7:55 PM with the ADM revealed the light in the beauty shop was always turned off when not in use and it was kept locked. The ADM asked if one of you had a staff member unlock the door. She commented she could not believe the door was left open. She then walked out of the beauty shop. 2.Review of Resident #91's face sheet, dated 7/17/26, revealed he was admitted to the facility on [DATE] with diagnoses including Hypertension (high blood pressure), depression (persistent feelings of sadness, loss of interest, and a range of emotional and physical problems) and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). Review of Resident #91's quarterly MDS, dated [DATE], revealed his BIMS score was 7 of 15, reflective of severe cognitive impairment and he required substantial assistance with most ADL's. Review of Resident #91's Care Plan, dated 12/11/25, revealed Resident #91 had a history of behaviors including becoming verbally and physically aggressive towards staff, he had a history of urinating into a milk carton and drinking it. The Care Plan also reflected Resident #91 would keep personal hygiene items on his bedside table. One of the interventions was to assess the Resident #91's ability to safely keep hygiene items on hand. Observation and interview on 7/14/26 at 1:44 PM revealed Resident #91 was lying in bed with the bedside table next to the bed. His bedside table was cluttered with personal items including a bottle of bodywash/shampoo that read keep out of reach of children. Resident #91 engaged in conversation; however, he presented as being nervous. It took him a few minutes to complete his thought process and provide answers to questions. Some of Resident #91 answers were flighty and did not relate to the question. Resident #91 presented as being alert to person and place with confusion. Observation and interview on 7/15/27 at 12:30 PM revealed Resident #91 was lying in bed with the bedside table next to the bed. His bedside table was cluttered with personal items including a bottle of bodywash/shampoo that read keep out of reach of children. There was also a razor inside a plastic bag on top of his nightstand. Interview with CNA B revealed Resident #91's space needed to get organized. She stated sometimes he would allow staff to assist and sometimes he did not want staff touching his belongings. CNA B stated Resident #91 should not have access to the bodywash/shampoo bottle and the razor because he could misuse the items. He could drink out of the bodywash/shampoo bottle and could cut himself with the razor if not careful. CNA B stated Resident #91 had behaviors and could be irrational. Interview on 7/16/26 at 4:33 PM with the DON, revealed Resident #91 had multiple behaviors. She stated Resident #91 was ok one minute then his mood would change drastically and would become upset when he did not get what he wanted. The DON stated she had known him to urinate into a milk carton, take a drink and then throw it at staff. The DON stated she was aware Resident #91 would keep hygiene items including bodywash/shampoo and a razor on his bedside table and per policy residents were not allowed to have such items accessible to them without supervision but stated Resident #91 had not had an issue to date. The DON stated Resident #91 knew what he was doing but also understood his BIMS score was 7. The DON stated drinking urine would question his ability to make safe decisions but believed his behaviors were attention seeking behaviors. Administrative staff was asked for a facility policy pertaining to ensuring the resident environment was free as possible of accident hazards. The policy was not provided by the end of the survey, 7/17/26.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 2 of 2 Residents (Resident #1 and Resident #93) reviewed for oxygen therapy. Nursing staff failed to ensure that Resident #1 received oxygen at 4 liters per minute per physician orders on 7/14/26 and 7/15/26. Nursing staff failed to ensure that Resident #93 received oxygen at 4 liters per minute per physician orders on 7/14/26. This deficient practice could place residents at risk of a decline in health status. The findings were: Record review of Resident #93's face sheet dated 4/17/2026 revealed an [AGE] year-old female admitted to the facility 3/5/2026 with diagnoses that included: COPD (Chronic Obstructive Pulmonary Disease-long term lung condition that damages the airway, causing difficulty to breath), dementia (significant decline in mental abilities), major depressive disorder (mental health condition with a persistent feeling of sadness, hopelessness, and loss of interest) , and hypertension (elevated blood pressure). Record review of Resident #93's Care Plan dated 3/5/2026 revealed the resident was care planned for fall risk, places self on the floor to pray, COPD, hospice (terminal illness COPD), and oxygen to be administered per physician's orders. Record review of #93's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 4, indicative of major cognitive disorder. Further review revealed she was coded as maximum assistance with all ADLs. Record review of Resident #93's order for oxygen dated 3/5/2026 revealed the setting for oxygen was to be set at 4 During an observation on 7/14/2026 at 10:24 AM, Resident #93 was in a low bed with a fall mat adjacent to the bed and the head of the bed was elevated at 85 degrees. She wore a nasal canula that delivered oxygen at 5 liters per minute with a concentrator. During an observation on 7/14/2026 at 11:13 AM, Resident #93 was in a low bed with a fall mat adjacent to the bed and the head of the bed was elevated at 85 degrees. She wore a nasal canula that delivered oxygen at 5 liters per minute with a concentrator. During an observation and interview on 07/15/2026 11:20 AM LVN C checked the oxygen concentrator's setting for Resident #93. The LVN checked the physicians' orders for the oxygen setting and said the order was for 4 liters. The LVN said it was his responsibility to ensure the setting for oxygen was correct. LVN C said not following the order could cause the resident to have too much oxygen that could cause toxicity (prolonged exposure to high levels of oxygen). During an interview on 7/16/2026 at 5:15 PM the DON said it was important to follow the physician's oxygen orders as prescribed because too much oxygen could cause oxygen toxicity( prolonged exposure to high levels of oxygen could become toxic to the resident) . The DON said it was the responsibility of the nurse assigned to a resident with oxygen to ensure everything about the concentrator was correct and that included the setting. The facility did not have a policy that reflected to follow the order of liters prescribed by the physician. 1.Review of Resident #1's face sheet, dated 7/17/26, revealed he was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypercapnia (occurs when the lungs cannot adequately remove carbon dioxide (CO2) from the blood, leading to elevated levels of CO2) and acute pulmonary edema (a sudden, life-threatening accumulation of fluid in the lungs that impairs oxygen exchange and requires immediate medical attention). Review of Resident #1's quarterly MDS assessment, dated 3/10/26, revealed his BIMS score was 12 of 15 reflective of moderate cognitive impairment, he required moderate to substantial assistance with most ADL's and he did not have behaviors. Resident #1 was receiving 02 therapy on a continuous basis. Review of Resident #1's Care Plan, dated 12/11/25, revealed Resident #1 required oxygen therapy related to acute respiratory failure with hypercapnia and one of the interventions included that Resident #1 should receive oxygen per physician orders. Review of Resident #1's physician orders for July 2026 revealed an order, dated 5/29/26, for oxygen at 4 LPM via N/C. Monitor O2 Saturation. Notify physician if SpO2 (peripheral oxygen saturation which is the percentage of oxygen carrying hemoglobin in your blood) falls below 90%, dated 5/29/26. Observation and interview on 7/14/2026 at 2:18 PM revealed Resident #1 was lying in bed receiving 02 at 5LPM via n/c. Resident #1 stated he received 02 because he could not breath. He stated he did not know why the setting was on 5LPM. Observation and interview on 7/15/26 at 11:36 AM revealed Resident #1 was lying in bed receiving oxygen at 2.5 LPM. He stated LVN L checked the machine earlier because it was making a loud sound. Observation and Interview on 7/15/26 at 11:45 AM revealed Resident #1 was lying in bed receiving oxygen at 2.5 LPM. LVN C stated LVN L replaced the concentrator earlier because it was alarming indicating some kind of malfunction. LVN C stated he was aware that Resident #1 required continuous 02 and believed he was receiving 2LPM. Upon reviewing Resident #1's physician orders he stated Resident #1 was actually supposed to receive 4 LPM. LVN C stated he reported for his shift about 5:45 AM and rounded on Resident #1 but did not check the setting on Resident #1's 02 concentrator. He stated he was supposed to check the concentrator for accurate setting. He stated it was important to ensure Resident #1 received oxygen per physician orders for his safety and to maintain good health. Interview on 7/16/26 at 4:29 PM with the DON revealed Resident #1 would change his 02 settings almost every day. He would change the settings to whatever he thought he needed. The DON stated nursing staff should round frequently on Resident #1 and check the 02 settings because he had the tendency to change the settings. The DON stated if the setting was a 5 LPM the resident could become over oxygenated; he would receive too much 02 and would not blow out enough carbon dioxide. She stated this could cause confusion as well as not receiving sufficient oxygen. She stated Resident #1's 02 level would drop. The DON stated she did not think Resident #1 was a high fall risk but receiving the wrong amount of oxygen could increase the chances of him falling.

Based on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) out of 4 residents reviewed for medical records. CNA-A documented inaccurately Resident #1's functional ability regarding the resident was able to walk 150 Feet on 05/06/2026 and 05/09/2026, but the resident could not walk 150 Feet. This failure could place residents at risk for missed treatments which could result in decline in healing and well-being. Findings included:Record review of Resident #1's face sheet, dated 07/01/2026, revealed the resident was a 62-years-old female and admitted to the facility on [DATE] with diagnosis of aftercare following surgery, abnormality of gait and mobility (feeling of balance when walking), and muscle weakness. The resident was discharged to the home on [DATE]. Record review of Resident #1's discharge MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident cognitive was intact, and in the Section GG (Functional Abilities), Walk 10 Feet was coded as 09 indicated Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. Record review of Resident #1's comprehensive care plan, dated 02/09/2026, revealed [Resident #1] has an Activities of Daily Living Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. For intervention - Walking - not attempted due to safety. Record review of Resident #1's Documentation Survey Report (Functional Abilities), dated May 2026, revealed CNA-A documented 05 - indicated Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity on 05/06/2026 and 05/09/2026. Interview on 07/01/2026 at 12:36 p.m., the DOR said Resident #1 was unable to walk, and the resident could stand up, turned, and sit down on the chair with a walker with assists but could not walk. Interview on 07/01/2026 at 2:45 p.m., CNA-A said she remembered Resident #1, and the resident was unable to walk. CNA-A stated she documented the resident completed walk 150 feet on 05/06/2026 and 05/09/2026, and it was her mistake because the resident could not walk, and inaccurate documentation might provide incorrect care to the resident. Interview on 07/01/2026 at 1:50 p.m., the DON said CNA-A documented Resident #1's ability for walking 150 feet as 05 - Helper sets up or cleans up; resident completes activity, and it was inaccurate because the resident was unable to walk. The DON said the medical records should be accurate. She said in this case the inaccurate documentation did not affect the resident because the resident could not walk, regardless of the inaccurate documentation. She said the medical record should have reflected the resident's status correctly. Record review of the facility policy, titled Maintenance of Clinical Records, dated 02/20/2021, revealed This facility will maintain clinical records for each resident in accordance with acceptable standards of practice that reflects the current plan of care and services provided as well as in a manageable size for use by the care providers.2. In accordance with accepted professional standards of practices, the facility must maintain medical records on each resident that are: a. Complete b. Accurately documented c. Readily accessible d. Systematically organized e. Maintained in folders or chart holders sufficient in size for the volume of the record f. Filed in an easily retrievable manner.

Based on observations, interviews, and record reviews, the facility failed to provide clean bed and bath linens that are in good condition for 5 of 8 residents (Resident #1, #2, #3, #4 and #5) reviewed for a safe, clean and comfortable environment The facility failed to ensure Residents #1, #2, #3, #4 and #5 had a fitted and top sheet on their bed for a dignified and comfortable experience in their own beds. This failure could place residents at risk for a decline in quality of life and feelings of frustration. The findings were:Record review of Resident #1 face sheet dated 5/14/2026 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses which included: cerebral infarction (stroke), memory deficit following cerebral infarction (memory problems after stroke), and generalized muscle weakness. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated he was cognitively intact, without symptoms of behaviors or rejections of care . Resident #1's functional abilities were listed as set-up/clean-up assistance for self-care and mobility. The assessment indicated Resident #1 was occasionally incontinent of bowel and bladder. Record review of Resident #1's Care Plan (undated) revealed he had a communication problem with interventions which included anticipate and meet needs. The Care Plan indicated Resident #1 had an ADL self-care performance deficit and required setup assistance for all ADLs and mobility. The Care Plan revealed Resident #1 had a behavior problem where he would strip his bed and then lay on the mattress with interventions to assess and anticipate resident needs. During an observation and interview on 5/14/2024 at 8:47 a.m., Resident #1 was observed fully clothed, including shoes, lying on his side on the bed with his face away from the door. There were no sheets on the bed. Resident #1 was lying directly on the mattress. A pile of sheets used sheets were observed on a chair in the room. Resident #1 stated he took the sheets off his bed but was unable to remember when this occurred or why he took the sheets off. He stated he would like sheets on his bed and would not want to lay on the bed all day without sheets. During an interview on 5/14/2026 at 10:25 a.m., CNA F stated Resident #1 had an accident every morning and took the sheets and blankets off his bed because he was embarrassed. CNA F stated when she arrived for her shift today at 6:00 a.m., Resident #1 had sheets on his bed. She stated she cleaned him up from the accident; he went to breakfast and then would come back and lay down in his bed after breakfast. She stated he had a little routine. CNA F stated she was unable to make his bed with clean linens until just now (at time of interview) because she had to wait for clean linens to come out from laundry. She stated this typically occurred around 9:30 a.m. CNA F stated there were somedays when she made her morning rounds with the residents at 6:00 a.m. that not everyone had sheets on their beds because there are not enough linens. CNA F stated the early morning time was a very active time in the building. She stated residents liked to get up early and shower and shave or had appointments or had therapy and needed to get ready early. She stated they had all just learned to work around the laundry, knowing the morning laundry would be out around 9:30 a.m. 2. Record review of Resident #2's face sheet dated 5/14/2026 revealed an [AGE] year-old female admitted on [DATE] with diagnoses which included: moderate dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (dementia), cardiomegaly (enlarged heart) and interstitial pulmonary disease (lung disease). Record review of Resident #2's admission MDS assessment dated [DATE] revealed a BIMS score of 5 which indicated a severe cognitive impairment. Behavior not directed toward others that occurred 1-3 days a week without impact to the resident or others and no rejections of care. The resident was dependent on staff for ADL care and mobility. Record review of Resident #2's Care Plan (undated) revealed she had a self-care performance deficit and was at risk of not having her needs met in a timely manner with interventions which included total dependence on staff for all ADL care and movement/mobility except eating, which required maximum assistance. The Care Plan also indicated Resident #2 was on hospice services for a terminal diagnosis for end-of-life care and the resident's dignity should be maintained and the residents should be kept comfortable. During an observation and interview on 5/14/2026 at 9:03 a.m. Resident #2 was observed with continuous oxygen, lying on her back in bed with her eyes closed. Her bed did not have any sheets on the contoured mattress. The resident had a folded blanket directly under her buttocks and lower torso, but her upper torso, arms and legs were directly on the uncovered mattress. She had a blanket covering her body. The resident opened her eyes when spoken to but was unable to answer any interview questions due to cognitive status. 3. Record review of Resident #3's face sheet dated 5/14/2026 revealed a [AGE] year-old female admitted [DATE] with diagnoses which included: atrial fibrillation (irregular heart rate pattern), unspecified dementia of unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (dementia), and insomnia. Record review of Resident #3's 5-day admission MDS assessment dated [DATE] revealed a BIMS score of 13 which indicated she was cognitively intact with no behaviors or rejection of care. The assessment indicated Resident #3 required maximal assistance with dressing and bathing, moderate assistance with personal hygiene and toileting, was non-ambulatory and required moderate assistance to transfer from bed to chair and standing. Record review of Resident #3's (undated) care plan revealed the resident needed max (maximum) assistance with dressing, bathing, and partial assistance with toileting, personal hygiene, and movement from bed. The Care Plan indicated Resident #3 was incontinent of bowel and bladder with interventions to ensure she was checked frequently for wetness and soiling and changed as needed. During an observation and interview on 5/14/2026 at 9:05 a.m. Resident #3 was observed sleeping in bed, with the head of the bed elevated to 45-degrees. The resident had a pillowcase on her pillow but there were no sheets on the bed. She had a white folded blanket under her buttocks and back, but her arms, legs and upper torso were lying directly on the uncovered mattress. She had a thin brown blanket covering her body. Resident #3 awoke when spoke to. She stated she was very upset about not having any sheets on her bed. She stated she had a bowel movement, and her sheets had been removed but not replaced. She was unable to remember what time this occurred or which staff provided care. She stated it was upsetting for her not to have the sheets replaced on her bed as she would be more comfortable with them on. During an observation and interview on 5/15/2026 at 8:05 a.m. Resident #3 was observed asleep in bed without a fitted sheet on the bed. The resident's torso was on a folded blanket, but her legs, arms and upper back were directly on the mattress. The pillow had a pillowcase. The resident was covered in two personal blankets. LVN J was at the bedside attempting to wake the resident for her medication and breakfast. The resident indicated by nodding that she wanted the staff member to come back later. During an interview on 5/15/2026 at 8:07 p.m., LVN J stated she noticed Resident #3 did not have sheets on her mattress. LVN J stated sometimes when day shift arrived, they would find residents without sheets on their beds from the night shift or it could also be from when day shift first arrived and did rounds, and they found the sheets to be wet or soiled from overnight and needed to be changed but no back up sheets were available. LVN J stated the CNAs were instructed to clean the resident, remove the soiled sheets and wait for laundry to come out while the resident was laid back down on the mattress waiting for laundry. LVN J stated it did not happen every day, it just depended on the day. She stated it was also not an all-day thing. She stated it mostly occurred in the morning before laundry had a chance to get laundry done and out to the floor. LVN J stated she would not want her own family member to be laid down on a mattress without sheets. 4. Record review of Resident #4's face sheet dated 5/14/2026 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness on one side of the body as a result of a stroke), mild dementia with behavioral disturbance, and type 2 diabetes mellitus with unspecified complications (dementia). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS of 8 which indicated a moderate cognitive impairment without behaviors or rejections of care. The assessment indicated Resident #4 was dependent on staff for toileting hygiene, required maximal assistance for showers, and lower body dressing, and required moderate assistance for personal hygiene. He was non-ambulatory, dependent on staff to go from sitting to standing and required maximal assistance with all other movement. Record review of Resident #4's Care Plan (undated) revealed the resident required extensive assistance from staff for ADL care. The Care Plan indicated Resident #4 was incontinent of bowel and bladder, related to activity intolerance, disease process, impaired mobility, inability to communicate needs, loss of peritoneal tone and physical limitation with interventions which included check frequently for wetness and soiling and change as needed. During an observation and interview on 5/14/2026 at 9:14 a.m., Resident #4 was observed seated in a wheelchair in his room fully dressed and groomed. There were no sheets on his bed. He stated he had sheets during the night, but when he woke up this morning someone took the sheets off and he doesn't know where they went. He stated he preferred sheets to lay down on but he was comfortable for now sitting in his wheelchair and did not want to lie down because he preferred to be up during the day. 5. Record review of Resident #5's face sheet dated 5/14/2026 revealed an [AGE] year-old female admitted on [DATE] with diagnoses which included: chronic respiratory failure with hypoxia (lung disease), adjustment insomnia (insomnia), and mild cognitive impairment of uncertain or unknown etiology (impaired cognition). Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 which indicated moderate cognitive impairment with no behaviors or rejections of care. The assessment revealed the resident required supervision with ADL care and movement. Record review of Resident #5's Care Plan (undated) revealed she required supervision with mobility, transfers, toileting and limited assistance with dressing and personal hygiene. During an observation and interview on 5/14/2026 at 9:32 a.m. Resident #5 was observed seated in her wheelchair watching TV. Her bed was stripped of sheets and blankets. She declined surveyor entry and interview at this time. During an observation and interview on 5/14/2026 at 4:40 p.m., Resident #5 was observed from the doorway seated in her wheelchair. Her bed was freshly made. She stated she did not have proper sheets on her bed this morning, but she did not know why. She stated, Sometimes they do that. She stated sometimes the staff would not bring clean sheets and they just lay her down on top of a folded-up blanket without a fitted sheet on the mattress. She stated it happened frequently. She stated it made her feel frustrated because it was not very comfortable. She stated she would prefer proper sheets. Resident #5 stated today, she was so uncomfortable that she had tried unfolding the blanket and spreading it out over the mattress, but it kept slipping off. She stated she got frustrated and eventually just threw it on the floor. She stated that was just the way it was here sometimes. During an interview on 5/14/2026 at 9:38 a.m. CNA A stated there were currently no sheets available for beds. She stated many residents on the 200 hallway including Residents #2. #3, #4, and #5 that did not have sheets on their beds. She stated the staff were waiting for laundry to come out for the day and restock. She stated this occurred approximately every other day. She stated she told her supervisors which were the nurses of the issues with not having enough linens to go around in the mornings. She stated she had gone to the laundry room herself in search of clean linen and was not able to get any. CNA A stated the nurses would also try to find clean linens for the residents, but it was the laundry who was responsible for providing them. CNA A stated most days clean laundry/linens arrived before lunch. During an observation and interview on 5/14/2026 at 9:42 a.m. with CNA A of the portable linen cart near the nurses' station for the 200-hallway revealed there were no sheets available. An observation of the linen closet on the south side of the building for part of the 100 hallway/200/300/400 hallways revealed the linen closet was completely empty and no linens were available in the closet. CNA A stated this linen closet supplied the entire south side of the building. During an interview on 5/14/2026 at 9:51 a.m. CNA B stated she worked at the facility for approximately one month. She stated there was a linen shortage or low linens the entire time. She stated when linen was delivered by laundry, she will grab what she can. She stated she was not sure what was causing the issue. She stated she had talked about it amongst her coworkers but not with any members of management. CNA B stated she had gone to laundry looking for clean linens and most of the time none were available. She stated she had been told by laundry personnel that the staff needed to wait until the linens came out onto the floor. She stated day shift linens usually arrive around 10 a.m. During an interview on 5/14/2026 at 9:55 a.m., LVN C stated the facility was having issues with enough linens. She stated the staff just had to wait for laundry to bring clean linens. She stated the CNA staff had been trying to put something under the resident, so they were not lying directly on the mattress, often a folded blanket. She stated the linen situation was a known issue and was discussed multiple times with multiple members of management. She stated the staff was told the management were ordering new linens. LVN C stated she instructed the CNA staff to remove any soiled linens and try to find something to put under the resident when linens were not available. She stated they had to have the residents clean while they waited for laundry service. During an observation and interview on 5/14/2026 at 10:00 a.m. of the facility laundry room, two people were present, identified as HK D and the HK Supervisor. The facility had two commercial washers and three commercial dryers all currently in use and operational. HK D declined to answer interview questions and deferred to the HK Supervisor. The HK Supervisor stated he worked for a contracted company and was not an employee of the facility. He stated the facility used the contracted company for their laundry services, for which he was in charge. He stated all laundry was done in house with the two washers and three dryers all of which he stated which were functioning normally. He stated the contracted company provided laundry services from 5:00 am - 7:00 p.m. He stated linens were supplied to the facility based on facility census which he monitored. He stated he kept cases of additional linens on premises which were locked up. He stated both he and the Maintenance Director had keys to the storage area. During an interview on 5/14/2026 at 10:11 a.m., CNA E stated all residents on the 400 hallway had linens on their bed when he arrived for his shift this morning. He stated he did not know what was causing the linen shortage. He stated he would go room-to-room looking for extra linens and would sometimes find an extra set in a closet. He stated he thought the staff were hiding linens because there was not enough to go around. CNA E stated if he found hidden linens would have to rewashed. CNA E stated he had discussed the linen shortage with the HK Supervisor and felt like the HK Supervisor watched the linens pretty well. During an observation and interview on 5/14/2027 at 2:47 p.m. CNA G was observed carrying a large clear bag overfilled with clean linens. She stated she was carrying the bag with clean linens because she worked the 2-10 pm shift. She stated when she first arrived for her shift, if there was linen, she gathered up what she would need for her residents so she would be able to get her work done. She stated she needed enough to take the residents to the bathrooms for showers and for linen changes. She stated if she does this because there were issues with having enough sheets for everyone and she wanted to make sure her residents were taken care of. She stated they would get one more delivery of linens from laundry around dinner and then that will be it until the next day. She stated she had not discussed the issue with management. During an observation and interview on 5/14/2026 at 4:31 p.m. of the laundry room, Contract Laundry Attendant H was observed seated in a chair beside the washing machines using her cell phone. Both washers were full of laundry items but neither washer was running. None of the dryers were in use and they were empty. She stated there were two people who worked in the laundry. The morning shift and she was afternoon shift. She stated she was the afternoon shift and was leaving at 5:00 p.m. During an observation on 5/14/2026 at 5:37 p.m. of the laundry room revealed the lights were out in the laundry room, both doors were locked. No one was observed through either glass door and no one answered knocking on either door. Through the windows, one of the washing machines could be observed and reflected laundry was still in the washer which was off and not in use. The second washer was unable to be observed through the window. All three dryers could be observed, and all were off and without any laundry in them. No extra linens were visible inside the laundry room or on any linen rack outside of the laundry room area. During an observation on 5/14/2026 5:40 p.m. both linen closets and portable linen carts were observed on both sides of the building. One linen closet held 7 fitted sheets, one flat sheet, one pillowcase, and 5 blankets The second linen closet had 9 fitted sheets, two flat sheets, no pillowcases, and 7 blankets for the evening and night shift. During an observation on 5/15/2026 at 8:00 a.m. of the laundry room revealed laundry personnel were present, and the washing machines were in use. An observation of the linen closets revealed: North side had one flat sheet. The south side had no bed linens. During an interview on 5/15/2026 at 1:30 p.m., the Social Worker stated they had received some verbal concerns about not having enough linen. She stated it was nothing significant enough to put on paper, it was just addressed in the moment, and laundry was located at that time. She stated there were no grievances about inadequate linens. She stated the facility had been down to one dryer and things were taking longer a while back, date unknown, but that had been resolved. She stated she did have one family member (unknown name) approach her and she told them the dryer was in the process of being fixed and there was no more concern. She stated she told the Administrator verbally at the time. The Social Worker stated the Administrator stated she would address it and follow up. She stated she had not had any complaints of laundry since the dryer was repaired (unknown date). During an interview on 5/15/2026 at 3:10 p.m. ADON K stated she was in charge of managing the residents on the 200/300/400 hallways to ensure they were getting the best care from the nurses and that they had the equipment they needed to provide care. She stated she monitored the residents by being out on the floor and being very involved with the staff. ADON K stated she thought linen was being thrown away which was prohibiting enough linens in the facility. She stated she instructed the CNAs to walk to the laundry room and ask the laundry tech for enough linens to provide care, during her shift from 7:30 a.m. to 3:00 or 4:00 p.m. She stated after her shift if the CNAs needed linen, they should tell the nurses. She stated after the laundry room closed, her hands were tied. She stated she did not know who had access to the laundry room after hours. She stated she did not have access, and her staff did not either. She stated she had not received any calls after hours or during the night telling her they had no linens. She stated if the staff were to call her, there was not much she could do. ADON K stated there were complaints by residents and their families, although she could not remember who. She stated she told the DON and other members of management. She stated the DON told her to tell staff to go to the laundry room. ADON K stated she had not discussed it with the Administrator. ADON K stated having adequate linens for bed changes was important for sanitary reasons and comfort. She stated she would not want her loved one laying directly on the mattress because it just would not be comfortable. During an interview on 5/15/2026 at 3:47 p.m., the DON stated she was not aware there were not enough bed sheets to go around. She stated she had some staff come to her about linens. She stated she told them to let laundry staff know and then go to laundry. She stated laundry would get the laundry out. The DON stated laundry services put laundry out before they left for the day so they should be stocked. She stated she was not sure when laundry left for the day. When asked how she monitors to ensure the residents have adequate amounts of linens to meet their needs, the DON stated the HK/Laundry Supervisor was good at communicating with her about it. The DON stated the Laundry Supervisor would send her pictures of the linen closet stocked. She stated the linen closets were stocked as needed by census. The DON stated if additional linens were needed the Laundry Supervisor would tell her he was opening an extra package. She stated she was not sure how the stocking of linens and billing worked with the contracted company. The DON stated she did not know if there was a certain number of sheets, or towels per residents. She stated she never counted and had never inquired about what census meant as far as quantity. The DON stated the contract HK Supervisor was on a department head daily chat and received a daily census. The DON stated she expected staff to notify management after hours if the laundry room was not open and there were inadequate sheets to meet the needs of the residents. She stated she had not received any grievances about laundry, and no family members had come to her with concern, and no residents had made any complaints. The DON stated having adequate linens was important so residents' beds were made and were clean. During an interview on 5/15/2026 at 4:15 p.m., the Administrator stated linens were supplied through a contract company. She stated the contracted company supplied services 7 days a week. She stated they supplied staff and supplies. The Administrator stated neither the Laundry Supervisor nor the attendants were employees of the facility. She stated she communicated with the Laundry Supervisor thru an app that included managers at least once per day. She stated the contract did not indicate hours. She stated laundry services were determined by PAR level. She stated if the facility goes under PAR for linens the Laundry Supervisor ordered linens. The Administrator stated if she saw he was going to go over budget then she ordered linens. She stated per contract she was back billed. She stated if she wanted more linen than the contract provided, she had to provide them. She stated she was unable to provide the numbers of PAR for sheets. When asked how she adjusted to meet the individual needs of each resident, the Administrator stated they use the same PAR level and if they see they need more, they order them and then she will have to pay more, but basically it changed according to the census. The Administrator stated the Laundry Supervisor was in charge of monitoring for adequate linen per shift, but also all management was responsible. The Administrator stated there were times when the Laundry Supervisor had to come to the facility to ensure adequate linens. She stated laundry services arrived for the day as early as 5 a.m. and stayed as late as 8:30 p.m. some days, but she had no idea when the laundry attendants came or left the facility because they did not clock in or out with her. The Administrator stated her expectation was for staff to change linen and get the residents cleaned up and then come to one of the members of management so they could address the issue if there were inadequate linens. The Administrator stated there was a linen closet on the 200 hallway with extra linens that was kept locked. She stated it was boxed linens. She stated she was unsure if the staff knew the linen was in that closet. She stated only staff with a master key would have access. The Administrator denied any complaints about laundry. The Administrator stated adequate lines were important for the dignity and comfort of the residents. Record review of the Laundry Contract titled Environmental and Linen Consulting and Materials and Supplies Procurement Agreement dated 1/07/2021 revealed: 1.1 Scope of WorkL a).[Contract Company] shall provide .linen operations at client's facility.and supervise and control the staff providing.linen services to the facilities.and procure and purchase the supplies and materials to perform.linen services at the facilities.1.2 Equipment.client [facility] shall make available in good working worder and condition.all laundry equipment.1.4 Linens: Decorative Linens: Client [facility] shall make available decorative lines.bedspreads, thermal blankets, bedspread.but excluding bed sheets, pillow cases.and bed pads. Non-Decorative Linens: Client [facility] will provide in good condition, appropriate base level at least three par of non-decorative linens i.e. bed sheets, pillowcases.and bed pads.Contracted Company shall be responsible for the replacement from time to time of such non-decorative linens, as a result of normal wear and tear. If requested by client, or required for an reason other than normal wear and tear, Contracted Company shall arrange at client's expense for the wholesale replacement or upgrade of linens on client's behalf. Record review of the facilities policy titled Laundry Standards dated May 2003 revealed: 1. The facility will provide a quality laundry operation. Record review of the facility policy titled, Provisions of Quality Life dated 1/10/2022 revealed: Based on comprehensive assessments, the facility will ensure that each resident will receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. 1. The facility will create and sustain an environment that humanizes and promotes each resident's well-being and feeling of self-worth and self-esteem. 2. The facility leadership will establish a culture that treats each resident with respect and dignity as an individual and addresses, supports and/or enhances his/her feelings of self-worth.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #2) reviewed for infection control in that: CNA D did not wear a gown when providing direct care to Resident #2 who had a foley catheter and was on enhanced barrier precautions (EBP). This deficient practice could affect residents on enhanced barrier precautions and place them at risk for infection. The findings were: Record review of Resident #2's undated face sheet revealed Resident #2 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes (a condition where the body has difficulty regulating blood sugar levels), Hemiplegia (paralysis of one side of the body) and chronic kidney disease (gradual loss of kidney function). Record review of Resident #2's quarterly MDS assessment, dated 10/30/2025, revealed a BIMS score of 14, indicating intact cognition. Section GG - Functional Abilities revealed Resident #1 was dependent on facility staff for toileting hygiene. Section H - Bladder and Bowel revealed Resident #2 had an indwelling foley catheter and was always incontinent of bowel. Record review of Resident #2's undated comprehensive care plan revealed a care plan that read, Resident #1 required enhanced barrier precautions due to a foley, date initiated 09/04/2025. Record review of Resident #2's November 2025 medication administration record revealed enhanced barrier precautions related to Resident #2's foley, start date 08/20/2025. Record review of Resident #2's November physician orders revealed Resident #2 had a physician order for enhanced barrier precautions, start date 08/20/2025. During an observation, 11/14/2025 at 11:40 a.m., Resident #2 had a sign on his door that said Enhanced Barrier Precautions. CNA D was observed walking out of Resident #2's room with a small clear bag that contained a brief and gloves. During an interview with Resident #2, 11/14/2025 at 11:50 a.m., Resident #2 stated CNA D had been in Resident #2's room changing his brief from an incontinent episode and emptied his foley catheter bag. Resident #2 stated CNA D wore gloves during the direct care but did not wear a gown. Resident #2 stated staff did not usually wear gowns when providing care to him. During an interview with CNA D, 11/14/2025 at 12:10 p.m., CNA D stated she had just changed Resident #2's brief and provided foley catheter care to Resident #2. CNA D stated she did not wear a gown while providing care. CNA D stated she had recently received training on infection control and EBP in a recent skills fair at the facility. CNA D stated she could identify which residents required EBP because they had a sign on their room door, and residents with wounds or foleys were on EBP and staff had to wear a gown and gloves when providing direct care. CNA D stated it was important to wear the appropriate PPE for EBP because, it was for the resident's safety and to not contaminate anything. CNA D walked over to Resident #2's dresser and opened the top drawer and revealed PPE gowns and stated PPE was located in resident rooms and accessible when providing direct care. During an interview with the DON, 11/18/2025 at 11:30 a.m., the DON stated staff had received training on EBP and the expectation was for staff to wear a gown and gloves when providing direct care to residents on EBP. The DON stated residents on EBP had a sign on their room door indicating the need for a gown and gloves when providing direct care, and a resident with a foley or a wound required the use of EBP. The DON stated it was important for staff to use the appropriate EBP when providing direct care, to help protect the patient from the transference of germs into open areas. The DON stated a resident could get an infection from the transference of germs. Record review of the facility's policy titled, Infection Prevention and Control Program, date implemented 10/24/2022 and revised 04/12/2025, revealed, this facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines. Record review of a document provided by the facility Administrator as part of the facility EBP program revealed the document was a CMS Memorandum directed to State Survey Agency Directors, dated 03/20/2024, with the subject identified as Enhanced Barrier Precautions in Nursing Homes. The document revealed, Guidance - 'Enhanced Barrier Precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. The document revealed, For residents for whom EBP are indicated, EBP is employed when performing the following high contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linen, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing.

Based on interview and record review, the facility failed to ensure sufficient nursing staff with appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plan of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 12 nursing staff (RN K) reviewed for nursing services. RN K did not demonstrate competency when she failed to identify and document a left heel DTI upon readmission from the hospital on [DATE] for Resident #1.This failure could place residents at risk of staff not providing nursing or related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. Findings include: Record review of Resident #1's undated face sheet revealed Resident #1 was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included cerebral infarction (a disruption in the brain's blood flow), type 2 diabetes (a condition where the body has difficulty regulating blood sugar levels) , congestive heart failure (a condition in which the heart doesn't pump blood as well as it should) and anemia (a low number of blood cells). Record review of Resident #1's admission MDS assessment, dated [DATE], revealed Resident #1 had a BIMS score of 15, indicating intact cognition. Section GG - Function Abilities revealed Resident #1 had impairments on both sides of Resident #1's upper and lower extremities and required substantial to maximum assistance with bed mobility and transfers. Section M - Skin Conditions revealed Resident #1 was at risk for developing pressure ulcers and revealed that Resident #1 did not have any pressure ulcers or any other ulcers, wounds, or skin problems. Record review of Resident #1's undated comprehensive care plan revealed Resident #1 has a care plan that stated Resident #1 was at risk for the potential development of a pressure ulcer, dated [DATE] and revised [DATE]. Record review of Resident #1's weekly skin assessment, dated [DATE], revealed a head-to-toe assessment was completed and Resident #1 did not have an impairment in skin integrity. Record review of Resident #1's SBAR Communication Form, dated [DATE], revealed Resident #1 was transferred to the hospital on [DATE] for an evaluation related to a change in condition. Record review of Resident #1's hospital discharge documentation, dated [DATE] revealed, Extremities: well healed incision of R BKA, L heal pressure ulcer-skin intact. Record review of Resident #1's Clinical admission Assessment, dated [DATE] by RN K, revealed Resident #1 readmitted to the facility from the hospital. The document revealed a skin assessment that stated Resident #1 had no skin issues. Record review of Resident #1's progress notes by the Wound Treatment Nurse, [DATE], revealed, Skin observation performed. DTI present to left heel, non-blanchable (a condition where skin redness persists even when pressure is applied) persistent maroon area. Edema (swelling) present to left upper extremity. Discoloration present to bilateral hip area. Friction/shear markings present to left hip. Healing shear marks present to bilateral breast folds. Record review of Resident #1's [DATE] medication administration record revealed and order, Clean left heel with wound cleanser, pat dry. Skin prep. Offload. Every day shift for PI, start date, [DATE]. The administration record revealed Resident #1 received the treatment on [DATE], [DATE] and [DATE]. Record review of Resident #1's progress note, dated [DATE] at 1:42 p.m., revealed Resident #1 was transferred to the hospital related to hypoglycemia. During an interview with Resident #1's responsible party, [DATE] at 12:53 p.m., the responsible party stated Resident #1 was deceased and passed away on [DATE] at the hospital on hospice services. During an interview with the Wound Treatment Nurse, [DATE] at 11:09 a.m., the Wound Treatment Nurse stated when a resident admits/readmits to the facility, the admitting nurse would complete an assessment of the resident and part of the assessment included a head-to-toe skin assessment. The Wound Treatment Nurse stated she would be notified by the admitting nurse if a resident admitted with any skin concerns, reviewed the admitting clinical assessment, and then completed a skin assessment of each new admission/readmission within 24 hours of the admission. The Wound treatment Nurse stated the admitting nurses should document any skin concerns on the clinical admission assessment. The Wound Treatment Nurse stated Resident #1 did not have any skin concerns prior to Resident #1's hospitalization from [DATE] to [DATE], and Resident #1 returned from the hospital with a left heel DTI. The Wound Treatment Nurse stated the DTI should have been identified on the Clinical admission Assessment completed by RN K, and when the Wound Treatment Nurse identified the left heel DTI, the Wound Treatment Nurse obtained physician orders for treatment. During an interview with RN K, [DATE] at 11:20 a.m., RN K stated she completed Resident #1's clinical admission assessment on [DATE]. RN K stated when she received a new admission, she was responsible for getting report from the hospital, reviewing hospital discharge paperwork, getting the resident settled into when they admit, completing an initial clinical assessment, getting orders from the physician, and scheduling any follow up appointments. RN K stated the initial clinical assessment was the assessment form completed when a resident admitted /readmitted to the facility and included a section for skin observations. RN K stated that when residents admitted to the facility, they had hospital linen, so RN K assisted with changing resident linen and brief and completed a head-to-toe assessment at that time. RN K stated she would document any obvious skin concerns like surgical wounds and pressure wounds on the clinical admission assessment, and notify the Wound Treatment Nurse of RN K's findings. RN K stated she would not contact the physician to get any treatment orders and would wait for the Wound Treatment Nurse to assess the patient. RN K stated she completed a head-to-toe assessment including the heels on Resident #1 when she readmitted to the facility and identified, nothing obvious. She stated, there might be different levels of it [skin concerns] but sometimes there was redness and I don't know exactly if that counts. RN K stated she did not see documentation in the discharge documentation regarding a left heel wound for Resident #1. RN K stated not identifying skin concerns in a timely manner could cause a wound to worsen. RN K stated she had received an overview on wound care and identifying skin concerns, and stated if wounds were not identified on the clinical admission assessment and treated upon admission the wounds, could get worse and lead to infections. During an interview with the DON, [DATE] at 11:30 a.m., the DON stated the admitting nurse should complete an initial skin assessment by completing a head-to-toe assessment when a resident admitted /readmitted from the hospital, document the findings on the clinical admission assessment, and notify the treatment nurse of any findings. The DON stated the Wound Treatment Nurse should complete an additional head-to-toe assessment within 24 hours of admission and document the findings. The DON stated Resident #1's DTI to the left heel should have been documented on the clinical admission assessment. The DON stated, even if the admitting nurse could not stage the wound, it should have been documented on the admission assessment and orders obtained to at least monitor the area on the date of admission. The DON stated it was important for the initial clinical assessment to be accurate and reveal documentation of any skin concerns, because we need to know what they admitted with so we can document it upon admission, and if a wound or skin issue was not identified upon admission, it could cause a wound infection or cause further skin break down. Record review of the facility's policy titled, Clinical Documentation Guideline, origination date [DATE], review date [DATE] and revision date [DATE] revealed a policy, The patient's clinical record provides a record of the health status, including observations, measurements, history and prognosis and serves as the primary document describing health care services provided to the patient. The document revealed the fundamental information, The clinical record is used by healthcare team to record, preserve and communicate the patient's progress and current treatment.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to not store chemicals on the bottom shelf of a refrigerator. 2. The facility failed to document freezer temperatures for May 14th closing temperature and May 15-19, and May 20th opening temperature. 3. The facility failed to not store personal beverages in the food preparation area. 4. The facility failed to ensure lettuce was stored in a closed container in the walk-in refrigerator. 5. The facility failed to take temperatures of pureed foods and cold foods from 05/18/25 to 05/22/25. The facility failed to take food temperature for 05/21/25 dinner. These failures could place residents at risk for food borne illness. The findings included: 1. Observation and interview on 05/20/25 at 09:53 AM, during initial kitchen tour, revealed there was a cleaning spray on the bottom shelf of a refrigerator and the same cleaning spray was placed near foods and left there while staff was prepping a meal. The CDM revealed the cleaning spray was not supposed to be in the refrigerator or near foods and staff were trained on this. She revealed the staff could have moved the cleaning spray away from the food preparation area while staff was prepping for meal. Observation and interview on 05/22/25 at 11:42AM, the CDM revealed there should not be a cleaning spray in the refrigerator to prevent cross contamination and for food safety. Record review of facility's policy Storage-Chemicals, revised October 2019, reflected It is the center policy to ensure all chemicals will be properly stored for safety and to prevent cross contamination with food . 1. The Dining Services Director ensures that all chemicals are stored in separate/secured area. 2. Record review and interview on 05/20/25 at 09:35AM, during initial kitchen tour, of Freezer Temperature Log for Non-24-Hour Operation for May reflected freezer temperatures were not written for May 14th closing temperature and May 15-19, and May 20th opening temperature. The CDM revealed she was not aware of why this was not filled out and she oversaw the temperature log being filled out appropriately. Interview on 05/22/25 at 11:42AM, the CDM revealed it was important to keep up with freezer temperatures for food safety, but the freezer was very cold, so she has not suspected the freezer had not been at appropriate temperature. Record review of the facility's policy, Food Storage: Cold, revised October 2019, reflected 3. The Dining Services Direct/Cook(s) monitors that all frozen foods will be stored at temperature to maintain frozen state, target temperature is 10 (degrees F) or below. 3. Observation and interview on 05/20/25 at 09:35AM, during initial kitchen tour, revealed there were 2 personal beverages on the top shelf, above the food preparation area while a staff member was prepping food. Observation and interview on 05/22/25 at 11:42AM, the CDM revealed there should not be personal beverages in the kitchen or cleaning spray near food preparation areas to prevent cross contamination and for food safety. She revealed the staff members who had their beverages and prepared food near a cleaning spray were new and she re-educated them. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. 4. Observation and interview on 05/20/25 at 09:35AM, during initial kitchen tour, revealed lettuce that was uncovered in the walk-in refrigerator. The CDM revealed they did not cover the lettuce because they did not have a container to fit the lettuce in with a cover. The CDM revealed this did not affect the quality of the lettuce and it was okay to keep it uncovered with only a paper towel on top of it. Observation and interview on 05/22/25 at 11:42AM, the CDM revealed lettuce was in a closed container today, because she had washed it and it was now ready to be served. She revealed she did not think this lettuce needed to be covered prior to this. Record review of the facility's policy, Food Storage: Cold, revised October 2019, reflected 5. The Dining Services Director/Cook(s) ensures that all food items are stored properly in covered containers, labeled, and dated and arranged in a manner to prevent cross contamination. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. 5. Observation and interview on 05/22/25 at 11:42AM, the cook (unidentified) did not take temperatures for the pureed foods. The CDM revealed they did not have to take temperatures for pureed foods because they took the temperature when they prepared the pureed foods, and they also take temperatures of the regular foods which were in the same steam table. The CDM was not able to show any records of taking pureed foods' temperatures for 05/18-05/22/2025. The CDM further revealed if the foods for the regular diet were at the proper temperature, they did not need to take temperatures of the pureed foods. The CDM revealed they did not have to take temperatures for cold milk because they get the milk straight from the refrigerator when it's time for meal service. She also revealed they did not take temperatures of the milk because they would have to open the milk container to put the thermometer inside the milk liquid. Record review of Final Cooking/Reheating Time & Temperature Log, dated 05/18-22, were reviewed 05/22/25 lunch meal service. The log reflected no temperatures taken for pureed foods and no temperatures taken for cold items. Record review of the facility's week 2 menu reflected Sunday (05/18/25) breakfast was scrambled eggs, sausage patty, wheat toast, and hot cereal; lunch was rosemary pork loin, Italian green beans, buttered pasta, and cherry pie; dinner was baked chicken thigh, roasted potatoes, cucumber salad, dinner roll, and mandarin oranges. Record review of Final Cooking/Reheating Time & Temperature Log, dated 05/18, reflected breakfast had 3 food items with temperatures documented: oatmeal, sausage, eggs; lunch had 3 food items with temperatures documented: pork loin, veggies, soup; dinner had 3 food items with temperatures documented: sandwich, veggies, soup. Record review of the facility's week 2 menu reflected Monday (05/19/25) breakfast was cheese egg bake, sausage patty, English muffin, and hot cereal; lunch was roast beef, broccoli, white rice, and lemon bar; dinner was chicken spaghetti, fried okra, dinner roll, ice cream. Record review of Final Cooking/Reheating Time & Temperature Log, dated 05/19, reflected breakfast had 3 food items with temperatures documented: french toast, sausage, eggs; lunch had 3 food items with temperatures documented: roast beef, rice, broccoli; dinner had 3 food items with temperatures documented: soup, chicken spaghetti, fried okra. Record review of the facility's week 2 menu reflected Tuesday (05/20/25) breakfast was French toast, sausage patty, and hot cereal; lunch was crabcake, mashed potatoes, dinner roll, spinach, and sugar cookie; dinner was polish sausage, egg noodles, carrots, cornbread, and apple crisp. Record review of Final Cooking/Reheating Time & Temperature Log, dated 05/20, reflected breakfast had 3 food items with temperatures documented: eggs, sausage, oatmeal, gravy; lunch had 4 food items with temperatures documented: crab patties, mashed potatoes, spinach, gravy; dinner had 3 food items with temperatures documented: soup, sausage, pasta. Record review of the facility's week 2 menu reflected Wednesday (05/21/25) breakfast was cheese omelet, sausage, and hot cereal; lunch was beef stew, rice pilaf, green beans, dinner rolls, and orange sherbet; dinner was BBQ pulled pork on a bun, tossed salad, baked potato, and tropical fruit cup. Record review of Final Cooking/Reheating Time & Temperature Log, dated 05/21, reflected breakfast had 3 food items with temperatures documented: eggs, sausage, oatmeal, gravy; lunch had 4 food items with temperatures documented: rice, soup, green beans, beef stew; dinner had 0 food items documented. Record review reflected there were no food temperatures take for 05/21/25 dinner. Record review of the facility's week 2 menu reflected Thursday (05/22/25) breakfast was scrambled eggs, sausage patty, wheat toast, and hot cereal; lunch was fried chicken, carrots with parsley, dinner roll, buttered noodles, and white pineapple upside down cake. Record review of Final Cooking/Reheating Time & Temperature Log, dated 05/22, reflected breakfast had 4 food items with temperatures documented: eggs, sausage, oatmeal, gravy; lunch had 6 food items with temperatures documented: noodles, chicken, gravy, soup, mash, carrots. Interview on 05/23/25 at 01:30PM, the RD revealed the cleaning spray should not been in the fridge and personal beverages should not be in food preparation areas as it can cause cross contamination. The RD revealed every item should have their temperature taken, prior to meal service. With other questions, the RD further revealed she would have to refer to the policies to answer questions and the policies trumped anything she had to say. Interview on 05/23/25 at 01:55PM, the DON revealed it was important to make sure temperatures for the fridge and freezer, that contained food products, were taken so they could ensure food didn't go bad. She further revealed food temperatures needed to be checked, prior to service, to make sure they were at proper temperature. to make sure food was cooked properly, and to prevent food borne illness. Record review of facility's policy Food: Quality and Palatability, dated October 2019, reflected The Cook(s) prepare food in a sanitary manner utilizing the principles of Hazard Analysis Critical Control Point and time and temperature guidelines as outlined in the Federal Food Code. Record review of the principles of Hazard Analysis Critical Control Point did not reflect any specifics to time and temperature recommendations. Record review of the FDA Food Code 2022 reflected, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3- 403.11(E) may be held at a temperature of 54°C (130°F) or above; or (2) At 5°C (41°F) or less.

Based on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 2 of 2 residents (Resident #89 and #53) reviewed for dialysis: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #89 and Resident #53. This failure could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: 1. Record review of Resident #89's face sheet dated 5/23/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included end stage renal disease (occurs when the kidneys can no longer function well enough to meet the body's needs) traumatic amputation of left foot, anemia in chronic kidney disease (an abnormal reduction in red blood cells due to impaired kidney function), and pain. Record review of Resident #89's most recent comprehensive MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and received dialysis treatments. Record review of Resident #89's Medication Administration Record, dated 5/21/25 revealed the following: - Check the shunt site for bleeding. If bleeding is present, apply pressure and notify the physician; every shift for monitor with start dated 4/27/25 and no stop date. - Do not take blood pressure on Left upper extremity with the shunt; every shift for Dialysis, with order dated 4/27/25 and no stop date. Record review of Resident #89's comprehensive care plan with revision date 5/7/25 revealed the resident received dialysis related to renal failure and was at risk for the potential complications of dialysis, with interventions that included to encourage the resident to attend scheduled dialysis appointment, monitor dialysis dressing and change as ordered, report abnormal bleeding to the physician, and monitor/document/report any signs or symptoms of infection to the access site such as redness, swelling, warmth, pain, or purulent drainage. Further review of Resident #89's comprehensive care plan revealed the resident attended dialysis treatments outside of the facility on Monday, Wednesday, and Friday. Record review of Resident #89's Hemodialysis Communication Records revealed the following: - 3/26/25: the dialysis center section was incomplete, and the post dialysis section was not signed or dated by the facility nurse. - 3/28/25: the post dialysis section was not completed by the facility nurse. - 4/2/25: the post dialysis section was not signed or dated by the facility nurse. - 4/7/25: the pre-treatment section and post-treatment section was not signed or dated by the facility nurse. - 4/9/25: the Hemodialysis Communication Record was not provided by the facility. - 4/11/25: the post dialysis section was not signed or dated by the facility nurse. - 4/14/25: the dialysis center section was not signed or dated, and the post dialysis section was not completed by the facility nurse. - 4/18/25: the Hemodialysis Communication Record was not provided by the facility. - 5/2/25: the Hemodialysis Communication Record was not provided by the facility. - 5/5/25: the Hemodialysis Communication Record was not provided by the facility. - 5/7/25: the Hemodialysis Communication Record was not provided by the facility. - 5/9/25: the Hemodialysis Communication Record was not provided by the facility. - 5/12/25: the Hemodialysis Communication Record was not provided by the facility. - 5/14/25: the Hemodialysis Communication Record was not provided by the facility. - 5/16/25: the Hemodialysis Communication Record was not provided by the facility. - 5/19/25: the Hemodialysis Communication Record was not provided by the facility. - 5/21/25: the dialysis center section was incomplete, and the post dialysis section was blank. During an observation and interview on 5/22/25 at 10:50 a.m., Resident #89 acknowledged he was getting dialysis treatments outside of the facility every Monday, Wednesday, and Friday. Resident #89 stated he was not aware of any paperwork given while at the dialysis center. Resident #89 raised his sleeve to expose his left upper arm and stated the area exposed was where the dialysis shunt was located. During an interview on 5/22/25 at 4:25 p.m., CNA C stated she was aware of at least two residents who received dialysis treatments and believed Resident #89 was one of them. CNA C stated the day shift nurses were responsible for ensuring the resident went to dialysis treatments and Resident #89 was usually in bed when she came on shift which was from 2:00 p.m. to 10:00 p.m. During an observation and interview on 5/22/25 at 4:29 p.m., ADON A acknowledged Resident #89 went to dialysis treatments on Monday, Wednesday, and Friday. ADON A stated, the nursing staff were responsible for providing the dialysis clinic with the Hemodialysis Communication Record which they gave to the driver who was taking the resident to the dialysis clinic. ADON A further stated, the Hemodialysis Communication Record was turned into the facility nursing staff by the driver after the resident returned from the dialysis clinic. ADON A stated, we get the information and it's filed and uploaded into the medical chart. Not sure of the process. ADON A further stated, the Hemodialysis Communication Records were audited by the ADON or DON. ADON A reviewed the Hemodialysis Communication Record for Resident #89, dated 5/21/25 and acknowledged the form was incomplete and was missing the dialysis clinic information and the post-dialysis information by the receiving facility nurse was blank. ADON A stated LVN D accidentally documented Resident #89's post dialysis vital signs in the wrong section of the Hemodialysis Communication Record dated 5/21/25. During an interview on 5/22/25 at 4:38 p.m., LVN D acknowledged Resident #89's Hemodialysis Communication Record, dated 5/21/25 was missing information from the dialysis clinic and the nurses were responsible for notifying the dialysis clinic to obtain that information. LVN D stated she called the dialysis clinic but they put me on hold for 10 minutes, twice, and did not get a call back, and then filed the sheet in the resident's dialysis binder. LVN D stated, we cannot accept it (Hemodialysis Communication Record) because we have to know of any changes while at dialysis or how he (Resident #89) tolerated the dialysis treatment. I guess I should have communicated that to the DON or ADON. During a joint interview on 5/22/25 at 4:43 p.m., the DON and ADON B acknowledged, the Hemodialysis Communication Records were supposed to be completed and if there was any missing information from the dialysis clinic, the facility nurse was responsible for calling the dialysis clinic to obtain that information. The DON and ADON B acknowledged, the Hemodialysis Communication Record was not supposed to be filed until all of the information required was obtained. The DON stated, we need to know baseline while here and baseline results when they come back. The DON and ADON B acknowledged nobody was really auditing the Hemodialysis Communication Records to ensure they were completed. During a follow-up interview on 5/23/25 at 2:11 p.m., the DON acknowledged there was no process in place for keeping track of the Hemodialysis Communication Records. 2. Record review of Resident #53's admission Record dated 05/23/25 documented an [AGE] year old male admitted to the facility 10/23/20 and readmitted [DATE] with diagnoses that included severe sepsis with septic shock (a life-threatening condition where the body's response to an infection causes wide-spread inflammation and organ damage), acute kidney failure, dependence on renal dialysis, atelectasis (whole or partially collapsed lung) and dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (indicates the dementia is a result of another underlying medical condition and doesn't specify whether the dementia is mild, moderate, or severe). Record review of Resident #53's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating he is cognitively intact. The MDS also noted that he is on dialysis and uses a bipap for sleep apnea (a sleep disorder in which breathing repeatedly starts and stops). Record review of Resident #53's May 2025 Physician's Orders revealed he was on oxygen as needed and goes to dialysis 3 times per week on Tuesday, Thursday and Saturday. Orders also include checking the central line to ensure the dressing is dry and intact, and if not, reinforce with an occlusive dressing. Additionally, check the clamp to ensure closure every shift. Review of the dialysis communication sheets for Resident #53 revealed the following deficient areas: 4/24/25: The Hemodialysis Communication Record was not signed by the dialysis facility nurse or the facility nurse upon return after taking the vital signs. No other information concerning observation of the shunt was documented by either nurse. 4/26/25: The Hemodialysis Communication Record was not signed by the dialysis facility nurse after taking vital signs. 4/29/25: The Hemodialysis Communication Record had no observation of shunt following the return to facility. 5/1/25: The Hemodialysis Communication Record was not signed by the dialysis facility nurse who completed the vital signs. 5/6/25: The Hemodialysis Communication Record was not signed by the dialysis facility nurse who completed the vital signs. None of The Hemodialysis Communication Record forms had the resident's name, ID #, Room # or Physician' Name completed at the bottom of the form. During an interview with the DON on 5/23/24 at 4:00 pm, the DON stated the resident's name was not completed on the forms since they were placed in a binder with his name on it and then uploaded into their EMR. During an interview on 5/23/25 at 4:10 p.m., the Regional Nurse stated the facility did not have a policy in place for the dialysis communication records.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 3 of 22 residents (Resident #11, Resident #92, and Resident #30) reviewed for accidents and hazards: 1. The facility failed to ensure Resident #11 did not have a large pair of nail clippers, and a pair of tweezers in her room. 2. The facility failed to ensure Resident #92 did not have a pair of sharp scissors and a disposable razor on her bedside table. 3. The facility failed to ensure Resident #30 did not have all-purpose cleaner in her restroom. These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health. The findings included: 1. Record review of Resident #11's face sheet dated 5/21/25 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included lack of coordination, dementia (a decline in cognitive function that interferes with a person's daily life and activities) with behavioral disturbance, age-related nuclear cataract (a type of cataract that develops in the center of the eye's lens making it harder to see clearly, especially in low light or when facing bright lights), and chronic pain. Record review of Resident #11's most recent quarterly MDS assessment dated [DATE] revealed the resident was able to see in adequate light, used corrective lenses, and was cognitively intact for daily decision-making skills. Record review of Resident #11's comprehensive care plan with revision date 3/5/25 revealed the resident had an ADL self-care performance deficit and was at risk for not having their needs met in a timely manner with interventions that included for supervision with personal hygiene and to provide shower, shave, oral care, hair care, and nail care per schedule and when needed. During an observation and interview on 5/20/25 at 10:15 a.m., Resident #11 had a large pair of nail clippers and a pair of tweezers on the resident's bedside table next to her recliner on the right. Resident #11 stated she trimmed her own nails but did not or would not indicate if staff were aware she was in possession of the items. Observation on 5/21/25 at 8:32 a.m. revealed Resident #11 sitting up in her recliner with a large nail clippers and tweezers on the bedside table to the right of the resident's recliner. Observation on 5/22/25 at 8:28 a.m. revealed Resident #11 sitting up in her recliner with a large nail clippers and tweezers on the bedside table to the right of the resident's recliner. During an observation and interview on 5/22/25 at 11:21 a.m., CNA E acknowledged there were no residents in the facility she was aware of that could trim their own nails. CNA E stated she was very familiar with Resident #11 and she was stable enough to cut her own nails but would prefer to observe the resident cutting her nails. CNA E further stated the facility did not use tweezers. CNA E observed a large pair of nail clippers and a pair of tweezers on Resident #11's bedside table to the right of the resident's recliner. CNA E stated, she would question a resident having a pair of nail clippers, and if she was not sure they weren't supposed to have them would then notify the nurse. CNA E could not or would not directly acknowledge if Resident #11 could have the large pair of nail clippers or the tweezers in her possession. During an observation and interview on 5/22/25 at 11:34 a.m., RN F acknowledged the facility CNAs were responsible for providing ADL supervision such as shaving, showering, peri-care and nail care. RN F stated, unless the resident was a diabetic, then only the nursing staff could provide the residents with nail care. RN F stated she was not aware of any resident who was allowed to cut their nails or shave without supervision. RN F stated, Resident #11 was stable to do most of this stuff but would prefer to supervise the resident if she wanted to cut her nails. RN F stated the facility did not use tweezers. RN F observed a large pair of nail clippers and a pair of tweezers on Resident #11's bedside table to the right of the resident's recliner and stated the items observed needed to be removed. During an observation and interview on 5/22/25 at 11:40 a.m., ADON B, after seeing the State Surveyor and RN F in Resident #11's room stated to Resident #11 she could keep the tweezers as it was the resident's right to keep them but told the resident the nail clippers needed to be removed and would be stored away for her. During an interview on 5/22/25 at 11:41 a.m., ADON B stated, Resident #11 had a high BIMS score and was alert and oriented and could therefore keep the nail clippers. ADON B further stated, in this resident's case (Resident #11), she is alert and oriented and she could manage it. ADON B stated she did not know what the facility policy was for having the items in the resident's room, including tweezers and nail clippers. During an interview on 5/22/25 at 12:09 p.m., CNA G stated, nobody here can cut their own nails. I don't even cut a resident's nails; I always refer them to the nurse. CNA G further stated residents were not allowed to have nail clippers and the facility did not use tweezers. CNA G stated, those items could cause a resident to cut themselves. During an interview on 5/22/25 at 12:23 p.m., the DON stated, a resident's possession of scissors, nail clippers, tweezers, or disposable razors depended on the resident's BIMS score. The DON further stated she would refer a resident to the podiatrist if the resident were a diabetic. The DON stated it was a resident's right to have those items in their room. The DON then stated the facility had Ambassadors assigned to resident rooms who were supposed to check every morning and were supposed to be looking for those items. During an interview on 5/22/25 at 2:53 p.m., the DOR acknowledged she was assigned as a Quality of Life Specialist (Ambassador) and had been tasked with making rounds of resident rooms, including Resident #11. The DOR stated, part of the assigned rounds was to check for broken items, trash, and prohibited items, such as disposable razors. The DOR stated she was not aware of residents who were allowed to have disposable razors, scissors, or nail clippers. The DOR stated, those items were not safe for the residents to use on their own and would need help to use those items. The DOR stated, somebody else could wander in the room and have access to them (nail clippers, razors, scissors) and it was a potential for an accident. The DOR stated she had made rounds in Resident #11's room and did not recall seeing the large nail clippers or the tweezers, and further stated, I did not even think about it, but one of the things I do look for is disposable razors. The disposable razors should not be in the rooms, they should be disposed of in a sharp's container for safety reasons. Somebody who did not know how to use it could hurt themselves or cut themselves with it. 2. Record review of Resident #92's face sheet, dated 5/21/25, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included lack of coordination, contracture of muscle, and muscle weakness. Record review of Resident #92's most recent quarterly MDS assessment, dated 3/2/25, revealed the resident cognition was moderately impaired for daily decision making. Section GG revealed she required partial/moderate assistance with personal hygiene. Record review of Resident #92's comprehensive care plan with revision date 3/27/25 revealed the resident had an ADL self-care performance deficit and was at risk for not having their needs met in a timely manner. Performance deficit is related to fracture of sacrum (break of the bone at the back of the pelvis between the hip bones) pain, neuropathy, cauda equina syndrome (a medical emergency that happens when an injury or herniated disk compresses nerve roots at the bottom of your spinal cord. The cauda equina nerves communicate with your legs and bladder. It causes back pain, weakness, and incontinence), unilateral inguinal hernia (occurs when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles), history of falling, muscle weakness, loss of coordination with interventions that included extensive assistance with personal hygiene. Record review of Resident #92's comprehensive care plan with revision date. 3/27/25, revealed resident has a behavior problem as evidenced by: Resident was angry that she can no longer perform ADLs without assistance and will last out at staff and her friend that comes to visit with an intervention to Approach resident in a calm manner, call by name, speak slowly, and maintain eye contact. Talk while providing cares, allow time for a response, and do not rush. During an observation and interview on 5/20/25 at 1:10 p.m., Resident #92 had a small pair of sharp scissors on her bedside table and a disposable razor. Resident #92 stated she used the scissors to cut candy because I can't eat it directly and eat it with scissors. Resident #92 stated she could not think of what she wanted to say because her memory was not good. During a follow up observation and interview on 5/22/25 at 10:17 a.m. revealed Resident #92 was lying in bed. Her items on her bedside table had been rearranged and straightened up. The pair of scissors and disposable razor were still on the bedside table. Resident #92 stated she could use the razor to shave but could only use one had to shave because the other hand was crunched up. During an interview on 5/22/25 at 10:19 a.m. the Staffing Coordinator stated all staff can check resident rooms for items they should not have. The Staffing Coordinator stated Resident #92 does not shave herself. The Staffing Coordinator stated the resident should not have the razor at her bedside table, an aide should have been assisting the resident with shaving, and then dispose of the razor in the sharp's container located in the residents in room bathroom. The Staffing Coordinator stated he was unsure where the scissors came from and picked them up and removed them from the room. The Staffing Coordinator stated he thought the razor and scissors came from family because the razor was not the same color as the razors the facility used. The Staffing Coordinator stated he would call to inform the family that the resident was not allowed to have those items. 3. Record review of Resident #30's admission record, accessed 05/20/25, reflected Resident #30 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses to include lack of coordination, major depressive disorder, mild cognitive impairment, altered mental status, and age-related nuclear cataract (a type of cataract that develops in the center of the eye's lens making it harder to see clearly, especially in low light or when facing bright lights). Record review of Resident #30's quarterly MDS assessment, dated 02/14/25, reflected Resident #30 had a BIMS score of 15 out of 15, indicating intact cognition. able to see in adequate light and used corrective lenses. Record review of Resident #30's comprehensive care plan reflected [Resident #30] has impaired cognition and is at risk for further decline in cognitive and functional abilities related to: altered mental status ., revised 02/28/24, with interventions to include, Monitor for changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness . Interview and observation on 05/20/25 at 11:19 AM, Resident #30 had an all-purpose cleaner on the lower shelf of an open faced cabinet in her restroom. Resident #30 revealed she had seen the cleaner in her restroom and believed it was left there by housekeeping. Interview and observation on 05/20/25 at 11:22 AM, Housekeeper H confirmed there was an all-purpose cleaner in Resident #30's bathroom, but it did not belong to housekeeping because they clean with different sprays and put them back on her cart so that the residents don't hurt themselves. Interview and observation on 05/20/25 at 11:26 AM, the Housekeeping Supervisor revealed the all-purpose cleaner observed in Resident #30's restroom was the resident's property so housekeeping did not touch this cleaner. Interview and observation on 05/20/25 at 11:32 AM, LVN I revealed chemicals were not allowed in residents' rooms. She revealed sometimes family brought items in for Resident #30, but Resident #30 did not have any visitors today. LVN I revealed she expected her CNA to tell her about this. LVN I proceeded to take the all-purpose cleaner out of Resident #30's room and would inform family this was not allowed. Interview on 05/22/25 at 12:25 PM, the DON revealed no resident should have chemicals like all-purpose cleaner. She revealed every staff member oversaw seeing any prohibited items and taking them out of the residents' rooms as needed, even if families bring the items in the facility. Interview on 05/23/25 at 11:31 AM, CNA G revealed residents were not allowed to have all-purpose cleaner in their room and if she saw this, she would take it away for resident safety. She revealed she would report to nurse so the nurse could educate family if it was family that brought it in. Record review of the facility policy and procedure titled, Nail Care, revision date 1/1/25 revealed in part, .Purpose: To provide for personal hygiene needs and prevent infection .13. Return equipment to designated area and clean/dispose as indicated . Record review of the facility policy and procedure titled, Resident Rights, review date 2/20/21 revealed in part, .Policy: The facility will inform the resident both orally and in writing in language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility,,,Safe environment .The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely .

Based on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, package and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 9 of 9 residents (confidential residents) reviewed for resident rights. The facility failed to ensure staff distributed mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. The findings were: During a confidential resident group meeting 9 of 9 members in the group stated they never received mail on Saturdays because the Business Office didn't work on Saturdays but they did have a receptionist. During an interview on 05/23/25 at 10:12 am, with the Receptionist and Business Office Manager, the Receptionist stated he worked for the facility Monday to Friday as well as weekends. The Receptionist stated the Business Office Manager ensures mail is delivered to the residents daily from Monday to Friday. The Receptionist stated that mail delivery is inconsistent but if a package arrives, he makes sure to deliver it to the resident that day. If there are letters delivered, he puts it in the Business Office to sort out. During the interview on 05/23/25 at 10:12 a.m., the BOM stated mail delivered on a Saturday should be distributed on Saturday and told the Receptionist to go ahead and distribute any mail that had the resident's name on it.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 of 8 residents (Resident #30, Residents #33, and Resident #66) reviewed for infection control. 1. The facility failed to ensure, during medication pass, MA M sanitized the blood pressure cuff between Resident #44, and Resident #30. 2. The facility failed to ensure LVN J wore a PPE gown while administering medication to Resident #33 via PEG tube ((an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate). 3. The facility failed to ensure CNA K and CNA L sanitized their hands between glove changes and changed their gloves after during incontinent care for Resident #66. These failures could place residents at risk for cross contamination and infection. The finding included: 1. Record review of Resident #30's admission Record, dated 5/23/25, revealed she was a [AGE] year-old woman admitted on [DATE] with diagnoses including heart failure, rash and other nonspecific skin eruption, seborrheic dermatitis (is a common skin condition that mainly affects your scalp. It causes scaly patches, inflamed skin, and stubborn dandruff.), and pneumonia (an infection that inflames the air sacs in one or both lungs). Record review of Resident #30's Quarterly MDS Assessment, dated 02/14/25, revealed the resident's cognition was fully intact for daily decision making. Record review of Resident #30's Care Plan, revised 5/18/25, revealed a care area for Resident #30 had an ADL self-care performance deficit and was at risk for not having their needs met in a timely manner. Performance deficits were related to cognitive impairment, functional limitations in range of motion or decrease mobility, activity intolerance, impaired imbalance coordination, and pain. Interventions included personal hygiene limited x1 assistance and report changes in ADLS of self-performance to nurse. During observations on 5/22/25 between 9:12 a.m. and 9:32 a.m. MA M took resident #44 blood pressure. MA A returned the blood pressure cuff to the cart. MA M then switched medication carts. MA M took the blood pressure cuff off the 400-hall cart and placed it on the 300-hall cart. MA M then took Resident #30's blood pressure without sanitizing the cuff prior. During an interview on 5/22/25 at 9:32 a.m. MA A stated she thought she had sanitized the blood pressure cuff but forgot. MA A stated she should sanitize the blood pressure cuff between residents to prevent cross contamination. 2. Record review of Resident #33's admission record, dated 5/23/25, revealed an [AGE] year-old male resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy, methicillin resistant staphylococcus aureus infections as the cause of disease classified elsewhere. Record review of Resident #33's quarterly MDS assessment, dated 4/22/25, revealed the resident cognition was intact for daily decision making. Record review of Resident #33's care plan, revised 3/27/25, revealed a care area for Resident #33 was on enhanced barrier precautions due to feeding tube and foley with interventions to ensure PPE was available for use on the resident. Record review of Resident #33's physician order summary, dated 4/16/25, revealed an order for enhanced barrier precautions every shift related to PEG tube/catheter, with a start date of 4/16/25, and no end date. During an observation on 5/22/25 at 3:49 p.m. LVN J administered a medication to Resident #33 through his PEG tube. LVN J wore gloves during the administration and did not wear a PPE gown. 3. Record review of Resident #66 admission record, dated 5/23/25, revealed an [AGE] year-old female resident admitted on [DATE] with diagnoses including dementia, enterocolitis due to clostridium difficile, bacteremia (bacteria in bloodstream), and stage 3 chronic kidney disease. Record review of Resident #66's quarterly MDS assessment, dated 4/16/25, revealed the resident cognition was severely impaired for daily decision making. Section H revealed the resident was always incontinent of bladder and bowel. Record review of Resident #66's care plan, revised 3/27/25, revealed a care area for Resident #66 was incontinent of bowel/bladder related to limited mobility with an intervention to check frequently for wetness and soiling, and changing as needed. During an observation on 5/22/25 at 3:17 p.m. CNA K and CNA L provided incontinent care to Resident #66. CNA K and CNA L washed their hands and put on gloves. CNA K cleaned the residents vaginal area, removed her gloves, did not sanitize her hands, and put on new gloves. CNA K and CNA L then turned Resident #66 to her side and CNA K cleaned her buttocks area. CNA K removed the brief from under resident #66 and threw it away. CNA K then removed her gloves, did not sanitize her hands, and put on new gloves. Resident #66 began to have a bowel movement and CNA K wiped her buttocks area again while rolling a pad up under her. CNA K then removed her gloves, did not sanitize her hands, and put on new gloves. CNA K then opened a new brief and put in on the resident. CNA K then applied barrier cream to the resident's buttocks. CNA K then removed her gloves, did not sanitize her hands, and put on new gloves. Both aides then turned the resident to her other side and CNA L then removed the soiled pad out from under the resident. CNA K then applied barrier cream to the resident's vaginal area. CNA K then removed her gloves, did not sanitize her hands, and put on new gloves. CNA L was wearing the same gloves from the start of the care then touches and fastens the new clean brief on Resident #66. During a joint interview on 5/22/25 at 3:27 p.m. CNA K and CNA L stated they perform hand hygiene by washing their hands prior to starting incontinent care and after it is complete. Both aides stated if their gloves became soiled or torn then they would need to perform hand hygiene. CNA K and CNA L stated to their knowledge they do not need to perform hand hygiene in between glove changes and never had training to sanitize their hands between glove changes. They both stated they had training for incontinent care as recent as two weeks prior. During an interview on 5/22/25 at 3:31 p.m. the Nursing Supervisor stated he was one of the staff responsible for training aides on incontinent care. The Nursing Supervisor stated staff had training to perform hand hygiene prior to providing care, after care, anytime hands are visibly soiled, or between glove changes. The Nursing Supervisor stated staff had little bottles of hand sanitizer they could take into the room with them during care. During an interview on 5/23/25 at 1:49 p.m. the DON stated staff should sanitize their hands between glove changes to prevent infection to the resident. A facility policy for Enhanced Barrier Precautions was request on 5/23/25 at 1:55 p.m. At 3:51 p.m. the Administrator provided the QSO from CMS for EBP, dated March 20, 2024. The facility's policy for, infection control prevention and control program, was updated last on 10/27/2022. The policy did not mention or include information for EBP. The QSO, titled Enhanced Barrier Precautions in Nursing Homes stated .Regulations and Guidance: F880 .Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements .)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to .(e) and following accepted national standards; .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . EBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies . Record review of the facility's policy titled Hand Hygiene, dated 11/12/2017, stated Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Policy Explanation and Compliance Guidelines: 1. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 2. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 3. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . Hand Hygiene Table . Condition . Before applying and after removing personal protective equipment (PPE), including gloves .

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 5 residents (Resident #66) reviewed for incontinent care: The facility failed to ensure CNA K provided incontinent care to Resident #66 in the order of cleanest to dirtiest, performed hand hygiene between glove changes, and CNA L changed her gloves and performed hand hygiene after touching soiled linen. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. Findings Included: Record review of Resident #66 admission record, dated 5/23/25, revealed an [AGE] year-old female resident admitted on [DATE] with diagnoses including dementia, enterocolitis due to clostridium difficile (a highly contagious bacterium that causes diarrhea), bacteremia (bacteria in bloodstream), and stage 3 chronic kidney disease (mild to moderate damage to the kidneys causing them to filter less waste and fluid from the body) . Record review of Resident #66's quarterly MDS assessment, dated 4/16/25, revealed the resident cognition was severely impaired for daily decision making. Section H revealed the resident was always incontinent of bladder and bowel. Record review of Resident #66's care plan, revised 3/27/25, revealed a care area for Resident #66 was incontinent of bowel/bladder related to limited mobility with an intervention to check frequently for wetness and soiling, and changing as needed. During an observation on 5/22/25 at 3:17 p.m. CNA K and CNA L provided incontinent care to Resident #66. CNA K and CNA L washed their hands and put on gloves. CNA K cleaned the resident's vaginal area, removed her gloves, did not sanitize her hands, and put on new gloves. CNA K and CNA L then turned Resident #66 to her side and CNA K cleaned her buttocks area. CNA K removed the brief from under resident #66 and threw it away. CNA K then removed her gloves, did not sanitize her hands, and put on new gloves. Resident #66 began to have a bowel movement and CNA K wiped her buttocks area again while rolling a pad up under her. CNA K then removed her gloves, did not sanitize her hands, and put on new gloves. CNA K then opened a new brief and put in on the resident. CNA K then applied barrier cream to the resident's buttocks. CNA K then removed her gloves, did not sanitize her hands, and put on new gloves. Both aides then turned the resident to her other side and CNA L then removed the soiled pad out from under the resident. CNA K then applied barrier cream to the resident's vaginal area. CNA K then removed her gloves, did not sanitize her hands, and put on new gloves. CNA L was wearing the same gloves from the start of the care then touches and fastens the new clean brief on Resident #66. During a joint interview on 5/22/25 at 3:27 p.m. CNA K and CNA L stated they perform hand hygiene by washing their hands prior to starting incontinent care and after it is complete. Both aides stated if their gloves become soiled or torn then they would need to perform hand hygiene. CNA K and CNA L stated to their knowledge they do not need to perform hand hygiene in between glove changes and never had training to sanitize their hands between glove changes. CNA L stated she did not think she needed to change her gloves after touching the soiled pad because her gloves were not visibly soiled. They both stated they had training for incontinent care as recent as two weeks prior. During an interview on 5/22/25 at 3:31 p.m. the Nursing Supervisor stated he was one of the staff responsible for training aides on incontinent care. The Nursing Supervisor stated staff had training to perform hand hygiene prior to providing care, after care, anytime hands are visibly soiled, or between glove changes. The Nursing Supervisor stated staff had little bottles of hand sanitizer they could take into the room with them during care. The Nursing Supervisor stated staff should clean the resident from cleanest to dirtiest and apply creams to the vaginal area first and then the buttocks to prevent infection. During an interview on 5/23/25 at 1:49 p.m. the DON stated staff should sanitize their hands between glove changes to prevent infection to the resident. The DON stated staff should have changed their gloves and performed hand hygiene after touching soiled items or wash with soap and water when hands were visibly soiled. Nurse aide competencies or training for incontinent care for CNA K and CNA L were request from the DON on 5/23/25 and not provided prior to exit. Record review of the facility's policy titled Incontinence Care, dated 4/17/14, reviewed last 2/14/20, stated Purpose: To outline a procedure for cleansing the perineum and buttocks after an incontinence episode . Procedure . 4. Wash hands 5. Put on non-sterile, latex-free gloves 6. Place linen or underpad beneath hips 7. Position on side turned away from caregiver 8. If feces present, remove with toilet paper or disposable wipe by wiping from front of perineum toward rectum. Discard soiled materials and gloves. Wash hands. 9. Put on non-sterile, latex-free gloves .

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Residents #32) of 8 residents reviewed for care plans. The facility failed to implement Resident #32 care plan to have his lateral supporting positioning device in order to assist with his upright posture to eat. This failure could place residents at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental, and psychosocial wellbeing. The findings included: Record review of Resident #32's admission record, accessed 05/20/25, reflected Resident #32 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include adult failure to thrive (decline seen in elderly individuals), protein-calorie malnutrition, dementia (group of symptoms affecting memory, thinking, and social abilities), lack of coordination, and major depressive disorder. Record review of Resident #32's quarterly MDS assessment, dated 02/12/25, reflected Resident #32 had a BIMS score of 10 out of 15, indicating moderate cognitive impairment. It reflected no weight changes in the past 6 months. Record review of Resident #32's comprehensive care plan reflected At times, [Resident #32] allows the staff to put a wedge on the right side of his chair to prevent him from leaning when eating his meal .[Resident #32] has lateral supporting positioning device attached to regular chair for meals to assist with upright posture while eating., revised 04/08/25. Dining observation for 05/20/25 lunch meal service started on 05/20/25 at 12PM. Interview and observation on 05/20/25 at 12:37 PM, Resident #32 was leaning to the right side of his wheelchair and had not touched his lunch meal. He revealed he was unable to sit upright to eat his lunch meal. He revealed he had a cushion for his chair to help him sit correctly. Interview and observation on 05/20/25 at 12:39 PM, Human Resources (HR) revealed she helped with meal service, but not all the time. She revealed she was not aware if Resident #32 needed a cushion while he was sitting down to eat. She revealed she would have to ask therapy. She proceeded to ask therapy person present at lunch meal service and this therapy person had to ask the director of therapy. Interview and observation on 05/20/25 at 12:45 PM, Resident #70 revealed Resident #32 always had a cushion in his chair so he can sit up right at meals. She revealed it was important for him to have it so he can complete his meals. She revealed Resident #32 might get tired from leaning and trying to eat. Resident #70 revealed she was aware of this because she used to sit with Resident #32 all the time. Interview on 05/20/25 at 12:47 PM, ST N revealed Resident #32 typically did have cushion on his chair while eating to sit upright. Observation on 05/20/25 at 12:49PM, COTA O brought a cushion for Resident #32 and repositioned him at his table. Observation on 05/22/25 at 12PM revealed Resident #32 had a cushion on his chair and was sitting upright for lunch. Interview on 05/23/25 at 11:31 AM, CNA G revealed Resident #32 sat in his wheelchair and would slant to his side. She revealed he had a cushion that he used during meals because he leaned over and could not eat food properly. She revealed it was the therapy department's responsibility to communicate this with the staff. Interview on 05/23/25 at 12:58PM, the DOR revealed Resident #32 did need a cushion while eating because it helped him sit properly while eating. She revealed sometimes he did not need the cushion. She revealed this should be reflected in the care plan so the nurses knew how to care for resident. Interview on 05/23/25 at 01:55PM, the DON revealed she was not sure if cushion should be in the care plan, but nurses used the care plans in order to know how to care for resident. During exit conference on 05/23/25 at 05:00PM, the ADM revealed it was care planned for Resident #32 to use his cushion as needed and not all the time. Record review of facility's policy Comprehensive Care Plans, dated 02/10/2021, reflected It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 3 residents (Resident #3) reviewed for accuracy of records, in that: The facility failed to ensure RN B and LVN C documented when they contacted the physician for Resident #3's high blood glucose levels (continuously over 200) for 5 days (1/25/25, 1/26/25, 1/27/25, 1/28/25, 1/29/25) and the physician's recommendations for Resident #3 who was not prescribed any insulin. This failure could put residents at risk due to inaccurate documentation and lead to missed or delayed diagnosis and treatment. The findings were: Record review of Resident #3's admission Record (face sheet), dated 4/15/25, revealed a [AGE] year-old female resident was admitted to the facility on [DATE] and discharged on 1/30/25 to a hospital with diagnosis which included sepsis unspecified organism (refers to a serious medical condition characterized by the body's extreme response to an infection, where the specific organism causing the infection is not identified. It involves the presence of pathogenic microorganisms or their toxins in the bloodstream, leading to a systemic reaction that can result in shock and organ failure), hypoglycemia (reading below 70 milligrams per deciliter (mg/dL) is generally considered too low and indicates hypoglycemia, which can lead to symptoms like shakiness, confusion, and sweating), narcolepsy with cataplexy (is a chronic neurological disorder that affects the brain's ability to control sleep-wake cycles. It can cause excessive daytime sleepiness, cataplexy (sudden muscle weakness), sleep paralysis, and other symptoms.), atherosclerotic heart disease of native coronary artery without angina pectoris (the build up of plaque in the arteries would limit the blood flow to the heart but severely impairs it to no extent for causing pain, which is angina), type 2 diabetes mellitus with ketoacidosis without coma (a person with type 2 diabetes has high levels of ketones (Ketones are produce when body burns fat for energy instead of glucose) in the blood but does not lose consciousness. This can lead to a serious complication if not treated.), and metabolic encephalopathy (a range of neurological disturbances that result from systemic metabolic dysfunction in the body. This condition can arise from various underlying causes, including liver failure, kidney dysfunction, infections, electrolyte imbalances, and endocrine disorders. In metabolic encephalopathy, the brain's normal functioning is compromised due to the buildup of toxins or deficiencies in essential nutrients, which can lead to symptoms such as confusion, altered consciousness, cognitive impairment, seizures, and even coma in severe cases). Record review of Resident #3's Discharge MDS assessment, dated 1/30/25, revealed the Resident #3 had moderately impaired cognition for daily decision making. Record review of Resident #3's care plan, dated 1/23/25, revealed the resident had a diagnosis of diabetes and was at risk for unstable blood sugars and abnormal lab results with interventions to Administer diabetic medications as ordered by the physician, monitor for adverse reactions and report abnormals [sic] as detected and monitor for signs and symptoms of hyperglycemia such as: Reduced appetite, increased thirst, urinary frequency, weight loss, fatigue, nausea, vomiting, dry skin, muscle cramps, Kussmaul breathing (an abnormal breathing pattern characterized by rapid, deep breathing at a consistent pace. It ' s a sign of a medical emergency - usually diabetes-related ketoacidosis (DKA)), acetone breath (smells fruity), stupor, and coma. Document and report to the physician as needed. Record review of Resident #3's physician orders, dated 4/17/25, revealed an order for sitagliptin phosphate (antidiabetic medication used to treat type 2 diabetes) give 1 tablet via PEG tube in the morning related to type 2 diabetes with ketoacidosis without coma, with a start date of 1/22/25 and no end date. Record review of Resident #3's physician orders, dated 4/17/25, revealed an order for blood glucose check for 7 days with a start date of 1/23/25 and an end date of 1/30/25. Record review of Resident #3's glucose readings were as follows: 1/29/2025 08:24 288.0 mg/dL RN B (Manual) 1/28/2025 08:28 245.0 mg/dL LVN C (Manual) 1/27/2025 08:42 219.0 mg/dL LVN C (Manual) 1/26/2025 08:55 337.0 mg/dL RN B (Manual) 1/25/2025 08:06 225.0 mg/dL RN B (Manual) 1/24/2025 08:46 269.0 mg/dL RN B (Manual) 1/23/2025 08:11 169.0 mg/dL LVN C (Manual) Record review of Resident #3's nursing progress notes, dated 4/17/25, revealed no nursing notes in refence to high blood glucose levels. Progress noted dated 1/30/25 at 8:14 p.m. written by RN D stated family called 911 due to change in condition. Notified family of chest x-ray ordered, family called 911. Vitals assessed BP: 103/80, O2 NC 3L 93%. No facial grimacing. Wheezing heard upon exhalation. HOB elevated to semi-Fowler_position. Blood sugar level 503. EMS arrived and tending to patient. Wound vac removed. Dressing applied to right hip. RP in room with patient and EMS. EMS transferring patient to [Hospital] via stretcher. Notified ADON, DON, and Administrator. Notified MD. During an interview on 4/17/25 at 9:43 a.m. LVN E stated she would notify the MD if a Resident blood glucose was over 300. During an interview on 4/17/25 at 10:54 a.m. RN B stated if a residents blood glucose is over 400 and they prescribed insulin they would administer the insulin and notify the doctor. RN B stated if the resident had a high glucose reading she would take it twice and then call the provider and let them know the resident does not take insulin and only takes an oral medication daily. RN B stated she did not recall if she notified the provider about the blood glucose reading of 337 on 1/26/25 or what interventions were provided. RN B stated she should document what happened. RN B stated the provider did rounds at the facility often and she most likely notified him in person and forgot to write a note. During an interview on 4/17/25 at 12:22 p.m. the DON stated staff should contact the provider if a resident is only on oral medication for blood glucose management and is regularly having glucose readings over 200. The DON stated they should contact the doctor and document. The DON stated best practice would be to write a note. The DON stated however the provider was there often and the staff mostly likely was updating him in person. During an interview on 4/17/25 at 2:23 p.m. The Doctor stated staff always notified him when Resident #3 had high blood glucose readings. The Doctor stated he recalled the family was more concerned with pain medication for the resident and never stated they thought the blood glucose was an issue. The Doctor stated he knew the Resident's family had called 911 and the resident went to the hospital, but he did not know anything else about her status after he discharged . Record review of the facility's policy titled Following Physician Orders, dated 9/28/21, stated Policy: The policy provided guidance on receiving and following physician orders .3. For consulting physician/practitioner orders received via telephone, the nurse will: a. Document the order on the physician order form, notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order. b. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. c. Carry out and implement physician orders d. Document resident response to physician order in the medical record as indicated .

Based on interviews, observations and record reviews, the facility failed to ensure the residents had the right to be free from physical abuse for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA B did not hit Resident #1 on her head while trying to get her undressed to take a shower on 11/13/24. The noncompliance was identified as PNC IJ. The noncompliance began on 11/13/2024 and ended on 11/13/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for harm and continued abuse. The findings included: Record review of Resident #1's admission record reflected a [AGE] year-old resident with an admitted [DATE] and diagnoses of cerebral palsy (a group of disorders that affect movement, balance, and posture) and aphasia (a language disorder that affects a person's ability to communicate effectively). Resident #1's Annual MDS with a completion date of 12/23/2024 reflected that she was not understood and was severely impaired cognitively. Resident #1 also require extensive assistance with all Activities of Daily Living. Record review of Resident #1's Care Plan revealed she was PASRR positive and received habilitative PT/OT/ST services due to mild intellectual disability; had a mood problem related to schizophrenia, depression, anxiety; and she is resistant to care and at risk for injury, a decline in functional abilities, and not having her needs met in a timely manner. Interventions included PT/OT/ST 3 times per week; anticipate and meet needs; and monitor/document for physical/nonverbal indications of discomfort or distress, and follow up as needed. Review of Provider Incident Report dated 11/13/24 revealed CNA A and CNA B were preparing Resident #1 for a shower on 11/13/24. While CNA B was getting Resident #1 undressed, resident was hitting out. CNA A stated Resident #1 was hit by CNA B on her hands and feet. Then CNA A stated she witnessed CNA B hit Resident #1 with her fist in the forehead. Resident #1 had a visible knot to the right side of her forehead. Observation of Resident #1 on 01/15/25 at 3:18 pm revealed a petite woman in the bed. Upon seeing surveyor, she appeared to get upset, was pointing and babbling and was unable to communicate. Resident #1 then calmed down after surveyor talked softly and calmly to her. Resident #1's bed was pushed against the wall on one side and she had a fall mat on the open side of the bed. There were no obvious signs of bruising or trauma to her head since these areas had healed prior to surveyor's entry. An attempted telephone interview on 01/15/25 at 3:18 pm was made to CNA B but the phone number was no longer in service. Interview with CNA A on 1/15/25 at 4:13 pm revealed while CNA B was getting Resident #1 undressed, she went to get some gloves. Upon her return she heard Resident #1 screaming, which she frequently does when she does not know someone. Resident #1 was also swinging her hands and feet at CNA B at which time CNA B used her fist and hit Resident #1 in the head and left the resident's room. CNA A then said she finished the shower and put Resident #1 in bed. CNA A began brushing Resident #1's hair and noted a knot on her head. CNA A said she reported the incident to Med Aide C who reported the incident to LVN D. Interview with Med Aide C on 01/16/25 at 11:00 am revealed she had been advised by CNA A about the incident. Med Aide C said she told CNA A that she needed to report it but CNA A expressed fear of CNA B. Med Aide C then reported to LVN D who reported it to the DON. Med Aide C stated CNA B seemed a little rough with residents but felt it was because she was a big girl and did not believe she would actually hurt a resident. Med Aide C stated the staff was given an inservice on the abuse policy immediately following the incident and she has also watched an online class on abuse as part of their annual training. Interview with LVN D via telephone on 01/15/25 at 1:59 pm revealed Resident #1 was in bed and had had a fall the week prior to this incident. Resident #1 was noted to have slight injuries to her face from the fall. LVN D stated she had pictures of Resident #1's injuries from that fall and the knot on the head following this incident was not present after her fall. LVN D stated she had worked with CNA B and some residents had complained about her attitude, but she had not been known to be physically aggressive toward residents. LVN D stated she reported the incident to the DON who then reported it to the Administrator. Interview with the DON on 1/15/25 at 1:38 pm revealed CNA B had told her she was just trying to assist CNA A and denied going in the shower. When the DON talked with CNA B, she denied she had hit Resident #1. The DON stated she asked CNA A to demonstrate how hard CNA B hit resident by having her hit a water bottle. The DON stated it was a substantial hit which she demonstrated for the surveyor. A loud pop could be heard as the fist hit the bottle. The DON also stated the Treatment Nurse had assessed the resident and found a 1 inch diameter mark on the resident's right eyebrow. Record review of CNA B's employee file revealed she was a Certified Nurse Aide hired on 07/15/24 and was employable. There were no disciplinary actions in her file prior to this incident. Record review of the facility Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/22 and Revised 09/06/24 stated: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property. Components of the facility abuse prohibition plan included: 3. Prevention of Abuse, Neglect and Exploitation including establishing a safe environment, Identifying, correcting, and intervening in situations in which abuse is suspected .and providing residents, representatives, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed. 4. Identification of Abuse, Neglect and Exploitation including possible indicators of abuse . 5. Investigation of Alleged Abuse, Neglect and Exploitation that included An immediate thorough investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. 7. Reporting/Response included reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes. The Administrator was notified on 01/17/25 at 1:40 p.m., that a past non-compliance IJ situation had been identified due to the above failures and was presented with a PNC IJ Template. It was determined these failures placed Residents #1 in an IJ situation on 11/13/24. During an interview with the Administrator on 1/16/25 at 2:22 pm, she stated the facility took the following measures after the incident: 1) The Administrator began an immediate investigation into the incident. 2) A police report was made and the physician and guardian were notified. 3) Both of the CNAs were suspended pending the outcome of the investigation. 4) CNA B was terminated, and the Administrator stated she tried to report her to the EMR but was told she could not do so. 5) CNA A was suspended for a couple of days due to not reporting the incident immediately and not intervening to prevent the aggression from CNA B. CNA A finished the shower and was brushing Resident #1's hair when she noted the knot on her head before she reported it. CNA A was then brought back to work after a 1:1 counseling about the abuse policy. 6) All facility staff were in-serviced on the Abuse and Neglect policy and the requirement to intervene to prevent injury to the resident. All new hires are also in-serviced as part of the new hire onboarding process. 7) The facility reported the incident to the state. Interviews from 01/16/25 at 3:15 pm through 01/17/25 at 10:30 am with 116 staff members from all shifts (MA C, LVN D, DON, MDS E, CNA F, RN G, RN, H, CNA I, Central Supply, Rehab Tech J, RN K, CNA L, HR, RN M, RN N, CNA N, LPN O, ADON P, CNA Q, CNA R, Nursing Staff S, CNA T, CNA U, LPN V, CNA W, RN X, Rehab Tech Y, ST Z, Director of Rehab, OTA AA, PTA BB, PTA CC, PTA EE, OTA FF, Social Services Director, RN GG, Receptionist, HH, OTA KK, Receptionist II, CNA JJ, Driver KK, RN LL, LPN MM, LPN NN, BOM, CNA OO, Maintenance Director, CNA PP, LVN QQ, MA SS, LPN TT, CNA UU, CNA VV, Nursing Staff WW, LPN XX, CNA YY, CNA ZZ, OTA AAA, CNA BBB, LPN CCC, CNA DDD, Business Development, CNA EEE, CNA FFF, RN GGG, PT HHH, Activities Director, CNA III, Maintenance JJJ, PT KKK, LPN LLL, LPN MMM, CNA NNN, CNA OOO, CNA PPP, CNA QQQ, CNA RRR, ST SSS, OT TTT, LPN UUU, PTA VVV, CNA WWW, LPN XXX, LPN YYY, LPN ZZZ, MA AAAA, LPN BBBB, RN CCCC, CNA DDDD, CNA EEEE, RN FFFF, CNA GGGG, CNA HHHH, Food Service Supervisor, Dietary Aide, JJJJ, Dietary Aide KKKK, Dietary Aide LLLL, Dietary Aide MMMM, Dietary Aide NNNN, Dietary Aide OOOO, Dietary Aide PPPP, Dietary Aide QQQQ, Dietary Aide RRRR, Dietary Aide SSSS, Dietary Aide UUUU, Housekeeping VVVV, Housekeeping WWWW, Housekeeping XXXX, Housekeeping YYYY, Housekeeping, ZZZZ, Housekeeping AAAAA, Housekeeping BBBBB, Housekeeping CCCCC and the Administrator) were able to describe the inservice conducted immediately following this incident and were able to explain they were supposed to intervene in an abusive situation immediately. Interview on 01/16/25 at 7:25 pm indicated one unidentified staff member who had been recently hired stated the Abuse Policy was part of her orientation. The noncompliance was identified as PNC. The IJ began on 11/13/2024 and ended on 11/13/2024. The facility had corrected the noncompliance before the survey began.