Every finding on record at Altamaha Healthcare Center

Based on resident and staff interviews, record review, review of the facility documents titled, PBJ (payroll-based journal) Staffing Data Report, and review of the facility policy titled, Staffing Policy, the facility failed to ensure Registered Nurse (RN) coverage was available in the facility for eight consecutive hours daily. This failure had the potential to negatively impact all residents at the facility.Findings included:Review of the facility's policy titled, Staffing Policy, dated January 2025 documented Procedure. 4. Staffing will include a Registered Nurse (RN) 8 hours a day. 5. The nursing services department will be under the authority and responsibility of the director of Nursing service who is a licensed registered nurse and who works as least eight hours a day. Review of the facility's PBJ Staffing Data Report for fiscal year 2026, Quarter 1 (October 1, 2025- December 31, 2025) identified by the submitted data, including but not limited to: no RN hours on four or more days during the quarter. The report documented no RN hours on the following dates: 10/04/2025, 10/05/2025, 10/11/2025, 10/18/2025, 10/19/2025, 10/20/2025, 10/25/2025, 10/26/2025, 11/01/2025, 11/02/2025, 11/16/2025, 11/29/2025, 11/30/2025, 12/21/2025 The facility was unable to provide PBJ staffing data for January through March 2026 A review of the 2-week staffing grid for 05/04/ 2026 to 05/17/2026 revealed that eight of 14 days had no RN coverage documented. A review of the 2-week staffing grid for 05/18/ 2026 to 05/31/ 2026 revealed that 12 of 14 days had no RN coverage documented. Review of the facility's list of open positions, provided by the Administrator, revealed vacancies for weekend RN Supervisors and a full-time RN Unit Manager. During an interview on 06/04/2026, at 12:20 PM, Licensed Practical Nurse (LPN) AA revealed she had been responsible for scheduling staff independently for approximately five months. LPN AA provided a staff roster and confirmed several individuals listed were no longer employed by the facility. Review of the roster revealed the facility had no regularly scheduled RN's, except for RN PP, a newly hired part-time weekend supervisor who had started the previous weekend. LPN AA stated RN DD was no longer employed at the facility, RN QQ worked only one weekend per as needed and did not work during May 2026, and RN RR was no longer employed. LPN AA stated that when the Director of Nursing (DON) was unavailable, administration was notified; however, no additional RN coverage was obtained. LPN AA confirmed no RN was scheduled on May 23 and May 24, 2026, while the DON was attending a previously scheduled wedding, and administration and corporate staff were aware that no RN coverage had been arranged.During an interview on 06/04/2026 at 12:40 PM with the Director of Nursing (DON), she revealed she began employment on May 11, 2026, and was not informed during the hiring process that she would be the only RN employed at the facility. The DON confirmed there was no RN coverage on May 23 and May 24, 2026. She stated she had notified the corporate office in advance that she would be unavailable on those dates due to a prior commitment. The DON stated her expectation was that the facility maintain RN coverage for at least 8 hours each day.

Based on observation, interview, record review, and review of the facility's policies titled Safe Smoking Standard and Fall Management, the facility failed to ensure an environment free from accident hazards for two of 42 sampled residents (R) (R51 and R6). Harm was identified to have occurred on 7/30/2025, when Certified Nursing Assistant (CNA)12 was independently providing a bed bath for R51, and the resident fell from the bed. It was determined that R51 required two-person assistance for bed mobility (turning from left to right in the bed). Findings included:A review of the facility's policy titled Fall Management, dated January 2025, indicated, The facility strives to reduce the risk of falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program. Residents are assessed for the fall risk factors. The interdisciplinary team works with the residents and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. A review of the facility's policy titled Safe Smoking Standard, revised December 2022, indicated, No staff member, visitor, or resident is permitted to smoke inside the building at any time, this includes e-cigarettes and smokeless products such as chewing tobacco. The policy specified, Oxygen use is prohibited in the smoking area.1. A review of R51's admission Record revealed the facility admitted R51 on 7/3/2025. According to the admission Record, the resident had a medical history that included diagnoses of generalized muscle weakness and a need for assistance with personal care. A review of R51's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 7/9/2025, revealed R51 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was dependent on the staff for bathing. A review of R51's Care Plan Report included a focus area initiated 7/28/2025 that indicated the resident required assistance with activities of daily living (ADL) care related to activity intolerance, confusion, fatigue, impaired balance, and limited mobility. Interventions directed the staff to provide the resident with extensive assistance from one staff member with bathing/showering per schedule and as necessary, and that the resident required extensive assistance of two staff members to turn and reposition in bed as necessary. A review of R51's progress note dated 7/30/2025, during the provision of a bed bath by CNA12, when the resident was rolled, the resident's leg went off the side of the bed, which caused the resident to roll off the bed onto the floor. Per the progress note, the resident hit their head, which caused a laceration. The progress note indicated the resident was assessed by the Nurse Practitioner and subsequently transferred to the emergency room for further evaluation and treatment. A review of R51's hospital Visit Record dated 7/30/2025, indicated the resident fell out of the bed and hit their head while getting a bed bath. The record indicated the resident had a laceration to the scalp, a four-centimeter (cm) linear which was closed with skin glue and an adhesive. During an interview on 8/8/2025 at 2:49 pm, CNA12 stated she was told in the report when she started her shift for work about the needs of the residents, such as whether they needed one or two people for assistance. CNA12 stated she took care of R51 on 7/26/2025 before the fall, and the resident did not require two-person assistance, so she thought it was okay to give the resident a bed bath by herself. She stated the resident turned over onto their right side and just kept going. CNA12 stated that when the resident's leg went off the side of the bed, the resident slid off the bed. She stated the Director of Nursing (DON) and Administrator educated her to use two people with R51. CNA12 stated she did not mean for it to happen. During an interview on 8/8/2025 at 9:39 am, the Licensed Practical Nurse Unit Manager (LPN UM) stated that two people should be used for a bed bath if the resident required two people for bed mobility. The LPN UM stated that on 7/30/2025, when she entered R51's room, the resident was wrapped up in the covers and lying on the floor with the covers draped off the bed. The LPN UM stated the resident had a bleeding laceration to their forehead. During an interview on 8/8/2025 at 11:03 am, the DON stated the CNA should have two people for a bed bath if two people were needed for bed mobility. The DON stated the CNA was giving R51 a bath, unassisted, and when she turned the resident over, the resident just kept going off the side of the bed. She stated the resident got a laceration on their forehead, first aid was rendered, and the resident was transferred to the emergency room for further evaluation and treatment. According to the DON, CNA12 was in-serviced one-to-one to make sure she used two people when giving care. During an interview on 8/8/2025 at 11:30 am, the Administrator stated the staff should use two people for a bed bath if the resident required two persons to assist with bed mobility. The Administrator stated she was told the CNA was giving R51 a bed bath, and the resident rolled and fell out of the bed that was in a high position. She stated the CNA worked as needed, and she did not look for or ask how much assistance the resident needed. The Administrator stated she filed a state report, the CNA was educated, and an in-service was done. 2. A review of R6's admission Record revealed that the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease (COPD).A review of R6's Annual MDS assessment, with an ARD of 4/1/2025, revealed R6 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS indicated the resident used oxygen therapy.A review of R6's Order Summary Report that contained active orders as of 8/5/2025, revealed an order dated 7/18/2024 for supplemental oxygen at three liters per minute by way of a nasal canula as tolerated every shift. A review of records revealed a Facility Incident Report Form, dated 11/19/2024, indicated residents reported today [11/19/2024] that [R6] was smoking in the smoking area with [his/her] oxygen on. Resident states that [his/her] oxygen was turned off. No one was hurt.A review of records revealed an Employee Interview Form, signed by the Activities Director (AD) and dated 11/19/2024, indicated, On smoke break today at 11:00 am the smokers reported to me that [R6] was outside on last night's smoke break with [his/her] oxygen on smoking. A review of records revealed a Witness Statement Form, signed by R6 and dated 11/19/2024, indicated the resident admitted they had one cigarette, they turned their supplemental oxygen off, CNA15 lit their cigarette, and once they finished their cigarette, they turned their supplemental oxygen back on. A review of records revealed, CNA15's Witness Statement Form, dated11/19/2024, indicated, I took [R6] out to smoke and forgot to leave the [his/her O2 [oxygen] tank inside, even still I turned it off, asked my nurse what should have been the best thing to do the next day and he said I should have left it by the door my mistake.A review of records revealed that CNA15's Separation Notice, signed by the Administrator and dated 11/21/2024, indicated CNA15's employment with the facility was terminated on 11/22/2024 for a violation of company policy. Per the Separation Notice, CNA15 placed residents in danger by allowing a resident to smoke with a supplemental oxygen tank. During an interview on 8/7/2025 at 2:15 pm, R6 stated they went out one time to smoke with their supplemental oxygen, and the CNA who let them go out lost their job. R6 stated that after that incident, they began to vape. Review of R6's progress note dated 5/20/2025 revealed that the CNAs approached R6 in the DON's office and informed nursing that a vape was found in the resident's room. Per the progress note, staff saw smoke in the resident's room and walked in and saw the vape. A review of R6's social service progress note dated 5/21/2025, indicated a vape device was found in the resident's possession after the resident was reportedly caught smoking. During an interview on 8/7/2025 at 9:10 am, the AD stated CNA15 let R6 go out during a smoke break with a supplemental oxygen tank on the back of the resident's wheelchair. During an interview on 8/7/2025 at 10:33 am, the DON stated she believed staff knew it was not okay to have supplemental oxygen outside for a smoke break. During a follow-up interview on 8/7/2025 at 3:57 pm, the DON stated that 5/20/2025 was the first time R6 was found with a vape in their room. The DON stated the vape was removed, and the resident was caught again with a vape on 5/24/2025 in their room. The DON stated that the risk of vaping in a resident's room was that it could potentially start a fire. During an interview on 8/7/2025 at 4:13 pm, the Administrator stated she thought she had heard a while ago that R6 was vaping in their room. She did not recall what was done after the incident and did not know how many times the resident was caught with a vape. The Administrator stated the resident was not allowed to vape in their room because the resident was on supplemental oxygen, and it was flammable. During a telephone interview on 8/9/2025 at 9:18 am, the former DON stated she was the DON at the time when CNA15 allowed R6 to go outside with a supplemental oxygen tank to smoke. According to the former DON, R6 wanted to go outside with the group, and CNA15 told the resident it was okay to go outside with the supplemental oxygen tank because he had turned it off. The former DON stated it scared the other residents, and they reported it the next day. Per the former DON, CNA15 admitted he made a mistake. During a telephone interview on 8/9/2025 at 10:18 am, the former Administrator stated he was the Administrator when CNA15 allowed R6 to go outside with a supplemental oxygen tank to smoke. The former Administrator stated that CNA15 was suspended, and then their employment was terminated. During an interview on 8/9/2025 at 1:54 pm, the DON stated her expectation was that all smoking materials were to be kept with the staff and no residents could have smoking materials in their room. The DON stated that staff were expected to report any found smoking materials to anyone in charge. During an interview on 8/9/2025 at 2:44 pm, the Administrator stated her expectation for vapes in a resident's room was that they were not allowed, and she expected them to be stored with cigarettes. The Administrator stated she expected staff to report to her, the DON, or a nurse if they found a resident with a vape. During an interview on 8/9/2025 at 2:46 pm, the Administrator stated her expectation was that there were to be no supplemental oxygen tanks outside while residents were smoking.

Based on staff interviews and review of the facility's policy titled Grievance Policy, the facility failed to develop a grievance policy that met all regulatory requirements. This failure had the potential to affect all 56 residents who resided in the facility.Findings included:A review of the facility's policy titled, Grievance Policy, dated January 2025, revealed the policy did not include procedures to notify the resident of their right to file a grievance in writing or orally, the right to file a grievance anonymously, the reasonable timeframe the resident could expect a completed review of the grievance, the right to obtain the review in writing, the required contact information of the grievance official, and the contact information of outside entities with whom grievances could also be filed. The policy did not identify the grievance official and did not include steps to prevent any further potential violation of any resident's rights during the grievance review. Furthermore, the policy did not describe how the facility supported the resident's right to voice any grievance without discrimination, reprisal, or the fear of discrimination or reprisal, made prompt efforts to resolve the resident's grievance, or made information on how to file a grievance or complaint available to the residents.During an interview on 8/7/2025 at 9:35 am with the Administrator and the Regional Nurse Consultant (RNC), the Administrator stated that the grievance policy was the policy that the facility had and that she was not aware of any other policy. After review of the policy, the RNC stated the grievance policy did not meet any of the regulatory requirements. The RNC stated that some of the grievance policy requirements were met under resident rights, but were not reflected in the grievance policy.During an interview on 8/8/2025 at 7:58 am, the Administrator stated she used the policies that the company provided and ensured they were followed.During a follow-up interview on 8/8/2025 at 8:07 am, the Administrator stated her expectation regarding the grievance policy was that it covered all the areas of regulation.

Based on observation, interview, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure that two of two medication carts were locked when out of the sight of a licensed nurse.Findings included:A review of the facility's policy titled Medication Administration, dated 1/2025, indicated, Medication carts are to be kept locked at all times and under the visual supervision of the licensed nurse.During an observation on 8/4/2025 at 11:22 am, the medication cart in the 300 Hall was unlocked, and the nurse was in a room down the hall.During a concurrent observation and interview on 8/6/2025 at 8:45 pm, a medication cart located by room [ROOM NUMBER] was unlocked, and there were three bottles of medications on top of the cart: iron, melatonin, and docusate sodium. Licensed Practical Nurse (LPN)1 walked down the hall after coming out of room [ROOM NUMBER] and stated the medication cart should have been locked when she walked away, but a resident needed something from her. LPN1 stated the medication cart should be locked anytime it was out of sight of the nurse. LPN1 again stated she should have locked the cart when she walked away from it.During an interview on 8/8/2025 at 9:39 am, the LPN Unit Manager stated the medication cart should be locked at all times when not in sight of the nurse to prevent anyone from getting into it.During an interview on 8/8/2025 at 11:03 am, the Director of Nursing stated the medication cart should be locked at all times when not in sight of the nurse so that no one could tamper with the cart.During an interview on 8/8/2025 at 11:30 am, the Administrator stated the medication cart should be locked at all times when the nurse is not in front of it.

Based on resident and staff interviews and review of the facility's policy titled Resident Rights & Dignity Management, the facility failed to ensure mail was delivered to residents on Saturdays. Specifically, mail was delivered to a locked box outside the facility on Saturdays; however, no staff retrieved and delivered the mail to the residents until Monday morning. This had the potential to affect all residents who might have received mail on Saturdays.Findings included:A review of the facility's policy titled Resident Rights & Dignity Management, dated January 2025, indicated, 3. The facility will make every effort to assist each resident in exercising their right to ensure that the resident is always treated with respect, kindness, and dignity.During a Resident Council meeting on 8/5/2025 at 3:00 pm, six residents stated they did not receive mail on Saturdays. Per the residents, the Activities Director (AD) delivered the residents' weekend mail on Monday mornings.During an interview on 8/9/2025 at 10:08 am, the AD stated that mail delivery came around 11:30 am, Monday through Friday, and on Saturdays to the locked box located outside the front door of the facility. The AD stated that if she was not at work on the days that the mail was delivered by the post office, the mail stayed in the mailbox until she came in on Monday mornings. During an interview on 8/9/2025 at 11:20 am, the Director of Nursing (DON) stated that before 8/9/2025, all she knew was that she saw the mail carrier come and place mail in the box outside the facility, and she believed the AD retrieved the mail from the box and distributed the mail to the residents. Per the DON, she was unaware of what occurred with the mail on Saturdays. The DON stated she had not thought about the mail or the days of the week the mail was delivered. During an interview on 8/9/2025 at 10:19 am, the Administrator stated that mail was delivered from the post office to a locked mailbox in front of the building. The Administrator stated she did not have any expectations about mail delivery on Saturdays, as she had not thought about the weekends. She stated her expectation going forward would be that the manager on duty would check and distribute the residents' mail on Saturdays. During an interview on 8/9/2025 at 11:38 am, the Regional Operations Manager stated the facility did not have a policy related to mail delivery.

Based on observation, interview, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure the medication error rate was five percent (%) or less. There were six medication errors out of 27 opportunities, which yielded a medication error rate of 22.2% for three of five residents (R) (R5, R10, and R45) observed for medication administration.Findings included:A review of the facility's policy titled Medication Administration, dated 1/2025, indicated, Policy: To promote the health and safety of the residents we serve by ensuring safe assistance and administration of medications and treatments. The policy specified, b. The residents' MAR [medication administration record] is reviewed to determine what medications are to be administered, and then the staff removes those medications from the medication cart. c. Staff will compare the MAR with the label of each medication for the following: i. Right Person ii. Right Medication iii. Right Date iv. Right Time v. Right Route vi. Right Dose vii. Expiration Date.1. A review of the manufacturer's instructions for use for the Novolin R FlexPen revised November 2022, indicated Giving the airshot before each injection. Before each injection, small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to make sure you take the right dose of insulin: E. Turn the dose selector to select 2 units. F. Hold your Novolin R FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the Novolin R FlexPen. A small air bubble may remain at the needle tip, but it will not be injected.A review of R45's Order Summary Report, which contained active orders as of 8/9/2025, included the following orders:- an order dated 6/24/2025, for omeprazole oral capsule delayed release 20 milligrams (mg), give one capsule by mouth at bedtime for gastroesophageal reflux disease.- an order dated 7/21/2025, for quetiapine fumarate tablet 25 mg, give one tablet by mouth at bedtime, related to a psychotic disorder with hallucinations due to a known physiological condition.- an order dated 6/24/2025, for senna oral tablet 8.6 mg, give one tablet by mouth at bedtime for constipation.- an order dated 6/24/2025, for Novolin R insulin solution, inject as per sliding scale if blood glucose level is 301-350 milligrams per deciliter (mg/dL), inject 8 units per sliding scale.During a concurrent medication administration observation and interview on 8/6/2025 at 8:14 pm, Licensed Practical Nurse (LPN)2 did not administer R45's omeprazole, quetiapine, or senna. LPN2 checked R45's blood glucose level, and it was noted to be 347 mg/dL. LPN2 did not prime the insulin pen needle after he placed it on the Novolin R pen and turned the dose knob to 6 units. LPN2 administered 6 units of insulin instead of the ordered 8 units. LPN2 stated he did not know the insulin pen needle needed to be primed.During a follow-up interview on 8/7/2025 at 6:45 am, LPN2 stated he should have followed the five rights of medication administration and double checked to make sure all the medications were given. LPN2 stated he did not realize he had not given the senna or omeprazole, and he overlooked getting the quetiapine out of the emergency kit.2. A review of the Basaglar Tempo Pen Instructions for Use, revised November 2022, indicated, Priming your Pen Prime before each injection. Priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your Pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with the Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat the priming steps 6 to 8, but not more than 4 times. If you still do not see insulin, change the Needle and repeat the priming steps 6 to 8. Small air bubbles are normal and will not affect your dose.A review of R10's Order Summary Report that contained active orders as of 8/9/2025 revealed an order dated 5/15/2025 for Basaglar Kwik Pen subcutaneous solution pen injector 100 units per milliliter, inject 30 units subcutaneously at bedtime for type 1 diabetes mellitus with diabetic neuropathy.During a concurrent medication administration observation and interview on 8/6/2025 at 9:23 pm, Licensed Practical Nurse (LPN)1 did not prime the needle after she placed it on the Basaglar Kwik Pen and turned the dose knob to 30 units. LPN1 stated she did not know the needle needed to be primed.3. A review of the Lantus Solostar Instructions for Use, revised May 2025, indicated, Step 3: Do a safety test. Always do a safety test before each injection to check your pen and the needle to make sure they are working properly. Make sure that you get the correct Lantus dose. 3A Select 2 units by turning the dose selector until the dose pointer is at the 2 mark. 3B Press the injection button all the way in. When insulin comes out of the needle tip, your pen is working correctly: If no insulin appears, you may need to repeat this step up to 3 times before seeing insulin. If no insulin comes out after the third time, the needle may be blocked. If this happens: change the needle, then repeat the safety test. Do not use your pen if there is still no insulin coming out of the needle tip. Use a new pen. Do not use a syringe to remove insulin from your pen. If you see air bubbles: You may see air bubbles of the insulin. This is normal; they will not harm you. The Instructions for Use specified, Step 5: Injecting Your Lantus Dose 5C. Place your thumb on the injection button. Then press all the way in and hold. 5D Keep the injection button held in and when you see 0 in the dose window, slowly count to 10. This will make sure you get your full dose.A review of R5's Order Summary Report that contained active orders as of 8/9/2025, revealed an order dated 11/25/2024, for Lantus Solostar subcutaneous solution pen-injector 100 units per milliliter, inject 15 units subcutaneously one time a day for diabetes.During a concurrent medication administration observation and interview on 8/7/2025 at 8:04 am, the Licensed Practical Nurse Unit Manager (LPM UM) did not prime the needle after she placed it on the Lantus pen injector and turned the dose knob to 15 units. When the LPN UM injected the insulin, she did not hold the pen in place for a count of 10. The LPN UM stated she did not know the needle needed to be primed.During an interview on 8/10/2025 at 11:03 am, the Director of Nursing stated the insulin pen needle should be primed with one to 2 units so no air is injected.During an interview on 8/8/2025 at 3:12 pm, the Nurse Practitioner stated insulin pens should be primed with two units before the dose being given to ensure the needle worked and the resident received the appropriate dose of insulin.During an interview on 8/8/2025 at 11:30 pm, the Administrator stated she deferred all medication questions to the clinical team but expected the staff to follow the manufacturer's guidelines and standards of practice.

Based on interview, record review, review of the Healthcare Professional Operator's Manual and review of the facility's policies titled, Glucometer Cleaning, and Respiratory Management, the facility failed to ensure that infection control practices were followed for five of five of 42 sampled residents (R) (R30, R45, R49, R24 and R47). Specifically, the nurse failed to ensure that the glucometer was cleaned and disinfected between use for R30, R45, and R49; the facility also failed to ensure that staff did not touch medication with their bare hands for R45 during medication administration; and the facility failed to ensure that respiratory equipment was cleaned and stored appropriately for R24 and R47.Findings included: A review of the facility's policy titled Glucometer Cleaning, dated January 2025, indicated, All glucometers must be cleaned/disinfected after each resident use. Per the policy, Wipe Down with Sani-cloths. The policy specified, Supplies and medications for finger stick monitoring or insulin administration should not be placed on potentially contaminated environmental surfaces.A review of the undated Healthcare Professional Operator's Manual for the EvenCare G3 Blood Glucose Monitoring System indicated, The EVENCARE G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The manual specified, Step 4. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter, including both the front and back surfaces, until visibly clean. Avoid wetting the meter test strip port. Step 5. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Other EPA-registered wipes may be used for disinfecting the EVENCAR G3 system; however, these wipes have not been validated and could affect the performance of the meter. Wipe all external areas of the meter, including both front and back surfaces, until visibly wet. Avoid wetting the meter test strip port. Wipe meter dry or allow to air dry.A review of the facility's policy titled Respiratory Management, dated January 2025, indicated Continuous Positive Airway Pressure (CPAP) or Bi-Level Positive Airway Pressure (BiPAP) Policy. CPAP/BiPAP is provided to residents who have a physician's order. Per the policy, 2. Clean mask and hose with soap and water as needed and/or weekly. Cleaning for CPAP mask, frame, and headgear: -Unplug from power source -Disconnect mask and air tubing from CPAP machine-Disassemble mask into three parts -In a sink, clean mask, and headgear to remove any oils using soap and water; avoid using strong chemicals including dish detergent and they may damage the mask -Place cushion and frame on flat surface on top of a towel to dry -Disconnect air tubing from mask and CPAP machine -Rinse the inside and outside of the air tubing with mild soap and warm water, rinse again -Place tubing on flat surface on top of towel to dry -Disconnect humidifier tub from CPAP machine and rinse with mild soap and water -Place tub on flat surface on a towel to dry. The section of the policy titled Aerosolized Medication indicated, 17. Rinse the nebulizer and mouthpiece. Shake the air dry and store it in a plastic bag that is labeled with the resident's name and room number. Nebulizer and mouthpiece may also be stored in the machine if a storage shelf is available. 1. A review of R45's admission Record revealed that the resident had a medical history that included a diagnosis of type 2 diabetes mellitus with hyperglycemia (high blood sugar). A review of R45's Significant Change in Status Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/30/2025, revealed R45 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident received insulin injections.A review of R45's Care Plan Report included a focus area initiated 10/11/2024, which indicated the resident had insulin-dependent diabetes mellitus. Interventions instructed staff to provide diabetes medication as ordered by the doctor and observe and document for side effects and effectiveness. During a concurrent medication administration observation and interview on 8/6/2025 at 8:14 pm, Licensed Practical Nurse (LPN)2 entered R45's room and obtained the resident's fingerstick blood sugar. Afterwards, LPN2 cleaned the glucometer with an alcohol wipe and allowed it to air dry. LPN2 stated he cleaned the glucometer between each use and thought it was appropriate to use an alcohol wipe to clean it since he used alcohol to sanitize his hands. LPN2 then went back to the medication cart and popped a pill out of a medication card into his bare hand and placed the pill in a medication cup. LPN2 was stopped and admitted that he had touched the pills. LPN2 stated he should not have touched the pills and threw both pills away, and popped out new pills appropriately. 2. A review of R30's admission Record revealed that the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. A review of R30's Quarterly MDS assessment, with an ARD of 7/15/2025, revealed R30 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated R30 received insulin injections.A review of R30's Care Plan Report included a focus area revised 5/25/2021, which indicated the resident had diabetes mellitus. Interventions instructed staff to provide diabetes medication as ordered by the doctor and observe and document for side effects and effectiveness. A review of R49's admission Record revealed, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. A review of R49's Quarterly MDS, with an ARD of 5/16/2025, revealed that R49 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated R49 received insulin injections.A review of R49's Care Plan Report included a focus area revised 9/17/2024, which indicated the resident had insulin-dependent diabetes mellitus. Interventions instructed staff to provide diabetes medication as ordered by the doctor and observe and document for side effects and effectiveness. During a concurrent observation and interview on 8/6/2025 at 8:48 pm, LPN1 had a glucometer sitting on top of the medication cart. LPN1 entered R30's room to check the resident's blood sugar. After obtaining the blood sample, LPN1 set the glucometer on the resident's bed while awaiting the results. Once the results were received, LPN1 took the glucometer out to the medication cart and did not clean or disinfect it prior to checking the blood sugar for R49. After checking R49's blood sugar, LPN1 went out of the resident's room and placed the glucometer on top of the medication cart. At 9:08 pm, LPN1 was stopped prior to checking the next resident's blood sugar, and she stated she was supposed to clean the glucometer between each use with the germicidal wipes. LPN1 stated she forgot, but she should have done it. LPN1 was not able to find the germicidal wipes on the medication cart and had to get a container of germicidal wipes from the front desk. During an interview on 8/8/2025 at 9:39 am, the LPN Unit Manager (UM) stated medications should not be touched with bare hands because it was an infection control and contamination issue. The LPN UM stated the glucometer should be cleaned before starting and between each resident use before it was placed back into the medication cart. The LPN UM stated the glucometer should be cleaned with germicidal wipes for infection control and to prevent cross-contamination. During an interview on 8/8/2025 at 11:03 am, the Director of Nursing (DON) stated the nurse should not touch medications with their bare hand, and if they did, the medication should be thrown away. The DON stated the glucometer should be cleaned after each resident's use with the germicidal wipes to prevent cross-contamination. During an interview on 8/8/2025 at 11:30 pm, the Administrator stated she deferred all questions to the clinical team but expected the staff to follow the facility policy, manufacturer's guidelines, and standards of practice. 3. A review of R47's admission Record revealed that the resident had a medical history that included a diagnosis of shortness of breath.A review of R47's Quarterly MDS, with an ARD of 5/12/2025, revealed R47 had a BIMS score of 15, which indicated the resident had intact cognition. A review of R47's Order Summary Report that contained active orders as of 8/6/2025, revealed an order dated 5/23/2025, for albuterol sulfate nebulization solution 0.083% three milliliters (ml) inhaled orally by way of nebulizer every six hours as needed for shortness of breath. A review of R47's Medication Administration Record for the timeframe 8/1/2025 through 8/31/2025 revealed the resident received an albuterol nebulizer treatment on 8/3/2025 at 12:22 pm. During a concurrent observation and interview on 8/4/2025 at 3:56 pm, the surveyor noted a nebulizer machine on R47's nightstand with the tubing attached to the machine and the mask with a medication cannister lying on top of the machine. R47 stated that the tubing, mask, and medication cannister were new, but they had never seen the staff clean the equipment before. During a concurrent observation and interview on 8/6/2025 at 8:30 am, the surveyor noted a nebulizer mask and a medication canister with a small amount of fluid were sitting on top of R47's nightstand next to the nebulizer machine. R47 stated the staff did not rinse it out. During a concurrent observation and interview on 8/6/2025 at 9:58 pm, LPN2 stated nebulizer equipment should be rinsed out and placed on a paper towel to air dry, then placed in the plastic bag. LPN2 entered R47's room and noted the resident's nebulizer mask and medication canister were lying on top of the nightstand on top of a plastic bag, and there was a small amount of fluid in the canister. LPN2 stated there should not be any fluid in the canister, and it should be stored in the bag, not on top of it. During an interview on 8/8/2025 at 9:39 am, the LPN Unit Manager stated that the nebulizer equipment should be rinsed out after use and stored in a plastic bag. During an interview on 8/8/2025 at 11:03 am, the DON stated that the nebulizer equipment should be wiped out after use, the tubing changed out once a week, and it should be stored where it is clean and dry or in a bag when not in use. During an interview on 8/8/2025 at 3:12 pm, the Nurse Practitioner stated the nebulizer mask should have been cleaned after use and stored in a bag to prevent infection. During an interview on 8/8/2025 at 11:30 pm, the Administrator stated she deferred all questions to the clinical team related to the use, cleaning, and storing of nebulizer machines, but stated the staff should be following their policy. 4. A review of R24's admission Record revealed that the resident had a medical history that included diagnoses of obstructive sleep apnea and dependence on other enabling machines and devices. A review of R24's Quarterly MDS assessment, with an ARD of 7/30/2025, revealed R24 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS indicated the resident received non-invasive mechanical ventilator treatment. A review of R24's Care Plan Report included a focus area initiated on 8/9/2023. The document revealed that R24 had an altered respiratory status and difficulty breathing related to sleep apnea. Interventions directed staff on CPAP settings, to titrate pressure per physician orders by way of nasal pillow, nose mask, and full-face mask as per the resident's preferences and tolerance.A review of R24's Order Summary Report that contained active orders as of 8/8/2025, revealed an order dated 2/6/2025, for CPAP settings at 14 at bedtime and naps as tolerated. There was also an order dated 5/15/2024, to cleanse the CPAP water chamber with soap and water weekly and rinse it out before putting distilled water into it.During an observation on 8/4/2025 at 11:36 am, revealed, a CPAP machine was revealed on R24's nightstand with the mask lying on top of the machine. There was dried debris noted in the mask, and there was no bag to store the mask in. During an interview on 8/8/2025 at 9:39 am, the LPN UM stated the CPAP mask should be stored in a plastic bag when not in use and cleaned once a week, and as needed, according to the facility's policy and procedure. During an interview on 8/8/2025 at 11:03 am, the DON stated the CPAP mask should be wiped out after use and the tubing cleaned weekly with soap and water. The DON stated the mask should be stored in a plastic bag or something to keep it clean and dry.During an interview on 8/8/2025 at 3:12 pm, the Nurse Practitioner stated the CPAP mask should be cleaned after use and stored in a bag. During an interview on 8/8/2025 at 11:30 pm, the Administrator stated she deferred all questions related to the use of the CPAP and cleaning and storing of the equipment to the clinical team.

Based on staff and resident interviews, record review, and review of the facility's policy titled Behavior Management Standard, the facility failed to discuss the risks and benefits and obtain informed consent before the administration of a psychotropic medication for one of five residents (R) (R4) reviewed for unnecessary medications.Findings included:A review of the facility's policy titled Behavior Management Standard, dated January 2025, indicated, The resident or their responsible party has the right to be informed about the resident's condition; treatment options; risks/benefits and expected outcomes of treatment for the purpose of making informed choices about the use of medications including the right to refuse care and treatment.A review of R4's admission Record revealed that the resident had a medical history that included diagnoses of vascular dementia, seizures, and nontraumatic subdural hemorrhage.A review of R4's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/20/2025, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated R4 received an antipsychotic medication within the last seven days of the look-back assessment period.A review of R4's Care Plan Report included a focus area initiated 8/4/2025 that revealed the resident used psychotropic medications related to behavior management and dementia. Interventions directed staff to educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of psychotropic medications being given.A review of R4's Psychotropic Medication Informed Consent for the antipsychotic quetiapine fumarate was signed by the resident with no date, and signed by Licensed Practical Nurse (LPN)10, dated August 5th, with no year.A review of R4's Medication Administration Record [MAR] for the timeframe 7/10/2025 through 7/30/2025, revealed an order entry for quetiapine fumarate (an atypical antipsychotic) 50 milligrams (mg) at bedtime for two weeks, with a start date of 7/14/2025 and a stop date of 7/30/2025. Documentation indicated the medication was administered to the resident daily from 7/14/2025 through 7/29/2025, for a total of 16 days. The MAR revealed another order entry for quetiapine fumarate 25 mg at bedtime with a start date of 7/31/2025. Documentation indicated the medication was administered to the resident on 7/31/2025.A review of R4's Medication Administration Record [MAR] for the timeframe 8/1/2025 through 8/31/2025 revealed an order entry for quetiapine fumarate 25 mg at bedtime for two weeks, with a start date of 7/31/2025. Documentation indicated the medication was administered to the resident daily from 8/1/2025 through 8/4/2025.During an interview on 8/6/2025 at 1:29 pm, R4 stated they did not know what the medication they were taking was or what it was for, but that on 8/5/2025, the nurse asked them to sign a paper to indicate it was okay to give it. R4 stated they signed the form because the nurse told them they would only be taking the medication for another couple of days. During an interview on 8/8/2025 at 10:25 am, LPN10 stated she was not aware that consents were needed for the use of psychotropic medications. She stated she obtained consent for R4's quetiapine when she was asked to by the Director of Nursing (DON).During an interview on 8/8/2025 at 9:39 am, the LPN Unit Manager (LPN UM) stated she found out the prior week that it was the nursing staff's responsibility to complete the consent forms for psychotropic medications. She stated the social worker had been obtaining consents previously. The LPN UM stated consent for the medication should be obtained before administering the medication. She stated she was not aware that R4 did not have consent for their quetiapine. During an interview on 8/8/2025 at 11:03 am, the DON stated the social worker was responsible for obtaining the consents for psychotropic medications, but she had been doing them in the social worker's absence since 7/30/2025. The DON stated consent should be obtained as soon as possible, within 72 hours of receiving the order. The DON stated she had just completed an audit and must have missed R4. During an interview on 8/8/2025 at 11:30 pm, the Administrator stated that consents for psychotropic medications should be obtained prior to the medication being administered, and the clinical team was responsible for obtaining the consent.

Based on staff and resident interviews, record review, and review of the facility's policy titled Freedom of Abuse - Abuse Prevention: Fast Alerts, the facility failed to report an allegation of abuse and neglect for two of two residents (R) (R66 and R14) reviewed for abuse out of a total sample size of 42 residents. Specifically, the facility failed to report an allegation of abuse/neglect made on 10/16/2024 by R66 that Certified Nursing Assistant (CNA)15 was rough during the provision of care and did not check on the resident or provide incontinence care from 6:00 pm to 6:00 am on 10/16/2024. Also, the facility failed to report an allegation of verbal abuse made on 10/22/2024 by R14 that CNA15 yelled at them.Findings included:A review of the facility's policy titled Freedom of Abuse - Abuse Prevention: Fast Alerts, dated January 2025, indicated, Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.A review of R66's admission Record revealed that the resident had a medical history that included a diagnosis of chronic pain. The admission Record indicated that the resident was discharged from the facility on 11/05/2024.A review of R66's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/8/2024, revealed R66 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff assistance for toileting hygiene and frequently experienced urinary and bowel incontinence during the seven-day assessment look-back period.A review of R66's Care Plan Report included a focus area initiated 10/31/2024, which indicated the resident had mixed bladder and bowel incontinence related to activity intolerance, impaired mobility, and diuretic use. Interventions directed staff that the resident used disposable briefs, and that staff were to change the briefs per routine and as needed (initiated 10/31/2024), and for staff to clean the perineal area with each incontinence episode (initiated 10/31/2024).A review of R66's medical records revealed a document titled Employee Counseling Form, signed by the former Director of Nursing (DON) on 10/17/2024 and by CNA15 on 10/18/2024, indicated R66 reported CNA15 did not check on the resident or provide incontinence care the entire 12-hour shift of 10/16/2024 from 6:00 pm to 6:00 am. The form further revealed CNA15 was rough with [the resident] during care. The form indicated R66 requested that CNA15 have no further contact with them.A phone interview was attempted with R66 on 8/8/2025 at 11:45 am and 8/9/2025 at 12:05 pm. No return call was received.During a telephone interview on 8/9/2025 at 9:07 am, the former DON stated she did not recall the incident with R66 and did not recall the resident. The former DON stated she did not think she reported the incident for abuse. She stated the resident being left soiled and care being rough were allegations that required reporting to the Abuse Coordinator and to the state agency.During an interview on 8/8/2025 at 10:45 am, the Administrator stated that the allegation that CNA15 did not change R66's brief and rough handled the resident on 10/17/2024 was an allegation of abuse and neglect and should have been reported to the state agency.2. A review of R14's admission Record revealed that the resident had a medical history that included the diagnoses of moderate intellectual disabilities and irritable bowel syndrome.A review of R14's Quarterly MDS assessment, with an ARD of 6/16/2025, revealed R14 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated the resident was dependent on staff assistance for toileting hygiene and was frequently incontinent of urine and always incontinent of bowel.A review of R14's Care Plan Report included a focus area initiated 7/18/2023, which indicated the resident had mixed bladder and bowel incontinence related to activity intolerance, impaired mobility, and cerebral palsy. Interventions directed staff that the resident used disposable briefs, and that staff were to change the briefs per routine and as needed (initiated 7/18/2023) and for staff to clean the perineal area with each incontinence episode (initiated 7/18/2023).A review of R14's medical record revealed a document titled Resident Grievance/ Concern/ Complaint Report, dated 10/22/2024 and signed by the Licensed Practical Nurse Unit Manager (LPN UM), indicated R14 was very upset that CNA15 yelled at them for having a bowel movement (BM) on themself. Per the report, the resident was very upset and stated they were going to have to find another place to go.A review of R14's medical record revealed a document titled Worksite Employee Warning Notice, signed by the former DON and dated 10/23/2024, indicating R14 stated CNA15 yelled at them for having a BM and soiling their sheets. Per the document, the resident accepted an apology from CNA15 but did not want CNA15 to provide care to them in the future.During an interview on 8/8/2025 at 11:25 am, R14 did not recall the incident in which a staff member yelled at them. During a telephone interview on 8/9/2025 at 8:43 am, the former DON stated she recalled R14's complaint on 10/22/2024. The former DON said the allegation that CNA15 yelled at R14 was an allegation of abuse. She stated the facility administration was aware of the allegation, but she did not recall if the allegation was reported to the state agency. The former DON stated that the Administrator was the Abuse Coordinator and would have made the report.During an interview on 8/8/2025 at 10:45 am, the Administrator stated that the allegation that CNA15 yelled at R14 on 10/22/2024 was considered an allegation of abuse and should have been reported to the state agency.During a follow-up interview on 8/8/2025 at 11:04 am, the Administrator stated the former Administrator should have reported the allegation regarding R14 and R66 to the state agency within two hours, but did not.During an interview on 8/9/2025 at 1:59 pm, the DON reviewed R14's and R66's incidents and stated they were allegations of abuse and should have been reported to the state agency.During an interview on 8/9/2025 at 2:47 pm, the Administrator stated her expectation for reporting abuse was that staff were to immediately report to the Abuse Coordinator, and the Abuse Coordinator had two hours to report to the state agency from the time the allegation occurred. The Administrator confirmed the allegations regarding R14 and R66 should have been reported to the state agency.

Based on staff interviews, record review, and review of the facility's policy titled Freedom of Abuse - Abuse Prevention: Fast Alerts, the facility failed to investigate an allegation of abuse and neglect for two of two residents (R) (R14 and R66) reviewed for abuse out of a total sample size of 42 residents.Findings included:A review of the facility's policy titled Freedom of Abuse - Abuse Prevention: Fast Alerts, dated 1/2025, indicated, All alleged violations involving mistreatment, sexually inappropriate behaviors, and abuse or neglect will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law.1. A review of R66's admission Record revealed the resident had a medical history that included a diagnosis of chronic pain. The admission Record indicated the resident was discharged from the facility on 11/5/2024.A review of R66's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/8/2024, revealed R66 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff assistance for toileting hygiene and frequently experienced urinary and bowel incontinence during the seven-day assessment look-back period.A review of R66's medical records revealed a document titled Employee Counseling Form, signed by the former Director of Nursing (DON) on 10/17/2024 and by CNA15 on 10/18/2024, indicated R66 reported CNA15 did not check on them or provide incontinence care the entire 12-hour shift of 10/16/2024 from 6:00 pm to 6:00 am. The form further revealed CNA15 was rough with [the resident] during care. The form indicated R66 requested that CNA15 have no further contact with them.2. A review of R14's admission Record revealed that the resident had a medical history that included the diagnoses of moderate intellectual disabilities and irritable bowel syndrome.A review of R14's Quarterly MDS assessment, with an ARD of 6/16/2025, revealed R14 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated the resident was dependent on staff assistance for toileting hygiene and was frequently incontinent of urine and always incontinent of bowel.A review of R14's medical records revealed a document titled Resident Grievance/ Concern/ Complaint Report, dated 10/22/2024 and signed by the Licensed Practical Nurse Unit Manager (LPN UM), indicated R14 was very upset that CNA15 yelled at them for having a bowel movement (BM) on themself. Per the report, the resident was very upset and stated they were going to have to find another place to go.A review of R14's medical records revealed a document titled Worksite Employee Warning Notice, signed by the former DON and dated 10/23/2024, indicating that R14 stated CNA15 yelled at them for having a BM and soiling their sheets. Per the document, the resident accepted an apology from CNA15 but did not want CNA15 to provide care for them in the future.During an interview on 8/9/2025 at 2:51 pm, the Administrator stated she was unaware if the allegations regarding R14 and R66 were investigated because she was unable to locate any documented evidence of an investigation.During an interview on 8/9/2025 at 4:23 pm, the Regional Nurse Consultant (RNC) stated that an investigation should have been conducted for the allegations regarding R14 and R66. The RNC said she was not aware of an investigation, and there was no evidence that an investigation occurred.During a follow-up interview on 8/9/2025 at 4:27 pm, the Administrator stated her expectation was that an investigation should have been conducted regarding the allegations of abuse and neglect and that the facility should have retained documentation of the investigation.

Based on staff interviews and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I was updated and resubmitted following the onset of a new mental illness diagnosis for one of 42 sampled residents (R) (R46) reviewed for PASARR.Findings included:A review of R46's admission Record revealed that the resident had a medical history that included diagnoses of vascular dementia with anxiety (onset date 7/1/2025), generalized anxiety disorder (onset date 11/1/2023), and other bipolar disorder (onset date 4/1/2025).A review of R46's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/25/2025, revealed R46 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident had active diagnoses to include anxiety disorder and bipolar disorder.A review of R46's Care Plan Report, included a focus area revised 4/25/2023, that indicated the resident used anti-anxiety medications related to a diagnosis of anxiety disorder. The Care Plan Report also included a focus area revised 5/1/2022, which indicated the resident used antidepressant medication related to a diagnosis of bipolar disorder.A review of R46's record revealed no evidence to indicate that a PASARR Level I was completed once the resident received a new mental illness diagnosis of bipolar disorder on 4/1/2025 or anxiety on 7/1/2025.During an interview on 8/7/2025 at 4:57 pm, the Regional Nurse Consultant stated that after reviewing R46's medical record, she determined that, based on the resident's current diagnoses, a review for a PASARR Level II should have been requested when the new diagnoses presented, and she was not sure why it was not done.During an interview on 8/8/2025 at 9:49 am, the MDS Coordinator stated that PASARR forms were completed by the admission staff, who initiated the PASARR and completed the PASARR Level I. The MDS Coordinator stated that if a resident acquired a new mental illness diagnosis, a new PASARR would be completed. The MDS Coordinator stated that a new PASARR should have been completed for R46. During an interview on 8/8/2025 at 8:00 am, the Administrator stated R46 should have had a new PASARR submitted, and she was not sure why it was not done.

Based on observations, staff interviews, record review, and review of the facility's policy titled Resident Hygiene, the facility failed to ensure nail care was provided for one of two residents (R) (R39) reviewed for activities of daily living (ADL) care. Findings included:A review of the facility's policy titled Resident Hygiene, dated January 2025, revealed that Nail care includes daily cleaning and regular trimming. Nail trimming for diabetic residents is per the MD [medical doctor] order. Podiatry care is scheduled as needed for those residents with identified podiatry needs. A review of R39's admission Record revealed that the resident had a medical history that included diagnoses of type 2 diabetes mellitus and the need for assistance with personal care. A review of R39's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/31/2025, revealed R39 had a Staff Assessment for Mental Status (SAMS), which indicated the resident was severely impaired in cognitive skills for daily decision-making. The MDS indicated the resident was dependent on staff assistance for bathing. A review of R39's Care Plan Report included a focus area initiated 6/9/2025, which indicated the resident required assistance with ADL care. Interventions directed staff to check nail length, trim and clean on bath day, and as necessary, and to report any changes to the nurse (initiated 6/9/2025).During an observation on 8/4/2025 at 12:45 pm, R39 was observed lying in their bed. The resident's toenails on both feet were long and extended approximately a half inch past the end of their toes. During an observation on 8/6/2025 at 9:14 am, R39 was observed lying in their bed. The resident's toenails on both feet remained long and extended a half inch past the end of their toes. A review of R39's medical records revealed a document titled Facility Visit History, dated 8/6/2025, which included a list of residents who had been seen by podiatry services from 5/5/2021 to 7/16/2025. R39 was not included on this list.During an interview on 8/6/2025 at 9:59 am, Certified Nursing Assistant (CNA)3 stated she kept R39's fingernails clean with daily care, but that the nursing staff did the trimming of the fingernails. She stated that she believed that the nurses cut the resident's toenails or that the podiatrist came in to cut them. During an interview on 8/7/2025 at 10:45 am, the Licensed Practical Nurse Unit Manager (LPN UM) stated that nail care was performed on Sundays by the CNAs. She stated that clipping or filing, and cleanliness were done daily and during showers. She stated that toenail care was completed by the podiatrist who came to the facility and trimmed toenails; however, if something needed immediate attention, it was taken care of. During a concurrent observation and interview on 8/7/2025 at 10:53 am, LPN UM inspected R39's feet and observed that on the resident's left foot, the big toenail was long, and the third and fourth toenails were long and curved over the top of each toe. All five toenails on the resident's right foot were long and extended approximately a half inch past the top of the toe, with the toenail on the large toe observed to be chipped. The LPN UM stated the resident should have been on the podiatry list and seen by the podiatrist, and she was not sure why they were not. The LPN UM stated she would get clippers and address the resident's toenails right away.During an interview on 8/8/2025 at 9:39 am, the Director of Nursing (DON) stated that nail care was generally done on Sundays, during ADLs, and as needed during bath or showers. She stated that CNAs were responsible for the cleaning portion of the nail care, and the nurses did the trimming. She stated that if a CNA saw a concern with a resident's toenails, they were to report the concern to the nurse. The DON stated the nurse should attempt to file or clip the nails, but if unable to trim the toenails, then the resident should be placed on the list to be seen by the podiatrist. The DON stated the CNA should have notified the nursing staff of R39's nails, and the concern should have been addressed by the assigned nurse or the podiatrist.During an interview on 8/8/2025 at 7:52 am, the Administrator stated that her expectation was for residents' toenails to be taken care of, and if the CNA saw a concern, they should go to the nurse immediately. The Administrator stated that if the nurse could not clip the toenails, they should refer the resident to the podiatrist. She said there was no reason R39's toenails should be long.

Based on observation, staff interviews, and record review, the facility failed to follow up on outside physician recommendations, which caused a delay in treatment for one of two residents (R) (R47) reviewed for skin conditions. Findings included: A review of R47's medical records revealed the resident had a medical history that included a diagnosis of seborrheic dermatitis.A review of R47's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/12/2025, revealed R47 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A review of R47's Care Plan Report included a focus area revised 4/15/2025, which indicated the resident had a potential for impairment to skin integrity related to eczema, edema, fragile skin, limited mobility, diabetes mellitus, and peripheral vascular disease. A review of R47's dermatology Office Visit Note dated 7/31/2025, revealed recommendations for treatment for the resident's diagnosis of seborrheic dermatitis on their face and ears included triamcinolone twice a day for two weeks on, then two weeks off, and ketoconazole 2% cream twice a day for two weeks on and then two weeks off. The note indicated recommendations for treatment for the diagnosis of actinic keratosis on the resident's body were for fluorouracil every night at bedtime for 30 days.A review of R47's Order Recap Report for the timeframe 3/1/2025 through 8/31/2025 revealed an order dated 7/31/2025, to cleanse the right side of the forehead with wound cleanser, pat dry, apply triamcinolone cream mixed with moisturizer, and cover with a small bandage every shift for 14 days, then off for 14 days. There was no evidence of an order for the ketoconazole and fluorouracil recommended by the dermatologist.During a concurrent observation and interview on 8/4/2025 at 1:30 pm, the surveyor noted R47 had a skin cancer removed from their left temple area. R47 stated it took them a year to get an appointment with the dermatologist to have it removed. During an interview on 8/6/2025 at 10:43 am, the Nurse Practitioner (NP) stated she gave the current orders for the treatment of the area to R47's right temple. The NP stated that the consultation from the dermatologist was not provided to her, and she had not seen the recommendations for the other areas of concern on the resident's body identified by the dermatologist. During an interview on 8/6/2025 at 12:15 pm, Licensed Practical Nurse (LPN)11 acknowledged that she was the treatment nurse and the only treatment orders that she received for R47 were for basic after-care treatment. LPN11 stated she did not get the dermatology notes or recommendation. LPN11 stated that when a resident came back from an outside physician appointment without paperwork, the nurse on the floor or the unit manager (UM) should call the physician's office and request it. During an interview on 8/8/2025 at 10:30 am, the LPN UM stated that the nurse assigned to the resident should follow up if a resident did not come back with paperwork from an outside appointment; however, it was also her responsibility to follow up. The LPN UM stated she did not know why R47's appointment was not followed up on, and she had not seen the consultation and could not say if there was a delay in treatment. During an interview on 8/8/2025 at 11:03 am, the Director of Nursing (DON) stated the nurse assigned to care for the resident should follow up when the resident went to an appointment. The DON stated that if the resident returned to the facility without paperwork, the UM should call to get the paperwork and see if there was a new order. The DON stated she was not aware that there were orders on the documentation from the dermatology office for other treatments besides the cancer removal area on the resident's temple. The DON stated she thought the resident already had those orders in place, and she could not say it was a delay in treatment. During an interview on 8/8/2025 at 11:30 am, the Administrator stated the UM should follow up on any resident appointments, and if the resident came back without paperwork, then they should call the physician's office to get the paperwork. The Administrator stated it was a delay in treatment because there was no follow-up done. During an interview on 8/8/2025 at 1:36 pm, the Regional Nurse Consultant stated the facility did not have a policy on following up after an outside provider appointment. During a follow-up interview on 8/8/2025 at 3:12 pm, the NP stated there had been an issue with follow-up from the outside provider since she started in March 2025. The NP stated she would go through the residents' charts and see that they went to the doctor and had recommendations, but nothing was done. The NP stated that the records needed to be available for her to review, and not having the records made the resident's record inaccurate, and it caused a delay in treatment for R47 when the documents from the dermatologist were not received and followed up on.

Based on observation, staff and resident interviews, record review, and review of the facility's policy titled Respiratory System Management, the facility failed to ensure respiratory equipment was available and functioning properly for one of four residents (R) (R24) reviewed for respiratory services.Findings included:A review of the facility's policy titled Respiratory System Management, dated January 2025, indicated Continuous Positive Airway Pressure (CPAP) or Bi-Level Positive Airway Pressure (BIPAP) Policy. CPAP/BIPAP is provided to residents who have a physician's order. The procedure specified, 10. The nurse or respiratory therapist should observe the resident with the mask on for proper fit.A review of R24's admission Record revealed that the resident had a medical history that included diagnoses of obstructive sleep apnea and dependence on other enabling machines and devices.A review of R24's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/30/2025, revealed R24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS assessment indicated the residents received non-invasive mechanical ventilator treatment.A review of R24's Care Plan Report included a focus area initiated 8/9/2023, which indicated the resident had altered respiratory status and difficulty breathing related to sleep apnea. Interventions directed staff on CPAP settings, to titrate pressure per physician orders by way of nasal pillow, nose mask, and full-face mask as per the residents' preferences and tolerance.A review of R24's Order Summary Report that contained active orders as of 8/8/2025 revealed an order dated 2/6/2025, for CPAP settings at 14 at bedtime and naps as tolerated. During an observation on 8/4/2025 at 11:36 am, the surveyor noted a CPAP machine on R24's nightstand with the mask lying on top of the machine.During an interview on 8/4/2025 at 11:45 am, R24 stated they needed a new CPAP mask and had been asking the facility for about three months. R24 stated they were told that since they brought the machine in from home, they would have to contact the company they got it from. Per R24, they did not have access to that information. R24 stated their sleep was getting worse, and their snoring was bad.During an observation on 8/5/2025 at 11:03 am, the surveyor noted a CPAP machine on R24's nightstand, but the mask was not visible.During an observation on 8/6/2025 at 9:33 am, the surveyor noted a CPAP machine on R24's nightstand with no mask or tubing attached.During a follow-up interview on 8/6/2025 at 12:34 pm, R24 stated that the staff placed the mask in their drawer, and the CPAP machine still had not been replaced. R24 stated it had been a long time, and they really needed it. According to R24, they thought the facility had supplies available and did not know why the facility had not replaced their CPAP mask.During an interview on 8/6/2025 at 9:50 pm, Licensed Practical Nurse (LPN)2 stated R24 had a CPAP but only wore it as needed. LPN2 stated R24 did tell him that they needed a new mask and hose, so he passed it on in the report, but could not remember when or to whom, and he did not follow up on it.During an interview on 8/7/2025 at 10:53 am, the Director of Nursing (DON) stated R24 told her about their CPAP mask on 7/31/2025, and she told the resident that she would look into it. The DON stated her plan was to call the resident's family and see where they got the machine and equipment so she could have that company come out and fit the resident for a mask. The DON stated she had not gotten to it yet. During a follow-up interview on 8/8/2025 at 11:03 am, the DON stated that when a resident needed a new CPAP mask, the facility should reach out to the durable medical equipment company to get replacement parts. Per the DON, the facility was responsible for ensuring it had the supplies needed to provide care that was ordered by the physician.During an interview on 8/8/2025 at 3:12 pm, the Nurse Practitioner (NP) stated that if a resident had orders for the use of a CPAP, the facility needed to ensure they had the supplies to provide the treatment. The NP stated she was not aware that R24 was not able to wear their CPAP at night. During an interview on 8/8/2025 at 11:30 pm, the Administrator stated she deferred all questions related to the use of the CPAP machine to the nursing staff, but the acquisition of supplies should be the responsibility of the clinical staff.

Based on interviews and record review, the facility failed to ensure the medical records were complete and accurate for two of 14 sampled residents (R) (R10 and R47). Findings included:A review of R10's admission Record revealed the resident had a medical history that included a diagnosis of cerebral infarction due to thrombosis of an unspecified precerebral artery.A review of R10's Annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/1/2025, revealed R10 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated that the resident currently used tobacco.A review of R10's Care Plan Report included a focus area initiated on 9/27/2022, which indicated the resident smoked.A review of R10's smoking assessment dated [DATE] indicated that the resident did not smoke, vape, or dip.During an interview on 8/4/2025 at 3:28 pm, R10 stated they smoked cigarettes.During an interview on 8/6/2025 at 9:54 am, Certified Nursing Assistant (CNA)3 stated R10 smoked cigarettes.During an interview on 8/7/2025 at 10:19 am, the Licensed Practical Nurse Unit Manager (LPN UM) stated that all residents were assessed for smoking when they were admitted to the facility. The LPN UM stated R10 smoked and required supervision from staff while they were outside smoking. During an interview on 8/7/2025 at 2:04 pm, the Director of Nursing (DON) stated that there was a smoking assessment in R10's electronic medical record dated December 2024.During an interview on 8/8/2025 at 8:47 am, the Activities Director (AD) stated she had been employed at the facility for three and a half years, and ever since she worked at the facility, she had known R10 to smoke. The AD stated she did not recall a time when R10 did not smoke.During a follow-up interview on 8/8/2025 at 9:31 am, the DON stated she was not sure why the December 2024 smoking assessment was completed to indicate the resident did not smoke.During an interview on 8/8/2025 at 7:43 am, the Administrator stated she was aware that R10 smoked, and she was unsure why the assessment was not accurate. The Administrator stated she expected the assessments to be accurate.2. A review of 47's admission Record revealed that the resident had a medical history that included polyneuropathy, shortness of breath, insomnia, type 2 diabetes mellitus, seasonal allergic rhinitis, anemia, and essential hypertension.A review of 47's Quarter MDS assessment, with an ARD of 5/12/2025, revealed R47 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident received insulin injections, antidepressant, antibiotic, diuretic, opioid, and hypoglycemic medications.A review of 47's Medication Admin [Administration]Audit Report from the timeframe 8/1/2025 - 8/6/2025, revealed the following medications were administered one hour or more later than ordered:-Insulin Lispro, scheduled to be administered at 7:00 am, was documented as being administered late on 8/1/2025, 8/2/2025, 8/3/2025, and 8/5/2025.-Insulin Lispro, scheduled to be administered at 11:00 am, was documented as being administered late on 8/1/2025, 8/2/2025, 8/3/2025, and 8/4/2025.-Insulin Lispro, scheduled to be administered at 12:00 pm, was documented as being administered late on 8/3/2025.-Insulin Lispro, scheduled to be administered at 4:00 pm, was documented as being administered late on 8/2/2025, 8/3/2025, and 8/4/2025.-Potassium Chloride, scheduled to be administered at 9:00 am, was documented as being administered late on 8/2/2025 and 8/4/2025.-Potassium Chloride, scheduled to be administered at 5:00 pm, was documented as being administered late on 8/2/2025.-Cranberry, scheduled to be administered at 9:00 am, was documented as being administered late on 8/4/2025.-Glycolax, scheduled to be administered at 9:00 am, was documented as being administered late on 8/4/2025.-Glycolax, scheduled to be administered at 9:00 pm, was documented as being administered late on 8/1/2025.-Lasix, scheduled to be administered at 9:00 am, was documented as being administered late on 8/4/2025.-Lasix, scheduled to be administered at 9:00 pm, was documented as being administered late on 8/1/2025.-Docusate Sodium, scheduled to be administered at 9:00 am, was documented as being administered late on 8/4/2025. -Docusate Sodium, scheduled to be administered at 9:00 pm, was documented as being administered late on 8/1/2025. -Ferrous Sulfate, scheduled to be administered at 9:00 am, was documented as being administered late on 8/4/2025.-Losartan, scheduled to be administered at 9:00 am, was documented as being administered late on 8/4/2025.-Protein Oral Liquid, scheduled to be administered at 9:00 am, was documented as being administered late on 8/4/2025.-Multivitamin with minerals, scheduled to be administered at 9:00 am, was documented as being administered late on 8/4/2025.-Claritin, scheduled to be administered at 9:00 am, was documented as being administered late on 8/4/2025.-Mucinex, scheduled to be administered at 9:00 am, was documented as being administered late on 8/4/2025.-Mucinex, scheduled to be administered at 9:00 pm, was documented as being administered late on 8/1/2025.-Clonidine, scheduled to be administered at 1:00 pm, was documented as being administered late on 8/4/2025.-Clonidine, scheduled to be administered at 9:00 pm, was documented as being administered late on 8/1/2025 and 8/3/2025.-gabapentin, scheduled to be administered at 9:00 pm, was documented as being administered late on 8/4/2025.-Tresiba, scheduled to be administered at 9:00 pm, was documented as being administered late on 8/4/2025. -Trazodone, scheduled to be administered at 9:00 pm, was documented as being administered late on 8/1/2025.During an interview on 8/7/2025 at 3:31 pm, Licensed Practical Nurse (LPN)9 stated she tried to sign the medications out as she went, but sometimes she did not sign the medications out on the MAR until later when she had more time. She stated that the medications were given on time; she just did not sign them out right when she gave them. During an interview on 8/8/2025 at 11:03 am, the Director of Nursing (DON) stated medications should be signed out on the MAR after the resident had taken them and should not be signed out at a different time. During an interview on 8/8/2025 at 11:30 pm, the Administrator stated that once a medication was given, it should be signed out at that time. She stated the record would not be accurate to document at a different time. During an interview on 8/8/2025 at 3:12 pm, the Nurse Practitioner stated medications should be documented at the time they were given; otherwise, the record was inaccurate.

Based on observations, interviews, and policy review, the facility failed to ensure food was not stored on the floor, expired foods were disposed of in a timely manner, ready-to-eat food was not touched with bare hands, and moldy food was not stored for use in accordance with professional standards for food service safety as required for 52 census residents who received meals from the facility kitchen. These failures had the potential to lead to food-borne illness among facility residents. Findings include: Review of a facility policy titled, Nutrition Services Manual, dated ,d+[DATE], revealed, The facility strives to promote good sanitation practices in order to protect its residents/patients and employees from foodborne illness. The facility sanitation system will ensure a clean, safe environment for its residents/patients and staff .The Nutrition Services staff follows infection control procedures including maintaining personal hygiene and handling foods to prevent contamination .Verify expiration dates are appropriate on individual cartons .Store delivered items immediately upon receipt. During an observation on [DATE] at 10:53 AM, sixteen boxes of canned foods and perishables were observed resting directly onto the pantry floor. During an interview on [DATE] at 10:54 AM, Cook1 stated that the food shipment had arrived the previous evening, but staff had not had time to properly store the food. During observation of a reach-in refrigerator on [DATE] at 11:00 AM, there was one 46-ounce (oz.) thickened orange juice carton, opened with [DATE] written on it. A second 46oz. thickened pomegranate berry juice, opened with [DATE] written on it. Both cartons documented, After opening, may be kept up to 7 days under refrigeration. Also, a large, opened container of turkey lunch meat with ,d+[DATE]-,d+[DATE] written on the side. During an interview on [DATE] at 11:05 AM, Cook2 stated she was not aware that the opened thickened juices had to be disposed of after seven days. Cook2 also confirmed the turkey lunch meat was dated past acceptable use by date. During lunch service observation on [DATE] from 12:00 PM through 12:15 PM, Cook1 was observed plating food from the steam table, touching the dinner rolls with her bare hands. Cook1 was observed to touch the meal trays, the tray rack, and again touched dinner rolls with her bare hands without handwashing. During an observation on [DATE] at 3:58 PM, one moldy 16oz. carton of strawberries was found in a refrigerated reach-in. During an interview on [DATE] at 3:58 PM, Dietary Aide (DA) 2 confirmed that there were moldy strawberries, and that staff had not always checked the produce when it arrived from the supplier to ensure it was still edible.

Based on observation, interview, record review, personnel file review, and policy review, the facility failed to 1. follow manufacturer's instructions regarding the cleaning and disinfecting of one of one glucometer between residents' use. 2. follow pre-employment and annual purified protein derivative (PPD) (skin test that determines if you have tuberculosis) guidelines of obtaining PPD 1st and 2nd step at the time of employment for six of nine personnel files (Administrator, Director of Nursing (DON), Certified Nurse Aide (CNA) 2, Licensed Practical Nurse (LPN) 2, Dietary Aide (DA) 1, and LPN3) reviewed, 3. obtain annual PPD test for two of nine personnel files (LPN1 and CNA1) reviewed, and 4. maintain a current infection surveillance program for 2024. Failure to follow infection control guidelines could result in the residents acquiring a blood-borne pathogen or infectious disease. Findings include: 1. Review of the facility's policy titled, Diabetic Management. dated August 2021. indicated Guidelines .14. Clean and disinfect the glucometer per the facility's infection control protocol/manufacturer's instruction . Review of the undated Evencare G3, Blood Glucose Monitoring System manufacturer's instructions for the glucometer and provided by the facility, revealed on page 11, The Evencare G3 Meter should be cleaned and disinfected between each patient .The following products have been approved for cleaning and disinfecting the Evencare G3 Meter .Medline Micro-Kill Bleach Germicidal Bleach Wipes . Further review of the manufacturer's instructions revealed on page 16, In-Service Training .Step6. Perform a blood glucose test 8. Clean and disinfect the meter . During an observation on 07/29/24 at 11:50 AM Registered Nurse (RN )1 stood at the medication cart on the 100 unit, removed the glucometer out of her uniform pocket. Without cleaning and disinfecting the glucometer, attached the Accu-Chek test strip into the glucometer and entered R3's room. After obtaining R3's glucose reading, returned to the medication cart and placed the glucometer directly on top of the cart without first placing a clean barrier between the glucometer and the cart. RN1 reviewed the Medication Administration Record (MAR) and determined that R3 required insulin. RN1 searched throughout the medication cart and was unable to find R3's insulin. Without cleaning and disinfecting the glucometer, RN1 placed the glucometer in the medication cart and locked the cart. RN1 went to the medication room to obtain R3's insulin. RN1 returned to the medication cart and prepared a syringe of six units of Humulin R. At this time, RN1 did not remove the glucometer to clean and disinfect it. During an interview on 07/29/24 at 12:28 PM, RN1 was asked what training she had received regarding the cleaning and disinfecting of the glucometer. RN1 stated at this time, I probably need to clean it. When asked what product she was to use, RN1 stated she was to use an alcohol wipe. RN1 removed the glucometer from the medication cart and cleaned it with an alcohol wipe. When asked what training the facility had provided regarding cleaning and disinfecting the glucometer between residents' use, RN1 stated that she had not received any training and just relied on her nursing knowledge. Review of the diagnosis list provided by the Regional Operations Manager (ROM) for all the residents in the facility revealed no evidence of a resident having a bloodborne pathogen diagnosis. Review of the list of residents with sliding scale orders per hallway and provided by the ROM revealed seven residents (R15, R48, R116, R18, R17, R30, and R3) on the 100 hallway. During an interview on 07/31/24 at 1:37 PM, the Administrator stated that it was her expectation that the nurses followed the manufacturer's instruction and to use the Micro Kill product, which was in each medication cart to disinfect the glucometer. During an interview on 07/31/24 at 4:35 PM, the ROM stated that they could not find any documentation that nurses, including RN1, had been trained on how to disinfect the glucometer prior to the incident on 07/29/24. 2. Review of the facility's undated document titled, Pre-Employment and Annual TB [Tuberculosis] Test Results indicated, Pre-employment requires a 2-step TB. Employee may not start working on the floor until 1st step is completed. 2nd step must be completed no later than 14 days after the 1st step. Annual TB test are a 1-Step . Review of six of nine personnel files revealed the Administrator was unable to provide PPD information for the following staff: -Administrator's file revealed hire date of 11/3/23 -Director of Nursing (DON) file revealed hire date of 07/08/24 -CNA2's file revealed hire date of 04/17/24 -LPN2's file revealed hire date of 07/0/2/24 -DA1's file revealed hire date of 06/10/24 -LPN3's file revealed hire date of 05/01/24 3. Review of two of two personnel files revealed the facility was unable to provide yearly PPD information for the following staff: -LPN1's file revealed hire date of 02/01/21 and the last documentation of the PPD was dated 02/23. -CNA1's file revealed hire date of 09/08/20 and the facility was unable to find documentation of the PPD for 09/23. During an interview on 07/31/24 at 1:45 PM, the Administrator confirmed she was unable to find the PPD information for the above employees. She stated that the facility no longer had a Human Resource Director (HRD). She stated the HRD was responsible for uploading the information into the computer system. 4. Review of the facility policy titled Infection Surveillance, dated 09/23, showed: Overview. The facility will use a systematic method of collecting, consolidating, and analyzing data concerning the distribution and determining factors of a given disease or event. An outbreak may be defined as an increase in the incidence of a disease, complication, or event above the background rate. The facility will have baseline surveillance data on the incidence of nosocomial infections in order to identify outbreaks. Following the collection and analysis of data, the information will be provided to the staff for educational purposes to strive to improve infection prevention/control outcomes. The facility will also use surveillance as follows . Procedure. 1. Gather information from each unit at least once per week. 2. Initiate a resident specific Infection Surveillance Worksheet if infection appears likely . 3. Summarize information from the Infection Surveillance Worksheet on the Monthly Line Listing Report .4. Tabulate infection data according to the following and document on the appropriate month on the Annual Infection Rate Summary .5. Calculate incidence rates and compare to previous rates within the facility. 6. Present the information at the next scheduled Infection Control/Prevention Team meeting .8. Implement an action plan as needed. Report to the Risk Management/ Quality Improvement Committee as needed. 9. Provide staff training as needed. 10. Review and revise action plan as needed. During the Infection Control review in response to a request for infection tracking and trending (surveillance) documentation for 2024, the Director of Nursing (DON) provided a binder with numerous tabs and blank schematics. On 07/31/24 at 6:46 PM, the DON stated it might be in another book that was taken out of here. I know I can do the schematic for the trends for cross contamination, and I can show you what I'm going to do. When the last six months was requested, the DON stated, I wasn't here. I can go through more boxes and books. At 6:54 PM, the DON was going through boxes in her office and related I feel sure she [prior DON] was doing that stuff, I don't know why she put things in such strange places before she left. On 07/31/24 at 7:05 PM, the DON stated, I can't provide any documentation about an infection control program before my arrival. I am putting my program [in place] but it's not up and running yet. I've been here about two weeks, maybe the 8th or 9th, and I worked on the floor for the first 13 or 14 days. During an interview on 07/31/24 at 7:08 PM, the Administrator [NAME] in a file for tracking and trending from 2023 but was unable to provide anything from 2024. The Administrator stated it was an expectation that the facility had an infection surveillance program. 28154

Based on record review, interview, and policy review, the facility failed to provide written information to five residents (Resident (R) 48, R18, R12, R24, and R4) and/or their resident representative concerning the right to formulate an advance directive of 28 sample residents. The failure to discuss advance directive information with the resident and resident representative could potentially affect their ability to make informed decisions about their care. Findings include: Review of the facility's policy titled, Advance Directive, dated 08/09/22, indicated The facility must inform and provide written information to all adult residents concerning the right .to formulate an advance directive .Upon admission/readmission, the facility Social Service Director will inform and educate the resident, or POA [Power of Attorney] in writing about the right .to an advance directive . and upload to the resident's chart . 1. Review of R48's electronic medical record (EMR) Profile tab, indicated R48 was admitted on [DATE]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/26/24 in the EMR under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderate cognitive impairment. Review of the EMR revealed no documentation that the resident was provided written information concerning the right to formulate an advance directive. 2. Review of R18's EMR Profile tab, indicated R18 was admitted on [DATE] and that R18 was her own responsible party. Review of the annual MDS with an ARD of 06/18/24 in the EMR under the MDS tab indicated a BIMS score of 15 out of 15 which indicated R18's cognition was intact. Review of the EMR revealed no documentation that the resident was provided written information concerning the right to formulate an advance directive. During an interview on 07/30/24 at 4:04 PM, the Social Services Director (SSD) stated that she could not find any documentation that R48 and R18 were provided with written information about formulating an advance directive. 3. Review of R12's EMR Profile tab indicated R12 was admitted on [DATE]. Review of the quarterly MDS with an ARD of 07/08/24 in the EMR under the MDS tab indicated a BIMS score of one out of 15 which indicated cognition was severely impaired. During an interview on 07/30/24 at 4:10 PM, the SSD confirmed she was unable to locate any documentation that R12's responsible party was provided written information concerning the right to formulate an advance directive. 4. Review of R24's undated Admission Record located in R24's EMR under the Profile tab revealed R24 was admitted to the facility on [DATE]. Review of R24's EMR revealed no documentation that R24 had an advance directive or that the facility provided written information to the resident, or the resident representative concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 5. Review of R4's Admission Record from the EMR Profile tab showed a facility admitted [DATE] and readmission on 12/26/17, with medical diagnoses that included convulsions, osteoporosis, intracranial injury, and dizziness. Review of R4's electronic EMR Documents tab revealed no information regarding an advance directive or education regarding an advance directive. Review of the 2016 admission agreement for R4 showed no education regarding an advance directive. Review of R4's annual MDS with an ARD of 06/04/24 revealed R4 had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. During an interview on 07/31/24 at 11:30 AM, R4 confirmed he had been in the facility since 2016; that the SSD had provided the advance directive information the previous day and had not received this information prior to 07/30/24. During an interview on 07/31/24 at 11:48 AM, the SSD confirmed she had found nothing in the EMR that R4 had presented previously during his admission. 26446 28154

Based on personnel file review, interview, and policy review, the facility failed to follow their policy to obtain background and criminal checks at time of employment for four of nine employee files (Certified Nurse Aide (CNA) 1, CNA2, Licensed Practical Nurse (LPN) 2, and Dietary Aide (DA) 1) reviewed for background checks. The failure to obtain background and criminal checks had the potential to allow facility staff with criminal backgrounds to work with the residents. Findings include: Review of the facility's policy titled, Background and Criminal Checks, dated 12/21/23, indicated The facility .may investigate all statements contained in any documents, applications and/or resumes you have provided. A background check will be conducted . to include .criminal history .fingerprints .references .upon submitting an application of employment, you release the facility . from obtaining such information . Review of four of nine personnel files revealed the Administrator was unable to provide background and criminal checks information for the following staff: -CNA1's file revealed hire date of 09/08/20. -CNA2's file revealed hire date of 04/17/24. -LPN2's file revealed hire date of 02/01/21. -DA1's file revealed hire date of 06/10/24. During an interview on 07/31/24 at 1:45 PM, the Administrator confirmed she was unable to find the background and criminal history information for the above employees. She stated that the facility no longer had a Human Resource Director (HRD) who was responsible for uploading the information into the computer system.

28154 Based on record review, interview, and policy review, the facility failed to ensure seven of seven residents and their representatives (Resident (R) 27, R29, R38, R48, R116, R112, and R44) reviewed for facility initiated emergent hospital transfer, from a total sample of 28 residents, were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, other information regarding the transfer, and information on the right to appeal the transfer. This failure had the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility's policy titled, Discharge Plan/Transfers, revised 10/20/23, showed it did not address a written notice of transfer, the required contents, or the provision of the notice to the Resident and RR. 1. Review of R27's Admission Record from the electronic medical record (EMR) Profile tab, showed a facility admitted [DATE], readmission on 06/18/24, with medical diagnoses that included end stage renal disease, type II diabetes, seizures, atrial fibrillation, psychotic disorder, and Alzheimer's dementia. Review of R27's EMR Census tab showed hospital leave on 06/26/24. Review of R27's Progress Notes tab showed nothing about a hospital transfer but did show a readmit progress note, dated 06/29/24 at 11:47 AM, that revealed resident back from hospital. Further review of R27's EMR Progress Notes, Documents, and Assessments tabs did not reveal any evidence of the provision of a written transfer notice. During an interview on 07/30/24 at 5:52 PM regarding receipt of any written documentation regarding the hospital transfer from the facility that stated why and where he was transferred and information on his right to appeal the transfer, R27 stated, No. 2. Review of R29's Admission Record from the EMR Profile tab showed a facility admitted [DATE], readmission on 05/29/24, with medical diagnoses that included toxic encephalopathy, congestive heart failure, chronic respiratory failure, end stage renal disease, chronic obstructive pulmonary disease, and anxiety disorder. Review of R29's Progress Notes showed on 07/16/24 at 7:15 PM, R29 was admitted to hospital, from dialysis. Further review of R29's EMR Progress Notes, Documents, and Assessments tabs did not reveal any evidence of the provision of a written transfer notice. During an interview on 07/30/24 at 11:40 AM, the Director of Nursing (DON) remarked she was unsure who did the transfer notices. 3. Review of R38's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses that included chronic kidney disease, atrial fibrillation, vascular dementia, glaucoma, history of cerebrovascular disease, type II diabetes, and Alzheimer's dementia. Review of R38's EMR Progress Notes tab showed on 04/14/24 at 3:12 PM that Resident transferred to hospital due to altered mental status. [Doctor name] notified. [R38's RR identified] notified and [name] DON notified as well. Further review of R38's EMR Progress Notes, Documents, and Assessments tabs did not reveal any evidence of the provision of a written transfer notice. During an interview on 07/30/24 at 5:42 PM regarding the facility process for an emergent transfer, Licensed Practical Nurse (LPN) 5 stated, When we find there is an issue, we call the doctor and let him know, get an order to transfer out. Call 911, let them know the issue, then call the hospital and give them report. Then, I print all the paperwork. [transfer/discharge record and medication administration record [MAR]. Then fill out all the paperwork on the computer, such as this E-transfer form [an E-Interact transfer form for the hospital] and do a change in condition, [an E-Interact form, both of which are saved in the EMR Assessment tab] call the family and let them know they are being or were transferred and why. Then write a progress note. When asked what was given to the Emergency Medical Services (EMS), LPN5 responded the E-transfer report and MAR. When queried if anything was provided to the resident or RR regarding the transfer, LPN5 stated, No. During an interview on 07/31/24 at 8:08 PM, the Administrator stated an expectation regarding the provision of written transfer notices that the document is sent, a signature that they are made aware and document that it went to family / POA [Power of Attorney or RR] is aware. When asked on her expectation as to when the notice should be provided, the Administrator responded, When they go to leave the facility on way out or as soon as possible. 4. Review of R48's EMR Profile tab indicated R48 was admitted on [DATE]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/26/24 in the EMR under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderate cognitive impairment. Review of R48's EMR Progress Notes, dated 05/13/24 and 07/11/24, revealed R48 experienced a change in condition and was transferred to the hospital. There was no documentation in the EMR that the resident and the resident's responsible party were provided the transfer notice for either time R48 was transferred to the hospital. 5. Review of R116's EMR Profile tab indicated R116 was admitted on [DATE]. Review of the quarterly MDS with an ARD of 06/21/24 in the EMR under the MDS tab indicated a BIMS score of seven out of 15 which indicated severe cognitive impairment. Review of R116's EMR Progress Notes, dated 07/09/24, indicated R116 was experiencing behavioral issues and was sent to the behavioral hospital. There was no documentation in the EMR that the resident and the resident's responsible party were provided the transfer notice when R116 was transferred to the hospital on 07/09/24. 6. Review of R112's EMR Profile tab indicated R112 was admitted on [DATE]. Review of R112's EMR Progress Notes, dated 02/14/24, indicated R112 experienced a change of condition and was sent to the hospital. There was no documentation in the EMR that the resident and the resident's responsible party were provided the transfer notice when R112 was transferred to the hospital on 02/14/24. 7. Review of the EMR Profile tab indicated R44 was admitted on [DATE]. Review of the quarterly MDS with an ARD of 07/10/24 in the EMR under the MDS tab indicated a BIMS score of one out of 15 which indicated severe cognitive impairment. Review of R44's EMR Progress Notes, dated 07/17/24, indicated R44 experienced a change in condition and was sent to the hospital. There was no documentation in the EMR that the resident's responsible party was provided the transfer notice when R44 was transferred to the hospital on 07/17/24. During an interview on 07/30/24 at 9:44 AM, the Social Service Director (SSD) stated that she would have to check with the Administrator to see who sent the transfer notices to the Ombudsman. During an interview on 07/30/24 at 12:33 PM, the Administrator stated that there was no documentation that the transfer notice was provided to the resident and their resident representative when the residents were transferred to the hospital. The Administrator also stated that since becoming the Administrator at the end of November 2023, the facility had not been sending the transfer notices to the Ombudsman.