Every finding on record at Avir at Jacksboro

Based on observation, interview, and record review the facility failed to ensure that the residents were treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 of 7 residents (Resident #2, Resident #3, Resident #4) reviewed for resident rights. The facility failed to ensure Resident #2, Resident #3, and Resident #4 were able to exercise his or her rights as a resident of the facility and as a citizen of the United States to be treated with dignity. The facility failed to ensure Resident #2, Resident #3, and Resident #4 exercised his or her rights without interference, coercion, discrimination, or reprisal from the facility staff. The facility failed to support Resident #3 in exercising her rights to have her personal property as required. This failure could place the residents at risk of inadequate care and services and/or unmet mental health needs.Findings included: Record review of Resident #2's Face Sheet reviewed on 6/01/2026 reflected a [AGE] year-old male, with an admission date of 5/31/2022. Resident #2 had diagnoses which included: encephalopathy (disease, damage or malfunction of the brain that alters its structure or function), Psychotic disorder with hallucinations due to known physiological condition (disconnect from reality seeing or hearing things not there), anxiety disorder (persistent worry or fear), dysphagia (impairment in the ability to produce and understand language), schizoaffective disorder ( affect the perception of reality with hallucinations, delusions, disorganized thoughts or speech), conduct disorder (persistent pattern of aggressive, destructive, and deceitful behaviors that violate social norms and the rights of others), muscle weakness (lack of physical strength). Resident #2 had a BIMS of 03 (severe cognitive impairment). In an observation on 5/31/2026 at 12:39 P.M., HA A stood over Resident #2 while providing feeding assistance. HA A mixed his food on his plate that was sitting on the table. Resident #2 sat in a large, padded medical recliner on wheels with a bib covering his clothes. HA A put food on a fork and handed him the fork. Resident #2 took the fork and fed himself. HA A took the fork from his hand, and he took a drink by himself. HA A put more food on the fork and handed him the fork and took his cup from his hand. Resident #2 paused and watched her put the cup down. HA A sat the cup down and Resident #2 took the fork and fed himself. Resident #2 tried to scoop food with the fork on his own and HA A reached to take the fork away from him and he pulled it back away from her. Resident #2 tried to reach towards the food with the fork, and HA A reached for the fork, and he pulled it away again. HA A reached for the fork again and he pulled away again. HA A picked up the spoon and put food on it and held it out towards Resident #2's mouth. He reached for the spoon, and she reached for the fork, and he let go of the fork and took the spoon and fed himself. HA A wiped his mouth with a napkin and put food on the fork and handed him the fork. Resident #2 took the fork and fed himself. In an interview on 5/31/2026 at 1:17 P.M. with Resident #2, he stated staff treat him with respect and he thought HA A did a good job at lunch. Resident #2 stated he had enough time and got enough to eat. In an interview on 5/31/2026 at 2:45 P.M. with HA A, she stated she had been trained in how to feed a resident. HA A did not answer when asked if she should sit in front of a resident during feeding and she did not answer when asked the procedure for feeding a resident. In an observation on 6/01/2026 at 12:41 P.M., Resident #2 sat in a large, padded medical recliner on wheels and fed himself with no assistance. In an interview on 6/01/2026 at 12:42 P.M. with LVN D, she stated Resident #2 decided how much assistance he got at mealtimes. She stated today he wanted to eat on his own with his hands, and we supervise and offer assistance if he needs or wants. LVN D stated Resident #2 is set up, supervise, and assist for meals. Record review of Resident #3's Face Sheet reviewed on 5/31/2026 reflected a [AGE] year-old female, with an admission date of 12/21/2023. Resident #3 had diagnoses which included: schizoaffective disorder, bipolar type (both schizophrenia and mood disorders that affect the perception of reality with hallucinations, delusions, disorganized thoughts or speech with bouts of mania and sometimes major depression), pleural effusion (fluid around your lungs), history of urinary tract infection (infections that happen when bacteria enter the urethra and infect the urinary tract), protein-calorie malnutrition (protein or calorie deficiency), history of dehydration (uses or loses more fluid than it takes in), bipolar disorder (mood disorder causing extreme highs and lows), major depressive disorder (persistent feelings of sadness and loss of interest), anxiety disorder (persistent feelings of worry or fear), obsessive compulsive disorder (pattern of unwanted thoughts and fears and uncontrollable and recurring thoughts), personality disorder (difficulty dealing with people due to being inflexible, rigid, and unable to respond to demands of life), kleptomania (repeatedly unable to resist urges to steal items), impulse disorder (difficult to control actions or reactions), extrapyramidal and movement disorder (drug induced movement disorders that primarily affect muscle tone, body posture, and involuntary movements). In an observation on 5/31/2026 at 11:48 A.M., Resident #3 walked to LVN C and asked for a coke. LVN C stated to Resident #3, We will have to see if you do good today staying away from other's drinks. LVN C asked her how much caffeine she had had today and Resident #3 stated there are non-caffeinated soda in there too. LVN C stated she did not believe there was any non-caffeinated soda. In an interview on 5/31/2026 at 11:48 A.M. with LVN C, she stated that if Resident #3 can stay out of other people's drinks, she can have a coke by the end of LVN C's shift but that she never really gets there. LVN C did not elaborate on what that meant. LVN C stated the coke is locked up in a storage room and Resident #3 had broken in so it was now padlocked because she would drink all of it. LVN C stated Resident #3 bought the coke in the storage room with her own money. LVN C stated Resident #3 is on caffeine restriction because she would run up and down the hallway yelling and screaming and get to wound up. LVN C was not able to answer what the restriction was or if it was a doctor's orders. LVN C stated Resident #3 is obsessed with drinking soda and tea and she asks everyone for some. LVN C further stated Resident #3 could have a soda if she is good and does not drink others. In an observation on 5/31/2026 at 11:48 A.M., LVN C gestured towards a brown door unmarked and secured with a padlock. In an interview on 5/31/2026 at 12:03 P.M. with CNA H, he stated that he had heard LVN C use Resident #3's soda as a reward and consequence system. He stated the soda belonged to Resident #3, but it was locked in a closet. CNA H stated he did not get the soda for her because he had to ask the nurse and eventually Resident #3 quit asking because the nurse decided if Resident #3 could have it. CNA H stated Resident #3 had water and tea and she got fluids during mealtimes and every time she goes to smoke. He stated he had seen Resident #3 with root beer bought by other staff, also. CNA H stated he did not know why Resident #3 was on caffeine restriction. Record Review of Resident #3's Physician Orders reviewed on 5/31/2026 lacked any order regarding fluid restrictions or caffeine restrictions. Record review of Resident #3's Care Plan undated revealed a focus that 'resident consumes more caffeine than preferred by family and resident will limit caffeine intake to one cup per day per family request' with interventions to educate the resident of the effects of caffeine and encourage hydration with non-caffeinated beverages and monitor intake. Further focus revealed that 'resident enters other residents' rooms and takes their snacks and or drinks' with interventions to collaborate with dietary staff to ensure the resident receives preferred snacks and drinks. In a follow up interview on 6/01/2026 at 10:18 A.M. with Resident #3, she stated she can have her coke if she does not take others and she had to be good to get it. Resident #3 stated she bought her own soda. She stated she does not always get it when she asks because they don't want her to have it. Resident #3 stated she does not know why facility staff don't want her to have it. Resident #3's only issue was she wanted her Coke Zero. Record review of Resident #4's Face Sheet reviewed on 6/01/2026 reflected an [AGE] year-old male, with an admission date of 02/18/2026. Resident #4 had diagnoses which included: hepatic encephalopathy (brain dysfunction due to liver dysfunction), malignant neoplasm of brain (aggressive fast growing mass causing life-threatening pressure in the head), muscle weakness (lack of physical strength), Unspecified dementia (loss of memory, language, problem-solving, and other thinking abilities), vitamin deficiency (doesn't get or absorb essential micronutrients needed), polyneuropathy (damaged nerve in skin, muscle, organs), cognitive communication deficit (difficulty communicating because of injury to the brain). Record review of Resident #4's Care Plan undated revealed the resident had unexpected weight loss with interventions added to assist with ADL: 'Assist with utensils, meal set up and feeder assist'. In an observation on 5/31/2026 at 12:32 A.M., RN B was standing over Resident #4 feeding him from a plate on the table. Resident #4 sat in a geriatrics chair with a bib over his clothes. RN B provided a bite of food to Resident #4's mouth. RN B looked around and stood over him. Resident #4 watched her and looked around to see what she was looking at and then she gave him another bite. RN B bent over to talk to him and then spoke to him about what was in his bite she provided. In an interview on 5/31/26 at 1:23 P.M. with Resident #4, he stated he felt staff treat him with respect and it did not bother him when RN B stood over him and looked around the room. Resident #4 stated he got enough to eat and felt he had choices. Attempted interview with RN B and she did not respond prior to exit. In an interview on 6/01.2026 at 2:13 P.M. with ADON E, she stated Resident #3 did not have a fluid restriction, but her mother and doctor wanted the facility to limit her caffeine intake because she became agitated and anxious. ADON E stated if Resident #3 wanted her Coke, they had to give it to her. She stated they attempt to sway her with Root Beer, but they have to give her Coke if that is what she wanted. ADON E stated the facility did not condone keeping Resident #3's Coke from her. They are hers and she can have them. ADON E stated RN B and HA A had both been trained in feeding assistance. ADON E stated they should sit in a chair in front of the residents and feed them that way. ADON E stated negative effects that could happen could be a dignity issue or make the residents feel less than or feel bad. In an interview on 6/1/2026 at 3:10 P.M. with DON G, she stated she was made aware of LVN C actions, and LVN C was now fully aware Resident #3's drinks cannot be withheld. DON G stated the reward system is not appropriate. DON G stated Resident #3 did get her drinks because DON G buys her soda and Resident #3 goes to the business office to get money to buy soda. DON G stated Resident #3 is offered non-caffeinated beverages and she would get Root Beer a lot of the time. DON G stated staff should be sat down having one on one with residents during feeding assistance. She stated if the residents wanted to feed themselves, they should. DON G stated Resident #2 can usually feed himself. She stated RN B and HA A should know the procedure but felt they were nervous. DON G stated the negative effects would be a dignity issue. Record review of LNV C's employee file reviewed on 6/1/2026 revealed she had been trained on Resident Rights on 7/1/2025. Record review of RN B's employee file reviewed 6/1/2026 revealed she had completed Assisting the Resident with Dining Competency dated 3/11/2026. Procedure for Assisting the Resident with Dining revealed 7. Sit facing the resident if possible.12. Include socialization, conversation during meal service. Record review of HA A's employee file reviewed 6/1/2026 revealed she had completed Assisting the Resident with Dining Competency dated 4/27/2026. Procedure for Assisting the Resident with Dining revealed 7. Sit facing the resident if possible.12. Include socialization, conversation during meal service. Record review of the facility's Resident Rights policy dated 2001 revealed Employee shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: a. a dignified existence; b. be treated with respect, kindness, and dignity.e. self-determination.g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights; i. Without interference, coercion, discrimination, or reprisal from the facility. Record review of the facility's Activities of Daily Living (ADL), Supporting policy dated 2001 revealed Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable.2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene.d. dining (meals and snacks);.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident 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 3 of 7 residents (Resident #3, Resident #4, Resident #5) reviewed for care plans.The facility failed to ensure the staff developed the comprehensive care plan goals and interventions from the comprehensive assessment for Resident #3, Resident #4 and Resident #5. The facility failed to ensure the comprehensive care plans for Resident #3, Resident #4 and Resident #5 described the resident's goals for admission and desired outcomes. The facility failed to ensure the comprehensive care plan for Resident #3, Resident #4 and Resident #5 described the resident's preference and potential for future discharge. The facility failed to ensure the comprehensive care plan Resident #3, Resident #4 and Resident #5 documented a desire to return to the community was assessed. This failure could place the residents at risk of inadequate care and services.Findings included: Record review of Resident #3's Face Sheet reviewed on 5/31/2026 reflected a [AGE] year-old female, with an admission date of 12/21/2023. Resident #3 had diagnoses which included: schizoaffective disorder, bipolar type (both schizophrenia and mood disorders that affect the perception of reality with hallucinations, delusions, disorganized thoughts or speech with bouts of mania and sometimes major depression), pleural effusion (fluid around your lungs), history of urinary tract infection (infections that happen when bacteria enter the urethra and infect the urinary tract), protein-calorie malnutrition (protein or calorie deficiency), history of dehydration (uses or loses more fluid than it takes in), bipolar disorder (mood disorder causing extreme highs and lows), major depressive disorder (persistent feelings of sadness and loss of interest), anxiety disorder (persistent feelings of worry or fear), obsessive compulsive disorder (pattern of unwanted thoughts and fears and uncontrollable and recurring thoughts), personality disorder (difficulty dealing with people due to being inflexible, rigid, and unable to respond to demands of life), kleptomania (repeatedly unable to resist urges to steal items), impulse disorder (difficult to control actions or reactions), extrapyramidal and movement disorder (drug induced movement disorders that primarily affect muscle tone, body posture, and involuntary movements). Resident #3's BIMS is 11 (moderate cognitive impairment). Record review of Resident #3's MDS dated [DATE] reflected dehydration was marked as a health condition, she was at risk of developing pressure ulcers, and antipsychotics were received on a routine basis. Record review of Resident #3's CAA dated 12/03/2025 reflected dehydration/fluid maintenance, pressure ulcers, and psychotropic medications were triggered and indicated a new care plan, revision, or continuation of care plan is necessary to address the identified area. It further reflected the care planning decision must be completed within 7 days. Record review of Resident #3's Care plan undated lacked documentation/goals for dehydration/fluid maintenance, pressure ulcers, and psychotropic medications. The Care Plan lacked documentation of Resident #3's preference and potential for future discharge or if her desire to return to the community was assessed In an interview on 5/31/2026 at 11:36 A.M. with Resident #3, she stated she takes medication and it helped. Resident #3 stated she gets fluids and does not have any sores. She stated her needs are met by the facility. The only issue was she wanted her Coke Zero. Record review of Resident #4's Face Sheet reviewed on 6/01/2026 reflected an [AGE] year-old male, with an admission date of 02/18/2026. Resident #4 had diagnoses which included: hepatic encephalopathy (brain dysfunction due to liver dysfunction), malignant neoplasm of brain (aggressive fast growing mass causing life-threatening pressure in the head), muscle weakness (lack of physical strength), Unspecified dementia (loss of memory, language, problem-solving, and other thinking abilities), vitamin deficiency (doesn't get or absorb essential micronutrients needed), polyneuropathy (damaged nerve in skin, muscle, organs), cognitive communication deficit (difficulty communicating because of injury to the brain). Record review of Resident #4's MDS dated [DATE] reflected a BIMS of 12, moderate cognitive impairment. Resident #4's MDS revealed he had upper extremity impairment on both sides requiring functional ability assistance and was frequently incontinent. Record review of Resident #4's CAA dated 4/06/2026 reflected cognitive loss, functional ability, urinary incontinence, and pressure ulcer were triggered and indicated a new care plan, revision, or continuation of care plan is necessary to address the identified area. It further reflected the care planning decision must be completed within 7 days. Record review of Resident #4's Care plan undated lacked documentation/goals for cognitive loss, functional ability, urinary incontinence, and pressure ulcer. The Care Plan lacked documentation of Resident #4's preference and potential for future discharge or if her desire to return to the community was assessed. In an interview on 5/31/2026 at 1:23 P.M. with Resident #4, he stated staff take care of him and he has no concerns with his care. Record review of Resident #5's Face sheet reviewed on 6/01/26 reflected a [AGE] year-old male, with an admission date of 2/18/2026. Resident #5 had diagnoses which included: hepatic encephalopathy (brain dysfunction due to liver dysfunction), pancytopenia (blood disorder characterized by a dangerous decrease in all three types of blood cells), vitamin deficiency. Record review of Resident #5's MDS dated [DATE] reflected a BIMS score of 11, moderate cognitive impairment, and functional abilities requiring setup or cleanup assistance. Record review of Resident #5's CAA dated 3/02/2026 reflected cognitive loss and functional abilities were triggered and indicated a new care plan, revision, or continuation of care plan is necessary to address the identified area. It further reflected the care planning decision must be completed within 7 days. Record review of Resident #5's Care plan undated lacked documentation/goals for cognitive loss and functional abilities. The Care Plan lacked documentation of Resident #5's preference and potential for future discharge or if her desire to return to the community was assessed. In an interview on 5/31/2026 at 1:06 P.M. with Resident #5, he stated he does not live at the facility and only staying there for the moment, and he has no concerns with his care. In an interview on 6/01/2026 at 2:13 P.M. with ADON E, she stated ADON F is responsible for MDS assessments and care plans from the assessment. ADON E stated Resident #3's needs are being met and does not plan to discharge. She stated Resident #4's needs are being met, and he can voice his wants and needs. ADON E stated Resident #5's needs are being met, and he can also voice his wants and needs to staff. Resident #5 plans to discharge back to the community when he can. In an interview on 6/01/2026 at 2:52 P.M. with ADON F, she stated she was responsible for the MDS and care plan after that. She stated when the CAA triggers and the column for it to be added to the care plan is checked, it should be added to the care plan. ADON F stated the negative effects that could occur if the CAA areas are not in the care plan could be skin breakdown or set up for failure if not assessed for discharge.Record review of Care Plans, Comprehensive Person-Centered policy dated 2001 reflected, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.c. includes the residents stated goals upon admission and desired outcomes.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 1 kitchen as evidence by: The facility failed to ensure:Cook A wore a hair restraint properly covering his facial hair. These failures could place residents at risk for foodborne illness and compromised health status and hair in food.The findings included:In an observation of food preparation on 03/31/26 at 11:45 am, [NAME] A did not have a hair restraint covering his facial hair. In a follow-up observation and interview during food preparation on 04/01/26 at 12:25 pm, [NAME] A did not have a hair restraint covering his facial hair. In an interview, [NAME] A said that he should wear a hair restraint to cover his facial hair but forgot to put one on. He said a potential negative outcome would be that residents would have hair in their food. The Dietary Manager was not available for interview. In an interview on 04/01/26 at 1:40 pm, the Administrator said it was her expectation that staff wear hair restraints the moment they enter the kitchen anytime. Failure to do so had the potential for residents to have hair in their food and infection control concerns.Record review of the facility policy Food Preparation and Service, dated as revised November 2022, revealed the following [in part]:Food and nutrition services employees prepare, distribute and serve food that complies with safe food handling practices. Food Distribution and Service: 8. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraints, etc.) so that hair does not contact food. Record review of the Food and Drug Administration Food Code, dated 2022, specified [in part]: 2-402 Hair Restraints(A) Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from FDA Food Code 2022 Chapter 2. Management and Personnel Chapter 2 - 22 contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 1 of 12 months (July 2025) reviewed for RN Coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for 6 of 31 days in July of 2025. This failure placed all residents at risk for inconsistency in care, services and decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.Findings include: In a record review and interview on 01/15/2026 at 05:45 PM, with the Administrator regarding RN week-end coverage, she stated she knew there were days or weekends that were not covered as required. The Administrator provided the staffing schedule and time sheets. Record review of Daily Staffing Hours vs. Daily Staffing Sign-in Sheets, regarding RN coverage presented by the Administrator revealed the following days did not have RN coverage for at least eight consecutive hours a day, seven days a week:July 5, 6, 12, 13, 26 and 27th of 2025. Totaling 6 days without an RN at least 8 hours a day, 7 days a week. In an interview on 01/15/2026 at 6:00 PM, the Corporate Nurse Consultant stated she knew RN coverage was supposed to be 7 days a week and 8 consecutive hours a day. She provided a copy of the facility policy named Staffing, Sufficient and Competent Nursing. She stated her expectation was to have coverage as required by law and that an adverse outcome could be a resident not assessed correctly and would be hard to run a code (Provide life saving measures)In an interview on 01/15/2026 at 6:15 PM, the Administrator stated the previous DON, that would help in covering weekends, had a stroke at the end of June and was unable to help provide coverage during these days. Stated her expectation was for an RN to be in the facility 8 consecutive hours a day, 7 days a week and an adverse outcome would be the resident not receiving care needed from an RN. Record review of the facility policy titled Staffing, Sufficient and Competent Nursing dated as revised August 2022 specified [in part]: Policy Statement:Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.Policy Interpretation and Implementation:Sufficient Staff:3. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.

Based on observation, interview and record review the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure proper sanitization of kitchen waste was kept in tightly closed trash cans.2. The facility failed to ensure that personnel change their gloves and wash their hands before serving and in between tasks. 3. The facility failed to ensure that food and nutrition services staff wear hair restraints. These failures placed the residents at risk of foodborne illness and being served food items that may be contaminated.The findings included: Observation on 01/13/2026 at 9:30 AM revealed the DM entered the kitchen and did not immediately wash her hands. She did not handle any food or food service equipment. During an observation and interview on 01/13/2026 at 9:39 AM, [NAME] O was not wearing a facial hair restraint or mask to cover his beard. [NAME] O reported he sometimes wore a facial hair mask and reported that his facial hair comes and goes depending on if he shaved his face. Observation on 01/13/2026 at 12:28 PM revealed [NAME] O was placing a dinner roll on each plate. He was handling the plates and did not change his gloves when he went in and out of the kitchen. He was observed using his cell phone and did not change his gloves. [NAME] O was observed taking the hall tray carts to each hallway with gloves on and did not change the gloves or wash his hands after re-entering the kitchen. He was not wearing a facial hair cover. In an interview on 01/13/2026 at 12:53 PM, [NAME] O reported his kitchen tasks included washing the dishes, placing plates and meal trays on the carts, and delivering the hall tray carts. He denied serving and handling food. When asked if he was placing the rolls on the plates at lunch today, [NAME] O responded, Well yeah, I guess. When asked if going in and out of the kitchen was his usual practice, [NAME] O responded yes because he delivered the meal tray carts to the halls. When asked if he was aware of how many times he had left the kitchen during the lunch meal service, [NAME] O responded, I don't know, maybe 4 or 5 times. When asked how many times he changed gloves and washed his hands after returning to the kitchen, [NAME] O responded, I don't know, every time. Then he changed his answer to I don't know, none I guess. When asked what the facility expectations were for hand washing, changing gloves and handling food, [NAME] O responded, I don't know. When asked what a negative outcome could be, [NAME] O responded, I wasn't trained right. I don't know. He then abruptly walked away and ended the interview. Observation on 01/13/2026 at 12:58 PM revealed signage for hand hygiene was posted by the hand-washing sink. Signage for hair/face covering was observed posted by the door inside the kitchen. In an interview on 01/13/2026 at 1:18 PM, the DM stated she expected the dietary staff to adhere to the facility policies and follow health guidelines for hand hygiene, infection control, and food distribution. DM reported that the staff were trained frequently on infection control. DM reported that proper hand hygiene instructions were posted by the sink. DM verbalized a negative outcome of not following the infection control and hand hygiene procedures may cause the residents to get sick, come in contact with something they might be allergic to, and most of all that it could cause death. Observation and interview on 01/15/2026 at 1:00 PM revealed [NAME] O was rolling the open top trash can from the kitchen through the dining room and down Hall B. [NAME] O stated he did not know where the lid was for the trash can. Observation revealed the trash can in the dining room near the drink station was also without a lid. In an interview on 01/15/2026 at 1:05 PM, the DM reported she was uncertain why the lids on the trash cans were not being utilized and she would correct this. The DM reported her expectation was that the staff would follow the policies for the kitchen. DM reported that not following the policy may result in spreading germs and odors around the facility. In an interview on 01/15/2026 at 5:00 PM, the Administrator stated her expectation for dietary employees was to use hand hygiene, use lids on trash cans, wear hair coverings and remove gloves between tasks. She stated her expectations included that the facility staff perform hand hygiene when going in and out of the kitchen and not to use their cell phones with gloves on. The Administrator stated the staff should also adhere to food preparation, sanitization and hygiene guidelines. She stated a negative outcome from not following these could result in foodborne illness and at worst death. Record review of the staff in-service training record for June 2025 with the topic of handwashing indicated [NAME] O was in attendance. The in-service included the policy for handwashing/hand hygiene. Review of the facility policy for Administrative Practices to Promote Hand Hygiene indicated [in part]: All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors. Record review of the facility policy for Sanitization, dated as revised November 2022, specified [in part]: #13 Kitchen wastes that are not disposed of by mechanical means are kept in clean, leakproof, nonabsorbent, tightly closed containers and disposed of daily. Record review of the facility policy for Food Preparation and Service, dated as revised November 2022, specified [in part]: Policy Interpretation and ImplementationFood distribution and service #5 Food and nutrition service staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays. #7 Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. #8 Food and nutrition services staff wear hair restraints (hair net, hat, beard restraints, etc.) so that hair does not contact food.

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 16 of 52 rooms (Room #s 3, 4, 6, 10, 12, 14, 22, 43, 44, 46, 47, 50, 51, 52, 53, and 54) observed for cleanliness and condition. 1. The doorway transition strips used to provide a smooth floor transition between the hallway and the room for the door thresholds were missing for resident Room #s 10, 12, 43, 44, 46, 47, 51, 52, and 54.2. Square vinyl floor tiles were broken and/or missing in Room #s 14, 22, 43, 44, 50, and by the nurse's desk in Hall C.3. The floors were soiled with a dark-colored build-up of dirt along the base of the toilets, cove-base (vinyl baseboard), and door frames in the restrooms for Room #s 3, 4, and 6.4. A fly paper glue strip was hanging on the wall above the head of Bed A in room [ROOM NUMBER].5. The floor in room [ROOM NUMBER] was soiled with chewing tobacco, and an open dresser drawer had a pizza box containing dried-up slices of pizza.6. A wash basin was positioned on the floor beneath the sink and the drain pipe was soiled with a dried brown colored substance in room [ROOM NUMBER].7. The restroom in room [ROOM NUMBER] had a urine odor on 1/14/2026. These failures placed the residents at risk for tripping and/or falling, illness, and decreased feelings of well-being within their living environment.The findings included: Observation on 1/13/2026 at 9:20 AM revealed room [ROOM NUMBER], used as a conference room, had square vinyl floor tiles with a worn and gray colored surface and an area of broken and missing tiles. Observation on 01/13/2026, between 9:30 AM and 10:00 AM revealed the following:room [ROOM NUMBER] was missing the doorway transition strip;room [ROOM NUMBER] was missing the doorway transition strip; room [ROOM NUMBER] had chipped floor tiles; room [ROOM NUMBER] was missing the doorway transition strip and had broken floor tiles;room [ROOM NUMBER] was missing the doorway transition strip and had missing floor tiles;room [ROOM NUMBER] was missing the doorway transition strip; room [ROOM NUMBER] was missing the doorway transition strip;room [ROOM NUMBER] had missing floor tiles;room [ROOM NUMBER] was missing the doorway transition strip; room [ROOM NUMBER] was missing the doorway transition strip;Floor tile was missing near the nurse's desk in Hall C. Observation on 1/13/2026 at 10:20 AM revealed the floor transition strip was missing from the doorway threshold to resident room [ROOM NUMBER]. In a confidential interview at an undisclosed date and time, a resident stated she had noticed, in the areas she visited within the facility, that the floors did not appear to be cleaned very well and there were parts of floor tiles that were broken. Observation on 1/13/2026 at 10:45 AM revealed a fly paper glue strip had been hung on the wall above the head of the bed for the resident in Bed A in room [ROOM NUMBER]. The paper glue strip had a few dead flies stuck to it. There was an accumulation of yellow colored glue from previous strips staining the wall. During an observation and interview on 01/14/2026 at 12:04 PM, the resident in room [ROOM NUMBER] stated his room had not yet been cleaned today. Dark colored clumps of chewing tobacco were observed on the floor in the middle of the room. The resident stated he had dropped the tobacco. The restroom floor had dark colored build-up at the bottom of the wall along the cove-base (vinyl baseboard) and around the base of the toilet, and a brown colored dirt build-up was at the base of the door frame. A pizza box containing 8 squares of sliced pizza was in the open third drawer of the resident's dresser. The box was a holiday season box, with holiday figures in red decorating the box. The pizza was dried and curled up at the edges. The resident stated the pizza had been in the drawer for at least a week. He said he thought his family member had brought it to him. The resident stated the pizza needed to be thrown away. During an observation and interview on 01/14/2026 at 10:26 AM, a resident in room [ROOM NUMBER] stated one of the housekeepers did not empty the trash. She stated the housekeepers cleaned the room daily and had not yet been in the room today to clean. Observation of the restroom revealed the floor around the base of the toilet and along the cove base was soiled with a dark colored build-up of dirt, and the floor around the base of the door frame was soiled with a brown colored dirt build-up. A wash basin was positioned on the floor beneath the sink, and the drainpipe was soiled with a dried brown colored substance. Observation on 01/14/2026 at 1:08 PM revealed the restroom in room [ROOM NUMBER] had a urine odor, the floor tile had dark colored stains behind the base of the toilet, and the floor was soiled with dirt build-up along the base of the door frame. In an interview on 1/15/2026 at 11:25 AM, the Housekeeping Director stated the housekeeping staff cleaned all the rooms every day and deep cleaned one resident room per hall a day, which included moving the bed and dresser to clean under them. She stated that they also cleaned the windows during a deep clean. The Housekeeping Director stated the Maintenance Director was responsible for the floors that need repaired. The Housekeeping Director stated the expectation was for all resident rooms to be cleaned. She was not sure what a negative outcome would be from not cleaning the residents' rooms. In an interview on 1/15/2026 at 2:15 PM, the Maintenance Director stated the housekeeping staff deep cleaned one room on each hall per day. She stated that included baseboards, windows, windowsills, and bathrooms. The Maintenance Director stated she had heard about the dirty bathrooms and doorways. She stated the daily sweeping and mopping of the bathrooms and doorways should clean the dirt and stuff that was found. The Maintenance Director stated she repaired floors with missing pieces of tile with new tiles if she had the supplies, but if not she had been applying concrete to areas of the floor to make them flush so not to be a trip hazard. The Maintenance Director stated she had been in contact with the corporate office regarding the transition strips for the room thresholds and was working on getting bids to have them replaced. She stated she was not aware of any resident falls that were caused by the flooring or thresholds. The Maintenance Director stated her expectation was that all resident rooms, including the bathrooms, were deep cleaned once a month. She stated a negative outcome could be making the resident sick, or the floor, depending on where the floor was missing tiles or had been built up with concrete, could be a trip hazard. In an interview on 1/15/2026 at 5:00 PM, the Administrator stated it was her expectation that the floors were cleaned daily to include sweeping, mopping, scrubbing, and using the proper tools to clean the floors. She stated all rooms were deep cleaned once a month, including windows. The Administrator stated for floors that were damaged with missing and/or broken tiles, the staff should put a request into the software used for reporting items that needed repair and it should be done as soon as possible. She stated a negative outcome could be trip hazards for the residents. Record review of the facility policy for Homelike Environment, dated as revised February 2021, specified [in part]: Policy StatementResidents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and ImplementationStaff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment. Record review of the facility policy for Falls and Fall Risk, Managing, dated as revised March 2018, specified [in part]: Policy headingBased on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Policy Interpretation and ImplementationFall Risk Factors:Environmental factors that contribute to the risk of falls include: d. obstacles in the footpath. [The policy did not include additional information that pertained to flooring.]

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 1 resident (Resident #1) reviewed for respiratory care. 1. The facility failed to ensure Resident #1's nebulizer nasal cannula and oxygen nasal cannula was kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. The findings included: Record review of Resident #1's face sheet, dated 12/10/2024, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (severe or complete loss of strength or paralysis), Shortness of breath, Nasal congestion (stuffy nose), nutritional deficiencies, Urinary tract infection (infection that affects a part of the urinary tract), type 2 diabetes (adult diabetes). Record review of Resident #1's MDS quarterly assessment, dated 12/04/2024, reflected a BIMS score of 8, which indicated moderate cognitive impairment. Section I: Stroke, Diabetes Section O: None. Record review of Resident #1's Physician Orders, dated 10/12/2024, reflected an order for Oxygen at 2 liters per minute for shortness of breath/saturation (The amount of oxygen in a person's blood) below 90% as needed, PRN. A separate order dated 10/12/2024 stated to change the humidifier, nasal cannula/mask, and oxygen tubing every week on Sunday. Physician orders dated 11/29/2024 reflected an order for Albuterol/Ipratropium 0.5mg/3mg/3ml, give 1 vial via nebulizer mask every 4hrs prn cough/shortness of breath, PRN. A separate order dated 10/12/2024 stated to change the humidifier, nasal cannula/mask, and oxygen tubing every week on Sunday. Record review of Resident #1's quarterly Care Plan, dated 11/27/2024, reflected a care plan that does not include oxygen therapy. In an observation on 12/10/2024 at 10:45 AM revealed Resident #1 was lying in bed sleeping. Nebulizer observed on nightstand located on the right side of the bed, nebulizer tubing and cannula was lying on top of the nightstand not bagged, Oxygen concentrator observed sitting to the right side of bed, not in use at this time, tubing and nasal rolled up and stuck between concentrator handle, tubing and cannula not bagged. In an Interview on 11/11/2024 at 3:40 PM the Administrator stated it was her expectation that staff store nebulizer, and oxygen tubing and cannula in a bag when not in use. In an Interview on 12/11/2024 at 3:56 PM the DON stated her expectation was for nebulizer and oxygen tubing and cannula to be changed out each Sunday and when it was not in use it needs to be covered, in a bag. If not store properly they can collect dust or being damaged. Record review of a policy titled Oxygen Administration stated Oxygen/nebulizer tubing/masks to be changed by nursing department, weekly, and documented in the electronic health record. Place oxygen tubing in a clear plastic bag when not in use.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 1 facility reviewed for environmental concerns. The facility failed to replace a ceiling panel, repair water discoloration marks, repair the leak in the ceiling in Resident #29's room and repair water discoloration marks and the sagging ceiling in the dining area. This deficient practice 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 10/02/2024 at 05:35 PM revealed the following: 1. The ceiling inside Resident #29's room near the door was the area of concern. An approximately 2 feet by 2-foot square area of watermarked discolored sheet rock was noted in the ceiling. The area appeared to be a previous replacement or repair. Edges of the area appeared to be worn away due to moisture. A black substance was noted on the middle of the sheet rock patch, and in three other areas on patches. Water damage appeared to be outside of the previously replaced sheet rock area and noted on the textured ceiling. 2. The ceiling in the middle of the dining room was sagging downward with watermark discoloration around the air vent. Texture was flaking off the ceiling. In an interview on 10/04/24 at 09:58 AM Resident #29 stated that the ceiling in her room has been in poor condition since her arrival to that room. Resident #29 further stated that the ceiling leaks at times, with only some due to weather conditions, and the facility staff will put a bucket under leakage. She also stated that due to the location of the spot and leakage in the ceiling being in front of the door to her room, it makes it difficult for her to come in and out of her room with her walker. Resident #29 stated that the ceiling was fixed after surveyor observation. Resident #29 denied any breathing concerns. In an interview on 10/4/24 at 1:45 PM Maintenance Director stated that the dining room has been leaking since 9/24/24 and she has received bids for repair from two companies but needs three bids per corporate advisement. She further stated she is waiting on her corporate office at this time for repair directives. She stated her expectation is for the ceiling to be repaired and not fixing the ceiling could cause the ceiling to fall, causing injury. She continued to state that the maintenance department and administration were responsible for repairs. In an interview on 10/4/24 at 1:57 PM the Administrator stated the ceiling concern was identified on 9/24/24 and bids were received for repair on 9/26/24. She further stated upon identification of concern, the area was immediately closed off and resident tables were moved away from area of concern. ADM stated ceiling repair for Resident #29's room was done previously in 12/2023 but it has recently started leaking again upon rain. She stated the leaking has been apparent for approximately one month. She further stated that the facility has an open bid that was received on 9/17/24 to repair a larger area of the roof in that portion of the facility. The ADM stated her expectation was for the ceilings in the dining room and in resident rooms to be fully intact, functional, and appealing. She further stated it is also her expectation for residents to remain in an environment free of leaks, cracks, hazards, or potential harm. She further stated that the current ceiling conditions could lead to possible falling materials from the ceiling or trip hazards from debris or moisture on the floor. She stated that it is the responsibility of maintenance director and ADM to ensure a safe and comfortable physical environment for residents. Record review of policy Work Order, Maintenance revised April 2010 revealed the following [in-part]: 5. Emergency requests will be given priority in making necessary repairs. Record review of facility's Maintenance Logbook for the month of September 2024 revealed no work orders for repair of the dining room ceiling or Resident #29's room ceiling.

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection 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 (Resident #28) of 5 residents reviewed for infection control, in that: The facility failed to ensure clinical staff donned (put on) proper personal protective equipment when providing care to Resident #28, who was on contact isolation precautions, including gown, gloves, and mask. Facility failed to ensure that staff used proper laundry handling precautions. This failure could affect residents and place them at risk for cross contamination and infections. The findings included: Record review of Resident #28's face sheet dated 10/04/2024 revealed a [AGE] year-old male admitted to facility originally on 01/04/2024 with readmission on 08/04/2024. His diagnoses included: Non-ST elevation myocardial infarction (heart attack), Essential hypertension (high blood pressure), depression, other acute osteomyelitis, left ankle and foot (bone infection), and pain. Record review of Resident #28's active physician order dated 08/19/2024 revealed contact isolation (contagious requiring barriers between people and germs.) for MRSA (Methicillin-resistant Staphylococcus aureus bacteria) of wound culture. Observation on 10/02/24 at 12:45 PM revealed NA C entered Resident # 28's room to deliver a lunch tray wearing no personal protective equipment. NA C did not use hand sanitizer upon entering resident room or upon exiting resident room. Personal protective equipment station was noted outside of resident room. Contact Isolation sign posted on wall outside door. In an interview on 10/02/2024 at 12:51 PM NA C stated that she is unsure of what contact isolation precautions mean. She further stated that when she entered into Resident #28's room she did not wear personal protective equipment nor did she use hand hygiene upon entry or exit of room. NA C was unsure of what lack of proper infection control precautions could cause to residents or others. In an interview on 10/02/2024 at 1:07 PM Administrator stated her expectation is for staff to follow instructions posted on the wall outside the resident room regarding entering a resident room on contact isolation. She further stated that her expectation is for staff to follow infection control policy regarding PPE when entering Resident #28's room. She stated that lack of following posted infection control precautions regarding contact isolation could put others at risk of infection. ADM further stated that Resident #28 has been on contact isolation precautions since 08/19/2024. In an interview on 10/03/2024 at 3:13PM LA D stated if a resident is on isolation their personal items and linens should be placed in a red or marked bag which would make her aware of contamination and the use of additional personal protective equipment. She further stated that she has not received any linens in red bags or otherwise marked bags, all linens and personal items have been mixed with other resident's laundry. In an interview on 10/03/2024 at 3:28 PM NA D stated that she has changed the linens in Resident #28's room while the resident has been on contact isolation TBP. She further stated that the linens and laundry for Resident #28 were not bagged in a bag that would label them as contaminated. She continued to state that the clinical staff gather all laundry of residents (both linens and personal), take the laundry to the laundry room, and sort the laundry by hand into appropriate bins in the laundry room. She continued to state that she has not worn PPE while doing so nor has she treated Resident #28's laundry as contaminated. In an interview on 10/3/2024 at 4:36 PM the DON stated her expectation regarding the laundry of residents on contact isolation TBP is that laundry should be bagged in a bag and tied outside of the resident's room. She further stated staff should put the tied bag in a bin that also has a clear bag. She stated that bag does not have to be marked or labeled as contaminated. She continued to state that when staff get to laundry, the staff take the big bag out of the bin, and sort into the appropriate bins in the laundry. DON stated that laundry staff should wear full PPE while doing all laundry, and that all laundry should be treated as contaminated. She further stated that she was not aware that clinical floor staff was sorting through resident laundry and linens until this day. In an interview on 10/3/24 at 4:42 PM the Administrator revealed her expectation regarding laundry handling of residents on transmission-based precautions. She stated the laundry of residents on transmission-based precautions (contact isolation precautions) must be bagged in the resident's room in an appropriately labeled yellow bag. She continued to state that appropriate labeling allows laundry staff to handle laundry appropriately regarding PPE for TBP. She stated lack of doing so could cause spread of infection and all staff are responsible. Record review of policy Isolation-Initiating Transmission Based Precautions revised August 2019 revealed the following [in-part]: Policy Statement: Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; . and is at risk of transmitting the infection to other residents. Transmission-based precautions may include contact precautions, droplet precautions, or airborne precautions. Transmission-based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. Policy Interpretation and Implementation: 3. When transmission-based precautions are implemented, the infection preventionist (or designee): a. clearly identifies the type of precautions, the anticipated duration, and the personal protective equipment (PPE) that must be used. e. ensures that protective equipment (i.e. gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment; g. ensures that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room. Record review of CDC Infection Control https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html dated April 3, 2024 reflected: Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Record review of CDC Infection Control https://www.cdc.gov/infection-control/hcp/environmental-control/laundry-bedding.html CDC Infection Control dated January 8, 2024 stated [in-part]: G. Laundry and Bedding 3. Collecting, Transporting, and Sorting Contaminated Textiles and Fabrics The laundry process starts with the removal of used or contaminated textiles, fabrics, and/or clothing from the areas where such contamination occurred, including but not limited to patients' rooms, surgical/operating areas, and laboratories. Bags containing contaminated laundry must be clearly identified with labels, color-coding, or other methods so that health-care workers handle these items safely, regardless of whether the laundry is transported within the facility or destined for transport to an off-site laundry service.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: A. The facility's walk-in refrigerator had dust, food crumbs, and dried, spilled milk on the floor and underneath shelves. B. Kitchen floors were not swept and free from dirt, food particles, and trash. The facility's failure could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status. The findings included: Observation on 10/02/24 beginning at 9:40 AM, during the initial tour of kitchen, revealed refrigerator #1 had spilled, dry milk on the bottom in multiple areas, and underneath the shelves. In the corners and against the wall, there was dust and food crumbs. In the kitchen area, the floor was dirty with dirt and food crumbs and trash underneath the shelves and along the walls. In a follow-up interview and observation of the kitchen on 10/02/24 at 11:00 AM, there was no change in the soiled floors. In refrigerator #1, there was dry spilled milk in multiple areas and food crumbs underneath the shelves and along the bottom. In an interview with the Dietary Manager on 10/03/24 at 2:15 PM, The dietary manager stated the refrigerators were usually cleaned every week by the evening cook but, she must not have done it last week. She said there was a cleaning schedule, but it did not work out too well. So, the evening cook cleans the kitchen after the last meal of the day is served. That she follows the next day when she gets to work. She said that system is not the best but it was working out better. On 10/04/24 at 2:30 PM requested a dietary cleaning log and no log was provided. In an interview with the Administrator on 10/04/24 at 2:00 PM, she said it was her expectation for the kitchen to be cleaned daily. If food was spilled, it should be cleaned up at that time. Failure to do so had the potential for infection and pests. A record review of the facility policy Cleaning and Disinfection of Environmental Surfaces, dated as revised August 2019, revealed the following [in part]: 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Review of the Food and Drug Administration Food Code, dated 2017, specified [in part]: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (April 2024, May 2024, and June 2024) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 19 days of 91 days in April, May, and June 2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Record review of the CMS' PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 3, 2024 (April 1, 2024 - June 30, 2024), run date 09/24/2024, revealed partial (on 04/27/24) or no evidence of RN coverage for 19 of 91 days: 1. 04/06/2024 with no RN coverage. 2. 04/07/2024 with no RN coverage. 3. 04/13/2024 with no RN coverage. 4. 04/14/2024 with no RN coverage. 5. 04/20/2024 with no RN coverage. 6. 04/21/2024 with no RN coverage. 7. 04/27/2024 with only 6.25 hours of RN coverage. 8. 05/04/2024 with no RN coverage. 9. 05/05/2024 with no RN coverage. 10. 05/11/2024 with no RN coverage. 11. 05/12/2024 with no RN coverage. 12. 05/18/2024 with no RN coverage. 13. 05/19/2024 with no RN coverage. 14. 06/01/2024 with no RN coverage. 15. 06/02/2024 with no RN coverage. 16. 06/08/2024 with no RN coverage. 17. 06/09/2024 with no RN coverage. 18. 06/22/2024 with no RN coverage. 19. 06/23/2024 with no RN coverage. In an interview and record review on 10/04/2024 at 10:00 AM, the Administrator provided the timecard reports for the months of April 2024, May 2024, and June 2024, for the dates of 04/06/2024, 04/07/2024, 04/13/2024, 04/14/2024, 04/20/2024, 04/21/2024, 04/27/2024, 05/04/2024, 05/05/2024, 05/11/2024, 05/12/2024, 05/18/2024, 05/19/2024, 06/01/2024, 06/02/2024, 06/08/2024, 06/09/2024, 06/22/2024, 06/23/2024. They revealed there was no RN coverage or a full 8 hours of RN coverage for those dates. The Administrator verbally confirmed there was no RN coverage or a full 8 hours of RN coverage for the dates of 04/06/2024, 04/07/2024, 04/13/2024, 04/14/2024, 04/20/2024, 04/21/2024, 04/27/2024, 05/04/2024, 05/05/2024, 05/11/2024, 05/12/2024, 05/18/2024, 05/19/2024, 06/01/2024, 06/02/2024, 06/08/2024, 06/09/2024, 06/22/2024, 06/23/2024. In an interview on 10/04/2024 at 12:04 PM, the DON said her understanding of the facility policy is an RN is to be on staff 8 hours a day. However, it took them a long time to find RNs. She said they try the best they can and they are not always successful. She continued to say, it's always better to have them. When asked about what the possible negative outcomes would be if a resident needed an assessment that only an RN could do she said I'm only 15 minutes down the road and I always answer my phone and if they call I'm coming. A facility policy was requested from the Administrator on 10/04/2024 at 11:15 AM. A policy statement was provided that states A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. The administrator reported finding RN staffing is difficult in this area; however, they have recently employed three RNs whom they have implemented into the RN staffing schedule.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured in locked compartments and permit only authorized personnel to have access to the keys for 1 of 2 medication carts observed for medication storage. The facility did not ensure the Medication Cart (C/D hall cart) was locked and secured. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them. Findings included: Observation on 10/04/2024 at 11:57 AM revealed the medication cart for C/D hall was found unlocked parked on the left side of the nurse's station. There was no nurse in sight, and no nurse near the nurse's station. The medication cart was unattended. Medications in the cart included prescription medications, over the counter medications and narcotics. In an interview on 10/04/2024 at 12:36 PM RN B stated she was not aware that the medication cart was unlocked. She further stated that the medication cart is to be locked at all times when not in use by the nurse. She continued to state that lack of medication cart security could result in tragedy such as residents taking other medications or giving them to other residents. RN B stated that she is responsible for security of her assigned medication cart. In an interview on 10/04/2024 at 1:57 PM Administrator revealed that her expectation is medication carts should always remain locked if the nurse is not directly with the cart or administering medications. She further stated that lack of medication cart security could result in resident or staff access to any medications in the cart. She stated the nurse assigned to the medication cart is responsible for medication cart security. She continued to state nursing management is responsible to ensure security of medication carts through observation and rounds in the facility. In an interview on 10/04/2024 at 2:15 PM DON revealed the medication cart observed unlocked was the medication cart for C/D halls. She stated that her expectation is for medication carts to be locked if the nurse it not with the medication cart. She further stated that lack of cart security would allow any resident and/or staff to open the door, have access to the medications, and could be detrimental. DON stated that the nurse assigned to the medication cart is responsible for security and she was ultimately responsible as well. Record review of policy Medication Labeling and Storage revised February 2023 revealed the following [in-part]: Medication Storage: 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 resident (Resident #11) reviewed for respiratory care. 1. The facility failed to ensure Resident #11's nasal cannula was kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. The findings included: Record review of Resident #11's face sheet, dated 10/04/2024, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #11 had diagnoses which included Dependence on Supplemental Oxygen (requires supplemental oxygen to properly breathe), Chronic Respiratory Failure with Hypoxia (occurs when the body has low levels of oxygen in the body causing breathing difficulty), Unspecified Chronic Bronchitis (inflammation of lungs making it difficult to breathe.) Record review of Resident #11's MDS annual assessment, dated 09/01/2024, reflected a BIMS score of 11, which indicated moderate cognitive impairment. Section I: Active diagnosis reflected chronic pulmonary disease, or chronic lung disease. Section O: Respiratory Treatments was marked for Oxygen Therapy. Record review of Resident #11's Physician Orders, dated 10/04/2024, reflected an order for Oxygen at 2 liters per minute for shortness of breath/saturation (The amount of oxygen in a persons blood)below 90% as needed. A separate order stated to change the humidifier, nasal cannula/mask, and oxygen tubing every week on Sunday. Record review of Resident #11's quarterly Care Plan, dated 09/18/2024, reflected a care plan for Oxygen Therapy: Resident requires oxygen therapy related to hypoxemia (Low oxygen in the blood). Resident has an order for oxygen per NC @ 2 L/M PRN SOB or SAT below 90%. The In an observation on 10/03/2024 at 12:32 PM revealed Resident #11 was lying in bed. She was using a nasal cannula attached to an oxygen concentrator. Her wheelchair containing a portable oxygen tank was noted with tubing and nasal cannula attached. A storage bag was noted on the wheelchair; however, the tubing and cannula were hung on the handle of the wheelchair, not stored inside the bag. In an Interview on 10/04/2024 at 3:10 PM the Administrator stated tubing is to be stored in a bag when not in use. In an Interview on 10/04/2024 at 3:30 PM DON stated When is in not in use it needs to be covered, in a bag. With resident that are mobile, they will take it off lay it down and staff doesn't know it laying out, with residents with limited mobility staff will place it in the bag. If not store properly they can collect dust or being damaged. In an observation on 10/03/24 at 3:45PM revealed Resident #11 was laying in bed. She was using a nasal cannula attached to an ocygen concentrator. Her wheelchair contained a portable oxygen tank and was observed with tubing and nasal cannula attached. A storage bag was on the wheelchair; howver, the tubing and cannual were hung on the handle of the wheelchair, and not stored inside the bag. The facility provided a policy titled Oxygen Administration that states Oxygen/nebulizer tubing/masks to be changed by nursing department, weekly, and documented in the electronic health record. Place oxygen tubing in a clear plastic bag when not in use.

Based on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one of one resident (Resident #40) reviewed for quality of care . The facility failed to ensure Resident #40 had physician orders regarding care of the surgery site, post hip replacement surgery, on 07/30/2023. The 8 surgical staples were not removed until 08/13/2023, 14 days after surgery which resulted in a superficial infection. This failure could place residents at risk of unmet care needs and infection. The findings include: Record review of Resident #40's Face Sheet, not dated, revealed a [AGE] year-old male who was admitted to the facility on [DATE] for aftercare following right hip replacement surgery on 07/20/2023. Resident #40 had diagnoses which included dementia (a decline in cognitive abilities that impacts a person's ability to do everyday activities), pathological fracture of hip, pain, aftercare following joint replacement surgery, and urinary tract infection. Record review of Resident #40's electronic record revealed from the time of admission on 07/22/2023 to 08/12/2023 there were no documented surgical wound assessments or treatments until Resident #40 complained of discomfort on 08/12/2023. Record review of progress note, dated 08/12/2023, revealed Resident #40 complained of discomfort to his right hip to the LVN . The LVN assessment revealed Resident #40's right hip was red with a scant amount of white drainage at the incision site. The Medical Director was notified, and Resident #40 was sent to the ER for evaluation on 08/13/2023. Record review of discharge paperwork from the hospital, dated 08/13/2023, revealed Resident #40 had a yeast infection surrounding the incision site. The staples were noted to have brown cream-colored exudative discharge. Foul smell was noted. The 8 staples were removed. The resident was treated for fungal and bacterial infections. The resident was placed on the oral antibiotic Bactrim for the infection and oral antifungal fluconazole for the yeast infection . In an interview on 08/23/2023 at 9:32 AM, Resident #40 said he did not receive any type of care for his surgical wound until after he came back from the hospital on 08/13/2023 with an infection at site of the staples. In an interview on 08/23/2023 at 9:55 AM, the DON said she handled the admission of Resident #40. There was not an order to remove Resident #40's surgical staples when he was admitted to the facility in the resident's admission paperwork. She said there was no documentation which indicated Resident #40's wound was assessed or any type of wound treatment between the time of admission on 07/22/2023 till the time the nurse checked his wound per resident request on 08/12/2023. The DON said Resident #40's staples should have been taken out in 7-10 days. She revealed that the resident's staples were always covered by a clean bandage. She said failure to do so had the potential to result in irritation and infection of the wound site. In an interview on 08/23/2023 at 10:01 AM, Resident #40 said he did not receive any type of care for his surgical staples until after he came back from the hospital on 08/13/2023. He said on 08/12/2023 he complained to the nurse that his bandage was bothering him and asked the nurse to check it. He revealed he did not have any type of pain or discomfort from the area around the staples prior to 08/12/2023. That was when signs of infection were discovered, and he was sent to the ER. He said no one had looked at the staples from the time he arrived at the facility until the time he asked the nurse to check it on 08/12/2023. He said he came back from the hospital on antibiotics for a possible infection from his surgical staples. He said the wound was now healed. In an interview on 08/23/2023 at 4:33 PM, the ADON said she did not evaluate or perform any care to Resident #40's surgical wound from the time of admission on 07/22/2023 to 08/12/2023. She said it was the charge nurse that was on duty responsibilitity to assess and treat the wound if needed. In an interview on 08/23/2023 at 5:15 PM, the Medical Director, who is also the primary care physican, said Resident #40's staples should have been removed by day 10 post surgery. He said he was very frustrated with the facility when he was notified on 08/12/2023 that Resident #40's staples had not been removed. He said it was his opinion the staples not being removed by day 10 post surgery caused the infection. He said Resident #40 was sent to the ER, his infection was superficial, he was placed on antibiotics, and returned to the facility. He said the wound was now healed. In a follow up interview on 08/24/2023 at 9:20 AM, the DON said the failure to have the staples removed was her responsibility. She revealed there was documentation for the staples to be removed in 7 to 10 days. When asked to provide the documentation, the DON stated she was too busy training a new agency nurse. In an interview on 08/24/2023 at 9:25 AM, The Administrator said she thought the DON saw something in Resident #40's paperwork about the staples being removed within 7-10 days. She looked in Resident #40's paperwork but said she didn't see it. She took the paperwork and said she would go and ask the DON. The documentation was never provided by the facility. In an interview on 08/24/2023 at 10:30 AM, LVN A said she did not evaluate or perform any care to Resident #40's surgical wound from the time of admission on 07/22/2023 to 08/12/2023. She said there was not any doctor's orders regarding Resident #40's surgical wound or removal of staples. In an interview on 08/24/2023 at 10:46 AM, LVN B said she did not evaluate or preform any care to Resident #40's surgical wound from the time of admission on 07/22/2023 to 08/12/2023. She said there were not any doctor's orders regarding Resident #40's surgical wound and removal of staples. Record review of the facility's policy Admission Notes, dated as revised September 2012, revealed the following [in part]: Policy Statement: Preliminary resident information shall be documented upon a resident's admission to the facility. Policy Interpretation and Implementation: 1. When a resident is admitted to the nursing unit, the admitting Nurse must document the following information (as each may apply) in the nurses' notes, admission form, and other appropriate place as designated by facility protocol: h. the time the physician's orders were received and verified; j. the presence of a catheter, dressings, etc .

Based on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one of one resident (Resident #40) reviewed for quality of care . The facility failed to ensure Resident #40 had physician orders regarding care of the surgery site, post hip replacement surgery, on 07/30/2023. The 8 surgical staples were not removed until 08/13/2023, 14 days after surgery which resulted in a superficial infection. This failure could place residents at risk of unmet care needs and infection. The findings include: Record review of Resident #40's Face Sheet, not dated, revealed a [AGE] year-old male who was admitted to the facility on [DATE] for aftercare following right hip replacement surgery on 07/20/2023. Resident #40 had diagnoses which included dementia (a decline in cognitive abilities that impacts a person's ability to do everyday activities), pathological fracture of hip, pain, aftercare following joint replacement surgery, and urinary tract infection. Record review of Resident #40's electronic record revealed from the time of admission on [DATE] to 08/12/2023 there were no documented surgical wound assessments or treatments until Resident #40 complained of discomfort on 08/12/2023. Record review of progress note, dated 08/12/2023, revealed Resident #40 complained of discomfort to his right hip to the LVN . The LVN assessment revealed Resident #40's right hip was red with a scant amount of white drainage at the incision site. The Medical Director was notified, and Resident #40 was sent to the ER for evaluation on 08/13/2023. Record review of discharge paperwork from the hospital, dated 08/13/2023, revealed Resident #40 had a yeast infection surrounding the incision site. The staples were noted to have brown cream-colored exudative discharge. Foul smell was noted. The 8 staples were removed. The resident was treated for fungal and bacterial infections. The resident was placed on the oral antibiotic Bactrim for the infection and oral antifungal fluconazole for the yeast infection . In an interview on 08/23/2023 at 9:32 AM, Resident #40 said he did not receive any type of care for his surgical wound until after he came back from the hospital on [DATE] with an infection at site of the staples. In an interview on 08/23/2023 at 9:55 AM, the DON said she handled the admission of Resident #40. There was not an order to remove Resident #40's surgical staples when he was admitted to the facility in the resident's admission paperwork. She said there was no documentation which indicated Resident #40's wound was assessed or any type of wound treatment between the time of admission on [DATE] till the time the nurse checked his wound per resident request on 08/12/2023. The DON said Resident #40's staples should have been taken out in 7-10 days. She revealed that the resident's staples were always covered by a clean bandage. She said failure to do so had the potential to result in irritation and infection of the wound site. In an interview on 08/23/2023 at 10:01 AM, Resident #40 said he did not receive any type of care for his surgical staples until after he came back from the hospital on [DATE]. He said on 08/12/2023 he complained to the nurse that his bandage was bothering him and asked the nurse to check it. He revealed he did not have any type of pain or discomfort from the area around the staples prior to 08/12/2023. That was when signs of infection were discovered, and he was sent to the ER. He said no one had looked at the staples from the time he arrived at the facility until the time he asked the nurse to check it on 08/12/2023. He said he came back from the hospital on antibiotics for a possible infection from his surgical staples. He said the wound was now healed. In an interview on 08/23/2023 at 4:33 PM, the ADON said she did not evaluate or perform any care to Resident #40's surgical wound from the time of admission on [DATE] to 08/12/2023. She said it was the charge nurse that was on duty responsibilitity to assess and treat the wound if needed. In an interview on 08/23/2023 at 5:15 PM, the Medical Director, who is also the primary care physican, said Resident #40's staples should have been removed by day 10 post surgery. He said he was very frustrated with the facility when he was notified on 08/12/2023 that Resident #40's staples had not been removed. He said it was his opinion the staples not being removed by day 10 post surgery caused the infection. He said Resident #40 was sent to the ER, his infection was superficial, he was placed on antibiotics, and returned to the facility. He said the wound was now healed. In a follow up interview on 08/24/2023 at 9:20 AM, the DON said the failure to have the staples removed was her responsibility. She revealed there was documentation for the staples to be removed in 7 to 10 days. When asked to provide the documentation, the DON stated she was too busy training a new agency nurse. In an interview on 08/24/2023 at 9:25 AM, The Administrator said she thought the DON saw something in Resident #40's paperwork about the staples being removed within 7-10 days. She looked in Resident #40's paperwork but said she didn't see it. She took the paperwork and said she would go and ask the DON. The documentation was never provided by the facility. In an interview on 08/24/2023 at 10:30 AM, LVN A said she did not evaluate or perform any care to Resident #40's surgical wound from the time of admission on [DATE] to 08/12/2023. She said there was not any doctor's orders regarding Resident #40's surgical wound or removal of staples. In an interview on 08/24/2023 at 10:46 AM, LVN B said she did not evaluate or preform any care to Resident #40's surgical wound from the time of admission on [DATE] to 08/12/2023. She said there were not any doctor's orders regarding Resident #40's surgical wound and removal of staples. Record review of the facility's policy admission Notes, dated as revised September 2012, revealed the following [in part]: Policy Statement: Preliminary resident information shall be documented upon a resident's admission to the facility. Policy Interpretation and Implementation: 1. When a resident is admitted to the nursing unit, the admitting Nurse must document the following information (as each may apply) in the nurses' notes, admission form, and other appropriate place as designated by facility protocol: h. the time the physician's orders were received and verified; j. the presence of a catheter, dressings, etc .

41871 45437 Based on interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 12 of 12 residents (Resident #1, Resident #10, Resident #11, Resident #12, Resident #14, Resident #15, Resident #19, Resident #22, Resident #23, Resident #28, Resident #40, and Resident #193) reviewed for care plans. The facility failed to ensure resident care plans were developed and updated within 7 days following the completion of the MDS as well as having an Intradisciplinary Team present and at the care conference and involved in the care planning process. This failure could place residents at risk of not have having their care plans completed accurately and timely. Findings include: 1. Record review of Resident #1's face sheet revealed an [AGE] year-old male who was admitted to the facility 06/07/2023 and readmitted on [DATE]. Resident #1 had diagnoses which included chronic venous hypertension (increased pressure in your veins), dysphagia (difficulty swallowing), Sickle cell disease (sickle cells have become stuck in the blood vessels), and Surgical instruments, materials and anesthesiology devices (including sutures) associated with adverse incidents. Record review of Resident #1's Annual MDS assessment, dated 02/06/2023, revealed the following: Section C revealed the resident had a BIMS score of 08, which indicated moderately Impaired cognition. The care plan had not been updated or revised following the annual assessment. Record review of Resident #1's electronic Care Conference record did not have a care plan meeting since 09/15/2021. 2. Record review of Resident #10's face sheet revealed a [AGE] year-old female who was admitted to the facility 01/21/2022. Resident #10 had diagnoses which included Depression (feelings of severe despondency and dejection), Anemia (low blood count), Atrial fibrillation (irregular often rapid heart rate), dementia (decline in cognitive abilities), repeated falls and psychotic disorder (mind cannot determine what is real or not real). Record review of Resident #10's Admission MDS assessment, dated 12/20/2022, revealed the following: Section C revealed the resident had a BIMS score of 02, which indicated severe cognitive Impairment. The care plan had not been updated or revised following the admission assessment. Record review of Resident #10's electronic Care Conference record did not have a care plan documented until 08/03/2023. 3. Record review of Resident #11's face sheet revealed an [AGE] year-old male who was admitted to the facility 07/27/2023. Resident #11 had diagnoses which included Vascular dementia (dentinal due to decreased blood flow), unspecified severity, with mood disturbance (inadequate blood flow to the brain which causes mood irregularities), Anemia (low blood count), bipolar (periods of mood disturbances and swings that last more than 2 weeks), and hypertension (high blood pressure). Record review of Resident #11's Admission MDS assessment, dated 08/03/2023, revealed the following: Section C revealed the resident had a BIMS score of 05, which indicated severe cognitive Impairment. The care plan had not been updated or revised following the admission assessment. Record review of Resident #11's electronic Care Conference record did not have a care plan meeting since admission in the facility. 4. Record review of Resident #12's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #12 had diagnoses which included retention or urine (not able to urinate properly), acute kidney failure (kidney is unable to filter waste), Type 2 diabetes mellitus (body does not produce enough insulin) and cerebral infarction (disrupted blood flow to the brain to due problems in the blood vessels). Record review of Resident #12's Admission MDS assessment, dated 06/21/2023, revealed the following: Section C revealed the resident had a BIMS score of 15, which indicated no cognitive impairment. The care plan had not been updated or revised following the admission assessment. Record review of Resident #12's electronic Care Conference record did not have a care plan meeting until 07/26/2023. 5. Record review of Resident #14's face sheet revealed a [AGE] year-old female who was admitted to the facility 03/02/2021 and readmitted on [DATE]. Resident #14 had diagnoses which included Chronic obstructive pulmonary disease (decreased airflow to the lungs), congestive heart failure (heart is unable to pump adequately), dysphagia (difficulty swallowing) and dementia (decline in cognitive abilities). Record review of Resident #14's Annual MDS assessment, dated 03/10/2023, revealed the following: Section C revealed the resident had a BIMS score of 14, which indicated no cognitive Impairment. The care plan had not been updated or revised following the annual assessment. Record review of Resident #14's electronic Care Conference record did not have a care plan meeting since 11/16/2022. 6. Record review of Resident #15's face sheet revealed an [AGE] year-old male who was admitted to the facility 03/02/2021. Resident #15 had diagnoses which included hypertension (high blood pressure), vascular dementia (inadequate blood flow to the brain which causes memory loss), cognitive communication deficit (unable to communicate adequately) and malnutrition (lack of proper nutrition to sustain the body). Record review of Resident #15's Quarterly MDS assessment, dated 07/26/2023, revealed the following: Section C revealed the resident had a BIMS score of 08 (Severe cognitive Impairment). The care plan had not been updated or revised following the quarterly assessment. Record review of Resident #15's electronic Care Conference record did not have a care plan meeting since 02/15/2023. 7. Record review of Resident #19's face sheet revealed a [AGE] year-old male who was admitted to the facility 01/27/203. Resident #19 had diagnoses which included cerebral palsy (congenital disorder of movement due to abnormal brain development), hypertension (high blood pressure), major depressive disorder (mood disorder that lasts more than 2 weeks), anxiety (state of anxiousness), Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis on the right side after inadequate blood flow to the brain). Record review of Resident #19's Admission MDS assessment, dated 02/01/2023, revealed the following: Section C revealed the resident had a BIMS score of 09, which indicated moderate cognitive Impairment. The care plan had not been updated or revised following the admission assessment. Record review of Resident #19's electronic Care Conference record did not have a care plan meeting since admission. 8. Record review of Resident #22's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #11 had diagnoses which included heart failure, chronic respiratory failure, chronic obstructive pulmonary disease (a group of lung diseases that block air flow and make it difficult to breath), bipolar disorder (a mental disorder characterized by mood swings resulting depressive lows and manic highs), Anxiety (state of anxiousness), repeated Falls and Hypertension (high blood pressure). Record review of Resident #22's Admission MDS assessment, dated 08/08/2023, revealed the following: Section C revealed the resident had a BIMS score of 2, which indicated severe cognitive impairment. The care plan had not been updated or revised following the admission assessment. Record review of Resident #22's Care Conference notes did not have a care conference meeting since admission. 9. Record review of Resident #23's face sheet revealed a [AGE] year-old male who was admitted to the facility 12/03/2020 and readmitted on [DATE]. Resident #23 had diagnoses which included schizophrenia (mental disorder that is characterized by continuous relapses in psychosis), dementia (decline in cognitive abilities) and delusional disorder (mind cannot determine what is real or not real). Record review of Resident #23's Annual MDS assessment, dated 07/28/2023, revealed the following: Section C revealed the resident had a BIMS score by staff assistance that revealed modified independence on cognitive skills. The care plan had not been updated or revised following the annual assessment. Record review of Resident #23's electronic Care Conference record did not have a care plan meeting since 02/15/2023. 10. Record review of Resident #28's face sheet revealed a [AGE] year-old male who was admitted to the facility 12/10/2021 and readmitted on [DATE]. Resident #28 had diagnoses which included Diverticulitis of intestine (inflammation of the large intestines), major depressive disorder (depression lasting more than 2 weeks), struck by turtle (hit with an object that was a turtle), and cognitive communication deficit (difficulty communicating). Record review of Resident #28's Admission MDS assessment, dated 12/20/2022, revealed the following: Section C revealed the resident had a BIMS score of 02, which indicated severe cognitive Impairment. The care plan had not been updated or revised following the admission assessment. Record review of Resident #28's electronic Care Conference record did not have a care plan meeting since 12/28/2022. 11. Record review of Resident #40's face sheet revealed a [AGE] year-old male who was admitted to the facility 07/22/2023. Resident #10 had diagnoses which included hypertension (high blood pressure), difficulty in walking, cognitive communication deficit (difficulty in communicating), aftercare following joint replacement surgery (surgery aftercare). Record review of Resident #40's Admission MDS assessment, dated 07/28/2023, revealed the following: Section C revealed the resident had a BIMS score of 14, which indicated no cognitive Impairment. The care plan had not been updated or revised following the admission assessment. Record review of Resident #40's electronic Care Conference record did not have a care plan documented until 08/16/2023. 12. Record review of Resident #193's face sheet revealed a [AGE] year-old female who was admitted to the facility 03/30/2023 and readmitted on [DATE]. Resident #193 had diagnoses which included chronic pain, hypertension (high blood pressure) and altered mental status. Record review of Resident #193's Quarterly MDS assessment, dated 07/07/2023, revealed the following: Section C revealed the resident had a BIMS staff assessment of 01 for modified independence for cognitive skills. The care plan had not been updated or revised following the quarterly assessment. Record review of Resident #193's electronic Care Conference record did not have a care plan since readmission into the facility. Interview with the DON on 08/23/23023 at 9:55 AM revealed normally the MDS Coordinator was responsible for completing the care plans after the MDS assessments and letting the other departments know to have a care plan meeting. She revealed she updated the care plans when a resident had an acute change of condition, but it was not a comprehensive care plan. She said she was going to start with the help of her ADON to complete the comprehensive care plans. She said they knew it was an issue and was trying to catch up, but she had only been in her position for a couple of months. She revealed this failure could place residents at risk for not having their care plan areas identified accurately . In an interview on 08/25/2023 at approximately 11:10 AM, the Regional MDS Coordinator said she was the one who was responsible for completing the Comprehensive Care plans and notifying the facility to schedule a meeting. She revealed there was a miscommunication, and she did not know she was supposed to complete the comprehensive care plans or even update the care plan. She said they had not been completed by her or anyone else in the building. She stated this failure could place the residents at risk for not having a care plan. Record review of the facility's policy titled: Care Planning- Interdisciplinary team, dated 09/2015 revealed the following: Policy Statement- Our facilities care planning interdisciplinary team is responsible for the development of an individual comprehensive care plan for each resident. Policy Interpretation and Implementation- 1. A conference of care plan for each resident is develop within seven days of completion of the resident assessment MDS. 2. The care plan is based on the residence comprehensive assessment and is developed by care planning/interdisciplinary team which includes but it's not necessarily limited to the following personnel . Every effort will be made to schedule care plan meeting so the best time of the day for the resident and family

Based on interview and record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 3 of 3 months (January, FebruaryFebruary, and March 2023) reviewed for nursing services. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours on ten weekends January, February, and March 2023 This failure placed could place the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings included: Record review of the facility's nursing schedule for RN coverage for January 2023, February 2023, and March 2023 revealed, the Director of Nurses worked Monday through Friday. The schedule did not reflect another RN working during that time period. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours on Sunday 01/01/2023, Saturday 01/07/2023, Sunday 01/08/2023, Saturday 01/14/2023, Sunday 01/15/2023, Saturday 01/21/2023, Sunday 01/22/2023, Saturday 01/28/2023, Sunday 01/29/2023, Saturday 02/04/2023, Sunday 02/05/2023, Saturday 02/11/2023, Sunday 02/12/2023, Saturday 02/25/2023, Sunday 02/26/2023, Saturday 03/11/2023, Sunday 03/12/2023, Friday 03/24/2023, Saturday 03/25/2023 and Sunday 03/26/2023. In an interview with the Director of Nurses on 08/26/2023 at 10:34 AM, she said she was not employed by the facility at that time, however her expectation was that the facility had seven day a week RN coverage . There were no other RNs working at the facility. The DON further stated, not having RN coverage 7 days a week could put the residents at risk of not having their healthcare needs managed properly. In an interview with the Administrator on 08/26/2023 at 10:45 AM, she stated she was not yet employed by this the facility but it is was her expectation that they provided RN coverage seven days a week.

Based on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 15 sampled residents (Residents #'s 12) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #12's MDS was accurately coded as receiving dialysis. 2. The facility failed to ensure Resident #12's MDS continence status was accurately . This failure could place residents at risk of not receiving the proper care and services due to inaccurate records. Findings include: Record review of Resident #12's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #12 had diagnoses which included retention or urine (not able to urinate properly), acute kidney failure (kidney is unable to filter waste), Type 2 diabetes mellitus (body does not produce enough insulin) and cerebral infarction (disrupted blood flow to the brain to due problems in the blood vessels). Record review of Resident #12's Admission MDS, dated [DATE], revealed the following: Section H revealed the resident was coded as having in indwelling catheter in H0100 under appliances but was always continent in H0300 under urinary continence. Section O revealed the resident received dialysis while a resident. Record review of Resident #12's current care plan revealed the following areas: Problem: Indwelling Catheter Potential for complications related to indwelling urinary catheter. Goal: Will remain free s/sx of complications related to catheter through review date. Problem: Resident has history of dependence on renal dialysis related to renal failure. Resident came off of dialysis in 2021. Goal: Resident will not exhibit signs of fluid volume excess. In an interview on 08/23/2023 at 2:05 PM with the ADON revealed Resident #12 had not been receiving dialysis. She was unsure why he was coded as receiving while in the facility . In an interview on 08/25/2023 at approximately 11:10 AM, the Regional MDS Coordinator said she was the one who was responsible for completing the MDS's with accuracy. She said she had inaccurately coded Resident #12 as receiving dialysis, since he was previously receiving dialysis. She revealed she should have checked the record more thoroughly. She revealed Resident #12 had an indwelling catheter and she should not have coded him as being continent under urinary continence. She stated she should have coded him as not rated , resident had a catheter. She revealed this failure could place residents at risk for inaccurate assessments and inadequate care areas . She revealed she went by the Resident Assessment manual for guidance. Record review of CMS'S RAI Version 3.0 Manual version 1.17.1, dated October 2019, revealed: The RAI process has multiple regulatory requirements, require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.

45437 Based on interviews and record reviews the facility failed to a comprehensive assessment was completed within 14 days after the facility determined or should have determined, that there was a significant change in the resident's physical condition or mental condition for 2 of 10 residents (Residents #14, and Resident #40) reviewed for assessments. The facility failed to capture a comprehensive MDS assessment after Resident # 14 and Resident #40 had a significant decline and a hospital stay. This failure could place residents at risk for not being assessed for a change in condition and the need to revise their care plans to address changes in condition and develop interventions to meet their needs for care assistance and treatments. The findings include: 1. Record review of Resident #14's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #14 had diagnoses which included Chronic obstructive pulmonary disease (decreased airflow to the lungs), congestive heart failure (heart is unable to pump adequately), dysphagia (difficulty swallowing) and dementia (decline in cognitive abilities). Record review of Resident #14's MDS schedule reflected an annual assessment on 03/10/2023, reflected In Section G- Bed mobility- independent, transfers- supervision, walk-in in room- supervision, locomotion of unit- supervision, dressing- supervision, toilet use- supervision, persona hygiene- supervision. Section O reflected - Received oxygen therapy while a resident Record review of Resident #14's MDS Schedule reflected the last assessment as a Quarterly assessment on 05/12/2023, not a significant change assessment. It revealed the following- Section A- On 05/07/2023 she was readmitted into the facility from an Acute hospital. Section G- Bed mobility- extensive, transfers- extensive, walk-in room- activity occurred once or twice, locomotion of unit- activity occurred once or twice, dressing- extensive, toilet use- extensive, personal hygiene- limited. Section O- Received oxygen while a resident and while not a resident. IV Medication while not a resident. 2. Record review of Resident #40 face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] for aftercare following right hip replacement surgery on 07/20/2023. Resident #40 had diagnoses which included dementia (loss of memory), pathological fracture of hip (broken hip), pain, aftercare following joint replacement surgery, and urinary tract infection (care after joint replacement surgery and an infection in the urinary tract). Record review of progress note, dated 08/12/2023, revealed Resident #40 complained of discomfort to his right hip. Resident #40's right hip was red with a scant amount of white drainage at the incision site. The Medical Director was notified, and Resident #40 was sent to the emergency room for evaluation on 08/13/2023. Record review of discharge paperwork from the hospital, dated 08/13/2023, revealed Resident #40 had a yeast infection surrounding the incision site, as well as a potential bacterial infection within the incision itself. The staples were noted to have brown cream-colored exudative discharge. Foul smell was noted. The 8 staples were removed. The resident was treated for both fungal and bacterial infections. The resident was placed on the oral antibiotic Bactrim for the infection and oral antifungal fluconazole for the yeast infection. In an interview on 08/25/2023 at approximately 11:10 AM, the Regional MDS Coordinator said she was the one who was responsible for completing the MDS's and identifying if the resident had a significance change. She revealed Resident #14 and Resident #40 had a decline when they went to the hospital, and she should have completed a significant change MDS upon their return. She revealed this failure placed the residents at risk for not having a comprehensive assessment and an updated CAAS. She revealed it was not updated to reflect the change in condition due to her missing it.

Based on observation, interview and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 2 residents, (Resident #11) reviewed for PASRR Level 1 screenings. The facility did not correctly identify Resident #11 as having a mental illness and did not complete a new PASRR Level One Screening. This failure could place residents at risk of not being evaluated for PASRR services. The findings were: Record review of Resident #11's face sheet, dated 08/25/2023, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #11's had diagnoses which included Mood disturbance (decreased blood flow to the brain that causes mood disturbances), bipolar (mental disorder that is characterized by mood swings that last more than 2 weeks), and depression (state of sadness). Record review of Resident #11 Physician Orders, dated 08/25/2023, revealed orders for olanzapine; 5 mg; 1 tablet 2 times a day for bipolar, and an order for Lexapro; 5 mg; 1 tablet 1 time a day for depression. Record review of the Admission MDS , dated 08/03/2023, revealed Resident #11 could understand others and was understood by others; had a severe cognitive impairment with a BIMS score of 05, which indicated severe cognitive impairment. No mood or behavior concerns were indicated on the MDS, dated [DATE]. Record review of Resident #11's Care Plan, dated 07/27/2023, revealed the resident received antipsychotic medicine. Record review of Resident #11's PASRR Level One Screening Forms, dated 08/25/2023, revealed he did not have a primary diagnosis of dementia. It revealed he was negative for mental illness, intellectual disability, or developmental disability. The form had not been updated. In an interview on 08/23/2023 at approximately 9:45 AM, the DON revealed she was somewhat familiar with the PASRR process. She stated they were in the process of hiring an in house MDS Coordinator. After looking over the clinical records of Resident #11, she revealed the PL1 should have been positive for mental illness do to the bipolar diagnosis and the resident being on antipsychotics . She had not updated the resident's PASRR due to just starting in her position and not having completed the adequate training to identify the need to update it. In an interview on 08/25/2023 at approximately 11:10 AM the Regional MDS Coordinator said that given the diagnosis of Resident #11 a PL1 reflecting Mental Illness should have been completed. She would be submitting the corrected forms at her earliest convenience.