Every finding on record at Aspire Senior Living Advance

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 30. Review of the facility's policy titled, Cleaning, dated 01/30/24, showed: - All equipment, food contact surfaces, and utensils shall be cleaned each time there is a use with a different type of raw animal product, each time there is a change from working with raw foods to ready-to-eat foods, whenever contamination may have occurred;- All food surfaces will be cleaned at the end of each food preparation session;- Refrigerator units must be cleaned. Review of the facility's policy titled, Food Safety Requirements, undated, showed: - Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage;- Follow contract/vendor procedures when food arrives damaged, or concerns are noted and remove these foods from use;- Practices to maintain safe refrigerated storage include labeling, dating, and monitoring refrigerated food, including leftovers, so it is used by its use-by date or frozen/discarded and keeping foods covered or in tight containers. Review of the facility's policy titled, Storage of Food in Refrigeration, dated 01/30/24, showed: - All containers must be labeled with the contents and date food item was placed in storage;- Previously cooked foods can be held in refrigeration of 41 degrees Fahrenheit or lower for up to three days and then must be discarded. Review of the February 2026 Dietary [NAME] Cleaning List on 02/24/26 at 9:45 A.M., showed: - No documentation the bottom of the fridge was cleaned daily from 02/19/26 - 02/28/26, with 10 out of 28 missed opportunities;- No documentation for the completion of the weekly duties for the month of February with four out of four missed opportunities;- Microwave and air fryer not addressed on the cleaning list. Observations of the kitchen on 02/24/26 at 9:45 A.M., and 02/27/26 at 11:30 A.M., showed:- Food particles in the bottom and brown grime on the top of the inside of the microwave;- The air fryer basket coated with black build up and food crumbs;- The air fryer handle with grime and food particles;- One 12-quart (qt.) container of shell noodles without a label or date;- One 12-qt. container of brown sugar without a label or date;- One four-liter (L) container labeled baking powder without a date;- One 22-qt. container of white sugar, incorrectly labeled brown sugar, dated 01/25/26;- One 6 pound (lb.) 15 ounce (oz.) can of black-eyed peas dented;- One 16 oz. bag of shelled pecans opened, exposed to air, and without a date opened. Observation of the reach-in cooler on 02/24/26 at 9:45 A.M., and 02/27/26 at 11:30 A.M., showed: - Food particles and a two inch (in.) by four in. dried brown substance on the floor of the cooler;- An uncovered head of cabbage shriveled and brown in spots;- One gallon (gal.) size bottle of ranch dressing, one third full, without a date opened;- One gal. size bottle of heavy-duty mayonnaise one half full, without a date opened;- One gal. size bottle one third full with the manufacturer's label of sweet pickle relish, containing a white substance with green particles. During an interview on 02/27/26 at 11:37 A.M., Dietary [NAME] G said he/she had not cleaned the air fryer or microwave and was not sure when they need to be cleaned. All items should be labeled and dated with the date opened and said there was nothing wrong with dented cans. During an interview on 02/27/26 at 11:45 A.M., the Dietary Manager said all items removed from their original packaging should be labeled and dated, items should be dated when opened, dented cans should be removed from other items, and should not be used, and all food items should be covered. He was aware more cleaning needed to be done but had been unable to do it due to the lack of staffing, and the cleaning schedule should be signed off when each task was completed. During an interview on 02/27/26 at 1:21 P.M., the Administrator said dented food cans should be returned to the food distributor, food should be labeled and dated with the date opened, and all equipment should be in good working order and cleaned per the cleaning schedule.

Based on interview and record review, the facility failed to ensure a resident diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure services to promote the resident's highest level of functioning and psychosocial needs for two residents (Residents #5 and #27) out of three sampled residents with dementia. The facility census was 30.The facility did not provide a policy regarding dementia care. Review of the facility's policy titled, Comprehensive Care Plans, dated 2025, showed: - It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality; - The comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Review of Resident #5's medical record showed: - An admission date of 03/04/25; - Diagnoses of unspecified dementia and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 01/05/26, showed: - Diagnosis of dementia; - Moderate cognitive impairment. Review of the resident's Care Plan, revised 12/30/25, showed: - Did not address dementia; - Did not address specific problems, interventions, or goals for dementia care; - Did not address specific problems, interventions, or goals for activities for a resident diagnosed with dementia. 2. Review of Resident #27's medical record showed: - admitted on [DATE]; - Diagnoses of dementia, hallucinations, restlessness and agitation. Review of the resident's quarterly MDS, dated [DATE], showed: - Diagnosis of dementia; - Cognitive impairment; - Inattention, disorganized thinking, and altered level of consciousness fluctuated. Review of the resident's Care Plan, reviewed 02/26/25, showed: - Failed to address dementia; - Failed to address specific problems, interventions, or goals for dementia care; - Failed to address specific problems, interventions, or goals for activities for a resident diagnosed with dementia. During an interview on 02/27/26 at 9:30 A.M., the MDS Coordinator said the care plan should address dementia with personalized interventions. During an interview on 02/27/26 at 1:30 P.M., the Administrator said she would expect the care plan to reflect a diagnosis of dementia. During an interview on 02/26/26 at 2:30 P.M., the Activity Director said he/she just started at the beginning of February, and the facility did not have any specialized activities for dementia residents.

Based on interview and record review, the facility failed have an appropriate diagnosis for an antipsychotic (psychiatric medications used to manage psychosis, particularly hallucinations, delusions, and severe agitation) medication for one resident (Resident #16) and failed to limit an as needed (PRN) antipsychotic medication to 14 days for one resident (Resident #27) and out of 12 sampled residents. Facility census was 30. Review of the facility policy titled, Use of Psychotropic Medications, undated, showed:- A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics ((drugs used to manage some mental health disorders by regulating brain chemicals), antidepressants, anti-anxiety, and hypnotics (medications for sleep);- Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication;- The indications for initiating, maintaining, or discontinuing medications(s), as well as the use of non pharmacological approaches, will be determined by evaluating the resident's physical, behavioral, mental, and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment;- The resident's medical record shall include documentation of this evaluation and the rationale for chosen treatment options. This includes any indicated documentation of rationale for prescribing multiple psychotropic medications or switching from one type of psychotropic medication, specifically an antipsychotic medication, to another category of psychotropic medication;- The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents, their families and/or representatives, other professionals, and the interdisciplinary team;- Psychotropic medications used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted: PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. PRN orders for antipsychotic medications only, shall be limited to 14 days with no exceptions. If the attending physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate. 1. Review of Resident #16's medical record showed:- admitted on [DATE];- Diagnoses of drug induced dyskinesia (involuntary uncontrollable movements), polyneuropathy (disorder affecting nerves in the body), Parkinson's (progressive neurological disorder affecting movement) disease with dyskinesia, and depression (a serious medical illness that negatively affects how you feel, the way you think, and how you act);- An order for quetiapine (an antipsychotic medication) 25 milligrams (mg) by mouth one time a day for depression, dated 02/07/26.- A Monthly Medication Review (MMR), dated 02/12/26, the pharmacist requested the quetiapine dosage be decreased but did not address the inappropriate diagnosis of depression;- The facility failed to have an appropriate diagnosis for the quetiapine. 2. Review of Resident #27's medical record showed:- admitted on [DATE];- Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) with mood disturbance, major depressive disorder (MDD - a long-term loss of pleasure or interest in life), anxiety (persistent worry and fear about everyday situations), neurocognitive disorder with Lewy bodies (a progressive, incurable disease characterized by abnormal protein clumps that destroy brain cells, leading to cognitive decline, visual hallucinations, parkinsonian movement issues, and fluctuating alertness), epilepsy (a disease that causes recurrent seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness)), pain, agitation and restlessness, fibromyalgia (widespread musculoskeletal pain and fatigue throughout the body), hallucinations, and Parkinson's disease;- An order for haloperidol (an antipsychotic medication) 0.5 mg by mouth every 6 hours PRN for hallucinations, dated 09/05/25 with no stop date;- Pharmacy Note, dated 01/16/26, requested attending physician/prescriber to address the order of haloperidol 0.5 mg every six hours PRN with no stop date. On 01/16/26, the physician responded to continue the PRN haloperidol 0.5 mg every 6 hours PRN for psychosis (disconnection from reality), but did not address a stop date. During an interview on 02/27/26 at 1:21 P.M., the Director of Nursing (DON) and the Administrator said they would expect medications to have an appropriate diagnosis. The Administrator said she would expect PRN psychotropic medications to have a 14 day stop date or another designated stop date if appropriate. Pharmacy sent the recommendations, and the facility had the physician look at it and address the recommendations. Pharmacy sent a monthly report and the DON forwarded the recommendations to the appropriate providers and followed up on those recommendations. During an interview on 03/05/26 at 1:10 P.M., the Medical Director (MD) said depression was not an appropriate diagnosis for quetiapine. PRN antipsychotic medications should have a stop date of 14 days. He/She attempted to address medications for Resident #27, but hospice disagreed. He/She does not like to use antipsychotic medications and would try to get Resident #16 off as soon as possible.

Based on observation, interview, and record review, the facility failed to follow physician orders when administering a medication as ordered for one resident (Resident#18) out of 12 sampled residents and during wound care for one resident (Resident #26) out of three sampled residents. The facility census was 30.The facility did not provide a policy for following physician orders. 1. Review of Resident #18's medical record showed:- admitted on [DATE];- Diagnosis of type 2 diabetes mellitus (a chronic condition causing high blood sugar);- An order for Lantus (a long-acting insulin) 8 units subcutaneously (an injection under the skin) at bedtime related to type 2 diabetes mellitus, dated 10/27/25. Review of the resident's Medication Administration Record (MAR), dated October 2025 - February 2026, showed:- Lantus (a long-acting insulin) 8 units subcutaneously at bedtime;- For October 2025, the resident didn't receive the Lantus dose 10/29/25 for a blood sugar (bs)=166, with one missed out of 31 opportunities to receive the Lantus dose;- For November 2025, the resident didn't receive the Lantus dose on 11/04/25 for bs=162, 11/07/25 for bs=162, 11/10/25 for bs=176, 11/18/25 for bs=129, 11/20/25 for bs=147, and 11/27/25 for bs=162, with six missed out of 30 opportunities to receive the Lantus dose;- For December 2025, the resident didn't receive the Lantus dose on 12/02/25 for bs=142, 12/03/25 for bs=167, 12/09/25 for bs=168, 12/10/25 for bs=126, 12/16/25 for bs=143, 12/17/25 for bs=166, 12/22/25 for bs=162, 12/24/25 for bs=144, 12/25/25 for bs=176, and 12/31/25 for bs=146, with 10 missed out of 31 opportunities to receive the Lantus dose;- For January 2026, the resident didn't receive the Lantus dose on 01/01/26 for bs=130, 01/02/26 for bs=174, 01/04/26 for bs=115, 01/05/26 for bs=172, 01/07/26 for bs=157, 01/10/26 for bs=169, 01/14/26 for bs=167, 01/22/26 for bs=168, 01/23/26 for bs=132, 01/26/26 for bs=128, 01/27/26 for bs=122, 01/28/26 for bs=158, 01/29/26 for bs=118, and 01/30/26 for bs=155, with 14 missed out of 31 opportunities to receive the Lantus dose;- For February 2026, the resident didn't receive the Lantus dose on 02/02/26 for bs=122, 02/04/26 for bs=166, 02/10/26 for bs=152, 02/11/26 for bs=140, 02/12/26 for=bs 146, 02/13/26 for bs=141, 02/16/26 for bs=168, 02/18/26 for bs=133, 02/25/26 for bs=144, with nine missed out of 25 opportunities to receive the Lantus dose. During an interview on 02/26/25 at 3:26 P.M., Registered Nurse (RN) A said insulin should be given as ordered. If the resident's blood sugar was under 70, he/she would give the resident a snack and then give the Lantus. He/She did not know why the resident's Lantus was held other than maybe nursing judgment. During an interview on 03/05/26 at 1:10 P.M., the Medical Director said physician orders should be followed as ordered. If there was a concern about an order, the facility should notify the physician for clarification. He/She would expect ordered insulin to be administered unless the blood sugar was low. During an interview at 2:55 P.M., Licensed Practical Nurse (LPN) D said he/she did not hold Resident #18's Lantus. He/She must have charted incorrectly because he/she administered Resident #18's Lantus doses on the dates shown as not administered from October 2025 - February 2026. If medication was given and it was documented as given in the electronic medical record, it would show as administered. He/She would notify the resident's physician if his/her blood sugar was below 90 as that would be low for Resident #18. He/She did not notify the physician regarding Resident #18's blood sugars. 2. Review of Resident #26's medical record showed:- admitted on [DATE];- Diagnoses of venous insufficiency (inefficient blood return to the heart), non-pressure chronic ulcer of other part of left lower leg, non-pressure chronic ulcer of other part of right lower leg with bone involvement, and peripheral vascular disease (impaired blood flow);- An order for the left heel to cleanse with Vashe (a cleaning solution usually applied to wounds), apply skin prep (a protective barrier) to the peri wound (the skin immediately surrounding a wound), apply mupirocin (an antibiotic) ointment followed by calcium alginate silver (a type of wound dressing) dressing, cover with ABD pad (wound dressing material), and wrap with gauze daily and as needed (PRN) for soiling and/or unscheduled removal every day shift for wound treatment until healed, dated 02/17/26;- An order for the left medial (middle) ankle to cleanse with Vashe, apply skin prep to the peri wound, apply mupirocin ointment followed by calcium alginate silver dressing, cover with ABD pad, and wrap with gauze daily and PRN for soiling and/or unscheduled removal every day shift for wound treatment, dated 02/17/26;- An order for the left posterior (back) leg to cleanse with Vashe, apply skin prep to the peri wound then apply calcium alginate silver dressing, cover with ABD pad, and wrap with gauze daily and PRN for soiling and/or unscheduled removal every day shift, dated 02/03/26;- An order for mupirocin ointment apply to the wounds to the bilateral (both) lower extremities topically every day shift for wound treatment, dated 02/17/26. Observation on 02/25/26 at 2:50 P.M., of the resident's wound care showed:- The Director of Nursing (DON) provided the treatment to the resident's left heel but did not apply the skin prep to the peri wound and the mupirocin ointment to the heel wound as ordered;- The DON provided the treatment to the resident's left posterior leg wound but did not apply the skin prep to the peri wound as ordered. During an interview on 02/25/26 at 3:00 P.M., the DON said she forgot to apply the skin prep and the mupirocin ointment to the resident's left leg/heel as ordered. During an interview on 02/27/26 at 1:21 P.M., the Administrator and the DON said they would expect physician orders to be followed as ordered. The Administrator said insulin should be held if the physician had written specifically the insulin be held dependent on the resident's blood sugar levels.

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were labeled in accordance with currently accepted practices for one resident (Resident #27) for one out of one sampled medication cart and one out of one sampled medication room. This practice had the potential to affect all residents. The facility's census was 30. Review of the facility policy titled, Medication Labeling and Storage, undated, showed:- All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices;- Labels for multi-use vials must include the date the vial was initially opened;- All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different date. Review of the manufacturer's guidelines for tuberculin purified protein derivative (a medication used to diagnose tuberculosis (TB - a contagious, often severe lung infection) solution, undated, showed:- Discard 30 days after opening. Review of the package insert for methadone (an opioid medication pain medication) concentrate, dated April 2015, showed:- Discard opened bottle after 90 days. 1. Review of Resident #27's medical record showed:- An order for methadone concentrate 10 milligram (mg) per milliliter (ml) 0.5 ml by mouth every 1 hour as needed for pain, dated 11/18/24, and a start date of 12/03/24;- No adverse reactions identified related to the methadone use. Observation of the 200 Hall medication cart on 02/25/26 at 1:55 P.M., showed:- An opened bottle of methadone concentrate 10mg/ml with 17 ml remaining, not dated, for Resident #27. Review of the 200 Hall Controlled Medication Count Sheet for Resident #27's methadone showed:- Administered first dose from bottle on 04/16/25;- Administered a dose on 10/04/25, 81 days after the expiration date of 07/15/25;- Administered a dose on 10/28/25, 105 days after the expiration date of 07/15/25;- Administered a dose on 11/11/25, 119 days after the expiration date of 07/15/25;- Administered a dose on 12/09/25, 147 days after the expiration date of 07/15/25;- Administered a dose on 12/30/25, 168 days after the expiration date of 07/15/25;- Administered a dose on 01/01/26, 170 days after the expiration date of 07/15/25;- Administered a dose on 01/02/26, 171 days after the expiration date of 07/15/25;- Administered a dose on 01/03/26, 172 days after the expiration date of 07/15/25;- Administered a dose on 01/08/26, 177 days after the expiration date of 07/15/25;- Administered two doses on 01/21/26, 190 days after the expiration date of 07/15/25;- Administered a dose on 01/26/26, 195 days after the expiration date of 07/15/25;- Administered a dose on 02/10/26, 210 days after the expiration date of 07/15/25;- The methadone was administered to the resident a total of 13 times beyond the 90-day expiration date. During an interview on 02/25/26 at 3:21 P.M., Registered Pharmacist F said methadone concentrate remained stable for up to 90 days after opening at room temperature. 2. Observation of the medication storage room refrigerator on 02/25/26 at 2:10 P.M., showed:- An opened tuberculin purified protein derivative one ml multidose vial, not dated. During an interview on 02/25/26 at 2:11 P.M., Registered Nurse (RN) E said the tuberculin solution should be dated when opened and discarded when expired per the directions on the box. During an interview on 02/25/26 at 3:10 P.M., the Minimum Data Set (MDS - a federally mandated assessment completed by the facility) Coordinator said the tuberculin solution should be dated when opened and discarded per the manufacturer's guidelines and medications should be discarded per the facility policy. During an interview on 02/25/26 at 3:15 P.M., the Administrator said multi-dose vials should be dated when opened and discarded when expired. During an interview on 02/27/26 at 1:21 P.M., the Administrator and the Director of Nursing said expired medications should not be administered to the residents.

Based on observation, interview, and record review, the facility failed to follow infection prevention measures when staff did not properly disinfect the glucometer (a portable device used to measure blood sugar levels) for four residents (Residents #1, #4, #18, and #28) out of four sampled residents. The facility census was 30.Review of the facility policy titled, Glucometer Disinfection, undated, showed: - The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. Review of the manufacturer's guidelines titled, Quintet AC Blood Glucose Meter Owner's Manual, undated, showed: - The following cleaning and disinfecting steps to be performed after each use: - Thoroughly wipe the entire surface of the meter with disinfecting wipes to clean any possible dirt, blood, and other body fluids; - Take another disinfecting wipe and wipe the meter thoroughly; - Allow the surface to remain wet for two minutes; - Allow to air dry. Review of the manufacturer's guidelines titled, Super Sani-Cloth General Guidelines for Use, undated, showed: - Use a wipe to remove visible soil prior to disinfecting; - Unfold a clean wipe and thoroughly wet surface; - Allow treated surface to remain wet for two minutes; - Let air dry; - Dispose of used towelette in trash. 1. Observation on 02/24/26 at 3:07 P.M., of Resident #18's blood glucose testing showed: - Certified Medication Technician (CMT) C performed the resident's blood glucose testing with the first glucometer; - CMT C wiped the first glucometer with a Super Sani-Cloth and did not allow the glucometer surface to remain wet for two minutes. Observation on 02/24/26 at 3:13 P.M., showed: - CMT C removed a second glucometer from the medication room; - CMT C wiped the second glucometer with a Super Sani-Cloth and did not allow the glucometer surface to remain wet for two minutes. Observation on 02/24/26 at 3:13 P.M., of Resident #28's blood glucose testing showed: - CMT C performed the resident's blood glucose testing with the first glucometer; - CMT C wiped the first glucometer with Super Sani-Cloth and did not allow the glucometer surface to remain wet for two minutes. Observation on 02/24/26 at 3:24 P.M., of Resident #4's blood glucose testing showed: - CMT C performed the resident's blood glucose testing with the second glucometer; - CMT C wiped the second glucometer with a Super Sani-Cloth and did not allow the glucometer surface to remain wet for two minutes. Observation on 02/24/26 at 3:34 P.M., of Resident #1's blood glucose testing showed: - CMT C performed the resident's blood glucose testing with the first glucometer; - CMT C wiped the first glucometer with a Super Sani-Cloth and did not allow the glucometer surface to remain wet for two minutes. During an interview on 02/24/26 at 3:45 P.M., CMT C said he/she was taught to wipe the glucometer down with a Super Sani-Cloth and then use another glucometer while the other one air dried. He/She was not aware of a wet contact time. During an interview on 02/24/26 at 4:00 P.M., the Director of Nursing (DON) said she expected her staff to wrap the glucometer with a Super Sani-Cloth for the wet contact time on the label of the wipes to sanitize the glucometer between residents. During an interview on 02/27/26 at 1:21 P.M., the Administrator said she would expect glucometers to be disinfected per the facility policy.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer/discharge to a hospital, including the reasons for transfer, for three residents (Residents #1, #28 and #32) out of 12 sampled residents. The facility's census was 34. Review of the facility's policy titled, Discharge-Transfer of Resident, dated 03/2015, showed: - Explain transfer and reason to the resident and/or representative and give copy of signed transfer or discharge notice to the resident and/or representative or person responsible for care. If an emergency transfer, transfer or discharge notice form may be completed later, but as soon as possible. 1. Review of Resident #1's medical record showed: - The resident transferred to the hospital on 02/28/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 03/14/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 04/13/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 04/27/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 05/06/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 06/17/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 07/20/24, and readmitted to the facility on [DATE]; - No documentation the resident or resident representative was informed in writing of the transfer/discharge to a hospital at the time of the the transfers. 2. Review of Resident #28's medical record showed: - The resident transferred to the hospital on 01/27/24, and readmitted to the facility on [DATE]; - No documentation the resident or resident representative was informed in writing of the transfer/discharge to a hospital at the time of the transfer. 3. Review of Resident #32's medical record showed: - The resident transferred to the hospital on 04/12/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 05/02/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 05/15/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 06/20/24, and readmitted to the facility on [DATE]; - No documentation the resident or resident representative was informed in writing of the transfer/discharge to a hospital at the time of the transfers. During an interview on 11/22/24 at 1:05 P.M., the Social Services Director (SSD) said he/she would fill out the transfer/discharge paperwork but not give it to the resident until he/she knew the resident would be admitted to the hospital. He/She would leave the paperwork in the resident's room for them for when the resident returned. During an interview on 11/22/24 at 3:18 P.M., the Administrator said she expected the notice of a resident's transfer to the hospital to be given to the resident and/or their representative in writing. 49152

Based on interview and record review, the facility failed to inform the resident and/or the legal representative of their bed hold policy at the time of transfer to the hospital for three residents (Residents #1, #28 and #32) out of 12 sampled residents. The facility's census was 34. Review of the facility's policy titled, Bed Hold, undated, showed: - The facility will notify the resident at the time of admission and again prior to a hospital transfer or therapeutic leave of its bed-hold and return policies; - Before any transfer, advance notice of the policy is given, usually at the time of admission and also included in the admission packet. Re-issuance of the first notice is not required unless the facility's policy changes; - In cases of emergency transfer, notice at the time of transfer means that the resident, family, or representative is provided with written notification within 24 hours of the transfer. 1. Review of Resident #1's medical record showed: - The resident transferred to the hospital on 02/28/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 03/14/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 04/13/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 04/27/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 05/06/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 06/17/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 07/20/24, and readmitted to the facility on [DATE]; - No documentation the resident or resident representative was informed in writing of the facility bed hold policy at the time of the transfers. 2. Review of Resident #28's medical record showed: - The resident transferred to the hospital on 01/27/24, and readmitted to the facility on [DATE]; - No documentation the resident or resident representative was informed in writing of the facility bed hold policy at the time of the transfer. 3. Review of Resident #32's medical record showed: - The resident transferred to the hospital on 04/12/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 05/02/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 05/15/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 06/20/24, and readmitted to the facility on [DATE]; - No documentation the resident or resident representative was informed in writing of the facility bed hold policy at the time of the transfers. During an interview on 11/22/24 at 1:05 P.M., the Social Services Director (SSD) said he/she would fill out the facility bed hold policy paperwork but not give it to the resident until he/she knew the resident would be admitted to the hospital. He/She would leave the paperwork in the resident's room for them for when the resident returned. During an interview on 11/22/24 at 3: 19 P.M., the Administrator said she expected the bed hold notice to be given to the resident and/or their representative at the time of the resident's transfer to the hospital. 49152

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for three residents (Residents #6, #11, and #32) out of 12 sampled residents. The facility census was 34. The facility did not provide a policy regarding MDS accuracy. 1. Review of Resident #6's medical record showed: - An admitted [DATE]; - Diagnoses of hypertension (high blood pressure), diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), convulsions (seizures - a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness), and hypothyroidism (abnormal thyroid producing wrong amount of hormones); - An order for lisinopril (blood pressure medication) 20 milligrams (mg) oral once a day for essential hypertension, dated 08/21/24; - An order for labetalol (blood pressure medication)100 mg oral twice a day for essential hypertension, dated 08/21/24; - An order for Jardiance (used for abnormal glucose levels)10 mg oral once a day for type 2 DM, dated 08/21/24; - An order for Cardizem (blood pressure medication)120 mg extended release 24 hour oral once a day for essential hypertension, dated 08/21/24; - An order for levothyroxine (thyroid medication) 50 micrograms (mcg) oral once a day for hypothyroidism, dated 08/21/24; Review of the resident's admission MDS, dated [DATE], showed: - Hypertension, hypothyroidism, and seizure disorder diagnoses not documented; - Hypoglycemic medication not documented. 2. Review of Resident #11's medical record showed: - An admitted [DATE]; - An order to discontinue Eliquis (an anticoagulant medication), dated 07/09/24; - No current order for an anticoagulant medication. Review of Resident #11's quarterly MDS, dated [DATE], showed: - The resident received an anticoagulant. 3. Review of Resident #32's medical record showed: - An admitted [DATE]; - Diagnoses of cerebral infarction (stroke), hemiplegia and hemiparesis (paralysis affecting one side of the body) of left side, gastroesophageal reflux disease (GERD - stomach acid being forced back into the throat region), and venous thrombosis/embolism (blood clot); - A fall on 09/12/24; - An order for pantoprazole (helps protect the stomach from ulcers and indigestion) 40 mg oral once a day for GERD, dated 05/18/24; - An order for Eliquis 5 mg tablet oral two times a day for hemiplegia and hemiparesis following cerebral infarction, dated 05/19/24. Review of the resident's annual MDS, dated [DATE], showed: - GERD and cerebral infarction diagnoses not documented; - The fall on 09/12/24, not documented. During an interview on 11/22/24 at 3:25 P.M., the Administrator said she expected the MDS to accurately reflect the resident's current condition. During an interview on 11/22/24 at 3:35 P.M., the MDS Coordinator said he/she would expect the MDS to accurately reflect the resident's current condition. 49152

Based on observation, interview and record review, the facility failed to appropriately assess the use of bed rails for four residents (Residents #1, #2, #7 and #28) out of 10 sampled residents and one resident (Resident #3) outside the sample. The facility census was 34. The facility did not provide a policy regarding bed rails. 1. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 11/01/24, showed: - Cognitively intact; - Required supervision with bed mobility; - The MDS did not indicate bed rail use. Review of the resident's care plan, revised 11/05/24, showed: - A risk of falls; - Addressed the resident's use of the bed rails. Review of the resident's medical record showed: - No documentation of bed rail assessments; - No documentation of informed consent for the use of the bed rails explaining the risks and benefits. Observation of the resident on 11/20/24 at 2:25 P.M., showed the resident lay in bed with 1/4 bed rails on both sides of the bed in the upright position. During an interview on 11/20/24 at 2:30 P.M., Resident #1 said he/she used the bed rails to turn and reposition in bed. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Independent with bed mobility; - Diagnoses of dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), pain, and repeated falls. Review of the resident's care plan, revised 10/31/24, showed: - A risk of falls; - Did not address the resident's use of the bed rails. Review of the resident's medical record showed: - No documentation of bed rail assessments; - No documentation of informed consent for the use of the bed rails explaining the risks and benefits. Observations on 11/19/24 at 8:53 A.M., and 11/21/24 at 12:26 P.M., showed: - The resident lay in bed with U shaped bed rails on both sides of the bed in the upright position. During on an interview on 11/21/24 at 12:27 P.M., Resident #2 said he/she used the left bed rail to get out of bed. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed: - Cognition intact; - Roll in bed needed partial to moderate assistance, sit to lying needed substantial assistance, and dependent on staff for other bed mobility; - Diagnosis of left below the knee amputation; - The MDS did not indicate bed rail use. Review of the resident's care plan, revised 11/12/24, showed: - At risk for falls due to mobility issues; - Assistance with one or two staff with bed mobility due to the left below the knee amputation; - Have a halo bar (type of bed rail) on the bed to help with mobility. Review of the resident's medical record showed: - No documentation of bed rail assessments; - No documentation of informed consent for the use of the bed rails explaining the risks and benefits. Observations of the resident showed: - On 11/19/24 at 9:45 A.M., the resident sat in a chair next to the bed with the upper left 1/4 square-shaped bed rail attached in the upright position; - On 11/21/24 at 2:25 P.M., the resident lay in bed with the upper left 1/4 square-shaped bed rail attached in the upright position. During an interview on 11/20/24 at 2:56 P.M., Resident #3 said he/she used the bed rail all the time to position him/herself in bed. 4. Review of Resident #7's medical record showed: - admitted on [DATE]; - An order for bed rails, dated 03/24/23; - No documentation of bed rail assessments; - No documentation of informed consent for the use of the bed rails explaining the risks and benefits. Review of the resident's significant MDS, dated [DATE], showed: - Cognition intact; - Did not use bed rails. Review of the resident's care plan, revised on 11/12/24, showed: - At risk for falls; - Required significant assistance with activities of daily living (ADLs); - Required a bed rail to promote independence with bed mobility. Observation on 11/21/24 at 11:21 A.M., showed the resident lay in bed with the upper 1/4 bed rails on both sides of the bed in the upright position. 5. Review of Resident #28's quarterly MDS, dated [DATE], showed: - Cognition intact; - Dependent with bed mobility; - Diagnoses of stroke (damage to the brain from interrupted blood supply), hemiplegia and hemiparesis (paralysis or inability to move one side of body) affecting left side, pain, morbid obesity (overweight), weakness. Review of the resident's medical record showed: - No documentation of bed rail assessments; - No documentation of informed consent for the use of the bed rails explaining the risks and benefits. Review of the resident's care plan, revised 11/07/24, showed: - At risk of falls due to limited mobility;. - Had grab bars on the bed to assist with independence in bed mobility. Observations on 11/19/24 at 9:45 A.M and 11/22/24 at 2:45 P.M., showed the resident lay in bed with the upper 1/4 circular-shaped bed rails on both sides of the bed in the upright position. During an interview on 11/22/24 at 3:10 P.M., the Director of Nursing (DON) said she would expect residents with any bed rails to have an assessment for use of the bed rails and informed consents. During an interview on 11/22/24 at 3:10 P.M., the Administrator said she would expect residents with any bed rails to have an assessment for use of the bed rails and informed consents. 47678 49152 49999

Based on observation, interview, and record review, the facility failed to ensure residents diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure appropriate services to promote the resident's highest level of functioning and psychosocial needs were provided for one resident (Residents #9) out of three sampled residents. The facility census was 34. The facility did not provide a policy regarding dementia care. 1. Review of Resident #9's medical record showed: - An admitted [DATE]; - Diagnoses of unspecified dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking) and cognitive communication deficit (difficulty communicating). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 09/16/24, showed: - Able to understand others and to be understood; - Diagnosis of dementia. Review of the resident's care plan, dated 09/22/24, showed: - Did not address dementia; - Did not address specific problems, interventions, or goals for dementia care; - Did not address specific problems, interventions, or goals for activities for a resident diagnosed with dementia. Observations of the resident showed: - On 11/21/24 at 11:10 A.M., the resident self propelled wheelchair around dining room and nurse's station; - On 11/22/24 at 9:05 A.M., the resident sat in the wheelchair in the dining room. During an interview on 11/22/24 at 3:10 P.M., the Director of Nursing (DON) and the Administrator said dementia should be addressed on the care plan. During an interview on 11/22/24 at 3:20 P.M., the MDS coordinator said dementia should be addressed on the care plan. 47678

Based on interview and record review, the facility failed to ensure an appropriate diagnosis for the use of a psychotropic (a drug that affects the brain activities associated with mental processes and behavior) medication for two residents (Residents #9 and #11) out of 12 sampled residents and one resident (Resident #15) outside the sample. The facility census was 34. The facility did not provide a policy regarding appropriate diagnosis of a psychotropic medication. Review of AstraZeneca's Product Monograph for quetiapine, revised 11/29/21, showed: - Quetiapine is indicated for schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations) and bipolar disorder (a mental disorder that causes unusual shifts in mood); - Quetiapine is not indicated in elderly patients with dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking); - Elderly patients with dementia treated with atypical antipsychotic (a drug that affects the brain activities associated with mental processes and behavior) drugs are at an increased risk of death compared to placebo. 1. Review of Resident #9's medical record showed: - An admitted [DATE]; - Diagnoses of unspecified dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking) without behavioral disturbance and anxiety disorder (disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities); - An order for quetiapine (an antipsychotic (a drug that affects the brain activities associated with mental processes and behavior) medication) 25 milligram (mg) at bed time, dated 09/12/24; - No documentation of an appropriate diagnosis for the quetiapine. 2. Review of Resident #11's medical record showed: - admitted on [DATE]; - Diagnosis of dementia; - An order for quetiapine 200 mg by mouth at bedtime for a diagnosis of unspecified dementia without behaviors, dated 05/15/24; - No documentation of an appropriate diagnosis for the quetiapine; - A pharmacy recommendation, dated 03/28/24, noted the diagnosis of unspecified dementia without behaviors for quetiapine was not appropriate. On 04/10/24, the resident's physician documented the quetiapine couldn't be decreased; - The physician failed to address a correct diagnosis for quetiapine. 3. Review of Resident #15's medical record showed: - An admitted [DATE]; - Diagnoses of parkinsonism (brain conditions that cause slowed movements, stiffness and tremors), neurocognitive disorder (a mental health condition that affects cognitive abilities like learning, memory, problem-solving, and perception), hallucinations (a sensory experience that seems real but is not), repeated falls, major depressive disorder, generalized anxiety disorder, and epilepsy (a chronic brain disorder that causes seizures, which are episodes of abnormal electrical activity in the brain); - An order for haloperidol (an antipsychotic medication), 0.5 mg every four hours as needed, dated 08/26/24 to 02/23/25; - A pharmacy recommendation, dated 08/27/24, noted the haloperidol must be renewed every 14 days by a physician with documentation for the reason to continue. On 09/27/24, the resident's physician documented to continue the resident's haloperidol for hallucinations and paranoia (a state of mind where a person has an irrational and persistent fear of being harmed or deceived by others). During an interview on 11/22/24 at 3:13 P.M., the Director of Nursing (DON) said unspecified dementia without behaviors was not an appropriate diagnosis for an antipsychotic medication. During an interview on 11/22/24 at 3:12 P.M., the Administrator said she expected orders for an antipsychotic medication to have an appropriate diagnosis. During an interview on 12/02/24 at 11:58 A.M., Physician K said that unspecified dementia without behaviors was not an appropriate indication for antipsychotic medication. He/She said that according to his/her records Resident #11 had a diagnosis of unspecified dementia with behavioral disturbance, which would be an appropriate diagnosis, and that when the nurse was entering the order into the electronic medical record, they must have entered the wrong diagnosis. 47678 49999

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 27 opportunities with three errors made, resulting in an error rate of 11.11% for three residents (Residents #1, #8 and #32) out of 12 sampled residents. The facility's census was 34. Review of the facility policy titled, Insulin Pen Injections, undated, showed: - Attach safety needle, turn dose selector to two units and perform airshot (priming), then turn dose selector to required units for injection. 1. Review of Resident #1's medical record showed: - Diagnosis of type 2 diabetes mellitus (a condition in which the body has trouble controlling blood sugar and using it for energy); - An order for insulin lispro pen to be given with meals according to sliding scale, dated 05/22/24. Observation on 11/21/24 at 11:08 A.M., showed: - Certified Medication Technician (CMT) D obtained a blood glucose check for Resident #1; - CMT D administered the insulin lispro dosage as ordered; - CMT D failed to prime the insulin pen with two units prior to dosing and administering the insulin. 2. Review of Resident #8's medical record showed: - Diagnosis of type 2 diabetes mellitus; - An order for Humalog (insulin) Kwik Pen to be given with meals according to sliding scale, dated 06/07/24; - An order for Humalog (insulin) Kwik Pen 3 units to be given with meals, dated 06/28/24. Observation on 11/21/24 at 11:15 A.M., showed: - CMT D obtained a blood glucose check for Resident #8; - CMT D administered the Humalog dosage as ordered; - CMT D failed to prime the insulin pen with two units prior to dosing and administering the insulin. 3. Review of Resident #32's medical record showed: - Diagnosis of type 2 diabetes mellitus; - An order for Novolog (insulin) FlexPen 10 units to be given with meals, dated 08/28/24. Observation on 11/21/24 at 11:08 A.M., showed: - CMT D obtained a blood glucose check for Resident #32; - CMT D administered the Novolog dosage as ordered; - CMT D failed to prime the insulin pen with two units prior to dosing and administering the insulin. During an interview on 11/22/24 at 9:36 A.M., CMT D said he/she had never primed insulin pens before. During an interview on 11/22/24 at 9:45 A.M., Licensed Practical Nurse (LPN) E said he/she primed insulin pens prior to administering the prescribed dose. During an interview on 11/22/24 at 3:10 P.M., the Director of Nursing (DON) said she would expect insulin pens to be primed prior to dialing up the dose and administering. During an interview on 11/22/24 at 3:10 P.M., the Administrator said she would expect insulin pens to be primed prior to administration.

Based on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This had the potential to affect all residents. The facility census was 34. Review of the facility policy titled, Storage of Medications, undated, showed: - No discontinued or outdated medications are to be used and all such medications are destroyed; - Multi-dose vials that have been opened or accessed should be dated and discarded within 28 days of opening unless manufacturer specified a shorter or longer date. Review of the manufacturer's recommendations for Tubersol (a solution used for a tuberculosis (TB - a contagious lung disease) testing showed the medication was to be discarded 30 days after opening. Observation on 11/21/24 at 3:25 P.M., of the medication room refrigerator showed: - Two opened vials of Tubersol with no opened date. Observation on 11/21/24 at 3:25 P.M., of the medication room STAT safe showed: - Two unopened vials of nafcillin (an antibiotic) with an expiration date of 12/2023. Observation on 11/22/24 at 8:58 A.M., of the medication cart showed: - Two labeled and opened Lantus (a type of insulin) pens not dated when opened; - One labeled and opened insulin lispro (a type of insulin) pen not dated when opened; - One labeled and opened insulin aspart (a type of insulin) pen not dated when opened; - Two labeled and opened basaglar (a type of insulin) pens not dated when opened. During an interview on 11/22/24 at 9:36 A.M., Certified Medication Technician (CMT) D said insulin pens were to be dated when opened. He/She checked the dates of medications as they were used and then weekly. During an interview on 11/22/24 at 9:45 A.M., Licensed Practical Nurse (LPN) E said multi-use vials and insulin pens should be dated when they were opened. Medication expiration dates were checked at the end of the month and as they were administered. During an interview on 11/22/24 at 3:10 P.M., the Director of Nursing (DON) said she would expect multi-dose vials and insulin pens to be dated when they were opened and medications to be check for expiration dates at least monthly. During an interview on 11/22/24 at 3:10 P.M., the Administrator said she would expect medication expiration dates to be checked at least monthly.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices while providing incontinent care, medication administration/tube feeding (a tube inserted into the abdomen to provide nutrition into the stomach), catheter (a tube inserted into the bladder to drain urine) care, and wound care for three residents (Resident #3, #16, and #237) out of four sampled residents and for one resident (Resident #17) outside the sample. The facility failed to ensure proper Tuberculosis (TB - a communicable disease that affects the lungs, characterized by fever, cough and difficulty breathing) screening of three residents (Residents #6, #12, and #16) out of five sampled residents. The facility's census was 34. Review of the facility's policy titled, Gloves, dated 03/2015, showed: - Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or persons with a rash; - Change gloves between contacts with different residents or with different body sites of the same resident. Review of the facility's policy titled, Enhanced Barrier Precautions, undated, showed: - Gown and gloves are to be worn during high-contact activities to all residents with wounds or indwelling medical devices; - High-contact activities includes dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care, use of device, and wound care. Review of the facility's policy titled, Mantoux (Tuberculosis Screening) Testing- Residents, undated, showed: - Residents will be screened for tuberculosis infections upon their admission to the facility and at intervals appropriate for the regional prevalence of tuberculosis, with screening performed at least annually; - Upon admission to the facility, the resident will be screened for tuberculosis; - A chest x-ray will be obtained within 72 hours if signs of tuberculosis are present, regardless of previous x-ray results or the skin test reaction (if performed); - If the PPD status is unknown or is known to have been negative in the past, the two-step Mantoux test will be administered. 1. Observation on 11/21/24 at 2:25 P.M., of the wound care dressing change for Resident #3 showed: - Signage for EPB precautions; - Certified Nurse Assistant (CNA) J did not put on a gown, entered the room, and assisted with the dressing change. 2. Review of Resident #6's medical record showed: - admitted [DATE]; - No documentation of the two step TB testing. Observation on 11/20/24 at 2:31 P.M., of suprapubic (a flexible tube inserted into the lower abdomen to drain urine from the bladder) catheter care for Resident #6 showed: - Signage for EPB precautions; - CNA G did not put on a gown, entered the room, and performed performed suprapubic catheter care. 3. Review of Resident #12's medical record showed: - admitted [DATE]; - No documentation of the two step TB testing. 4. Review of Resident #16's medical record showed: - admitted [DATE]; - No documentation of the two step TB testing. Observation on 11/20/24 at 8:39 A.M. of Resident #16's incontinent care showed: - CNA A cleaned the resident while CNA C positioned the resident on his/her side; - CNA A removed gloves, did not wash hands, and fastened a clean brief on the resident with his/her bare hands; - CNA C did not change gloves or perform hand hygiene, and touched the sheet and pulled it over the resident; - CNA A, with his/her bare hands, touched the sheet and adjusted it over the resident. During an interview on 11/20/24 at 2:01 P.M., CNA A said gloves should be changed when going from dirty to clean care and hands should be washed after incontinent care had been completed. During an interview on 11/22/24 at 10:30 A.M., CNA C said hand washing should be done before and after incontinent care and gloves should be changed before putting a clean brief on a resident. 5. Observation on 11/19/24 at 2:03 P.M. of incontinence care for Resident #17 showed: - CNA I and CNA J performed hand hygiene and put on gloves; - CNA I and CNA J performed incontinent care; - CNA I and CNA J did not change gloves, did not perform hand hygiene, touched the resident's thighs, lower legs, and feet when rolling the resident to the sides; - CNA I and CNA J did not change gloves, did not perform hand hygiene, and placed a clean brief on the resident; - CNA I and CNA J did not change gloves, did not perform hand hygiene, and put pants on the resident. During an interview on 11/20/24 at 12:50 P.M., CNA I said to change gloves when going from front to back peri care during incontinence care and to wash hands between glove changes and when finished with care. 6. Observation on 11/21/24 at 3:45 P.M., of Resident #237's feeding tube medication administration showed: - Signage for EPB precautions; - Licensed Practical Nurse (LPN) F did not put on a gown, entered the resident's room, and administered medications through the resident's feeding tube. During an interview on 11/20/24 at 2:00 P.M., the Administrator said some residents did not receive their two step TB testing. Observation on 11/22/24 at 12:10 P.M., of Resident #237's tube feeding administration showed: - Signage for EPB precautions; - LPN E did not put on a gown, entered the resident's room, and administered the resident's feeding through the resident's feeding tube. During an interview on 11/22/24 at 9:45 A.M., LPN E said gloves and gowns should be used during care on residents with catheters, wounds, and feeding tubes. During an interview on 11/22/24 at 3:10 P.M., the Administrator and Director of Nursing (DON) said they would expect staff to follow guidelines for enhanced barrier precautions. During an interview on 11/22/24 at 3:22 P.M., the DON said she expected staff should wash hands before and after care, and wash hands and change gloves when when going from dirty to clean care during incontinent care. 49999

Based on observation, interview, and record review, facility staff failed to post, in a form and manner accessible to the residents and resident representatives, the required telephone number to the Department of Health and Senior Services (DHSS) hotline (to report allegations of abuse and neglect), or a list of names, addresses, and phone numbers of the State Survey Agency (SSA). The census was 34. The facility did not provide a policy. Observation of the facility on 11/19/24 through 11/21/24, showed the facility did not post the name, address and toll free telephone number for the DHSS Abuse and Neglect Hotline or the SSA information in a form and manner accessible to residents or visitors. During a group interview on 11/21/24 at 9:35 A.M., six residents (Residents #3, #6, #8, #20, #21, and #237) said they did not how to find the state hotline number and had not seen it posted. During an interview on 11/21/24 at 9:49 A.M., Licensed Practical Nurse (LPN) E said if a resident wanted the state hotline number, he/she could look it up for them. During an interview on 11/21/24 at 9:51 A.M., Certified Nursing Assistant (CNA) G said he/she did not know if the abuse and neglect hotline number was posted anywhere. During an interview on 11/21/24 at 9:55 A.M., the Social Services Designee (SSD) said residents were given the DHSS hotline number when they were admitted and thought the number was on the resident rights poster. During an interview on 11/21/24 at 9:58 A.M., the Administrator said the DHSS Abuse and Neglect Hotline number should be posted.

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year. This affected one out of two sampled Certified Nurse Assistants (CNA) (CNA B). The facility's census was 34. The facility did not provide a policy regarding in-service training. 1. Record review of CNA B's in-service record showed: - A hire date of 09/01/21; - A total of eight hours of annual in-service training for November 2023 through November 2024; - Less than twelve hours of in-service education for November 2023 through November 2024. During an interview on 11/21/24 at 8:30 A.M., the Director of Nursing (DON) said in-service training was conducted on a monthly basis and all CNA's were expected to attend at least 12 hours of in-service training annually. During an interview on 11/22/24 at 3:20 P.M., the Administrator said she expected CNA's to have at least 12 hours of in-service training annually.

Based on interview and record review, the facility failed to have a Quality Assurance and Performance Improvement (QAPI) (a program to improve the processes for the delivery of health care and quality of life for the residents) program in place with policies and protocols describing how the facility will identify and correct its own quality deficiencies. This deficient practice had the potential to affect all residents in the facility. The facility's census was 33. The facility did not provide a policy in regards to the QAPI program. Review showed the facility did not have a QAPI plan that contained the necessary policies and protocols describing how they would identify and correct their quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurement. During an interview on 08/18/23 at 11:45 A.M., the Administrator and the Director of Nursing said they had not held any QAPI meetings since they went to work in February 2023, but felt that they were finally at a point they could start holding QAPI meetings beginning next week.

Based on interview and record review, the facility failed to allow resident access to personal funds on an ongoing basis. This practice affected 24 residents with personal funds accounts out of a census of 33. Review of the facility's policy titled, Petty Cash, undated, showed: - Ensure accountability for use of petty cash funds; - The only employee permitted access to petty cash is the bookkeeper. In his/her absence, another designated employee shall be permitted access. During the resident council group meeting on 08/16/23 at 9:16 A.M., Residents #3, #4, and #25 said they did not have access to funds after Friday afternoon until the following Monday morning due to the business office was closed. During an interview on 08/18/23 at 8:30 A.M., Resident #3 said the Business Office Manager (BOM) did not work on the weekends. He/she tried to get money on Thursday or Friday, because he/she knew they can't get any money on the weekends. During an interview on 08/18/23 at 8:40 A.M., Resident #18 said he/she had to plan ahead to get money from the business office since they were closed on the weekends. The resident said if something comes up unexpectedly on the weekend, he/she had no access to his/her cash. During an interview on 08/18/23 at 12:07 P.M., the Administrator said there was no staff member that had access to the resident funds on the weekends except the BOM. He said he would put a system in place, if a resident had a request for cash, then the manager on duty would have access to some cash.

Based on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of Medicare benefits and a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to the resident's representative in writing. This notification informs the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. This practice affected one resident (Resident #15) out of three sampled residents. The facility census was 33. Review of the facility's policy titled, Medicare Beneficiary Notices, undated, showed an advance written notice of non-coverage should be signed and dated by the beneficiary or their representative. 1. Review of Resident #15's NOMNC form showed: - The resident discharged from skilled services on 06/27/23; - The resident's representative verbally notified by phone by the facility staff on 06/27/23; - No signature by the resident's representative on the NOMNC. Review of Resident #15's SNF ABN form showed: - The resident discharged from skilled services on 06/27/23 and the resident remained in the facility; - The resident's representative verbally notified by phone by the facility staff on 06/27/23; - No signature by the resident's representative on the SNF ABN form. During an interview on 08/17/23 at 2:30 p.m., the Social Services Director said he/she had placed a typed summary of his/her phone notification to Resident #15's representative in the chart and thought that no signature was required on the SNF ABN and/or NOMNC forms because he/she had given the notifications over the phone. During an interview on 8/18/23 at 12:25 P.M., the Director of Nursing (DON) said that she would expect the SNF ABN and the NOMNC forms to be completed and signed appropriately by the resident or the resident's representative.