Every finding on record at Aviata at South Daytona

Based on record review, interviews, and review of facility records, the facility failed to ensure the residents' right to be free from neglect by failing to implement sufficient safeguards and supervision to prevent one (Resident #1) of five residents reviewed for Activities of Daily Living (ADL) care from an avoidable fall with subsequent fractures of the lower right femur (thigh bone) and right patella (kneecap). The facility failed to ensure that staff implemented care plan interventions specifying two-person assistance and the use of a mechanical lift during transfers for Resident #1. On April 22, 2026, one certified nursing assistant (CNA) attempted to transfer Resident #1 from her bed to her chair by using a stand-and pivot method rather than following the resident's care plan indicating the need for a mechanical lift and two staff members for transfers. The resident fell during the transfer and sustained right femur and patellar fractures.Any resident requiring two-person staff assistance during transfers was at risk. There were 19 residents who required two-person assistance and/or the use of a mechanical lift during transfers at the time of the survey.The facility's failure created a situation that caused a serious injury to Resident #1 and resulted in the determination of Immediate Jeopardy on May 18, 2026. The findings of Immediate Jeopardy were determined to have been corrected as of April 27, 2026.The findings include:Cross reference F0689A review of Resident #1's medical record revealed an initial admission date of 9/25/2025, with a re-entry on 4/30/2026 and subsequent discharge on [DATE]. The resident's diagnoses included nondisplaced unspecified condyle fracture of lower end of right femur (thigh bone), subsequence encounter for closed fracture with routine healing; unspecified fracture of right patella (kneecap), subsequent encounter for closed fracture with routine healing; cerebral palsy (a lifelong neurological disorder affecting a person's movement, muscle tone, balance and posture).A review of Resident #1's Change in Condition report, dated 4/22/2026 at 2:42 PM, revealed the resident had a fall. Recommendations included imaging of bilateral hip and pelvis, right femur, right knee, tibia/fibula (lower leg).A review of a nursing progress note, dated 4/22/2026 at 7:45 PM, revealed that per the physician's request, the portable x-ray provider was returning to the facility to re-take x-rays due to poor positioning. There were no further orders other than to continue pain management with hydrocodone (opioid pain reliever used to manage severe, persistent pain) 5/325 every six hours to keep the resident comfortable.A review of a nursing progress note dated 4/22/2026 at 8:13 PM revealed that the physician ordered the resident to be transferred to the hospital for further assessment due to inadequate imagery.A review of the hospital discharge paperwork, dated 4/30/2026, revealed that the resident was admitted on [DATE] at 8:30 PM with a chief complaint of knee pain in the back of her right knee, after the staff at her living facility were trying to transfer her but they were unable to support her weight, so she fell onto her knee. A knee CT (computed tomography) scan (imaging test using x-rays and computer processing to create detailed cross-sectional images of the inside of the body) was ordered and reviewed by the physician who confirmed a distal femur fracture.A review of Resident #1's active care plan, revised on 4/8/2026, revealed that the resident had an ADL (activities of daily living) self-care performance deficit related to a diagnosis of cerebral palsy. The care plan noted that the resident required assistance as follows: All care to be provided by two staff. Bed mobility: The resident requires extensive assist of two staff for turn and reposition in bed as necessary. Transfer: The resident requires a Hoyer lift (mechanical lifting device used to transfer residents with limited mobility) with two staff assistance for transfers.A review of Resident #1's quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/18/2026, revealed that Resident #1 had a brief interview for mental status (BIMS) score of 14 out 15 possible points, indicating intact cognition. She was noted as dependent with toileting hygiene, bed mobility and transfers.A review of the facility's investigation of the 4/22/2026 event revealed a 4/23/2026 written statement provided by Certified Nursing Assistant (CNA) A, Resident #1's assigned CNA on 4/22/2026, that read, On the morning of April 22nd, I wasn't feeling well so I was doing my rounds slowly. Once I reached [Resident #1's] room, I noticed she hadn't been in the facility for a period of time. I initially attempted to locate a Hoyer lift pad but being unable to find the Hoyer pad and a sit-to-stand (lift) and based on my previous experience of successfully pivoting this resident to her chair, I proceeded to manual pivot transfer. During the transfer, the resident's weight shifted, and it was clear we would not reach the chair safely. To ensure her safety, I did not allow her to fall, I guided her slowly and controlled to the floor. The nurse was stationed outside the room, so I'm sure he would of heard something . back. I immediately called for the nurse, the nurse entered and attempted to assist me with lifting the resident, but due to her weight keep shifting, we were unable to complete the lift with two people. I then sought out a third coworker. Together the three of us successfully and safely assisted the resident into her chair. During the entire process and immediately following the assist, the resident did not express pain, showed no signs of physical or emotional distress, did not scream or call out.On 5/18/2026 at 1:45 PM, Resident #1 was observed lying in bed. She reported having been in the facility for almost a year, but she had been in and out, so she could not say exactly how long. When she was asked if she recently had a fall, she reported she did and had to wear this brace for another three weeks, as she pointed to her right leg. She stated at one time she used to sit and stand when she got in and out of a chair or her bed. When she came back from one of her hospital stays, she needed more help getting in and out of bed, so she used a sit-to-stand lift, but now they used a Hoyer lift with a sling. The day the incident occurred, CNA A came to get her out of bed and into her wheelchair. CNA A wrapped her arms around her body. She held me like a bear, and once she had me up, she couldn't hold on. We've done this before, but I guess she got tired because she dropped me, and when she tried to help me back up, she dropped me again, and I fell and my leg was caught underneath me, and I ended up with a break.On 5/19/2026 at 9:14 AM, an attempt to reach CNA A (who was no longer employed by the facility) by telephone was unsuccessful.On 5/19/2026 at 9:54 AM, an interview was conducted with the Interim Director of Clinical Services (IDCS). She reported coming in after the incident on the morning of 4/22/2026 to work the medication cart, and she was informed by Resident #1 that her knee was bothering her. The IDCS assessed Resident #1 and noted no swelling, shortness of leg or bruising, but she informed the resident that she would contact her physician. She administered pain medication and the portable x-ray provider was called with an order for bilateral hip pelvis, knee, femur and tib/fib (tibia/fibula - lower leg). Resident #1 pointed at her thigh but could not pinpoint the exact location of the pain. The portable x-ray provider arrived but was unable to get clear imaging due to Resident #1's positioning, and they were unable to repeat. The physician ordered Resident #1 to be transferred to the emergency room and there, CT imaging was completed and fractures were found. CNA A did not report the fall. The IDCS stated she was brought into it afterward to focus on staff education. All direct care CNAs and nursing staff were provided with education on how to complete proper transfers and how to utilize the Kardex (a quick-reference summary of the resident's medical history, care plans, and daily needs) in the computer that explains resident-specific transfer mobility status. She further stated this information was also available in the residents' physical chart at the nursing stations.On 5/19/2026 at 11:28 AM, an interview was conducted via telephone with Licensed Practical Nurse (LPN) B, who stated he was on the hall and close to Resident #1's room when the fall occurred. He heard CNA A call for help. He entered the room and saw CNA A holding Resident #1 up on the side of the bed as she was slipping down. The resident's feet were on the floor. She was too heavy and the two of them could not get her back in bed. LPN B asked CNA A to get help from another CNA while he held the resident up. He stated, Another CNA and I, along with [CNA A], got her back in bed safely. Her [Resident #1's] transfer status is lift-to-stand or Hoyer lift, but both lifts require two staff. He confirmed that CNA A had worked with Resident #1 before. She [Resident #1] has been two staff assist since she's been at the facility; her legs don't hold her up too well. LPN B stated he asked CNA A if the resident had a fall, and she said, No, I'm just holding her here. He confirmed having participated in training on abuse and neglect, and proper resident transfers to include mechanical lifts, annually during skill competencies. He also received training and education on 4/23/2026 after Resident #1's 4/22/2026 incident. The education included safe transfer of a resident by utilizing the resident's Kardex to ensure proper transfer techniques. The education also included notifying the DCS immediately after a fall occurred, as well as Abuse and Neglect training. LPN B stated he was aware that Resident #1 returned to the facility with fractures and that they probably could have been avoided. He stated the expectations for CNAs was that they accessed/reviewed the care plans for their assigned residents, which explained each resident's needs, prior to and during provision of care. This was confirmed when the CNAs signed off on their assignments throughout the shift, so they all had access to their assigned residents' plans of care to include transfer needs.On 5/20/2026 at 12:18 PM in a follow-up interview with the IDCS, she stated the expectation for all CNAs at the start of their shift was that they got their assignments. There's a printed-out list of the aide assignments at the nurses' station, and the assignments are posted on the whiteboard. The oncoming CNA will get a report from the off-going CNA, and they will complete walking rounds together to discuss any changes/updates or notifications needed to provide care to their assigned residents for that shift. This is the expectation, and all CNAs are educated during new orientation, annually and incidentally. She confirmed that the 4/22/2026 incident involving Resident #1's fall with injury could have been avoided if the resident's care plan had been reviewed and followed prior to providing transfer assistance to Resident #1 from the bed to the chair. A review of the CNA Job Description revealed essential duties and responsibilities including:Purpose:The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan.Duties and Responsibilities:2. Participate in resident care assessments.3. Assist in development of resident treatment plans.4. Provide direct care in accordance with treatment plan.10. Act in accordance with all corporate, state, federal and other regulatory standards.31. Follow established safety precautions in the performance of all duties.43. Wear and/or use safety equipment and supplies (e.g. back brace, mechanical lift, etc.) when lifting or moving residents.A review of the facility's policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation (revised 11/16/2022), revealed:Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property.Definition:Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to;Failure to take precautionary measures to protect the health and safety of the resident.The facility's immediate actions to remove the Immediate Jeopardy included: The CNA involved in the incident was suspended on 4/22/2026, terminated on 4/30/2026, and was reported to the licensing board on 4/30/2026.An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held on 4/23/2026 with the QAPI committee to review the incident, root cause analysis and plan to be implemented.On 4/23/2026, Abuse and Neglect education was initiated and completed by the Interim Director of Nursing (IDCS) for all facility staff regarding the abuse and neglect policy with 100% of staff having received the education as of 4/27/2026.Resident assessments were initiated on 4/23/2026 by the IDCS to determine which residents required a mechanical lift for transfers, with a 100% resident review completed by 4/27/2026.A second Ad Hoc QAPI meeting was conducted on 4/28/2026 to review and report progress on the implemented plan. The root cause analysis was identified as initial transfer attempt without the use of a mechanical lift; staff failed to review or follow the care plan to transfer. No other residents were affected by the deficient practice; all components of the incident were addressed with substantial compliance as of 4/27/2026.The monitoring procedure to ensure that the removal plan was effective and remained corrected/in compliance with the regulatory requirements included:To remain in compliance and under the direction of the Administrator, beginning 4/28/2026:Initiated monitoring on 4/28/2026 by the NHA (Nursing Home Administrator) and DCS of new admissions/readmissions to ensure the baseline care plan is initiated with the appropriate transfer status.Initiated random observations on 4/28/2026 by the DCS and UM (Unit Manager) of staff during the transfer process to ensure proper technique is being used, along with randomly interviewing CNAs to ensure they can articulate the process for how to determine the residents' transfer status and where to locate the Kardex.Verification of the facility's removal plan was completed by the surveyor from 5/18/2026 through 5/20/2026.Interviews were conducted with 11 clinical staff members who worked across all shifts, as well as facility management, including the Interim Administrator, Interim Director of Nursing, Unit Managers, and Rehabilitation Director. Interviews revealed that staff were able to state they had been trained and were knowledgeable about facility policies and procedures regarding care plans, use of the Kardex, the definition of neglect, and the required number of staff needed when transferring a resident requiring a mechanical lift.Tours of the facility indicated that safe resident transfers and bed mobility assistance, using appropriate equipment and number of staff to assist, were in place.A review of in-service documentation revealed that 100% of staff had acknowledged education and training related to neglect, safe resident transfers and the process for reviewing the care plan/Kardex prior to transfer, in addition to skilled competencies regarding mechanical lifts for clinical staff.Based on verification of the facility's Immediate Jeopardy removal plan, the immediate jeopardy was determined to have been corrected as of 4/27/2026.

Based on record review, interviews, and review of facility records, the facility failed to implement sufficient safeguards and supervision to prevent one (Resident #1) of five residents reviewed for Activities of Daily Living (ADL) care from an avoidable fall with subsequent fractures of the lower right femur (thigh bone) and right patella (kneecap). The facility failed to ensure that staff implemented care plan interventions specifying two-person assistance and the use of a mechanical lift during transfers for Resident #1. On April 22, 2026, one certified nursing assistant (CNA) attempted to transfer Resident #1 from her bed to her chair by using a stand-and pivot method rather than following the resident's care plan indicating the need for a mechanical lift and two staff members for transfers. The resident fell during the transfer and sustained right femur and patellar fractures.Any resident requiring two-person staff assistance during transfers was at risk. There were 19 residents who required two-person assistance and/or the use of a mechanical lift during transfers at the time of the survey.The facility's failure created a situation that caused a serious injury to Resident #1 and resulted in the determination of Immediate Jeopardy on May 18, 2026. The findings of Immediate Jeopardy were determined to have been corrected as of April 27, 2026.The findings include:Cross reference F0600A review of Resident #1's medical record revealed an initial admission date of 9/25/2025, with a re-entry on 4/30/2026 and subsequent discharge on [DATE]. The resident's diagnoses included nondisplaced unspecified condyle fracture of lower end of right femur (thigh bone), subsequence encounter for closed fracture with routine healing; unspecified fracture of right patella (kneecap), subsequent encounter for closed fracture with routine healing; cerebral palsy (a lifelong neurological disorder affecting a person's movement, muscle tone, balance and posture).A review of Resident #1's Change in Condition report, dated 4/22/2026 at 2:42 PM, revealed the resident had a fall. Recommendations included imaging of bilateral hip and pelvis, right femur, right knee, tibia/fibula (lower leg).A review of a nursing progress note, dated 4/22/2026 at 7:45 PM, revealed that per the physician's request, the portable x-ray provider was returning to the facility to re-take x-rays due to poor positioning. There were no further orders other than to continue pain management with hydrocodone (opioid pain reliever used to manage severe, persistent pain) 5/325 every six hours to keep the resident comfortable.A review of a nursing progress note dated 4/22/2026 at 8:13 PM revealed that the physician ordered the resident to be transferred to the hospital for further assessment due to inadequate imagery.A review of the hospital discharge paperwork, dated 4/30/2026, revealed that the resident was admitted on [DATE] at 8:30 PM with a chief complaint of knee pain in the back of her right knee, after the staff at her living facility were trying to transfer her but they were unable to support her weight, so she fell onto her knee. A knee CT (computed tomography) scan (imaging test using x-rays and computer processing to create detailed cross-sectional images of the inside of the body) was ordered and reviewed by the physician who confirmed a distal femur fracture.A review of Resident #1's active care plan, revised on 4/8/2026, revealed that the resident had an ADL (activities of daily living) self-care performance deficit related to a diagnosis of cerebral palsy. The care plan noted that the resident required assistance as follows: All care to be provided by two staff. Bed mobility: The resident requires extensive assist of two staff for turn and reposition in bed as necessary. Transfer: The resident requires a Hoyer lift (mechanical lifting device used to transfer residents with limited mobility) with two staff assistance for transfers.A review of Resident #1's quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/18/2026, revealed that Resident #1 had a brief interview for mental status (BIMS) score of 14 out 15 possible points, indicating intact cognition. She was noted as dependent with toileting hygiene, bed mobility and transfers.A review of the facility's investigation of the 4/22/2026 event revealed a 4/23/2026 written statement provided by Certified Nursing Assistant (CNA) A, Resident #1's assigned CNA on 4/22/2026, that read, On the morning of April 22nd, I wasn't feeling well so I was doing my rounds slowly. Once I reached [Resident #1's] room, I noticed she hadn't been in the facility for a period of time. I initially attempted to locate a Hoyer lift pad but being unable to find the Hoyer pad and a sit-to-stand (lift) and based on my previous experience of successfully pivoting this resident to her chair, I proceeded to manual pivot transfer. During the transfer, the resident's weight shifted, and it was clear we would not reach the chair safely. To ensure her safety, I did not allow her to fall, I guided her slowly and controlled to the floor. The nurse was stationed outside the room, so I'm sure he would of heard something . back. I immediately called for the nurse, the nurse entered and attempted to assist me with lifting the resident, but due to her weight keep shifting, we were unable to complete the lift with two people. I then sought out a third coworker. Together the three of us successfully and safely assisted the resident into her chair. During the entire process and immediately following the assist, the resident did not express pain, showed no signs of physical or emotional distress, did not scream or call out.On 5/18/2026 at 1:45 PM, Resident #1 was observed lying in bed. She reported having been in the facility for almost a year, but she had been in and out, so she could not say exactly how long. When she was asked if she recently had a fall, she reported she did and had to wear this brace for another three weeks, as she pointed to her right leg. She stated at one time she used to sit and stand when she got in and out of a chair or her bed. When she came back from one of her hospital stays, she needed more help getting in and out of bed, so she used a sit-to-stand lift, but now they used a Hoyer lift with a sling. The day the incident occurred, CNA A came to get her out of bed and into her wheelchair. CNA A wrapped her arms around her body. She held me like a bear, and once she had me up, she couldn't hold on. We've done this before, but I guess she got tired because she dropped me, and when she tried to help me back up, she dropped me again, and I fell and my leg was caught underneath me, and I ended up with a break.On 5/19/2026 at 9:14 AM, an attempt to reach CNA A (who was no longer employed by the facility) by telephone was unsuccessful.On 5/19/2026 at 9:54 AM, an interview was conducted with the Interim Director of Clinical Services (IDCS). She reported coming in after the incident on the morning of 4/22/2026 to work the medication cart, and she was informed by Resident #1 that her knee was bothering her. The IDCS assessed Resident #1 and noted no swelling, shortness of leg or bruising, but she informed the resident that she would contact her physician. She administered pain medication and the portable x-ray provider was called with an order for bilateral hip pelvis, knee, femur and tib/fib (tibia/fibula - lower leg). Resident #1 pointed at her thigh but could not pinpoint the exact location of the pain. The portable x-ray provider arrived but was unable to get clear imaging due to Resident #1's positioning, and they were unable to repeat. The physician ordered Resident #1 to be transferred to the emergency room and there, CT imaging was completed and fractures were found. CNA A did not report the fall. The IDCS stated she was brought into it afterward to focus on staff education. All direct care CNAs and nursing staff were provided with education on how to complete proper transfers and how to utilize the Kardex (a quick-reference summary of the resident's medical history, care plans, and daily needs) in the computer that explains resident-specific transfer mobility status. She further stated this information was also available in the residents' physical chart at the nursing stations.On 5/19/2026 at 11:28 AM, an interview was conducted via telephone with Licensed Practical Nurse (LPN) B, who stated he was on the hall and close to Resident #1's room when the fall occurred. He heard CNA A call for help. He entered the room and saw CNA A holding Resident #1 up on the side of the bed as she was slipping down. The resident's feet were on the floor. She was too heavy and the two of them could not get her back in bed. LPN B asked CNA A to get help from another CNA while he held the resident up. He stated, Another CNA and I, along with [CNA A], got her back in bed safely. Her [Resident #1's] transfer status is lift-to-stand or Hoyer lift, but both lifts require two staff. He confirmed that CNA A had worked with Resident #1 before. She [Resident #1] has been two staff assist since she's been at the facility; her legs don't hold her up too well. LPN B stated he asked CNA A if the resident had a fall, and she said, No, I'm just holding her here. He confirmed having participated in training on abuse and neglect, and proper resident transfers to include mechanical lifts, annually during skill competencies. He also received training and education on 4/23/2026 after Resident #1's 4/22/2026 incident. The education included safe transfer of a resident by utilizing the resident's Kardex to ensure proper transfer techniques. The education also included notifying the DCS immediately after a fall occurred, as well as Abuse and Neglect training. LPN B stated he was aware that Resident #1 returned to the facility with fractures and that they probably could have been avoided. He stated the expectations for CNAs was that they accessed/reviewed the care plans for their assigned residents, which explained each resident's needs, prior to and during provision of care. This was confirmed when the CNAs signed off on their assignments throughout the shift, so they all had access to their assigned residents' plans of care to include transfer needs.On 5/20/2026 at 12:18 PM in a follow-up interview with the IDCS, she stated the expectation for all CNAs at the start of their shift was that they got their assignments. There's a printed-out list of the aide assignments at the nurses' station, and the assignments are posted on the whiteboard. The oncoming CNA will get a report from the off-going CNA, and they will complete walking rounds together to discuss any changes/updates or notifications needed to provide care to their assigned residents for that shift. This is the expectation, and all CNAs are educated during new orientation, annually and incidentally. A review of the facility's policy and procedure titled Plans of Care (Effective: 11/30/14, Revised: 9/25/2017), revealed:An individual person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal requirements. Plan of care is to be maintained as part of the final medical record.Procedure:Develop and implement an individualized person-centered baseline plan of care within 48 hours of admission that includes, but is not limited to, initial goals based on the admission orders, physician's orders, dietary orders, therapy services, social services, PASRR recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed.Develop and implement an individualized person-centered comprehensive plan of care by the interdisciplinary team that includes but is not limited to, the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident, and, to the extent practicable, the participation of the resident and the resident's representative(s) within seven (7) days of completion of the comprehensive assessment.A review of the facility's policy and procedure titled Transfer/Mobility Evaluation Low Lift (Effective: 11/30/2014, Revised: 11/2/2025), revealed:Center will evaluate the transfer and lifting needs of the resident to safely and comfortably transfer according to their individualized needs.Procedure:3. Two staff members are required when using a mechanical lift.4. Lift status will be indicated on the resident's care plan and Kardex.The facility's immediate actions to remove the Immediate Jeopardy included: The CNA involved in the incident was suspended on 4/22/2026, terminated on 4/30/2026, and was reported to the licensing board on 4/30/2026.An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held on 4/23/2026 with the QAPI committee to review the incident, root cause analysis and plan to be implemented.Resident assessments were initiated on 4/23/2026 by the IDCS to determine which residents required a mechanical lift for transfers, with a 100% resident review completed by 4/27/2026.On 4/23/2026, clinical staff training was initiated by the IDCS for safe transfers, the process to review the care plan/Kardex prior to completing resident transfers, and the process for reporting a resident's fall. 100% of clinical staff received the education by 4/27/2026. Education was validated using a post test. Clinical staff were not permitted to work until the education was received.Competencies for the proper use of mechanical lifts were initiated on 4/23/2026 by the IDCS for licensed nurses and certified nursing assistants. 100% of nurses and CNAs completed competencies as of 4/27/2026.A second Ad Hoc QAPI meeting was conducted on 4/28/2026 to review and report progress on the implemented plan. The root cause analysis was identified as initial transfer attempt without the use of a mechanical lift; staff failed to review or follow the care plan to transfer. No other residents were affected by the deficient practice; all components of the incident were addressed with substantial compliance as of 4/27/2026.The monitoring procedure to ensure that the removal plan was effective and remained corrected/in compliance with the regulatory requirements included:To remain in compliance and under the direction of the Administrator, beginning 4/28/2026:Initiated monitoring on 4/28/2026 by the NHA (Nursing Home Administrator) and DCS of new admissions/readmissions to ensure the baseline care plan is initiated with the appropriate transfer status.Initiated random observations on 4/28/2026 by the DCS and UM (Unit Manager) of staff during the transfer process to ensure proper technique is being used, along with randomly interviewing CNAs to ensure they can articulate the process for how to determine the residents' transfer status and where to locate the Kardex.Verification of the facility's removal plan was completed by the surveyor from 5/18/2026 through 5/20/2026.Interviews were conducted with 11 clinical staff members who worked across all shifts, as well as facility management, including the Interim Administrator, Interim Director of Nursing, Unit Managers, and Rehabilitation Director. Interviews revealed that staff were able to state they had been trained and were knowledgeable about facility policies and procedures regarding care plans, use of the Kardex, the definition of neglect, and the required number of staff needed when transferring a resident requiring a mechanical lift.Tours of the facility indicated that safe resident transfers and bed mobility assistance, using appropriate equipment and number of staff to assist, were in place.A review of in-service documentation revealed that 100% of staff had acknowledged education and training related to safe resident transfers and the process for reviewing the care plan/Kardex prior to transfer, in addition to skilled competencies regarding mechanical lifts for clinical staff.Based on verification of the facility's Immediate Jeopardy removal plan, the immediate jeopardy was determined to have been corrected as of 4/27/2026.

Based on observations, interviews, facility record review, and a review of facility policies and procedures, the facility failed to ensure it provided a clean, comfortable and homelike environment in four (Rooms #7, #8, #12 and #16) of 30 sampled rooms.The findings include: 1.On 08/11/25 at 11:07 AM, room [ROOM NUMBER] was observed and the bottom portion of the window was missing and covered with a large piece of wood and duct tape. On 08/11/25 at 11:11 AM, room [ROOM NUMBER]'s wall was observed with missing drywall and chipped paint. On 08/11/25 at 11:15 AM, room [ROOM NUMBER] was observed with a wall unit air conditioner missing the control knob and a 3 foot by 2-foot area adjacent to the wall air conditioner unit covered with chipped and bubbling paint. The door frame adjacent to the bathroom door was observed with rotting wood and chipped paint. Several baseboards in the room were missing paint. On 08/14/25 at 9:35 AM, a second observation was made of room [ROOM NUMBER] and the bottom portion of window was missing and covered with a large piece of wood and duct tape. On 08/14/25 at 9:40 AM, a second observation was made of room [ROOM NUMBER]'s wall with missing drywall and chipped paint. On 08/14/25 at 9:48 AM, a second observation was made of room [ROOM NUMBER] with a wall unit air conditioner missing the control knob and a 3 foot by 2 foot area adjacent to the wall air conditioner unit covered with chipped and bubbling paint. The door frame adjacent to the bathroom door was observed with rotting wood and chipped paint. Several baseboards in the room were missing paint. A review of the previous three months of TELS (maintenance computer program) work orders revealed no documentation of work orders related to a broken window adjacent to a window air conditioner unit, bathroom door frames, baseboards or chipped paint in rooms. On 08/14/2025 at 1:25 PM, an interview was conducted with Certified Nursing Assistant (CNA) A who reported that she had worked in the facility for three months. If she noticed an environmental problem, such as a rotting door frame or chipped paint in a resident's room, she would go into the Relias system (computer program) and make a maintenance request. She would also make a verbal request with the Maintenance Director. On 08/14/2025 at 1:31 PM, an interview was conducted with Licensed Practical Nurse (LPN) B who reported she had worked at the facility for one year. She explained that if she noticed an environmental concern, such as a broken window with a wood board cover, she would call the Maintenance Director's cell phone and put a work order request in the TELS system, which went to the Maintenance Director's phone. On 08/14/25 at 2:13 PM, an interview was conducted with the Maintenance Director who reported he had worked in the facility since 11/4/25. He explained that there was no specific plan or calendar for the repair work in resident rooms. Every Friday he met with the Resident Experience Director, and they discussed which rooms repair work will be completed in. Repair work varied because some residents could not walk, and it would take longer to evacuate those rooms to make repairs and repaint the entire room. The Maintenance Director reported that he could paint an entire resident room in six hours. Sometimes other issues took priority, such as a burst pipe, and would interrupt renovation plans. He explained that he had been working on building renovations for the last seven months and had renovated 23 areas of the facility. The process to receive work orders for repair work included information received through angel rounds assigned to managers and conducted daily. Angel rounds included visually inspecting resident rooms and providing an angel rounds report issue identified during the daily morning meeting. He also received work order requests from staff through the TELS system. On 08/15/25 at 1:57 PM, the Maintenance Director verified the observations made in rooms #7, #8 and #12. A review of facility daily angel rounds conducted between 08/04/25 and 08/14/25 documented rooms #7, #8 and #12 were observed for areas including: floor free of holes or tears or stains and walls are in good repair (no unpainted areas or holes in the walls). Daily angel rounds conducted between 08/04/25 and 08/14/25 for rooms #7, #8 and #12 were checked as meeting angel round requirements. 2.On 8/12/25 at 11:06 AM, Resident #59 (room [ROOM NUMBER]) was awake and engaged with the surveyor. His bathroom was observed with no paper towels; the floor tile was heavily stained; tiles and grout were unattached from the wall above the sink; there was a leaking pipe under the sink that had a trash container catching water; there was water pooled at the threshold of bathroom door, and an unpleasant odor was detected. (Photographic evidence obtained) On 8/13/2025 at 10:44 AM, Resident #59's bathroom was observed with the floor tile heavily stained; tiles and grout were unattached from the wall above the sink; a leaking pipe under the sink had a trash container catching water; a piece of bed linen was on the floor, soaked and wet; water was pooled at the threshold of bathroom door, and an unpleasant odor was detected. (Photographic evidence obtained) On 8/14/2025 at 1:55 PM, an interview was conducted with Resident #59. He was asked if he could remember how long his bathroom floor had been flooding. He stated, It's been at least six days that it has been like that; it's about time somebody came to fix it. On 8/14/2025 at 2:25 PM, an interview was conducted with the Maintenance Director. He was asked about the condition of Resident #59's bathroom. He acknowledged that the sink pipes had been leaking on the floor. He explained that the leak occurred this week due to the resident sitting on the sink and causing the sink to detach from the wall. He was asked what the plan was for repair. He stated, I have a plumber in there now making repairs. He was asked what the plan was for other needed repairs around the facility. He stated, I don't have a written plan, the Resident Experience Director (RED), Admissions and I get together every Friday and discuss which residents can be moved so that we can repair the walls and paint. We plan to change the color of the paint all over the building. We have been doing this for the last seven months and to date, 23 areas including resident rooms and the common area have been completed. It's difficult to plan ahead because moving residents involves several considerations. He was asked how other needed repairs were identified throughout the facility while they were doing these projects. He stated, We use Angel Rounds. Every day each manager has 2-3 rooms to check for any needed repairs, call light placement, privacy curtains and things like that. We can't repair anything unless it's entered in TELS. Even if we see it, it still has to be entered in TELS, and all the staff have access to TELS. He was asked how the Angel Rounds were documented. The Maintenance Director provided a form the facility used to document Angel Rounds. The documentation was requested for 8/7/25 through 8/14/25. The Angel rounds were provided and did not indicate any of the repairs needed that were identified in Resident #59's bathroom (room [ROOM NUMBER]). A review of the facility's policy and procedure titled Maintenance (Effective Date: 11/30/2014), Document Name: M-200 revealed: Policy: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair. Procedure: The Director of Environmental Services will follow all policies regarding routine periodic maintenance. The Director of Environmental Services will perform daily rounds of the building to ensure the plant is free of hazards and in proper physical condition. All employees will report physical plant areas or equipment in need of repair or service to their supervisor.

Based on a main nursing station refrigerator observation, facility documentation, staff interviews, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect more than a limited number of residents who consumed foods from the facility, by failing to properly monitor and log temperatures of the main nursing station refrigerator. Unsafe food handling practices represent a potential source of pathogen exposure.The findings include: A follow-up tour was conducted on 08/13/2025 at 11:05 AM. During the tour, it was observed that temperatures were not accurately monitored for the refrigerator at the main nursing station where resident supplements were stored. Temperature documentation was missing for August 2025. (Photographic evidence obtained) An interview was conducted on 08/13/2025 at 12:17 PM with Registered Nurse (RN)/Infection Preventionist M. When asked who was responsible for checking and logging temperatures for the main nursing station refrigerator, she stated nursing was responsible for logging those temperatures. An interview was conducted on 08/14/2025 at 10:33 AM with Cook/Aide I who stated the process for providing snacks and supplements to residents was to transport snacks on the cart to the dining room. Certified nursing assistants (CNAs) and nurses passed snacks from the cart to residents in the dining room and resident rooms. Med pass supplements and applesauce were maintained in the refrigerator at the main nursing station. When asked who was responsible for logging temperatures for the nourishment refrigerator at the main nursing station, Cook/Aide I replied, the CDM (certified dietary manager). An interview conducted on 08/14/2025 at 10:40 AM with [NAME] J revealed that snack carts were provided to residents twice a day; at 2:00 PM and 8:00 PM. Applesauce and med pass supplements were stored in the mini refrigerator at the main nursing station. When asked who was responsible for logging temperatures for the nourishment refrigerator at the main nursing, station, [NAME] J replied, the dietary aide.On 08/14/2025 at 10:42 AM the CDM confirmed that the process for providing snacks and supplements to residents was that snacks were prepared for residents and were transported on the cart to the dining room or nursing station. The snack cart consisted of hot coffee, tea, juice, cups, snacks and supplements. Snacks were provided to residents at 10:00 AM, 2:00 PM, and 8:00 PM. Supplements were stored in an ice bath on the cart and med pass supplements and applesauce were stored in the mini refrigerator at the main nursing station. The CNAs or nurses logged refrigerator temperatures and Dietary staff checked for signatures/initials when restocking the refrigerator, usually daily. A review of the facility's policy and procedure titled Food Storage: Cold Foods, HCSG Policy 019 (dated 8/2022) revealed: Policy Statement: All time/temperature control for safety (TCS foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines for the FDA Food Code. Procedures: 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. (Copy obtained)

Based on interviews, record review, facility document review, and the facility Policy and Procedure, the facility failed to ensure the Pharmacist Medication Regimen Reviews were maintained and carried out to minimize or prevent adverse consequences, to the extent possible for two (Residents #4 and #43) of five residents reviewed in a total survey sample of 30 residents.The findings include: 1.A review of Resident #4's Consultant Pharmacist Medication Regimen Review, dated 2/18/2025, revealed a recommendation made by consultant pharmacist: Need behavior monitoring added to electronic Medication Administration Record (eMAR) while on Trazodone and Zoloft. Another review dated 7/10/2025, included a recommendation to please add behavior monitoring to eMAR while on Trazodone and Sertraline. (Copies obtained) A review of Resident #4's active physician's orders included trazodone HCl (hydrochloride) oral tablet 100 mg (milligrams), give 200 mg by mouth at bedtime related to major depressive disorder, recurrent, unspecified (F33.9) (dated 7/16/2025), Sertraline HCl oral tablet 100 mg, give 1 tablet by mouth at bedtime for depression (dated 5/28/2025), Eliquis oral tablet 5 mg (Apixaban), give 1 tablet by mouth two times a day for clot prevention (dated 5/22/2025), check for bleeding and bruising every shift for monitoring (dated 5/22/2025), Lasix oral tablet 40 mg (Furosemide), give 0.5 tablet by mouth one time a day for CHF (congestive heart failure) (dated 5/31/2025), Spironolactone oral tablet 25 mg, give 1 tablet by mouth one time a day for CHF (dated 5/22/2025). Other orders included a pain assessment every shift (dated 5/21/25). A medical record review revealed that Resident #4 was admitted to the facility on [DATE]. Her diagnoses included generalized anxiety disorder, coagulation deficit- unspecified, and major depressive disorder. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was receiving antidepressant medication and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. The care plan, focus, goals, and interventions related to Resident #4 included the requirement to monitor for behaviors and side effects. 2.A review of Resident #43's Consultant Pharmacist Medication Regimen Review, dated 3/23/2025, revealed a recommendation made by consultant pharmacist: Need behavior monitoring added to electronic Medication Administration Record (eMAR) while on Depakote and Ativan. A review dated 4/7/2025 included a recommendation: Need behavior monitoring added to the eMAR while on Depakote, Ativan, and Trazodone. A review dated 5/12/2025 included a recommendation: Need behavior monitoring added to the eMAR while on Trazodone, Depakote, and Ativan. A review dated 5/12/2025 included a recommendation: Need behavior monitoring added to the eMAR while on Lorazepam and Mirtazapine, and a review dated 7/10/2025 included a recommendation: Need behavior monitoring added to eMAR while on Trazodone, Depakote, Lorazepam and Mirtazapine. (Copy obtained) A review of Resident #43's active physician's orders included Depakote Sprinkles oral capsule delayed release sprinkle 125 mg (Divalproex Sodium), give 250 mg by mouth three times a day related to persistent mood [affective] disorder (dated 3/12/2025); Trazodone HCl oral tablet 50 mg, give 50 mg by mouth at bedtime related to major depressive disorder, (dated 3/31/2025); Mirtazapine oral tablet 7.5 mg, give 1 tablet by mouth at bedtime for depression-related appetite loss (dated 5/7/2025); Lorazepam oral tablet 0.5 mg, give 0.5 tablet by mouth every 12 hours for anxiety related to generalized anxiety disorder, hold for lethargy (dated 6/4/2025); Side effects use - Mirtazapine every shift for monitoring (dated 6/26/2025); Side effects use - Lorazepam every shift for monitoring (dated 6/26/2025); Enhanced barrier precautions due to wound (dated 3/27/2025), and advance directives: do not resuscitate (dated 6/17/2025). Further review of the medical record revealed that Resident #43 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, persistent mood (affective) disorder; other specified personal risk factors, not elsewhere classified; generalized anxiety disorder; and unspecified dementia, unspecified severity, with mood disturbance. A review of the Quarterly MDS, dated [DATE], revealed the resident was receiving antidepressant, opioid, and anticonvulsant medication, and had a Brief Interview for Mental Status (BIMS) score of 4/15, indicating severe cognitive impairment. The care plan, focus and goals related to resident #43 included impaired cognitive function/dementia or impaired thought processes related to dementia and use of antidepressant medications. Interventions included administering medications as ordered, anticipate and meet Resident #43's needs, and monitor/document for side effects and effectiveness. On 7/11/2025 at 1:00 AM, an encounter progress note revealed that Resident #43 was doing well overall. She was receiving psych meds with a gradual dose reduction (GDR) considered. Based on history, the resident was not able to tolerate a GDR and would likely become unstable (exacerbation of underlying psychiatric disorders that are mentioned in the diagnosis section) if medications were reduced. Tapering down the medication would not achieve the desired therapeutic effect; therefore, the resident is on minimal effective dosages of psychotropic medications to maintain or improve the patient's function, well-being, safety, and quality of life. GDR is therefore contraindicated and so GDR was not performed. On 8/13/2025 at 2:45 PM, an interview was conducted with Licensed Practical Nurse (LPN) L and Registered Nurse (RN)/Infection Preventionist M. LPN L verified that Resident #4 was receiving Trazodone, Zoloft/Sertraline, Lasix, and Spironolactone. When asked, how did she document behavior monitoring for residents on antidepressants. She replied, observe behavior. She also stated there was no documentation on the TAR (treatment administration record) for resident behaviors and there was no documentation of monitoring for diuretic use. On 8/13/2025 at 3:06 PM, RN N, Interim Director of Nursing (DON) confirmed that DON/ADON (assistant DON) was responsible for updating pharmacy medication regimen reviews. Pharmacy emailed reviews to the facility and the DON/ADON reviewed the recommendations. Pharmacy recommendations were delegated as appropriate. Medication changes were logged, and the sheets were placed in the binder. The DON/ADON followed up to ensure the tasks were completed, and the nursing staff added the orders in the computer for the residents to be monitored. On 8/13/2025 at 5:21 PM, LPN L was asked to verify Resident #43's documented behavior monitoring for Trazodone and Depakote. She confirmed that there was no documented monitoring for Trazodone and Depakote.

Based on observations, interviews, and policy and procedure review, the facility failed to ensure staff followed the facility's infection prevention and control program (IPCP) and adhered to isolation precautions for one (Resident #8) of six residents who were positive for COVID-19, by entering the resident's room without donning the required personal protective equipment (PPE) and transporting the resident without a mask to a common area, exposing other residents to COVID-19. The findings include: On 08/11/25 at 1:00 PM, upon entry to the facility, staff notified the survey team of an outbreak of COVID-19 with six of a census of 59 residents positive for COVID-19. On 08/11/25 at 2:08 PM, Certified Nursing Assistant (CNA) C was observed exiting Resident #8's room wearing only a surgical mask. Resident #8's door had droplet precaution signage and a fully stocked personal protective equipment (PPE) cart in the hallway adjacent to the door. CNA C reported that she had worked as a CNA at the facility since January of 2025. When she was asked what the facility's policy was for entering a room under droplet precautions, she replied that Resident #8 had COVID-19, and she entered the room to help Resident #8 turn on a movie on his phone. She admitted she should have worn full PPE, which consisted of a gown, an N95 mask, and gloves. On 08/11/25 at 3:30 PM, CNA D was observed transferring Resident #8 in a Geri chair (mobile recliner) from his room to the common dining/activities room. The resident was not wearing a mask. On 08/11/25 at 3:42 PM, Resident #8 was observed in the common dining/activities room not wearing a mask. Eight residents in the dining/activities room were within close proximity to Resident #8. On 08/11/25 at 3:43 PM, Resident #8 was interviewed while in the dining/activities room and stated he knew that he should be wearing a mask. He asked for a mask. A surgical mask obtained from the nursing station was provided to the resident. On 08/11/25 at 4:15 PM, CNA D was interviewed and reported that she had worked at the facility since May 2025. She explained that Resident #8 was diagnosed with COVID-19 about seven days ago. She stated she did not place a mask on Resident #8 while transferring him through the facility to the main dining/activities room because he did not like wearing a mask. She further explained that she transferred Resident #8 to the main dining/activities area because he was at risk for falls and having him nearby would allow the staff to keep a close eye on him. On 08/11/25 at 4:26 PM, Registered Nurse (RN) E was interviewed and reported she had worked at the facility since September of 2024. She explained that the facility's policy for residents diagnosed with COVID-19 should immediately be placed on isolation and droplet precautions should be initiated for the COVID-19-positive resident's room. Isolation for a positive COVID-19 resident was 10 days. She was not sure if the facility's policy noted whether or not a COVID-19-positive resident could leave their room during that time. On 08/11/25 at 4:40 PM, an interview was conducted with the facility's Infection Preventionist (IP)/Registered Nurse (RN). She explained that positive COVID-19 residents must be quarantined in their rooms for 10 days and were not permitted to leave their rooms during that time unless it was medically necessary. If that was the case, they were to wear a mask when outside of their rooms. She said Resident #8 was positive for COVID-19. She observed and verified that Resident #8 was in the common dining/activities room without a mask. On 08/11/25 at 4:45 PM, the IP/RN reported that she informed staff assigned to Resident #8 that the resident could not remain in the dining/activities room without wearing a mask and should be taken back to his room. She further explained that she instructed staff assigned to Resident #8 that because he was at risk for falls, he must be provided 1:1 (one-on-one) supervision while in his room. On 08/12/25 at 10:27 AM, the IP/RN stated staff entering rooms of residents who were positive for COVID-19 should perform hand hygiene and must don personal protective equipment (PPE), including an N95 mask, gown, eye protection and gloves prior to entering the room. Normally, residents on droplet precautions had a trash bag in the room or directly outside of the room for staff to dispose of used PPE. The facility was following CMS (Centers for Medicare and Medicaid Services) and the local Health Department's recommendations for isolation of COVID-19-positive residents for 10 days. On 08/14/25 at 3:40 PM, an interview was conducted with the Assistant Director of Nursing (ADON), who was acting as the interim Director of Nursing (DON). She reported that she had worked for the facility since 07/15/25. She explained that when residents were placed on contact precautions, staff must wear a gown, N95 mask and gloves when entering the resident's room. She further explained that residents diagnosed with COVID-19 must be on isolation precautions for 10 days and should not leave their rooms unless medically necessary. If they had to leave their rooms, a mask, preferably an N95 mask, was to be worn. A review of the facility's policy titled COVID-19-Resident (effective 05/15/23) revealed: Policy: The Center will follow current guidance for managing COVID-19 . Procedure: 4. Managing a resident with a COVID-19 infection. (a) Place the resident in a single-person room with the door closed, if safe, with a dedicated bathroom. If single person rooms are limited or if numerous residents are simultaneously identified as having COVID-19 symptoms, residents should remain in current location . , (c) Initiate TBP (transition-based precautions), staff will adhere to standard precautions and use the following while caring for a resident, respirator (N95 or higher), gown, gloves and eye protection (goggles or face shield). (d) Limit movement outside room to medically essential needs . 5. Duration of Transmission-Based Precautions: (c) Residents with confirmed COVID-19 Infection.1. At least 10 days have passed since symptoms first appear .

Based on observations, record reviews, interviews, and a review of facility policies and procedures, the facility failed to ensure that the call system was accessible to residents while in their beds for three (Residents #10, #20, and # 31) of a facility census of 59 residents. The findings include: 1.On 8/12/2025 at 11:35 AM, Resident #10 was observed awake in bed. His call light was observed out of his reach under the bed. He was asked how he would get the staff's attention if he needed help. He stated, You push the button, or you holler out. He was asked if he could reach his call light. He was unable to reach it. (Photographic evidence obtained) On 08/13/2025 at 9:24 AM, Resident #10's call light was observed out of his reach under the bed. (Photographic evidence obtained) On 8/13/2025 at 9:30 AM, an interview was conducted with Certified Nursing Assistant (CNA) H. She was asked how residents alerted the staff that they needed help when they were in their rooms. She stated, They use the call light. She was asked what she thought was a reasonable amount of time to lapse before a call light was answered. She stated, I usually answer it as soon as I see it. She was asked what the appropriate placement of a call light was. She stated, Within reach (of the resident). On 08/13/2025 at 9:38 AM, an interview was conducted with Licensed Practical Nurse (LPN) O, who was administering medications in Resident #10's room at the time. She was asked how she determined whether or not residents needed assistance when they were in their rooms. She stated, When I go into the room, I always ask them if they need anything while I'm giving medications. She was asked how the residents summoned help from staff when they were in their rooms. She stated, They use their call bell. She was asked to observe Resident #10 to determine whether his call light was in reach. She confirmed that the call light devices for Resident #10 and his roommate, Resident # 20, were not in reach; they were under the beds. She attempted to place the call lights within reach of the residents but was unable to do so. She stated, I don't know why the call lights are stuck under the beds, but I'll get someone to straighten it out. On 08/13/2025 at 1:05 PM a record review revealed that Resident #10 was admitted to the facility on [DATE]. A review of Resident #10's admission MDS (minimum data set) assessment, dated 7/22/2025, revealed that the resident had a BIMs (brief interview for mental status) score of 12 out of 15 possible points, indicating moderate cognitive impairment. He required partial/moderate assistance with toileting and required supervision/touching assistance with bed mobility and transfers. The MDS indicated the resident was frequently incontinent of urine and always incontinent of bowel. A review of Resident #10's Care Plan revealed the following focus areas:Resident is at risk for falls r/t balance problems, incontinence, poor communication/comprehension, psychoactive drug use. Goal: Minimize risk of minor injury through the review date (initiated 06/11/2025, revised 08/11/2025). Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. 2. On 08/13/2025 at 9:40 AM an interview was conducted with Resident #20, who was admitted to the facility on [DATE] with a BIMS (brief interview for mental status) score of 15/15, indicating intact cognition. He was Resident #10's roommate. His call light was observed under his bed. He was asked how long his call light had been out of reach, and he replied that he didn't know exactly how long it had been. He stated, It's down there behind the bed somewhere. 3. On 08/11/2025 at 5:00 PM, Resident #31 was observed in bed asleep. The call light was not within her reach. It was located underneath bed A. (Photographic evidence obtained) On 08/13/2025 at 8:50 AM, Resident #31's call light was observed to be out of the resident's reach. (Photographic evidence obtained) An interview was conducted with the resident at this time. She was asked how she was able to let the staff know if she needed help when she was in her room. She stated, I let them know but I do most everything for myself. She was asked if she could reach her call light. She looked for the call light device on the bed where she was sitting and could not locate it. On 08/13/2025 at 3:15 PM, an interview was conducted with the Interim Director of Nursing (DON). She was asked what the facility provided to the residents to use to alert staff that they needed assistance in their rooms. She stated, The call bell. She was asked how often call light placement was monitored. She replied, Whenever any staff go into the rooms. She was asked whose responsibility it was to ensure call lights were within the residents' reach. She stated, It's everybody's responsibility. She was asked what her expectation was for the nursing staff regarding call light placement. She replied, The staff need to ensure that call lights are within reach so residents can get the help they need, and I also expect that they respond to the lights; everyone needs to respond to the call lights, not just nursing.

Based on observations, staff interviews, document review, and facility policy and procedure review, the facility failed to maintain a sanitary and comfortable environment for residents and staff by failing to ensure hot water was available in resident rooms, resident shower rooms and employee bathrooms. This deficient practice had the potential to impact all 51 residents residing in the facility at the time of the survey. The findings include:On 07/14/25 at 12:41 PM, water temperatures in the facility were taken in the presence of the Regional Plant Operations. Using a dial stem thermometer, resident bathrooms, shower rooms and employee hand washing stations were measured and revealed the following:East Sideroom [ROOM NUMBER]: 78 [NAME] #2: 78 [NAME] #3: 91 [NAME] #4: 78 FRooms #5 and #7 (Jack and [NAME]/ shared bathroom): 70 FRooms #6 and #8: 80 FRooms #10 and #12: 80 [NAME] Side Shower Room: 78 FEmployee Restroom [ROOM NUMBER]: 80 FEmployee Restroom [ROOM NUMBER]: 80 FWest SideRooms #16 and #18: 78 FRooms #19 and #21:100 FRooms #20 and #22: 80 FRooms #24 and #26: 78 [NAME] #27: 98 FWest Side Shower Room: 90 [NAME] 07/14/25 at 11:01 AM, an interview was conducted with Employee C, who works in housekeeping. He reported he has worked at the facility for almost a year and complained that the lack of hot water affects his ability to clean effectively. He especially has a hard time waxing the floors, as he cannot use cold water for the waxing process and has to go to the kitchen to obtain hot water to wax the floors. On 07/14/25 at 11:04 AM, an interview was conducted with Employee B, CNA, who reported she has worked at the facility for 11 months and explained that the hot water has not worked since she started working at the facility. The shower room on the east and west hallway get somewhat warm and many resident bathrooms don't have hot water. Residents often refuse incontinent care or bed baths because they don't want to be bathed in cold water. A resident recently yelled at her that she was cruel for using cold water for incontinent care. She explained that residents are supposed to receive 2 showers each week. On 07/14/25 at 11:12 AM, an interview was conducted with the Infection Control Preventionist/Wound Care, RN, who reported she has worked at the facility since December of 2024. The lack of hot water has been a problem from the start and felt that the lack of hot water may affect effective infection control, as hot water is needed for all aspects of infection control. The lack of hot water forced CNAs to switch from using wash clothes with warm water to using disposable wipes. On 07/14/25 at 11:22 AM, an interview was conducted with Employee A, RN, who reported she has worked at the facility since September of 2024. She explained that the lack of hot water makes her job difficult. Residents have been complaining about the lack of hot water since she started working at the facility. Residents have refused incontinent care and hygiene assistance because they complain the water is too cold. During the last staff meeting, the Maintenance Director informed staff that the facility will soon spend $50K to fix the plumbing. On 07/14/25 at 1:15 PM, an interview was conducted with the Regional Plant Operations, who reported he has worked as the Regional Plant Operations for 1 1/2 years. He explained that he oversees the maintenance of buildings in this region. He usually communicates with the building's Maintenance Director through email. He further explained that we were made aware of the lack of hot water problem as a company in approximately April 2025. He said a plumber has been out to the facility and diagnosed the problem stems from the cold water leaking into the hot water. The building will need to be re-piped on the hot side. He verified that hot water temperature should be between 105 - 110 degrees Fahrenheit. An estimate for the plumbing work was submitted to the corporate office two months ago, and they are waiting for approval. On 07/14/25 at 2:17 PM, the Administrator was interviewed and reported she has worked at the facility since November of 2024. She mentioned that the immediate plan for residents without hot water in their room is a wipe warmer located at the nurse station. They also offer residents bed baths, and CNAs know which rooms they can obtain warm water from. She was notified about the problem with the lack of warm water in April of this year. She explained that the corporate office has known about the problem of a lack of hot water since April 2025. When asked about the facility's Performance Improvement Plan (PIP) for the lack of hot water, she explained that actions of the PIP are to gather resident feedback on water temperature preferences during resident council meetings and town hall meetings. She could not provide documented evidence resident feedback on water temperature preferences were obtained. On 07/14/25 at 3:00 PM, an interview was conducted with Resident #11. She described an incident which took place in May 2025, which she filed a facility grievance. She explained that while receiving incontinent care, a certified nurse assistant (CNA) wiped her with a cold washcloth. She explained that she had a stroke, and her body does not react well to cold water. She said she has not had a shower since the incident and uses disposable wipes to clean herself.Review of facility grievances documented that Resident #11 complained that on 05/27/25, a CNA. wiped her with a cold washcloth. The resident expressed dislike of coldness, and the CNA did it again. On 07/14/25 at 3:56 PM, the Administrator provided resident council meeting minutes. Review of the resident council meeting minutes lacked documented evidence of resident feedback on water temperature preferences. She stated that she spoke to a resident related to water temperatures at the 05/30/25 town hall meeting but didn't document the resident's water temperature preference. Review of the previous 3 months of maintenance work orders lacked documentation of work orders related to hot water. Review of the Ad Hoc Quality Assurance and Performance Improvement Meeting, which was created on 04/07/25 and documented the facility was to solicit resident responses to temperatures as a means of tracking. The PIP lacked documented evidence of obtaining resident responses to water temperatures. Review of the facility's policy Monitoring and Recording Facility Hot Water Temperature for Resident Rooms, Common Areas and Shower Rooms, Document Name: M-227; Effective: 11/30/14. Policy: To maintain and control hot water temperatures within the facility to federal and state standards. Hot water temperatures will be maintained to an acceptable level for the safety of the residents and staff. Page 2 of 2 documented.Hot water drawn for bathing and/or whirlpool usage must be between 100- 110 degrees Fahrenheit.

Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of less than 5%. There were five errors with 38 opportunities for error, resulting in an error rate of 13.15789% and involving four (Residents #24, #29, #44, and #9) of six residents observed during medication administration, from a total of 22 residents in the sample. The findings include: During medication administration on 8/28/23 at 3:45 p.m., Licensed Practical Nurse (LPN) A was observed preparing medication for Resident #24. She obtained Eliquis (anticoagulant) 5 milligrams (mg), Coreg 6.25 mg for blood pressure, another Eliquis 5 mg and Vitamin C 500 mg. She stated medication should be crushed and administered via gastrostomy tube (G-tube - feeding tube). She picked up a pill crusher pouch ready to pour the medication in. She was asked to verify the medications with the orders and she confirmed that she had pulled two tablets of Eliquis 5mg instead of one as was ordered. She removed one Eliquis pill from the medication cup and discarded it. On 8/28/23 at 3:53 p.m., LPN A was preparing medication for Resident #29. She obtained Aspirin (blood thinner) 81 mg chewable, Senna S 8.6-50 mg for constipation, Midodrine 10 mg for hypotension (low blood pressure), and clonazepam 0.5 mg for anxiety disorder. She crushed the medication, mixed it in apple sauce then administered the medication to the resident by mouth. She was asked to review the physician's orders. After reviewing the physician's orders, she stated the medication should have been administered via G-tube. She further stated the resident was able to eat by mouth and was only getting bolus feedings via the G-tube. She said she did not pay attention because she thought since the resident was eating a mechanically textured diet, he could have the medication crushed. (Copies of the physician's orders were obtained.) On 8/29/23 at 10:08 a.m., LPN B was observed preparing medications for Resident #44. After reviewing the physician's orders, she stated she was missing Glimepiride 1 mg and Folic acid 1 mg for type II diabetes. She obtained over-the-counter folic acid 800 micrograms (mcg) and stated she would administer one and a quarter tablets of the folic acid. As she was pulling the medication from the packaging, she was asked to review the physician's order again. She stated the order was for Folic Acid 1mg, give 2 tablets by mouth one time a day. It was explained to her that 2 mg (two tablets) was the equivalent of 2000 mcg and again stated she would administer 1.25 tablets from the 800 mcg. She said, I don't know what I'm doing wrong. She then walked to the medication storage area at the nurses' station to see whether there was medication available of that strength. The Assistant Director of Nursing (ADON), who was at the nursing station, asked what she was looking for. She said folic acid 1mg. She was told that the resident would have their own medication for that strength; central supply did not order that strength. When asked if she had taken care of the resident previously, she replied,I had him on Wednesday and Thursday last week. She was asked what medication she administered then and she replied that she could not remember. A review of the reorder history revealed that the order for glimepiride was reordered on 8/22/23 and the medication administration record was signed off indicating the medication was not available. She was asked what the facility's protocol was for reordering medication. She replied, I'm not sure about the process in this facility, I work as needed. LPN B was observed again on 8/29/23 at 10:08 a.m. preparing medication for Resident #9. She obtained Vitamin D 1250 mg. A review of the physician's orders revealed an order for Calcium - Vitamin D 600- 400 mg. As LPN B was about to administer the medication to the resident, she was asked to clarify the mediations in the cup. She confirmed that she had the wrong medication (Vitamin D 1250 mg instead of Calcium - Vitamin D 600- 400 mg). She discarded the medication and obtained the correct medication. During an interview with the ADON on 8/29/23 at 10:45 a.m., she stated the nursing staff should reorder medications when they have at least three days' worth of medication left. When asked about the medications for Resident #44, she confirmed that the medication had not been available since 8/22/23. She added that she contacted the pharmacy and there was an issue with the insurance. The nurse assigned to the resident should have followed up. During an interview on 8/29/23 at 11:46 a.m., the Director of Nursing (DON) and ADON were notified of the concerns observed during medication administration. They both acknowledged the errors and the DON stated she would initiate training and competency checks for all nurses. A review of the facility's policy and procedure for Administering Medications (revised April 2019), revealed: 4. Medications are administered in accordance with prescriber orders, including any required time frames. 10. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dose, right time and right method (route) of medication before giving the medication. (copy obtained)

Based on observations throughout the facility and interviews with staff, the facility failed to provide a sanitary, homelike environment for residents, staff and visitors by neglecting to maintain walls that housed resident personal air conditioner units in five of five rooms observed on the east wing (rooms 2, 3, 4, 6 and 12) out of 10 rooms on the unit and a total of 22 resident rooms in the facility. The facility also failed to provide needed maintenance and cleaning to the baseboards and the carpeted walls under the handrails on both the east and west wings. The findings include: Observations of the east wing were conducted on 8/27/23 at 12:56 p.m. In room [ROOM NUMBER], approximately 16 inches of the vertical surface wall to the right of the window air conditioner was observed with a significant amount of what appeared to be water damage. The wall was warped, bubbled, and cracking/peeling. The area extended approximately 16 inches up the right side of the unit. A 1/4 inch gap between the unit and the wall exposed sunlight and the outdoors. Several feet of the horizontal wall surface above the baseboard had similar damage (warping and peeling paint and drywall). The windowsill housing the air conditioner was coated with dark dust and dirt-like matter. The floors and door jambs were scuffed and stained. (Photographic evidence obtained) Four more rooms on the east wing were inspected on 8/29/23 at 2:01 p.m. The window air conditioner in room [ROOM NUMBER] was observed with a similar 1/4 inch gap to the outdoors along the right side of the unit. The sill to the right of the unit was coated with dark substance resembling dirt and dust. The sill and wall to the left of the unit in room [ROOM NUMBER] was observed with the same dark substance on the sill and wall. room [ROOM NUMBER] presented with the same condition on the right side of the air conditioner. In room [ROOM NUMBER], the grates and interior of the air conditioner were observed with black spots, resembling biological growth. The wall to the right of the unit was chipped and warped. There was also a 1/4-inch gap between the unit and the wall at the top of the unit on the right. Sunlight could be seen through the gap. (Photographic evidence obtained) The wall carpeting beneath the handrails on both the east and west wings was soiled with dark stains at the bottom where the carpet met the baseboard. Horizontal surfaces of the baseboard throughout both units were coated with dark substances resembling dirt and dust that wiped off with a finger swipe. The baseboards and doors were scuffed, dirty and in need of repairs or paint, as were the floors at the corners of door jambs throughout. (Photographic evidence obtained) A tour of the unit and halls was conducted with the Interim Administrator on 8/29/23 at 2:22 p.m. She confirmed the condition of the air conditioning units and walls and stated she had already spoken to the new owners about the situation. She acknowledged this was only a sampling of rooms and confirmed the condition of the walls, doors, floors and baseboards throughout the facility.

Based on a review of resident records, facility policies and procedures, and interviews with staff, the facility failed to provide written notification of emergency transfer and failed to send that notification to the Office of the State Long-Term Care Ombudsman for one (Resident #47) of one resident reviewed for [NAME] Acts (voluntary or involuntary hospital admission for psychiatric care and stabilization), from a total of 22 residents in the sample. The findings include: A review of Resident #47's medical record found he was admitted to the facility on [DATE]. He had diagnoses including, but not limited to, dementia with behavioral disturbance, history of transient-ischemic attack (a brief stroke-like attack), mild cognitive impairment, insomnia, anxiety, and major depressive disorder, single episode, moderate. Resident #47's medical record revealed that he had a family member designated as his primary emergency contact and responsible party. A quarterly minimum data set (MDS) assessment with a reference date of 8/22/23, noted that Resident #47 presented with continuous inattention and disorganized thoughts. He was assessed with a short temper and was easily annoyed on 7 to 11 out of a total of 14 days over the assessment look-back period. Physical behavior towards others such as hitting, kicking, pushing, and scratching, and verbal symptoms toward others (threatening, cursing, screaming) occurred on 1 to 3 days of the 7-day look-back period. Resident #47 was ambulatory without assistance. Resident #47 was care planned on 2/28/23, and was last reviewed 8/9/23 for multiple behaviors including, but not limited to, kicking, slapping, or punching others, awake throughout the night, wandering, pacing, exit seeking, combativeness, hallucinations, delusions, screaming, cursing and rejection of care. The care plan description reported a resident-to-resident altercation on 8/3/23 and a hospital transfer for a [NAME] Act on 8/4/23. The goal was to have fewer episodes of behavior by the review date. Interventions included medications as ordered, anticipating and meeting needs, explaining procedures, and intervening as necessary to protect the rights and safety of others. Remove resident from situation and take to alternate location. Send out for psychiatric evaluation (8/4/23). A review of the July and August 2023 medication administration records (MARs), revealed that Resident #47 received Quetiapine Fumarate (an antipsychotic medication used to treat bipolar disorder and schizophrenia) 100 mg (milligrams) three times daily and Ativan (a medication used to treat anxiety) 0.5 mg twice daily. A review of the resident's nursing progress notes revealed that on 8/3/23, a certified nursing assistant (CNA) called a nurse to the dining room. The CNA stated she saw Resident #47 punch a female resident in the face, and the CNA sustained a bump on the left side of her lip. The nurse and CNA tried to move Resident #47 away from the woman, when he became combative, hitting staff in the face. They were unable to redirect Resident #47. He was described as confused, combative, and unable to answer questions about the incident. A physician's order was obtained to send Resident #47 to the emergency room (ER) for a change in cognition and combative behavior toward staff. 911 was called, police and emergency medical services (EMS) arrived, and Resident #47 was transported to the emergency room . A progress note dated 8/4/23 indicated the psychiatric nurse practitioner (NP) and physician were both notified of the altercation. The NP evaluated Resident #47 and completed the [NAME] Act paperwork. The sheriff and responsible party were notified. Resident #47's record contained a Certificate of Professional Initiating Involuntary Examination (a form required to initiate a [NAME] Act) dated 8/4/23, initiated by the psychiatric NP. It noted diagnoses including major depressive disorder, general anxiety disorder and dementia with agitation. The NP noted Resident #47 had a mental illness and because of the mental illness, was unable to determine for himself whether an examination was necessary. There was substantial likelihood that without care or treatment, the resident would cause serious bodily harm to others in the near future as evidenced by his recent behavior. The supporting evidence noted the incident, and assessed Resident #47 as unpredictable and dangerous to residents and staff. He could not be managed on psychotropic medications and would benefit from psychiatric hospitalization to adjust medication in a safe environment. (copy obtained) Further review of the record found there was no written notification provided to Resident #47 or his representative stating the reason for or effective date of the transfer; the location to which the resident was being transferred; a statement of the resident's appeal rights, including the the name, address (mailing and email), and telephone number of the entity that received such requests; or information about how to obtain an appeal form, assistance in completing the form, and submitting the appeal hearing request; including the name, address and telephone number of the Office of the State Long-Term Care Ombudsman. An interview was conducted with the facility's Regional Nurse Consultant (RNC) on 8/28/23 at 3:28 p.m. She confirmed that she had reviewed Resident #47's record and was unable to locate the required written notification of the transfer. The RNC stated it was her expectation that the form be completed for an emergency transfer. Review of the facility's policy for Transfer/Discharge Notification and Right to Appeal (policy OP-102) effective 9/23/17 and revised on 10/24/22 revealed: Policy: Transfer and discharges of resident, initiated by the center (facility initiated) will be conducted according to Federal and/or State regulatory requirements. Procedure: The center must permit each resident to remain in the center and not transfer or discharge the resident unless: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the center . Notice Before Transfer: Before a center transfers a resident, the center must: -Notify the resident and resident representative(s) of the transfer and reason for the move in writing . -The center must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman . -Notice must be made as soon as practicable before transfer . Contents of the Notice: The written notice must include the following: -The reason for the transfer . -The effective date of the transfer . -The location to which the resident is transferred . -A statement of the resident's appeal rights including the name, address, telephone number of the entity which receives such request . (copy obtained)

Based on a review of resident records, facility policies and procedures, and interviews with staff, the facility failed to provide written information prior to hospital transfer that notified the resident/representative of the facility's bed hold policy for one (Resident #47) of one resident (Resident 47) reviewed for a hospital transfer/Baker Act, from a total of 22 residents in the sample. The findings include: A review of Resident #47's medical record found he was admitted to the facility on [DATE]. He had diagnoses including, but not limited to, dementia with behavioral disturbance, history of transient-ischemic attack (a brief stroke-like attack), mild cognitive impairment, insomnia, anxiety, and major depressive disorder, single episode, moderate. Resident #47's medical record revealed that he had a family member designated as his primary emergency contact and responsible party. A quarterly minimum data set (MDS) assessment with a reference date of 8/22/23, noted that Resident #47 presented with continuous inattention and disorganized thoughts. He was assessed with a short temper and was easily annoyed on 7 to 11 out of a total of 14 days over the assessment look-back period. Physical behavior towards others such as hitting, kicking, pushing, and scratching, and verbal symptoms toward others (threatening, cursing, screaming) occurred on 1 to 3 days of the 7-day look-back period. Resident #47 was ambulatory without assistance. Resident #47 was care planned on 2/28/23, and was last reviewed 8/9/23 for multiple behaviors including, but not limited to, kicking, slapping, or punching others, awake throughout the night, wandering, pacing, exit seeking, combativeness, hallucinations, delusions, screaming, cursing and rejection of care. The care plan description reported a resident-to-resident altercation on 8/3/23 and a hospital transfer for a [NAME] Act on 8/4/23. The goal was to have fewer episodes of behavior by the review date. Interventions included medications as ordered, anticipating and meeting needs, explaining procedures, and intervening as necessary to protect the rights and safety of others. Remove resident from situation and take to alternate location. Send out for psychiatric evaluation (8/4/23). A review of the resident's nursing progress notes revealed that on 8/3/23, a certified nursing assistant (CNA) called a nurse to the dining room. The CNA stated she saw Resident #47 punch a female resident in the face, and the CNA sustained a bump on the left side of her lip. The nurse and CNA tried to move Resident #47 away from the woman, when he became combative, hitting staff in the face. They were unable to redirect Resident #47. He was described as confused, combative, and unable to answer questions about the incident. A physician's order was obtained to send Resident #47 to the emergency room (ER) for a change in cognition and combative behavior toward staff. 911 was called, police and emergency medical services (EMS) arrived, and Resident #47 was transported to the emergency room . A progress note dated 8/4/23 indicated the psychiatric nurse practitioner (NP) and physician were both notified of the altercation. The NP evaluated Resident #47 and completed the [NAME] Act paperwork. The sheriff and responsible party were notified. A Certificate of Professional Initiating Involuntary Examination was completed by the psychiatric nurse practitioner (NP) on 8/4/23 and noted that the resident could not be managed on psychotropic medications and would benefit from psychiatric hospitalization to adjust medication in a safe environment. (copy obtained) Per the record, Resident #47 remained hospitalized until 8/9/23, however, there was no bed hold notice provided to the resident or representative notifying them of the facility's bed hold policy, the duration the bed would be held in his absence, or any daily room rate should the resident/representative choose to hold a bed while hospitalized . An interview was conducted with the facility's Regional Nurse Consultant on 8/28/23 at 3:28 p.m. She confirmed she had reviewed Resident #47's record and was unable to locate written notification of the bed hold. She stated it was her expectation that the form be completed for an emergency transfer. A review of the facility's policy for Bed Hold (policy SS-136), effective 3/1/15 and revised 11/1/17, revealed: Policy: Resident or Resident Representative will be notified on admission and at the time of transfer (to the hospital or therapeutic leave) of the bed hold policies, according to Federal/State requirements. Procedure: .2. At the time of transfer to the hospital. the center will provide a copy of notification of bed hold. -Requirement at time of transfer is met if the resident's copy of the notice is sent with other papers accompanying resident to the hospital. 3. The resident and/or representative to sign the Bed Hold Authorization, if possible, or if not available, telephone authorization may be used and documented in the clinical record or on a bed hold authorization form. (copy obtained)

Based on observation, interview, and record review, the facility failed to ensure that one (Resident #1) of two residents who were unable to carry out activities of daily living (ADL) independently, from a sample of 22 residents, received the care and services necessary to maintain good grooming and personal hygiene. Resident #1 was not provided adequate nail care. The findings include: On 8/27/23 at 3:00 p.m., Resident #1 was observed in bed watching television. Her fingernails were long on both hands. In an interview on 8/27/23 at 3:02 p.m., Resident #1 confirmed that she preferred her fingernails short and polished. She looked at her thumbnails and said, These are too long and dirty; they need to be trimmed. A review of the resident's medical record revealed that she was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to, neurocognitive disorder with Lewy bodies (dementia), osteoarthritis, unspecified cognitive/communication disorder, major depression, and unspecified dementia and without behavioral disturbance. A review of the care plan revealed that Resident #1 had a focus area for activities of daily living (ADL) self-care deficit related to dementia, impaired balance, limited mobility, and musculoskeletal impairment. Interventions included, but were not limited to: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. (copy obtained) A review of the quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 6/13/23, revealed that the resident had a brief interview for mental status (BIMS) score of 3 out of 15 possible points, indicating severe cognitive impairment. She also required limited one-person physical assistance with bed mobility and transfers, extensive one-person physical assistance with toilet use and personal hygiene, and total one-person physical assistance with bathing. She was documented as always incontinent of bowel and bladder. Rejection of care behaviors was not exhibited. (copy obtained) On 8/29/23 at 2:15 p.m., Resident #1 was observed in bed, alert, pleasant, and responding appropriately to questions about her fingernails. Both of her thumb nails were approximately two inches long and covered with brown matter. The resident stated she previously told a man that she wanted nail care. She was asked if she desired nail care today and she said, yes. On 8/29/23 at 2:19 p.m. in an interview with Certified Nursing assistant (CNA) C, she was asked who was responsible for providing nail care to the residents. She stated, CNAs provide nail care as we give care on shower days and as needed. She confirmed that she was assigned to Resident #1. She stated the resident required extensive to total care assistance for all ADLs. CNA C was accompanied to the resident's room and confirmed that the resident's nails were long and soiled. She stated the resident's brother did her nails at times when he visited. The resident stated again that she would like her nails clipped and filed. CNA C left to collect supplies to perform nail care. On 8/29/23 at 2:29 p.m. in an interview with Licensed Practical Nurse (LPN) D, she was asked who was responsible for providing nail care to residents. She replied, CNAs do nail care on shower days and anytime that it is needed. When asked how she ensured that that care/tasks assigned to CNAs had been completed, she stated that at times she went into the residents' rooms with the CNAs to assist in the provision of care. Additionally, the CNAs completed shower sheets and documentation for the care they provided during their shift. A review of the facility's policy and procedure for Bathing/Showering (revision date 9/1/17), revealed: Assistance with showering and bathing will be provided at least twice a week and PRN (as needed) to cleanse and refresh the resident. The resident shall be asked on admission to establish a frequency schedule for bathing. This schedule will take precedence over the twice a week and PRN cleansing. The resident's frequency and preferences for bathing will be reviewed at least quarterly during care conference. A review of the facility's policy and procedure for Care of Nails (revision date 9/1/17), revealed that the procedure for nail care included the following: 1. Perform hand hygiene 2. Explain procedure to resident and bring the following equipment to resident's bedside. a. Basin, optional b. Towel c. Emery board d. Orange sticks e. Nail clippers 3. Place towel beneath the area to be treated. 4. May soak hand in basin half- full with warm water if needed. 5. Trim fingernails. 6. Clean nails. 7. Apply lotion to nail area if indicated. 8. Clean and return equipment to designated area. 9. Discard disposable equipment. 10. Perform hand hygiene.

Based on record review, interviews, and review of the facility's contract for radiological services, the facility failed to ensure an X-ray was completed and results relayed to the physician in a timely manner for one (Resident #1) of three residents reviewed for falls, as evidenced by a delay in obtaining the X-ray. The findings include: A review of Resident #1's clinical record revealed she was admitted on [DATE], with a re-entry date of [DATE]. Her primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She required total care for all activities of daily living and mobility. On [DATE], Resident #1 had an unwitnessed fall, resulting in a black eye and reddened forehead. Resident #1 expired in the facility on [DATE]. She was receiving hospice care at the time of her death. A review of the progress notes for Resident #1, dated [DATE] at 7:31 AM, noted Resident #1 to have a black eye (right eye) and a reddened area on her forehead. The Medical Director was contacted. (Copy obtained) A review of the progress notes for resident, dated [DATE] at 12:33 PM, noted Medical Director (Resident #1's attending physician) into see resident. Face/right eye x-ray ordered. (Copy obtained) A review of the progress note, dated [DATE] at 6:03 PM, read, Late note from [DATE] at 1:00 AM, Resident #1 found on floor next to bed lying on left side. (Copy obtained) A review of the progress notes for Resident #1, dated [DATE] at 9:15 AM, noted Medical Director informed x-ray company has not shown up to complete order, assessed patient and noted no sign of distress or pain. X-ray company rep reached and promised to be at facility on [DATE]. (Copy obtained) A review of the physician's note, dated [DATE] at 11:09 AM, noted patient was observed on floor by nursing staff on [DATE], she was noted to have bruising to her left orbit. Patient seen by physician after the incident and STAT orbital x-rays were ordered. Per nursing staff, x-ray company was shorthanded and will be coming out today to complete x-rays. (Copy obtained) A review of the Radiology Results Report for Resident #1 revealed x-rays (optic formina ,d+[DATE] V, right) were taken on [DATE] at 10:19 AM. Findings included: Orbital rim is intact. No blowout fracture is seen. Maxillary sinus is unremarkable. Frontozygomatic junction is intact. No foreign body is seen. (Copy obtained) An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:41 AM. She was asked why the x-ray order on [DATE] for Resident #1 had not been fulfilled until [DATE]. She responded, Good question. She explained that when the administrator investigated it, she found out the x-ray company was short on staff. An interview was conducted with Physician A, MD on [DATE] at 12:17 PM regarding Resident #1. Physician A confirmed a stat order was created for the resident to get results very quickly. Physician A explained that when he found out the stat order was not completed by [DATE], an assessment was completed of Resident #1, but the order was not changed. Physician A confirmed that the stat order by radiology was not completed because the radiology provider had staffing issues. Physician A acknowledged that a STAT order was intended to be completed quickly. A review of the facility's agreement with mobile diagnostic services revealed under section 1. Paragraph 3, The turn-around time for STAT x-ray and ultrasound results (from call to report) shall be 2 to 4 hours. The turn-around time for routine x-ray and ultrasound results (From call to report) shall be ,d+[DATE] hours. (Copy obtained)

Based on observations and staff interviews, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety. This failure affected all 54 residents who received meals from the kitchen, as well as any residents who received food from the nourishment room, from a total of 55 residents in the facility. The findings include: On 11/7/21 at 12:39 p.m., two clinical staff were observed entering the kitchen without hairnets. On 11/9/21, the trayline was observed at 12:10 p.m. Observations were made of Dietary Aide S putting plastic bottoms on top of a resident's plate. The Certified Dietary Manager (CDM) was asked at this time whether bottoms were being used as tops and he stated no. Observations were made of a barbequed chicken sandwich being served on a plate that was being compromised by being pressed down on with the plastic bottom. The CDM stated they were bottoms, then proceeded to ask staff to use tops and bottoms plastic ware on each plate. At this time Dietary Aide S stated, We don't have enough tops. The CDM did not respond to her, so she proceeded with the use of the bottoms. Observations were made of the dietary staff running out of plastic tops and bottoms. Kitchen Staff Member R was asked how many plates they had left to serve and she stated about 20. The CDM then directed the dietary staff to go to the resident hallways and get the plastic tops so they could be cleaned and used again for the last 20 trays. During trayline, a clinical staff member entered the kitchen without a hairnet and took 5 to 7 steps across the kitchen before being told to exit. Kitchen Staff Member R changed gloves without washing her hands first. It was observed at this time the kitchen had run out of hamburger buns for the lunch meal service and had to use sandwich bread for the last 20 or so plates. Kitchen Staff Member R was again observed changing gloves without washing her hands between glove changes. The CDM told the kitchen staff to wash the tops before putting them on the remainder of the plates. Dietary Aide S was observed waving two tops through the air to get them dry before placing them on top of the plates. During an interview with Dietary Aide S, she was asked how long the kitchen had been low on plastic tops and bottoms. She replied, Around the same time as the pandemic started sometime last year. She reported the CDM was aware of the equipment shortage. An interview was conducted with the CDM on 11/09/21 at 1:48 p.m. He stated he was not aware of the shortage of plastic tops and bottoms, and he was not able to place an order for more himself. An interview was conducted with Manager in Training T on 11/10/21 at 9:30 a.m. He stated he had been employed with the facility for 2.5 weeks, and was not made aware of the shortage of plastic tops and bottoms, but he would order more of them. On 11/9/21 at 4:00 p.m., an observation was made of the facility's nourishment room refrigerator. A pitcher of cranberry juice was dated 11/1/21 to 11/4/21. (Photographic evidence obtained) On 11/10/21 at 2:45 p.m., a second observation was made of the facility's nourishment room refrigerator. A bag containing two cupcakes was labeled with a name but it was not dated. One Styrofoam container with food in it was labeled with a name and room number on it but no date. Applesauce to be used for medication pass was dated 11/5/21 to 11/8/21, and a bag of fruit was labeled with a name, a room number and was dated 8/24/21. (Photographic evidence obtained) An interview was conducted the Manager in Training T on 11/10/21 at 2:45 p.m. When asked who was responsible for cleaning the nourishment room, he reported the Certified Nursing Assistants (CNAs) were responsible. On 11/10/21 at 3:48 p.m., Personal Care Assistant (PCA) D was asked about cleaning of the nourishment room and refrigerator. She reported that housekeeping was responsible for cleaning out the refrigerator. On 11/10/21 at 3:49 p.m., the Housekeeping Manager was asked who was responsible for cleaning the nourishment room. He reported that housekeeping cleaned the floors and wiped down the inside of the refrigerator on Fridays, but they did not dispose of anything in the refrigerator. On 11/10/21 at 4:15 p.m., the Director of Nursing (DON) was interviewed about the nourishment room cleanliness. She stated she believed the kitchen staff were responsible for cleaning it, and she had no duties assigned to nursing staff related to the nourishment room.

Based on observations and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment. Specifically, the facility failed to ensure dining throughout the facility was provided in a way to maximize independence, personalization, and a comfortable, homelike environment at mealtimes. This had the potential to affect all 54 residents in the facility. The facility also failed to ensure resident bed linens were clean and in good condition for one (Resident #2) of eight sampled residents reviewed for environmental concerns, from a total of 30 residents in the sample. The findings include: 1. Lunch service was observed on 11/7/21 at 12:28 p.m. Residents were served lunch in resident rooms and in the main dining room with all meals left on top of the plastic serving trays. The meals were not placed on tables or prepared for the residents in a homelike manner. Lunch service was observed on 11/9/21 at 12:32 p.m. Meal service was again served with the food kept on the plastic serving trays for all residents in the dining room and in resident rooms. Lunch service was observed on 11/10/21 at 12:18 p.m. Meal service was again served to all residents with the food items kept on the plastic serving trays. An interview was conducted with the Registered Dietitian (RD) on 11/10/21 at 12:00 p.m. She stated she tried to come to the facility on ce a week to review initial, quarterly, and annual nutritional assessments. She further stated it would not be a homelike environment to serve meals on top of plastic serving trays. It would limit the dining space the resident would have to use while eating, and it could minimize a resident's ability to eat sufficiently without feeling rushed. An interview was conducted with the Certified Dietary Manager (CDM) on 11/10/21 at 2:24 p.m. He stated once the resident meals were sent to the floor, the dietary department did not monitor how the food was prepared in front of the residents. He was not aware that keeping serving trays underneath resident meals was not considered a homelike environment during dining. 2. On 11/7/21 at 12:25 p.m., Resident #2 was observed watching television while lying in his bed. There were two pillows observed under Resident #2's head. The pillows were observed to be without pillowcases. One pillow, beige in color, was observed to have darker beige stains and was observed to have a rip along one seam with white filler coming out. The second pillow, blue in color, was observed to have it's first layer of cloth ripped away from it's second layer, and beige stains were observed. Permission was obtained from Resident #2 to take a photograph of his pillows. In an interview with Resident #2 at this time, he was asked how long his pillows had been in this condition. He shrugged and replied, I really don't know. These have been my pillows for a while. On 11/8/21 at 9:45 a.m., the same two previously mentioned pillows were observed on Resident #2's bed. They were not in pillow cases, and were in the same condition as described on 11/7/21. On 11/9/21 at 12:20 p.m., Resident #2 was observed lying in bed. Two pillows were observed under his head with pillowcases on them. Resident #2 was asked if he had received new pillows. He stated he wasn't sure if they were new pillows. He was asked if staff had placed pillowcases on the pillows for him, and he stated yes. On 11/9/21 at 4:40 p.m., Resident #2 was observed returning to his room. He was asked if his pillows could be checked before he got in bed. He stated yes. Under the pillow cases, the pillows were observed to be the same two pillows from the observations made on 11/7 and 11/8/21. One pillow remained stained and torn on the seam with white filler coming out. The second pillow remained with a ripped top blue covering, exposing the actual pillow, and was stained. On 11/9/21 at 4:45 p.m., the Director of Nursing (DON) was asked to come to Resident #2's room to observe his pillows. The DON asked Resident #2's permission to inspect his pillows. He agreed. The DON pulled the cases back and observed one pillow with stains and a ripped seam with white filler coming out, and the second pillow with stains and a ripped blue top layer exposing the inside of the pillow. The DON was advised the pillows were observed in this condition on 11/7/21 ans 11/8/21 without pillowcases. Today both pillows had pillow cases on them, but the same soiled, ripped pillows were inside the cases. The DON was asked who was responsible for ensuring bed linens and pillows were in acceptable condition. She stated, Well, I would hope if a nurses' aide saw these pillows, they would remove them and get new pillows before just putting cases on them.

Based on observations, a review of resident records, and staff interviews, the facility failed to ensure each resident's right to a dignified existence by failing to 1) Ensure privacy during enteral feeding for one (Resident #12) of three residents reviewed for dignity, 2) Refrain from using labels to identify residents by their dining needs in the presence of the resident for one (Resident #38) of three residents reviewed for dignity, and 3) Respectfully escort one (Resident #44) of one resistive resident to her room for incontinence care, from a total of three residents reviewed for dignity and a total of 30 residents in the sample. The findings include: 1. An observation of Resident #12's room was conducted with the Administrator on 11/10/21 at 1:54 PM. The bedroom door was open upon arrival and Resident #12 was observed in the B bed. Licensed Practical Nurse (LPN) G was standing over him. Another (unsampled) resident was in the C bed, approximately four feet away from Resident #12. The privacy curtain between the two beds was open, leaving Resident #12 visually exposed. LPN G was using a 60 milliliter enteral feeding (tube feeding) bolus syringe to plunge its unknown contents through Resident #12's gastrostomy tube (a surgical opening into the stomach from the abdominal wall for the introduction of food or medications). Anyone in the hallway and Resident #12's roommate in the C bed could see the procedure. LPN G was asked to provide Resident #12 with privacy during the procedure by closing the curtain. She complied. The Administrator, who was present, acknowledged that LPN G's failure to provide privacy during the procedure was a dignity concern for Resident #12. A record review for Resident #12 found he was [AGE] years old. His Admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/27/21, noted he had memory problems and moderately impaired cognitive skills for daily decision making. Resident #12 required extensive assistance from staff with all activities of daily living. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 had a current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Director of Nursing (DON) on 11/10/21 at 2:10 PM. She was told of the observation of Resident #12 and LPN G. The DON said, Oh no and shook her head. She said, That is a dignity issue. 2. An observation of Resident #38 was conducted in her room on 11/07/21 at 12:55 PM. She was lying partially on her left side in her bed. Resident #38 was not able to respond to any greetings other than to stare at the speaker. She appeared thin and frail. Certified Nursing Assistant (CNA) J entered the room at this time. It was lunch time and she was asked if the residents would be eating in their room today. She said, Yes, but she (pointing to Resident #38) is a feeder. Resident #38's roommate, who was in the next bed, exclaimed, I'm not a feeder! CNA J responded by saying No, you are not a feeder. An interview was conducted with LPN K on 11/09/21 at 11:44 AM. When asked about Resident #38's nutritional needs, she replied, She is a feed. She is total (assist) for everything, Hoyer (a mechanical lift used for transferring a resident between surfaces) and a feed. A record review for Resident #38 found a quarterly MDS assessment with an ARD of 10/12/21. She was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nutritional Review, dated 4/14/21, also noted Resident #38 required total assistance with eating. A review of the CMS (Centers for Medicare and Medicaid Services) 672 (Resident Census and Condition) form found there were seven residents in the facility who were dependent on staff for dining at the time of the survey. In an interview with CNA M on 11/10/21 at 11:12 AM, she was asked how the facility staff referred to residents who needed to be fed by staff. She replied Feeders. When it was suggested the term was degrading, CNA M explained that was what everyone here called it. She stated she had received training in treating residents with dignity and respect and acknowledged using such a label was a dignity issue. In an interview with the DON on 11/10/21 at 2:10 PM, she was told of the observation. The DON said the term feeder should not be used for residents who were dependent diners. The DON agreed the use of labels for residents, especially in their presence, was a dignity issue, and said she did not realize the term was being used by staff. 3. Observations of Resident #44 throughout the survey (11/7/21 to 11/10/21) found she had a preference for independently walking up and down the long hallway repeatedly during the day. During an observation on 11/09/21 at 2:10 PM, CNA H and another unsampled employee were seen escorting Resident #44, who was able to walk without assistance, to her bedroom. Each employee had one arm hooked under each of the resident's underarms. When the trio reached Resident #44's room, the unidentified CNA walked away. CNA H let go of Resident #44's arm at the threshold of the bedroom in order for the resident to enter the room. Instead, Resident #44 started to back out of the room. CNA H, who was now directly behind the resident, placed her open right hand on the resident's upper middle back and pushed her towards and into the bedroom. The Activities Director, who was present at the time, explained that Resident #44 would walk and walk and refuse to stop to go to her room for personal care. She often needed assistance getting that care. CNA H emerged from Resident #44's room on 11/09/21 at 2:13 PM with a tied up plastic bag in her hand, contents unknown. She disposed of the bag in the soiled utility room. CNA H was interviewed at this time. She explained that Resident #44 had been up wandering the hallways since the overnight shift last night. Resident #44 needed personal care and hopefully, a nap. This resident did not like to stop walking for personal care and when staff tried to direct her to her room, she plopped herself on the floor. It took two staff members to get Resident #44 back to her room. A record review for Resident #44 found she was [AGE] years old. The Significant Change MDS with an ARD of 10/19/21 noted inattention was continuously present. She required supervision with locomotion on and off the unit. Her walking was not steady, but she was able to stabilize without staff assistance. Resident #44 was assessed as requiring extensive assistance from one person with toilet use and was always incontinent of bowel and bladder. Resident #44 was care planned on 10/12/21 for her multiple behaviors which included wandering while holding several items, and removing her brief and voiding on the floor. There was no mention of her refusing to go to her room for personal or incontinence care in her behavioral plan of care. (Photographic evidence obtained) On 11/10/21 at 3:14 PM during an interview with LPN I, she said she was not aware staff were using a 2-person escort when Resident #44 refused to be changed. She explained it was a very rare occasion that this resident plopped down to the ground, but she usually responded well enough to one person accompanying her to her room. The DON, who was also present, also expressed unawareness of the 2-person transport and nudge into the room. She also stated a side-by-side one-person escort was usually sufficient. The DON acknowledged while it was not a forceful gesture, the method used to get Resident #44 to, and into, her room was not dignified. The DON said she had recognized that overall, facility staff needed retraining in dignity issues for this population. She said staff did receive some dignity training online, but face-to-face training was her goal.

Based on observations, record review and interviews, the facility failed to ensure that one (Resident #23) of four residents reviewed for nutritional risk, out of 30 sampled residents, was properly monitored for acceptable parameters of nutritional status. Specifically, the facility failed to ensure Resident #23 was properly monitored for potential weight loss. The findings include: A review of Resident #23's medical record revealed she was admitted to the facility on [DATE]. Her primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/16/21 minimum data set (MDS) assessment documented a brief interview for mental status (BIMS) score of 0 out of a possible 15 points, indicating severe cognitive impairment. Resident #23 was documented as requiring supervision with set-up only for eating. Her weight was documented as 142 lbs. (pounds), and she was noted to have had no recent weight loss. She was documented as not rejecting care. Further review if the record revealed the resident had two documented weights. She was noted to weigh 153 lbs. on 3/9/21 and 142 lbs. on 5/25/21. There were no additional weights documented. This weight decline was a 7.19% loss, indicating a downward trend. (A weight loss of 7.5% in a three-month period of time is considered a significant loss.) A 6/16/21 Nutrition Therapy Recommendation documented that the resident needed fortified foods with meals, due to a weight trending down. A Nutritional Review, dated 9/17/21, indicated the resident was on a consistent carbohydrate diet (CCD), regular texture. She was also on fortified foods, and no added salt (NAS), for weight loss. She was documented as dependent with eating and needs to be fed, as she was difficult to get to eat or drink at times. The nutritional assessment documented that she had no recent weights, with the last being recorded as 142 lbs. on 5/25/21. The assessment noted that there was no identified weight trend in the last 30, 90, 180 days due to no trend due to no recent weights. The resident was noted to need continued monitoring of weights and intake, as needed. The resident was documented to have an anticipated decline if unable to consume adequate intake. A physician's progress note, dated 10/7/21, indicated the resident was somewhat dependent for activities of daily living. She was noted to have mild protein-calorie malnutrition, and the facility should encourage completion of all meals and snacks. The physician's progress note also identified that the resident had [CONDITION(S)], and it was advised that the facility report any weight changes. The progress note also documented that the resident had [CONDITION(S)], and was advised to be on a low-fat diet with daily exercise. This physician's progress note identified that the resident's weight was 142 lbs. (documented on 5/25/21). A care plan initiated 3/17/21, and last revised on 7/7/21, revealed that the resident had a nutritional problem or potential nutritional problem related to dementia, [CONDITION(S)] disorder, diabetes, hypertension, multiple behaviors, wandering, refusal to eat or drink at times, therapeutic diet, and above BMI (body mass index) range of 27.1. She had the potential for weight loss anticipated. She was noted to have fortified foods, refusal to be weighed at times, and combative with staff. Identified interventions, in pertinent part, indicated to offer snacks during the day; provide and serve diet as ordered, with fortified foods with meals; RD (registered dietitian) to evaluate and make diet change recommendations PRN (as needed); and weigh as ordered. A care plan initiated on 3/9/21, and last revised on 5/14/21, revealed that the resident had an ADL (activities of daily living)/self-care performance deficit related to dementia. Interventions, in pertinent part, identified that the resident was able to eat with set-up to limited assistance with meals. The lunch meal was served to Resident #23 on 11/10/21 at 12:18 p.m. Resident #23 was observed sitting up in her room next to her lunch tray. Staff was heard in the hallway stating that someone would come and assist her with her meal. On 11/10/21 at 12:44 p.m., Resident #23 was observed resting in bed, and her food tray was gone. An interview was conducted with Certified Nursing Assistant (CNA) P on 11/10/21 at 12:45 p.m. He stated he had assisted Resident #23 with her lunch because she required assistance with meals. He stated the resident did not want to eat her lunch, he could not make her eat her meal, and he had not provided her an alternative meal. He stated he had not been trained to provide alternatives or offer interventions to encourage the resident to eat if she did not want what had been provided. He further stated he had three other residents on the unit to assist with meals during this shift, and he could not force Resident #23 to eat her provided meal. An interview was conducted with the registered dietitian (RD) on 11/10/21 at 12:00 p.m. She stated she tried to come to the facility on ce a week to review initial, quarterly, and annual nutritional assessments. She would review for wounds, weight loss, and significant changes in weights. In October, she noted that a lot of residents did not have documented weights. She stated she gave this list to the Director of Nursing (DON). She further stated some of these residents may not have been compliant or may have been on hospice. She said the facility had tried to get resident weights, because they were needed. An interview was conducted with the DON on 11/10/21 at 4:09 p.m. She stated when she started, she had spoken with the RD. She stated she had not known that they did not have all of the resident weights. The restorative aide would do the weights, but they had been hiring new restorative aides, and were still training them. She sent the information to the RD so the facility could assess for any resident weight loss. She stated she would then take the information to the physician, and they would establish physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility policy for Weighing the Resident, last revised 10/4/2021, stated in pertinent part: Residents will be weighted unless ordered otherwise by the physician: -Admission/readmission x 3 days -Weekly x 4 weeks -Monthly thereafter -As needed Weights will be completed as indicated and documented in the clinical record. Record weight and alert nurse to any significant change. Nurse to notify the physician of any significant weight change; consult with the Director of Dietary Services and/or dietitian; Notify the Interdisciplinary Team in order to update the plan of care. (Photographic evidence obtained) The facility policy on Dining and Food Preferences, last revised 9/2017, stated in pertinent part: The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies and intolerances, and preferences. Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value. The alternate meal and/or beverage selection will be provided in a timely manner. (Photographic evidence obtained)

Based on observation, review of facility records and interviews with staff, the facility failed to post daily staffing information that included the name of the facility and the actual number of hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Certified Nurse Aides (CNAs) on one of four days during the survey, and on an indeterminate number of days between 10/27/21 and 11/7/21. The findings include: An observation of the posted nurse staffing hours was made on 11/07/21 at 11:15 AM. The form was encased in a plastic picture frame and prominently displayed on the countertop at the nurses' station. The document, however, reflected the staffing hours for RNs, LPNs and CNAs for the day of 10/27/21. There were no additional completed staffing forms for more recent dates behind the single sheet. (Photographic evidence obtained) An interview was conducted with the Staffing Coordinator (SC) on 11/10/21 at 3:01 PM. She stated the night nurse was responsible for posting the daily nurse staffing form, but if the night nurse did not post it, she would. The SC did not realize the staffing was still posted for 10/27/21 on the day survey commenced, 11/7/21. She had no explanation. By survey exit on 11/10/21 at 5:50 PM, no staffing hour sheets for the missing dates 10/28/21 to 11/6/21 had been provided for review.

Based on a review of resident records, interviews with staff, and a review of facility policies and procedures, the facility failed to ensure PRN (as needed) orders for [CONDITION(S)] medications were limited to 14 days, and were not renewed unless the prescribing practitioner evaluated the resident for one (Resident #5) of one residents with an open-ended PRN order, out of six residents reviewed for unnecessary medications, from a total of 30 residents in the sample. The findings include: A record review for Resident #5 revealed she was [AGE] years old. An admission Minimum Data Set (MDS) assessment with an assessment reference date of 8/9/21, noted inattention and disorganized thought were continuously present. Diagnoses included non-Alzheimer's dementia, anxiety, depression and [CONDITION(S)]. Resident #5 had a physician's order for Lorazepam (used to treat anxiety) 0.5 milligrams every two hours as needed for anxiety, which was started on 9/18/20. The end date was noted as indefinite. (Photographic evidence obtained) Further review of the clinical record found there was no documentation by Resident #5's physician(s) justifying or extending the use of the Lorazepam beyond the 14-day period as required. A review of Resident #5's medication administration records (MARs), found the Lorazepam was administered on the following dates in 2021: January 1st and 7th; February 5th, 7th, 10th, 20th, 22nd and 26th; March 10th; April 9th, 19th and 23rd; May 6th, 14th and 19th; June 10th and 19th; July 3rd, and August 9th, 16th, and 28th. (Photographic evidence obtained) A review of the Narcotic Count Sheet for Resident #5's Lorazepam, indicated additional doses were counted and signed out for administration on: May 9, 2021, May 22, 2021, October 4, 2021 and October 25, 2021. (Photographic evidence obtained) An interview was conducted with Licensed Practical Nurse (LPN) I on 11/10/21 at 1:08 p.m. She was asked who entered physician's orders into the electronic record. She stated the night nurse usually filed the orders and checked them for accuracy. LPN I was asked if she was aware of the duration PRN [CONDITION(S)] medications was limited to. LPN I stated some medications might be prescribed indefinitely. She was unaware of the requirement for a 14-day limit on PRN [CONDITION(S)] medications, unless that medication was reviewed with justification documented by the physician. An interview was conducted with the Director of Nursing (DON) on 11/10/21 at 2:10 p.m. She was asked to review the order for Resident #5's Lorazepam. When she recognized the order duration was indefinite, she said, No, that is supposed to have a 14-day stop date. The DON acknowledged there had been no stop date since the order was written on 9/18/20. A review of the facility's policy and procedure titled Medication Management, [CONDITION(S)] Medications (policy N-1255 revised 3/23/18), revealed: Policy: Residents who have not used [CONDITION(S)] medications are not given these medications unless it is necessary to treat a specific condition as diagnosed . Procedure: . 7. PRN physician orders for [CONDITION(S)] medications are limited to 14 days, except, if the physician or prescribing practitioner believes that it is appropriate to extend beyond 14 days and documents the rationale in the medical record. (Photographic evidence obtained)