Every finding on record at Althea Woodland Nursing Home

Based on observation, record review, and interview with facility staff, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations to prevent possible foodborne illness. This was evident during the kitchen tours of the annual survey. The findings include: A food-contact surface refers to any surface of equipment and utensils that typically comes into contact with food; or from which food may drain, drip, or splash onto food; or a surface that is usually in contact with food. On 06/15/2026 at 8:06 AM, the surveyor conducted a tour of the kitchen alongside Staff #10 and observed the following deficient practices:The 2-compartment preparation sink failed to provide hot water at the minimum required temperature of 100 degrees Fahrenheit (F), measuring 78 degrees F.The 3-compartment sink initially reached 117 degrees F. However, the temperature decreased to 78 degrees F once the vats were filled and maintained for wash, rinse, and sanitization process.The drain line beneath the 3-compartment sink was leaking greywater onto the kitchen floor.Condensation was dripping from the ceiling in front of the evaporator fans and created a pool of standing water on the walk-in refrigerator floor. In addition, several food items wrapped in plastic were unlabeled and could not be identified. These items were discarded at the time of the survey.The high-temperature mechanical dishwasher failed to reach the required final rinse temperature of 180 degrees F. The surveyor observed a final rinse temperature of 149 degrees F. In addition, trays and dome covers were improperly air-dried and stored in a wet-nested condition. Shelving units within the walk-in refrigerator/kitchen and mobile rolling carts were observed to be unclean with excessive buildup of grease, dust, dirt and debris. At 8:25 AM, the Maintenance Director and the Dietary Manager reviewed the findings listed above. The Maintenance Director and the surveyor reevaluated the hot water temperatures dispensing at the 2-compartment prep sink and 3-compartment sink, which measured 103 degrees F and 114F respectively. The Maintenance Director also had to reset the high-temperature dishwasher booster heater. Following 9 operational cycles, the dishwasher achieved a final rinse temperature of 189 degrees F. The Maintenance Director confirmed that the above ground grease trap interceptor would be cleaned more frequently to prevent greywater overflowing onto the kitchen floor. In addition, he stated that the walk-in refrigerator walls, floors, ceilings, and doors would be properly cleaned and sealed to prevent possible cross-contamination from condensation dripping on to the food items.The Dietary Manager confirmed that the staff would receive education regarding the proper procedure for resetting the booster heater on the high-temperature dishwasher to ensure dishware are sanitized at the required minimum final rinse temperature of 180 degrees F.On 06/17/2026 at 10:00 AM, a review of the facility's water management plan revealed that the facility documented water temperatures throughout the building only once per month. During an interview, the Maintenance Director acknowledged that hot water temperatures should be monitored on a regular basis and at various times throughout the day to verify that water temperatures meet the requirements outlined in the facility's water management plan policies and procedures. On 06/17/2026 at 2:20 PM, the surveyor revisited the kitchen with the Nursing Home Administrator (NHA) and reviewed the previously identified deficient practices. During the revisit, the surveyor verified the hot water temperatures at the handwashing sink, 2-compartment sink, and 3-compartment sink which measured 92 degrees F, 93 degrees F and 103 degrees F respectively. At 3:30 PM, the NHA administrator acknowledged that the hot water temperatures fluctuated throughout the day. He confirmed that the internal temperature of the water heater was increased to maintain adequate hot water temperatures and meet facility wide hot water demands. On 06/18/2026 at 9:30 AM, the surveyor verified that the hot water temperatures measured above 100 degrees F at the handwashing sink, 2-compartment preparation sink, and the 3-compartment sink. However, the surveyor was unable to verify a service report or written documentation demonstrating how corrective actions had been implemented to ensure that hot water temperatures remained consistent throughout the facility in accordance with regulatory requirements. Cross reference to CMS 2567F-880

Based on observation and interviews, it was determined the facility failed to ensure medications were properly wasted, labeled and dated. This was evident for 1 of 1 medication storage rooms observed during the recertification survey. The findings include:Aplisol should be used within 30 days after opening the vial. Any remaining solution after this period should be discarded due to the potential for oxidation and loss of potency. The integrity of the vial and solution must be maintained to avoid inaccurate test results, which can lead to false negative or positive findings with tuberculosis screening.On 06/18/2026 at 10:53 AM, an observation of the medication storage room was completed with the Director of Nursing (DON).The observation revealed:An opened vial of Aplisol not labeled with an open or expiration dateAn opened vial of Admelog that was labeled with an expiration date of 2/21 The DON confirmed the findings and removed the two vials of medication from the refrigerator.

Based on review of medical records and interviews it was determined that the facility failed to respond to recommendations made by the consulting pharmacists in a timely manner. This was evident for 2 (Residents #1 & #5) of 2 residents reviewed for Medical Regimen Reviews during the recertification survey.The findings include:1. During a review of medical records for Resident #1 on 06/16/2026 at 9:48 AM it was discovered that the pharmacist had made recommendations for the Resident on 4/07/2026. There was no copy of the recommendation in the electronic medical recordsDuring a review of the Medication Regimen Review - Nursing Recommendations form for Resident #1 provided by DON #1 on 06/17/2026 at 8:42 AM it was discovered that the Medication Regimen Review Completed on 4/07/2026 recommended, In order to avoid local skin irritation (rash, puritis, etc.) please clarify the Lidocaine Patch order to include on 12 hours, off 12 hours. This is also the manufacturer's recommendation for use. The MRR recommendation form was not signed off by the doctor or staff to show it had been reviewed and there was documentation in the follow-through column of the recommendation.During an interview with Director of Nursing #1 on 6/17/2026 at 10:31 AM he reported the MRR recommendation form for Resident #1 had not been followed through to completion. He advised the form should have been signed off by the doctor and the recommended changes made to the MAR. He reported that the staff was contacting the doctor in reference to the MRR recommendation. He advised the expectation for handling MRR recommendations would be for the form to be provided to the doctor and then after the doctor approves or declines the recommendation it would be provided to the DON so the medication orders could be updated as needed.During a review of the Medication Administration Record (MAR) for Resident #1 on 6/17/2026 at 10:35 AM it was revealed the order was for Lidocaine external patch 5% Apply to affected areas topically one time a day for pain. There was no indication of when the patch should be removed in the order.During a review of the facility's Medication Regimen Reviews Policy on 6/17/2026 at 11:04 AM it was revealed that the attending physician documents that the irregularity has been reviewed and what (if any) action was taken to address it and Copies of Medication Regimen Review reports, including physician responses, are maintained as part of the permanent medical record.2. During a review of medical records for Resident #5 on 06/16/2026 at 10:52 AM it was discovered that the pharmacist had made recommendations for the Resident on 4/07/2026. There was no copy of the recommendations in the electronic medical recordsDuring a review of the Medication Regimen Review - Nursing Recommendations form for Resident #5 provided by Director of Nursing #1 on 06/17/2026 at 8:42 AM it was discovered that the Medication Regimen Review completed on 4/07/2026 recommended to Indicate dose on Medication Administration Record (MAR) for the use of Diclofenac Sodium External Gel 1%. The MRR form was not signed off by the doctor or staff to show it had been reviewed and there was nothing listed in the follow-through column of the recommendation.During an interview with Director of Nursing #1 on 6/17/2026 at 8:44 AM he reported the MRR recommendation form dated 4/07/2026 for Resident #5 had not been followed through to completion. He advised the form should have been signed off by the doctor and the recommended changes made to the MAR. He reported that the staff was contacting the doctor in reference to the MRR recommendation. He advised the expectation for handling MRR recommendations would be for the form to be provided to the doctor for and then after the doctor approves or declines the recommendation it would be provided to the DON so the medication orders could be updated. During a review of the Medication Administration Record for Resident #5 on 6/17/2026 at 9:01 AM it was confirmed that the previous order did not show a dosage and read, Diclofenac Sodium External Gel 1% (Diclofenac Sodium Topical) Apply to Bilateral knee topically two times a day for knee pain. Further review showed the order was updated on 6/17/2026 with Diclofenac Sodium External Gel 1% (Diclofenac Sodium Topical) Apply to bilateral knee topically two times a day for knee pain, apply 4 grams to bilateral knee.During a review of the facility's Medication Regimen Reviews Policy on 6/17/2026 at 11:04 AM it was revealed that the attending physician documents that the irregularity has been reviewed and what (if any) action was taken to address it and Copies of Medication Regimen Review reports, including physician responses, are maintained as part of the permanent medical record.

Based on interviews and record reviews it was determined the facility staff failed to report an allegation of suspected resident abuse in a timely manner. This was evident for 1 (Resident #6) of 3 residents reviewed for abuse allegation reporting during the recertification survey. The findings include:During an interview with Resident #6 on 6/15/2026 at 10:18 AM he/she reported that he/she felt abused when Geriatric Nursing Assistant (GNA) #30 banged on his/her groin about a week ago. Resident #6 stated he/she told GNA #30 that she was hurting him/her during cleaning of his/her groin area and then she banged on the groin area. He/she stated s/he notified RN #31.During an interview with Director of Nursing (DON) #4 on 6/15/2026 at 12:41 PM he reported he was not aware of the allegation and was not aware of the Nursing Home Administrator being notified of the concern.During a telephone interview with Nursing Home Administrator (NHA) #4 on 06/16/2026 at 11:21AM he reported that he was not aware of the allegation. He advised if abuse is reported to a nurse, then the concern would be brought to the attention of the NHA. He added that the NHA and the Director of nursing (DON) can both submit incident reports.During a telephone interview with Registered Nurse (RN) #31 on 6/18/2026 at 3:51 PM she reported that Resident #6 had reported to her that a GNA had banged on his/her groin. She advised that she felt this was an allegation of abuse because that was how the Resident presented it to her. At that time RN #31 removed GNA #30 from the care of Resident #6 and had her write a statement about her care with the resident. RN #31 reported she texted Assistant Director of Nursing (ADON) #2 on 5/26/2026 at 12:55 A.M. and told her the care concerns expressed by Resident #6 and advised she didn't hear anything back from ADON #2.During an interview with Assistant Director of Nursing #2 on 6/23/2026 at 7:40 AM she reported that if there was a report of abuse the NHA would be notified and an investigation would be completed. She added that regardless of the time of day, even during night shift, we have to meet the two-hour window. She confirmed she did receive a text message reference the concern reported by Resident #6, but she advised the message did not specify abuse for Resident #6. She confirmed that no report was submitted.During a review of the facility Abuse Investigation and Reporting Policy on 6/23/2026 at 9:41 AM it stated An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure clean, safe, and comfortable environment. This was evident in 3 (Rooms 5, 26 and 27) of 4 rooms reviewed during the annual survey. The findings include: On 06/15/2026 at 1:11 PM, the surveyor toured the facility with the Maintenance Director and observed that there was no airflow in the bathroom of room [ROOM NUMBER]. The bathroom ambient air temperature felt warm, and an odor remained in the bathroom. During an interview, the Maintenance Director acknowledged that the exhaust fan was nonfunctional and confirmed that the unit would be repaired or replaced promptly. On 06/18/2026 at 9:43 AM, the surveyor observed the footboards for Beds A and B in room [ROOM NUMBER] were torn, chipped, cracked, and pitted. At 9:55 AM, the surveyor observed water-damage at the bottom of the closet doors in room [ROOM NUMBER]. The closet doors showed signs of swelling, warping, and bubbling paint. At 10:01 AM, the surveyor notified the Maintenance Director of the findings and reviewed the damaged footboards in room [ROOM NUMBER] and the damaged closet doors in room [ROOM NUMBER]. During an interview, the Maintenance Director acknowledged that several other footboards throughout the facility were also in process of being replaced and confirmed that the footboards for Beds A and B were on the replacement list. The Maintenance Director also stated that new closet doors had been purchased and would be installed promptly.

Based on medical record reviews and interviews it was determined the facility failed to obtain informed consent for psychotropic medication. This was evident for 3 (Resident #1, Resident #2, Resident #47) of 5 Residents reviewed for psychotropic medication consents during the recertification survey.The findings include: All residents have the right to be informed of their health status and to accept or refuse medical treatment. Psychotropic medications are prescription drugs that alter brain chemistry to affect mood, thoughts, behavior, and perception. They are primarily used to treat mental health disorders like depression, anxiety, and schizophrenia. The intent of this form (Psychotherapeutic Medication Informed Consent Form) is to provide informed consent for the administration of psychotropic medications. Two or more medications in the same drug class simultaneously may increase the risk of side effects and or adverse reactions. 1) During a review of medical records for Resident #1 on 6/16/2026 at 10:32 AM it was discovered that Resident #1 was taking two psychotropic medications, Trazadone for insomnia which was started on 4/03/2026 and mirtazapine for depression which started on 5/27/2026. Further review of medical records revealed no documentation of informed consent being obtained for the psychotropic medications. During an interview with Director of Nursing (DON) #1 on 6/18/2026 at 11:47 AM he reported that the facility has consent forms for psychotropic medications that should be completed when a psychotropic medication is ordered. He confirmed that he was unable to find a psychotropic medication consent for Trazadone or Mirtazapine for Resident #1 and confirmed that a consent should have been obtained for Resident #1. During a review of the facility Psychotropic Medications – Informed Consent policy on 6/17/2026 at 11:41 AM it stated, The facility informed Consent for Psychotropic Medications form shall be used to document the resident's or resident representative's consent or refusal before a psychotropic medication is initiated or it's dose or frequency is increased. The policy added, The completed form shall be maintained in the resident's medical record. 2) On 06/16/2026 at 8:44 AM, a review of Resident #2 medical record revealed medication orders for 3 psychotherapeutic medications: DULoxetine HCl, RisperDAL, and LORazepam. On 06/17/2026 at 8:37 AM, a review of Resident #2 medical record for a signed Psychotherapeutic Medication Informed Consent Form was completed and this surveyor was unable to locate a form in the medical record. On 06/17/2026 at 9:35 AM, during an interview with the Director of Nursing (DON) they confirmed the process upon admission is that residents are given a Psychotherapeutic Medication Informed Consent Form to sign when they are admitted to the facility and are prescribed psychotherapeutic medications. The DON also stated the form would be used for any newly prescribed psychotherapeutic medications to existing residents. On 06/17/2026 at 10:23 AM, the DON was given Resident #2 medical record to locate the signed form. The DON confirmed they were unable to locate the signed Psychotherapeutic Medication Informed Consent Form in the medical record. 3) On 06/16/2026 at11:47 AM, a review of Resident #47 medical record revealed a medication order for 1 psychotherapeutic medication: RisperDAL. On 06/17/2026 at 8:37 AM, Resident #47 medical record was reviewed for signed Psychotherapeutic Medication Informed Consent Form. This surveyor was unable to locate the form in Resident #47 medical record. On 06/17/2026 at 9:35 AM, during an interview with the Director of Nursing (DON) they confirmed the process upon admission is that residents are given a Psychotherapeutic Medication Informed Consent Form to sign when they are admitted to the facility and are prescribed psychotherapeutic medications. The DON also stated the form would be used for any newly prescribed psychotherapeutic medications to existing residents. On 06/17/2026 at 10:23 AM, the DON was given Resident #47 medical record to locate the signed form. DON confirmed they were unable to locate the signed Psychotherapeutic Medication Informed Consent Form in Resident #47 medical record.

Based on observation, record review, and interviews with the resident, resident's representative, and facility staff, it was determined that the facility failed to ensure that the resident and/or resident's representative was offered an opportunity to participate in the development and review of the resident's care plan. This was evident for 1 (Resident #30) of 1 complaint investigated during the annual survey.The findings include:A care plan is a comprehensive guide that addresses each resident's individualized needs and is used to plan, assess, and evaluate the effectiveness of care provided. On 06/15/2026 at 11:10 AM, the surveyor observed Resident #30 lying in bed watching television in a darkened room with the lights turned off. During an interview, the resident expressed concerns regarding when he/she would be returning home and stated that he/she was unaware of the last time he/she participated in a care planning meeting.At 12:30 PM, the surveyor contacted the resident's representative to verify the last date of the care plan meeting that was offered by the facility. The resident's Power of Attorney (POA) stated that the most recent care plan meeting occurred on 4/29/2026. The POA further stated that only one additional care plan meeting had occurred since the resident's admission in 2024.On 06/17/2026 10:44 AM review of Minimum Data Set (MDS) assessments and care plan revealed that updates and revisions were completed on a quarterly basis. However, review of social services documentation showed evidence of only two care plan meetings offered to the resident and/or the resident's representative: one on 4/29/2026 and another on 2/20/2026 since the resident's admission date of 7/24/2024.At 11:30 AM, the surveyor interviewed the Social Services staff member. Staff #6 acknowledged that documentation within the electronic medical record system reflected only two care plan meetings offered to the resident and/or resident's representative. Staff #6 confirmed that the most recent meeting occurred on 4/29/2026 and stated that he could not verify whether additional meetings had been offered prior to April 2026. Staff #6 acknowledged that only one additional care plan meeting was documented on 2/20/2025 since the resident's admission and confirmed that quarterly care plan meetings would be offered to the resident and/or resident's representative to discuss the resident's needs and evaluate the effectiveness of care provided.

Based on medical record review and staff interview, it was determined that the facility failed to maintain resident records completely and accurately. This was evident for 4 (Resident #15, #6, #34, #21) out of 16 sampled residents reviewed during the annual survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Everyone who applies for admission to a nursing facility must be screened for evidence of serious mental illness (MI) and/or intellectual disabilities (ID), developmental disabilities (DD), or related conditions. On 04/21/25 12:53 PM, a review of Resident #15's medical record revealed no evidence of advance directives or a signed copy of the facility's advance directive policy. On 4/22/25 at 9:07 AM, the surveyor requested Resident #15's advance directive information from Social Services Director #6. During an interview conducted on 4/22/25 at 12:08 PM, the Social Services Director #6 confirmed that there was no advance directive information in Resident #15's medical record. The Social Services Director #6 then provided the surveyor with a policy titled Althea Woodland Nursing and Rehabilitation Advance Directive Policy that was signed by Resident #15 on 2/26/25 and stated, I pulled this form from my email. On 04/21/2025 at 1:17 PM, a review of Resident #6's medical record revealed no evidence that a preadmission screening and resident review (PASRR) was completed. On 4/22/25 at 9:07am, the surveyor requested Resident #6's PASSR information from Social Services Director #6. During an interview conducted on 04/24/25 at 1:27 PM, the Social Services Director #6 confirmed that there was no PASSR form in Resident #6's medical record and stated, I pulled this from email. On 04/21/2025 1:33 PM, a review of Resident #34's medical record revealed no evidence of advance directives or a signed copy of the facility's advance directive policy. On 4/22/25 at 9:07 AM, the surveyor requested Resident #34's advance directive information from Social Services Director #6. During an interview conducted on 04/24/25 at 1:42 PM, the Social Services Director #6 confirmed that there was no advance directive information in Resident #34's medical record. The Social Services Director #6 then provided the surveyor with a document titled Department of Veterans Affairs VA Advance Directive Durable Power of Attorney for Health Care and Living Will that was signed by Resident #34 on 7/29/2021and stated I pulled this form from a file in my office. It was not in the resident's record. On 04/21/25 at 1:50 PM, a review of Resident #21's medical record revealed no evidence that a preadmission screening and resident review (PASRR) was completed. On 4/22/25 at 9:07 AM, the surveyor requested Resident #21's PASSR information from Social Services Director #6. During an interview conducted on 04/24/25 at 1:07 PM, the Social Services Director #6 confirmed that there was no PASSR form in Resident #6's medical record and stated, I pulled this form from a file in my office. It was not in the resident's record.

Based on observation and interview, it was determined that the facility failed to maintain proper sanitation for storage of food in the nursing units and in the kitchen. This was evident on 1 of 2 nursing units and on the initial tour of the kitchen during review of food storage and sanitation. The findings include: During the initial tour of the kitchen on 4/21/25 at 8:29 AM with the Food Services Director (FSD) and Staff #17 in attendance, the surveyor observed the following sanitation concerns: In Refrigerator #1, there was an opened half- gallon container of mustard, void of ¾ of its contents with a label 12/27/24 written in black on its cover. The label did not indicate when the item was opened and when the contents should have been used. The FSD stated the item was opened on 12/27/24 and should it have been discarded a long time ago. He immediately placed the item in the trash. Also, one half gallon container of chicken-base with opened on 4/15/25 which the FSD stated should have been discarded after 3 days of opening. In Refrigerator #2 was a white half gallon plastic container with a yellow cover, void of ½ of its contents of cranberry colored jelly. The yellow cover of the container was visibly dirty with a black substance and a label with the date 3/31/25 was attached to the cover. The FSD stated that the date on the cover was the date the jelly was placed in the container. He further stated the jelly should have been discarded 3 days after the open date. All expired items were discarded by the FSD. On 04/21/25 at 9:05 AM in an interview during the initial tour of the kitchen the FSD confirmed the surveyor's sanitation concerns and stated that it is the policy of the facility to label items in the refrigerator with the date opened and date expired. He also stated the kitchen refrigerators are cleaned out every Tuesday and expired items discarded. On 04/22/23 the surveyor reviewed the facility's policy and procedure for food Brought in by Family/ Visitors dated 2001 and revised October 2017. This food policy indicated that food items will be labeled and the nursing/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor and past due package expiration dates). At 4/23/25 at 07:07 AM the surveyor conducted an observation of the nourishment refrigerator on the 1st floor Nursing Unit in the presence of the Director of Nursing (DON). The DON stated there was only one refrigerator in the facility used for food brought in by family and visitors. The findings of the observation were as follows: One opened ½ gallon Neapolitan ice cream with expiry date 11/10/24, 16oz Potato Salad void of ¾ of its contents, undated, 16 oz blue personal mug filled with liquid unknown with no label, Pancake Syrup Aunty Maple expired July12, 2022 and one unlabeled black and white food container containing green vegetables with foul odor. The DON immediately put the expired and unlabeled items in the trash. The DON confirmed the findings and stated that the expired items should have been removed from the refrigerator per the facility's policy, and the food items should have been labeled and dated. She also stated the nourishment refrigerator is cleaned out weekly. On 04/25/25 at 03:15 PM the Administrator was notified of the sanitation and food storage concerns by the surveyor.

Based on facility staff interviews and employee record reviews, it was determined that the facility failed to ensure that the required in-service training for nurse aides was completed. This finding was found to be evident in 3 out of 3 employee personnel files (#10, #11 and #14) reviewed for the annual required in-service training for nurse aides. The findings include: On 04/24/2025 at 07:15 AM the surveyor reviewed 3 nurse aide employee personnel files #10, #11 and #14. During the record review of the 3 nurse aide personnel files it was revealed that the facility had incomplete documentation on the annual required in-service training for the 3 nurse aides #10, #11 and #14. Further review of the nurse aide personnel files revealed that nurse aides #11 and #14 had Dementia Training certificates (6 hour Cognitive training course) dated 3/19/2018 and 10/10/2022 respectively. At 07:45 AM on 04/24/2025 the surveyor interviewed the Director of Nursing (DON). During this interview the surveyor conveyed to the DON that the 3 nurse aide personnel files #10, #11 and #14 had incomplete documentation for the annual required in-service training. The Director of Nursing (DON) acknowledged that there was incomplete documentation for the required in-service training for the 3 nurse aides #10, #11 and #14 in the personnel files. The DON stated that there was a new program for in-service training called RELIAS that facility staff would be using for completion of required in-service training, but this program was not in use yet at the facility. In a follow up interview with the Director of Nursing (DON) on 04/24/2025, the surveyor requested additional documentation of in-service training for nurse aides. The DON provided the following in-services that were conducted over the past year: 02/27/2025 - Resident Rights, Abuse, HIPPA, Exploitation; 08/09/2024 - Infection Control, Handwashing, Prevention; 06/20/2024 - Resident Rights, Knocking on Resident doors, Wait for Response; and 05/15/2024 - Infection Control, Hand Hygiene. During the review of these in-services for the past year, it was revealed that there were no in-services documented on Dementia Management Training, Cognitively Impairment Training and Resident Abuse Prevention Training for 2024. The Director of Nursing (DON) acknowledged the incomplete documentation on the annual required in-service training for the nurse aides. The Licensed Nursing Home Administrator (LNHA) at 01:45 PM on 04/24/2025 was notified with the Director of Nursing (DON) in attendance of the incomplete documentation for the annual required in-service training for nurse aides. At the time of exit on 04/25/2025 at 03:15 PM no further documentation was provided by the facility for the required in-service training for the nurse aides.

Based on medical record review and interviews, it was determined that the facility failed to facilitate the inclusion of the resident and/or resident representative in care plan meetings. This was evident for 1 (Resident #21) out of 3 residents reviewed for care planning during the annual survey. The findings include: During an interview conducted on 04/23/25 at 02:25 PM, Resident #21's Resident Representative (RP) stated that he/she had not been informed about care plan meetings for Resident #21 in a while. On 04/23/25 02:37 PM, a review of Resident #21's clinical record revealed no evidence that care plan meetings were held for Resident #21 after 03/01/2023. On 04/24/2025 at 10:51 AM, an interview with the Director of Nursing stated that care plan meetings for residents are conducted quarterly and documented in the resident's medical record. During an interview conducted on 04/24/25 at 01:00 PM, the Social Services Director #6 confirmed that there were no care plan meeting notes documented in Resident #21's electronic medical record after 03/01/2023 but that she would look in another file. On 04/24/25 at 02:26 PM, a follow up interview with Social Services Director #6 revealed that there were no care plan meeting notes or care plan attendance log/sign-in sheets found after 03/01/2023 in Resident #21's medical record or in any other file. At the time of exit conference, the facility did not provide any additional evidence to show that Resident #21 and/or the RP was included in the resident's care plan meeting process after 03/01/2023.

Based on record review and interview, it was determined that the facility failed to implement and develop comprehensive care plans to address the residents' use of (1) anti-psychotic medications and (2) Anti-coagulant medications. This was evident in 2 (Resident #39 and #40) of 17 residents reviewed the development of comprehensive care plans during the recertification survey. The findings include: A Care Plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. (1) Resident #39 was admitted to the facility with diagnoses which included Parkinson's disease, Dementia and Neurocognitive Disorder with Lewy Bodies. On 04/23/25 at 12:45 PM a review of Resident #39's clinical record revealed that the resident was receiving anti-psychotic medication, Quetiapine Fumarte 25mg daily at bedtime for Mood Disorder - start date 07/24/24 Further review of Resident #39's clinical record revealed that a care plan was not developed to monitor the resident's behaviors neither was a care plan developed to monitor the side effects of the medication Quetiapine. On 04/24/25 at 09:50 AM in an interview the Director of Nursing stated that residents who received anti-psychotic medications such as Quetiapine, were monitored for behaviors and also monitored for side effects of the drug. The DON reviewed Resident #39's clinical record in the presence of the surveyor and confirmed the findings. The DON stated I do not know why it was not done. (2) Resident # 40 was admitted to the facility with diagnoses which included Cerebral Infarction and Pulmonary Embolism. On 04/23/25 at 09:00 AM a review of resident #40's clinical record revealed that the resident was receiving anti-coagulant medication, Eliquis 2.5mg two times a day for Prophylactic CVA - start date10/2/24 Further review of Resident # 40's clinical record revealed that a care plan was not developed regarding the medication Eliquis and its side effects. 04/23/25 at 11:13 AM the Director of Nursing who was made aware of the surveyor's findings and she stated that a care plan should have been in place.

Based on observation, facility staff interview and surveyor record review it was determined that the facility failed to revise a Resident's care plan. This finding was found to be evident in 1 (Resident #31) out of 2 Residents reviewed for care plan timing and revision. The findings include: The surveyor conducted an initial tour of the facility on 04/21/2025 and observed Resident #31 in his/her room at 10:56 AM in bed with left lower extremity elevated and a heel protector boot to left lower extremity. A care plan is a written document that outlines the care to be provided to a Resident, tailored to their specific needs and goals. It's a document, evolving as the Resident's condition changes, allowing for ongoing assessment and modification of care. It's a guide detailing how to assess, diagnose, plan, implement and evaluate Resident's care. At 02:00 PM on 04/22/2025 the surveyor conducted a record review of Resident #31's medical record. Review of Resident #31's care plan revealed that Resident had a skin abrasion to his/her left great (big) toe on 01/10/2025. Further review of Resident #31's medical record revealed that there was a wound evaluation note from the VOHRA Wound Physicians which indicated that the non-pressure wound of the left first toe was resolved (healed) on 01/14/2025. In addition, there was not a current physician order for treatment to a left great toe wound. As of 04/22/2025 during the record review, this wound to the left great toe was still on Resident #31's current care plan. In an interview with the Director of Nursing (DON) on 04/23/2025 at 09:27 AM the surveyor conveyed to DON that Resident #31 had a current care plan for a left great toe abrasion, and that according to the documentation from the VOHRA Wound Physician, this abrasion to the left great toe was healed on 01/14/2025. The DON acknowledged the surveyor and stated that she did notice that this left great toe abrasion was on Resident #31's current care plan, but she resolved that care plan today. The DON provided a copy of Resident #31's current care plan which indicated that the wound on the left great toe was resolved - 04/23/2025.

Based on record review and interview, it was determined that the facility failed to assess the nutritional needs of newly admitted residents in a timely manner. This was evident of 2 (Resident #42 and #10) of 17 residents reviewed for nutrition during the recertification survey. The findings include: Resident #42 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease and Diabetes Mellitus On 04/22/25 at 10:00 AM a review of Resident #42's clinical record revealed that an initial nutritional assessment by the Registered Dietitian (RD) was not completed until 04/15/25, three months after the resident was admitted to the facility. An excerpt of the assessment is as follows: Weight loss trend noted. Cont to monitor weight, po intake, meds, labs and skin. Adjust recommendations as indicated per collaboration with IDT. If po intake declines or weight loss trend continues - offer oral nutrition supplement to optimize nutrition status. A further review of Resident #42's clinical record revealed that the facility also failed to develop a care plan to address the RD's recommendations. On 04/24/25 at 12:27PM in a telephone interview, the RD stated that an initial assessment was completed earlier than 04/15/25 but was not documented in the resident's electronic record. The RD did not provide the surveyor with documented evidence of an earlier assessment. On 04/24/25 at 01:29 PM the Director of Nursing was notified of the surveyor's findings. Resident #10 was admitted to the facility on [DATE] with diagnoses which included Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Tracheostomy Status and Gastrostomy Status. On 04/24/25 at 12:55 PM a review of the clinical record of Resident #10 revealed that on 12/11/24, two months after the resident was admitted to the facility, an initial nutritional assessment was completed by the RD. The RD's assessment 12/11/24 recommended several changes to the resident's tube feeding regimen. On 04/24/25 at 02:53 PM in a telephone interview, the RD confirmed that an initial nutritional assessment was completed on 12/11/24. The surveyor enquired as to how the resident's nutritional needs were met since the resident was not assessed until 2 months after admission. The RD stated that upon Resident #10's admission, he/she communicated with the nurses regarding the resident's tube feeding orders. However, the communication was not documented in the resident's clinical record. The 04/25/25 at 08:15 AM the Director of Nursing was made of the surveyor's concerns regarding timeliness of the dietitian's assessment.

Based on record review and interviews, it was determined that the facility failed to provide appropriate pain management for residents. This was evident for 1 (Resident #10) of 17 residents reviewed for pain during the recertification survey. The findings include: A pain scale is a tool used to help patients communicate the intensity of their pain to healthcare providers. It provides a standardized way to assess and track pain levels, enabling health care providers to better understand a patient's pain experience and adjust treatment plans accordingly. Numbers, generally 0-10 indicate the intensity of pain. Zero means no pain while 10 signifies severe pain. On 04/24/25 at 7:36 AM a review of Resident #10's clinical record revealed a physician's order dated 2/8/25 for Oxycodone HCL Oral solution 5Mg/5ml . Give 5ml via G-tube every 6 hours as needed for Pain and physician's order dated 11/18/24 for Acetaminophen 500mg. Give enterally every 8 hours as needed for pain not to exceed 3 grams in 24 hours. Further review failed to reveal a scale to determine at what pain level each medication should be given. On 04/25/25 at 8:42 AM during an interview with the surveyor Resident #10 was asked if he/she had pain and how it was managed. The resident stated that their pain was not always relieved by the pain medication given and the nurses do not say what medication is being given. Further, Resident #10 stated that they were aware of Tylenol and another medication ordered for their pain but cannot remember the name of the other medication. A review of Resident #10's medication administration record revealed inconsistencies by the nursing staff when their judgement was used to decide which pain medication to administer for to the resident for different levels of pain. On 04/08/25 at 10:00 the resident was given Tylenol for pain level of 6 and on 4/10/25 at 13:03 Tylenol was given for pain level of 4. While on 04/07/25 at 7:30 Oxycodone was given for pain level 6 and on 04/11/25 at 02:35 Oxycodone was given for pain level 4. On 04/25/25 at 09:05 AM the RN Staff #18 was asked about the process for administering PRN (as needed) pain medications when there were two medications ordered with no pain level parameter indicated. The nurse stated that she would ask the resident for his/her pain level, do an assessment then use her judgement to decide which medication to administer. On 04/25/25 at 09:30 AM the Director of Nursing was made aware of concerns regarding pain management and the lack of pain scale parameters for PRN pain medications ordered for Resident #10.

Based on facility staff interviews and employee record reviews it was determined that the facility failed to ensure that the required nurse aide performance reviews - 12 hour/year in-services were completed. This finding was found to be evident in 3 out of 3 employee personnel files (#10, #11 and #14) reviewed for annual required nurse aide performance review - 12 hour/year in-service. The findings include: On 04/24/2025 at 07:15 AM the surveyor conducted a record review of 3 nurse aide employee personnel files #10, 11 and 14. The record review revealed that the 3 employee personnel files did not contain current performance reviews - 12 hour/year in-services for the 3 nurse aides #10, 11 and 14. At 07:45 AM on 04/24/2025 the surveyor interviewed the Director of Nursing (DON). During the interview the surveyor conveyed to DON that the 3 nurse aides #10, #11 and #14 personnel files did not contain any current performance reviews - 12 hour/year in-services. The DON acknowledged that the 3 nurse aides #10, #11 and #14 did not have current performance reviews - 12 hour/year in-services in the employee personnel files and stated that the annual evaluations were not being done. The DON further stated that the facility was in the process of a new program called RELIAS that facility staff would use for completion of required in-service training. At 01:45 PM on 04/24/2025 the Licensed Nursing Home Administrator (LNHA) was notified with the Director of Nursing (DON) in attendance that the nurse aide performance reviews - 12 hour/year in-services were not being done. At the time of the exit on 04/25/2025 at 03:15 PM no further documentation was provided by the facility for nurse aide performance reviews - 12 hour/year in-services.

Based on observation, clinical record review and staff interview, it was determined that the facility failed to ensure a medication error rate of less than 5% for 1 (Resident #7) of 3 residents observed during the medication pass observation. This was evident for 3 medication errors out of 33 opportunities which resulted in an error rate of 9.09%. The findings include: PEG stands for percutaneous endoscopic gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach. PEG allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus. On 4/24/25 at 8:53 AM, the surveyor observation of medication pass for Resident #7 revealed that Licensed Practical Nurse (LPN) #15 administered all scheduled AM medications to the resident via PEG tube. The medications included ProSource Protein Oral Liquid 30ml (milliliters), half tablet of Oxycodone 5mg (milligrams) and 1 packet of Arginaid. On 04/24/25 at 8:44 AM, the surveyor reviewed Resident #7's clinical record. The review revealed that Resident #7 had an NPO (nothing by mouth) diet order. Continued record review revealed that Resident #7's ProSource Protein Oral Liquid and Oxycodone medications were both ordered to be administered by mouth. The Arginaid medication order did not state which route to administer the medication by. On 04/24/25 at 9:15 AM, the surveyor conducted an interview with LPN #15 regarding the medication administration routes for Resident #7's scheduled AM medications. LPN #15 confirmed that she checked Resident #7's orders prior to medication administration and stated, Resident #7 is NPO so I gave all oral medications via PEG tube. On 04/25/25 at 9:20 AM, the surveyor reviewed Resident #7's April 2025 Medication Administration Record (MAR) together with LPN #15 at the medication cart. LPN #15 confirmed that Resident #7's ProSource Protein Oral Liquid and Oxycodone medication orders said to give by mouth and that the Arginaid medication order did not state what route to give the medication. LPN #15 stated, I didn't notice the orders for these medications did not say to give via PEG tube. On 4/24/25 at 9:25 AM, the surveyor reviewed the findings from the medication pass observation together with LPN #15 and the DON.

Based on observation, facility staff interviews and surveyor record review it was determined that the facility failed to follow infection prevention and control practices and ongoing infection surveillance. This finding was found to be evident in the review of infection prevention and control practices and medication administration. The findings include: Infection surveillance is the systematic collection, analysis and interpretation of data related to infections, primarily in healthcare settings, to identify and address outbreaks, trends and risks. It plays a crucial role in preventing and controlling the spread of infections, including healthcare-associated infections (HAIs). On 04/23/2025 at 09:42 AM the surveyor reviewed the facility's Surveillance for Infections Policy which was from MED-PASS, Inc. dated 2001 and revised September 2017. The policy revealed that the facility was to have reports available for gathering surveillance data, data collection and recording, calculating infection rates, and interpreting surveillance data on an ongoing basis. At 11:15 AM on 04/24/2025 an interview with the Director of Nursing (DON), who was also the Infection Preventionist (IP) revealed that the facility did not have the infection surveillance reports for 2025. The surveyor requested from DON the monthly infection surveillance reports for January, February, March and April of 2025. The DON stated that she was behind in this data collection and did not have January, February, March and April 2025 reports completed for infection surveillance. On follow-up interview with the Director of Nursing (DON) at 02:00 PM on 04/24/2025 the DON provided the monthly infection surveillance reports for June 2024 through December of 2024. The DON acknowledged that there were no infection surveillance reports completed for 2025. Enhanced Barrier Precautions (EBP) are an infection prevention strategy, particularly in nursing homes, that uses personal protective equipment (PPE) to reduce the transmission of multi-drug-resistant organisms (MDROs). It involves using gowns and gloves (PPE) during specific high-contact care activities for Residents at risk of MDRO transmission. EBP aims to prevent the spread of MDROs, which are resistant to multiple antibiotics, among Residents in skilled nursing facilities. During observation of medication administration on 04/24/2025 at 08:48 AM Licensed Practical Nurse (LPN) #15 entered room [ROOM NUMBER] with the rolling blood pressure (BP) machine and applied the BP cuff to Resident #7. LPN #15 did not sanitize the BP cuff/machine before use on Resident #7. LPN #15 rolled the BP machine out of room [ROOM NUMBER] into the hallway after use on Resident #7 and did not sanitize the BP cuff/machine. Resident #7 was on Enhanced Barrier Precautions (EBP). In an interview with the Director of Nursing (DON) and LPN #15 at 09:20 AM on 04/24/2025, the surveyor conveyed to the DON and LPN #15 that the BP cuff/machine was not sanitized before and after use on Resident #7 during medication administration. DON and LPN #15 acknowledged the surveyor. No additional information was provided by the facility at the time of exit.

Based on observation, and interview, it was determined that the facility failed to keep a sanitary environment. This was evident in the Kitchen during the facility's annual recertification survey. The findings include: On 4/22/25 at 7:07AM during a tour of the Kitchen, the surveyor observed the floor on both sides of the dishwasher and the floor under the sink located next to the dishwasher were covered with mineral deposit/build up. The surveyor notified the Food Services Director (FSD) who walked over to the area and confirmed the findings. I will get it cleaned. On 04/25/25 at 3:15 PM the surveyor informed the Administrator of the findings.

Based on facility staff interview and surveyor record review it was determined that the facility failed to document if Residents had an advance directive, wished to formulate an advance directive and were provided the educational information on advance directives. This finding was found to be evident in 2 out of 2 Residents (#16 & #31) reviewed for advance directives. The findings include: An advance directive is a legal document that specifies a person's wishes for end-of-life healthcare. It also specifies who should make healthcare decisions on your behalf if you are unable to do so yourself. On 04/22/2025 at 07:05 AM the surveyor conducted a record review of Resident #16's medical record. During this review it was revealed that Resident #16 or Resident's Representative was not asked if he/she had an advance directive, wished to formulate an advance directive or was provided the educational information on advance directives. There was a form in Resident #16's medical record titled Advance Directives Policy. This form was not completed by Resident #16 or Resident's Representative. In an interview with the Social Services Director (SSD) at 08:10 AM on 04/22/2025 the surveyor conveyed to the SSD that the Advance Directives Policy form in Resident #16's chart was not completed and signed by the Resident or Resident Representative. The SSD acknowledged the surveyor and stated that she would take care of this. On 04/22/2025 at 07:30 AM the surveyor conducted a record review of Resident #31's medical record. During this review it was revealed that Resident #31 or Resident's Representative was not asked if he/she had an advance directive, wished to formulate an advance directive or was provided the educational information on advance directives. There was a form in Resident #31's medical record titled Advance Directives Policy. This form was not completed by Resident #31 or Resident's Representative. In an interview with the Social Services Director (SSD) at 08:15 AM on 04/22/2025 the surveyor conveyed to the SSD that the Advance Directives Policy form in Resident #31's chart was not completed and signed by the Resident or Resident Representative. The SSD acknowledged the surveyor and stated that she would take care of this. No additional information was provided by the facility at the time of exit.

Based on surveyor review of the clinical record, review of the facility's investigation report, and staff interviews, it was determined that the facility failed to utilize two staff members to safely transfer a resident using a Hoyer Lift. This resulted in harm to the resident when the resident fell out of the Hoyer (hydraulic) lift during transfer and sustained an injury to the mouth that required treatment at a hospital for 2 days. This finding was evident during the investigation of facility reported incident MD 537 and is past non-compliance. This finding is evident in 1 of 5 residents reviewed during a complaint survey (#1). The findings include: Hoyer lifts are used for those people who require complete assistance to get into and out of bed (transfer). A pad fits under the person's body in the bed and connects with chains to the Hoyer lift frame. A hydraulic pump is used to lift the person off the bed surface. The use of the lift always requires at least two staff members to complete the transfer; one person to handle the lifting device and the other to support and guide the person into the transfer place. The facility failed to ensure that resident #2 remain free of accidents by not using the proper technique for transferring with the Hoyer Lift. On 11-3-16, surveyor review of the clinical record revealed that resident #1 was immobile and dependent for all care and activities of daily living. Further review of the clinical record revealed that, on 8-6-16, resident #1 fell out of the Hoyer (hydraulic) Lift during transfer from the bed to the chair; Resident #1 was bleeding in the mouth and was sent to the emergency room via Emergency Medial Service for evaluation of the facial injury. Resident #1 was re-admitted to the facility on [DATE]. Surveyor review of the facility's investigative report revealed that only one staff member transferred resident #1 by the Hoyer Lift. It is a standard of practice and the manufacturer recommendation that mechanical lifts should never be completed alone. Review of the facility's policy on transferring residents revealed that all mechanical lifting with transfers will be done by two employees who have demonstrated knowledge of the techniques. Surveyor review of resident #1's hospital record revealed that he/she had sustained a lip laceration which required sutures and several loose teeth were noted. A dental consult revealed a recommendation for tooth extractions, but the family declined any surgical procedures or dental extraction. On 11-3-16, surveyor interview with the director of nursing and the administrator revealed no further information. Corrective action was taken by the facility, on 08-11-16, when the facility trained staff on the transfer of residents via the Hoyer lift as well as counseling and corrective action with the employees performing the transfer on 08-06-16. Spot checks will be performed by DON/designee to determine compliance with proper use of hoyer lifts, with results reported in QA for 3 months, or until consistent compliance is confirmed This was reviewed and accepted as correction during this visit.

Based on surveyor observation, clinical record review, and facility staff interview it was determined that facility staff failed to prevent the development and worsening of pressure ulcers. This finding rose to the level of harm and was evident in 1 of 27 residents selected in the stage 2 reviews. (#30). The findings include: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A stage 2 pressure ulcer is a partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured or filled blister. A stage 3 pressure ulcer is full thickness skin loss. Fat may be visible but bone, tendon or muscle are not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. The depth of a stage III pressure ulcer varies by anatomical location. On 07-07-16 surveyor review of the clinical record for resident #30 revealed that despite an assessment completed on 03-06-16 that indicated resident #30 was at high risk to develop pressure sores there was no evidence of a care plan to address the increased risk for skin breakdown. Further review of the clinical record revealed resident #30 developed a stage 2 pressure sore on the sacrum on 05-06-16. The area measured 2cm x 2cm x 0cm. A physician's order [REDACTED]. Surveyor review of the skin sheet for 05-06-16 revealed under pressure relieving interventions, needs air mattress . On 05-09-16 a new physician's order [REDACTED]. On 05-13-16 resident #30's [MEDICATION NAME] level was 3.0 (reference 6.2-8.3) and protein level was 5.6 (refernce range 6.2-8.3). On 05-16-16 resident #30 was seen by the wound care physician who gave orders to continue the [MEDICATION NAME] dressing to the sacral pressure sore. Further review of resident #30's skin sheets revealed that the area on the sacrum worsened to a stage 3 pressure sore on 05-23-16 with the following measurements: 1.5cm x 1cm x 0.1cm. On 05-24-16 resident #30 was seen by the wound care physician who gave orders to continue the [MEDICATION NAME] dressing to the sacral pressure sore. Further review of the wound care physician ' s notes for resident #30 revealed that on 05-30-16 the sacral pressure area worsened and increased in size measuring 2cm x 1.5 x 0.1cm. The treatment orders for the wound were changed to apply hydrogel to sacral area every day. Surveyor review of the physician's order [REDACTED]. In addition, on 06-06-16 the sacral area again increased in size to 7cm x 2cm x 0.1cm and resident #30 had developed a 1.5cm x 1.5cm x 0.1cm stage 2 on the right buttocks. Resident #30 had a G tube and was only receiving formula feedings. Formula feedings were not ordered to be increased until 6-5-16 despite the development of a pressure ulcer on 5-6-16. In addition, there was no nutritional assessment by the registered dietician. Furthermore, per interview with the DON (director of nursing), the formula feeding increase was only secondary to an inadequate supply of the resident's normally ordered formula rather than based on an assessment of her potentially changing nutritional needs. See F325 for additional information. Surveyor review of the clinical record for resident #30 revealed despite the development of the pressure ulcers, there was no development of an interdisciplinary care plan to address the actual pressure sores, no dietary consultation regarding any change in nutritional needs due to the pressure sores, and no evidence of interventions for pressure relief while out of bed in a geri-chair. (A geri-chair is a recliner designed to allow someone to get out of bed and sit in a variety of positions while being fully supported.) In addition, interventions such as adding an air mattress for pressure redistribution while in bed and administering zinc to aide in wound healing were not implemented until 06-03-16 after the worsening of the sacral pressure ulcer. On 07-08-16 at 1:45 PM surveyor interview with the DON provided no additional information.