Every finding on record at Avir at Heritage

Based on interview and record review the facility failed to provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, within 24 hours for 1 of 1 Resident (Resident #1) reviewed for resident rights. The facility failed to provide Resident #1's representative with Resident #1's medical records per oral and written requests made on 6/17/2026.This deficient practice could result in the residents or family members not having access to medical records.Findings included: Record Review of Resident #1's undated face sheet revealed he was admitted to the facility on [DATE] with diagnoses including nontraumatic subdural hemorrhage unspecified (is bleeding beneath the dura mater without recent head injury, often linked to underlying vascular or coagulation issues), type 2 diabetes mellitus (is a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), unspecified dementia (cognitive decline that interferes with daily life, but without a clearly identified underlying cause), hypertensive chronic kidney disease (is a condition where high blood pressure both causes and worsens kidney damage), ischemic cardiomyopathy (a condition where the heart muscle weakens due to reduced blood flow), unspecified atrial fibrillation (irregular heart rhythm), heart failure (occurs when the heart muscle doesn't pump blood as well as it should), end stage renal disease (is the most advanced stage of chronic kidney disease), dysphagia (difficulty swallowing is a symptom of many different medical conditions), tracheostomy status (documents the presence of a tracheostomy), gastrostomy status (Indicates a functional gastrostomy tube (G tube) used for long term enteral nutrition, hydration, or medication delivery), presence of cardiac pacemaker (A pacemaker is used to control or increase the heartbeat), aortocoronary bypass graft (is a procedure used to treat coronary artery disease), dependence of renal dialysis, muscle wasting and atrophy (is the loss of muscle mass and strength caused by disuse, aging, disease, or nerve damage, and it can significantly impact mobility and quality of life), muscle weakness, other lack of coordination, cognitive communication deficit. Further review revealed a family member was identified as a responsible party. Resident #1 was discharged from the facility on 2/26/26. Record Review of Resident #1's BIMS evaluation, dated 12/5/25, revealed BIMS score was 99 reflective of severe cognitive impairment, and the evaluation indicated the resident was non-verbal. Record Review of Resident #1's Authorization for Disclosure of Medical Information, dated 6/17/26, revealed Resident #1's family member was designated as the representative. Record review of an email dated 6/17/26, and addressed to the social worker, revealed Resident #1's family member submitted an Authorization to Disclose Protected Health Information.requested the following documents:All health informationPhysician's ordersPathology reportsProgress notesHistory/physical examPatient allergiesDischarge summary [NAME] information Past/present medicationsOperation ReportsDiagnostic test reportsRadiology reports and imagesLab ResultsConsultation reportsEKG/Cariology ReportsOther: Dialysis Record Review of an email, dated 6/17/26, written by the Social Worker and addressed to Resident #1's family member read [Medical Records Staff A], please see the attached request for Resident#1's medical records. Thank you.Record review of an email dated 7/27/26 addressed to the Social Worker revealed Resident#1's family member reached out for a status updated on the medical records requested submitted on 6/17/26. Record review of an email dated 7/27/26 written by the Social Worker and addressed to Resident#1's family member read We apologize for the delay in you receiving your requested medical records. I have attached our medical records clerk to complete your request. An interview was conducted with Resident#1's family member on 8/20/26 at 2:24 PM. She stated she had not heard back from the facility regarding the medical record request. She stated she had asked verbally prior but submitted the request in writing on June 17th. An interview was conducted on 8/21/26 at 10:40 AM with Medical Records Staff B, she stated she had started her current position in medical records on Tuesday (8/18/2026). She stated for medical records requested she would obtain the residents information, ask who they were to the resident, where the request was going, obtain basic information, and ensure whoever was requesting the documentation was legally authorized. Medical Record Staff B stated she had not received any requests. For any requests she would obtain assistance from the Administrator or DON. Medical Records Staff B stated she was not sure if the front desk receptionist had forms up front but there was a form that could be filled out and turned into her. She was not aware of specific time frames to submit the request but would try to address them as soon as possible by 3 days. Medical Records Staff B stated she had sent out a request recently from a request that was not directly requested from her for a male resident. The request was sent by mail. She stated she received the request on Monday and sent it out Tuesday or earlier that week. Medical Records Staff B stated she did not know when the request came in but it was mentioned to her prior on Friday morning, about a request sent to the Administrator. She stated she had not heard if it was received or not and gathered all information and submitted it to the Administrator. Medical Records Staff B stated she would have typically sent out the request, but it was a delayed request. An unsuccessful attempt was made to interview Medical Records Staff A on 8/21/2026 at 2:31 PM, a voice message was placed. An interview was conducted on 8/21/26 at 12:02 PM with the Social Worker, she stated she did not usually handle medical records requests. She stated the receptionist would get a form and submit it to medical records staff. If she receives the request, she will forward the request to medical record staff and copy the person who is requesting the information and inform them it could take up to 30 days to receive the information. The Social Worker she had assisted with medical records for Resident#1 and has the email trail from June when the initial requested was made and sent it over to medical records. She stated she could not recall who the medical records staff was. The Social Worker stated once the request was sent out, she does not handle processing the request. The Social Worker stated the facility had gone through a couple of medical records staff and when she received an inquiry into the request, she informed the Administrator about not getting a response back from medical records. In an interview on 8/21/26 at 3:46 PM with the Administrator, he stated a medical records request came in sometime in June for Resident#1. The Administrator stated requested would take about 30 days to send over request documentation. He was contacted on Monday (8/17/2026) about pending requests. The request was then sent out that day or the following morning to an address they had on file for Resident#1. Medical Records Staff A was the one working during the time the request was made and was in charge of the request. The Administrator stated he was not sure of the outcome of the request during Medical Records Staff B, if the request was received or if it was sent and was not aware of the pending request prior to Monday. Record review of the facility's policy revised on May 2017 and titled Access to Personal and Medical Records, reflected each resident has the right to access and/or obtain his or her personal and medical records upon request.

Based on observation, interview, and record review, the facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span for one of one kitchen. The facility failed to ensure that there was no more than 14 hours between dinner and breakfast the following day or offer a snack when mealtimes span was greater than 14 hours. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for unplanned weight loss, and side effects from medication given without food, and diminished quality of life.The findings included: Record review of resident 22 medical record revealed resident was a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident 22 had active diagnoses of Rheumatoid arthritis (chronic autoimmune disease that primarily affects the joints, causing pain, swelling, and stiffness), Gastro-esophageal reflux disease without esophagitis (GERD or acid reflux), and anemia (deficiency of healthy red blood cells leading to insufficient oxygen delivery to the body's tissues). Record review of the Minimum Data Set (MDS) dated [DATE] revealed resident 22 had a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. Record review of Resident's 22 list of medical orders. Dated 06/19/2026, revealed resident 22 had an order for regular diet and did not have an order for evening snacks. Recode review of resident's weekly weighs in her medical record revealed Resident 22 had no recent weigh loss. Record review of resident 34 medical record revealed resident was a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident 34 had active diagnoses of muscle wasting (decrease in muscle mass and strength) and atrophy (waste away), unspecified dementia (signs of dementia, but the underlying cause-such as Alzheimer's disease, vascular dementia, Lewy body dementia, or frontotemporal dementia-has not been definitively identified), essential hypertension, and type 2 diabetes. Review of the Minimum Data Set (MDS) dated [DATE] revealed resident 34 had a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. Record review of Resident's 34 list of medical orders. Dated 06/19/2026, revealed resident 34 had an order for regular diet and did not have an order for evening snacks. Recode review of resident's weekly weighs in her medical record revealed Resident 34 had not had recent weigh loss. Record review of resident 49 medical record revealed resident was a [AGE] year-old male who was readmitted to the facility on [DATE]. Resident 49 had active diagnoses of chronic obstructive pulmonary disease (COPD, lung condition caused by damage to the lungs), muscle wasting (decrease in muscle mass and strength), and unspecified dementia (signs of dementia, but the underlying cause-such as Alzheimer's disease, vascular dementia, Lewy body dementia, or frontotemporal dementia-has not been definitively identified). Record review of the Minimum Data Set (MDS) dated [DATE] revealed resident 49 had a BIMS (Brief Interview for Mental Status) score of 05 indicating severe cognitive impairment. Record review of Resident 49's list of medical orders, dated 06/19/2026, revealed resident 49 had an order for regular diet with mechanically altered texture and did not have an order for evening snacks. Recode review of residents weekly weighs in his medical record revealed Resident 49 had no recent weigh loss. Record review of facility provided list of resident receiving evening snack, not dated, revealed Resident 22, Resident 34, and Resident 49 were not identified as needing an evening snack. Observation of the facility's dining room on 06/16/2026 at 12:05 PM revealed the facility posted the mealtimes by the kitchen door. Mealtimes were listed as breakfast at 7:00 AM, Lunch at 12:00 PM, and Dinner at 5:00 PM. Observation on 06/16/2026 at 4:40 pm revealed meal trays on the 400 hall had been served to residents that ate in their rooms. Observation on 06/17/2026 at 4:24 pm revealed staff started passing meal trays on the 400 hall to residents that ate in their rooms. Observation on 06/18/2026 at 7:09 AM revealed staff started passing meal trays on the 400 hall to residents that ate in their rooms. Observation on 06/18/2026 at 4:17 PM meal trays on the 400 hall had been served to residents that ate in their rooms. A group interview during resident council meeting on 06/17/2026 at 2:14 PM with Resident 22, Resident 34 revealed the facility started serving dinner between 4:00 PM and 4:30 PM for the hallways. Resident 22 stated dinner was served before 4:30 PM and breakfast is served about 7:30 AM. Resident 22 stated she gets hungry before bedtime and was not offered a snack at bedtime. Resident 34 stated she also got hungry at bedtime and at times had asked for a snack. Resident 22 stated she received a snack when she asked and it was usually a banana or graham crackers, sometimes a sandwich. Resident 34 stated when she asked for a snack the staff state they will look to see if there were any extras. Both Resident 22 and Resident 34 stated the kitchen provided snacks to residents with orders but there were not enough for all residents and they were not automatically provided to all residents. An interview with resident 49 on 06/17/2026 at 3 PM was attempted but resident could not recall what time he received meals or if he received snacks after dinner. An interview with LVN C on 06/18/2026 at 11:06 AM revealed breakfast trays usually arrived to the halls about 7:30 am. LVN C stated she was unaware if residents had expressed concerns about the timing of the meals. LVN C stated she was unsure if residents in her assigned hall, 100 hall, had any recent weight loss. An interview with LVN K on 06/18/2026 at 11:26 AM revealed breakfast trays arrived on the 400 hall between 7:15 AM and 7:30 AM most days. LVN K stated resident had not complained of the mealtimes to her. LVN K stated there were usually crackers or other snacks for residents at the nurse's station if a resident asked for a snack. LVN K stated she was unaware of any unplanned weight loss among the residents. A group interview with CMA R and CMA S on 06/18/2026 at 3:57 PM revealed dinner is usually served about 4:15 pm and the hall trays come out first. CMA R and CMA S stated that snacks are not given to all residents. CMA R and CMA S stated residents with orders receive evening snacks and there were usually a few extra snacks for the residents who ask for them. CMA R and CMA S stated they were unaware if residents had expressed concerns about the timing of meals or being hungry in between dinner and breakfast the next morning. An interview with CNA T on 06/18/2026 at 4:04 PM revealed hall trays are served first and dinner usually started around 4:15 PM. CNA T stated there were snacks provided for some residents and the other residents had to ask for a snack after dinner. CNA T stated she was not aware of any residents who had expressed concerns about the mealtimes or being hungry before bed. An interview with DON on 06/19/2026 at 9:14 AM revealed the meals times were posted in the dining room but DON could not remember the exact times that were posted. DON stated meals were served in the halls first and breakfast usually started around 7:15/7:30 am and dinner usually started about 4:15 pm. DON stated resident had expressed concern about dinner being served too early but none of the residents had filed a formal complaint. DON stated the kitchen provides snacks to residents with medical orders and a few extras for residents that could ask for snacks. DON stated the kitchen did not provide enough snacks for all resident. DON stated meals being served more than 14 hours apart could affect the residents weights and/or the effectiveness of medications. DON stated, to her knowledge, there has not been widespread unplanned weight loss at the facility. An interview with Dietary Manager (DM) on 06/19/2026 at 9:49 AM revealed breakfast is served to the halls first and starts at 7 am. DM stated dinner is also served to the hallways first and starts about 4 pm. DM stated dinner and breakfast were served 14 hours apart because dinner was not served in the dining room until 5:00 PM. DM stated residents had not expressed concern regarding the mealtimes. DM stated the kitchen provides all residents with snacks after dinner. DM stated the kitchen provides 60 half sandwiches, a few crackers, and a few fruits for resident snacks. DM stated the facility census was over 90 on 06/18/2026 and the kitchen provided 60 half sandwiches and a few crackers but not enough for every resident to have a snack. DM stated snacks were available upon resident request. DM stated serving dinner and breakfast more than 14 hours apart could lead to weight loss among the residents. Record review of facility policy labeled Food and Nutrition Services revised 2017, revealed 9. Meals are scheduled at regular times to assure that each resident receives at least three (3) meals per day. Mealtimes are posted in facility common areas.A policy identifying frequency of meals and mealtimes was requested from the DON on 06/19/2026 at 9:14 AM, from the Administrator on 06/19/2026 at 10:30 AM but was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispending, and administering of all drugs and biologicals, to meet the needs of each resident for 3 of 8 residents (Resident #9, # 117 and #22) reviewed for pharmacy services. 1. The facility failed to ensure Resident #22's propylene-glycol (MiraLAX) was administered as ordered by a physician. 2. The facility failed to ensure Resident #9's glucosamine-chondroitin was administered as ordered by a physician. 3. The facility failed to ensure Resident #117 had blood pressure parameters set up as a prompt to complete before administering Midodrine and Amiodarone. These failures could place residents at risk of missed medication dosages and could lead to ineffective symptom management or treatment. The findings were: 3. Record review of Resident #117's face sheet, dated 06/16/2026, revealed a [AGE] year-old female admitted [DATE] with diagnoses to include atrial fibrillation (an irregular heart rhythm) and atherosclerotic (buildup of fats, cholesterol and other substances in and on the artery walls) heart disease of native coronary artery without angina pectoris (chest pain or discomfort). Record review of Resident #117's admission MDS assessment, dated 04/20/2026, reflect Resident #117 had a BIMS score of 14 out of 15, indicating intact cognition. Record review of Resident #117's order summary report, dated 06/16/2026, reflected Amiodarone HCl Oral Tablet 200 MG. Give 1 tablet orally one time a day for ANTIARRYTHMICS HOLD IF SBP IS LESS THAN 110 with start date 04/14/2026 and Midodrine HCl Oral Tablet 5 MG. Give 1 tablet by mouth three times a day for hypotension (low blood pressure) hold if SBP IS GREATER THAN 130 with start date 04/13/2026. Record review of Resident #117's care plan, undated, reflected a focus The resident has altered cardiovascular status r/t: PVD, ASHD, A-Fib, HTN, HLD,, Hypotension, initiated 04/27/26, with intervention Monitor VITAL SIGNS., initiated 04/27/26. Record review of Resident #117's blood pressure summary, reviewed 06/17/2026, revealed the last blood pressure checked was on 05/28/2026. Record review of Resident #117's June MAR reflected no blood pressure readings documented for medications Amiodarone and Midodrine. It reflected the following: MA G administered Amiodarone HCl Oral Tablet on 06/01/2026-06/04/2026, 06/07/2026-06/10/2026, and 06/13/2026-06/18/2026. MA G administered Midodrine in the morning on 06/01/2026-06/04/2026, 06/07/2026-06/10/2026, and 06/13/2026-06/18/2026. MA P did not administer Amiodarone on 06/06/2026. MA P administered Midodrine in the afternoon on 06/01/2026-06/04/2026, 06/07/2026-06/10/2026, and 06/13/2026-06/18/2026 and did not administer Midodrine on the evenings of 06/02/2026, 06/08/2026, and 06/13/2026. MA P administered Midodrine in the evening on 06/01/2026, 06/03/2026, 06/04/2026, 06/07/2026, 06/09/2026, 06/10/2026, 06/14/2026, and 06/15/2026. During a combined interview on 06/18/2026 at 03:12 PM, ADON D revealed she updated the doctor's orders for Midodrine and Amiodarone today because it was missing a prompt for nurses to record blood pressure. The DON confirmed the last blood pressure was on 05/28/2026, and she could not find any blood pressure readings taken for June 2026 except on 06/18/2026. She revealed it was important to take blood pressure before administering midodrine because it increased the blood pressure, so they did not want the blood pressure to get too high. The DON revealed Amiodarone decreased the blood pressure so there were parameters, so the blood pressure did not get too low. The DON further revealed the doctor's orders included taking blood pressure readings before administering. During an interview on 06/18/2026 at 05:35 PM, the ADM revealed it was important to follow doctor's orders to ensure the safety and health of the residents. During an interview on 06/19/2026 at 02:03 PM, the DON revealed she talked to MA P about Resident #117's Amiodarone and Midodrine. She revealed MA P was checking the resident's blood pressure but was not able to document this in the resident's electronic medical record. The DON revealed she spoke with MA G and MA G said if the blood pressure was not prompted for her to check before administering that medication, then why would she check blood pressure. The DON revealed the facility missed that blood pressure was not being documented for Resident #117. She revealed she oversaw this but expected the team to help catch any mistakes because the nursing staff were a team and would have hoped someone would have caught this. She further revealed it was important, so the resident did have an adverse effect and so far, resident did not have any adverse effects due to this. During an interview on 06/19/2026 at 03:40 PM, MA P revealed Resident #117's MAR did not have BP parameters for medications Midodrine and Amiodarone because there was no place to document it in Resident #117's electronic medical record. She revealed she had been checking resident's blood pressure and only administered the medications according to the doctor's orders. She revealed it was important to administer these medications as ordered so that the blood pressure did not get too high or too low. Record review of the facility policy titled Administering Medications, revised April 2019, reflected, 4. Medications are administered in accordance with prescriber orders .11. The following information is checked/verified for each resident prior to administering medications: .b. Vital signs, if necessary Record review of Resident #22's face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: rheumatoid arthritis (a disease that attacks the joints causing pain and swelling), cerebral palsy (a condition that makes it hard to control muscles) and generalized weakness. Record review of Resident #22's quarterly MDS assessment dated [DATE] revealed a BIMS of 15 which indicated she was cognitively intact. The assessment indicated the resident's functional abilities included dependance on staff for toileting hygiene and total dependance on staff for all movement. The assessment indicated Resident #22 was always incontinent of bowel. Record review of Resident #22's Physician Order summary dated 6/19/2026 revealed orders with a start date of 8/27/2025 for polyethylene glycol 3350 power (MiraLAX), give 17 gram by mouth two times a day for constipation mix with 8 ounces of water During an observation and interview on 06/19/2026 8:29 AM, MA G administered Resident #22's morning medications but omitted and did not administer her propylene glycol 3350 powder (MiraLAX). MA stated the facility did not have the medication in stock, and none was available. MA G stated she tells the nurse so it could be reordered. She stated she had not notified the nurse. She stated she did not know what it was last ordered. During an interview on 6/19/2026 at 10:00 a.m., LVN K stated the medications aides should tell the nurses if they are missing medication. She stated the medications are ordered 7 days in advance. She stated there was no specific person in charge of ordering. LVN K stated no one told her and she did not know the medication aide did not have propylene glycol to administer. She stated the medication was found in storage and there was plenty available, all the medication aides had to do was ask. 2. Record review of Resident #9's face sheet revealed an [AGE] year-old male admitted on [DATE] with diagnoses which included: encounter for surgical aftercare following surgery on the skin and subcutaneous (beneath) tissue, parkinsonism (set of movement symptoms that resemble those of Parkinson's disease) and hydrocephalus (abnormal accumulation of cerebrospinal fluid in the brain's ventricles or cavities). Record review of Resident #9's quarterly MDS dated [DATE] revealed a BIMS score of 7 which indicated a severe cognitive impairment. His functional ability was listed as dependent on staff for all care. Record review of Resident #9's physician orders dated 3/23/2026 revealed an order for glucosamine-chondroitin oral tablet 250-200 mg by mouth. Give one tablet by mouth two times a day for supplement. During an observation and interview on 06/17/2026 at 12:32 pm revealed MA E administered Resident #9's medications but omitted and did not administer glucosamine-chondroitin. MA E stated the facility did not have glucosamine-chondroitin available for administration. He stated when he runs out of medication or supplements, he had already told several nurses but was unable to remember the names of the nurses he informed. He stated there was one specific nurse who was responsible for ordering the medications, but he did not know the nurses name and had not seen the nurse in the facility that day. During an interview on 6/19/2026 at 10:07 a.m., LVN J stated the medication aides should let him know if they are out of a medication so he could get it from storage. He stated he also expected the medications aides to tell him when they were running low or were out so he could reorder the medication. LVN J stated glucosamine-chondroitin an over-the-counter supplement. He stated if they did not have the medication in stock, the person who would reorder it was central supply. He stated central supply could go to the local grocery store to obtain the medication if there was not any storage. He stated he had looked in the storage, and the facility did not have any available. He stated no one had informed him they did not have the medication to administer. LVN J stated it was important for residents to receive their medications, so they did not have additional complications. During an interview on 6/19/2026 at 10:18 a.m ., the DON stated the facility had a person in central supply who had been unreliable for the schedule and was not fully trained. She stated the central supply person was not in the facility today and she was unsure when or if he would be returning to the position and was not available. The DON stated they were aware that some medications had not been ordered by the central supply staff. She stated the Medication Aides were responsible for notifying the nurses of missing medications. She stated the nurses take care of ordering prescription medications and central supply orders the supplements and over-the-counter medications. The DON stated the computer system did allow the Medication Aides to reorder, and they should also tell the ADON or DON. The DON stated neither MA E nor MA G notified her of missing medications. The DON stated it was important for the residents to receive glucosamine-chondroitin because it was a supplement that supported bone and joint health. She stated polyethylene glycol was important because they did not want the resident to get constipated During an interview on 6/19/2026 at 12:11 p.m., the Regional Compliance Nurse stated the facility did not have a policy for ordering medications. Record review of the facility policy titled Administering Medications dated April 2019 revealed: Medications are administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity and to provide care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 1 dining area reviewed for dining and 1 of 6 residents (Resident #34) reviewed for resident rights. The facility failed to ensure all residents at one table, to include Resident #65, were served their meals before moving on to the next table for 06/16/2026 lunch.The facility failed to ensure CNA N knocked on 4 residents' rooms, to include Resident #34, before entering. These failures could result in the loss of dignity of residents and decreased quality of life. 1. Record review of Resident #65's face sheet, dated 06/19/2026, reflected a [AGE] year-old female initially admitted on [DATE] and re-admitted [DATE] with diagnoses to include anxiety (a feeling of worry, nervousness, or unease) disorder and mild protein-calorie malnutrition (lack of proper nutrition). Record review of Resident #65's quarterly MDS assessment, dated 05/09/2026, reflected Resident #65 had a BIMS score of 07 out of 15, indicating severe cognitive impairment. Record review of Resident #65's care plan, undated, reflected focus The resident has an ADL self-care performance deficit r/t weakness, debility, impaired mobility, impaired cognition, dated 02/09/2026 with intervention Requires assist with all ADL's. Able to feed self after set up, dated 02/09/2026. During an interview and observation on 06/16/2026 at 11:56 AM, Resident #65 did not have her meal and the other resident at her table was already eating her meal. Resident #65 revealed their table did not get served their meals together. She revealed sometimes she had to wait to get her meal last. She revealed sometimes it bothered her. CNA L revealed she got the residents' meals after the nurse checked them and sometimes, they served the meals to separate tables. During an interview on 06/18/2026 at 12:09 PM, the RD revealed it was important to make sure the residents were served at the same time at the same table to make sure the residents were not waiting for their food, were comfortable and their dining experience mimicked home life. 2. Record review of Resident #34's face sheet, dated 06/19/2026, reflected a [AGE] year-old female initially admitted on [DATE] and re-admitted [DATE]. Her diagnoses included anxiety (a feeling of worry, nervousness, or unease) disorder. Record review of Resident #34's quarterly MDS assessment, dated 05/16/2026, reflected Resident #34 had a BIMS score of 15 out of 15, indicating intact cognition. Record review of Resident #34's care plan, undated, reflected focus I am at risk for psycho-social concerns or emotional distress r/t a diagnosis of depression and anxiety, revised 05/21/2025, with an intervention Keep environment calm, quiet, and avoid loud noises as much as possible., revised 05/21/2025.During an interview and observation on 06/16/2026 at 12:20 PM, CNA N went inside of Resident #34's room [ROOM NUMBER] times without knocking. She revealed that she normally knocked on the residents' doors before entering, but she was just getting something. She revealed she had been trained on knocking before entering. During an interview on 06/16/2026 at 12:25 PM, Resident #34 revealed that the nursing staff entered her room without knocking but it did not bother her anymore because she was used to it. She was not able to recall exactly how long this had been going on. She revealed she would like them to knock before entering and stated what if I was naked?. She further revealed she did not want anyone to see her naked. During an interview on 06/16/2026 at 12:52 PM, CNA N revealed it was important to knock on residents' door before entering their room to provide privacy and for general respect. During an interview on 06/18/2026 at 05:35 PM, the ADM revealed the DON/nursing staff oversaw trays being served at one table at a time. He revealed this was important because it affected the residents' dignity. During an interview on 06/19/2026 at 02:03 PM, the DON revealed when it came to staff knocking on residents' doors, the expectation was to knock and announce their position, so the residents knew exactly why staff were in their rooms. She revealed she gave residents a moment to acknowledge before coming in, even with residents who did not respond because this was a privacy and dignity issue. She further revealed the facility was the residents' home, and they did not know what the resident was doing. She revealed if staff walk in without knocking, they took a resident right away from them. In regard to residents being served at the same table first before moving to the next table, the DON revealed they had been working on this issue with the kitchen. She revealed the kitchen was not grouping the trays by table, so the nursing staff had to look through all the trays to find the next tray needed. She revealed the staff passing out the trays for meal service end up grabbing the most convenient meal tray, so the food did not get cold and residents were not waiting. She was not aware how long this was going on but it came up a week ago to implement a system to separate cards by table and serve them out that way, so staff did not have to keep checking the meal tray tickets. The DON further revealed it was important to serve all the residents at one table before moving onto the next table, because it's a resident right and dignity issue because residents not served yet had to sit at the table and watch everyone eat. She revealed this could affect self-esteem and have them ask: why am I being left out? Record review of the facility's policy Resident Rights, revised February 2021, reflected 1. Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . t. privacy and confidentiality Record review of the facility's policy The Dining Experience, dated 2023, reflected . 13. Individuals at the same table will be served and assisted at the same time.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Residents #9 and #76) reviewed for infection control.1. The facility failed to ensure MA E utilized contact isolation precautions when administering medications to Resident #9. 2. The facility failed to ensure CNA L and CNA M utilized EBP when providing peri-care to Resident #76.These deficient practices could affect all residents who receive care, placing them at risk of infection. The findings were: Record review of Resident #9's face sheet revealed an [AGE] year-old male admitted on [DATE] with diagnoses which included: encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, parkinsonism and hydrocephalus. Record review of Resident #9's quarterly MDS dated [DATE] revealed a BIMS score of 7 which indicated a severe cognitive impairment. His functional ability was listed as dependent on staff for all care. Record review of Resident #9's Care Plan dated 2/23/2026 revealed there were no interventions or plan of care for urinary tract infection or contact isolation precautions. Record review of Resident #9's urinalysis dated 6/8/2026 revealed he tested positive in his urine for MRSA staphylococcus aureus-gram-positive, During an observation on 06/17/2026 at 10:58 AM, Resident #9 had contact Isolation signage on door on the door to include use of a gown and gloves when entering the resident room for contact precautions. PPE including gown, mask, gloves station was observed immediately outside of the resident's room door in a plastic cart. MA E dispensed medication in the hallway and then entered Resident #9's room without any PPE specifically without gloves and without a gown. MA E stood at bedside, touched resident bed with his uniform and assisted the resident with positioning, administered medication and touching and utilizing a water thermos in the room to assist withe resident in obtaining water for medication administration. During an interview on 06/17/2026 at 11:04 PM MA E stated he did not wear PPE including gown and gloves for contact precautions when administering medication to Resident #9. He stated staff should wear a gown and gloves upon entrance at all times. He stated it was important, so infection was not spread to other residents. MA E stated he was in a hurry and did not see the signs. 2. Record review of Resident #76's face sheet dated 6/19/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: cerebral infarction (stroke), gastrostomy status (feeding tube in abdominal wall), and generalized muscle weakness. Record review of Resident #76's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 which indicated a moderate cognitive impairment. The assessment indicated Resident #76's functional status was total dependance on staff for all ADL care and all movement. Record review of Resident #76's care plan dated 5/18/2026 revealed she had EBP with interventions that included: staff must use gown and gloves during high-contact resident care activities that could result in transfer of MDRO to hands and clothing of staff. Gowns will be available outside of room or in room for staff to don w when performing direct care with resident, sign for EBP will be outside residents' room to alert staff of precautions with direct care procedures. During an observation on 4/17/2026 at 4:40 p.m., Resident #76 room had a sign for EBP and a plastic storage bin with PPE was located immediately outside of the room. CNA L and CNA M were observed providing peri-care and positioning to Resident #76 in her bed. Neither CNA had on a gown to cover their uniform which touched the sides of the resident's bed while providing care. During an interview on 4/17/2026 at 4;50 p.m., CNA M stated she did not wear a gown when she provided peri-care to Resident #76. She stated she was not aware Resident #76 was on EBP. She stated she had been trained in EBP, and she was supposed to look for the sign on the door. She stated she did not wear the gown because when she saw the call light turn on, she just went into the room to assist and was not looking at the sign. During an interview on 4/17/2026 at 4:52 p.m., CNA L stated she did not wear a gown when she provided peri-care to Resident #76. She stated she did not wear one because she was called to assist. She stated she had been trained on EBP and knew she was supposed to wear a gown when she provided care. During an interview on 4/19/2026 at 10:02 a.m., the Infection Preventionist stated Resident #9 had an infection of MRSA to his urine and was on contact isolation precautions. She stated staff should wear a gown and gloves when entering the resident room, including when administering medication. The Infection Preventionist stated EBP required the use of gown and gloves with direct patient care. She stated signage for both contact precautions and EBP were posted outside of each resident's room along with PPE. She stated staff was expected to look at the sigs before entering and ask a nurse if they were unsure. She stated all staff had been trained in isolation precautions. The Infection Preventionist stated utilizing isolation precautions was important to prevent the spread of infection. During an interview on 4/19/2026 at 10:18 a.m., the DON stated staff should wear a gown and gloves upon entering the room, regardless of the reason for entering for someone on contact precautions. The DON stated staff should wear a gown and gloves upon contact with a resident with open areas on EBP. She stated PPE was located right by the door. She stated before staff touch a patient their uniforms should be covered up. She stated the staff had been trained many times, and the facility was constantly retraining. The DON stated isolation precautions were important to prevent contact because the staff have to treat other patients. Record review of the facility policy titled Isolation-Categories of Transmission-Based Precautions dated 2001 revealed: Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with the environmental surfaces or resident-care items in the resident's environment. 7. Staff and visitors wear gloves (clean, non-sterile) when entering the room. 8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Record review of the facility policy titled Enhanced Barrier Precautions (EBP) dated 2001 revealed Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply a. gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include d. providing hygiene e. changing linens f. changing briefs or assisting with toileting .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to correctly label salsa with its proper use-by date in the reach-in refrigerator located in the food preparation area. 2. The facility failed to label ranch dressing with a use-by date in the reach-in refrigerator located in the food preparation area. 3. The facility failed to throw out cucumbers, that were exposed to air, from the walk-in refrigerator because they became soft and not servable to residents. 4. The facility failed to have a place to document the temperature for alternate foods for 06/18/2026 lunch. These failures could place residents at risk for food borne illness.The findings included:During an observation and interview on 06/16/2026 at 09:05 AM, in the reach-in refrigerator located in the food preparation area, there was salsa dated 6/9 with no use by date. The CDM revealed the date needed to be updated because it was made yesterday, 06/15/2026. Dietary Aide H revealed she had to update the label for the salsa. Further observation revealed there was ranch dressing that was dated 06-15-2026 with no use-by date. The CDM revealed it was important to have the correct dates, so the food did not expire and be given to the residents. She revealed the RD told the kitchen staff to put discard dates on food products during their last visit on 05/20/2026. She revealed the kitchen staff knew to throw food out after 3 days. There were cucumbers exposed to the air in the walk-in refrigerator. The CDM revealed it was okay that the cucumbers were not covered, but the cucumbers needed to be thrown out because they got soft and could not be served to residents. During an interview on 06/18/2026 at 09:45 AM, [NAME] F revealed she was trained to write discard dates on food products so that foods were thrown out when they were not good anymore. She revealed this was important for the safety of the residents. During an interview and record review on 06/18/2026 at 10:35 AM, [NAME] F revealed there was no place to document the temperatures for the alternate foods (today was hamburgers) on the temperature log for meal service. She revealed it was important to make sure the temperatures were taken and documented so they could ensure the temperatures were appropriate for the foods. During an interview on 06/18/2026 at 12:09 PM, the RD revealed the kitchen should label food products with their use-by or expiration dates. She revealed it was important to make sure the food was fresh and good. She revealed it was important to discard mushy cucumbers in order to not serve to residents if not good nor appealing. The RD revealed it was important for food that have a temperature taken to document it on the temperature log. She revealed it was important to ensure the food was good to eat. Record review of the facility's policy Food Receiving and Storage, revised November 2022, reflected Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date).Record review of the facility's policy Food Temperatures, dated 2023, reflected The temperatures of all food items will be taken and properly recorded prior to service of each mealRecord review of the FDA Food Code 2022, U.S. Department of H&HS, reflected, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that facility was free of pests and rodents for 1 of 6 resident's rooms (Resident #117). The facility did not maintain an effective pest control program to ensure the facility was free of multiple black flying things in Resident #117's room. This failure places residents at risk of frustration, anxiety, and could result in the residents not having a safe, sanitary environment. The findings included:Record review of Resident #117's face sheet, dated 06/16/2026, revealed a [AGE] year-old female admitted [DATE] with diagnoses to include depression (a common and serious mood disorder characterized by persistent feelings of sadness, loss of interest, and a range of emotional and physical problems) and anxiety (a feeling of worry, nervousness, or unease) disorder. Record review of Resident #117's admission MDS assessment, dated 04/20/2026, reflected Resident #117 had a BIMS score of 14 out of 15, indicating intact cognition. Record review of Resident #117's care plan, undated, reflected a focus EBP: Staff must use gown and gloves during high-contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. During an observation and interview on 06/16/2026 at 12:53 PM, Resident #117 was lying in bed with a towel covering her face while there were at least 5 black flying living things flying around her, landing on the resident and on her bed. There were no foul odors present. Resident #117 stated she was not aware of how long the gnats had been around her. She revealed she told someone about them but could not recall who she told or when she told them, but the facility was aware. She stated the gnats bothered her. During an observation and interview on 06/16/2026 at 12:57 PM, PTA R revealed he had not been at this facility for a long time but since he had been working here, there had been gnats in the building. During an interview on 06/17/2026 at 11:40AM, the Maintenance Director revealed he had been working at the facility for about a year. He stated since the time he had been working at the facility there had been an issue with gnats. He stated the gnats were a seasonal issue and were not a problem at the facility all the time. He stated that the pest control company offered gnat treatment services and stated as of now the facility was not being treated for gnats. He stated he would reach out to the pest control company to see about adding that package to the facility contract. During an interview and record review on 06/17/2026 at 12:40 PM, the Maintenance Director stated that there was a pest control sightings book that staff used to document sightings of insects or pests. When the pest control company visits the facility the pest control technician would look at the sightings book and treat where needed. Record review of the pest control sightings binder revealed there were no other documented sightings of insects in Resident #117's room. During an observation and interview on 06/17/2026 at 12:45 PM, revealed Resident #117's bed had approximately 6 black flying living things on the bed and flying around the resident. There were no foul odors in the room. The Maintenance Director stated gnats had been an issue in Resident #117's room for a couple of days. He stated he was unsure where the gnats were coming from but stated he believed it had something to do with food in resident's room. He stated the resident's family had expressed concerns about the gnats, and the plan was to move the residents out of the room for the day and deep clean the entire room. He stated the cleaning had not been scheduled yet because the facility was being surveyed and he had not had time to speak to the DON about scheduling the cleaning. The Maintenance Director stated he would have it scheduled as soon as possible. He stated he was responsible for ensuring there was effective and ongoing pest control, he stated he was responsible. During an interview on 06/18/2026 at 05:35 PM, the ADM revealed that the facility could not keep all gnats out of the facility and there had been no grievances from Resident #117 about it nor was it brought to his attention. He revealed the facility had a logbook for pest control, and this was where staff wrote down about any pests to include gnats. He further revealed there was not much they can do to eliminate them, just be proactive by taking garbage out, store food correctly. He revealed pest control was important to analyze the facility for pests, and the facility was able to call pest control as needed. He stated pest control was important for health reasons because they could transport stuff.Record review on 06/17/2026 of the latest pest control visit, provided by the Maintenance Director on 06/17/2026, revealed the last pest control visit at the company was dated 05/19/2026. Further review of the document revealed Findings & Treatments Performed: Interior: Met with Maintenance Director, who reported no additional issues. Performed a preventative liquid residual treatment throughout the rest of kitchen and dining room. Treated therapy and other common areas with a liquid residual. Performed a preventative liquid residual treatment in rooms 114, 407, 410, 205, & 200 shower with a liquid residual for roaches. The pest control chemical used during the visit was used to treat for American Roach, [NAME] Banded Roaches, Nuisance Ants. In the pest control report, there was no documentation or mention of treatment for flies or gnats. Record review on 06/17/2026 of the facility pest control contract, provided by the Maintenance Director on 06/17/2026, revealed the facility had an ongoing contract with a pest control contractor. Further review of the document revealed, PESTS INCLUDED IN THE AGREEMENT. (Pest Control Company) shall attempt to adequately suppress and/or treat the following to the best of their ability or as needed. Some pests are not preventable, and may require additional services to control or eradicate, pricing dependent on the scale and scope of specific work described in exhibit B: 4.1 Roaches 4.2 Bed Bugs 4.3 Spiders/Scorpions 4.4 Crickets/Silverfish/Beetles 4.5 Rodents 4.6 Flies/Gnats/Fruit Flies 4.7 Wasps/Bees 4.8 Ants 4.9 Termites. The contract was signed by the CEO of the pest control company and the facility Director of Special Projects on 12/01/2025. Record review of the facility's policy Pest Control, revised May 2008, reflected 1. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on interview and record review the facility failed to develop policies and procedures to ensure the resident's medical record included documentation that indicated, at minimum that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization and influenza immunizations and that the resident either received the pneumococcal immunization and influenza immunizations or did not receive the pneumococcal immunization and influenza immunization due to medical contraindication or refusal for 2 of 5 residents (Residents #1 and #12) reviewed for immunizations. 1. The facility failed to ensure Resident #12 had record of receiving education or being offered the pneumococcal vaccine and influenza (flu) vaccine and education.2. The facility failed to ensure Resident #1 had record of receiving education for the pneumococcal and flu vaccines. These failures could cause residents to be vulnerable to preventable diseases and illness.The findings were: Record review of Resident #12 face sheet, dated 6/19/2026 revealed a 76-yo-female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: Parkinson's disease, type 2 diabetes mellitus, and dementia moderate with behavioral disturbance. Record review of Resident #12's annual MDS assessment dated [DATE] revealed a BIMS score of 3 which indicated a severe cognitive impairment. The assessment indicated Resident #9 was offered a flu vaccine and declined and her pneumococcal vaccine was up to date. Record review of Resident #12's Care Plan dated 9/19/2025 revealed the resident was at risk for infection or recurrent/chronic infection related to compromised medical condition with interventions which included: report changes in condition to MD as clinically indicated. Record review of Resident #12's Medical Record reviewed no signed consents for acceptance or refusal of flu vaccine. Record review of Resident #12's Medical Record indicated the last flu vaccine was administered 10/02/2024. There were no indications the flu vaccine was offered for the 2025/2026 flu season or that education was provided about the flu vaccine. An attempt was made to reach Resident #12's RP on 6/19/2026 at 1:19 p.m. without success. No return call back was received. 2. Record review of Resident #1's face sheet dated 6/19/2026 revealed a [AGE] year-old male admitted on [DATE] with metabolic encephalopathy, type 2 diabetes mellitus and chronic kidney disease. Record review of Resident #1's 5-day admission MDS revealed a BIMS score of 5 which indicated a severe cognitive impairment. The assessment revealed the resident was offered the influenzas vaccine and pneumococcal vaccine and declined. Record review of Resident #1's medical record revealed the pneumovax vaccine was refused by the resident as documented by ADON/Infection Preventionist D. ADON/Infection Preventionist D documented no education was provided. Record review of Resident #1's medical record revealed the influenza vaccine was refused on 6/02/2026 by the resident and no education was provided as documented by ADON/Infection Preventionist D. During an interview on 6/19/2026 at 12:14 p.m., ADON D stated she was also the facility Infection Preventionist. She stated the role of IPC was new to her. ADON/Infection Preventionist D stated she was not obtaining written consent for vaccinations or providing education of risk or benefits of vaccinations. She stated she would ask the resident verbally if they wanted the vaccine. She stated they either said yes or no and that was what she documented. She stated she did not provide Resident #1 education or obtain written consent for the pneumococcal or flu vaccines. She stated she just documented the refusal. She stated she was not in the role for the 2025/2026 flu season. She stated there was no documentation in Resident #12's medical record that the flu vaccine was offered or that education was provided. During an interview on 6/19/2026 at 12:46 p.m., the DON stated she was new to the facility as of November 2025. She stated the facility typically did a mass flu vaccination clinic in October. She stated each resident was asked upon admission. The DON stated the former ADON/Infection Preventionist was in charge of the immunizations, but she was no longer with the facility. She stated the current ADON/Infection Preventionist and herself were now responsible for obtaining consent. The DON stated the facility did not have a written consent form with risks and benefits of each vaccination. She stated consent was obtained verbally. The DON stated immunizations were important for prevention of the spread of disease. Record review of the facility's admission packet revealed there were no consents for information about immunizations in the packet. Record review of the facility policy for Pneumococcal Vaccine dated October 2023 revealed: All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. 3. Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine .Provision of such education is documented in the resident's medical record. Record review of the facility policy for Prevention and Control of Seasonal Influenza, dated 3/2022 revealed: This facility follows current guidelines and recommendations for the prevention and control of seasonal influenza. 1. Teh prevention of seasonal influenza outbreaks is a coordinated effort which is organized the Infection Preventionist and overseen by the medical director. Vaccination: 2. all residents and staff are offered the vaccine prior to the onset of the influenza season. 3. All residents and staff are encouraged to receive the vaccine unless there is a medical contraindication.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly within 1 of 4 medication carts (nurse cart on 100 hall) observed for medication storage. One small yellow capsule, one small round while pill and one small round red pill were observed in the bottom drawer of the nurse cart on the 100 hall. This failure could place residents at risk of missing or misuse of drugs by unauthorized personnel.The findings were: An observation on 06/18/2026 at 11:04 AM of nurse cart on 100 hall revealed a small, unidentified, yellow capsule, a small, unidentified, white pill and a small, unidentified, red pill in the bottom of the 2nd drawer of the cart. The pills were loose and not labeled with identifying marks to indicate what they were. LVN C was present at the cart when observation was made. Interview with LVN C on 06/18/2026 at 11:06 AM revealed she was assigned to the nurse cart on the 100 hall at the time of the observation. LVN C stated it was the responsibility of the nurse or Med Aide assigned to the cart to ensure the carts were clean and medications were stored correctly. LVN C stated medications were to be stored in pharmacy packaging with label that identified the medication name and dose, the resident it was prescribed for and the expiration date. LVN C stated the loose pills that were observed in the bottom of the drawer must have accidentally popped out of the blister packs. LVN C confirmed the pills were loose, unlabeled and did not have any identifying marks on them that would indicate what medications they were. LVN C stated she was unaware that there were loose medications in the cart prior to the observation and that she was about to clean her cart when the observation was made. LVN C then stated it was the facility's policy that the nurse or Med Aide assigned to the carts cleaned the carts daily. LVN C stated loose pills in the cart could have affected the count of the medication, could cause the medication to run out prior to refills being delivered and could have potentially led to resident missing a dose of their medications. LVN C stated only the nurse assigned to the cart had access to the cart and there was no possibility for a resident to get the loose medications from the bottom of the drawer. Interview with DON on 06/19/2026 at 9:14 AM revealed it was the expectation that medication carts and nurse carts were clean and medications stored in pharmacy packaging. DON stated it was the responsibility of the staff assigned to the cart to ensure it was clean and medications stored correctly. DON then stated staff should check the carts at least once a day to ensure they are clean and medications were stored correctly. DON stated residents did not have access to the meds in the carts and the only potential harm to the residents was the possibility of running out of medications prior to the refill being delivered to the facility. Record review of facility policy titled Medication Labeling and Storage dated February 2023 revealed 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #105) reviewed for respiratory care. The facility failed to ensure Resident #105's oxygen concentrator was set to 3 liters per minutes as ordered by physician. This failure could place residents at risk of illness, respiratory complications and accidents. The findings included:Record review of Resident #105's face sheet dated 06/18/2026, revealed Resident #105 was admitted to the facility on [DATE] with diagnoses that included: chronic respiratory failure with hypoxia (critical condition where the lungs cannot adequately transfer oxygen to the blood), obstructive sleep apnea (adult) (chronic sleep disorder where the throat muscles repeatedly relax and block your airway during sleep, causing pauses in breathing), and dependence on supplemental oxygen.Record review of Resident #105's Quarterly MDS assessment, dated 04/08/2026, revealed the residents' BIMS score 15 indicating resident cognition was intact. Section O Special Treatments, Procedures, and Programs revealed C1 Oxygen Therapy was coded for Resident #105's oxygen use while a resident.Record review of Resident #105's care plan, initiated on 01/02/2026, revealed Resident #105 had a focus of I have Congestive Heart Failure and interventions/task of Oxygen as ordered/indicated. Record review of Resident #105's physician order summary report, dated 06/18/2026, revealed an order with a start date of 12/31/2026 that read O2 @ 3L VIA NASAL CANNULA every shift. During an observation and interview on 06/16/2026 at 10:49 am. Resident #105 was observed to be resting in his bed with the head of the bed elevated and wearing his nasal cannula with oxygen concentrator observed to be set at 4 liters per minute. Resident #105 stated he had been using oxygen since his admission to the facility, and he used 3 liters per minute. During an observation and interview on 06/18/2026 at 2:22 p.m. Resident #105 was observed in his bed with head of the bed elevated wearing his nasal cannula and the oxygen concentrator was set at 4 liters per minute. Resident #105 stated his oxygen was supposed to be set at 3 liters per minute. During an interview and observation on 06/18/2026 at 2:34 p.m. LVN B stated Resident # 105's oxygen concentrator was supposed to be set at 4 or 5 liters per minute and that she would leave it at 5 liters per minute. LVN B was observed checking Resident #105's oxygen concentrator setting. LVN B stated the oxygen concentrator was set to 4 liters per minute. Resident #105 told LVN B his oxygen was usually set on 3 liters per minute, and he further stated to LVN B they had increased it when he was having trouble breathing last week. LVN B exited Resident #105's room and proceeded to review Resident #105 EMR. LVN B stated Resident #105 physician orders read that he was to receive 3 liters per minute and further stated he did not have an order PRN to change the oxygen liters as needed. LVN B stated by not following the physician orders it could possibly cause difficulty breathing because they could be are giving him more. LVN B stated she would go and place Resident #105's oxygen concentrator at 3 liters per minute. During an interview and observation on 06/18/2026 at 2:44 p.m. the DON was observed reviewing Resident #105's physician orders. The DON stated Resident #105's oxygen was ordered to be given at 3 liters per minute. The DON stated his oxygen concentrator should have been set for 3 liters per minute because his physician order was 3 liters per minute due to what the physician had seen to maintain Resident #105's oxygen levels. The DON stated she did not feel the 4 liters per minute would or had caused him harm however, it was wrong because the staff were not following the physician order. The DON stated she would be worried or concerned if he had a diagnosis of COPD due to risk of making him feel like he was suffocating, however, did not have a diagnosis of COPD. During an interview on 06/18/2026 at 3:02 p.m. Resident #105 stated that they the nurses had turned his oxygen concentrator up when he was being treated for an infection due to his having some difficulty breathing. Resident #105 stated he was doing fine. Record review of the facility's policy titled, Oxygen Administration, revised October 2010, read, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders, facility protocol for oxygen administration. Steps in the Procedure: 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 8 residents (Resident #1, and #9) reviewed for care plans.1. The facility failed to ensure Resident #9's comprehensive care plan included information for a UTI caused by MRSA and the need for contact isolation precautions. 2. The facility failed to ensure Resident #1's comprehensive care plan included information for multiple wounds and wound care. These failures could place residents at risk for not having their needs and preferences met.The findings were:1. Record review of Resident #9's face sheet revealed an [AGE] year old male admitted on [DATE]. His diagnoses included: encounter for surgical aftercare following surgery on the skin and subcutaneous (beneath) tissue, parkinsonism (set of movement symptoms that resemble those of Parkinson's disease) and hydrocephalus (abnormal accumulation of cerebrospinal fluid in the brain's ventricles or cavities). Record review of Resident #9's quarterly MDS dated [DATE] revealed a BIMS score of 7 which indicated a severe cognitive impairment. His functional ability was listed as dependent on staff for all care. Record review of Resident #9's urinalysis dated 6/8/2026 revealed he tested positive in his urine for MRSA staphylococcus aureus-gram-positive, Record review of Resident #9's Care Plan dated 2/26/2026 revealed there was no information about Resident #9's positive urinalysis for a urinary tract infection colonized by MRSA bacteria and the need for contact isolation precautions. 2. Record review of Resident #1's face sheet dated 6/19/2026 revealed a [AGE] year-old male admitted on [DATE]. His diagnoses included metabolic encephalopathy (a condition where the brain is not working properly due to illness or chemical imbalance), type 2 diabetes mellitus and chronic kidney disease. Record review of Resident #1's 5-day admission MDS dated [DATE] revealed a BIMS score of 5 which indicated a severe cognitive impairment. Record review of Resident #1's care plan dated 6/04/2026 revealed there was no plan of care for wounds and wound care. Record review of Resident #1's Physician Order Summary dated 6/16/2026 revealed:-An order with a start date of 6/09/2026 for wound care to left buttock. Cleanse with wound cleanser, pat dry, apply collagen particles to wound bed, cover with TRIAD and leave open to air. -An order with a start date of 6/09/2026 for wound care to the right ankle. Cleanse with normal saline, pat dry, paint with betadine and leave open to air.-An order with a start date of 6/09/2026 for wound care to the right shin. Cleanse with wound cleanser, pat dry, apply collagen particles to wound bed, cover with kerlix and secure with tape.-An order with a start date of 6/12/2026 for wound care to the nose. Cleanse with normal saline, pat dry, apply triple antibiotic ointment and leave open to air.During an interview on 6/19/2026 at 12:29 p.m., the MDS Coordinator stated Resident #9 did not have a care plan to address his UTI or need for contact precautions. She stated the care plan should address those issues. The MDS Coordinator stated Resident #1 did not have a care plan to address his wounds or need for wound care. She stated it should have been included in the resident care plan. The MDS Coordinator stated the MDS Coordinators were responsible for updating and revising care plans. She stated the MDS staff learns of resident updates during morning meetings each morning. She stated sometimes the nurses will also tell them directly when a resident had care plan updates. She stated the ADON and the DON could also update the care plan as needed. The MDS Coordinator stated an accurate care plan was important, so everyone knew what was happening with the resident. During an interview on 6/19/2026 at 12:46 p.m., the DON stated the MDS Coordinators were responsible for care plans. She stated when the staff have risk management meetings, the MDS Coordinators listen and ensure any interventions were implemented. The DON stated they were also responsible for updating based on other meetings such as care plan meetings. The DON stated any identified infection should automatically trigger a box in the electronic medical record to add to the care plan. She stated she did not think the facility care planned constipation. The DON stated accurate care plans were important because the care plan was the guide to caring for the resident and staff go by what was documented in the care plan. Record review of the facility policy for Comprehensive Assessments dated 2001 revealed: Comprehensive assessments are conducted to assist in developing person-centered care plans. The facility did not provide a separate policy for comprehensive care plans.

Based on observation, interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission, including initial goals based on admission orders, physician orders, dietary orders, and social services for 1 of 6 residents (Resident #129) reviewed for baseline care plans. The facility failed to ensure a pain baseline care plan was completed within 48 hours from admission for Resident #129. The failure could place newly admitted residents at risk for not receiving care and services as needed. The findings included:Record review of Resident #129's face sheet, dated 06/18/2026, revealed Resident #129 was admitted to the facility on [DATE] with diagnoses which included: unilateral primary osteoarthritis, left hip, pain in left hip, restless leg syndrome, Brown-Sequard syndrome (a rare neurological condition caused by damage to one half of the spinal cord), unspecified osteoarthritis, unspecified site, and age-related osteoporosis without current pathological fracture. Record review of Resident #129's admission MDS assessment, dated 06/17/2026, revealed Resident #129's BIMS score was 9 indicating moderate cognitive impairment. The admission MDS assessment further revealed Section J0300 Pain Presence coded 1 for yes resident having had pain or hurting at anytime in the last 5 days and Section J0410 Pain Frequency coded 3 for resident experiencing pain frequently over the last 5 days.Record review of Resident #129's Baseline Care Plan dated 06/10/2026, revealed Resident #129 did not have a baseline care plan completed for pain and had been coded no for presence of pain. Record review of Resident #129's Pain assessment dated [DATE], revealed Resident has had pain or hurting at sometime during the last 5 days. How much of the time have you experienced pain or hurting over the last 5 days: Frequently. Record review of Resident #129's physician order summary, dated 06/19/2026, revealed, an order of Oxycodone HCl oral Tablet 5 MG give 1 tablet by mouth every 4 hours as needed for pain with a start date of 06/10/2026. During an interview and observation on 06/16/2026 at 10:22 a.m. Resident #129 was observed lying in her bed with the head of the bed elevated. She stated she felt there was a wait for pain medications. Resident #129 did not express any pain at the time of interview. During an interview and observation on 06/19/2026 at 2:22 p.m. the ADON stated while reviewing Resident #129's baseline care plan that she completed the baseline care plan based on assessment and conversation with the resident. She further stated the baseline care plan was done within the initial 24 to 48 hours and was used as a baseline of the resident. The ADON was not sure if she stated the baseline care plan triggered any task for the staff. The ADON stated the completion of the baseline care plans were the responsibility of the DON and herself. The ADON further stated the importance a pain care plan would be to make sure Resident #129 had adequate pain medications and that her pain was addressed. During an interview on 06/19/2026 at 2:55 p.m. the DON stated the baseline care plan was opened upon a resident's admission, and it would come from what was triggered from the admission assessments. The DON stated pain would be triggered and stated in the admission assessment there was a section regarding pain and asked if the resident had pain in the last 5 days. The DON stated the baseline care plan was only as accurate as the day they talked to the resident. The DON stated her or the ADON completed the baseline care but at the time they spoke to the resident if she expressed no pain that was what they would document in the baseline care. The DON stated the baseline care plan was how the resident came on admission and what was going on currently. The DON stated the purpose of the baseline care plan was to know a resident's abilities, how much help that was needed or what the staff need to do for the resident. The DON further stated the baseline care plan was based off responses from the resident and at that time the resident may have said no and they must go based off what the resident said. The DON stated she did not feel there would be an issue and that the baseline care plan was a starting point. The DON further stated pain was constantly monitored and was evaluated daily. Review of facility policy, Care Plans - Baseline, dated March 2022 read A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident with forty-eight (48) hours of admission.1. The baseline care plan includes instructions needed to provide effective, person-centered of the resident that meet professional standards of quality of care and must include the minimum healthcare information necessary to properly care for the resident including but not limited to the following: a. Initial goals based on admission orders and discuss with the resident/representative; b. Physician orders .

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 6 residents (Residents #9 and #29) reviewed for assessments. 1.The facility failed to accurately reflect weight loss of 5% or more in the last month on Resident #9's quarterly MDS assessment, dated 06/02/2026. 2.The facility failed to accurately reflect weight loss of 5% or more in the last month on Resident #29's quarterly MDS assessment, dated 05/26/2026. These failures could place residents at risk for inadequate care due to inaccurate assessments.The findings included:1. Record review of Resident #9's face sheet, dated 06/18/2026, reflected an [AGE] year-old male admitted on [DATE] and re-admitted [DATE] with diagnoses to include dysphagia (difficulty swallowing), muscle wasting and atrophy (progressive shrinking and loss of muscle mass), protein-calorie malnutrition (condition that occurs when your body does not get the right balance of nutrients, calories, or energy to stay healthy), Record review of Resident #9's quarterly MDS assessment, dated 06/02/2026, reflected Resident #9 had a BIMS score of 7 out of 15, indicating severe cognitive impairment. It further reflected there was no weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Record review of Resident #9's weight history, undated, reflected on 05/06/2026 a weight loss of 14.4% in the last month. Record review of Resident #9's care plan, undated, reflected focus The resident has nutritional problem or potential for weight loss r/t mechanically altered diet, dysphagia, and refusal meals at times. [appetite] stimulant added, revised 06/17/2026. 2. Record review of Resident #29's face sheet, dated 06/19/2026, reflected an [AGE] year-old female initially admitted on [DATE] and re-admitted [DATE] with diagnoses to include Huntington's disease (rare, inherited genetic disorder that progressively damages nerve cells in the brain, affecting movement, cognition, and emotions), dysphagia (difficulty swallowing), and muscle wasting and atrophy (progressive shrinking and loss of muscle mass). Record review of Resident #29's quarterly MDS assessment, dated 05/26/2026, reflected Resident #29 could not have a BIMS conducted and had short-term and long-term memory problem. It further reflected there was no weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Record review of Resident #29's weight history, undated, reflected on 05/08/2026 a weight loss of 6.9% in the last month. Record review of Resident #29's care plan, undated, reflected focus I am at risk for nutritional deficits and/or dehydration risks r/t Disease Process of Huntington's and Dementia with impaired gross and fine motor skills, mechanically altered diet. Having a lot of spontaneous movement with Huntington's. Dysphagia, revised 06/04/2026. During an interview on 06/19/2026 at 11:50 AM, the MDS nurse revealed Resident #9 and Resident #29 had a significant weight loss and should have been reflected in his 06/02/2026 quarterly MDS assessment and her 05/26/2026 quarterly MDS assessment, respectively. She revealed it was important to input significant weight loss in residents' MDS assessments to monitor ups and downs and see trends for weights, whether the residents were having a decline in overall function or any swallowing issues. She further revealed that the MDS nurses oversaw the accuracy of the MDS assessments and she was going to modify Resident #9 and Resident #29's MDS assessments for the DON to review and approve the changes.During an interview on 06/19/2026 at 12:22 PM, the DON revealed she was told about Resident #9 and Resident #29 not have significant weight loss documented in their most recent MDS assessments. She revealed she had to add the significant weight losses. She revealed this should be updated, so they can monitor intakes and what not for signification weight loss. Record review of the facility's policy Comprehensive Assessments, revised February 2025, reflected 1. Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual . Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025, reflected for Section K in the MDS assessments, Code 2, yes, not on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was not planned and prescribed by a physician. It further revealed Weight loss may be an important indicator of a change in the resident's health status or environment. If significant weight loss is noted, the interdisciplinary team should review for possible causes of changed intake, changed caloric need, change in medication, or changed fluid volume status. Weight should be monitored on a continuing basis; weight loss should be assessed and care planned at the time of detection and not delayed until the next MDS assessment .

Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 2 of 8 (Resident #59 and Resident #114) residents who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #59 and Resident #114. This failure could place residents at risk of not being able to call for help as needed. The findings included: Record review of Resident #59's face sheet, dated 06/19/2026, revealed she was admitted to the facility on [DATE] with diagnoses which included: unqualified visual loss, both eyes, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, anxiety disorder, muscle wasting and atrophy, not elsewhere classified, multiple sites and overactive bladder. Record review of Resident #59's Annual MDS assessment, dated 03/13/2026, revealed the resident's BIMS score was 09, which indicated moderate cognitive impairment. The Annual MDS assessment further revealed Resident #59 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity) for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, personal hygiene, eating and oral hygiene. Record review of Resident #59's care plan, initiated date 08/28/2024, revealed, Focus: I am at risk for falls r/t . Intervention/Tasks: Anticipate & meet needs & keep call bed within reach as indicated.Record review of Resident #114's face sheet, dated 06/17/2026, revealed she was admitted to the facility on [DATE] with diagnoses which included: contracture, left hand, nontraumatic intracerebral hemorrhage, unspecified, unspecified lack of coordination, contracture, right hand, muscle wasting and atrophy, not elsewhere classified, multiple sites, and epilepsy, unspecified, intractable, without status epilepticus. Record review of Resident #114's BIMS evaluation, effective date 06/11/2026, revealed the resident's BIMS score was 10, which indicated moderate cognitive impairment. Record review of Resident #114's GG IDT Review of Functional Abilities-Admission, effective date 06/11/2026, revealed resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity) for eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. Record review of Resident #114's revealed, Resident #114's did not have a comprehensive care plan. During an observation and interview on 06/17/2026 at 10:15 a.m. revealed Resident #59 was comfortable as she rested in bed. Resident #59's call light was observed to be clipped to the top left corner of her bed and hung down toward the floor. Resident #59 stated the staff mostly came and checked on her as she attempted to locate her call light by feeling around for her call light on the right upper side of the pillow, however, could not locate it. During an observation and interview on 06/17/2026 at 10:15 a.m. revealed Resident #114 lying in her bed with hands pulled up on her chest, head of the bed elevated with her soft touch call light observed to be hanging down from between the side rail and the top of the mattress on the floor under Resident #114's bed. Resident #114 stated usually the staff would put her call light on her stomach and motioned with her arm to her chest and further stated her call light had probably fallen. During an interview and observation on 06/17/2026 at 10:25 a.m. CAN B stated Resident #59 rarely would use her call light and that Resident #114 when she saw people pass by in the hallway she would call out to them as they passed instead of using her call light. CNA B further stated both residents' call lights were out of reach, and they would not be able to use them where they were. CNA B stated the call lights for both residents should have been placed within reach. CNA B was observed placing Resident #59's call light on her side and then CNA B placed Resident #114's soft touch call light next to her right side. Resident #114's arms were pulled up to her chest. Resident #114 demonstrated she could not reach the call light, and CNA B moved the call light across her stomach and resident was still not able to demonstrate being able to reach the soft touch pad. CNA B again moved the call light placing it on her chest of which resident was able to tap the pad and activate the call light. CNA B stated all staff were responsible for making sure call lights were within reach. CNA B stated the use of the call light was for residents to be able to call for care and in emergencies. During an interview on 06/19/2026 at 3:13 p.m. the DON stated call lights were used for communication and the way the resident communicated with the staff. The DON further stated, It's their lifeline their way to get a hold of us for what they need. The DON stated that by not having the call light it could delay the resident from getting assistance and the resident could not communicate anything without their call light. The DON stated it was the responsibility of everyone to ensure the call lights were within reach. During an interview on 06/19/2026 at 3:24 p.m. the Administrator stated it was the responsibility of all staff, anybody that went in the room to ensure the call light was within reach. The Administrator stated call lights were so the residents could get provided assistance and so they could communicate need for help or emergency assistance. Record review of facility's Call System, Residents policy, updated January 2025, read Policy Statement: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy Interpretation and Implementation: 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on interview and record review, the facility failed to ensure the resident had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives, or treatment options and to choose the alternative or options he or she preferred, for 1 of 6 residents (Resident #74) reviewed for resident rights. The facility failed to obtain signed consent for psychotropic (a medication that affects brain function and used to treat psychiatric conditions) antidepressant medication, Sertraline for Resident #74. This failure could place residents at risk of receiving medications without their, or that of their responsible party's prior knowledge or consent and could place the residents at an increased risk for adverse reactions to the medications. The findings included:Record review of Resident #74's face sheet, dated 06/16/2026, reflected a [AGE] year-old female initially admitted on [DATE] and re-admitted [DATE]. Her diagnosis included cognitive communication deficit but did not include depression. There was no responsible party noted on her face sheet. Record review of Resident #74's quarterly MDS assessment, dated 03/30/2026, reflected Resident #74 had a BIMS score of 15 out of 15, indicating intact cognition. It revealed her PHQ 9 scored an 8 out of 27, indicating mild depression. It further reflected that Resident #74 did not have depression as an active diagnosis. Record review of Resident #74's care plan, undated, reflected focus I have a history of non-compliance with medication regimen/treatment, initiated 12/15/2025. It further reflected a focus of I use antidepressant medication r/t Depression, initiated and revised on 03/04/2026, with intervention Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of antidepressant medication(s)., initiated and revised on 03/04/2026. Record review of Resident #74's order summary report, dated 06/16/2026, reflected Sertraline HCl Oral Capsule 150 MG. Give 150 mg by mouth one time a day for depression, with start date 06/01/2026. Record review of Resident #74's June MAR, dated 06/19/2026, reflected Resident #74 took Sertraline HCl Oral Capsule 150 MG 06/01/2026 to 06/19/2026, except on 06/11/2026. During an interview on 06/19/2026 at 02:03 PM, the DON revealed she could not find a consent form for Resident #74's Sertraline. She revealed it was important for the facility to have a consent form signed so that Resident #74 was informed of possible adverse effects, side effects, and the resident had the right to not accept order if they did not want to. During an interview on 06/19/2026 at 04:57 PM, Resident #74 revealed she refused that pill for depression because she did not need it. She revealed she needed it a while ago (could not pinpoint exact time) and her family memberold the facility to give it to her, but now she was better and did not want to take it anymore. Record review of the facility's policy Resident Rights, revised February 2021, reflected 1. Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . p. be informed of, and participate in, his or her care planning and treatment . The medication consent form for Sertraline HCl for Resident #74 was requested from the DON on 06/19/2026 at 02:03 PM and 6 PM and was not received.

Based on interviews and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, complete, accurately documented, readily accessible, and systemically organized medical records for 2 of 5 residents (Residents #1 and #2) reviewed for accurate records. 1. The facility failed to document wound care treatments for Resident #1 for two days - 05/22/2026 and 05/23/2026. 2. The facility failed to document wound care treatments for Resident #2 for one day - 05/31/2026. These failures placed residents at risk for untreated or unmanaged wound care by inaccurate and missing records documentation. Findings included: 1. Record review of Resident #1's face-sheet revealed the resident an 86year-old, Female; with an admission date to the facility of 05/21/2026. Record review of Resident #1's Orders for May 2026 revealed diagnoses which included: muscle weakness (A lack of muscle strength), unspecified dementia without behavioral disturbance (A Neuro Developmental disorder without physiological conditions), and hypertensive chronic kidney disease (The kidneys are not working properly and are beginning to lose their function). Further review revealed an order, Coccyx: Cleanse with wound cleanser, Wound care: Coccyx: Cleanse with wound cleanser, Verbal Active, with a start date of 05/22/2026. Record reviewed of Resident #1's TAR for May 2026 revealed wound care treatments were not documented as completed for the wound to the resident's coccyx on 05/22/2026 and 05/23/2026. Observation on 06/03/2026 at 2:55 p.m. revealed Resident #1 was awake and alert and lying in bed. During an interview with Nurse B (Wound Care Nurse) on 06/04/2026 at 6:53 p.m., regarding the missing wound care documentation dated 05/22/2026 revealed Nurse B (Wound Care Nurse) completed wound care for Resident #1's coccyx. Nurse B (Wound Care Nurse) stated, I do all my patients' wound care first and then I sign. I probably forgot or something. I don't remember. Nurse B (Wound Care Nurse) B stated if wound care was not completed, the resident's wound could worsen and the resident could be at risk for infection. Nurse B (Wound Care Nurse) further stated, I expect the nursing staff to complete wound care according to physician orders and accurately document completion of treatments provided. Nurse B (Wound Care Nurse) acknowledged failure to complete, and document wound care could negatively affect wound healing and increase the risk of infection. 2. Record review of Resident #2s face-sheet revealed the resident was admitted to the facility on [DATE]. The resident was an ([AGE] year-old) male. Record review of Resident #2's physician orders, dated 05/25/2026, revealed wound care treatments for multiple areas: coccyx, left heel, left lateral foot, left medical foot, and right rear thigh to be cared for daily.- Wound care: Coccyx: cleanse with wound cleanser, pat dry, apply zinc oxide and Iota. one time a day, with a start date of 05/26/2026.- Wound care: L heel: Cleanse with ns, pat dry, add calcium alginate, wrap with ker1ix and secure with tape. one time a day, with a start date of 05/29/2026. Record review of Resident #2's TAR for May 2026 revealed wound care treatments scheduled for 05/31/2026 were not documented as completed. Further review revealed there was no documentation of the resident refusing the wound care treatments. Observation conducted on 06/03/2026 at 2:18 p.m. revealed Resident #2 was lying on his bed sleeping with the covers pulled up to his chin. The resident appeared clean, the bed was clean and dry, and the call light was clipped to the resident's blanket within reach. Resident #2's wounds were not observed, and the wound care nurse was not present at that time. During an interview with Nurse A on 06/03/2026 at 2:31 p.m., Nurse A revealed Resident #2 was receiving hospice services. Nurse A stated the resident slept frequently, experienced shaking and seizures when stimulated, and required extensive assistance with care. Nurse A stated the resident's spouse visited daily and was actively involved in his care. During an interview with the DON on 06/04/2026 at 4:54 p.m., the DON stated treatment refusals were expected to be documented and reported according to facility policy. The DON confirmed the absence of documentation prevented verification that physician-ordered wound care treatments were completed as ordered on the identified dates. During an interview with Nurse A on 06/04/2026 at 7:03 p.m. regarding the missing wound care document dated 05/31/2026, Nurse A stated hospice staff had performed the wound care treatment for Resident #1 on 05/31/2026. Nurse A stated, I should have documented that. Nurse A further stated failure to provide wound care could result in worsening wounds, infection, and deterioration of the resident's condition. Record review of the facility's policy titled, Charting and Documentation, dated 2001, revealed, all services provided to a resident and the resident's response to care were to be documented in the resident's medical record. The policy further directed documentation of procedures and treatments including the date and time the treatment was provided. The name and title of the individual providing the care, assessment findings, resident response to treatment, treatment refusals, notifications made as indicted, and the signature and title of the individual documenting the care. Record review of the facility's policy titled, Wound Care, dated 2001, revealed, wound care documentation was to include the date wound care was provided, the initials of the individual performing the wound care, any changes in the resident's condition, resident complaints related to the procedure, whether the resident refused the procedure, and the signature and title of the individual documenting the care.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #2) reviewed for infection control. The facility failed to ensure staff implemented EBP when providing care for Resident #2. This failure could lead to infection or illness. Findings included: Record review of Resident #2's admission record dated 11/26/2025 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included gastrostomy status (a surgical opening in the abdomen to allow the intake of food and medications) and presence of urogenital implants (a catheter to allow the drainage of urine). Record review of a significant change MDS dated [DATE] for Resident #2, reflected the BIMS score was not assessed due to the resident's cognitive status. Section H0100 of the MDS reflected Resident #2 required an indwelling catheter, and section K0520 of the MDS reflected Resident #2 received nutrition via a feeding tube. Record review of Resident #2's order summary report dated 11/26/2025 did not reveal an order for EBP. Record review of Resident #2's care plan report printed 11/26/2025 revealed infection risk: EBP (Enhanced Barrier Precautions) Date initiated: 07/01/2025. In an observation on 11/26/2025 at 11:10 AM, no EBP signage was observed to be present at the entrance to Resident #2's room or within his room. An interview was attempted, but Resident #2 was unable to participate due to cognitive decline. LVN A was observed assisting Resident #2 with a position change in his bed. LVN A donned [put on] gloves to provide care, but she did not don a gown. LVN A departed the facility before a follow-up interview could be conducted. LVN B was interviewed on 11/26/2025 at 4:01 PM and said she was the primary nurse for Resident #2. She was unsure if Resident #2 required EBP, but she said he should be on EBP since he had a foley catheter and a G-tube. She was unable to find a sign in or around Resident #2's room that indicated the implementation of EBP, and she was unable to locate a physician's order for EBP within the medical record. She said she was unsure of the process for implementing EBP at the facility because she was new and only worked occasionally, but she had received training regarding TBP and infection prevention. She said the potential harm to residents of not implementing proper TBP was infection. In an interview with the ADON on 11/26/2025 at 3:06 PM, she said she was responsible for the facility's infection prevention program. She was unaware that Resident #2 did not have a physician's order for EBP, and she said it must have been mistakenly discontinued during a recent hospitalization. She also said Resident #2 previously had a sign indicating the need for EBP, but she was unsure why it was not posted. She said staff should be wearing gloves and gowns when providing direct care to residents on EBP, and the potential harm to residents of not implementing proper TBP was infection. Record review of the facility policy titled Enhanced Barrier Precautions dated 2001, revised March 2024, revealed the following: .EBP's employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply . Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #2) reviewed for care planning. The facility failed to develop a care plan for Resident #2 that included the resident's NPO status. This failure could result in residents not receiving proper care. Findings included: Record review of Resident #2's admission record dated 11/26/2025 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included cerebral infarction (interruption of blood flow to the brain causing tissue damage), dysphagia (difficulty swallowing), and gastrostomy status (a surgical opening in the abdomen to allow the intake of food and medications). Record review of a significant change MDS submitted on 11/17/2025 for Resident #2, reflected the BIMS score was not assessed due to the resident's cognitive status. Section K0520 of the MDS reflected Resident #2 received nutrition via a feeding tube. Record review of Resident #2's order summary report dated 11/26/2025 revealed the following: Enteral (directly into the digestive tract) feed order every shift Glucerna 1.5 at 60cc via G-tube stationary pump . (start date 11/22/2025). Record review of Resident #2's care plan report printed 11/26/2025 revealed the following: I am at risk for nutritional deficits and/or dehydration risks r/t therapeutic diet, 10/17/25- NPO, G-tube (revision 11/25/2025) . *Nutrition/Hydration risk: Offer me an alternate meal or supplement if I eat less than 50% of my foods at each meal (date initiated 8/01/2025) *Nutrition/Hyrdration Risk: Encourage/Offer/Assist me to drink fluids during care time opportunities, during activities as well as during therapy as indicated. Ask my nurse if you have any questions (date initiated 8/01/2025) [sic] In an observation on 11/26/2025 at 11:10 AM, Resident #2 was noted to be resting in bed with an enteral feeding pump and nutrition solution attached to a pole near his bed. An interview was attempted, but Resident #2 was unable to participate due to cognitive decline. In an interview with the MDS Nurse on 11/26/2025 at 2:47 PM, she said care plans are updated on a daily basis, after incidents or review by the interdisciplinary team. She said Resident #2 was currently NPO due to dysphagia, and his care plan had not been updated after a recent hospitalization. The MDS Nurse stated the care plan should reflect the NPO status without the interventions of encouraging oral intake and had been mistakenly overlooked. The MDS Nurse stated the importance of an updated care plan was to ensure residents ordered care. In an interview with the DON on 11/26/2025 at 3:51 PM, she said Resident #2 was currently NPO and his care plan should reflect that status. The DON stated she was unaware the care plan included interventions for oral intake, and her expectation was the care plans would be updated with necessary care to ensure proper care. Record review of the facility policy titled Care Planning- Interdisciplinary Team dated March 2022, updated 12/2024 did not reveal guidelines related to ensuring the accuracy of the content of the care plan.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 4 resident rooms (room [ROOM NUMBER]) reviewed for environmental concerns in that: The facility failed to repair a bathroom door, repair a broken toilet, and secure a sprinkler system access panel in resident room [ROOM NUMBER]. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: Observation on 9/16/25 at 3:15pm with the Administrator and Maintenance Director revealed the following:a. There was a penetration (hole) which measured approximately 3 inches by 2 inches on the bathroom door in room [ROOM NUMBER].b. There was water running in the toilet which would also not flush in room [ROOM NUMBER].c. There was a sprinkler system access panel which measured approximately 1.5 ft by 1.5 ft on the bathroom wall in room [ROOM NUMBER] that was unsecured. During an interview on 9/16/25 at 3:00pm with the Social Worker she stated that there was only one resident residing in room [ROOM NUMBER] and the resident was not able to be interviewed. During an interview on 9/17/25 at 2:15 pm with the Administrator and Maintenance Director, the Maintenance Director stated staff will notify him of repairs needed in resident rooms on the TELS work order system. The Maintenance Director stated that he had not received a work order request for the repairs needed in room [ROOM NUMBER]. The Maintenance Director stated resident rooms were checked on a weekly basis as needed for repairs to be completed. The Administrator stated the access panel on the wall in the resident's bathroom in room [ROOM NUMBER] had a sprinkler system valve that was used for sprinkler system tests only. The Administrator stated the sprinkler system access panel in room [ROOM NUMBER] was now secured. The Administrator and Maintenance Director stated that repairs made in room # 217 would promote the resident who lived in this room's dignity status. Record review of the facility policy titled Physical Environment dated 01/2023 revealed The community has a preventative maintenance program that ensures all essential mechanical, electrical, and patient care equipment is in safe operating condition.

Based on interview, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 3 of 6 Residents (Resident #23, # 43, and #51) whose records were reviewed for care plan revision/timing, in that: The care plans of Residents #23, #43, and #51 were not updated to reflect thickened liquids. Thisdeficient practices could affect any resident and contribute to Residents not receiving the care and services they need. The findings included: 1. Record review of Resident #23's face sheet, dated 4/24/2025, revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of gout (a form of inflammatory arthritis characterized by recurrent attacks of pain), dysphagia (difficulty swallowing) and paraplegia ( is a form of paralysis that primarily affects the lower half of the body). Record review of Resident #23's quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. Record review of Resident #23's quarterly MDS, dated [DATE], revealed that section K, the thickened liquids option, was selected. Record review of April 2025, monthly physician orders for Resident #23 revealed an order for moderately thick / honey-like consistency liquids. 2. Record review of Resident #43's face sheet, dated 4/23/25, revealed an [AGE] year-old female, admitted to the facility on [DATE] with the diagnoses of schizophrenia (mental health condition tending to have a profound impact upon personal, interpersonal, and occupational functioning, of which typical features are the occurrence of hallucinations and delusions), dysphagia (difficulty swallowing) and type II diabetes (happens when the body cannot use insulin correctly and sugar builds up in the blood ) Record review of Resident #43's quarterly MDS, dated [DATE], revealed the BIMS score was left blank, which indicated the Resident was unable to complete the interview. Record review of Resident #43's quarterly MDS, dated [DATE], revealed that section K, the thickened liquids option, was selected. Record review of April 2025 monthly physician orders for Resident #43 revealed an order for moderately thick / nectar-consistent liquids. 3. Record review of Resident #51's face sheet, dated 4/23/25, revealed an [AGE] year-old female, admitted to the facility on [DATE] with the diagnoses of type II diabetes (happens when the body cannot use insulin correctly and sugar builds up in the blood), dysphagia (difficulty swallowing) and anxiety disorder (symptoms of intense anxiety or panic). Record review of Resident #51's quarterly MDS, dated [DATE], revealed a BIMS score of 11, which indicated moderate cognitive impairment. Record review of Resident #51's quarterly MDS, dated [DATE], revealed that section K, the thickened liquids option, was selected. Record review of April 2025 monthly physician orders for Resident #51 revealed an order for moderately thick / honey-like consistency liquids. Interview on 4/24/2025 at 1:40 PM: The MDS nurse stated that she had not updated the care plans for Residents #23, #43, and #51 concerning thickened liquids due to her inability to review the residents' physician orders. She emphasized that failing to update these care plans might prevent nurses from being aware of the liquid diet orders, which could potentially result in a Resident aspirating if they were provided with regular thin liquids. Interview on 4/25/2024 at 10:00 a.m. the DON stated the MDS nurse should have updated Resident #23's, # 43's, and #51's care plan to reflect the thickened liquids order. Record review of the facility policy, titled Care Plans, dated February 2017, revealed .The care plan should be updated and reviewed at least quarterly thereafter, then annually, and with significant changes in conditions as defined in the RAI manual.