Every finding on record at Altercare of Nobles Pond, Inc

Based on observation, interview, and review of facility policy, the facility failed to ensure appropriate sanitation and temperature tracking logs were maintained, failed to ensure resident foods were stored at an appropriate temperatures, and failed to ensure the resident refrigerator for outside foods was monitored and food was appropriately labeled and discarded when expired. This had the potential to affect all 61 residents receiving meals from the kitchen. The facility census was 61.Findings include: 1.Observation on 03/16/26 at 8:40 A.M. during the initial kitchen tour with [NAME] #607 revealed the March 2026 sanitizer tracking log, food service cart sanitation record, and the dishwasher temperature tracking log were incomplete with dates that were missing or not completed. Review of the facility form called Sanitizer Tracking for March 2026 for the three-compartment sink revealed lunch sanitization checks were not completed for 03/02/26, 03/03/36, 03/04/26, 03/05/26, 03/09/26 and dinner sanitization checks were not completed on 03/01/26, 03/04/26, 03/05/26, 03/09/26, 03/10/26, 03/11/126, 03/12/26, and 03/13/26. Review of the facility form called Food service cart sanitation record for March 2026 revealed sanitation was not completed following dinner for 03/01/26, 03/03/26, 03/04/26, 03/04/26, 03/10/26 and 03/12/26. Review of the facility form called Dishwasher Temperature Tracking for March 2026 revealed temperatures were not recorded for lunch on 03/03/26, 03/04/26, and dinner 03/01/26, 03/03/26, 03/05/26, 03/12/26. At the time of the observation on 03/16/26 at 8:40 A.M., [NAME] #607 confirmed the above listed forms were not completed as required for each day.2.Observation on 03/17/26 at 11:30 A.M. with [NAME] #941during lunch temperatures revealed the serving station room was a small room with two entrance/exit doors with a standing warming oven, steamtable, a heated plate dispenser cart, coffee maker station, standing refrigerator, and a storage rack that contained various items including condiments and individual size salad dressing and mayonnaise packets on the racks. The temperature of the serving room was observed to be very warm, and staff were observed to be sweating.Interview on 03/17/26 at 11:40 A.M. with [NAME] #941 confirmed the temperature of the room felt very hot and was not a comfortable temperature to work in, but the temperature was usually like this. Interview on 03/17/26 at 11:54 A.M. with Regional Foodservice Director #634 stated it was very warm in the serving room, staff were sweating, and it was not a comfortable temperature to work in. A test tray was completed on 03/17/26 at 1:02 P.M. with Regional Foodservice Director #634 following the last tray being passed on the 100 hall. Temperatures of the food items revealed the barbecue pork was 136 degrees Fahrenheit (F), carrots were 126 degrees F, the rice was 151 degrees F, the pureed noodles were 125 degrees F, the milk temped at 41 degrees F, and 1.5-ounce packet of ranch dressing temped at 88 degrees F. Interview and observation at the time of temperatures with Regional Foodservice Director #634 confirmed the serving station was very warm, he was sweating through his shirt and stated the temperature was uncomfortable. Regional Foodservice Director #634 confirmed the temperature of the ranch salad dressing was not a safe storage temperature for shelf stable food items to be stored at.Observation on 03/17/26 at 1:22 P.M. with Maintenance Director #606 revealed using his infrared thermometer gun confirmed the temperature of the serving station was 97 degrees F and also confirmed it was not a comfortable temperature to work or store foods in. Further observation on 03/17/26 at 1:24 P.M. with Regional Foodservice Director #634 revealed the stored condiment packets in the serving station included 1.5-ounce packets of honey mustard dressings which temped 90 degrees F, 1.5-ounce packets of thousand island dressing which temped 91 degrees F, and 0.38-ounce packet of mayonnaise which temped at 93 degrees F. Regional Foodservice Director #634 confirmed the temperatures were not a safe food storage temperature. 3.Observation on 03/19/26 at 9:20 A.M. with Registered Dietitian #902 of the resident refrigerator in the employee lounge revealed a plastic bag labeled with Resident #76's name on it. The bag included a pumpkin loaf with a use-by date of 10/22/25, two one-half cups of diced peaches with a use by date of 09/30/23, two spicy falafel packets with a use by date of 03/12/26, one half cup of red Jello with a use by date of 04/16/23, and a 6.2 ounce ham and Swiss on a baguette with a use by date of 01/08/26. The refrigerator also contained an unlabeled, eight-ounce bottle of ensure plus with a use by date of 02/01/26. Multiple other items were found in the refrigerator that were not expired but had no name on them. Interview on 03/19/26 following the observation with Registered Dietitian #902 confirmed the above listed items were either out of date or not labeled as required.Interview on 03/19/26 at 9:37 A.M. with Regional Foodservice Director #634 confirmed dietary staff were responsible for monitoring the resident refrigerator. Review of the facility policy titled Dry Storage and Supplies revised 01/2015 revealed all non-perishable food shall be stored in a manner that optimized food safety and quality. The storeroom shall be ventilated and maintained as close to optimal temperature (50-70 degrees F) and humidity as possible. Review of the facility policy titled Food Brought to Residents by Family and Visitors revised 04/2024 revealed food brought in from the outside will be checked by the nurse or member of the food and nutrition department staff to ensure foods item(s) would be labeled with the resident's name, the date it was prepared, if known and an expiration date. The policy additionally noted that expired food items would be discarded.

Based on observation, interview, record review, and facility policy review, the facility failed to preserve the dignity of one resident with a Foley (indwelling) catheter. This affected one resident (Resident #98) of two residents reviewed for dignity with Foley catheters. The facility census was 61.Findings include:Resident #98 was admitted to the facility on [DATE] with diagnoses including urinary retention, severe sepsis with septic shock, high blood pressure, and congestive heart failure.Observation of Resident #98 on 03/19/26 at 10:01 A.M. revealed the resident was sitting in a wheelchair in a hospital gown. A Foley drainage bag containing urine was hanging from the back of the wheelchair and did not have a privacy cover covering the drainage bag. Interview with Regional Registered Nurse (RRN) #633 at the time of observation stated the resident must be a new admission as the facility went through every resident with a Foley catheter and ensured a privacy bag was in place. Interview with RRN #619 on 03/19/26 at 10:40 A.M. confirmed Resident was a new admission from the previous evening, and staff should have changed his drainage bag over from the hospital bag to a facility bag, which has a privacy cover. RRN #619 confirmed staff placed a privacy cover over the drainage bag.Review of the facility's Resident Rights policy, last revised October 2016, revealed it was the facility's policy that employees treat all residents with kindness, respect, and dignity.

Based on record review, interview, and facility policy review, the facility failed to ensure the responsible party was notified of a medication change. This affected one resident (Resident #4) of five residents reviewed for unnecessary medications. The facility census was 61.Findings include:Resident #4 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, peripheral vascular disease, a urinary tract infection, calculus of the kidney, and osteonecrosis to the left femur from a previous trauma. Review of Resident #4's admission psychiatric evaluation on 03/04/26 by Medical Doctor (MD) #950, the facility's consulting psychiatrist, revealed the resident reported feeling sad and depressed, complaints of not sleeping, feeling anxious and restless as he is not able to do things. MD #950 diagnosed Resident #4 with Generalized Anxiety Disorder and added BuSpar (an antianxiety medication) 10 milligrams (mg) orally twice a day to treat it.Review of the nursing progress notes from 02/27/26 to 03/05/26 for Resident #4 revealed no documentation regarding MD #950's assessment on 03/04/26. There was no documentation of the resident's responsible party being notified of the new order for BuSpar. On 03/06/26 at 3:42 P.M, the DON documented she had spoken with the family and they requested the order for BuSpar be discontinued. Review of Resident #4's Medication Administration Record (MAR) for March 2026 revealed the order for BuSpar was entered on 03/05/26. The resident received his first dose on 03/05/26 between 6:30 P.M. and 10:30 P.M. The second dose was administered on 03/06/26 between 6:30 A.M. and 10:30 A.M.Interview with Resident #4's responsible party (RP) on 03/17/26 at 3:30 P.M. revealed the facility started the resident on BuSpar 10 mg orally twice a day for an unknown reason as well as Trazodone 25 mg orally every evening. The RP stated Resident #4 has had adverse reactions to psychotropic medications in the past and did not want him on anything that crosses the blood brain barrier. She did not know the facility had started him on the medication until she went in to visit and the nurse told her about it. The RP requested the medication be discontinued.Interview with the ADON #603 on 03/18/26 at 4:30 P.M. revealed ADON #603 was given an order for BuSpar as MD #950 had completed his admission psychiatric evaluation. ADON #603 said she gave the order to ADON #524 was on the phone with the responsible party (RP)for Resident #4 and informed her of the new order. The following day the RP for Resident #4 came to the facility with her two children and met with ADON #603 in her office and spoke with the RP for about an hour regarding the BuSpar order. The RP informed ADON #603 she did not want Resident #4 to take the BuSpar due to the potential side effects of the medication. ADON #603 said the resident received two doses before it was discontinued.Interview with ADON #524 on 03/19/26 at 11:35 A.M. revealed she did not notify Resident #4's family over the phone regarding the addition of BuSpar to the resident's medication. ADON #524 said all communication with the RP was in person, not over the phone. She spoke with the RP daily. ADON #524 said she received the order for BuSpar and discussed it with the RP the next day she visited. The RP said she did not want Resident #4 to be on it and requested it not be given. ADON #524 notified the nurse practitioner when she next her. ADON #524 said she did not believe Resident #4 received any doses of the medication.Review of the facility's Change in the Resident's Condition or Status policy, last revised 05/01/25, revealed the nurse is to immediately notify the resident, consult with the resident's attending physician, on call physician, nurse practitioner, physician assistant or clinical nurse specialist, and notify the resident's authorized representative when there is a change in the mental, physical, or psychosocial status. This information must be documented in the resident's medical record. This deficiency represents noncompliance investigated under Complaint Number 2807084.

Based on interview, observation, and record review, the facility failed to ensure a clean and homelike environment was maintained for Resident #58. This affected one resident (#58) of 61 residents screened for environmental concerns. The facility census was 61.Findings include:Review of Resident #58's medical record revealed an admission date of 11/04/25. Diagnoses include but not limited to the need for personal care, difficulty walking, muscle weakness, and repeated falls.Review of Resident #58's care plan dated 01/21/26 revealed the resident had an impaired ability to perform or participate in daily ADL care. Interventions included to assist with toileting if needed and provide incontinence care as needed. Interview and observation on 03/16/2026 at 11:40 A.M. with Resident #58 revealed her bedpan smelled terrible and staff did not clean the bedpan after use. During the interview, two unlabeled and unbagged orange bedpans were observed in the bathroom. One bedpan was inside the toilet bowl and one bedpan was on the floor between the wall and toilet. Both bedpans appeared to have barrier cream residue on them. Interview on 03/16/26 at 11:42 A.M. with Certified Nursing Assistant (CNA) #615 confirmed the two bedpans were stored inappropriately. Review of the facility's resident rights policy, dated 05/01/25, our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. This deficiency represents non-compliance investigated under Complaint Number 2807084.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure Resident #4 was provided appropriate medical treatment in response to a change in condition. Additionally, the facility failed to ensure appropriate wound care and services were provided to Resident #24 and Resident #95. Additionally, the facility failed to ensure daily weights were obtained as ordered for Resident #76. This affected four residents (#4, #24, #76, and #95) of 25 residents reviewed for quality of care and treatment. The facility census was 61. Findings include:1.Review of Resident #4's medical record revealed the resident was admitted on [DATE] with diagnoses including acute kidney failure, calculus of the kidney and urinary tract infection. Review of Resident #4's physician orders revealed an order dated 02/27/26 for Eliquis (an oral anticoagulant medication) 2.5 milligrams (mg) twice daily. Review of Resident #4's physician orders revealed an order dated 02/28/26 for catheter care twice a day from 6:00 A.M. to 6:00 P.M. and 6:00 P.M. to 6:00 A.M. Resident #4 also had an order dated 03/02/26 to irrigate the resident's Foley (indwelling urinary) catheter one time for a diagnosis of hematuria. The MAR and TAR indicated this was completed. Review of Resident #4's Office Visit Note dated 03/03/26 at 10:28 A.M. authored by Urologist #622 revealed the resident had urinary retention and a Foley catheter was inserted for 900 cubic centimeters (cc) of urine. An order would be put in to remove the Foley catheter for a voiding trial. Review of Resident #4's lab results dated 03/03/26 at 6:15 P.M. revealed the red blood cell count (RBC) and hemoglobin (HGB) were 8.3 and 26.3 (normal was 14.0 to 18.0 for RBC and 42.0 to 54.0 on HGB). Review of Resident #4's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #4's Resident Progress Note dated 03/05/26 at 2:07 P.M. authored by Registered Nurse (RN) Assistant Director of Nursing (ADON) #524 revealed the Nurse Practitioner (NP) spoke to the urology's office regarding the Foley and voiding trial the family was asking about. The NP stated urology wanted to wait until the stents were removed to remove the Foley and try a voiding trial.Review of Resident #4's Physician Progress Note authored by the Medical Director dated 03/09/26 revealed the [AGE] year-old male with a past medical history significant for hyperlipidemia, anemia, and chronic left hip pain who was receiving skilled therapies. The resident had benign prostatic hypertrophy (BPH) with urinary retention, and a Foley catheter was placed during hospitalization. The resident was noted with hematuria on 03/02/26 and moderate sized blood clots and thick mucous sediment on 03/05/26. A urinalysis was ordered and staff to notify Urologist #622. Per the urology department, the Foley to remain in place until stents were removed and then attempt a voiding trial. Review of Resident #4's lab results dated 03/10/26 at 4:23 P.M. revealed the RBC was 9.6 and the HGB was 29.6. Review of Resident #4's NP progress note dated 03/12/26 revealed the resident was disoriented and continued to have blood clots and mucous in catheter. Concerns were identified for a urinary tract infection (UTI). A physical exam revealed a moderate amount of blood clots. Review of Resident #4's progress note dated 03/14/26 at 3:25 A.M. authored by RN #620 revealed the resident was having large blood clots with urination and some bloody drainage from the end of his penis. A message was left for the NP on call to address. The medical record did not have evidence Resident #4's family were notified per the medical record and the note did not have evidence the NP returned the call to address the concerns. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated March 2026 revealed nursing staff documented catheter care on 03/13/26 on both shifts, 03/14/26 on both shifts, and 03/15/26 on both shifts. Review of Resident #4's progress note dated 03/14/26 at 11:50 A.M. authored by RN #581 revealed the resident was having large amounts of bloody urine and no complaints voiced. The NP was paged per the medical record but the medical record did not have evidence Resident #4's family members were notified per the medical record. Review of Resident #4's lab result form dated 03/14/26 at 12:56 P.M. revealed the RBC was 7.2 and the HGB 24.5. Review of Resident #4's progress note dated 03/14/26 at 1:46 P.M. authored by RN #581 revealed the NP gave new orders for an immediate complete blood count (CBC) and to notify Urologist #622 of the bleeding. Review of Resident #4's progress note dated 03/14/26 at 1:47 P.M. revealed Urologist #622 was notified of the bleeding at this time and stated the bleeding was still normal and to monitor for blood clots. Review of Resident #4's progress note dated 03/15/26 at 2:41 A.M. revealed the immediate CBC results came back and the NP was notified. The facility was waiting on orders for a RBC of 7.2 and a HBG of 24.5. The medical record did not have evidence the family members were notified of the results of the bloodwork. Review of Resident#4's MARS revealed the resident's Eliquis was due from 6:30 A.M. to 10:30 A.M. (morning) and 6:30 P.M. to 10:30 P.M. (evening). The MARS confirmed the resident received the Eliquis anticoagulant for both shifts on 03/10/26; held for the morning administration on 03/12/26 and administered for the evening administration of 03/12/26; administered on 03/13/26 both shifts; administered on 03/14/26 both shifts; administered on 03/15/26 both shifts; administered on 03/16/26 morning shift.Review of Resident #4's progress note dated 03/16/26 at 3:32 P.M. authored by the Director of Nursing (DON) revealed the NP was contacted regarding the resident's hematuria. New orders were obtained to hold the Eliquis anticoagulant for three days and an immediate CBC. The note also stated to call the urologist. Urologist #622 was called and the family and resident were notified of new orders.Review of Resident #4's progress note dated 03/16/26 at 4:19 P.M. authored by RN ADON #524 revealed Urologist #622 returned call and was notified of HGB of 7.2 and bleeding from the penis. Eliquis was to be held for three days and repeat CBC.Review of Resident #4's lab results dated 03/16/26 at 8:04 P.M. revealed the RBC was 5.6 and the HGB was 18.3.Review of Resident #4's progress note dated 03/16/26 at 10:24 P.M. revealed a new HGB of 5.6 and the NP ordered for the resident to be sent to the emergency room. The family were notified and thankful for the update. Review of Resident #4's ED Provider Note dated 03/16/26 at 11:38 P.M. authored by Physician #625 revealed the resident came to the ED via EMS from the SNF. The resident stated that he had been experiencing a bleeding penis for the past few days. The resident had a hemoglobin of 5.6. According to the EMS, the resident had been experiencing bleeding from his penis for the last few days. EMS stated that the SNF had completed a hemoglobin level on the resident and it was 5.6 hence the reason for the ED visit. The resident's skin color was pale. Blood was noted coming from the penile meatus. Review of Resident #4's hospital history and physical note dated 03/17/26 at 5:36 A.M. authored by Physician #624 revealed the resident was admitted on [DATE] and the resident was a [AGE] year-old male who presented from the SNF with bleeding from his penis. EMS was called for abnormal labs; however, when EMS arrived, there was no copy of the blood work. The resident was noted to have hematuria. The resident's hemoglobin was 5 and two units of packed red blood cells were provided. A CT of the abdomen and pelvis without contrast revealed dense fluid in the urinary bladder with foci of internal gas, possibly a clot, bilateral staghorn calculi, mild right hydroureter and inflammatory changes surrounding the left ureter. An ascending infection was considered. Started on continuous irrigation and ceftriaxone was administered. Chart review revealed the resident was status post (s/p) cystoscopy with the removal of a foreign body calculus, ureteral stent from urethra or bladder on 03/12/26 by Urologist #622 and the urine culture on 03/05/26 was positive for pseudomonas. Antibiotics were ordered. No paperwork was provided from the nursing facility.Review of Resident #4's progress note dated 03/17/26 at 8:10 A.M. revealed the resident was admitted to the hospital with a diagnosis of gross hematuria.Review of Resident #4's hospital documentation dated 03/17/26 at 8:59 A.M. authored by CNP #623 revealed the key findings of the assessment revealed gross hematuria, clot retention, acute blood loss anemia, acute, complicated diagnosis of hematuria including UTI, BPH exacerbated by anticoagulation. Large amount of clot removed from the bladder and the hematuria was currently mild. Telephone interview with NP #621 on 03/17/26 at 3:27 P.M. revealed she had reviewed the NP call logs, and the facility notified their agency early in the morning (of 03/14/26) for the hemoglobin of 7.2 and no new orders were provided to the facility. NP #621 reported she had reviewed the NP call logs for the dayshift on-call person on 03/14/26 (no time specified) and the on-call staff member gave an order to contact urology for blood clots. NP #621 confirmed their protocol was to call facilities within 20 minutes and there was an escalation protocol. NP #621 confirmed their call logs did not have exact times and only shifts due to the large volume of calls to their agency.Interview on 03/17/26 at 12:42 P.M. with RN ADON #603 revealed the facility sent Resident #4 to the ED due to a low hemoglobin level. When questioned as to why it took approximately eight hours and twenty-five minutes for the NP to respond to a change in condition from 03/14/26 at 3:25 A.M. to 03/14/26 at 1:46 P.M., she stated the resident did not have a change in vitals and she felt it was appropriate.Interview on 03/17/26 at 1:50 P.M. with the Director of Nursing (DON) revealed approximately eight hours and twenty-five minutes was not a timely notification of blood clots from the resident's penis. She stated 10 hours was too late to address a change in condition. Interview on 03/17/26 at 2:05 P.M. with Regional RN #619 revealed eight hours and twenty-five minutes was a long time to wait for a change in condition, but she felt the HGB level of 7.2 was stable and it was not harmful.Telephone interview on 03/17/26 at 4:01 P.M. with Resident #4's family member revealed she had previously voiced concerns about the resident's care and the bleeding from the penis to the DON.Telephone interview on 03/18/26 at 9:22 A.M. with Urologist #622 revealed he had assessed Resident #4 on 03/03/26 and placed an order to remove the Foley catheter. He stated on 03/05/26, he received a message from the NP reporting bleeding from the resident's penis, and he decided to leave the Foley catheter in place until the stents were removed on 03/12/26. He stated he was aware the resident was bleeding and on Eliquis and stated the facility's NP and Physician were covering and monitoring the resident. Telephone interview on 03/18/26 at 12:05 P.M. with Medical Director (MD) #627 revealed he had discussed the bleeding and Eliquis with Resident #4's family, the cardiologist, and the urologist. MD #627 revealed the resident's bloodwork was monitored and there was not a significant drop in the resident's RBC or HGB levels. He stated the hospital documents wanted the resident to stay on the Eliquis anticoagulant unless the resident's condition deteriorated and reported the resident's RBC hovered around 7.3 to 8.3. MD #627 revealed he had assessed the resident on 03/09/26 and everything was clear and he did not identify bleeding, but he was aware the resident had bleeding on and off. Review of the Change in a Resident's Condition policy updated 05/01/25 revealed it was the policy to ensure the resident's attending physician and the resident's authorized representative or interested family member were notified in the resident's physical, mental, or psychosocial status. 2. Review of Resident #95's medical record revealed the resident was admitted on [DATE] with diagnoses including displaced fracture of the right femur, aftercare following joint replacement surgery and pleural effusion. Review of Resident #95's X-ray dated 03/05/26 (completed prior to admission to the facility) revealed the resident had interval placement of the right hip arthroplasty which was in near anatomic alignment. Review of Resident #95's care plans did not reveal care plans and interventions for the resident's right surgical hip dressing. Observation on 03/16/26 at 1:09 P.M. revealed the resident had a dressing to the right hip and no orders for wound care. Interview on 03/19/26 at 11:27 A.M. with the DON confirmed the resident did not have orders or a care plan for wound care and interventions for the resident's right hip. 3. Review of the medical record for Resident #24 revealed an admission date of 11/25/25. Diagnoses included but not limited to an encounter for surgical aftercare following surgery on the digestive system, muscle weakness, need for assistance with personal care, and malignant neoplasm of the liver and colon. Review of Resident #24's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 had one stage four pressure ulcer and no evidence of a skin tear to her left thigh. Review of Resident #24's physician orders did not reveal evidence of assessments and treatments to the left posterior inner thigh skin tear. Observations on 03/18/26 at 2:20 P.M. with Regional RN #628 and RN #514 of Resident #24's sacrum wound care revealed no concerns. However, the resident had a wound dressing on the left posterior inner thigh which was dated 03/15/26. Interview on 03/18/26 at 3:14 P.M. with the DON confirmed Resident #24 had a skin tear on the left posterior inner thigh signed off by Licensed Practical Nurse (LPN) #564 and the medical record did contain documentation of or orders to treat the skin tear. Review of the facility's wound care policy, dated 05/01/25, revealed wound care was provided using professional standards of practice. The police instructed staff to review the resident's care plan to assess for any special needs. Also, verify there was a physician order for the procedure. 4. Review of the medical record or Resident #76 revealed an admission date of 10/23/24. Diagnoses included but were not limited to unilateral primary osteoarthritis, morbid obesity, type II diabetes mellitus and irritable bowel syndrome. Review of the physician orders for Resident #76 revealed an order dated 02/06/26 for daily weights to be obtained. Review of the 02/13/26 admission Minimum Data Set (MDS) 3.0 for Resident #76 revealed a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. Resident #76 was noted to require set-up assistance for meals and was also noted to receive a diuretic medication. Review of the 02/18/26 care plan for Resident #76 revealed the resident would maintain daily routine without chest pain or cardiac complications. Interventions included observing for any edema (swelling) of pedal, and lower extremities, and obtaining vital signs as ordered and as needed. Review of the daily weights recorded on the TAR for February 2026 for Resident #76 revealed a daily weight was not obtained on 02/06/26, 02/22/26, 02/23/26, and 02/24/26. Out of 23 ordered daily weights, four daily weights were not obtained as physician ordered for Resident #76. Review of the daily weights recorded on the TAR for March 2026 for Resident #76 revealed a daily weight was not obtained on 03/08/26, 03/12/26 and 03/16/26. Out of 18 ordered daily weights, three daily weights were not obtained as physician ordered for Resident #76. Review of progress notes from 02/01/26 to 03/19/26 for Resident #76 revealed no evidence related to why daily weights were not being completed as ordered. Interview on 03/19/26 at 10:33 A.M. with LPN #586 confirmed Resident #76 had an order for daily weights and some of the required daily weights had not been completed as ordered. Review of the facility policy Weight/Reweigh Policy dated 05/01/25 revealed a resident's weight will be monitored to evaluate the resident's nutrition status, within the parameters of the resident's overall medical condition. A resident's weight will be obtained and recorded in the electronic medical record (EMR) by the nursing staff. This deficiency represents non-compliance investigated under Complaint Numbers 2807084 and 2786114.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure appropriate care and treatment was provided for Residents #4 and #24's pressure ulcers. This affected two residents (#4 and #24) of two residents reviewed for pressure ulcers. The facility census was 61.Findings Include:1. Resident #4 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, peripheral vascular disease, a urinary tract infection, calculus of the kidney, and osteonecrosis to the left femur from a previous trauma. Review of the admission Assessment and Baseline Care Plan for Resident, dated 02/27/26 and completed by Licensed Practical Nurse (LPN) #588, revealed the resident did have a wound but the location was not documented. The Baseline Care Plan revealed a care plan for wound care was initiated. Review of the nursing progress notes from 02/27/26 through 03/17/26 revealed no documentation regarding Resident #4 having any wounds. Review of the physician's orders for Resident #4 revealed there were no orders for wound care. Interview with the Responsible Party (RP) for Resident #4 on 03/17/26 at 3:30 P.M. revealed the resident did have pressure wounds to his buttocks. The RP provided a photo of the wound she photographed on 03/08/26 showing two open areas to the left and right of the gluteal fold. The area was reddened. The RP stated the facility was not providing wound care for it. Review of the nursing documentation from Resident #4's urology office, dated 03/12/26 at 1:36 P.M., revealed Urology Registered Nurse (RN) #632 documented Patient came to OR with 2 open skin areas on his left medial buttock area. He also has a stage 1 pressure ulcer on his coccyx. The resident was at the office to have ureteral stents removed. Interview with Resident #4's Family Member #901, on 03/17/26 at 10:51 A.M. revealed she was present in the room when the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #603 entered the room to complete a skin check on the resident. Family Member #901 was present during the skin assessment and observed a round red area to the resident's buttock with yellow slough present. Review of the Initial Wound Grid Documentation 8.9 for Resident #4, dated 03/03/26, was completed by Assistant Director of Nursing (ADON) #603. The only wound documented was a skin tear to the resident's right arm. No other wounds were noted. Interview with Regional Registered Nurse (RRN) #619 on 03/18/26 at 2:00 P.M. revealed the skin tear present upon admission was the only wound Resident #4 had during his stay. RRN #619 said she had spoken with ADON #603, who was also the facility's wound nurse, who said she had provided incontinence care for Resident #4 on 03/16/26 with the assistance of an unknown aide and ADON #603 denied the resident had any wounds to his buttocks. RRN #619 could not identify who the aide was assisting ADON #603 with incontinence care. A second interview with RRN #619 at 3:30 P.M. revealed she had spoken with all nurses, the DON, ADON #603, and the nurse aides and no one reported seeing a wound to Resident #4's buttocks. Interview with RRN #619 on 03/19/26 at 8:50 A.M. confirmed the urology nurse documented Resident #4 had wounds to his buttocks on 03/12/26. RRN #619 said no orders were provided by the urologist, Medical Doctor (MD) #622, with the resident's discharge orders. Interview with the DON, ADON #603, and ADON #524 on 03/19/26 at 1:35 P.M. revealed all denied Resident #4 had any wounds other than the skin tear to the resident's left arm. 2. Review of the medical record for Resident #24 revealed an admission date of 11/25/25. Diagnoses included but not limited to an encounter for surgical aftercare following surgery on the digestive system, muscle weakness, need for assistance with personal care, and malignant neoplasm of the liver and colon. Review of Resident #24's care plan dated 12/04/25 revealed a pressure injury to the sacrum due to impaired mobility, urinary incontinence, and cancer. Interventions included performing treatment as ordered, reporting non-compliance, observing the wound, and complete preventative measures. Review of Resident #24's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 was cognitively intact, needed supervision or touch assistance for rolling left to right, frequently incontinent of urine, had a colostomy in place, and one stage four pressure ulcer. Review of Resident #24's physician orders revealed an order for the sacrum to be cleansed with soap and water, pat dry, gently fill Aquacel AG (a sterile, antimicrobial dressing used to manage moderate-to-highly exudating wounds) rope into the wound and undermining, then apply foam dressing every other day and PRN. Review of Resident #24's Treatment Administration Record (TAR) for February 2026 revealed the resident's sacral wound treatment was not recorded as completed on 02/17/26, 02/21/26, and 02/22/26. Review of Resident #24's TAR for March 2026 revealed the resident's sacral wound treatment was not recorded as completed on 03/02/26, 03/05/26, and 03/08/26. Interview on 03/17/26 at 8:29 A.M. with Resident #24 indicated the facility was not consistently changing her sacral wound dressing. Resident #24 was not aware of whether the wound developed in the facility or in the hospital but indicated it occurred from not being repositioned. A follow up interview on 03/17/26 at 1:06 P.M. with Resident #24 indicated only two nurses in the facility regularly changed her sacral dressing. Interview on 03/17/26 at 4:25 P.M. with RRN #619 verified the missing TAR entries for Resident #24's sacral wound pressure ulcer treatment. Interview on 03/17/26 at 4:06 P.M. with ADON #603 indicated an outside wound center managed Resident #24's sacral wound care. ADON #603 indicated the wound center recently changed her treatment frequency, possibly to ensure the treatment would be completed. ADON#603 indicated Resident#24 was normally compliant with treatment. ADON #603 was unaware of treatments not being completed but indicated it could have been an issue with agency nursing staff usage. Review of the facility's Wound Care-Clean Technique policy, last revised 05/01/25, revealed it was the facility's policy to provide wound care to residents using professional standards of practice. This deficiency represents non-compliance investigated under Complaint Numbers 2807084 and 2786114.

Based on review of medical record, interview, review of facility investigations, and facility policy review, the facility failed to ensure complete and thorough fall investigations were completed for one resident (#5) of three residents reviewed for falls. The facility census was 61.Findings include:Review of the medical record for Resident #5 revealed an admission date of 12/06/25. Diagnoses included but were not limited to displaced fracture of upper end of right humerus, abnormalities of gait and mobility, history of contusion of lung, type II diabetes mellitus, morbid obesity, and stage III chronic kidney disease.Review of the five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #5 revealed a Brief Interview of Mental Status (BIMS) of 10 which indicated moderate cognitive impairment. Resident #5 was noted to require substantial staff assistance for activities of daily living (ADLs). Review of the facility incident log revealed Resident #5 had falls on 12/07/25, 12/27/25, 02/06/26, and 03/02/26.Review of the facility fall investigation for Resident #5 dated 12/07/25 revealed the unwitnessed fall occurred at 5:00 A.M. Resident #5 was noted to have fallen out of bed and landed face down on the floor. Resident #5 was noted to have sustained ecchymosis (bruising) to the right posterior upper arm. Resident #5 was sent to the emergency room for evaluation. The fall report indicated it was unknown what the resident was doing just prior to the fall. Review of the two staff witness statements obtained for the 12/07/25 fall for Resident #5 indicated Certified Nursing Assistant (CNA) #569 did not observe the fall or assist staff with the fall and CNA #542 did not witness the fall. No additional witness statements were found in the fall investigation and no indication was found of when the last time Resident #5 was checked prior to the fall or who found Resident #5.Review of the nursing progress note dated 12/07/25 timed at 5:44 A.M. for Resident #5 revealed the resident was found face down on the floor in her room next to the bed and was found by two unidentified CNAs. Resident stated her foot got caught in the bed sheet and she fell. Resident then army crawled into the into the position she was found and complained of abdominal and full body pain. Vital signs were obtained and orders were obtained to send resident to the emergency room (ER) for evaluation.Review of the hospital notes dated 12/08/25 the computed tomography (CT scan) of head and cervical spine were negative. Resident #5 was admitted with diagnoses of acute hypoxic respiratory failure and pneumonia.Review of the 12/27/25 fall investigation for Resident #5 revealed an unwitnessed fall at 5:39 A.M. in the bathroom while ambulating without assistance. Vitals were completed and the resident was sent to the ER for evaluation. Circumstances noted were ambulating without staff assistance. Review of the witness statement from CNA #567 revealed she did not witness the fall or have knowledge of the fall. Review of the witness statement from CNA #541 revealed she was not working on the hall nor did she witness the fall. No evidence was found of who found the resident or when she was last seen prior to the fall.Review of the nursing progress noted dated 12/27/25 timed at 5:39 A.M. revealed Resident #5's roommate observed Resident #5 fall coming out of the bathroom. Resident #5 complained of pain to her tailbone area. The physician was noted to be aware of cognitive changes this week and was made aware of fall.Review of the 12/27/25 hospital notes revealed Resident #5 was admitted for pneumonia and fall. Chest x-ray completed revealed right lower lob infiltrate and effusion. No acute bony injury. Hip x-ray and pelvis revealed no acute fracture.Review of the 02/06/26 fall investigation for Resident #5 revealed Resident #5 had an unwitnessed fall in the bathroom and was found at 8:30 A.M. Resident was noted to be last be seen in the bed, but no time was specified as to the last time seen. An unidentified CNA was noted to have found her in the bathroom sitting on the floor. Resident #5 stated she needed to go to the bathroom and had used the walker to walk to the bathroom and slipped. No injuries were indicated. Review of the witness statement dated 02/06/26 from CNA #535 revealed the bathroom light was on and when she entered, she found Resident #5 on the floor and no other specifics to time or observations were listed. Review of the witness statement for CNA #546 revealed CNA #535 found Resident #5 on the floor and after the nurse assessed her, they assisted her back up. No other witness statements were provided.Review of the nursing progress note dated 02/06/26 timed at 8:30 A.M. written by LPN #532 revealed CNA notified her resident fell in the bathroom. Upon entering the room, Resident #5 was observed sitting on the floor in front of the toilet. Resident #5 stated she grabbed her walker and walked to the bathroom herself and slipped. No injuries were noted.Review of the fall investigation dated 03/02/26 for Resident #5 revealed an unwitnessed fall timed at 9:30 A.M. in her room. Resident #5 was noted to be reaching for something and fell out of bed and hit her head. Resident #5 was sent to the ER for evaluation. Review of the 03/02/26 witness statement from CNA #539 revealed CNA #548 requested assistance since Resident #5's head was underneath her roommate's bed and had a small bump/abrasion on the right side of her head. Resident #5 was noted to be alert after the fall. Review of the witness statement dated 03/02/26 from CNA #548 revealed she walked in and saw Resident #5 on her left side with her head half underneath her roommate's bed. The wheelchair brake was locked, grippy socks were on and call button was in reach, and the resident had a bump on her head. Review of the witness statement dated 03/02/26 written by Hospitality Aide #523 revealed she walked in and found Resident #5 on her left side. Her head was underneath her roommate's bed. Wheelchair brakes were locked, grippy socks were on and call button was in reach. Resident was noted to have a bump on her head. No indication was found of when Resident #5 was last seen prior to the fall.Review of the nursing progress note dated 03/02/26 timed at 9:52 A.M. revealed Resident #5 was observed on the floor on her left side with her head under her roommate's bed. Resident was noted to have scalp hematoma and stated she had a headache with a pain level of three out of ten and denied anything else hurt. Nurse practitioner notified who stated she was rounding and would see the resident shortly. Neurological checks were started.Review of the hospital discharge notes dated 03/02/26 for Resident #5 revealed a diagnosis of abrasion, anxiety and depression, dementia, and a fall. No indications were noted of any fractures. Interview on 03/18/26 at 3:49 P.M. with the Director of Nursing (DON) confirmed the fall investigations for Resident #5's falls did not provide evidence of when the resident was last checked on prior to any of the above-listed falls and did not provide enough details to complete a thorough investigation.Review of the 05/01/25 revised facility policy called Fall investigation revealed fall investigations would include obtaining witness statements from residents, resident roommates, visitors, and staff working the unit where the resident resides and stated a root cause analysis would be conducted by a member of the interdisciplinary team (IDT).

Based of medical record review, interview and review of facility policy, the facility failed to ensure weights and reweights were obtained as required to ensure accuracy. This affected one (Resident #24) of seven reviewed for weights. The facility census was 61.Findings include: Review of the medical record for Resident #24 revealed an admission date of 11/25/25. Diagnoses included but were not limited to infection following a procedure, colostomy, secondary malignant neoplasm of liver and intrahepatic bile duct, unspecified severe calorie malnutrition, and malignant neoplasm of colon.Review of the 02/19/25 quarterly Minimum Data Set (MDS) 3.0 for Resident #24 revealed a Brief Interview of Mental Status (BIMS) of 15 which indicated intact cognition. Resident #24 was noted to require set up for eating and was noted to be on a therapeutic diet with desired weight gain.Review of the weights recorded for Resident #24 revealed:On 11/26/25, the resident weighed 132 pounds (lbs) upon admission. On 12/04/25, the resident weighed 142.2 lbs, reflecting a 10.2 lb (7%) gain in one week. On 12/08/25, the resident weighed 138.1 pounds, reflecting a 4.1 lb loss in four days and a 6.1 lb (4.6%) gain in two weeks.On 12/15/25, the resident weighed 137.5 lbs, reflecting a 0.6 lb loss in one week and a 5.5 lb (4%) gain in three weeks.On 12/23/25, the resident weighed 115.8 lbs, reflecting a 21.7 lb (15.7%) loss in one week and a 16.2 lb (12.2%) loss in one month. On 01/16/26, the resident weighed 101.9 lbs, reflecting an additional 13.9 lb (12%) loss in one month. On 02/02/26, the resident weighed 116 lbs, a 14.1 lb (13.8%) gain in two weeks and a 16 lb (12.1%) loss over approximately two months. On 03/02/26, the resident weighed 134.4 lbs, a 18.4 lb (15.8%) gain in one month and a 7.8 lb (5.4%) loss over three months.On 03/13/26, the resident weighed 112.2 lbs, a 22.2 lb (16.5%) loss in two weeks and 25.3# (18.4%) loss over three months.On 03/17/26, the resident weighed 125.5 lbs, a 13.3 lb (11.8%) gain in four days and a 12 lb (8.7%) loss over three months.Interview on 03/18/26 at 12:38 P.M. with Registered Dietitian (RD) #902 confirmed if something is identified as a significant weight change such as a 5% change in a month, 7.5% change in three months, or a 10% change in six months. If there is a significant weight change, a re-weight is requested and supposed to be completed within the same day or the next day. RD #902 confirmed Resident #24's weights have fluctuated and re-weights were not always timely obtained. RD #902 stated different people obtained the weights which may have contributed to the fluctuation of weights.Review of the 05/01/25 revised facility policy titled Weight/Reweigh Policy revealed a resident's weight will be monitored to evaluate the resident's nutritional status, within the parameters of the residents overall medical condition. Under procedure number 3, a resident's weight will be obtained weekly for a minimum of four weeks for the following situation, new admission, readmission, pressure injuries, significant unplanned monthly weight loss of 5% or greater, 10% or greater in six months or as determined by the skin and weight assessment team.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure Resident #4 received appropriate care and services to manage the resident's pain. This finding affected one (Resident #4) of four residents reviewed for medication administration. The facility census was 61.Findings include:Review of Resident #4's medical record revealed the resident was admitted on [DATE] with diagnoses including acute kidney failure, calculus of the kidney, and urinary tract infection.Review of Resident #4's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #4's physician orders revealed an order dated 02/27/26 for Acetaminophen (a mild over-the-counter pain reliever and fever reducer) 325 milligrams (mg) orally every four hours as needed for pain. The medication was discontinued on 03/03/26. Resident #4 also had an order dated 03/03/26 for Oxycodone (a narcotic analgesic) 2.5 mg orally every eight hours as needed for pain. Review of Resident #4's Medication Administration Records (MAR) for March 2026 revealed on 03/02/26, the resident was administered a Tylenol at 11:07 A.M. for a pain level of six which was not effective and a Tylenol at 2:42 P.M. which was effective.Review of an Orthopedic Note dated 03/09/26 authored by Orthopedic Physician #626 revealed the [AGE] year-old male presented with a complaint of primary osteoarthritis of the left hip. The resident was from a skilled nursing facility (SNF) and had been hospitalized and in a facility since 01/2026 due to multiple medical issues. He had a catheter in place due to urinary retention and kidney stones. The orthopedic note indicated they were unclear how ambulatory the resident was and the history was provided by the daughter-in-law (DIL). The resident stated he had left hip pain. A discussion was held that the catheter needed to be removed and had to have dental clearance prior to proceeding with a left total hip arthroplasty (THA) utilizing a posterior approach. He was to see a urologist to discuss the catheter and stents that were being removed. Review of Resident #4's Oxycodone Controlled Drug Receipt Disposition Form revealed the resident received Oxycodone 2.5 mg on 03/16/26 at 4:30 A.M.Observation and interview on 03/16/2026 at 11:31 A.M. with Resident #4 revealed he was hurting all over, including his arms, legs and teeth.Review of Resident #4's progress note dated 03/16/26 at 12:02 P.M. authored by Registered Nurse (RN) Assistant Director of Nursing (ADON) #524 revealed the resident was yelling out and stated his pain was a 9 out of 10. Narcotics were not due. Tylenol was administered and the NP was notified.Review of Resident #4's progress note dated 03/16/26 at 12:19 P.M. authored by RN ADON #524 revealed the provider ordered Oxycodone 5 mg every eight hours as needed for pain and a dose was administered.Review of Resident #4's Oxycodone Controlled Drug Receipt Disposition form revealed the resident received 5 mg of Oxycodone (two, 2.5 mg tabs) on 03/16/26 at 12:32 P.M.Review of Resident #4's MARS revealed on 03/16/26 at 2:20 P.M., the Oxycodone was effective and the resident was resting.Observation on 03/16/26 at 2:39 P.M. revealed Resident #4 was in bed yelling out that he was in pain. During a telephone interview on 03/17/26 at 3:17 p.m. with NP #621, the NP revealed she was aware of Resident #4's pain concerns on 03/16/26 around 12:00 P.M. and she had ordered an increase in the Oxycodone pain medication for the resident. NP #621 indicated that the family felt too many narcotics would make the resident more confused and she had raised the narcotic to manage the resident's pain.Telephone interview on 03/17/26 at 4:01 P.M. with Resident #4's DIL revealed she had voiced concerns about the resident's care, including pain control.Interview on 03/18/26 at 10:12 A.M. with RN ADON #603 revealed Resident #4 was resting following the Oxycodone narcotic administration on 03/16/26 around 2:20 P.M. and she did not hear the resident if he hollered out.Telephone interview on 03/19/26 at 12:50 P.M. with Resident #4's family member who visited the resident on 03/02/26, revealed she had to find staff members to assist the resident and provide the resident pain medications. Resident #4's family member stated the resident was screaming in pain on 03/02/26 and was told that the Tylenol would not be available for another 40 minutes. Resident #4's family member revealed Licensed Practical Nurse (LPN) #635 was the nurse and the nurse stated the NP would not be in until 03/03/26 and she would not address the resident's pain. Resident #4's family member stated the nurse would not call the physician and the resident was in pain.Telephone interview on 03/19/26 at 1:23 P.M. with LPN #635 revealed she was aware Resident #4's family had come to her and told her the resident needed pain medication. LPN #635 revealed the family wanted her to call the NP and she told them the NP would be at the facility the next day. She did not remember if the resident hollered out in pain and stated she gave the resident a Tylenol. LPN #635 confirmed the NP wanted to see resident's in person for narcotic pain medication and that was why she did not call the NP but she did leave a message in the log book for the physician.Review of the Change in a Resident's Condition policy updated 05/01/25 revealed it was the policy to ensure the resident's attending physician and the resident's authorized representative or interested family member were notified in the resident's physical, mental, or psychosocial status.Review of the Pain Medication Administration policy revised 05/01/25 revealed it was the facility policy to administer pain medications in accordance with professional standards of practice.This deficiency represents non-compliance investigated under Complaint Number 2807084.

Based on review of medical record, interview, and facility policy review, the facility failed to ensure pharmacy recommendations were implemented timely. This affected one (Resident #5) of five residents reviewed for unnecessary medications. The facility census was 61.Findings include: Review of the medical record for Resident #5 indicated an admission date of 12/06/25. Diagnoses included but were not limited to a displaced fracture of upper end of right humerus, abnormalities of gait and mobility, type II diabetes mellitus, morbid obesity and chronic kidney disease.Review of the 01/13/26 five-day admission Minimum Data Set (MDS) 3.0 for Resident #5 indicated a Brief Interview of Mental Status (BIMS) of 10 which indicated moderate cognitive impairment. Resident #5 was noted to be receiving diuretic, opioid, antiplatelet, and antidepressant.Review of the physician order dated 01/27/26 for Resident #5 revealed an order for 25 milligram (mg) capsule of Hydroxyzine Pamoate (a prescription antihistamine used to treat anxiety and itching) 25 milligrams (mg) to be given orally one time per day as needed. The order was noted to be discontinued on 03/16/26.Review of the 02/16/26 pharmacy recommendations for Resident #5 revealed recommendations to discontinue Hydroxyzine Pamoate 25 milligram (mg. The physician reviewed the recommendation and recommended discontinuation of Hydroxyzine Pamoate on 02/20/26. Review of the Medication Administration Record (MAR) dated February 2026 for Resident #5 revealed an order for a Hydroxyzine Pamoate 25 mg capsule to be given orally one time per day as needed. It was noted to be administered on 02/25/26.Review of the MAR dated March 2026 for Resident #5 revealed an order for a Hydroxyzine Pamoate 25 mg capsule to be given orally one time per day as needed. The medication was noted to be given on 03/06/26 and 03/11/26.Interview on 03/17/26 with Regional Nurse #619 confirmed the 02/16/26 pharmacy recommendation was to discontinue Hydroxyzine Pamoate, the physician signed to discontinue the medication on 02/20/26, but the medication continued to be administered on 02/25/26, 03/06/26, and 03/11/26, and the order was not discontinued until 03/16/26. Review of the May 2020 facility policy titled Preparation and General Guidelines revealed under section B. Administration number (2) Medications are administered in accordance with orders of the prescriber(s).This deficiency represents noncompliance investigated under Complaint Number 2807084.

Based on record review, interview, and policy review, the facility failed to ensure residents medication regimens had an appropriate indication for use. This affected one resident (Resident #4) of five residents reviewed for unnecessary medications. The facility census was 61.Findings include:Resident #4 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, peripheral vascular disease, a urinary tract infection, calculus of the kidney, and osteonecrosis to the left femur from a previous trauma. Resident #4's medical record did not include diagnoses of generalized anxiety disorder, depression, or any psychiatric conditions. Review of Resident #4's progress notes from 02/27/26 through 03/04/26 revealed no indication or record of Resident #4 exhibiting any signs or symptoms of anxiety. There was no documentation of Resident #4 being referred to the facility's psychiatric services. Review of Resident #4's admission psychiatric evaluation on 03/04/26 by Medical Doctor (MD) #950, the facility's consulting psychiatrist, revealed the resident reported feeling sad and depressed, complaints of not sleeping, feeling anxious and restless as he is not able to do things. MD #950 diagnosed Resident #4 with Generalized Anxiety Disorder and added BuSpar (an antianxiety medication) 10 milligrams (mg) orally twice a day to treat it and Trazodone 25 mg orally every evening for depression. The note indicated depression was being ruled out and did not list depression as a new diagnosis. Review of the nursing progress notes for Resident #4 revealed no documentation on 03/04/26 regarding MD #950's assessment and order for BuSpar 10 mg twice a day for anxiety or Trazodone 25 mg every evening for depression. There was no documentation noted regarding the initial order for BuSpar or notification of Resident #4's responsible party. On 03/06/26 at 3:42 P.M., the DON documented she had spoken with the family and they requested the order for BuSpar be discontinued. Review of Resident #4's Medication Administration Record (MAR) for March 2026 revealed the order for BuSpar was entered on 03/05/26. The resident received his first dose on 03/05/26 between 6:30 P.M. and 10:30 P.M. The second dose was administered on 03/06/26 between 6:30 A.M. and 10:30 A.M.Interview with Resident #4's responsible party (RP) on 03/17/26 at 3:30 P.M. revealed the facility started the resident on BuSpar 10 mg orally twice a day for an unknown reason as well as Trazodone 25 mg orally every evening. The RP stated Resident #4 has had adverse reactions to psychotropic medications in the past and did not want him on anything that crosses the blood brain barrier. She did not know the facility had started him on the medication until she went into visit and the nurse told her about it. The RP requested the medication be discontinued.Interview with the Assistant Director of Nursing (ADON) #603 on 03/18/26 at 4:30 P.M. revealed ADON #603 was given an order for BuSpar as MD #950 had completed his admission psychiatric evaluation. ADON #603 said she gave the order to ADON #524, who was on the phone with the responsible party (RP) for Resident #4 and she informed her of the new order. The following day the RP for Resident #4 came to the facility with her two children and met with ADON #603 in her office. She spoke with the RP for about an hour regarding the BuSpar order. The RP informed ADON #603 she did not want Resident #4 to take the BuSpar due to the potential side effects of the medication. ADON #603 said the resident received two doses before it was discontinued.Interview with ADON #524 on 03/19/26 at 11:35 A.M. revealed she did not notify Resident #4's family over the phone regarding the addition of BuSpar and Trazodone to the resident's medications. ADON #524 said all of her communication with the RP was in person, not over the phone. She spoke with the RP daily. ADON #524 said she received the order for BuSpar and discussed it with the RP the next day she visited. The RP said she did not want Resident #4 to be on the BuSpar and requested it not be given. Nothing was discussed regarding the order or rationale for Trazodone. ADON #524 notified the nurse practitioner when she next saw her regarding the BuSpar. The nurse practitioner discontinued the medication as requested. ADON #524 said she did not believe Resident #4 received any doses of the medication.Review of the facility's Change in the Resident's Condition or Status policy, last revised 05/01/25, revealed the nurse is to immediately notify the resident, consult with the resident's attending physician, on call physician, nurse practitioner, physician assistant or clinical nurse specialist, and notify the resident's authorized representative when there is a change in the mental, physical, or psychosocial status. This information must be documented in the resident's medical record. This deficiency represents noncompliance investigated under Complaint Number 2807084.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure a medication error rate of 5% or less. A total of 26 medications were administered with six errors for a medication error rate of 23.08%. This affected two residents (Residents #27 and #37) of three residents observed for medication administration. The facility census was 61.Findings include:1. Review of Resident #37's medical record revealed the resident was admitted on [DATE] with diagnoses including muscle weakness, need for assistance with personal care and chronic obstructive pulmonary disease.Review of Resident #37's physician orders revealed an order dated 03/13/26 for Calcium Citrate (supplement) 250 milligrams (mg) once daily; an order dated 02/17/26 for Glucosamine-Chondroit-Vitamin C-minerals (supplement) 500-400 mg administer 200-250 mg twice daily; an order dated 02/20/26 for Miralax (laxative) 17 grams once daily; an order dated 03/02/26 for Preservision Areds (eye vitamin supplement) 200 micrograms (mcg)-15 mcg-5 mg-1 mg one capsule daily; and an order dated 02/17/26 for Coenzyme Q10 (CQ10) supplement 100 mg once daily.Observation on 03/16/26 at 8:45 A.M. with Registered Nurse (RN) #531 of Resident #37's medication administration revealed 14 medications were administered with one error. The nurse administered one Fiber Plus Calcium tablet and the order was for Calcium Citrate. In addition, RN #531 did not administer the resident's Preservision Areds tablet, COQ10 tablet, Miralax, or Glucosamine-Chondroit-Vitamin C-minerals tablet.Interview on 03/16/26 at 10:48 A.M. with RN #531 confirmed the nurse administered Calcium Plus Fiber instead of Calcium Citrate as ordered. In addition, RN #531 indicated he did not administer the other four omitted medications because he could not find them in the medication administration cart and he was going to go back and administer the medications.2. Review of Resident #27's medical record revealed the resident was admitted on [DATE] with diagnoses including atherosclerotic heart disease, hyperlipidemia and major depressive disorder.Review of Resident #27's physician orders revealed an order dated 04/08/25 for aspirin chewable 81 mg once daily.Observation on 03/16/26 at 11:04 A.M. with RN #514 of Resident #27's medication administration revealed nine medications were administered with one error. RN #514 administered aspirin 81 mg enteric coated (EC) when the order was for aspirin 81 mg chewable.Interview on 03/16/26 at 11:04 A.M. with RN Regional #629 and RN #513 confirmed the wrong form of the aspirin was administered to the resident.A total of 26 medications were administered with six errors for a medication error rate of 23.08%. Review of the Medication Administration policy dated 05/2020 revealed medications were administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications and medications were administered in accordance with orders of the prescriber(s).

Based on observations, interview, and policy and procedure review the facility failed to ensure food was stored in a manner to protect from contamination/spoilage, the oven was maintained in a clean/sanitary manner, and food was prepared/served in accordance with standards for food service safety. This had the potential to affect 68 out of 69 residents receiving food from the kitchen. Resident #127 was identified as not receiving anything by mouth and received no food from the kitchen. The facility census was 69. Findings Include: Observation during tour of the kitchen on 06/09/25 at 8:10 A.M. with the Dietary Manager revealed in the dry goods storage room there was an open bag of cake mix and an open bag of instant mashed potatoes with no label or date as to when opened. Inside the walk-in freezer there were frozen french toast sticks in a zip lock bag and an opened bag of biscuits with no labels or dates. In the preparation area, the oven had food residue and food splatter on it. Observation on 06/10/25 from 11:30 to 12:53 P.M. during lunch meal service tray line revealed that at 11:59 A.M., Dietary Aide #889 took a deli sandwich out of a sandwich bag with her bare hands and placed it on a plate for a resident. Review of the facility policy dated 08/12/20 titled, Dating Foods, revealed open food items in the cooler/refrigerator, freezer, storeroom was to be labeled with the opened date, expiration date, and food item name. Review of the facility policy dated 02/2014 titled, Glove Usage revealed no barehand food contact was allowed. Gloves must be worn when handling food whether it was ready to eat or going to be cooked as part of the process. Review of the facility policy dated January 2020 with a revision date March 2022 titled, Operation and Cleaning Procedures, revealed that all areas of the kitchen were to cleaned daily to insure proper sanitation in the operation.

4. Review of Resident #31's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, adult failure to thrive and unspecified dementia with hospice services. Review of Resident #31's physician orders revealed an order dated 05/16/25 for a regular diet, thin liquid consistency with a four ounce fortified nutritional treat daily at lunch. Review of Resident #31's Significant Change in Status MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #31's care plans revealed an intervention dated 06/10/25 to provide the diet per the physician's order. Review of Resident #31's lunch meal ticket dated 06/10/25 revealed a regular diet regular texture with a thin liquid consistency with milk, coffee, one fortified ice cream, Salisbury steak, mashed potatoes with brown gravy, peas and apple crisp. Observation on 06/10/25 at 11:34 A.M. revealed Resident #31 was sitting on side of bed waiting on the lunch meal. Observation on 06/10/25 at 12:10 P.M. revealed Resident #31's meal tray was delivered to the resident. A four ounce fortified nutritional treat was not on the meal tray as ordered by the physician. Interview on 06/10/25 at 12:20 P.M. with CNA #810 confirmed Resident #31's lunch meal tray did not include the fortified ice cream as indicated on the resident's meal ticket. 5. Review of Resident #32's medical record revealed the resident was admitted on [DATE] with diagnoses including systemic lupus, weakness and need for assistance with personal care. Review of Resident #32's physician orders revealed an order dated 04/18/25 for a regular diet, regular thin liquid consistency with no bananas or seafood per an allergy and provide four ounces of fortified nutritional treat daily at lunch. Review of Resident #32's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and lost weight of more than five percent in the last month or 10 percent in the last six months. Review of Resident #32's lunch meal ticket revealed a regular diet, regular thin liquids consistency with allergies to bananas and shellfish. The meal ticket indicated to add one fortified ice cream, Salisbury steak, mashed potatoes with brown gravy, peas, apple crisp and milk/beverage. Interview on 06/10/25 at 11:51 A.M. with Resident #32 revealed the resident was aware of a recent weight loss and was happy with the weight loss. Observation on 06/10/25 at 12:20 P.M. of Resident #32's meal tray revealed the tray did not have four ounces of fortified nutritional treat on the tray as ordered by the physician. Interview on 06/10/25 at 12:25 P.M. with Regional Licensed Social Worker #922 confirmed Resident #32's lunch tray did not include a fortified nutritional treat. Based on observation, interview, and record review, the facility failed to provide residents with their preferences during meals. This affected five ( #28, #30, #31, #32, and #40 ) of six residents reviewed for food and drink. The facility census was 69. Findings Include: 1. Review of Resident #28 medical record revealed the resident was admitted on [DATE] with diagnoses including anorexia, adult failure to thrive and anxiety disorder. Review of Resident #28's care plans revealed an intervention dated 11/25/24 to provide the diet per the physician's order and honor preferences. Review of Resident #28's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 exhibited moderate cognitive impairment. Review of Resident #28's physician orders for June 2025 revealed an order for a regular diet, thin liquid consistency. Observation on 06/09/25 at 1:36 P.M. revealed Resident #28's lunch ticket indicated the resident chose apple juice but received cranberry juice. This was verified by Certified Nursing Assistant (CNA) #832 at time of observation. Interview and observation on 06/11/25 at 8:50 A.M. revealed Resident #28 taking a drink and then indicating the beverage tasted horrible and she was supposed to get apple juice. Activities Coordinator #881 verified that the drink was not the color of apple juice, and the meal ticket indicated Resident #28 was to receive apple juice. Interview on 06/11/25 at 8:53 A.M. with Dietary Aide (DA) #896 verified Resident #28 did not receive apple juice, she received lemonade. 2. Review of Resident #30's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia, sepsis, muscle wasting and atrophy. Review of Resident #30's care plans revealed an intervention dated 12/28/20 to provide the diet per the physician's order and honor preferences. Review of Resident #30's physician orders for June 2025 revealed an order for a regular diet, thin liquid consistency. Observation of Resident #30's breakfast meal and meal ticket on 06/09/25 at 9:47 A.M. revealed Resident #30 selected cheddar egg bake, coffee cake, hash brown patty, and cranberry juice. Resident #30 did not receive the hash brown patty and received orange juice instead of cranberry juice on her breakfast tray. CNA #832 verified the ticket and stated that the kitchen ran out of hash browns. 3. Review of Resident #40's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, fracture of right femur and hypo-osmolality and hyponatremia. Review of Resident #40's care plans revealed an intervention dated 08/23/22 to provide the diet per the physician's order and honor preferences. Review of Resident #40's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #40 exhibited moderate cognitive impairment. Review of Resident #40's physician orders for June 2025 revealed an order for a regular diet, thin liquid consistency. Observation of Resident #40's meal ticket on 06/09/25 at 9:35 A.M. revealed Resident #40 selected cheddar egg bake and a hash brown patty for breakfast but was not served the hash brown patty on his breakfast tray. CNA #832 verified the meal ticket and stated the kitchen ran out of hash browns.

Based on observation, record review and interview, the facility failed to ensure call lights were in working order. This affected one resident (#36) of one resident reviewed for call light placement. Findings Include: Review of Resident #36's medical record revealed the resident was admitted on [DATE] with diagnoses including pancytopenia, diabetes mellitus, and atherosclerotic heart disease. Review of Resident #36's admission Minimum Data Set 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of a plan of care dated 04/21/25 revealed Resident #36 was at risk for falls. Interventions included to encourage Resident #36 to use call light for transfer/ambulation assistance. Observation and interview on 06/10/25 at 12:57 P.M. revealed Resident #36 needed assistance. Resident #36 stated that he had been using the call light, and it was not working. He stated that he wanted to be positioned for when lunch arrived. An attempt to activate the call light at time of observation/interview revealed the call light did not activate the electronic message board. Observation and interview on 06/10/25 at 1:02 P.M. with the Administrator revealed that the call light cord was pulled out of the wall and that is why it did not activate. Review of the policy dated 05/01/25 titled, Call Light-Answering, revealed call lights would be responded to timely to meet the resident's needs.

Based on observation, record review and interview, the facility failed to ensure Resident #21's left palm protector was implemented as ordered to prevent skin breakdown and prevent deformity. This affected one (Resident #21) of one resident reviewed for position and mobility. Findings Include: Review of Resident #21's medical record revealed the resident was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, muscle weakness and vascular dementia. Review of Resident #21's physician orders revealed an order dated 01/23/25 for a left palm protector to be placed on in the morning and removed at bedtime and to check skin integrity twice daily. Review of Resident #21's Quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #21's care plans revealed an intervention dated 04/15/25 for a palm protector to the left hand. Review of Review of Resident #21's medication administration records and treatment administration records from 06/01/25 to 06/11/25 revealed documentation the palm protector was applied as ordered. Observation on 06/09/25 at 9:54 A.M. revealed Resident #21 had a contracted left hand with no palm protector in place. Interview with Resident #21 at the time of the observation confirmed the resident was supposed to wear a left hand splint during the day. Interview on 06/09/25 at 1:03 P.M. with Certified Nursing Assistant (CNA) #849 confirmed Resident #21's left hand palm protector was not in place as ordered by the physician. CNA #849 placed the palm protector to the left hand at this time. Observation on 06/11/25 at 6:15 A.M. revealed Resident #21's palm protector was on the resident's left hand and the resident was in bed sleeping. Interview on 06/11/25 at 6:31 A.M. with CNA #824 revealed she had helped provide care to Resident #21 around 5:00 A.M. and the palm protector was in place at that time. Interview on 06/11/25 at 6:33 A.M. with CNA #830 revealed she worked 10:30 P.M. to 6:30 A.M. and Resident #21's was wearing the left hand palm protector when she came in the facility. CNA #830 indicated she was not aware the palm protector was to be removed at bedtime. Interview on 06/12/25 at 1:11 P.M. with Regional Registered Nurse #927 revealed the facility did not have a policy regarding use of palm protectors.

Based on record review, observation, interview, and review of facility policy, the facility failed to provide enteral feeding as ordered for Resident #127. This affected one (#127) of one resident who received enteral feedings. The facility census was 69. Findings Include: Review of the medical record for Resident #127 revealed an admission date of 05/24/25 with diagnoses including dysphagia oropharyngeal phase, aphasia, and gastrostomy status. Review of the admission Minimum Data Set assessment, dated 05/31/25, revealed Resident #127 was cognitively intact, dependent on staff for activities of daily living, and received 51 percent or more of calories and 501 milliliter (ml) or more of fluids from tube feeding daily. Review of the physician's orders for June 2025 for Resident #127 identified an order dated 05/27/25 for continuous enteral feeding formula Isosource 1.5 at 55 ml per hour. There were no physician's orders for enteral feeding formula substitutions. Review of the medication administration record for 06/08/25 revealed continuous enteral feeding formula Isosource 1.5 at 55 ml per hour was signed as administered on 06/08/25 at 10:42 P.M. On 06/09/25 at 11:55 A.M., an observation of Resident #127 revealed the resident was sitting in bed with the head of bed elevated and Vital 1.5 enteral formula at 55 ml per hour infusing. On 06/09/25 at 12:40 P.M., an observation and interview with Registered Nurse (RN) #926 confirmed Vital 1.5 enteral formula was hooked up and running through Resident #127's feeding tube. RN #926 verified Resident #127 was ordered Isosource 1.5 enteral formula. On 06/09/25 at 1:02 P.M., an observation of the supply room revealed there were several cases of Isosource 1.5 formula available for use, which was verified by Regional RN #915 at the time of observation. On 06/09/25 at 1:17 P.M., an interview with Registered Dietitian (RD) #921 revealed nobody had called her regarding substituting Vital 1.5 in place of Isosource 1.5 for Resident #127. RD #921 said there should have been physician input regarding the enteral formula substitution. On 06/10/25 at 1:39 P.M., an interview with Medical Records Coordinator #881 revealed the current supply of enteral formula was ordered on 05/28/25 and delivered by the end of the month (May 2025). There were no other orders placed for enteral feeding formulas since then. Medical Records Coordinator #881 stated the Isosource 1.5 enteral formula was available for use and she was unsure why the Vital 1.5 enteral formula was administered instead for Resident #127. Review of the facility's policy titled Enteral Feeding - Continuous Pump, dated 05/01/25, revealed the facility would provide enteral nutrition and hydration in accordance with professional standards of practice, including administering the prescribed enteral feeding to residents.

Based on observation, record review and interview, the facility failed to ensure Resident #34's carbohydrates were monitored during meals, assisted with adding the carbohydrate count to the insulin pump, the resident's care plans were updated to reflect accurate interventions for caring for the resident's insulin pump, the resident's physician orders accurately reflected the amount of as needed insulin to be administered to the resident and the staff were knowledgeable in operating the resident's insulin pump. This resulted in significant insulin medication errors affecting one (Resident #34) of two residents reviewed for insulin administration. The facility census was 69. Findings Include: Review of Resident #34's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified nondisplaced fracture of the surgical neck of the right humerus, type one diabetes mellitus and spastic quadriplegic cerebral palsy. Review of Resident #34's admission Minimum Data Set 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Further review revealed Resident #34 was dependent upon staff for performance of all activities of daily living including eating, toileting, bathing, and hygiene. Review of Resident #34's care plans revealed an intervention dated 04/29/25 to approach insulin pump as per the physician's orders. There were no intervention regarding assisting Resident #34 with the carbohydrate count necessary to calculate insulin bolus via the insulin pump. Review of Resident #34's physician orders revealed an order dated 04/17/25 for a low concentrated sweets diet, regular texture with regular thin liquid consistency; an order dated 04/26/25 to assist the resident with entering carbohydrate counts into the resident's insulin pump to deliver a bolus of insulin after each meal, referring to carbohydrate sheets at the bedside bulletin board with meals due at 8:00 A.M., 12:00 P.M. and 5:00 P.M.; an order dated 05/01/25 for U-100 insulin fast acting insulin, 100 units/milliliter (ml), up to 90 units per day subcutaneous via an insulin pump due from 6:30 A.M. to 10:30 A.M.; and an order dated 05/21/25 to check the resident's blood sugars before meals and at bedtime and notify the physician if the blood sugar was less than 60 or greater than 400. Review of Resident #34's progress note authored by Licensed Practical Nurse (LPN) #813 dated 04/18/25 timed 1:31 P.M. revealed the resident's insulin pump was not working correctly and the alarm for a high blood sugar had been going off. The insulin pump showed a fasting blood sugar of over 400 with a fingerstick confirming a fasting blood sugar of 552. Ten units of Humalog insulin was administered subcutaneously. Review of Resident #34's progress note dated 04/19/25 timed 1:16 A.M. authored by LPN #923 indicated at approximately 12:40 A.M., the resident's insulin pump displayed a reading above 400. A finger stick was performed, and the blood sugar was 493. A note on the report sheet indicated the insulin pump was not functioning and that the son was bringing a replacement part. A review of the resident's chart showed a similar incident documented on 04/18/25 at approximately 1:30 P.M. The physician was called and awaiting on a physician to return the call. Review of Resident #34's progress note dated 04/25/25 timed 9:00 P.M. authored by Registered Nurse (RN) #801 revealed the resident's insulin pump had been beeping on and off for the floor staff. The floor staff were unsure how to operate the insulin pump or what orders to use for caring for the insulin pump. The endocrinologist was contacted multiple times throughout the day requesting specific orders for administering bolus insulin as well as educational materials related to refilling the pump and changing the monitor. Review of Resident #34's progress note dated 05/14/24 at 5:22 A.M. authored by RN #924 revealed the blood sugar reading at 5:00 A.M. was 470. The resident stated he had been running high. The certified nurse practitioner (CNP) advised the resident to administer 8 units via the insulin pump and a new order to check the resident's blood sugars before meals and at bedtime. Review of Resident #34's medication administration records (MARS) and treatment administration records (TARS) from 05/01/25 to 05/31/25 revealed no evidence of entering a carbohydrate count into the resident's insulin pump to deliver a bolus of insulin after each meal on 06/01/25 at 8:00 A.M., 05/02/25 at 8:00 A.M., 05/03/25 at 8:00 A.M., 05/04/25 at 8:00 A.M., 05/04/25 at 12:00 P.M., 05/06/25 at 8:00 A.M., 05/07/25 at 8:00 A.M., 05/08/25 at 12:00 P.M., 05/09/25 at 8:00 A.M., 05/09/25 at 12:00 P.M., 05/10/25 at 8:00 A.M., 05/11/25 at 8:00 A.M., 05/11/25 at 12:00 P.M., 05/11/25 at 5:00 P.M., 05/13/25 at 12:00 P.M., 05/13/25 at 5:00 P.M., 05/14/25 at 8:00 A.M., 05/14/25 at 12:00 P.M., 05/17/25 at 8:00 A.M., 05/17/25 at 12:00 P.M., 05/19/25 at 8:00 A.M., 05/20/25 at 5:00 P.M., 05/21/25 at 8:00 A.M., 05/22/25 at 8:00 A.M., 05/27/25 at 8:00 A.M., 05/22/25 at 12:00 P.M., and 05/30/25 at 8:00 A.M. Review of Resident #34's MARS and TARS from 06/01/25 to 06/11/25 revealed no evidence the staff assisted the resident with carbohydrate count into the resident's insulin pump to deliver a bolus of insulin after each meal on 06/02/25 at 8:00 A.M., 06/02/25 at 12:00 P.M., 06/03/25 at 8:00 A.M., 06/06/25 at 8:00 A.M., 06/06/25 at 12:00 P.M., 06/09/25 at 8:00 A.M., 06/09/25 at 12:00 P.M., 06/09/25 at 5:00 P.M. Review of Resident #34's MARS and TARS dated 05/14/25 revealed to administer a one-time dose of 80 units of insulin for a blood sugar reading of 470. The MARS and TARS did not reveal evidence the nurse administered the insulin. An observation on 06/09/25 at 12:00 P.M. of Resident #34 while in his room revealed Resident #34 was alert, appropriately groomed and able to converse without limitations. An interview on 06/09/25 at 12:01 P.M. with Resident #34 indicated the resident had been waiting since 8:30 A.M. for the nurse on shift to tell the resident how many carbohydrate the resident had for breakfast for the insulin bolus and a blood sugar of 207. Resident #34 requested assistance to remove his glucose monitor from his pocket so that he could check his blood sugar. He shared that he was unable to do so because he had limited ability to move his right arm due to right shoulder and upper arm fracture. He further shared that he did not have the ability to grasp things with his left hand due to cerebral palsy. An interview on 06/09/25 at 12:47 P.M. with RN #926 confirmed that she did not assist Resident #34 with a carbohydrate count for his insulin bolus due at 8:00 A.M. and 12:00 P.M. RN #926 shared that they did not know that they were supposed to provide Resident #34 with a carbohydrate count and thought that the insulin pump delivered insulin automatically. Further, RN #926 shared they were not familiar with insulin pumps in general. RN #926 verified the physician's order to assist Resident #34 to calculate carbohydrate counts at each meal to be programmed into the insulin pump for an insulin bolus was on Resident's #34 medication administration record. RN #926 stated that she would notify the doctor. An interview On 06/10/25 at 7:54 A.M. with Resident #34 revealed that he had a list of carbohydrate counts for common foods at his bedside. Resident #34 shared that he did not add up the total carbohydrates based on the provided information and that nurses were supposed to do this for him. Resident #34 stated that occasionally the nurses did not assist him with the carbohydrate counts and that he was unable to independently calculate carbohydrate counts and program them into his insulin pump. Further, he shared that while at home he ate the same foods most of the time and he knew the carbohydrate counts without calculation, also he had food package instructions to help him figure out serving sizes, and full use of his dominant side prior to falling at home. Resident #34 stated that he had no way of knowing what the serving sizes were at the facility. Resident #34 was alert and laying in bed during this interview. Resident #34 denied ever experiencing discomfort related to elevated or low glucose levels. An interview on 06/10/25 at 7:46 A.M. with Regional RN #915 revealed that the nurse was to supply Resident #34 with the carbohydrate count for each meal, using the chart at his bedside. Resident #34 then injected the correct dose of insulin via his insulin pump. An interview on 06/10/25 at 4:54 P.M. with Regional RN #915 verified that carbohydrate counts were not documented for multiple days/shifts and that she could not verify that the insulin bolus were given. An interview on 06/11/25 at 9:20 A.M. with LPN #813 revealed that Resident #34 usually walked the staff through the process with his insulin pump and that he knew everything about his insulin pump. LPN #813 indicated that she routinely went online with her phone and looked up carbohydrate counts based on serving sizes Resident #34 gave her. LPN #813 was not sure how Resident #34 determined serving sizes. LPN #813 shared that they were not provided with education on the insulin pump for Resident #34 and they were not sure what brand or type of insulin pump he used. An interview on 06/11/25 at 9:34 A.M. with Regional RN #915 verified that the medical record for Resident #34 contained no orders to monitor glucose prior to 05/14/25. An interview on 06/11/25 at 9:39 A.M. with Assistant Director of Nursing (ADON) #802 revealed that the glucose levels for Resident #34 were tracked on his insulin pump. ADON #802 verified that the expectation for residents with continuous glucose monitoring was to obtain blood glucose levels and to record them at regular intervals. The facility was unable to provide glucose monitoring data prior to 05/14/25 for Resident #34. ADON #802 furthered shared that no education was provided to the staff for Resident #34's insulin pump and that it was not a routine practice to provide staff education for residents admitted with devices unfamiliar to staff. An interview on 06/11/25 at 2:30 P.M. with RN #924 revealed that they made a transcription error when receiving orders for an elevated glucose level for Resident #34. RN #924 shared that they did not administer 80 units of insulin to Resident #34 and they did not know much about Resident #34 or his insulin pump other than his blood sugar was high and they called the Nurse Practitioner (NP) on call. The NP ordered 8 units of insulin and that was what RN #924 gave Resident #34. An interview on 06/11/25 at 2:45 P.M. with the Director of Nursing (DON) verified that Resident #34's care plan did not reflect current orders specifically carbohydrate counting. An interview on 06/11/25 at 2:58 P.M. with Regional RN #927 revealed that when care plans were done, they were general and not specific. If they were too specific to the orders, then they would have to update them every time an order was changed. An interview on 06/11/25 at 3:30 PM with the DON revealed that Resident #34 had not been assessed for self-administration of medication and it was not expected that the residents would self-administer medications. The DON verified that the facility did not have any documentation of staff education for the use, care, and maintenance of Resident #34 insulin pump or for carbohydrate counting.

Based on record review and interview, the facility failed to accurately document the details of a fall and fall investigation. This affected one resident (#10) out of two residents reviewed for falls. The facility census was 69. Findings Include: Review of the medical record for Resident #10 revealed an admission date of 03/17/25 and readmission date of 05/13/25 with diagnoses including bilateral osteoarthritis of the knee, atrial fibrillation, difficulty in walking, type two diabetes mellitus, chronic obstructive pulmonary disease, bipolar disorder, hypertension, acute and chronic respiratory failure with hypoxia, and weakness. Review of the admission assessment dated [DATE] revealed Resident #10 was at low risk for falls with a score of 4.0 (the assessment indicated high risk was a score of 10.0 or higher). Review of the fall investigation report dated 05/20/25 timed 6:00 A.M. indicated Resident #10 had a fall with injury. The question asking Was the patient injured? was answered Other: -states none. The question asking Further assessment/findings related to injury: was answered Resident self-reported fall but said she did not hurt self and had no issues. The assessment indicated the nurse practitioner (NP) was notified on 05/21/25 at 1:00 P.M. and the resident representative was notified on 05/21/25 at 2:15 P.M. Resident #10 reported a pain level of zero. The assessment indicated the resident reported pain the following day, an x-ray was ordered and the results were negative. The investigation report was closed on 05/22/25 at 3:05 P.M. Review of the fall investigation report dated 05/22/25 timed 3:10 P.M., with a note indicating it was for the self reported fall on 05/20/25, indicated Resident #10 had a fall with injury. The question asking Was the patient injured? was answered Other: - none reported. The question asking Further assessment/findings related to injury: was answered Resident reported fall but unsure of when it happened. States no injury. The assessment indicated the nurse practitioner and resident representative were notified on 05/20/25 at 6:00 A.M. (which was inconsistent with the dates/times of notification listed on the other assessment for this same fall). Resident #10 reported a pain level of zero. The assessment indicated an x-ray was ordered the day after the fall. The investigation report was closed on 06/10/25 at 2:36 P.M. Review of the progress note dated 05/22/25 timed 12:05 P.M., written by NP #914, indicated Resident #10 reported a recent fall in the restroom with head involvement and the resident was unsure of what day it occurred, reporting it was possibly on 05/17/25 (which was inconsistent with the date reported on the two fall investigation reports). There was a small abrasion on the back of the head (which was inconsistent with the findings reported in the two fall investigation reports), Resident #10 denied any headache, Resident #10 complained of right thigh pain, and x-rays were negative. Review of the care plan, dated 06/04/25, revealed Resident #10 was at risk for falls or injury related to bowel incontinence, bladder incontinence, anti-depressant, anti-hypertensive, anti-convulsant, anti-psychotic, diabetic oral hypoglycemic, diuretic, and impaired gait stability. Interventions included occupational therapy as per plan, physical therapy as per plan, educate resident about limitations and safety concerns, encourage resident to use call light for assistance, encourage resident to wear glasses, evaluate resident safety with devices, identify non-compliance with safety issues and report to the physician as needed, observe resident for safety needs, redirect for safety as needed, pharmacy and physician to review medications with resident visits, report any possible medication side effects, and observe for mental and physical side effects with device use. On 06/10/25 at 9:15 A.M., an interview with Resident #10 stated she had one fall since arriving to the facility. Resident #10 said she fell while self-transferring, hit her head, and hurt her arm. On 06/10/25 at 3:06 P.M., an interview with Regional Registered Nurse (RN) #915 verified there were two incident reports for the same incident for Resident #10, both with an incident type of fall with injury, and on both incident reports, the question asking what injury the resident had was answered as none. On 06/10/25 at 4:07 P.M., an interview with the Director of Nursing (DON) confirmed Resident #10's fall was classified as a fall with injury even though the incident reports indicated there was no injury and no pain. The DON said there were two incident reports because the first one was accidentally closed out before it was completed and confirmed the information in the two assessments did not match.

Based on observation, record review and interview, the facility failed to ensure call lights were in working order. This affected one resident (#36) of one resident reviewed for call light placement. Findings Include: Review of Resident #36's medical record revealed the resident was admitted on [DATE] with diagnoses including pancytopenia, diabetes mellitus, and atherosclerotic heart disease.Review of Resident #36's admission Minimum Data Set 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of a plan of care dated 04/21/25 revealed Resident #36 was at risk for falls. Interventions included to encourage Resident #36 to use call light for transfer/ambulation assistance.Observation and interview on 06/10/25 at 12:57 P.M. revealed Resident #36 needed assistance. Resident #36 stated that he had been using the call light, and it was not working. He stated that he wanted to be positioned for when lunch arrived. An attempt to activate the call light at time of observation/interview revealed the call light did not activate the electronic message board. Observation and interview on 06/10/25 at 1:02 P.M. with the Administrator revealed that the call light cord was pulled out of the wall and that is why it did not activate.Review of the policy dated 05/01/25 titled, Call Light-Answering, revealed call lights would be responded to timely to meet the resident's needs.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency, dated [DATE], review of Centers for Medicare and Medicaid (CMS) Quality Safety Oversight (QSO ,d+[DATE] NH) memo, review of Nursing Home Guidance from the Centers for Disease Control (CDC) website related to preparing for Coronavirus Disease 2019 (COVID-19) for nursing homes and health care facilities, review of the facility policy and procedures for isolation and personal protective equipment (PPE), review of the facility infection control log, review of daily resident census reports, review of Point of Care (POC) and Polymerase Chain Reaction (PCR) COVID-19 testing results, medical record review, review of facility complaint log documentation, interview with local health department (LHD) staff, interview with Ombudsman #141, Medical Director #143 and staff interview, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19 to residents in the facility including moving COVID-19 positive residents out of rooms with COVID-19 negative residents and not reusing personal protective equipment (N95 masks) after use in COVID-19 isolation rooms. With positive and negative residents cohorting and personal protective equipment (PPE) reuse in between residents in isolation and non-isolation rooms, the likelihood exists for serious harm or death related to the spread of the COVID-19 virus. This resulted in Immediate Jeopardy on [DATE] when two residents, Resident #72 and Resident #73 tested positive for COVID-19 and Resident #47 (who was COVID-19 negative) remained in the room being shared with Resident #72. Between [DATE] and [DATE], 30 additional residents tested positive for COVID-19 and eight of the 30 positive residents remained in a room being shared with a COVID-19 negative resident. This has the potential to affect all residents in the facility and specifically affected nine COVID-19 negative residents (Resident #8, #17, #47, #50, #53, #65, #69, #70 and #71) who resided in rooms with COVID-19 positive residents. The facility also failed to develop an infection control policy to mitigate the spread of COVID-19 related to the reuse of N95 masks between isolation and non-isolation rooms. This lack of development of current infection control policy and implementation of current infection control practices placed all 68 residents at risk for hospitalization , complications and/or death related to the facility's COVID-19 outbreak. The facility census was 68. On [DATE] at 1:33 P.M. the Administrator was notified Immediate Jeopardy began on [DATE] when routine facility wide outbreak testing for COVID-19 was completed for all staff and residents due to five staff testing positive for COVID-19 beginning on [DATE]. On [DATE] the first residents, Resident #72 and Resident #73 tested positive for COVID-19. Resident #47 tested negative for COVID-19 on this date but remained in a room with Resident #72 who was positive. The facility remained in an outbreak until [DATE]. The Immediate Jeopardy continued [DATE], four days after being out of outbreak status when Resident #50 who tested negative for COVID-19 remained in a room with Resident #74 who had tested positive on this same date. The facility had a policy for N95 mask reuse, although they were not in crisis or contingency status, to wear the same N95 mask with a surgical mask over top while caring for all residents regardless of COVID-19 status. Staff were directed to remove the surgical mask upon exit of a resident's room and continue to wear the same N95 mask for an entire day unless it was soiled or damaged. No changes were made to this facility policy or facility practice following the COVID-19 outbreak. The Immediate Jeopardy was removed on [DATE] when the facility completed the following corrective actions: · On [DATE] at 4:00 P.M. the Director of Nursing Services (DNS) or designees began mandatory in-services of all staff related to COVID policies. By [DATE] at 10:30 P.M. 15 nurses, 33 State tested Nursing Assistants (STNAs) and 34 other staff including 13 management staff including the Admissions Coordinator and Intake Coordinator who are responsible for room changes, and assignment of rooms, eight therapists, four dietary staff, four housekeeping and laundry staff, four receptionists and one activity assistant were educated on COVID cohorting and proper PPE usage. 100% of facility staff have been educated. A plan for all new hires and agency staff to be educated prior to their shift was implemented. · On [DATE] at 1:00 P.M., the Regional Nurse completed a whole house audit and validated no COVID positive and negative residents were cohorted. On [DATE] the audit revealed one resident was on transmission based precautions (non-COVID related) without cohorting. · On [DATE] at 2:45 P.M. education was provided by the Chief Nursing Officer to the Executive Director (ED) and DNS on the facility policy which prohibited cohorting of COVID positive and negative residents. · On [DATE] at 3:00 P.M. the ED, DNS, Regional Nurse and Regional Vice President reviewed the Optimizing Mask and Eye Protection Policy (updated [DATE]) with changes made to reflect current CDC guidelines (i.e., not utilizing surgical masks over N95 masks.) · On [DATE] at 3:15 P.M., the ED, DNS, Regional Nurse and Regional Vice President reviewed the COVID 19 Pandemic Admission/Readmission policy and validated it addressed cohorting and conventional use of PPE. · On [DATE] at 5:15 P.M. an ad hoc Quality Assurance/Performance Improvement meeting was held with the Medical Director to review the plan of correction, cohorting and PPE procedures. · Beginning [DATE] at 5:00 P.M., the Infection Preventionist, DNS or designee initiated daily infection control surveillance rounds with focus on PPE use, isolation, quarantine, cohorting, and general infection control practices throughout the facility. · On [DATE] between 6:10 P.M. and 6:41 P.M. interview with Registered Nurse (RN) #113 and #149, STNA #116, #124, #126 and #150, Physical Therapy Assistant #133, Dietary #92, Receptionist #94, Regional Vice President #151, Administrator #102 and Licensed Practical Nurse #148 revealed they had received education within the last six days regarding not cohorting COVID-19 positive and negative residents and proper use of N95 mask. On [DATE] at 12:11 P.M. Administrator #102 provided a sign in sheet for education provided to staff between [DATE] and [DATE] which all staff were notified and educated. The staff have been educated and were on not cohorting positive and negative patients or reusing N95 masks after exiting an isolation room. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1. Review of the Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo QSO ,d+[DATE]-ALL dated [DATE], revealed CMS is committed to taking critical steps to ensure America's healthcare facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (Covid-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of infection control priorities during this time of crisis, and providers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to nursing homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of Covid-19. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable diseases or infections should be reported (42 CFR 483.80 (a) (2) (i) and (ii). Review of QSO ,d+[DATE] NH, revised [DATE] revealed nursing homes have been severely impacted by COVID-19, with outbreaks causing high rates of infection, morbidity, and mortality. The vulnerable nature of the nursing home population combined with the inherent risks of congregate living in a healthcare setting have required aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes On [DATE] at 1:32 P.M. interview with Ombudsman #141 revealed she had recently (no date provided) contacted the Administrator with a concern of a COVID-19 negative resident (Resident #70) being left in a room with a COVID-19 positive resident (Resident #80). Resident #70 indicated she requested a room change on [DATE] due to her roommate testing positive for COVID-19 and was told no other rooms were available. The ombudsman reported the facility indicated they had a semi-private room but since the resident had been exposed to her roommate who tested positive, they could not move her into a semiprivate room. Ombudsman #141 revealed she had received an email response from the Administrator indicating due to Resident #70 being exposed to COVID-19 by her roommate they left her in the room. The email communications were dated [DATE]. Review of a spreadsheet of COVID-19 positive staff and residents revealed a new COVID-19 outbreak began in the facility on [DATE] when Activities #71, who was asymptomatic tested positive for COVID-19 during routine facility testing. The facility began testing all staff and residents with POC testing every Monday and PCR testing every Friday and testing for any staff/residents who were symptomatic between these dates. The facility remained in outbreak until [DATE]. The facility returned to outbreak status on [DATE] when three residents, Resident #81, #82, and #83 tested positive for COVID-19 and remained in outbreak until [DATE]. Between [DATE] and [DATE] a total of 32 residents and 35 staff members tested positive for COVID-19. 2. Record review revealed Resident #72, #73 and #84 passed away after testing positive for COVID-19. Resident #81, #83 and #85 were hospitalized after testing positive for COVID-19 and Resident #47 and #65 tested positive for COVID-19 after cohorting with a positive roommate. a. Review of Resident #72's medical record revealed a [DATE] admission with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident tested positive for COVID-19 on [DATE]. Review of the nurse's notes revealed the resident had diarrhea, body aches, fatigue, lack of appetite and was pale. His oxygen saturation dropped to 77 percent on room air [DATE] and the resident expired [DATE]. b. Review of Resident #73's medical record revealed a [DATE] admission with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident tested positive for COVID-19 on [DATE]. Review of the nurse's notes included the resident developed fever, fatigue, and dizziness. The resident expired [DATE]. c. Review of Resident #84's medical record revealed a [DATE] admission with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident tested positive for COVID-19 on [DATE]. Review of the nurse's notes included the resident stated he was tired, had a lack of appetite and was lethargic. On [DATE] Intravenous hydration was ordered. The resident had a fall on [DATE], received pain medication [DATE] for grimacing and moaning and expired [DATE]. The resident received Hospice care. d. Review of Resident #81's medical record revealed a [DATE] admission with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident tested positive for COVID-19 on [DATE]. Review of the nurse's notes included the resident received an as needed dose of [MEDICATION(S)] [NAME] on [DATE] per order for cough and an aerosol treatment which she said she received in the hospital, and it helped. On [DATE] stat labs including a stool for [CONDITION(S)] were ordered as well as a chest x-ray. On [DATE] the resident was coughing, having difficulty breathing, oxygen saturation dropped to 87 percent, and she was started on oxygen. A COVID test came back positive. The resident was transported to the hospital due to not being able to maintain he oxygen saturation. She did not return to the facility. e. Review of Resident #83's medical record revealed a [DATE] admission with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident tested positive for COVID-19 on [DATE]. The resident was due to be discharged [DATE] but remained at the facility due to the positive COVID-19 diagnosis. Review of the nurse's notes included the resident had some confusion, cough, chest congestion, fatigue, loss of appetite, weakness and loss of taste. On [DATE] the resident had a critically high potassium and was started on intravenous fluid. On [DATE] the resident was transported to the hospital with change in mental state, low blood pressure, emesis, shakiness, weakness, and blood in urine. The resident was admitted to intensive care on multiple vasopressors to increase blood pressure. He did not return to the facility. f. Review of Resident #85's medical record revealed a [DATE] admission with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] the resident developed signs and symptoms of COVID-19 when he became confused, lethargic, struggling to breath, an oxygen saturation of 80 percent and an elevated heart rate. The resident was started on oxygen and receives a stat chest x-ray. The resident tested positive for COVID-19 on [DATE]. On [DATE] the resident was transported to the hospital and admitted with [CONDITION(S)], pulmonary embolism, COVID-19, [CONDITION(S)] and [CONDITION(S)]. He did not return to the facility. g. Review of Resident #47 revealed a [DATE] admission with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #47 tested negative on [DATE] and remained in the same room with his roommate, Resident #72 who tested positive. On [DATE] Resident #47 was retested for COVID-19 using a POC test and was positive for COVID-19. His symptoms included a dry cough, stuffy nose, that developed into a runny nose. h. Review of Resident #65's medical record revealed a [DATE] admission with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #65 tested negative for COVID-19 on [DATE] and remained in the same room with his roommate, Resident #53 who tested positive. On [DATE] Resident #65 became symptomatic was retested for COVID-19 with a POC and was negative for COVID-19. On [DATE] Resident #65 tested positive for COVID-19 with a PCR test. The resident was lethargic with wheezing in left lower lung. She refused some medications and meals. Her potassium dropped and medications were adjusted. Review of the facility Infection Control logs, dated ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and ,d+[DATE] revealed only five residents, Resident #53, #64, #73, #77 and #78 of the 32 residents who tested positive for COVID-19 were listed on the logs. Review of facility data revealed between [DATE] and [DATE] five staff members tested positive for COVID-19. On [DATE] STNA #76 who worked the 300 hall and on [DATE] STNA #146 who worked the 300 hall tested positive for COVID-19. The first six residents to test positive for COVID-19 all resided on the 300 hall: Resident #72 and #73 on [DATE], Resident #59 and #65 on [DATE], Resident #75 on [DATE] and Resident #47 on [DATE]. On [DATE] at 5:49 P.M. interview with the Administrator revealed the facility did conduct a contact tracing sheet for each positive staff and resident. They facility did not identify a reason or person who caused the spread of COVID-19. During the interview, the administrator revealed the facility had not linked the infecting of residents to any breach in isolation precautions related to staff. 3. Review of facility spreadsheet documentation, daily bed boards, resident medical record/census/room information and staff interviews confirmed after testing positive for COVID-19 in the facility, residents remained in the same room as COVID-19 negative residents which included: a. Resident #72 tested positive for COVID-19 on [DATE]. Resident #47 (roommate of Resident #72) tested negative on [DATE] and remained in the same room with Resident #72. On [DATE] Resident #47 was retested for COVID-19 using a POC test and was positive for COVID-19. b. Resident #65 tested positive for COVID-19 on [DATE]. Resident #53 (roommate of Resident #65) tested negative on [DATE] and remained in the same room with Resident #65. c. Resident #75 tested positive for COVID-19 on [DATE]. Resident #17 (roommate of Resident #75) tested negative on [DATE] and remained in the same room with Resident #75. d. Resident #79 tested positive for COVID-19 on [DATE]. Resident #69 (roommate of Resident #79) tested negative on [DATE] and remained in the same room with Resident #79. e. Resident #74 tested positive for COVID-19 on [DATE]. Resident #50 (roommate of Resident #74) tested negative on [DATE] and remained in the same room with Resident #74. f. Resident #17 tested positive for COVID-19 on [DATE]. Resident #8 (roommate of Resident #17) tested negative on [DATE] and remained in the same room with Resident #17. g. Resident #80 tested positive for COVID-19 on [DATE]. Resident #70 (roommate of Resident #80) tested negative on [DATE] and remained in the same room with Resident #80. h. Resident #50 tested positive for COVID-19 on [DATE]. Resident #71 (roommate of Resident #50) tested negative on [DATE] and remained in the same room with Resident #50. i. Resident #53 tested positive for COVID-19 on [DATE]. Resident #65 (roommate of Resident #53) tested negative on [DATE] and remained in the same room with Resident #53. On [DATE] Resident #65 became symptomatic was retested with a POC and was negative for COVID-19. On [DATE] Resident #65 tested positive for COVID-19 with a PCR. Review of a facility Concern Tracking Log revealed on [DATE] Resident #70 complained she was in a room with a resident who was positive for COVID-19 so she chose to be discharged home as the resolution. The comment section included the resident had refused a room move. On [DATE] the family of Resident #8 voiced concerns about the resident being in a room with a positive roommate. The resolution noted the family refused to pay for a private room and no other rooms were available. The comment section included the family was satisfied with a room move once a room opened. Review of the facility [DATE] COVID-19 Pandemic Admission/readmission Policy revealed current residents of the facility who newly test positive for COVID-19 would be placed in a red zone for 10 days and may be extended up to 20 days for severely immunocompromised or experiencing a severe critical illness and as directed by the physician. Newly positive residents required a private room and if outbreak may cohabitate with another COVID-19 positive resident. The previous version of the policy in effect from [DATE] through [DATE] contained the same verbiage. On [DATE] at 3:29 P.M. interview with the Administrator confirmed there were COVID-19 negative residents, including Resident #8, #17, #47, #50, #53, #65, #69, #70 and #71 who remained in the same room as COVID-19 positive residents because the residents were roommates at the time the resident tested positive. The Administrator revealed Ombudsman #141 had reached out to her with concerns from Resident #70 related to COVID-19. The Administrator then read an email reply dated [DATE] she sent to Ombudsman #141 verifying Resident #70, who was negative for COVID-19 remained in a room with a resident who tested positive for COVID-19 on [DATE]. She included on [DATE] she requested a room change but we only had semi private rooms and since she had exposure we would've had to place her in a private room. Because we didn't have a room to move her to, she asked for assist with discharge plans to return home on ,d+[DATE]. The Administrator revealed the facility felt as though the negative roommate had already been exposed to the virus and moving a resident out of the room would cause a greater risk of outbreak of the virus. When asked about a resident having to pay for a private room to not co-habitat with a COVID-19 positive roommate, the Administrator provided no additional information. On [DATE] at 10:52 A.M. interview with Communicable Disease Clerk #145 for the Local Health Department revealed typically the facility sends in spreadsheets with new positive staff and resident cases. We would offer the facility an Infection Prevention and Control Assessment Tool for Response (ICAR) which outlines practices and protocols for infection control. Clerk #145 revealed they follow CDC and Ohio Department of Health (ODH) guidelines. On [DATE] at 8:53 A.M. interview with Medical Director (MD) #143 revealed he had weekly conversations with the Administrator to discuss facility policies and procedures during the outbreak of COVID-19. MD #143 revealed he was purely an advisor. During the interview, MD #143 denied knowledge of the facility having COVID-19 positive residents reside in rooms with COVID-19 negative residents. MD #143 revealed if he knew of this practice and there were private rooms open he would have advised the facility to separate the residents regardless of their policy related to private room payments. During the interview, MD #143 also revealed the facility had ample supply of N95 mask use and denied any knowledge of the facility having staff re-use N95 masks when caring for COVID-19 positive and negative residents. Review of the CMS website included a [DATE] entry addressing Conventional Capacity Strategies (should be incorporated into everyday practices) including cohorting. Cohorting is the practice of grouping together patients who are infected with the same organism to confine their care to one area and prevent contact with other patients. Cohorts are created based on clinical diagnosis, microbiologic confirmation when available, epidemiology, and mode of transmission of the infectious agent. Cohorting has been used extensively for managing outbreaks of multi-drug resistant organisms including [CONDITION(S)], VRE, MDR-ESBLs, Pseudomonas aeruginosa; [CONDITION(S)]-susceptible Staphylococcus aureus, RSV, adenovirus keratoconjunctivitis, rotavirus, and [CONDITION(S)]. When single patient rooms are not available, patients with confirmed [CONDITION(S)]-CoV-2 infection may be placed in the same room. 4. On [DATE] at 3:25 P.M. interview with Activities #71 revealed during an outbreak staff were required to wear an N95 mask and eye protection (face shield or goggles). Activities #71 revealed when entering the room of a COVID-19 positive resident she would place a surgical mask over the N95 mask and then apply a gown and gloves. Upon leaving the room, she would remove the gloves, gown and surgical mask, wash her hands and use hand sanitizer. She would also cleans her face shield with alcohol or bleach wipes. Activities #71 revealed she would not change or discard the N95 mask and would continue to use the same N95 mask for the entire day going then into rooms of residents who did not have COVID-19. Activity #71 revealed there were always N95 masks available. On [DATE] at 3:35 P.M. interview with State tested Nurse Assistant (STNA) #97 revealed when she enters the room of a COVID-19 positive resident she would cover the N95 mask she was wearing with a surgical mask. Upon exiting the room, the surgical mask was removed and discarded but she would continue to wear the same N95 mask all day. STNA #97 revealed she had a bag in the car and puts the N95 mask in it when she leaves work so she can wear the same N95 for three consecutive days unless it became visibly soiled. STNA #97 revealed some staff change their N95 mask daily. STNA #97 denied ever running out of masks in the facility or being told there were no N95 masks available for use. On [DATE] at 3:53 P.M. interview with STNA #76 revealed when she enters the room of a COVID-19 positive resident she covers her N95 mask with a surgical mask. Upon exiting the room, the surgical mask would be removed and she would continue to wear the same N95 mask all day. This resulted in the STNA wearing the same N95 mask when caring for both COVID-19 positive and COVID-19 negative residents. On [DATE] at 4:49 P.M. interview with Director of Nursing #105, who was identified to be the facility infection preventionist and the Administrator revealed staff were to change their N95 mask every fifth time they removed it and/or change it every day. Review of the facility [DATE] Optimizing Mask and Eye Protection in extended use situations policy revealed facility staff would utilize an N95 mask in the following situations: When caring for a resident in quarantine (surgical mask over top of N95 when in room), when caring for a resident in isolation, when conducting an aerosol generating procedure on a resident (surgical mask overtop N95), when conducting staff screening, when conducting staff and resident COVID testing, and during an outbreak all staff when engaging in a patient care encounter. For the purpose of this policy, a patient caring counter was defined by CMS as encounter where a medical treatment was provided and or evaluation and management services were provided. When PPE supplies were not readily available to use according to the manufacture guidelines, but the facility was not in a crisis situation, a surgical KN95 mask could be changed daily provided it does not become contaminated or damaged. When PPE supplies were not readily available according to manufacturer guidelines, but the facility was not in crisis situation an N95 mask could be changed after five removals (doffing) or at least daily provided it does not become contaminated or damaged. While performing aerosol generating procedures a surgical mask should be placed over top the N 95 mask prior to beginning the procedure upon completion doff PPE including surgical mask. N 95 mask may continue to be worn if not visibly soiled. During the complaint investigation, the facility failed to provide evidence they were in a situation that required extended use of an N95 mask. There was no evidence PPE supplies including N95 masks were not readily available placing the facility in a crisis situation. Review of the CMS website COVID-19 Summary for Healthcare Facilities: Strategies for Optimizing the Supply of N95 Respirators during Shortages included a Situational update as of [DATE]: The supply and availability of NIOSH-approved respirators have increased significantly over the last several months. Healthcare facilities should not be using crisis capacity strategies at this time and should promptly resume conventional practices. On [DATE] at 5:22 P.M. interview with Registered Nurse (RN) #144 revealed the most current mask policy the company had was the policy dated [DATE] (above). RN #144 was unaware of CDC guidelines not to reuse N95 masks if not in crisis mode. RN #144 revealed the facility was not and had not been in PPE crisis and had N95 masks available. On [DATE] at 11:10 A.M. interview with Local Health Department Epidemiologist (LHD) #147 revealed she received an email from the Administrator [DATE] with the spreadsheet of new COVID-19 positive staff and residents. The department responded they would open an outbreak. LHD #147 revealed they asked the facility if they needed anything, if they had enough PPE and if they would be interested in another tele-ICAR with ODH. The facility indicated they had enough PPE and they had staff scheduled to come and audit the following week to see if there was anything they would need to improve upon and they would reach out to get additional support if needed. LHD #147 revealed the facility continued to send spreadsheets with testing results. LHD #147 revealed the Administrator asked on [DATE] if there was a requirement to follow a positive POC with a PCR. LHD #147 revealed the facility was informed of the requirements that they just needed one or the other positive but to follow CDC guidance. On [DATE] the Administrator asked about contingency staffing. LHD #147 told the facility they could not authorize it. It would be determined by their current capacity, Human Resource department and CDC guidance. There was no further communication except for the spreadsheet of new positives cases. If the question was asked about keeping positive and negative residents together and there was a lack of rooms, the LHD would recommend cohorting two residents who were exposed together and removing them from the room where the roommate was positive. Local Health Department Epidemiologist #147 denied being asked by the facility about reusing PPE. On [DATE] at 2:33 P.M. interview with Director of Nursing #105, the facility infection preventionist revealed the facility infection control log was only used to include infections for infections requiring antibiotics. If the COVID-19 resident was not on antibiotics they would not show up on the log. She indicated she was new to the role and finished the Infection Preventionist training on [DATE]. A regional nurse was covering the infection control program until she received the certification. She was aware staff were reusing N95 masks which was the facility policy. For cohabitation of positive and negative COVID-19 residents the DON indicated they thought to keep the residents centrally located and not spread COVID-19 throughout the whole building. This deficiency substantiates Complaint Number OH 525.