Every finding on record at Azure Shores Rehab

Based on observations, interviews, and records reviewed it was determined that the facility did not appropriately maintain the Advance Directives for one (101) out of four sampled residents receiving hospice services. Resident # 101's medical record included a signed Do Not Resuscitate form, a physician's order for Full Code and a signed Advanced Directive Acknowledgment form indicating Full Code. There were 119 residents residing in the facility at the time of survey. The findings included: On 04/06/2026 at 11:34 AM Resident #101 was observed in bed, no apparent distress noted.Record review of Resident #101's face sheet revealed the residents was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included but not limited to Acute Myeloblastic Leukemia.Record review of a Quarterly Minimum Data Set reference dated 02/10/2026 indicated Resident #101 had moderate cognitive impairment and receiving hospice care.Record review of Resident #101's care plan initiated on 10/09/2025 and revised on: 04/07/2026 revealed Resident # 101 has Advanced Directives wishes in place for Do Not Resuscitate (DNR) and receiving hospice services. Interventions documented included: We will communicate your Advance Directives wishes to pertinent staff and your wishes will be communicated via orders in medical record.Record review of the March 2026 physicians order sheets revealed Resident #101 had an order dated 2/25/2026 for Full Code and an order dated 03/05/2026 for hospice admission with diagnosis of unspecified B-cell lymphoma.Review of an Advanced Directive Acknowledgment form dated 02/25/2026 indicated Resident # 101 choose Full Code.Review of Resident # 101's hospice binder revealed a list of the hospice team with phone numbers, an initial certification dated 02/27/2026 and physician orders. Review of the Electronic Health Record revealed a yellow signed Do Not Resuscitate form dated 9/17/2025 signed by Resident #101. and the physician. Record review a Social Services note dated 02/27/2026 documented Resident # 101's code status is Full Code. The following Advance Directives are in place: none. Resident is oriented. Resident is involved and participates in activities. During an interview on 04/09/2026 at 11:38 AM the Hospice Social Worker stated: We are working on getting [Resident #101] to sign a DNR. During an interview on 04/09/2026 at 3:51 PM Staff I, Licensed Practical Nurse (LPN) revealed Resident # 101's Advanced Directives is Full code.During an interview on 04/09/2026 at 4:22 PM the Director of Nursing (DON) revealed Resident #101 had a DNR that was signed upon initial admission and upon readmission the resident wanted to be Full Code and signed a Full Code Advance Directive. We keep the DNR in the file because it is part of the medical record. [Resident # 101] spoke with the Social Services Director and confirmed wanting a Full Code Advanced Directive. On 04/09/2026 at 4:34 PM the Social Services Director stated, I was not aware [Resident#101] wanted a Full Code Advanced Directive. I do not know who wrote the Social Services note indicating Resident # 101 wanted an Advanced Directive of Full Code and I do not know who wrote it and signed with my electronic signature. During a telephone interview on 04/09/2026 at 5:00 PM the Hospice nurse revealed, Resident # 101 has an Advanced Directive of Full Code. Record review of the facility's policy titled, Advanced Directives revised on 08/13/2025 revealed Purpose: To honor the advance directives of all residents and to make information available to the resident on how to prepare such directives, should the resident not have them in place or to change existing directives.

Based on observations, records reviewed and interviews, the facility failed to ensure privacy of confidential information on two (medication carts 400/500 and 100) out of five medication carts and during medication administration for one (Resident #32) out of five sampled residents as evidenced by staff left medication bingo card with resident's medical information visible unattended on top of the unattended 400/500 medication cart. Paper census with residents' pictures and medical information visible left unattended on the 100-medication cart and Staff observed administering medications to Resident #32 in the hallway in front of the nursing station. There were 119 residents residing in the facility at the time of the survey.The findings included:Observation on 04/06/2026 at 12:33 PM revealed a bingo card with resident's name and medical information visible on top of the unattended 400/500 medication cart. (photo evidence). On 04/06/2026 at 12:42 PM, the Assistant Director of Nursing (ADON) was interviewed about the facility's policy regarding protecting residents' information and stated, Staff are to ensure any documentation containing resident's information is stored in a way to prevent visibility to anyone outside of the medical care team. On 04/06/2026 at 12:45 PM Staff E, Registered Nurse (RN) was made aware of the identified concern and stated, I turn the bingo cards over for confidentiality. I don't know how I forgot.Observation on 04/07/2026 at 1:13 PM, revealed Resident # 32 being escorted in a wheelchair by two family members towards the elevator on the second floor. Staff E, RN stopped Resident #32 and administered medications, and the resident took the medications.On 04/07/2026 at 1:14 PM Staff E, RN, was interviewed about the facility's policy for providing privacy during medication administration and stated, Medications are to be administered in the rooms for privacy. I administered the medication to [Resident # 32] because I was trying to get to the resident before the resident left the floor. On 04/07/2026 at 4:30 PM the Director of Nursing was made aware of the identified concern and stated, It is not acceptable to administer medications in the hallway. Record review of Resident #32 clinical records revealed the resident was admitted on [DATE] with diagnosis that included: Sequelae of cerebral infarction. Record review of a Quarterly Minimum data set (MDS) reference dated 3/16/2026 revealed Resident #32 had a Brief Interview of Mental Status score of 8 indicating moderate cognitive impairment.Observation on 04/09/2026 at 11:15 AM, a paper census with residents' pictures and medical information visible on top of the First floor 100-section medication cart (photo evidence).On 04/09/2026 at 11:16 AM Staff H, Licensed Practical Nurse returned to the 100-section medication cart and was made aware of the identified concern and stated, I am supposed to turn the paperwork over to protect resident information. Record review of the facility's Policy: Health Information Privacy and Accountability Act (HIPAA) effective date: 04/01/2022 revision date: 11/27/2025 revealed: Purpose: The Center shall protect the privacy of our residents in person and as related to their personal health information and maintain compliance with HIPAA laws in order to protect the privacy of health care information and privacy of the resident.Procedure: 3. All residents are entitled to their privacy as well as the privacy of their medical or financial record.6. Paper notes or reminders with residents' personal or medical information shall not be left unattended or viewable by unauthorized persons. These paper notes and reminders should be disposed of in a way that will not compromise resident's personal or medical information.

Based on record reviews and interviews, the facility inaccurately coded the Minimum Data Set (MDS) for one (Resident #128) out of three residents closed records reviewed. Staff coded Resident #128, who had expired at the facility, as having been hospitalized in the Minimum Data Set (MDS). At the time of the survey, 119 residents resided in the facility. The findings included. Record review of Resident # 128 clinical records revealed the resident was admitted to the facility on [DATE], readmitted on [DATE] and expired at the facility on [DATE]. Clinical diagnoses included Chronic Obstructive Pulmonary Disease, (COPD), Record review of the Death in Facility Minimum Data Set (MDS) Section A (Identification Information) dated [DATE] documented Resident #128 was discharged to a short-term general hospital.During an interview on [DATE] at 11:50 AM, the MDS Director revealed she had intended to record the resident as deceased , but the system registered the entry under code 4, which is designated for short term general hospital. On [DATE] at 3:57 PM the Director of Nursing stated that the facility had no written policies or procedures for resident assessment related to coding. Staff relied solely on regulatory guidance, rather than facility-developed protocols.

Based on observations, interviews and record reviews the facility's staff failed to implement an oxygen care plan for two (Resident #124 and Resident #13) out of two sampled oxygen dependent residents. Resident #124 and Resident #13 oxygen was being delivered above the prescribed rate. There were 119 residents residing in the facility at the time of survey. The findings include:Resident #124On 04/06/2026 at 9:48 AM Resident #124 was observed in bed with oxygen in progress via nasal cannula at 3.25 Liters Per Minute (LPM). No humidification was observed.Record review of Resident #124's clinical records revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Chronic respiratory failure with hypoxia, Pneumonia, and Dependence on supplemental oxygen.Record review of a physician's order sheet revealed Resident #124 had an order dated 03/6/2026 for oxygen Inhalation via nasal cannula at 2 LPM as tolerated every shift for shortness of breath (SOB) with humidification.Record review of Resident #124 Care Plan initiated on: 09/13/2024 and revised on: 02/11/2026 focus revealed the resident's potential for altered respiratory status/difficulty breathing related to Chronic respiratory failure with history of tracheostomy, recent hospitalization due to respiratory distress from 01/03/2026 to 01/26/2026 readmitted to the facility with interventions that included: Oxygen as ordered.On 04/06/2026 at 2:03 PM Staff E, Registered Nurse (RN) was asked about Resident #124's physician's order for oxygen and notified of the identified concerns; Staff E, RN stated: The physician order is for 2 (LPM). Staff E, RN was and during a side-by-side observation of Resident #124's oxygen flowmeter Staff E, RN stated: It is at 3 LPM. I don't know why.During an interview on 04/09/2026 at 4:24 PM, the Director of Nursing (DON was made aware of the identified concern. The DON stated: The staff are to follow the physician's order when administering oxygen.Resident #13 On 04/06/2026 at 10:07 AM Resident #13 was observed in bed with oxygen in progress at 2.75 LPM via nasal cannula (photo).On 04/06/2026 at 2:02 PM Staff E, RN was observed leaving Resident #13's room and was asked about Resident # 13's current physician's order for oxygen. Staff E, RN verified the physician's order and stated, The order is for 2 Liters per minute. The surveyor made Staff E, RN aware of the identified concern and the surveyor and Staff E, RN entered Resident#13's room and viewed the rate setting on the oxygen flowmeter. Staff E, RN acknowledged the oxygen was not being administered at the prescribed rate.Record review of a demographic sheet revealed Resident #13 was initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Acute and Chronic respiratory failure with Hypoxia and Pneumonia.Record review of a physician's order sheet revealed Resident #13 had an order: dated 01/16/2026 for oxygen at 2 Liters via nasal cannula as tolerated every shift related to Acute and Chronic respiratory failure with hypoxia.Record review revealed Resident #13's care plan initiated on: 12/28/2023 and revised on: 01/10/2024 indicated the resident's potential for altered respiratory status/difficulty breathing related to respiratory failure with interventions that included: Oxygen Settings: Oxygen as ordered.Record review of the facility's Policy and Procedure: Clinical-Care Plans. Revised 11/11/2025 revealedPurpose: To ensure the development and implementation of a comprehensive, person-centered care plan that includes measurable objectives and interventions to meet the resident's physical, psychosocial and functional needs. Policy: 1. The Interdisciplinary Team (IDT), in conjunction with the resident/resident representative, develops and implements a comprehensive, person-centered care plan for each resident.

Based on observations, interviews, and record review, it was determined that the facility did not update the Advanced Directive Care Plan for one (Resident #101) out of four sampled residents who were receiving hospice services. Resident #101's current care plan did not reflect the resident's Advanced Directive for Full Code documented on the Advance Directive form signed by Resident 101 upon reentry to facility. There were 119 residents residing in the facility at the time of survey.The findings included:On 04/06/2026 at 11:34 AM Resident #101 was observed in bed, no apparent distress and voiced no complaints.Record review of clinical records revealed Resident #101 was admitted on [DATE] and readmitted on [DATE] with diagnosis that included but not limited to: Acute Myeloblastic Leukemia.Record review of a Quarterly minimum data set reference dated 02/10/2026 indicated Resident #101 had moderate cognitive impairment and receiving hospice care.Record review of a March care plan initiated on 10/09/2025 and revised on: 04/07/2026 revealed Resident # 101 has advanced directives wishes in place (DNR) Resident is under Hospice with interventions that included: we will communicate your Advance Directives wishes to pertinent staff and your wishes will be communicated via Order in medical record.Record review of the March 2026 physicians order sheets revealed Resident #101 had orders dated 2/25/2026 for Full Code and 03/05/2026 for Hospice Admit Diagnosis: Unspecified B-cell lymphoma. Record review of an Advanced Directive Acknowledgment form dated 02/25/2026 indicated Resident # 101 choose Full Code.Record review of the Hospice binder belonging to Resident # 101 revealed a hospice team list with phone numbers, an initial certification dated 02/27/2026 and physician orders.Record review of the Electronic Health Record revealed a yellow signed Do Not Resuscitate form dated 9/17/2025 signed by the physician and Resident #101.Record review a Social Services note dated 02/27/2026 revealed Resident # 101's code status is Full Code. The following advance directives are in place: none. Resident is oriented. Resident is involved and participates in activities.During an interview on 04/09/2026 at 11:38 AM the Hospice Social Worker stated: We are working on getting [Resident #101] to sign a DNR.On 04/09/2026 at 3:51 PM Staff I, Licensed Practical Nurse (LPN) revealed Resident # 101's Advanced Directives is Full code.During an interview on 04/09/2026 at 4:22 PM the Director of Nursing (DON) revealed [Resident #101] had a DNR that was signed upon initial admission and upon readmission voiced wanting to be full code and signed a full code advance directive. We keep the DNR in the file because it is part of the medical record. [Resident # 101] spoke with the Social Services Director and confirmed wanting a full code advanced directive.On 04/09/2026 at 4:34 PM the Social Services Director was interviewed and stated, I was not aware [Resident#101] wanted a full code advanced directive. I do not know who wrote the Social Services note indicating Resident # 101 wanted an advanced directive of full code and I do not know who wrote it and signed with my electronic signature.During a telephone interview on 04/09/2026 at 5:00 PM the Hospice nurse revealed, Resident # 101 has an advanced directive of full code.Record review of the facility's Policy and Procedure titled, Clinical-Care Plans Revised 11.11.25 revealed Purpose: To ensure the development and implementation of a comprehensive, person-centered care plan that includes measurable objectives and interventions to meet the resident's physical, psychosocial and functional needs. Policy:The Interdisciplinary Team (IDT), in conjunction with the resident/resident representative, develops and implements a comprehensive, person-centered care plan for each resident.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment. 7. An explanation should be included in a resident's medical record if the participation of the resident/resident representative for developing the resident's care plan is determined to not be practicable.The care planning process should:Reflect the resident's expressed wishes regarding care and treatment goals.Reflect treatment goals, timetables and objectives in measurable outcomes.

Based on observations, interviews, and record reviews, it was determined that the facility did not consistently maintain an environment free of accident hazards in one of two soiled utility rooms and one of three housekeeping carts. Staff were observed on two occasions failing to secure the soiled utility room door, which housed biohazardous and sharp materials. Additionally, staff were observed twice leaving a housekeeping cart open, with chemicals visible and accessible. These practices presented potential risks to the 119 residents residing in the facility. The findings included:On 04/06/2026 at 10:19 AM an observation was made of an unlocked Soiled Utility room door on the second floor (photo).On 04/06/2026 at 10:27 AM Staff F, Certified Nursing Assistant was observed exiting the Soiled Utility room on the second floor leaving the door unlocked (photo).On 04/06/2026 at 10:28 AM Staff J, Housekeeping observed exiting The Soiled utility room on the second floor second floor and the door remained unlocked.On 04/06/2026 at 10:35 AM, the Assistant Director of Nursing (ADON)/Infection Preventionist was asked about the facility protocol for safety in terms of The Soiled utility room and it was stated: The Soiled utility room door is to be kept locked for infection control and safety of residents. At that time surveyor made the ADON aware of the identified concern.On 04/06/2026 at 10:38 AM Staff D, Registered Nurse (RN) was made aware of the identified concern and stated, The Soiled utility room door is supposed to be locked, and staff enter with a code. It is kept locked for the safety of the residents because there are items that can harm the residents. On 04/06/2026 at 11:20 AM Staff J, Housekeeping was interviewed about identified concern and stated: I did not realize the door was being left open.On 04/06/2026 11:26 AM Staff F, CNA was interviewed about identified concern and stated: The Soiled Utility room door is to be locked and enter with a code. I did not realize the door was remaining unlocked when I exited. I will check next time.On 04/06/2026 at 1:03 PM observation on the 2nd floor, 600 sections hallway revealed Staff L, Floor tech walking away from a housekeeping cart, leaving the cart unlocked and chemical exposed and accessible (photo).On 04/06/2026 on 1:06 PM the Housekeeping Director walked past the open cart and was interviewed about the facility's protocol for safety regarding the housekeeping carts and stated, We have 3 housekeeping carts in the facility, and the carts are to be kept locked when unattended for the safety of residents because there are chemicals in the cart. At that time surveyor made the housekeeping director aware of the identified concern.Interview on 04/06/2026 at 3:21 PM Staff L, Floor tech revealed the cart is to be locked when unattended. The purpose is for the precautions of the residents. I was cleaning and left it unlocked.

Based on observations, records reviewed and interviews the facility staff did not properly position an indwelling urinary tubing to facilitate the flow of urine for one (Resident #101) out of two sampled residents with an indwelling urinary catheter. Loops in Resident #101's indwelling catheter tubing prevented urine from flowing freely, which increased the resident's risk for catheter-associated urinary tract infections and other serious medical issues. At the time of the survey, four residents with indwelling urinary catheters resided in the facilityThe findings included:Resident #101 Observation on 04/06/2026 at 11:34 AM revealed Resident #101 in bed, the indwelling urinary catheter tubing was looped and contained urine (photo).On 04/06/2026 at 12:05 PM Staff D, Registered Nurse (RN) was made aware of the identified concern and observed the Resident #101's indwelling urinary catheter tubing with surveyor. Staff D, RN stated, I will change the position to allow urine to flow to prevent infection. At that time Staff D, RN repositioned catheter tubing to allow the free flow of urine.Resident #101's clinical records revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include but are not limited to: Urinary Tract Infection (UTI).Record review of Resident #101's Care Plans started date 10/09/2025 and revised on 04/07/2026 for an indwelling catheter related to urinary retention with interventions that included: Change urinary catheter as needed, monitor/document for pain/discomfort due to catheter, and monitor/record/report to medical doctor for signs and symptoms of UTI.Review of the Quarterly Minimum Data Set (MDS) reference dated 02/10/2026 revealed Resident #101 had a Brief Interview of Mental Status score of 12 out of 15 which indicated moderate cognitive impairment. Functional status indicated the resident is dependent for toileting hygiene and had an Indwelling catheter.Record review of Resident #101's physician's order sheets revealed an order dated: 03/30/2026 for Levofloxacin oral tablet 500 milligrams (mg) 1 tablet by mouth one time a day for UTI for seven days was completed on 04/06/2026.Record review of the March 2026 medication administration record indicated Resident #101 received Ertapenem Sodium intravenously from 03/11/2026 to 03/17/2026 for a diagnosis of UTI.Review of the April 2026 medication administration record indicated Resident #101 received Levofloxacin from 03/30/2026 to 04/05/2026 for a current UTI. During an interview on 04/06/2026 at 12:40 PM the Infection Preventionist stated: Indwelling urinary catheter tubing should be patent to allow the free flow of urine to prevent infection.Record review of the facility's infection surveillance report for January 1, 2026, to January 31, 2026, revealed the facility had an increase in facility acquired infections indicating that four of six urinary tract/ kidney infections were facility acquired and noted Resident #101 received an antibiotic medication for diagnosis of UTI.Record review of the facility's infection surveillance report for March 1, 2026, to March 31, 2026, revealed the facility had an increase in facility acquired infections with Resident #101 noted to have received an antibiotic medication for UTI. On 04/07/2026 at 10:24 AM Resident #101 was observed in bed, the indwelling urinary catheter tubing had dependent loops with urine in the tubing. On 04/07/2026 at 10:26 AM, the Registered Nurse Supervisor was informed of the identified concern and observed the catheter tubing with the surveyor (photo). At that time Resident #101 moved in bed and the urine that was already in tubing moved upwards inside the tubing. The RN supervisor stated, I didn't know that could happen. The RN supervisor repositioned the catheter tubing to allow urine to flow freely. I will check other catheter tubing to make sure they are positioned properly to prevent back flow of urine. On 04/07/2026 at 11:57 AM Staff F, Certified Nursing Assistant was interviewed about the facility's protocol for positioning the urinary tubing stated: I am the assigned to [Resident #101] today. I position this resident's catheter tubing straight to prevent the urine from going backwards. Record review of the facility's policy titled, Catheter care - Urinary Effective Date: 04/01/22, Revision Date:09/24/25 revealed POLICY: NURSING - CATHETER CARE - URINARY. PURPOSE: The purpose of this procedure is to prevent catheter-associated urinary tract infections.Maintaining Unobstructed Urine FlowCheck the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.Unless specifically ordered, do not apply a clamp to the catheter.The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observations, records review and interviews, the facility failed to ensure oxygen was delivered at the prescribed rate for two (Resident #124 and Resident #13) out of two sampled oxygen dependent residents. The oxygen flowmeters indicated Resident #124 and Resident #13 oxygen was being administered above the prescribed level. There were 119 residents residing in the facility at the time of survey. The findings include:Resident #124 On 04/06/2026 at 9:48 AM Resident #124 was observed in bed with oxygen in progress via nasal cannula at 3.25 Liters Per Minute (LPM). No humidification was observed.Record review of Resident #124's clinical records revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Chronic respiratory failure with hypoxia, Pneumonia, and Dependence on supplemental oxygen.Record review of a physician's order sheet revealed Resident #124 had an order dated 03/6/2026 for oxygen Inhalation via nasal cannula at 2 LPM as tolerated every shift for shortness of breath (SOB) with humidification.Record review of a Quarterly Minimum data set (MDS) reference dated 3/31/2026 revealed Resident #124 had an undetermined Brief Interview of Mental Status (BIMS) score indicating severe cognitive impairment, dependent for Activities of Daily Living (ADL), and received oxygen therapy.Record review of Resident #124's Care Plan initiated 09/13/2024 and revised on: 02/11/2026 revealed the resident's potential for altered respiratory status/difficulty breathing related to Chronic respiratory failure with history of tracheostomy and recent hospitalization due to respiratory distress from 01/03/2026 to 01/26/2026 readmitted to the facility with interventions that included: Oxygen setting as ordered.On 04/06/2026 at 2:03 PM Staff E, Registered Nurse (RN) was asked about Resident #124's physician's order for oxygen and notified of the identified concerns; Staff E, RN stated: The physician order is for 2 (LPM). while viewing Resident #124's oxygen flowmeter Staff E, RN stated: It is at 3 LPM. I don't know why.During an interview on 04/09/2026 at 4:24 PM, the Director of Nursing (DON) was made aware of the identified concern. The DON stated: The staff are to follow the physician's order when administering oxygen. Resident #13 On 04/06/2026 at 10:07 AM Resident #13 was observed in bed with oxygen in progress at 2.75 LPM via nasal cannula (photo).On 04/06/2026 at 2:02 PM Staff E, RN was observed leaving Resident #13's room and was asked about Resident # 13's current physician's order for oxygen. Staff E, RN verified the physician's order and stated, The order is for 2 Liters per minute. The surveyor made Staff E, RN aware of the identified concern and the surveyor and Staff E, RN entered Resident#13's room and viewed the rate setting on the oxygen flowmeter. Staff E, RN acknowledged the oxygen was not being administered at the prescribed rate.Record review of a demographic face sheet revealed Resident #13 was initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Acute and Chronic respiratory failure with Hypoxia and Pneumonia.Record review of a significant change in status Minimum Data Set reference dated 01/10/2026 revealed Resident #13's Brief Interview of Mental Status (BIMS) score was undetermined, was dependent for ADLs, received oxygen therapy.Record review of a physician's order sheet revealed Resident#13 had an order: dated 01/16/2026 for oxygen at 2 Liters via nasal cannula as tolerated every shift related to Acute and Chronic respiratory failure with hypoxia.Record review revealed Resident #13's care plan initiated on: 12/28/2023 and revised on: 01/10/2024 indicated the resident's potential for altered respiratory status/difficulty breathing related to respiratory failure with interventions that included: Oxygen Settings: Oxygen as ordered.Record review of the facility's policy titled, Clinical-Oxygen Administration Effective Date 04/01/22 Revision Date 1.26.2026 revealed Policy and Procedure: Clinical Oxygen Administration. Purpose: To provide guidelines for administering oxygen therapy as ordered. Process: 5. Set to the prescribed liter of oxygen to be delivered.

Based on observations, interviews and record review the facility failed to properly store medications and biologics for two (#132, #116) out of seven sampled residents as evidenced by 1. an observation of two medicated inhalers on the side table of Resident#132. 2. Two observations of a medicated lotion on the nightstand of Resident#116. There were 119 residents residing in the facility at the time of survey. The findings included:Resident #132On 04/06/2026 at 11:37 AM Resident #132 was observed in bed with no apparent distress. Two medicated inhalers were observed inside a plastic bag on the side table next to Resident #132 (photo).On 04/06/2026 at 11:45 AM Staff D, Registered Nurse (RN) stated, Medications are not allowed to be in the rooms. We keep medications in the medication cart. Surveyor notified Staff D, RN of the identified concern and Staff D, RN removed both inhalers from Resident #132's bedside; and S further revealed: There are no physician orders for inhalers. Rounds are made every two hours and any medications observed are removed. I did not see those inhalers next to [Resident #132].Staff F, Certified Nursing Assistant (CNA) was interviewed and stated, I do rounds and if I see any medications at the bedside I inform the nurse.On 04/06/2026 at 12:38 PM, the Assistant Director of Nursing (ADON) was made aware of the identified concern and interviewed about the facility's protocol for storing medications and stated, Medications are kept locked in the medication room and medication carts. Residents are not allowed to keep any medications in their rooms. On 04/06/2026 at 4:14 PM the Director of Nursing was interviewed about the facility's policy for medication storage and stated, Medications are to be properly stored in locked areas. Staff are to do rounds daily to ensure the removal of any medications observed in the rooms; once removed, staff are to inform administration and educate the resident and family. Record review of Resident #132's clinical records revealed the resident was admitted on [DATE] with diagnosis that included: Chronic Obstructive Pulmonary Disease (COPD) and Atrial fibrillation.Record review of a physician's order sheet revealed Resident#132 had orders dated 4/6/2026 for Albuterol Sulfate HFA Inhalation Aerosol Solution and an order dated 04/07/2026 for Trelegy Ellipta Inhalation Aerosol Powder Breath Activated for COPD.Resident #116Observations on 04/06/2026 at 10:07 AM and on 04/09/2026 at 10:50 AM in Resident #116's room a medicated lotion was on the nightstand. (photo).On 04/09/2026 at 10:51 Staff E, RN made aware of the identified concern and removed lotion.On 04/09/2026 10:52 AM Staff G, CNA was interviewed about facility's protocol for medication storage and stated, I do rounds and if I see any medications I inform the nurse.Record review of Resident # 116's clinical records revealed the resident was admitted on [DATE] with diagnosis that included: Chronic Obstructive Pulmonary Disease and Atrial fibrillation. Record review of Resident # 116's physician's order sheet revealed no orders for medicated lotions. Record review of the facility's policy titled: Clinical-Medication Storage & Labeling. Effective Date: 04/01/2022. Revision Date: 12/9/2025.Policy & Procedures: Clinical-Medication Storage & Labeling.Purpose: To ensure proper storage and labeling of medications within the facility.Process: 1. Medications and biologicals in medication rooms, carts, boxes, and refrigerators are to be maintained within Secured (locked) locations, accessible only to designated staff.

Based on observations, interviews, and record review, the facility failed to maintain an accurate medical record for two (Resident #8 and Resident #101) out of two sampled residents. 1) Resident #8 medical record contained documentation that an ordered medication was not administered and facility had documentation that the medication was administered. 2) Resident #101's medical record contained a signed DNR form and care plan. However, upon reentry the signed Advance Directive acknowledgment form indicated Resident #101 expressed wishes to be full code. There were 119 residents residing in the facility at the time of survey. The findings included: Resident # 8On 04/09/2026 at 10:32 AM Resident # 8 was observed receiving left heel wound treatment conducted by the wound care Licensed Practical Nurse (LPN).Record review revealed Resident #8 was admitted on [DATE], clinical diagnosis included but not limited to: Sepsis, Streptococcus, and Bacteremia. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident # 8 had a Brief Interview of Mental Status score of 10, indicating moderate cognitive impairment and was dependent for Activities of Daily Living (ADLs).Review of care plan with initiated 12/05/2025 and revised 12/13/2025 revealed Resident # 8 had sacrum, buttocks and coccyx pressure present upon admission, related to multiple diagnoses and co-morbidities and malnutrition with interventions that included: Encourage resident to accept medications as ordered, encourage resident to accept wound care/dressing changes as ordered, routinely evaluate and document wound status for progress with healing/response to treatments, and notify provider of abnormal findings such as signs and symptoms of infection, increased pain, change in color, and change in temperatureReview of physician orders revealed Resident # 8 had orders dated 3/30/2026 for Levofloxacin Tablet 500 milligrams (mg)1 tablet by mouth one time a day for wound culture infection for 10 Days. Review of nursing notes dated 04/04/2026 revealed Levofloxacin Tablet 500 mg. Give one tablet by mouth one time a day for wound culture infection for 10 Days. Waiting on pharmacy to bring medication. Medication was not administered. Review of nursing notes dated 04/05/2026 documented: Levofloxacin Tablet 500 mg. Give 1 tablet by mouth one time a day for wound culture infection for 10 Days waiting to be receive indicated medication was not administered. Record review of the April electronic Medication Administration Record (EMAR) revealed signatures on 04/01/2026, 04/02/2026, 04/03/2026, 04/06/2026, 04/07/2026 and 04/08/2026 indicating Levofloxacin was administered. On April 4 and 5, 2026 a signature with the code 9 was written indicating Other / See Nurse Notes.On 04/08/2026 at 2:14 PM the Wound Care Licensed Practical Nurse (LPN) reported Resident # 101's wounds are improving.04/08/2026 3:12 PM The Director of Nursing (DON) was made aware of the identified concern and stated, The nurses sign an attestation if anything changes with administration. They do not need to write a progress note. The DON presented surveyor with two documents titled, Attestation of Late entry MAR/TAR indicating Resident # 8 was administered Levofloxacin 500 mg tablet on the 7:00 AM to 3:00 PM shift and the nurse forgot to sign the MAR/TAR, one was signed by Staff and the other by the 1st floor unit manager. The attestations were not found in Resident #8's electronic health record.Interview on 04/08/2026 at 4:06 PM Staff H, Licensed Practical Nurse (LPN) was asked about the concerns with the documentation for 04/05/2026, and stated, I could not find the bingo card for the antibiotic, so I signed 9 in the EMAR, and I explained in the progress note. When I found the antibiotic, I gave it to [Resident # 8], and I forgot to put a progress note. I did sign the Attestation that I administered the medication.On 04/09/2026 at 9:02 AM the DON entered conference room and revealed the physician was called and additional days of antibiotic treatment was ordered for Resident # 8.On 04/09/2026 at 11:42 AM The 1st floor Unit Manager Registered Nurse (RN) stated, I administered Levofloxacin to [Resident # 8] and I did not write a progress note because I completed an attestation and uploaded it to the medical record. On 04/04/2026 the prior nurse was sent home and that nurse recorded 9 in the EMAR. I took over the cart and looked for the antibiotic, found it and administered it. I did not write the time it was administered, only the shift. Resident #101On 04/06/2026 at 11:34 AM Resident #101 was observed in bed, no apparent distress noted.Record review of Resident #101's face sheet revealed the residents was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included but not limited to Acute Myeloblastic Leukemia.Record review of a Quarterly Minimum Data Set reference dated 02/10/2026 indicated Resident #101 had moderate cognitive impairment and receiving hospice care.Record review of Resident #101's care plan initiated on 10/09/2025 and revised on: 04/07/2026 revealed Resident # 101 has Advanced Directives wishes in place for Do Not Resuscitate (DNR) and receiving hospice services. Interventions documented included: We will communicate your Advance Directives wishes to pertinent staff and your wishes will be communicated via orders in medical record.Record review of the March 2026 physicians order sheets revealed Resident #101 had an order dated 2/25/2026 for Full Code and an order dated 03/05/2026 for hospice admission with diagnosis of unspecified B-cell lymphoma.Review of an Advanced Directive Acknowledgment form dated 02/25/2026 indicated Resident # 101 choose Full Code.Review of Resident # 101's hospice binder revealed a list of the hospice team with phone numbers, an initial certification dated 02/27/2026 and physician orders.Review of the Electronic Health Record revealed a yellow signed Do Not Resuscitate form dated 9/17/2025 signed by Resident #101. and the physician.Record review a Social Services note dated 02/27/2026 documented Resident # 101's code status is Full Code. The following Advance Directives are in place: none. Resident is oriented. Resident is involved and participates in activities.During an interview on 04/09/2026 at 11:38 AM the Hospice Social Worker stated: We are working on getting [Resident #101] to sign a DNR.During an interview on 04/09/2026 at 3:51 PM Staff I, Licensed Practical Nurse (LPN) revealed Resident # 101's Advanced Directives is Full code.During an interview on 04/09/2026 at 4:22 PM the Director of Nursing (DON) revealed Resident #101 had a DNR that was signed upon initial admission and upon readmission the resident wanted to be Full Code and signed a Full Code Advance Directive. We keep the DNR in the file because it is part of the medical record. [Resident # 101] spoke with the Social Services Director and confirmed wanting a Full Code Advanced Directive.On 04/09/2026 at 4:34 PM the Social Services Director stated, I was not aware [Resident#101] wanted a Full Code Advanced Directive. I do not know who wrote the Social Services note indicating Resident # 101 wanted an Advanced Directive of Full Code and I do not know who wrote it and signed with my electronic signature.During a telephone interview on 04/09/2026 at 5:00 PM the Hospice nurse revealed, Resident # 101 has an Advanced Directive of Full Code. Record review of the facility's Policy and Procedure: Medical Records-Documentation Effective Date 04/01/22Revision Date 11.25.2025 revealed Purpose: To ensure compliance with required medical record documentation per regulatory guidelines for both the paper and electronic medical record (EMR).Procedure:Should an entry be made in error, a line will be drawn through documentation or struck out in the electronic health record

Based on observations, interviews, and record review, the facility failed to collaborate and coordinate with hospice representative for one (Resident #101) out of one sampled resident receiving hospice services as evidenced by: facility staff failed to obtain and keep hospice nursing notes in the hospice folder for Resident #101 since March 2026 when Resident #101 received a physician order for hospice services. There were four residents receiving hospice care residing in the facility at the time of survey. The findings included:On 04/06/2026 at 11:34 AM Resident #101 was observed in bed, call light in reach, no apparent distress and voiced no complaints. Record review of Resident #101's clinical records revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnosis that included but not limited to: Acute Myeloblastic Leukemia. Record review of a Quarterly minimum data set reference dated 02/10/2026 indicated Resident #101 had moderate cognitive impairment and was receiving hospice care. Record review of a March 2026 physicians order sheet revealed Resident #101 had orders dated 03/5/2026 for Hospice admission Diagnosis: Unspecified B-cell lymphoma. Record review of a care plan initiated 10/09/2025 and revised 04/07/2026 revealed Resident # 101 had Advanced Directives wishes in place for Do Not Resuscitate (DNR) and under hospice interventions that included: We will communicate your Advance Directives wishes to pertinent staff and your wishes will be communicated via order in medical record. On 04/08/2026 at 9:35 AM Resident # 101's [company] hospice binder located at the second-floor nursing station was reviewed and revealed a list of hospice team with number, an initial certification dated 02/27/2026 and physician orders. No nursing notes or sign in sheet were found in the binder. On 04/09/2026 1:35 PM the [company] hospice binder belonging to Resident # 101 located at the second-floor nursing station was reviewed and revealed a list of hospice team with number, an Initial certification dated 2/27/26 and physician orders. No nursing notes or sign in sheets were noted. On 04/08/2026 at 12:56 PM the Hospice admission Registered Nurse was interviewed and stated, I determine eligibility for hospice by examining the resident, reviewing the records, speaking with the medical doctor, and medical staff. The [company] nurse comes weekly and as needed. I communicate with the nursing staff. The notes are usually kept in the binder. I do not know for sure because I do not write the notes. You would have to speak with the assigned hospice nurse.On 04/09/2026 at 3:51 PM Staff I, Licensed Practical Nurse (LPN) was interviewed about hospice visits and how hospice services are coordinated; Staff I, LPN stated: The hospice nurse comes a few times per week. I have never seen the hospice nurse due to the visits occurring in the morning. When the hospice nurse visits the day shift nurse gives me report. Staff I, LPN was asked revealed the notes are to be kept in the hospice binder. The surveyor requested to view the hospice notes; and Staff I, LPN reviewed the hospice binder with the surveyor and stated: The hospice binder contains a list of nurses, demographic sheet, initial certification, representative consent, and medication list. There are no notes in the binder.On 04/09/2026 at 4:05 PM, the Evening Supervisor Registered Nurse was asked where the hospice notes are kept and stated: Notes are kept in the hospice binder. The Evening Supervisor Registered Nurse reviewed the binder and stated, I will ask the Assistant Director of Nursing (ADON).On 04/09/2026 at 4:08 PM the ADON was asked about the facility protocol for coordinating care with hospice nurse and keeping hospice notes; the ADON stated: The hospice nurse reports to the floor nurse and the unit mangers about any new changes. The surveyor inquired if there was any other place that the hospice notes were kept readily available and the ADON revealed hospice notes are kept in the hospice binder. The ADON reviewed Resident # 101's hospice binder and stated: There are no notes for [Resident #101] in the hospice binder. I will have to call the hospice nurse. Indicating notes had not been received by facility since March 2026. Interview on 04/09/2026 at 4:22 PM, the Director of Nursing (DON) stated: The hospice nurse visits a few times week. They don't sign in. The notes are kept in the binder. The surveyor informed the DON of the identified concern. During a phone interview on 04/09/2026 at 5:00 PM with the [company] hospice nurse it was revealed I visit weekly and send the notes to medical records.

Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate an effective plan of action to correct repeated deficiencies in the problem area as evidenced by repeated deficient practices for F761; failed to properly store and label medications during medication administration, F689; failed to prevent accident hazards, F690; failed to ensure a resident with an indwelling urinary catheter received care to prevent infection and F867; QAPI/QAA improvement activities. These repeated deficient practices have the potential to affect the 119 residents residing in the facility at the time of survey. The findings included:Record review of the facility's survey history revealed the facility was cited for F761, F690, F689, and F867 during the recertification and Relicensure survey with an exit date of 09/26/2024. Record review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan revealed revised January 20, 2026 revealed Purpose: The purpose of QAPI in our organization is to take a proactive approach to continually improving the way we care for and engage with our residents, caregivers, and other partners so that we may realize our vision to be a leader in long-term care recognized for excellence, innovation, and outstanding resident outcomes. To do this, employees will participate in ongoing quality assurance and performance improvement efforts which support our mission by striving to care for our residents with compassion, respect, and professionalism. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 01/29/26 revealed the facility had a QAA Committee meeting quarterly and attendees included: Administrator, Medical Director, Director of Nursing (DON) and other department heads. During an interview on 04/09/26 at 4:40 PM with the Administrator/QAA and the Director of Nursing it was revealed, The members of the QAPI team include: the medical doctor, DON, department heads, and the pharmacist. The purpose of QAPI is to discuss continuous quality improvement and review if our Performance Improvement Plans are working by using quantitative data. Surveyor made The Administrator and DON aware of the repeated deficiency concerns that would be cited. The [NAME] stated, We take this as a learning lesson. Record review of the facility's Quality Assurance Performance Improvement Plan Policy Revised January 20, 2026, revealed A facility-wide training will be conducted to inform staff about the QAPI Program. This training will be conducted often and in multiple ways (e.g., in services, department head in services, examples, exercises, etc.). Facility staff will be educated to raise quality concerns, that it is safe to do so, and everyone is encouraged to think about systems.The QAPI approach will also be communicated to consultants, contractors and collaborating agencies, to ensure they recognize their role in the QAPI plan.The facility will ensure residents and families are aware of the QAPI program, and that their views are sought, valued, and considered in facility decision-making and process improvements.

Based on observation, interview, and record review, it was determined that the facility failed to provide housekeeping and maintenance service to maintain a sanitary, safe, orderly, and comfortable interior for the first and second (2/2/) residential living floors. The findings included: During the resident screenings performed by the surveyors on 09/23-24/25, and environment tours conducted on 09/25-26/24 accompanied with the facility's Administrator, Infection Control Preventionist, Corporate Housekeeping Director. and Corporate Registered Nurse, the following were noted: The findings included: FIRST FLOOR: room [ROOM NUMBER] - Room windows screens (2) heavily torn and in disrepair. room [ROOM NUMBER]: Exterior of room chair was stained, worn, and torn. room [ROOM NUMBER] - Fall mat (A-bed) soiled and stained, exterior of over-bed table damaged and in disrepair, bathroom floor soiled and large black stains, and exterior of night-stand (B-bed) damaged and in disrepair. room [ROOM NUMBER] - Exteriors of over-bed table worn and in disrepair, 1 of 2-bathroom light bulbs not working, and exterior of bathroom entry door was worn and in disrepair. room [ROOM NUMBER] - Phone not working properly (A-bed- resident complaining of not receiving calls), wall air-conditioning unit requires re-caulking to the room walls, window screens torn and in disrepair, 1 of 3-bathroom lights not operating, toilet requires recaulking to the floor, and room walls damaged and in disrepair, exterior of over-bed table was damaged and in disrepair. room [ROOM NUMBER] - Room walls damaged and in disrepair, exterior of room charge worn and danged, exterior of over-bed table damaged and in disrepair, and large open area behind room wall mounted air-conditioning unit. First Floor Community Shower: Two exterior covers of the ceiling light fixtures were cracked/broken, wheelchair scale was heavily soiled, Shower Stall #2 noted that a ceiling tile was covered in black mold type matter, and floor tile grout located in shower stall #1 and #2 was heavily stained. SECOND FLOOR: room [ROOM NUMBER] - Bathroom floor soiled and numerous large black stains, bathroom light bulb not working, wall area behind wall air-conditioning unit damaged and in disrepair, exterior of room chair worn and in disrepair, over-bed light cord too short for resident use (B-bed). room [ROOM NUMBER] - Bathroom floor soiled and large black stains, bathroom light bulbs not working, room window screens torn and damaged, and exterior of over-bed table (B-ed) damaged and in disrepair. room [ROOM NUMBER] - Room walls damaged and in disrepair, bathroom floor soiled and large black stains, and exterior of room chair was worn and in disrepair. room [ROOM NUMBER] - Exterior of bathroom entry door damaged and in disrepair, bathroom floor soiled and large black stains, exterior of room chair heavily worn and in disrepair, room walls damaged and in disrepair, privacy curtain soiled and stained, exterior of over-bed table damaged and in disrepair, bathroom base boards missing, exterior of night-stand damaged and in disrepair, and landing mat soiled and stained. room [ROOM NUMBER] - Bathroom call light cord wrapped around wall handrail, bathroom floor soiled and large black stains, exteriors over-bed tables damaged and in disrepair, and exterior of room chair worn and damaged. room [ROOM NUMBER] - Room floor soiled, damaged, and stained, bathroom light bulbs not working, and bathroom floor soiled and large black stains. room [ROOM NUMBER] - Exterior of room chair worn and in disrepair, room walls danged and in disrepair, over-bed pull cord (B-bed) too short for resident use, bathroom floor soiled and large black stains. room [ROOM NUMBER] - Exterior of room chair heavily worn and in disrepair, bathroom floor soiled and large black stains, room window screens torn and in disrepair, and overbed light cord (B-bed) too short for resident use. room [ROOM NUMBER] - Room walls damaged and in disrepair, toilet requires re-caulking to the bathroom floor, bathroom floor soiled and large black stains, bathroom call light cord wrapped around wall handrail, and two of three-bathroom light bulbs not working. room [ROOM NUMBER] - Nursing medication ointment packet (opened) left on bathroom sink, bathroom floor soiled and large black stains, interior of toilet bowl heavily soiled, exterior of overbed tables (2) damaged and in disrepair, exterior of room furniture ( 2) in disrepair, and room walls damaged and in disrepair. room [ROOM NUMBER] - Exterior of bathroom entry door damaged and in disrepair, room furniture damaged (2) and in disrepair, window screens torn and in disrepair, room walls damaged and in disrepair, and exterior of room chair heavily worn and in disrepair. room [ROOM NUMBER] - Room entry door damaged and in disrepair, exterior of bathroom entry door damaged and in disrepair, bathroom floor soiled and large black stains, room walls damaged and in disrepair, and exterior of room chair heavily worn and in disrepair. room [ROOM NUMBER] - Window screen torn and in disrepair. room [ROOM NUMBER] - Air-conditioning filter heavily soiled and not cleaned on a regular basis room [ROOM NUMBER]- Exterior of room chair heavily worn and in disrepair. room [ROOM NUMBER]- Wardrobe closet missing 1 of 3 drawers. room [ROOM NUMBER] - Air-conditioning filter heavily soiled and not being cleaned on a regular basis. room [ROOM NUMBER] - Room window shades damaged and in disrepair, bathroom floor soiled and large black stains, and room walls damaged and in disrepair. room [ROOM NUMBER] - Bathroom floor soiled and large black stains, toilet requires re-caulking to the bathroom floor, and exterior of room furniture (1) damaged and in disrepair. room [ROOM NUMBER] - Bathroom floor soiled and large black stains, exterior of room chair heavily worn and in disrepair, bathroom base boards missing from wall, and exterior of overbed table (1) in disrepair and damaged. Room # 606 - Exterior of bathroom entry door damaged and in disrepair, room walls damaged and in disrepair, exterior of room chair heavily worn and in disrepair, and bathroom floor soiled and large black stains. room [ROOM NUMBER] - Exterior of bathroom door damaged and in disrepair, bathroom floor soiled and large black stains, bathroom nurse call light wrapped around wall handrail, large hole in room wall, room [ROOM NUMBER] - Wall area around the wall air-conditioning unit was damaged and in disrepair. room [ROOM NUMBER] - Room window blinds broken and in disrepair, and exterior of bathroom door damaged and in disrepair, room [ROOM NUMBER] - Wall area around the wall air-conditioning unit was damaged and in disrepair. Hallway (600 Rooms) - Large area of wall paper torn and missing, and ceiling lights in disrepair. Hallway (600 Unit) - The walls on the entire hallways were noted to have large areas of peeling and missing wallpaper, and ceiling mounted lights (4) were not properly attached and were in disrepair. Following the 09/25-26/24 tours the findings were again reviewed and confirmed with the facility's Administrator. Further discussion noted that the facility has a computerized computer system for staff to document housekeeping/maintenance issues and concerns. Further stated that it is unknown if the computer system is operational and/or staff is not utilizing the system.

Based on observation, interview, and record review, it was determined that the facility's menu failed to meet the nutritional needs for 28 facility residents (included Sampled Resident's #21, #57, #65, #69, #76, #97, #102 and #140) residents with physician ordered Dysphagia Advanced/Dysphagia Mechanical Soft, and 9 facility resident's (included Sampled Resident's #53, #58, #59, and #95) with physician ordered Dysphagia Pureed. The findings included: During the review of the approved menu for the Lunch meal for 09/24/24, the following were noted: Lettuce & Tomato Plate (4 ounces) and Pickle Spear (1) to be server to Regular diet. Further review noted that there was no planned vegetable substitution documented for Dysphagia Advanced Diet, Dysphagia Mechanical Soft Diet, and Dysphagia Pureed Diet. Interview with the Corporate Food Service Director (CFSD) at the time of the review confirmed diets failed to have a documented vegetable substitution planned on the approved menu. It was discussed with the CFSD that the menu failed to meet the nutritional requirements for vegetable serving for the day on 09/24/25 and that a planned vegetable such as a vegetable Juice, Tomato Juice, or Pureed cold (lettuce) or hot vegetable should have been planned into the approved lunch menu. The CFSD stated that there was an error in the planned approved menu and that he would contact his corporation for clarification. Review of the facility's Diet Census for 09/24/24 noted there were twenty eight facility residents with physician ordered Dysphagia Advanced/Dysphagia Diet, Mechanical Soft Diet, and nine facility resident's with physician ordered Dysphagia Pureed Diet.

Based on observation, interview, and record review, it was determined that the facility failed to prepare foods by methods that conserve nutritive value, palatable flavor and appearance for Dysphagia Mechanically Altered Diet, Mechanical Soft Diet, Dysphagia Pureed Diet, and Regular Diet . The findings included: 1) During the initial dietary/food service observation tour conducted on 09/23/24 at 8:45 AM accompanied with the Corporate Food Service Director (CFSD) , it was noted that quarter and half pans of prepared foods were located within the steamer , however the unit was not on. Further observation noted that the steamer contained fully cooked/prepared foods that included the following half pan of Ground Chicken, half pan of Pureed Chicken, quarter pan Pureed Rice, quarter pan Pureed Macaroni Noodles, half pan Purred Spinach, and quarter pan Pureed Carrots. Further observation noted that the foods appeared non-appetizing and tasteless when tested by the surveyor. Interview with the breakfast/lunch cook (Staff I) revealed the ground and pureed foods were prepared in the early morning hours of 09/23/24 and are held under steam heat until the lunch serving time of 11:30 AM. It was further noted that the foods would be cooked and held for 4 hours until the lunch service and would loose much of their nutrient content as well as appearance and palatability. Staff I stated that the food is prepared in this manner on a daily basis no education had been received on food preparation technique. Following the interview the CFSD stated to the survey that this method of food preparation is not acceptable and not allowed. The CFSD directed Staff to discard all of the prepared ground and pureed foods that were located in the steamer and start with fresh menu foods prepared close to the lunch serving time of 11:30 AM. During the screening process of facility residents on 09/23-24/24 it was noted numerous residents complained of poor quality foods, poor taste and palatability of foods, and poor temperature of served foods. A review of the diet census for 09/23/25 noted that there were currently 28 residents with Dysphagia Advanced and Dysphagia Mechanical Soft Diet. It was also noted that there were currently 9 residents with physician ordered Dysphagia Pureed diet. A review of the facility's Diet Census for 09/23/24 noted that there were currently 28 facility residents with physician ordered Dysphagia Mechanically Altered and Mechanical Soft Diet that included Sampled Residents # 21, #24, #57, #65, #76, #97, #102, and #104, and 9 physician ordered Dysphagia Pureed which included sampled Resident's #53, #58, #59, and 95. 2) During the review of the facility's standardized recipe for the preparation of Eggs, Scramble with Cheese (Liquid/Milk) on 09/24/24 the following were noted: Ingredients: Pasteurized Whole Liquid Eggs (5.58 quarts) Milk 2% (7/8 quart) Shredded Cheddar Cheese (2.75 lb) Ground [NAME] Pepper (1.78 Tsp) Procedures: Combine egg mixture, pepper, milk with wire whip Add grated Cheese Cook on griddle or frying pan over low heat until eggs set Serve with #16 scoop During the observation of the breakfast meal in the main kitchen on 09/24/24 at 7:15 AM and accompanied with the CFSD it was noted that the approved menu for meal included the entree of Scramble Eggs with Cheese. Observation of the Egg Entree in the steam table noted that there were large pieces of cheese that had not melted and incorporated into the eggs, the eggs were undercooked (runny) with large pieces of black mold type matter and/or black carbon from the preparation pan in the egg mixture. The surveyor discussed with the CFSD that the eggs were not prepared according to the standardized recipe for Scrambled Eggs with Cheese. It was also discussed with the CFSD the black matter in the egg mixture that could not be identified. The surveyor requested to the CFSD that the egg and cheese entree not be served. * Photographic Evidence Obtained A review of the diet census for 09/23/24 noted that there was the potential that 104 of the 116 resident census would have potentially been served the egg and cheese entree.

Based on observation, interview, and record review, it was determined that the facility failed to prepare food in a Mechanically Altered and Pureed Form designed to meet resident needs for 28 (Includes Sampled Resident's # 21, #24, #57, #65, #69, #76, #97, #102, and #04) physician ordered Mechanically Altered Diet, and 9 (Includes Sampled Resident's #53, #58, 59, and #95) physician ordered Dysphagia Pureed Diet. The findings included: During the review of the facility's approved Diet and Nutrition Care Manual - Chapter 2: Consistency Alterations 2-16, 2019 .Noted the following: (A) Mechanically Altered (Level 2) of Mechanical Soft Diet: This diet is used for residents with mild to moderate oral and/or pharyngeal dysphagia. Some chewing is required and difficult to chew foods that are chopped, ground, shredded, cooked, or altered to make it easier to chew and swallow. Foods should be soft and moist enough to form a bolus. (B) Dysphagia Puree (Level 1) Diet: The diet is used for resident who have sever chewing and/or swallowing problems. All foods are pureed to simulate a soft food bolus, eliminating the whole chewing phase. All foods must be of the consistency of moist mashed potatoes or puddings During the observation of the lunch meal on 09/24/24 at 11:15 AM and accompanied by the Corporate Food Services Detain (CFSD), it was noted that the approved menu documented the entree of Ground BBQ Cheeseburger be served to Dysphagia Advanced and Dysphagia Mechanical Soft Diets. Observation of the lunch tray of 09/24/24 noted the following: (a) The half steam pan of the Ground BBQ Cheeseburger was noted watery and thin, and diluted with too much mater. When served on a plate it was noted that the ground mixture turned into a large puddle of brown substance. A taste test of the ground mixture conducted by the surveyor confirmed lack of palatability and taste. The CFSD agreed with the surveyor's findings and requested Staff I prepare fresh entree with proper ground preparation techniques. Staff additionally stated that the food is not tasted prior to serving. Following the observation, it was concluded by the surveyor with the CFSD that the Dysphagia Mechanically Altered Diet foods and Mechanical Soft Diet foods were not prepared according to physician orders and the facility's Approved Diet Manual. ( Photographic Evidence Obtained) (b) The quarter steam table pan of Pureed BBQ Cheeseburger was observed by the surveyor and CFSD with visible pieces of ground beef noted in the mixture. The puree was tasted by the surveyor and CFSD and confirmed that the pureed mixture was not pureed to the required smooth consistency and that Staff I was not aware that pureed foods must be prepared to a smooth consistency to prevent resident choking and potential aspiration. Staff I stated that she has not received education on the proper method of preparing pureed foods,. Following the observation, it was concluded by the surveyor with the CFSD that the Dysphagia Puree Diet foods and Mechanical Soft Diets foods were not prepared according to physician orders and the facility's Approved Diet Manual. ( Photographic Evidence Obtained) (c) A review of the facility's Diet Census for 09/23/24 noted the following: * There were currently 28 facility residents' with physician ordered Dysphagia Mechanically Altered and Mechanical Soft Diet. The 28 resident's included Sampled Resident's # 21, #24, #57, #65, #69, #76, #97, #102, and #04. * There were currently 9 facility residents' with physician ordered Dysphagia Pureed Diet. The 9 resident's included Sampled Resident's #53, #58, #59, and 95.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a therapeutic diet of Lactose Intolerance/No Dairy was obtained from the attending physician and followed by the facility for 1 (Resident #324) of 5 residents sample for nutrition review. The findings included. On 09/25/24 at 9:00 AM during observation of Resident #324 in his room the resident appeared to be underweight/malnourished, but was alert and oriented. Observation of the breakfast tray noted the tray ticket document NO Dairy/Double Entree Portions, however the food tray contained an 8-ounce carton of whole milk and a single portion of sausage gravy that the ingredients include whole milk. The resident at the time of the observation stated he became Lactose intolerant approximately 5 years ago and has suffered weight loose due to the side effects of being Lactose Intolerant and receives milk and foods made with milk for almost all meals served. Resident #324 revealed he continuously spoke to staff concerning his Lactose Intolerance and receiving milk and food prepared with milk. The resident further stated that his appetite and food intake is very poor. During the 09/25/24 observation; the surveyor requested the Corporate Food Service Director (CFSD) to the room of Resident #324 to view the meal tray served and the resident's concerns. The CFSD confirmed that milk and food prepared with milk were served on the 09/25/24 breakfast tray and confirmed the resident again stated he receives milk and foods prepared with milk for numerous meals. The CFSD also confirmed that the meal tray ticket documented NO DAIRY/DOUBLE PORTIONS. Review of Resident #324's clinical records revealed an original admitted [DATE], discharge date of [DATE], and readmitted [DATE]. Review of admission diagnoses noted Necrosis of Toes, Difficulty Walking, Peripheral vascular disease (PVD), Surgical Aftercare, and Weight Loss. It was noted that there was no physician diagnoses noted in the clinical record for Lactose Intolerance. Review of current physician orders noted no diet order for Lactose Free /No Milk of Milk Products and the diet order was for only No Added Salt/Double Entree. It was also noted that Between meal snacks at 2:00 PM and HS (bedtime) were discontinued on 09/22/24. A review of the resident's weight history noted a weight of 92 pounds recorded on 09/12/24 with a BMI of 14 (Malnutrition), height of 68 inches Record review on 09/25/24 of the Nutrition assessment dated [DATE] documented the resident stated to be Lactose Intolerant, Usual Body Weight (UBW) of 120 pounds, Ideal Body Weight of 151 pounds. Resident consuming 50-75% of meals, and a summary assessment of Protein Calorie Malnutrition -Severe Underweight. A review of the current Care Plan dated 09/21/24 documented Nutritional Problem due to weight loss and lactose intolerant. The facility's Registered Dietitian following the record review of 09/25/24 noted that the attending physician failed to document a primary diagnoses of lactose Intolerant and failed to order a Lactose Free and No Dairy Diet for Resident #324. It was also discussed with the Registered Dietitian of the potential need to obtain a proper Lactose free diagnoses, Lactose free Diet, and potentially the need to obtain an order for an appetite stimulant. On 09/26/24 the surveyor noticed a visitor leaving the room of Resident #324. The surveyor was able to identify the visitor as a sibling who stated the resident has suffered with Lactose Intolerance and weight loss over the past few years. Further stated that the facility constantly serves milk and milk products to the resident resulting in gastric issues. On 09/26/24 the Registered Dietitian (RD) submitted a copy of a Nutrition Note dated 09/25/24 that documented she and the Unit Manager spoke to the physician regarding appetite stimulant and a new order was obtained for Cyproheptadine for 1 month and to begin to monitor weekly weights and oral intake of all meals and diagnoses of Lactose Intolerance. The RD also submitted documentation of a new diet order Lactose Free/Double Entree Portions and snacks at 2:00 PM and HS. The RD also submitted new meal tray tickets which documented diet of - NO DAIRY/LACTOSE/DOUBLE ENTREE PORTIONS, and also documented NO MILK/YOGURT OR CHEESE - Allergies of: Dairy Allergen.

Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for potentially 104 of the 116 residents who eat foods by mouth. The findings included: 1) During the initial dietary/food service observation tour conducted on 09/23/24 at 8:45 AM, and accompanied with the facility's Certified Dietary Manager and Corporate Food Service Director (CFSD), the following were noted: (a) Observation of the cook's preparation sink noted a large cooking pot full of water that contained a 10 pound package of raw chicken. Further observation noted that no cold water was running over the chicken and the CFSD stated that the chicken was thawing, and staff failed to ensure that the cold water was running into the pot at full volume. At the request of the surveyor the temperature of the water within the pot was taken by the CFSD with the facility's calibrated food thermometer and was recorded at 100 degrees Fahrenheit (F). The surveyor reviewed that the regulatory temperature for thawing hazardous foods via cold water was a maximum 70 degrees F. The surveyor requested that the chicken be discarded due to the potential for food born illness if utilized for facility residents. * Photographic Evidence Obtained (b) Observation of the walk-in refrigerator noted that the interior food storage shelving (5) were soiled and in disrepair. It was also noted that the fan covers (2) of the unit were covered with dust. * Photographic Evidence Obtained (c) Observation of ceiling mounted air-conditioning vents (6) located in the food preparation and serving area were noted soiled and covered with a black mold type substance. The surveyor discussed with the CFSD that the black substance could result in food contamination and food borne illness. Photographic Evidence Obtained (d) Observation of the dish machine area noted that the walls behind and around the machine were soiled and covered with a black mold type substance. The surveyor discussed with the CFSD that dish may potentially become contaminated. Photographic Evidence Obtained (e) During the tour it was noted that large areas of the room walls located in food preparation and serving areas were in heavy disrepair. It was noted that at minimum 5 wall areas were in need of repair. * Photographic Evidence Obtained (f) During the observation of hot and cold temperatures, foods located on the serving steam table were taken with the use of the facility's calibrated food thermometer. The food temperatures were taken by the CFSD and it was noted that hot foods were not being held at the regulatory temperature of 135 degrees F or below as evidenced by the following: * Sausage Patties (12 individual) = 120 degrees F. * French Toast (50 servings) = 125 degrees F. * Pureed Scrambled Eggs with Cheese = 110 F. * Pureed Scrambles Eggs = 120 F. 2) During a second dietary/food service observation conducted of the main kitchen on 09/24/24 at 7:15 AM accompanied with the CFSD the following were noted: (a) During the calibration of the facility's food thermometer it was noted that the thermometer was inaccurate and could not be utilize for food temperature testing. The CFSD stated that a there was not a alternative working food thermometer in the dietary department. The surveyor was forced to utilize the a State issued calibrated thermometer for food temperature testing. (b) Two Certified Nursing Assistants were noted to enter into the food preparation/serving area without gowns, face masks, gloves, and hair restraints. The surveyor requested to the CFSD that the nursing staff leave immediately and discussed that only dietary employees were allowed into the dietary department. The CFSD stated that it was a daily occurrence. 3) During a third follow-up kitchen/food service observation tour conducted on 09/24/24 at 11:15 AM and accompanied with the Corporate Food Service Director, the following were noted: (a) Cleaning rags (3) and soiled paper towels were noted to be stored directly on clean food preparation and serving surfaces when not in use. The surveyor reviewed with the CFSD that soiled cleaning cloths are to be stored in a regulatory chemical solution when not in use, and that soiled paper towels should not be used for cleaning and should be thrown away after each use. * Photographic Evidence Obtained (b) During the tour it was noted that a personal staff cell phone was being stored directly on a clean food serving surface. The surveyor discussed with the CFSD that cell phones are highly soiled and cannot be store directly of clean food surfaces. The CFSD identified the phone as belonging to a dietary staff and staff have been in-serviced concerning the issue previously.

Based on observation, record review and interview, it was determined that the facility failed to dispose of garbage and refuse properly that potentially effected all of the 116 facility residents. The findings included: During the kitchen/food service observation tour conducted on 09/23/24 at 8:45 AM and accompanied with the Certified Dietary Manager and Corporate Food Service Director the garbage/refuse noted to have the garbage/trash container with the lid open and had open garbage and trash spewing onto the [NAME] area around the unit. Further observation of the garbage/refuse area noted that the area behind the dumpster was heavily covered in soiled PPE's (gloves, gowns, masks, unidentifiable resident and nursing waste materials, rotting trash and garbage, and presence and evidence insect and rodent activity. It was estimated that the area was approximately 25 feet long and 5 feet wide and a large area of stagnant, fowl, garbage and trash was located at one end. The surveyor requested that the Administration be notified immediately of the area and potential health hazard. On 09/23/26 at 1:00 PM the Administrator met with the surveyor and informed that the area had been terminally cleaned. On 09/25/24 at 11:30 AM the area was again viewed by the surveyor and the facility Infection Control Preventionist and Corporate Registered Nurse. The observation noted that the garbage /refuse area remained in the same condition as observed on 09/23/24. The Administration was again notified of the potential health hazard conditions and stated that incorrect information was obtained from staff during the 09/23/25 observation.

Based on observations, interview and record review the facility failed to assure services being provided to residents meet professional standards of quality for 1 of 4 of residents observed during med pass (Resident #54). The findings included: Review of the facility's employee handbook with revised date of 2024 under section titled, Personal Appearance, Dress Code and Uniform Policy included the following in part: Nails must be clean, neat and trimmed to 1/4 inch for resident/patient care responsibilities; acrylic and gel nails or any other artificial nails are prohibited under any circumstances. Review of the CDC's (Center for Disease Control) website titled, Clean Hands at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html Under the section Maintain fingernail and jewelry safety included in part the following: Natural nails should not extend past the fingertip. Do not wear artificial fingernails or extensions when having direct contact with high-risk patients like those at intensive-care units or operating rooms. Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing. On 09/23/24 at 9:45 AM, observation of med pass with Staff D Licensed Practical Nurse (LPN) for Resident #54; a total of 4 oral medication and 1 inhaler (Breo Ellipta) were administered. Staff D, LPN had long pointed artificial nails with rhinestones on top. The fingernails extended about 1 inch past the edge of her fingers. During an interview conducted on 09/23/24 at 10:00 AM with Staff D, LPN was asked if the facility has a policy about staff fingernails, she stated: I don't think so. During an interview conducted on 9/24/24 at 2:20 PM with Staff J Licensed Practical Nurse/Unit Manager was asked about fingernails for staff, she stated : you cannot have fake fingernails, if they are gel, they have to be short and can only be just past the tip of the fingers like mine. She then showed the surveyor her fingernails and said: mine are gel. During an interview conducted on 09/25/24 at 11:10 AM, Staff C Registered Nurse was asked about fingernails for staff, she revealed they need to be short and not fake. When asked about her fingernails that extended about 1/2 inch past the tip of the fingers, she stated: I didn't know the State was coming.