Every finding on record at Autumn Lake Healthcare at Crystal Springs

Based on policy review, staff interview and observation, the facility failed to maintain a clean, comfortable and home-like environment regarding odors in the facility. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 74. Findings included: The facility's policy and procedure for Safe and Homelike Environment stated, 9.a. Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to the Housekeeping Department. On 06/29/26 at 11:30 AM upon entering the facility, the Survey Team identified a strong urine-like odor. On 06/29/26 at approximately 12:15 PM, both dining rooms had a strong urine-like odor. On 07/06/26 at 1:25 PM, a urine-like odor was identified in all three (3) hallways on the South side of the facility. Registered Nurse (RN)#23 confirmed there was a urine-like odor and reported the floors were being replaced in two (2) rooms and possibly part of the hallway flooring at the end of the middle hall on the South side of the facility due to urine-like odors. The Director of Nursing (DON) confirmed the urine-like odors on the South wing of the building, stating, Definitely here on 07/06/26 at 1:35 PM and This one, too in the front and back hallways on the South side. On 07/06/26 at 1:45 PM, the DON confirmed a urine-like odor on the North side of the facility's back hallway near the end of the hallway, close to the back door.

Based on record review and staff interview, the facility failed to ensure complete and thorough investigations for alleged violations of resident to resident abuse and neglect were conducted. This failed practice had the potential to affect more than a limited number of residents. Resident Identifier: #29 and #84. Facility Census: 74. a) Resident #29 On 07/07/26, a Facility Reported Incident (FRI) #3017743 was reviewed. The facility did not thoroughly and completely investigate an incident of resident-to-resident abuse. Basic Information of the incident reported that a fellow resident bent and twisted Resident #29's finger at the dinner table and the residents were separated. On 05/15/26, Nurse Aide #1's statement included, While sitting at dining room table male resident grabbed resident (Resident #29) left pointer finger, twisted it and bent finger backwards. A progress note dated 05/15/26, stated, This resident was sitting in her chair in the dining room when another resident squeezed her right hand. Resident was immediately removed from the the other resident. no visible injuries noted. MD notified and said to get an x-ray if this resident has any worsening symptoms. Resident able to move hand, wrist, and all fingers without any s/s of pain or discomfort. Vitals assessment; BP-122/68, HR-71,RR-16,temp-98.3, O2-96% on room air. The allegation of abuse was verified by the facility. The five (5) Day Follow-up was reviewed, but no five-day follow-up was emailed to OHFLAC. The Administrator stated that it did not have to be reported. The State Surveyor stated the office received the Initial Investigation Report but did not receive the Five (5) Day Follow-Up. The State Surveyor reviewed that there were no witness statements nor psychosocial/emotional follow-up documentation for the victim or other residents in the dining room, if applicable. No additional investigations were listed under Steps Taken to Investigate the Allegation on the Five (5) Day Follow-up. No additional assessments were completed for the resident since the initial incident and progress report. The FRI and Five (5 ) Day Follow-Up were reported to the Ombudsman and Adult Protective Service, but not to the OHFLAC. On 07/07/2026 at 2:35 PM, the Administrator asked about reporting the incident and stated that she was aware of what Appendix PP stated as reportable. The State Surveyor stated that the incident should have been reported since it wasn't an accident but resident-to-resident abuse and the facility should utilize the current Appendix PP guidelines for reporting versus Reporting Requirements dated 06/2012 which the administrator had given to the State Surveyor. b) Resident #84 The facility failed to ensure an allegation of neglect was completely and thoroughly investigated following a choking episode where the resident expired in the facility. On 07/09/26, Resident #84's medical record was reviewed for a death in the facility. The resident's diet order stated, CCD diet Chopped texture, Thin Liquids consistency, double protein for weight maintenance. The following Progress Note was documented on 05/25/26: Incident Description - Nurse was notified by CNA in regards to this residents room for a possibly choking. Began to assess this resident and witnessed him sitting at a 90 degree angle, with blue lips. Nurse began the Heimlich maneuver numerous times and was unsuccessful. Other LPN began Heimlich Maneuver and was unsuccessful, RC/EMS was contacted at 1300. Oxygen applied at 2L via face mask, and suctioning performed in an attempt to clear airway, which was unsuccessful. RC/EMS arrived on scene and began assessing resident. Resident pronounced deceased by RC/EMS x2 personnel. Immediate Action Taken - Immediate intervention from floor nurses attempting Heimlich Maneuver to clear residents airway. Additional help arrived and continued to attempt to clear what was thought to be choking. Heimlich attempted and unsuccessful. Resident laid on left side and inhaled and exhaled, back thrusts, abdominal thrusts, suction all attempted without success. High flow oxygen applied with no results. Resident had agonal breaths during this time frame. RC/EMS arrived on scene and began assessing resident. EMS stated fixed pupils and pulseless. Resident DNR. RC/EMS transferred residents body to DMC morgue for examination. Residents body will then be transferred to Tomblyn funeral Home for services. The Facility Reported Incident (FRI) was requested by the State Surveyor for the incident dated 05/25/26. The Administrator reported a FRI had not been completed. On 07/09/26 at 10:47 PM, the Administrator reported a FRI was not completed for the incident. The Administrator reported that the resident did not choke to death. The Administrator reported that the airway was clear and the person was breathing and stated, He was likely having a heart attack. The Administrator reported there were nurse aides in the room. When the Administrator was asked about the nursing documentation, the Administrator stated, Absolutely not what happened, and What (Licensed Practical Nurse #28) put in the note was not accurate. The Administrator reported she was not at the facility when the incident occurred but came in when she was called and informed of the resident's death. Resident #84's death certificate was requested by the State Surveyor multiple times. On 07/14/26, the Director of Nursing (DON) reported that they did not have a death certificate. The DON stated, She ( Administrator) does not have the death certificate. On 07/09/26, a folder containing witness statements was reviewed. The following witness statements were noted: On 05/25/26, Nurse Aide #3's written statement included, The Paramedic did retrieve a pretty big piece of meat which coulda had bread on it to. I didn't inspect the piece. On 05/25/26, Registered Nurse #37's written statement included, The paramedic used the laryngoscope and removed food from the airway with forceps. The resident was without respirations or pulse. On 05/25/26, Licensed Practical Nurse #24's written statement included, EMS removed object w/forceps upon arrival, object appeared to be a piece of meat that was not fully chopped. On 05/25/26, Licensed Practical Nurse #53's written statement included, When EMS arrived, a piece of meat was retrieved via forceps. On 07/14/26, the DON reported that she did not see the bolus removed but went to the kitchen afterwards. The bolus was covered with paper and she removed things to uncover the tray. The DON described the material removed from the resident's airway as having mucous on it, appearing more like bread with meat and she was able to tear the bolus apart. The DON described the material as brown, stringy and mushy and reported she felt it was bread, not fat. On 07/09/26 at 2:07 PM, the Administrator sent three (3) pictures of the resident's tray via email for the survey team to review. Photos attached. The removed bolus was identified by the Administrator on the right corner of the tray and the resident's tray card was still on the resident's lunch tray. The tray card stated,Chopped CCDDouble ProteinMonday (WV1-D2) Lunch05/25/2026HAVE A BLESSED MEMORIAL DAY!!!BBQ PORK SANDWICHESCOLE SLAWBAKED BEANSFRUIT. The photos were reviewed by the State Survey team. The pork on the resident's bun was covered by a sauce, but larger pieces of pork were judged not to be ground consistency by the team upon review. The resident had coleslaw on the tray also. The menu extension for a chopped diet level stated, Ground BBQ Pork on Bun. The menu extension for confetti coleslaw on a chopped diet recommended Chopped, Marinated Cauliflower Salad (no raw veg). The menu extension for creamy coleslaw recommended, Chopped Marinated Mixed Vegetable Salad. On 07/09/26 at 2:40 PM, the Administrator confirmed the resident should not have been served coleslaw and stated the resident was, Served what would be printed. The larger pieces of pork on the meal tray photos were reviewed with the Administrator and the survey team. The facility's guideline for Chopped consistency solids recommended, Ground texture for poultry, beef and pork. and Kitchen staff should prepare meats the same as the ground consistency unless otherwise noted on the tray ticket. The facility's policy and procedure for Aspiration Risk Precautions stated, 3. Provide the diet as ordered for solids and liquids. The facility's policy and procedure for Food: Quality and Palatability stated, 3. Food and liquids/beverages are prepared in a manner, form and texture that meets each resident's needs. A review of the facility's policy and procedure for Abuse, Neglect and Exploitation, stated, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or report of abuse, neglect or exploitation occur. and 6. Providing complete and thorough documentation of the investigation.

Based on observation, record review, and staff interview, the facility failed to provide catheter care and services within accepted standards of practice. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of urinary catheters. Resident identifier: #70. Census: 74. Findings included: a) Resident #70 The facility's policy titled Catheter Care, Urinary, with no implementation date given, stated as follows: Be sure the catheter tubing and draining bag are kept off the floor to maintain infection control. Ensure the catheter remains secure with a leg strap strapped to the resident's inner thigh to reduce friction and movement. Review of Resident #70's physician's orders showed orders relating to his suprapubic urinary catheter. An order written on 01/28/26 stated a leg strap was to be in place. On 07/09/2026 at 10:01 AM, Resident #70 was noted to be sleeping in bed. His suprapubic catheter urine collection bag was hanging off the side of his bed. His bed was in the lowest position, and the urine collection bag was resting on the floor. On 07/09/2026 at 10:44 AM, Resident #70's suprapubic catheter care was observed. The catheter care was performed by Certified Nursing Assistant (CNA) #40. When questioned about the urine collection bag being on the floor, she stated she would try to reposition the bag, so it wasn't on the floor. She stated would get a basin for the collection bag if she could not keep the bag off the floor due to the low position of the bed. It was also noted during observation of catheter care that the catheter did not have a leg strap to secure the drainage bag tubing and prevent it from being accidentally pulled. This surveyor talked to the resident about the leg strap and he said he thought he had one on. He stated he would like one to be placed. On 07/09/2026 at 10:57 AM, Licensed Practical Nurse (LPN) #93 was told Resident #70 had an order to have a catheter leg strap but didn't have one. LPN #93 stated she would place one. No further information was provided.

Based on record review and staff interview the facility failed to submit a five (5) day followup for a Facility Reported Incident as required. This was true for one (1) of two (2) incidents reviewed during this survey. Resident Identifier: #5 Facility Census: 76Findings Include:a) Resident #5On 12/29/25 at 3:03 PM record review of a Facility Reported Incident (FRI) found that the facility did not file a five-day follow-up to the investigation of this incident.On 09/18/25 at 2:30 PM the initial allegation of sexual abuse was reported to the appropriate facilities (Adult Protective Services, the Ombudsman and the Office of Inspector General). The facility investigated the allegation which was unverified. The resident was interviewed at the time of the investigation, however, she does not have capacity and reported that the incident happened months ago. There were twenty (20) additional residents (that have capacity) interviewed with no further allegations reported. The perpetrator and a co-worker were interviewed. On 12/29/25 at 3:30 PM during an interview with Resident #5, she reported to the surveyor that she did not remember anything concerning inappropriate touching. The Administrator attempted to locate the five-day follow-up report but was unable. On 12/30/25 at 10:10 AM it was confirmed with the Administrator that the facility should have filed a 5-day follow-up report to the appropriate office at which time she agreed.

Based on observation, policy review, and staff interview, the facility failed ensure catheter care was provided according to professional standards of practice. This failed practice was true for one (1) of one (1) residents observed for catheter care. Resident identifier: #62. Facility census: 83.Findings included:On 10/21/25 at 10:30 AM, Licensed Practical Nurse #24 was observed providing urinary catheter care for Resident #62. The urinary catheter was not secured to the resident. When LPN #24 was asked what was the facility policy regarding securing urinary catheters, she stated the resident had one but he pulls them off. The Director of Nursing (DON) was informed of the above findings and a request was made for the facility policy and procedure. Review of the policy and procedure titled Catheter Care with an implementation date of 04/01/25 with Centers for Medicare and Medicaid Services (CMS) referenced at F690 (August 2024), found no intervention to secure the urinary catheter in the policy and procedure. In addition, LPN #24 lifted the urinary drainage bag above the level of the resident's bladder allowing urine to drain back into Resident #62's bladder before attaching the drainage bag to the bed frame.

Based on observation, staff interview, and policy review, the facility failed to follow Enhanced Barrier Precautions (EBP) during urinary catheter care and wound care. This was true for one (1) of one (1) residents viewed for urinary catheter care and wound care. Resident identifier: #62. Facility census: 93.Findings included: On 10/21/25 at 10:30 AM, observed Licensed Practical Nurse (LPN) #24 perform urinary catheter care and wound care. Resident #62 was ordered EBP due to having an indwelling urinary catheter and open wound in the right groin area. LPN #24 wore gloves but did not wear a gown. When asked if the resident was on EBP she looked puzzled and then stated Yes, both residents are on EBP. LPN #24 did not attempt to put on a gown. At the end of the care, LPN #24 did not have a plastic bag in which to place soiled washcloths and towels and dropped them on the floor before being given a plastic bag.

Based on record review and staff interviews, the facility failed to have Sufficient and Competent staffing due to the lack of RN coverage for eight (8) consecutive hours a day for eight (8) of eight (8) sampled days. Findings included: a) On 03/04/25 at approximately 2:25 PM the administrator reported the facility did not have the eight (8) consecutive hours a day Registered Nurse (RN) coverage for the following sampled days: -Sunday, 07/07/24 -Sunday, 07/21/24 -Sunday, 08/04/24 -Sunday, 08/18/24 -Saturday, 09/14/254 -Sunday, 09/15/24 -Saturday, 09/28/24 -Sunday 09/29/24 The payroll based journal (PBJ) report review revealed there was no RN coverage on the days listed above.

Based on observation and interviews, the facility failed to established a grievance policy that meets essential requirements. Specifically, it failed to: Notify residents individually or provide clear postings throughout the facility about their right to file a grievance. The facility did not provide easy access to grievance forms. They facility did not notify residents of the right to file a grievance anonymously. Additionally, the facility did not provide easily accessible and clearly presented contact information for independent entities where grievances can be filed, such as the appropriate state agency, Quality Improvement Organization, State Survey Agency, and State Long-Term Care Ombudsman programs. Facility Census: 77 Findings include: a) On 03/03/25, at around 2:00 PM, it was observed that there were no posted notices informing residents about their right to file a grievance, including the option to do so anonymously. Further investigation indicated that residents had been directed to submit any complaints or grievances directly to the administrator. During an interview with Resident #14 on 03/03/25 at approximately 2:08 PM, when asked how she would file a complaint, she responded, I'll talk to the nurse, I guess! During another interview with Resident #26 on 03/03/25 at 2:45 PM, the resident stated that he would have to request a grievance form. On 0303/25, at approximately 3:00 PM, the administrator stated during an interview that the contact information for submitting a grievance was prominently displayed on the facility's TV screens in large text, making it visible to everyone. Further investigation revealed that the TV screens displayed various messages in a continuous loop. Observation showed that the following message appeared approximately every two and a half minutes: Questions, comments, or concerns Call our compliance hotline 1-888-983-7080 Compliance is everyone's responsibility Help us improve our care See something, Say something The administrator insisted the message was visible to all residents and they could call in their complaints or grievances. During an interview, with the Assistant Director of Nursing (ADON) on 03/04/25, at approximately 10:45 AM, the ADON confirmed that the sign stating Resident Rights was posted too high for a person using a wheelchair to read. During a Resident Council Meeting on 03/05/25 at approximately 2:05 PM, when asked how residents would file a grievance, the Resident Council President (RCP) stated that you write a letter. During an observation on 03/03/25 at approximately 2:00 PM, it was noted that there were no postings indicating where grievance forms were located. Additionally, there were no grievance forms readily accessible for residents to file concerns anonymously. Further investigation revealed that residents had been instructed to submit complaints or grievances to the Administrator. During an interview with the administrator on 03/03/25, at approximately 3:00 PM, the administrator stated that the contact information for submitting a grievance was displayed in large text on the TV screens throughout the facility, making it visible to everyone. When asked how a resident could file a grievance in writing, the administrator explained that grievance forms were available at the nurses' station and that residents could request one whenever needed. A follow-up interview with the administrator revealed that completed grievance forms could be submitted at the nurses' station or dropped off at the administrator's office. When asked how a resident could submit a grievance anonymously, the administrator explained that residents could call the compliance number displayed on the TV screens throughout the facility. During a Resident Council Meeting on 03/05/25 at approximately 2:05 PM, when asked how residents could file a grievance, the Resident Council President (RCP) stated, You write a letter. During a resident council meeting on 03/05/25, at approximately 2:05 PM, the Resident Council President (RCP) was asked how residents could file a grievance. The RCP responded, You write a letter. When inquired about how someone could file a grievance anonymously, she replied, I don't care; I tell them what I want! Upon being asked again how someone who wished to remain unidentified could file a complaint, the RCP stated, You just write a letter and slide it under the Administrator's door! You don't sign it! On 03/05/25, at around 3:00 PM, the Administrator confirmed during an interview that grievance letters could be submitted anonymously by sliding them under her door. However, she noted that the facility is small and that everyone can be easily observed, which limits true anonymity. d) No easily accessible location to submit a grievance. On 03/05/25, it was observed that there was no lockbox or designated location for residents to drop off grievance forms. During an interview on the same day at approximately 11:25 AM, the ADON mentioned that there was a box located in the lobby. However, upon inspecting the box, it was found to be a small container labeled Suggestions that was fixed to the wall. The ADON confirmed that it was not possible to insert any documents into this box.

Based on medical record review, observation, and staff interview, the facility failed to ensure Resident's received treatment and care in accordance with professional standards of practice. Resident #68's nebulizer treatment was left running for 20 minutes longer than it should have been. A resident was receiving oxygen at a rate that was not prescribed. Resident #22 did not receive blood sugar monitoring as required by physician order. Resident #28 was identified as a fall risk and had an order for their bed to be in the lowest posiotion did not have their bed in that position. Resident #85 had a seizure disorder and an intervention for padded side rails did not have padded side rails in place. Resident #8, #68, #22, #28, and #28. Facility census: 77. Findings included: a) Resident #68 An observation of Resident #68, on 03/04/25 at 8:55 AM, revealed the Resident was lying in bed receiving a nebulizer treatment (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs.) The nebulizer medication cup was empty at this time. During an Interview on 03/04/25 at 9:29 AM, The Director of Nursing (DON) verified the nebulizer treatment was still running after 40 minutes. She stated that the Treatment should have only been on for about 20 minutes. b) Resident #8 An observation, on 03/04/25 at 10:23 AM, found Resident #8 was receiving oxygen at three (3) Liters via nasal cannula (LPM) from an oxygen concentrator (an oxygen delivery device). A review of Resident #8's medical record revealed a Physicians order for: -Oxygen at 1-2 LPM via Nasal Cannula as needed Post Treatment Evaluate heart rate, respiratory rate, pulse oximetry, skin color, and breath sounds with an order date 7/11/2024. An observation on 03/06/25 at 9:53 AM found the Resident #8 was receiving oxygen at two (2) Liters via nasal cannula (LPM). During an Interview, on 03/06/25 at 10:00 AM, the Director of Nursing verified an Oxygen order was incorrect with the flow liter. She stated that she would notify the physician for a accurate order. 50551 50795 c) Resident #22 Record review and interview on 03/04/25 at 11:18 AM revealed that Resident #22 had been admitted to the hospital on 03/03/25 at approximately 6:15 PM, and returned back to the facility at approximately 9:15 PM on 03/03/25. Record review revealed a physician's order dated 02/12/25, which stated the following: Accu-Chek before meals and at bedtime for diabetes. Insulin Lispro 100 UNIT/ML Solution Inject subcutaneously before meals and at bedtime insulin Lispro 100 UNIT/ML Solution Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units; 451 - 600 = 14 units, subcutaneously before meals and at bedtime Further record review revealed the following historical Accu-Chek results at bedtime: 03/03/25 at 8:04 PM 268.0 mg/dL - Struck out - Clerical correction 03/03/25 at 8:04 PM 268.0 mg/dL - Struck out - Clerical correction 03/02/25 at 9:15 PM 233.0 mg/dL 03/01/25 at 8:42 PM 234.0 mg/dL 02/28/25 at 8:00 PM 195.0 mg/dL 02/27/25 at 8:55 PM 256.0 mg/dL 02/26/25 at 9:49 PM 320.0 mg/dL During an interview with the Director of Nursing (DON) on 03/04/25, at approximately 11:25 AM, the DON stated the records would indicate the resident was not in the facility at 8:00 PM for the regular bedtime Accu-Chek. She further mentioned that the resident's blood glucose was not checked after arriving at the facility because it had already been checked at the hospital prior to discharge. A review of the hospital's discharge summary revealed that the resident's blood glucose level was checked in the hospital on 03/03/25 at 6:34 PM, and it was recorded as 138 mg/dL. The resident returned to the facility at 9:15 PM on 03/03/25. Upon return, records show that the resident was allowed to go to bed without her blood glucose being checked. 50801 d) 28 The facility failed to ensure padding was installed on bed rails due to Seizure precautions, as ordered by his physician. On 03/03/25 at 2:49 PM, during an interview with Nurse Aide (NA) #85, he acknowledged the padding had not ben installed on the resident's bed rails. A physician's order dated 11/27/24 indicated the resident was to have seizure precautions at all times. Padded rails for safety every shift. d) Resident #28 Review of care plan on 03/05/25 at 10:11 AM revealed the following: Focus- Risk for falls related to history of falls, receives antidepressant medications daily. Fracture to right hand on 10/02/24. Date initiated 01/07/25. Interventions included Keep bed at lowest level at all times. initiated on 01/07/25. On 03/05/25 at 01:20 PM observation of Resident #28 lying in bed with non-skid socks, 1/4 assist rails up and his bed in a high position. On 03/05/25 at 01:28 PM during an interview with Nursing Assistant (NA) #83 to inquire about resident's bed position the resident was lying in bed with non-skid slippers. NA #83 stated that she did not know if his bed was in the lowest position. She used the bed control and moved the bed down to lowest position. She acknowledged that the bed had not been in lowest position. During an interview with Licensed Practical Nurse #89 on 03/06/25 at 10:48 AM LPN #89 said that Resident #28 should have his bed in lowest position at all times.

Based on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to the water management, PPE, resident hand washing, resident's personal products and unsanitary practices. This practice had the potential to affect all residents that reside in the facility. Resident identifiers: #26, #24, #30, #40, #46, #53, #70, #74, and #285. Facility census: 72. Findings included: a) Hand Hygiene Prior to Meals An observation on 03/03/25 at 12:15 PM revealed that the resident's on north hall did not receive hand hygiene prior to or during the lunch meal tray pass. During an interview, on 03/03/25 at 12:26 PM, Nursing Assistant (NA) #16 was asked if the residents on the north hall had their hands washed or sanitized prior to the lunch meal on this day. NA #16 stated she was not sure if they had hand hygiene before lunch. NA #16 stated some residents get their hands washed in the resident rooms during AM care, and some residents wash their own hands. During lunch service on 03/03/25 at approximately 12:45 PM, It was noted that Nursing Assistant (NA) #71 did not offer hand sanitizer to Residents # 30, #40, #46, #53, #70, and #74. Upon being asked why the residents had not been offered hand hygiene prior to eating their meal, NA #71 stated Well if I could find sanitizer, I would have used it! During an interview with Licensed Practical Nurse (LPN) #39, at approximately 1:11 PM she stated We have plenty of sanitizer!, and produced two containers of hand sanitizer. LPN #39 confirmed that the residents had not been offered hand hygiene. On 03/03/2025, at 12:48 PM, it was observed, On the south wing of the facility, while delivering the residents lunch trays, CNA # 85 did not wash or sanitize any of the resident's hands. In and interview with CNA # 85, on 03/03/2025 at 12:52 PM, he acknowledged he did not offer to wash or sanitze the residents hands before he served them On 03/05/2025 at approximately 3:30 PM, the DON acknowledged the CNA's should have been offering to sanitize or wash the resident's hands before serving them. b) Water Management Plan During facility record review of the water management revealed, the documentation was not maintained to prevent growth of water borne pathogens including description of the building water system. The flow diagram did not Identify the buildings water systems for which Legionella control measures are needed. No documentation was provided for weekly water flushes for dead legs, unused showers, water fountains and bathtubs. On 03/05/25 at 1:07 PM the Maintenance Director verified the facility did not maintain the water management program. He stated that it would be corrected. 50795 c) Resident #24 During an observation of wound care on 03/04/25, at approximately 3:30 PM, Wound care was administered to Resident #24 by Nurse Practitioner (NP) #104 and Registered Nurse (RN) #5. During this procedure, RN #5 and NP #104 assessed, turned, and repositioned the resident to be able visualize his wounds. However, neither NP #104 nor RN #5 donned personal protective equipment (PPE) during the process. Resident is a bilateral amputee. The resident's right lower thigh has a ligature scar that is in the process of healing, and his suture line showed an area of dehiscence about 2 inches long, with light drainage. NP #104 stated that she would notify the surgeon that the resident has to be seen immediately. NP #104 and RN #5 continued turning resident in his bed to better visualize and document his wounds. They then continued would care, still without donning any PPE d) Resident #26 On 03/04/25, at approximately 3:25 PM, NP #104 and RN #5 were providing wound care to Resident #26. However, neither NP #104 nor RN #5 were wearing personal protective equipment (PPE) during the procedure. They then proceeded to turn and reposition the resident in order to address the wounds on the resident's back. NP #104 wore an instrument pouch around her waist. She used a pair of scissors to cut the resident's dressing and then returned the scissors to her pouch without cleaning or disinfecting them. During an interview with the Assistant Director of Nursing (ADON) on 03/04/25, at approximately 3:45 PM, it was reported that both Nurse Practitioner #104 and Registered Nurse #5 were not wearing personal protective equipment (PPE). The ADON stated that she would investigate the situation and follow up regarding why the staff were not wearing PPE. At approximately 3:55 PM, the ADON returned and confirmed that NP #104 and RN #5 were performing wound care without following barrier precautions. The ADON noted that NP #104 and RN #5 had not put on personal protective equipment (PPE) because there was no sign indicating that Enhanced Barrier Precautions (EBP) were required outside the doors of Resident #24 and Resident #26. The ADON verified that both residents were under Enhanced Barrier Precautions and stated that she had posted a new EBP notice on the door. She further stated that education on infection control would be implemented immediately. A note by NP #104 on 03/05/25 at approximately 3:55 PM stated: Recommended to ADON to contact surgeon regarding small wound dehiscence with purulent drainage. Dark area to the left of dehiscence is concerning but is covered by eschar. The resident's wound is healing. Continue the current treatment plan. Wound care to follow. e) Resident #285 During an inspection of Resident #285's room on 03/04/25, at approximately 1:20 PM, the bathroom was observed to have a toilet seat in the bathtub, with a brown substance splattered on it. Licensed Practical Nurse (LPN) #107 confirmed that the toilet seat should not have been left in the bathtub. She stated that she would contact the housekeeping department to have it removed. On 03/05/25 at approximately 1:34 PM an inspection of Resident #285's bathroom revealed the toilet seat with the brown substance still in the bathtub. LPN #89 confirmed that it should be removed and housekeeping should be directed to remove the toilet seat. Housekeeping staff removed the toilet seat a few minutes later. f) room [ROOM NUMBER] An observation of room [ROOM NUMBER], which had no occupant, on 03/05/25 at approximately 1:30 PM revealed an IV pump with a tube feed still connected. The tube feed still had residual solution in the bag and tube. The bag was dated 02/23/25. A container one third (1/3) full of tube feed solution was observed on the side table. Further investigation revealed that the resident had been admitted to the hospital on 02/25/25. LPN #89 confirmed that the room should have been cleaned ,and the tube feed discarded. She further stated the tube feed solution could have grown all kinds of organisms. During an interview with the ADON on 03/05/25, at approximately 2:00 PM, the ADON stated the resident was transferred to the hospital, and the bed was being held because he was expected to come back to the facility soon. ADON further stated that the room should have been cleaned after the resident had left for the hospital on 02/25/25. ADON notified the housekeeping department to clean the room immediately. 50801 g) Shower Room On 03/05/25 at 09:11 AM, during facility water temperature tests with the Maintenance director, it was observed that several bottles ot hygiene products were left in the shower rooms without labels with names or dates. In an interview with the Administrator and DON present on 03/05/2025, at approximately 4:15 PM, they both acknowledged the bottles of hygiene products should not have been in the shower rooms without labels/dates.

Based on observation, staff interview, and food tray temperatures the facility failed to serve food to residents that was at an appetizing temperature. This failed practice was true for one (1) of one (1) hallways tested for food tray temperatures throughout the Long-Term Care Survey Process. Facility census: 77. Findings included: a) South Side Front Hall Lunch Time Meal Observation During an observation on 03/03/25 at 12:15 PM, it was noted that food carts were brought out of the south side nurses' station. One staff member began to feel cups with the appropriate beverages according to residents' dietary slips. Another staff member began delivering meals. At 12:37 PM, meal service / delivery began on the south side front hall. At 12:43 PM, when four (4) trays were left on the food truck, the Surveyor requested that Nurse Aide (NA) #85 select one tray that would be served last. NA #85 selected Resident #39's tray. On 03/03/25 at 12:49 PM, the Dietary Manager tested the temperature of Resident #39's lunch tray with the following results: -Hotdog: 104.9 degrees Fahrenheit (F) -Fries: 108.1 degrees F -Pineapple Cake: 62.6 degrees F -Yogurt: 59.3 degrees F The Dietary Manager agreed the food temperatures obtained were not considered to be the appropriate desired temperature for the point of delivery to the residents. It was discussed that hot foods would typically be served at 120 degrees F or above and cold foods would be served at 40 degrees F or below. The Dietary Manager stated the food is always 135 degrees or above when it leaves the kitchen and that she was not sure what it ended up being when it was delivered to the residents.

Based on observation, interview and policy review, the facility failed to properly store food in accordance with professional standards. This is true for the facility kitchen and nourishment pantry. This had the potential to affect all residents in the facility. Facility census 77. Findings included: a) On [DATE] at 11:27 AM, during Initial Brief Tour of Kitchen, with Kitchen Account Manager #44 who acknowledged the following in Freezer #1 with no dates: Bag of unopened frozen chicken breasts. Bag of opened fish filets. Bag of opened fish patties. Bag of opened french fries. On [DATE] at 1:00 PM a review facility policy labeled HCSG Policy 019, Food Storage: Cold Foods. Procedures, number 5 stated All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. b)Freezer #1 also contained frozen foods that KAM #44 reported had belonged to a resident who was no longer in the facility, there were no names written on the food boxes and the best by dates were as follows: Gardein Ultimate Plant based chicken filet with a best by date of [DATE]. Gardein Ultimate Turkey and gravy with best by date of [DATE]. On [DATE] at 1:00 PM a review facility policy labeled HCSG Policy 019, Food Storage: Cold Foods. Procedures, number 5 stated All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. c)[DATE] 11:30AM Observation of North Hall Pantry: -Oreos and packaging in a ziplock bag in cabinet- not sealed, no date or name -Freezer ziplock bag full of prepackaged cookies and cakes with no date that included *2 fudge rounds- undated *2 gram crackers - undated *6 [NAME] Soft Baked Sugar free lemon cookies with best by date of [DATE], 5 dated [DATE], and 7 with no date. *2 undated small baggies of animal crackers- undated and not labeled -24 Bowls of dry cereal with lids with no expiration dates On [DATE] at 11:40AM, during an interview with the Kitchen Manager it was reported the kitchen brings new food from the kitchen and it was housekeeping responsibility to dispose of expired food. On [DATE] at 11:50AM, during an interview with the DON, it was acknowledged that the cookies had expiration dates, and the cereal had no dates. She acknowledged that the staff drinks and food should not have been in the pantry. On [DATE] a review of facility policy marked HCSG Policy 018 Food Storage: Dry Goods, listed under procedures number six (6) stated: 'Storage areas will be neat, arranged for easy identification, and date marked as appropriate. d)On [DATE] at 11:33 AM observed Resident nourishment room cabinet contained staff keys, two (2) [NAME] drink cups, three (3) opened canned drinks, an open bottle of soda, a to-go cup with drink, and an open bag of BBQ snacks. On [DATE] at 9:00 AM observed a sign on the outside of the nourishment room that stated: Do not put personal food and drink in the kitchenette. Room is only to be used for food/drink for residents. On [DATE] at 11:50AM, Interview with DON who acknowledged the cookies with expiration dates, as well as cereal with no dates. She acknowledged that the staff drinks and food should not have been in the pantry.

Based on resident interview, staff interview and record review the facility failed to provide evidence that residents were invited to care plan meetings in order to participate in planning for her their own care. This was true for Resident #15. Facility census: 77. Findings included: a) On 03/03/25 at 3:41 PM during an interview with Resident #15, she reported that she had never been asked to attend her care planning meetings. She reported that she did not feel she was a part of the decision making process for her care. On 03/05/25 at 3:14 PM an interview was conducted with Facility Administrator who reported that they do not have documentation to support that Resident #15 had been invited to care plan meetings. She stated that the facility, was cited for this last time and they were doing what they were supposed to but do not have current documentation that they have been doing this. A review of Minimum Data Set MDS assessment dated [DATE] Section Q, Participation in Assessment and Goal Setting, question A. Resident #15 responded Yes indicating that she would like to be included in this process.

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. Resident #34's bathroom wall was not in good repair. This was a random opportunity for discovery. Resident identifier: #34. Facility census: 77. Findings included: a) Resident #34 Upon entering Resident #34's bathroom on 03/06/25 at approximately 9:20 AM, an immediate observation found one (1) rectangle shaped tear approximately 11 inches wide by 8 inches long in the dry wall on the left wall area, to the left side above the sink. On 03/06/25 at 9:25 AM, during an interview with Registered Nurse (RN) #5 she acknowledged there was a tear in the drywall on the bathroom wall left of the sink. She said she would notify maintenance for repair schedule.

Based on record review and staff interview, the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) letter to one (1) of three (3) residents reviewed during the annual survey process. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #333, #334, and #335. Facility census: 77. Findings Included: a) Resident #333 On 02/19/25 at 2:15 PM, a review was completed regarding the beneficiary protection notification liability notices given for the following resident: Resident #333 began Medicare Part A skilled services on 01/07/25. The last covered day of Part A service was 02/08/25. There was no evidence that a NOMNC form was provided. Review of the social worker's social service notes to Resident # 333's daughter, dated 02/06/25, verified a planned discharge. The note stated, This worker updated (Resident #333) on upcoming discharge that PT/OTwill be put in the home and Lincare is dropping resident off an oxygen tank to have on Saturday after discharge. In an interview on 02/20/25 at approximately 1:10 PM, the Administrator stated the facility was unable to provide verification the NOMNC form was given to Resident # 333.

Based on observation and interviews, the facility failed to display notices regarding the availability of survey results, and the related plans of correction, in areas that are prominent and easily accessible to residents and their representatives. Facility census: 77. Findings include: a) Observation on 03/04/25 at approximately 10:55 AM, revealed there was no signage posted indicating the availability of the survey results for residents to review. After being notified of this lapse, on 03/04/25 at approximately 11:30 AM, the Administrator indicated that the survey results were available for review in a binder located on the table near the entrance of the facility. During a resident council meeting on 03/05/25, at approximately 2:05 PM, when resident council members were asked, Do you know where the facility survey results are? Resident #5 stated, That's not our business; that's for the staff! The Assistant Director of Nursing (ADON) confirmed on 03/05/25 at approximately 2:30 PM that there was no posted notice identifying where residents or their representatives could review the survey results. During a meeting with the Administrator, on 03/05/5 at 3:18 PM, the Administrator addressed Resident #5's response to a question about the survey results. The Administrator noted that they had a meeting last year and explained to the residents what survey tags were and what they were doing to correct each of them following the last annual survey. The Administrator said the current resident council president was not a resident at that time. The Administrator also said they had discussions in resident council with residents about being involved in the healthcare information of others.

Based on observation and staff interview, the facility failed to allow residents to have a dignified existence related to having an uncovered catheter bag. This failed practice was a random opportunity of discovery. Resident identifier: #23. Facility census: 77 Findings included: a) Resident #23 On 03/03/2025 at 2:46 PM, during a resident interview, it was observed that Resident # 23's catheter bag did not have a bag cover. On 03/03/25 at 2:44 PM the LPN acknowledged the catheter bag was not covered. During an interview, on 03/05/2025, at approximately 3:45 PM, the facility administrator stated the facility had purchased enough catheter bag covers for all needed residents but did not know why Resident # 23 did not have one

Based on observation and staff interview the facility failed to ensure the updated staffing information was posted. Facility census: 77. Findings included: a)The facility failed to post an updated staffing report sheet for 03/03/2025. On 03/03/25 at 11:35 AM, Upon entrance to the facility the posted daily staffing report sheet had not been updated for 5 days. The daily staffing report sheet was dated 02/26/2025 actual date of entry was 03/03/2025. 03/05/25 at10:54 AM In an interview with the DON, she acknowledged that on Monday 03/03/25, the Daily Staffing report sheet was dated 02/26/25. The Facility failed to post the census on the nurse staffing data at the beginning of each shift for eight (8) of eight (8) sampled days. Not listed for the 7:00 PM - 7:00 AM shift: -Sunday, 07/07/24 -Sunday, 07/21/24 -Sunday, 08/04/24 -Sunday, 08/18/24 -Saturday, 09/14/54 -Sunday, 09/15/24 -Saturday, 09/28/24 -Sunday 09/29/24 In an interview 03/05/2025 at 10:45AM, the DON confirmed census was not listed.

Based on observations, staff interviews, and record review, The facility failed to ensure two (2) of two (2) resident environments were free from accident hazards for which it had control. Resident identifiers: #23 and #34. Facility census: 77. Findings included: a) Resident #23 On 03/03/25 at 02:46 PM It was observed there were no fall mats at Resident #23 bedside per physician orders. 03/03/25 at 2:48 Nurse Aide (NA) #85 acknowledged there were no fall mats on the floor at resident #23's bedside. Physician Order dated 11/27/25 indicated: Fall Mats were to be located at bedside while Resident #23 was in bed. A Care Plan review revealed: Risk for fall R/T (related to) S/P (status post) CVA. Contractures right knee and left hip. Unable to ambulate on own or transfer self in/out of bed. b) Resident #34 During an observation in Resident # 34's room, on 03/06/2025 at 9:20 AM, a 6 fluid ounce bottle of Derma-[NAME] containing Hydro-Cortisone Cream was found in Resident 34's bathroom. A subsequent record review revealed there was no physician order stating that Resident #34 could administer her own medication. In addition, there was no physician order for the bottle of Derma-[NAME], which had been found in the resident's possession. c) Material Safety Data Sheet (MSDS): Review of the MSDS revealed the following information: -This product is not meant for oral consumption or for ophthalmic use. -Inhalation: May cause irritation of nose and throat -Ingestion: May be harmful if swallowed -Skin Contact: May cause slight irritation. -Eye Contact: Will cause irritation to the eyes During an interview on 03/06/25 at 9:25 AM, Registered Nurse (RN) #5 verified the Derma-[NAME] with Hydrocortisone was in resident's room and stated it should be removed from the resident's room.

Based on record review and staff interview, the facility failed to ensure the resident's Pre-Admission Screening (PAS) was updated after a new diagnosis. This was true for two (2) out of three (3) residents reviewed for the category of PASARR (Pre-Admission Screening and Record Review, during the Long-Term Care Survey Process. Resident identifiers: #23, #28 and #27. Facility census: 77. Findings included: a) Resident #28 - A PAS, completed on 01/04/18, marked Mental Retardation under Section III Question 30 entitled, Current Diagnosis . Additionally, Section IV Question 37 entitled, Diagnosis included the following: Spontaneous rupture of flexor tendons, right lower leg. Fracture of unspecified part of scapula, left shoulder, initial encounter for closed fracture. essential (primary) hypertension. Mild intellectual disabilities Anxiety disorder, unspecified. A medical record review, completed on 03/04/25 at 9:18 AM, revealed Resident #28 had a diagnosis of: Unspecified Psychosis Not due to due to a substance or physiological condition with onset date of 06/08/21 and Major Depressive Disorder, Single Episode with an onset of 06/02/21. During an interview, on 03/05/25 at 11:23 AM, the Director of Social Services reported that no new PASARR had been completed after the new diagnosis. b) Resident #27 A medical record review, completed on 03/04/25 at 9:45 PM, revealed Resident #27 had a diagnosis of: Unspecified Psychosis not due to due to a substance or known physiological condition with onset date of 06/22/21. A PAS, completed on 03/21/24, marked NONE under Section III Question 30 entitled, Current Diagnosis . Additionally, Section V Question 40 entitled, Major Mental Illness or Suspected MI was marked NONE, During an interview on 03/05/25 at 11:23 AM, the Director of Social Services reported that new PASARR had been completed after the new diagnosis but failed to capture the diagnosis. c) Resident #23 A medical record review, completed on 03/04/25 at 9:07 AM, revealed Resident #23 had been admitted to the facility on [DATE] with the following diagnoses: -Major Depression Disorder -Schizoaffective Disorder A PAS, completed on 11/27/24, marked NONE under Section III Question 30 entitled, Current Diagnosis (Check all that apply). Additionally, Section V Question 40 entitled, Major Mental Illness (MI) or Suspected MI - Major Depression Disorder was not marked. During an interview on 03/05/25 at 11:23 AM, the Director of Social Services reported that resident's Major Depression Disorder diagnoses had not been captured on the 11/27/24 PAS and a new one had not been completed.