Every finding on record at Bedford Court Healthcare Cent.

Based on observations and interviews, it was determined that the facility failed to store and process linens to prevent the spread of infection. This was evident for 1 out of 1 observation made in the facility's laundry room. The findings include: On 03/19/2026 at 8:47 AM, an observation of the laundry room revealed that clean laundry was stored uncovered. This included towels, placed on a rectangular table, clean tablecloths on a metal rack, an additional metal rack containing tablecloths, bed sheets, towels, and clothing, and clean linens in a basket all of which were uncovered. On 03/19/2026 at 8:47 AM, an interview with the Housekeeping Director (Staff #12) revealed that the laundry room typically had uncovered linen. On 03/19/2026 at 9:28 AM, an interview with the Director of Nursing revealed that the expectation was for linen to be covered.

Based on observation, record review, and staff interview, it was determined that the facility failed to ensure that controlled substances were consistently accounted for and documented through the required dual nurse signatures during shift-to-shift narcotic counts. This was evident for 2 (Choice and Independent) out of 3 units during the facility's recertification survey.The findings include:On 03/17/2026 at 9:18 AM, following an observation of a medication pass conducted by the surveyor on the choice unit with Licensed Practical Nurse (LPN) #7, the surveyor reviewed the narcotic control book and identified a missing signature for the incoming nurse on 03/13/2026 for the 3:00 PM to 11:00 PM shift, as well as a missing signature for the outgoing nurse for the 11:00 PM to 7:00 AM shift. LPN #17 was requested to participate in a concurrent review of the narcotic book and she confirmed the date and the absence of the required signatures. On 03/17/2026 at 9:20 AM, during an interview with LPN #7, when asked for the expectation regarding signing in the narcotic book, she stated that at the beginning of each shift, narcotics are counted jointly by the outgoing and incoming nurses, and both nurses are expected to sign the narcotic book to validate that the count was completed. When asked why the signatures were missing, LPN #7 stated that the incoming nurse experienced a family emergency, and a nurse from another unit assisted with the narcotic count. LPN #7 further stated that although the count was completed and report was given, the assisting nurse failed to sign the narcotic book. LPN #7 indicated that she would follow up with LPN #17, who assisted with the count, to determine why the signature was omitted and to request completion of the documentation.On 03/18/2026 at 8:36 AM, following an observation of a medication pass conducted by the surveyor on Independence unit with LPN #21, the surveyor reviewed the narcotic binder and identified three missing signatures. These included a missing signature for the incoming nurse on 03/01/2026 for the 3:00 PM to 11:00 PM shift, a missing signature for the outgoing nurse on the same date for the 11:00 PM to 7:00 AM shift, and a missing signature for the incoming nurse on 03/04/2026 for the 11:00 PM to 7:00 AM shift. LPN #21 reviewed the narcotic binder and confirmed the missing signatures. On 03/18/2026 at 8:38 AM, during an interview, LPN #21, when she was asked about the facility's expectation for signing the narcotic book, LPN #21 stated that both the outgoing and incoming nurses are required to sign to verify that the narcotics were counted.On 03/18/2026 at 8:42 AM, LPN #7 approached the surveyor and reported that LPN #17 had subsequently signed the narcotic book while present in the facility for her shift on the night of 03/17/2026.On 03/19/2026 at 7:29 AM, during an interview with the Director of Nursing (DON), when asked for the expectation regarding signing the narcotic book, she stated that the expectation was for two nurses (the outgoing nurse and the incoming nurse) to sign the narcotic book after jointly counting and verifying that all controlled medications are accounted for. The DON further stated that the presence of two signatures serves as documentation that the narcotic count was completed. When the DON was informed of the identified missing signatures, she acknowledged the findings.

Based on observations and interviews, it was determined that the facility failed to ensure that food items were stored in a manner that maintained the integrity of the specific items. This was evident for 1 (initial observation) of 2 of the kitchen areas upon facility entry. The findings include: On 03/16/2026 at 8:05 AM, an observation of the kitchen revealed a tray of freshly cooked chicken in the refrigerator that was uncovered. On 03/16/2026 at 8:07 AM, an observation of the kitchen's dry storage revealed a packet of crackers that was unlabeled. On 03/16/2026 at 8:10 AM, an observation of the kitchen's freezer revealed unlabeled shrimp, cinnamon sticks, and chicken. On 03/17/2026 at 12:24 PM, an interview with the Dining Services Director (Staff #3) revealed that the expectation was that the food items should have been labeled and not left uncovered. On 03/18/2026 at 9:05 AM, the concerns were addressed with the Director of Nursing and she indicated that she understood.

Based on review of facility documents and interviews, it was determined that the facility failed to: 1) conduct quality assurance meetings on a quarterly basis, and 2) ensure the presence of required quality assurance committee members in meetings. This was evident during the quality assurance and performance improvement task conducted as part of the recertification survey process. The findings include:QAPI (Quality Assurance and Performance Improvement) is a data-driven, proactive approach to healthcare management, mandated by CMS for nursing homes and home health agencies, merging Quality Assurance (QA) with Performance Improvement (PI) to improve patient care, safety, and quality of life.On 03/19/2026 at 10:04 AM, the surveyor requested QAPI attendance sheets for the past 12 months.On 03/19/2026 at 12:00 PM, an interview with the Facility's QAPI coordinator, Staff #1, was conducted. She reported that the facility's QAPI binder was missing and that she could not find attendance sheets for April 2025, May 2025 and October 2025. When asked when quarterly QAPI meetings were held, she stated April 2025, July 2025, October 2025 and January 2026. On 03/19/2026 at 12:28 PM, Staff #1 further reported that she had looked for quarterly meeting minutes and confirmed that there was no evidence that a QAPI meeting was held in April 2025. On 03/19/2026 at 1:32 PM, the surveyor and Staff #1 reviewed the attendance sheets and meeting minutes for the past 12 months. The review of attendance revealed the following: No infection preventionist was present for 7 months (April, May, June, July, October, November and December).No Administrator or Board Member was present for 2 months (April and July). No Medical Director was present for 2 months (April and August). No Dietitian was present for 8 months (April, May, June, July, August, September, October, and December).No Geriatric Nursing Assistant (GNA) was present for 7 months (April, May, June, July, August, September and October).On 03/19/2026 at 1:53 PM, a follow up interview with Staff #1 was conducted. She acknowledged that not all members of the quality assurance committee attended the meetings as required and that the facility had been encouraging staff members to participate to fulfill both federal and state attendance requirements. On 03/19/2026 at 2:23 PM, the Facility Administrator was notified of the QAPI concerns.

Based on record review and staff interviews, it was determined that the facility failed to ensure staff received ongoing Quality Assurance and Performance Improvement (QAPI) training. This deficient practice was identified in 5 of 5 employee files reviewed during the facility's recertification survey.The findings include:On 03/19/2026 at 7:44 AM, a review of employee records for Registered Nurse (RN) #16, Licensed Practical Nurse (LPN) #17, and Geriatric Nursing Assistants (GNAs) #18, #19, and #20 revealed no evidence of ongoing QAPI training following initial hire. Hire dates for the GNAs ranged from 2003 through 2025, indicating employment without documented continuation of QAPI education.On 03/19/2026 at 11:17 AM, during an interview, the Human Resources (HR) Director, when asked who was responsible for ensuring staff members maintained required training, she stated that she was responsible. When asked to provide documentation of QAPI training for the identified employees, she stated she would locate and provide the records.On 03/19/2026 at 12:49 PM, the HR Director reported that she was unable to locate documentation of QAPI training but would continue searching for any relevant records. On 03/19/2026 at 1:50 PM, upon follow-up, the HR Director confirmed that she was still unable to produce the requested documentation. On 03/20/2026 at 7:10 AM, during a follow-up interview, the Director of Nursing (DON) stated that the identified staff members had not received QAPI training and confirmed that no documentation was available to support that such training had been conducted. When she was informed that this was a concern, the DON acknowledged it.On 03/20/2026 at 7:18 AM, in an interview with the Nursing Home Administrator (NHA), when he was asked for the expectation regarding QAPI training for staff members, he stated that staff are expected to receive QAPI training; however, he did not have access to training records. Upon being informed of the identified concerns regarding the lack of QAPI training for the selected staff members, the NHA acknowledged the issue.

Based on interviews, observations and record reviews, it was determined that the facility failed to: 1) provide appropriate treatment to maintain an individual's limited range of motion, and 2) evaluate a resident for therapy services to prevent further decline in the range of motion. This was evident for 1 (Resident #19) out of 6 residents reviewed for position and mobility during the recertification survey. The findings include:On 03/16/2026 at 8:40 AM, an interview with Resident #19 was conducted. The resident reported that they had a stroke during their stay at the facility and that they wore a splint on their right hand, but the therapy services took it away.During the interview, the surveyor observed that Resident #19 had a contracture on the right hand. When asked if they were receiving any therapy services, the resident stated that they had not had therapy services for a long time. On 03/17/2026 at 9:04 AM, a review of Resident #19's medical records was conducted. The care plan indicated that the resident had musculoskeletal condition, hemiparesis and contracture on the right upper and lower extremity. An intervention was entered for Resident #19 to wear a right elbow and right-hand splint per doctor's order.On 03/17/2026 at 11:04 AM, another observation was conducted. Resident #19 was observed not wearing a splint on the right hand. Surveyor requested therapy notes for Resident #19.On 03/17/2026 at 11:15 AM, a review of the therapy notes provided by facility revealed that Resident #19 was last evaluated for therapy services in January 2024. The therapy notes provided had a sentence that stated the resident had refused to wear a splint. On 03/18/2026 at 9:14 AM, an interview with Staff #25, Directory of Therapy Services, was conducted. When asked how often residents are supposed to be evaluated for therapy services, Staff #25 stated that it's the facility's expectation that residents are evaluated quarterly. Staff #25 further stated that she was not aware of any restorative services that the resident was receiving at the facility. After another review of the therapy notes, Staff #25 confirmed that there were no records that indicated Resident #19 was re- evaluated for therapy services in 2025. On 03/19/2026 at 10:36 AM, an interview with the Director of Nursing (DON) was conducted. She stated that if a resident refused an intervention, the facility staff is supposed to educate the resident on the benefits of care and was expected to try again later. If the resident continued to refuse and there was a pattern, then the refusal is supposed to be documented, provider and resident representative notified, and the care plan should be updated to reflect the refusals.The surveyor asked the DON to provide documentation to indicate a pattern of splint refusals for Resident #19.On 03/19/2026 at 10:55 AM, the DON confirmed that there were no documented refusals beside the one-time documentation in January 2024. She also stated the care plan had not been updated to indicate the resident had a pattern of refusing to wear the splint.On 03/20/2026 at 8:09 AM, the Facility Administrator and the DON were notified of the splint concerns and failure to re-evaluate a resident for therapy services.

Based on record review and interviews, it was determined that the facility failed to verify the accuracy of hospital discharge paperwork prior to placing admission medication orders for newly admitted residents. This was evident for 1 (Resident #40) out of 20 residents reviewed during the survey.The findings include: On 03/18/2026 at 11:44 AM, the surveyor began reviewing a complaint that stated Resident #40 received incorrect medication on the first 4 days of their stay.On 03/18/2026 at 12:02 PM, record review revealed that Resident #40 was admitted to the facility from the hospital on [DATE]. Discharge paperwork from the hospital dated 02/20/2026 reflected that the resident was prescribed the following medication at the hospital: Eliquis (blood thinner) 5 mg by mouth twice daily, amiodarone (blood pressure medication) 200 mg 1 tablet by mouth once daily, and Buspirone (anxiety medication) 5 mg take 1 tablet by mouth twice daily.Facility records indicated that orders were entered for Eliquis (blood thinner) 5 mg by mouth once daily with a start date of 02/21/2026 and a discontinue date of 02/25/2026, and was administered as ordered. Amiodarone 200 mg by mouth twice daily was also ordered with a start date of 02/21/2026 and a discontinue date of 02/25/2026, and was administered as ordered. Additionally, Losartan Potassium (blood pressure medication) 50 mg by mouth once daily was ordered and administered from 02/21/2026 through 02/27/2026; however, this medication was not listed on the hospital discharge medication list. Buspirone administration began on 02/27/2026.In an interview on 03/18/2026 at 1:03 PM, the Medical Director (Staff #9) recalled that a medication error had occurred involving the above medications for Resident #40. Staff #9 indicated that these errors were corrected once discovered by nursing staff and that the corrections had been made by the time he evaluated the resident. On 03/19/2026 at 9:19 AM, an interview with the Director of Nursing revealed that the facility had received the resident's hospital discharge summary from a prior hospitalization on 07/18/2025. However, the Director of Nursing also stated that nursing staff had misread the date and did not identify the error. The error was corrected after it was identified by a family member four days after admission during which the resident had been receiving incorrect medication. On 03/19/2026 at 10:55 AM, the surveyor reviewed the hospital discharge paperwork from 07/18/2025 and confirmed the error.

Based on record review and staff interview, it was determined that that the facility failed to refer a resident for a PASARR evaluation review after a new mental health diagnosis.This was evident for one (Resident # 4) out of five residents reviewed for unnecessary medications.The findings include:A review of Resident # 4's medical record on 3/17/26 revealed Resident # 4 was admitted to the facility on [DATE] with diagnoses that include: dementia, generalized anxiety disorder and major depressive disorder. An admission PASARR (preadmission screening and resident review) level I screen dated 7/14/21documented Resident # 4 as not having any mental health or intellectual disability or related conditions.Further review of Resident # 4's medical record revealed that Resident # 4was diagnosed with bipolar disorder on 1/9/26. There was no evidence in Resident # 4's medical record that a new PASARR screening was completed after the addition of this mental health diagnosis.In an interview with Staff # 2 (social service coordinator) on 3/18/26 at 9:46 AM, Staff #2 stated, .If I get notified of a new diagnosis or medication, I reapply for a new PASARR review for the resident. It can take several days to get a reply. I was not aware that Resident # 4 was given a new psychiatric diagnosis of bipolar disorder. I did not put Resident #4 in for a new PASARR evaluation because I did not know about his/her new diagnosis.

Based on observations, record reviews, and interviews it was determined that the facility failed to develop and/or update residents care plan. This was for 2 (Resident #1 and #49) out of 3 residents reviewed for care plan during the recertification survey. The findings include: A care plan is a simple written plan that explains how to take care of a resident's health and daily needs. It lists what the resident needs help with, what their goals are, and what caregivers should do to help them. It makes sure everyone helping the resident knows the same plan so the care stays organized and consistent. 1). On 03/16/2026 at 8:57 AM, an observation of Resident #1 revealed that the resident was receiving oxygen therapy. On 03/17/2026 at 8:55 AM, record review revealed that Resident #1's MDS (Minimum Data Set) the resident was on oxygen therapy. At the same time, further review of the comprehensive care plan revealed no goals, or interventions addressing oxygen therapy, including administrations, monitoring or safety precautions. On 03/18/2026 at 8:57 AM, an interview with the Director of Nursing revealed that the expectation was that residents receiving oxygen therapy had this addressed in the comprehensive care plan. On 03/18/2026 at 9:00 AM, the concern was addressed with the Director of Nursing, and she indicated that she understood. 2). On 03/17/2026 at 11:17 AM, a review of Resident #49's medical records was conducted. The review revealed that the resident was re-admitted into the facility on 1/11/2026. The review of the hospital discharge summary indicated that Resident #49 had a new diagnosis of respiratory insufficiency which required the resident to be on 3L of Oxygen. Further review of the records revealed a nurses note entered on 1/11/2026, that stated Resident #49 returned to the facility with a wound to the sacrum. Additionally, there was a new order for Oxygen at 3L via nasal cannula continuously every shift. On 03/17/2026 at 12:59 PM, a review of Resident #49 care plan was conducted. The care plan failed to indicate that the resident had a new wound to the sacrum and that the resident was on supplemental oxygen therapy. On 03/17/2026 at 1:15 PM, a review of Resident #49's Treatment Administration Records (TAR) for January, indicated that the resident received 3L of oxygen every shift. On 03/19/2026 at 10:31 AM, an interview with the Director of Nursing (DON) was conducted. When asked who was responsible for revising the care plan after a resident is admitted /re-admitted into the facility, the DON stated that the admitting nurse is supposed to revise the care plan. If the revisions are not done, then the nurse supervisor can also update the care plan. DON further stated that for Resident #49, respiratory monitoring should have been added to the care plan before the end of shift. On 03/19/2026 at 11:36 AM, the surveyor notified the DON and Facility Administrator of the care plan revision concerns.

Based on observations, record reviews, and interviews it was determined that the facility failed to maintain professional standards of practice related to: 1) oxygen orders and 2) providing sufficient documentation to support a new mental health diagnosis. This was evident for 2 (Resident #1 and #4) out of 6 residents reviewed for respiratory orders and unnecessary medications during the recertification survey. The findings include: 1). On 03/16/2026 at 8:57 AM, an observation of Resident #1 revealed that the resident was receiving oxygen therapy. On 03/16/2026 at 9:55 AM, record review failed to reveal an active order for oxygen. On 03/18/2026 at 8:57 AM, an interview with the Director of Nursing revealed that the expectation was that if a resident was on oxygen, there should be an order to reflect it. 2) The DSM-5 (Diagnostic and Statistical [NAME] of Mental Disorders, Fifth Edition) is the standard of care for diagnosing and treating patients with mental health conditions. The DSM- 5 Bipolar Disorder Adult Guidelines 2019-20 set the criteria for the diagnoses of bipolar disorders. For a diagnosis of Bipolar I disorder, it is necessary to meet the following criteria for a manic episode. A manic episode is defined as a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes. During the period of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: (1) Inflated self-esteem or grandiosity , (2)Decreased need for sleep (e.g., feels rested after only 3 hours of sleep), (3) More talkative than usual or pressure to keep talking , (4) Flight of ideas or subjective experience that thoughts are racing, (5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless, non-goal-directed activity), (6) Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). The DSM-5 documents the criteria for the diagnosis of Bipolar II disorder. For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a current or past hypomanic episode and the criteria for a current or past major depressive episode. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. During the period of mood disturbance and increased energy and activity, 3 (or more) of the above symptoms (4 if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree. On 3/17/26 at 10:34 AM, a review of Resident # 4's medical record revealed that Resident # 4 was diagnosed with moderate dementia with other behavioral disturbances on 8/1/25. The review also revealed that Resident # 4 was diagnosed with bipolar disorder, unspecified on 1/9/26. A review of Resident # 4's Minimum Data Set (MDS) assessment dated [DATE] revealed no documented evidence of bipolar behaviors in Section D Mood, Section E Behaviors or Section I Active Diagnoses. During an interview on 3/18/26 at 10:48 AM, Nurse Practitioner (NP) # 10 stated that Resident # 4 does have visual and auditory hallucinations and he/she does have behaviors that fall within the DSM diagnosis criteria for bipolar, saying, He/she gets hyper and has exit seeking behavior. He/she has insomnia. Yes, I know bipolar is typically diagnosed in younger adults and Resident # 4 was [AGE] years old when diagnosed. He/she is on Seroquel for dementia with neuropsych behaviors. A review of Resident # 4's medical record on 3/18/26 at 11:30 AM failed to provide documentation of Resident # 4 exhibiting behaviors such as grandiosity, hallucinations, distractibility, pressured speech, flight of ideas, excessive involvement in harmful activities in the timeframe between the 11/10/25 MDS assessment and the 1/9/26 diagnosis of bipolar disorder. During an interview on 3/18/26 at 11:52 AM, Physician # 9 stated, [Resident # 4] does not have a diagnosis of bipolar. While it may have been coded in his/her medical record, he/she does not meet the criteria for that diagnosis. During an interview with caregivers, Licensed Practical Nurse (LPN) #11 stated that Resident # 4 cannot even hold a conversation anymore. Staff # 11 stated that Resident # 4's medications had to be decreased because he/she has been lethargic and less interactive the past few months. Further review of Resident # 4's medical record on 3/19/26 at 1:35 PM revealed none of the psychiatric provider's (Staff # 27) notes, with the most recent note dated 3/16/26, documented a diagnosis of bipolar disorder or behaviors that meet the diagnostic criteria. The facility failed to have documented evidence of Resident # 4 exhibiting behaviors that meet the diagnostic criteria to warrant the diagnosis of bipolar disorder.

Based on record review, observations and staff interview, it was determined that the facility failed to maintain good grooming and personal care services for Resident # 6. This was evident for one (Resident # 6) out of one resident reviewed for Activities of Daily Living (ADLs).The findings include: During screening on 3/16/26 (Monday) at 9:08 AM, Resident # 6 was observed to have greasy hair. When interviewed about ADLs, Resident # 6 stated, .I only remember getting showered one time when I got my hair washed.During an observation on 3/19/26 at 9:13 AM, Resident #6 was in bed in a hospital gown and his/her hair appeared greasy. Resident #6 stated, I think I had a bath yesterday . I am not sure when my hair was washed last. During an interview on 3/19/26 at 9:49 AM, Staff # 11 (LPN) stated, We [staff] document showers/baths in the Task Tab in the [medical record system]. We don't use a shower book in this facility.A review of Resident # 6's medical record on 3/19/26 (Thursday) at 11:14 AM revealed Resident # 6 was admitted on [DATE]. Further review of Resident #6's medical record revealed that Resident # 6 was scheduled for baths on Wednesdays and Saturdays. There was evidence in the GNA's (geriatric nursing assistant) task documentation that on 3/18/26 at 10:27 PM Resident # 6 was given a bath in which he/she required partial/moderate assistance. However, there was no documentation of any showers or baths prior to 3/18/26 in the EMR (electronic medical record).During an interview with Resident # 6 on 3/19/26 at 12:18 PM, Resident # 6 stated, My preference would be a bed bath. I was given a bed bath last night. But to get my hair washed, I have to go to the shower room every once in a while. I don't remember the last time that I had my hair washed.The facility was unable to provide evidence of more than one bath since Resident # 6's admission on [DATE] and there was no evidence of his/her hair being washed.During an interview with the DON and Staff # 13 (Senior Director of Nursing Services) on 3/19/26 at 2:22 PM, Staff # 13 stated, I had not trained [the DON] on adding the bathing tasks to (the medical record system]. I added the task for Resident # 6 when I got her on Tuesday [3/17/26]. The DON stated that the expectation would be that the GNA (geriatric nursing assistant) would document the care given in the Task tab of [the medical record system].

Based on observations and interviews, it was determined that the facility failed to properly dispose of waste in the kitchen area in a manner to prevent contamination and the attraction of pests. This was evident for 1 out of 2 kitchen areas in the facility. The findings include: During the initial tour of the main kitchen on 12/04/24 at 8:36 AM, the Surveyors observed a pile of 14 empty boxes that lay on the floor beside the doorway. The pile of boxes blocked the doors of the free-standing refrigerator, freezer, and holding warmer. An observation of the trash can beside the door was overfull and would not allow the lid to completely close. Several Sysco Classic Sliced [NAME] Potatoes cans were visible on top of the trash holding the lid open. During an interview on 12/04/24 at 08:40 AM, Lead [NAME] #1 said the trash should not be there and needs to be cleaned up. During an interview conducted on 12/04/24 at 9:46 AM, the Dining Service Director stated that the boxes should not have been piled on the floor and the trash overfilled and stated there was no excuse. During an observation with the Dining Service Director of the dumpster area on 12/06/24 at 10:24 AM, it was discovered that trash was not disposed of properly. The area was fenced in with trash scattered over several areas. Trash was found lying around the dumpster, against the fence, and other parts of the dumpster area, trash included disposable cups, papers, and carry-out trays. There is also a heavy buildup of dried leaves around the dumpster area. A cart with two bags of trash was noted sitting beside the dumpster waiting to be thrown out and a stack of boxes was sitting beside the dumpster. During an interview with the Dining Service Director on 12/06/24 at 10:26 AM, he advised he was going to have someone come to clean up and throw away the trash left beside the dumpster. The Director stopped to tell a passing dietary employee to make sure the trash is thrown away because it can attract rodents.

Based on observations and interviews with facility staff, it was determined that the facility failed to store and prepare food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared by the facility kitchens. The findings include: During observations in the Dining Room Kitchen on [DATE] at 08:15 AM, the following items were found: 1 metal container with a lid containing cooked ham labeled with a prepared date of [DATE] and a use by date of [DATE], 1 unlabeled and undated pack of cheese in clear plastic wrap, 1 undated plastic container labeled Rice Krispies, 1 5-pound plastic container of Creamy Peanut Butter that had an open date of ,d+[DATE] with no year written on the lid but had no expiration date identified. There was also 1 container of Old Bay seasoning that was labeled with an open date of [DATE] and a use-by date of [DATE]. During an interview with the Lead Dietary Aide #2 On [DATE] at 08:15 AM, the Lead Dietary Aide acknowledged the pack was some type of cheese but was unable to identify it and was unsure when it was opened or when it would expire. The Lead Dietary Aide further stated I didn't know what expiration date to put for the cereal so it's not labeled yet. We are waiting for the manager to advise a date on expirations. The Lead Dietary Aide reported that things are not labeled because I don't know the correct date to put. The Lead Dietary Aide observed the expired Old Bay Seasoning, acknowledged the seasoning had expired, and explained it should have been disposed of once it expired. During the initial tour of the Main Kitchen on [DATE] at 8:30 AM conducted with the lead Cook, several items were found opened with no label showing the expiration date. The following foods identified were: Foods found in the refrigerators opened and with no expiration date: A plastic container containing Roasted Peppers had a label with a prepared date of [DATE] and no expiration date. Three undated aluminum pans filled with muffins with no label or dates. Cookie dough wrapped in plastic wrap in a metal pan with no label or dates. Tomato sauce in a plastic container with no label or dates. Pearl Onion in a blue bag with no label or dates. Wholesome Farms Sour Cream 5-pound plastic container in the refrigerator with no label or dates. Ken's Essentials Classic Caesar Dressing gallon plastic container with no label or dates. Sysco Classic Mint Jelly 4-pound glass jar in refrigerator with no label or dates. Ken's Fat-Free Italian Dressing 1 Gallon plastic container with no label or dates. Ken's Deluxe Thousand Island Dressing 1 Gallon plastic with no label or dates. Sysco Imperial [NAME] French Dressing 1 Gallon plastic container with no label or dates. Plastic Container with a Facility label labeled as Honey mustard in a gallon container with no label or dates. Block & Barrel Mild Banana Pepper Rings ,d+[DATE] Crinkle Cut 1 gallon container with no label or dates. [NAME] Premium Capers Non-Pareille Crunchy & Briny 1 Quart Glass jar with no label or dates. Ken's Table Side Caesar Dressing gallon plastic container with no label or dates. Ken's Ranch gallon plastic container with no label or dates. Bag of shredded carrots open, top loosely folded over with no label or dates. 5 dressing dispensers unlabeled with dressing in the dispensers with no label or dates. Apple pie -,d+[DATE] pie in an aluminum pie pan dated as prepped on [DATE], with no expiration date or label. Pecan Pie -,d+[DATE] pie in an aluminum pie pan dated as prepped on [DATE], with no expiration date or label. King's Hawaiian Original Sweet Roll's pack of 24 rolls has been opened with no label or dates. La Catalina Blueberries opened with no label or dates. Jello in a metal container with no label or dates Land O Lakes Half and Half opened with no label or dates. Two Containers of Minor's Zesty Orange Sauce half a gallon plastic containers with no label or dates. Sweet Baby Ray's Barbeque Sauce gallon plastic container opened with no label or dates. [NAME] Wild Swedish Lingonberries 14.2 oz jar with no label or dates. Additionally, there were two expired items found in the refrigerator, 1 plastic container of [NAME] Bananas [NAME] with a prepared date of [DATE] and an expiration date of [DATE] and 1 14.2-ounce jar of [NAME] Wild Swedish Lingonberries with an opened date of ,d+[DATE] with no year written and an expiration date of ,d+[DATE] with no year written. During an interview with Lead [NAME] #1 on [DATE] at 08:47 AM, the Lead [NAME] agreed the items were expired and should have been disposed of and would be thrown out. During the continued tour foods were found on the counters and freezers opened and with no expiration date including: On the counters, there was 1 [NAME] Mayo 12 FL oz plastic container with no label or dates, 2 House Recipe Fancy Tomato Ketchup 24 oz plastic containers with no label or dates and 1 glass bottle of A.1. Original sauce glass bottle with no label or dates. In the freezer, there was 1 bag of biscuits that laid in a pan with no label or dates, 1 unwrapped pita that sat in a container with no lid, label, or dates, 1 pie crust opened with no label or dates, 4 metal containers of muffins covered with aluminum foil, with no dates on three and one with a date of [DATE], 3 pizzas in an opened bag open to air with no label or dates, 1 large bag of biscuits in a tied bag in the freezer with no label or dates, pearl onions in a blue bag with no label or dates, pierogies classic cheddar 6-pound bag with no label or dates. Meat was found in a sealed bag in the freezer and did not have a label or expiration date. The Lead [NAME] #1 was unable to identify what was in the package and advised it was some kind of meat. During the tour, the surveyors observed a sign posted on a refrigerator that stated Make sure all open items in this refrigerator have a label with the following information - item description, item opened date, item expiration date, initials of team member who wrote the labels. There are no exceptions. An observation of the outside walk-in freezer was conducted on [DATE] at 8:58 AM. There was a plastic 12-quart container with no lid that sat on the bottom shelf of the freezer rack. The container had several prepackaged unidentified items and some ravioli wrapped loosely in a bag. A light brown sticky substance had leaked into the container and onto several of the food items. During observations of each refrigerator and freezer in the Main Kitchen during the initial tour, it was discovered that none of the refrigerators and freezers had internal temperature monitoring devices in place and the logs to record the temperatures were incomplete. During an interview with Lead [NAME] #1 on [DATE] at 08:36 AM, the Lead [NAME] reported he didn ' t know a device was needed to measure the internal temperatures and that the staff used the external thermometer to monitor the temperatures. During an interview with the Dining Service Director on [DATE] at 9:46 AM, the Dining Service Director was made aware of the issues with the unlabeled items, expired items, the lack of internal temperature monitoring, and the incomplete records of the refrigerator and freezer temperatures. The Director stated that the facility follows a health code for the time that open foods can be kept. The Director reported he was having staffing issues but there's no excuse for the findings. During a follow-up interview conducted on [DATE] at approximately 11:15 PM, the Director of Dining advised the Surveyors that thermometers had been ordered for each refrigerator and freezer.

Based on observations and staff interviews it was determined that the facility failed to maintain a safe and effective system for securing medication. This was found to be evident for 3 out of 3 medication carts observed during the re-certification survey. The findings include: During a random tour of the nursing unit conducted on 12/06/24 at 6:12 AM, the surveyors observed an unattended medication cart unlocked. The surveyors were able to open each drawer that contained prescribed and over the counter medications. In addition, the laptop was open to resident names. The medications were labeled with resident names and room numbers. During the continued observation the Surveyors observed RN #3 exit resident room [ROOM NUMBER]. During an interview conducted on 12/06/24 at 6:16 AM, RN #3 apologized for leaving his medication cart unattended and unlocked as well as the laptop open to resident names. The RN stated that he had a rough night but that the facility's policy was to always lock your medication cart when unattended as well as lock the screen on the laptop. On 12/06/2024 at 8:10 AM, during an interview this surveyor advised the NHA of the observation of the unlocked med cart. On 12/09/2024 at 6:22 AM the surveyors observed an unattended medication cart unlocked. The surveyors were able to open each drawer that contained prescribed and over the counter medications. The medications were labeled with resident names and room numbers. During the continued observation, Licensed Practical Nurse (LPN) 12 was observed exiting resident room [ROOM NUMBER]. During an interview conducted on 12/09/2024 at 6:26 AM, the NHA and Regional Director of Clinical Care #1 observed the unlocked med cart and stated they would educate the LPN and staff on unattended unlocked med carts. During a random observation conducted on 12/09/2024 at 10:09 AM, the surveyor observed a medication cart unattended and unlocked. The surveyors were able to open each drawer that contained prescribed and over the counter medications. The surveyor then went to the NHA and Regional Director of Clinical Care #1 and advised another medication cart was unlocked. Both the NHA and Regional followed the surveyor back to the unattended unlocked medication cart and observed LPN #18 exit resident room [ROOM NUMBER] from down the hallway. The LPN returned to the unlocked medication cart and locked his cart. During an interview conducted on 12/09/24 at 10:14 AM, the LPN stated the facility's policy is to always lock your assigned medication cart when unattended. The NHA stated she has educated the nursing staff and would continue the education.

Based on observation, record review and interview, it was determined the facility failed to 1) obtain physician orders for residents to receive Continuous Positive Airway Pressure (CPAP) treatment and 2) maintain Quality of Care. This was evident for 3 (Resident #17, #8 and #292) of 24 residents reviewed during the annual survey The findings include: 1) CPAP treatment, which stands for Continuous Positive Airway Pressure, is a therapy that uses a machine to deliver pressurized air through a mask worn while sleeping, keeping the airway open and preventing breathing interruptions caused by sleep apnea. On 12/04/24 at 09:30AM during rounds the surveyor observed a CPAP machine sitting on Resident #17's bedside table. The resident stated he/she had problems sleeping so the machine was used at night. They put it on every night so I could sleep On 12/05/24 at 07:37 AM a review of Resident #17 clinical record confirmed that the resident had been receiving CPAP treatment at night. This was evident in a progress note dated 11/10/24 by Staff #17. Further review of the clinical record revealed no evidence of a physician's order for the CPAP treatment. On 12/05/24 at 08:56 AM in an interview with the Director of Nursing (DON) the surveyor enquired whether a physician order was required for a resident to receive CPAP treatment. The DON replied, who is the resident, tell me and I will get back to you? The surveyor gave the name of the resident to the DON. On 12/05/24 at 10:15AM the DON informed the surveyor that a physician's order was obtained for Resident #17's CPAP treatment and a copy of the order dated 12/5/24 was given to the surveyor. The Physician's order stated Apply CPAP at time of sleep in the night and remove in the AM every evening and night shift. Assist resident applying and removing CPAP. The order was confirmed in Resident#17's electronic chart by the surveyor. 51491 2a) During an observation on 12/04/24 at 12:41 PM Resident #8 was observed sitting in a wheelchair with another resident at the table. Resident #8 was slumped forward sleeping with a stream of drool draining from the resident's mouth onto the resident's lap. A plate of food was placed in front of the Resident and no food had been eaten. During an observation on 12/04/24 at 12:51 PM Resident #8 was observed still sitting in a wheelchair with another resident at the table. Resident #8 was still slumped forward sleeping with a stream of drool draining from his mouth onto his lap. A plate of food was placed in front of him/her and no food had been eaten. No assistance was provided from the staff. The surveyor attempted to awaken the resident by saying the resident's name but received no response. A Geriatric Nursing Assistant (GNA) (#9) came over to assist. The GNA had to say the Resident's name loudly and shake his/her shoulders to awaken him/her. The Resident appeared groggy and struggled to keep his/her head held up. The GNA had the resident taken back to his/her room. During an observation on 12/05/24 at 08:47 AM, Resident #8 was asleep in bed with a food tray set up in front of him/her. The resident would wake to verbal stimuli from the Surveyor but would fall back to sleep, with no assistance being provided or offered by staff, During an observation on 12/05/24 at 10:07 AM Resident is awake and in bed, breakfast tray still on table. The resident was still in the t-shirt he slept in. The resident appears very thin. During an observation on 12/05/24 at 12:38 PM Resident #8 was again observed slumped over and asleep in a wheelchair for lunch, no food had been delivered yet. The resident sat at a table in the corner alone and had wet spots on his/her shirt from drool. During the continued observation the Surveyors returned to the dining room at 12:47 PM. The Resident was still slumped forward sleeping. The Resident now had a plate of food in front of him/her. The Surveyors left the dining room and located the Assistant Director of Nursing (ADON). The Surveyors explained their concern with the ADON. The Surveyors and the ADON returned to the dining room and found the Resident still asleep, slumped forward and his/her food was untouched. The ADON woke the Resident by calling his/her name loudly and shaking his/her shoulders. The Resident responded but appeared groggy with difficulty lifting his/her head. There was visible drool on the napkin that lay on the Resident's lap. The MDS (Minimum Data Set) is a health status screening and assessment tool used for all residents of long-term care nursing facilities. The MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid-certified nursing homes. This process provides a comprehensive assessment of each Resident's functional capabilities and helps nursing home staff identify health problems. A Care Plan is used in nursing facilities to summarize a resident's health conditions and care needs. It is used to ensure resident's needs are met and consistent care is provided to the resident based on those needs. During a Medical Record Review on 12/06/24 at 08:41 AM it was revealed the Resident has had a 6.04% weight loss; the Residents weight was 122.5 pounds on 11/09/24 and 115.1 on 12/02/24. An additional record review showed the Resident's Minimum Data Set (MDS) in Section GG Functional Abilities identified the Resident as needing Supervision or touching assistance while eating and the helper provides verbal cues and/or touching/steadying and/or contact guard assistance as residence completes activity. The Service Evaluation and Health Assessment for Resident #8 identifies the Resident as I am dependent with assistance of helpers with eating. On the Resident's care plan, it states I require supervision or touching assistance with eating which was initiated on 11/13/2024. During a review of a Nutrition/Dietary on 12/09/24 at 8:33 AM, a note on 12/6/2024 at 07:04 AM was discovered and the Dietician identified the Resident as severely underweight noted with significant weight loss. During an observation on 12/10/24 at 09:18 AM, Resident #8 was sitting up in bed, falling asleep while eating. No facility staff in the room. During an observation on 12/11/24 at 10:09 AM Resident sitting up in bed, holding a piece of bacon in his hand, and falling asleep, no facility staff was with the resident, and food was running down the Resident's chin and spilled onto the napkin sitting on the Resident's chest. During a Medical Record Review on 12/11/24 at 12:56 PM, it was revealed that the resident has had additional weight loss. The Resident's weight was 122.5 pounds on 11/09/24 and 111.8 pounds on 12/10/24 for an 8.73% weight loss. 2b.) A hip abduction pillow is a soft but firm foam pillow that is placed between the thighs and strapped onto the patient's legs while they are in a resting position. This aids in keeping the body stable and prevents an abducting motion that could cause pain or further injury post-surgery. During a medical chart review on 12/10/24 at 07:57 AM it was revealed the Resident has had a Left femur fracture and had had surgery on his left hip. There was a doctor's order for the Abduction Pillow while in bed every shift which was ordered on 11/08/24. The Resident ' s Care Plan interventions included using the Abduction Pillow when in bed which was initiated on 11/13/24. During an observation on 12/10/24 at 10:17 AM LPN #18 showed the resident had Pressure-relieving boots on as ordered and it was noted the Resident did not have the abduction pillow in place. The pillow was observed on the floor in the corner of the room. During an observation on 12/11/24 at 12:56 PM, it was discovered that Resident #8 was asleep in bed, the Resident did not have the abduction pillow in place, it was sitting on the floor in the corner of the room. During an interview on 12/12/24 at 06:40 AM, the Surveyor asked RN #3 if Resident #8 had the abduction pillow in place. RN #3 reported, It should be, the evening shift does it. The Surveyor advised the order is scheduled for all three shifts when the Resident is in bed and RN #3 confirmed their initials as the last one to sign off the order. During an interview and observation with the Nursing Home Administrator (NHA) on 12/12/24 at 06:48 AM, the NHA was taken into the Resident's room and explained concerns about the order being signed off but the adduction pillow was not on the Resident. The abduction pillow was sitting on the floor in the corner of the resident's room. During a review of the Treatment Administration Record (TAR) on 12/12/24 at 07:10 AM it was revealed that the order for the Abduction Pillow to be on when the patient was in bed had been signed off as complete for every shift that occurred from 12/04/24 through 12/12/24. During an observation of Resident #8 on 12/12/24 at 09:12 AM, it was discovered the Abduction Pillow is no longer in the corner of the room. The Abduction Pillow was found on the Resident while he/she was lying in bed. 2c) During an observation on 12/04/24 at 7:58 AM the daughter of Resident #292 advised Registered Nurse (RN) #3 that the Resident was vomiting. The RN returned to the nursing station without any intervention or assessment of the Resident. During an interview with the daughter conducted on 12/04/24 at 08:08 AM she reported that Resident #292 had been having lots of pain and was now vomiting. During an interview with Licensed Practical Nurse (LPN) #6 on 12/04/24 at 08:10 AM, the Surveyors made LPN #6 aware of Resident #292 complaining of pain and vomiting. The LPN reported that RN # 3 had left and that the nurse for that area was on the way. During an interview on 12/04/24 at 8:42 AM, LPN #13 stated she arrived at the facility at 8:15 AM. When asked if she received a report on Resident #292, the LPN stated that RN #3 reported that the Resident had complained of pain and wanted Gabapentin. She further stated that the RN reported that the medication had not been ordered during RN #3's night shift. The LPN did not report that the RN notified her that Resident #292 had vomited. During an interview with the Nursing Home Administrator (NHA) on 12/04/24 at 09:22 AM, the NHA reported that when a nurse is running late, the facility expects the nurse assigned to remain on duty until the oncoming nurse arrives and relieves the nurse of their duties. The NHA further stated that the Assistant Director of Nursing (ADON) can also fill the staffing vacancies as needed. The NHA confirmed she was not aware that RN #3 left the facility before being relieved of his duties by the late oncoming nurse and that the middle hallway was unattended until the oncoming nurse arrived. During an interview on 12/06/24 at 06:26 AM, RN #3 stated he did not return to Resident #292 after being advised that the resident had vomited. The RN reported that he told the Geriatric Nursing Assistant #9 GNA about the Resident vomiting before leaving. When asked why the RN told the GNA about the vomiting resident and why he did not assess the Resident, the RN advised I don't have an answer. The RN confirmed he gave a verbal report over the telephone to LPN #13 and left a written report inside the medication cart. During an interview on 12/06/24 at 07:16 AM, GNA #9 reported becoming aware of Resident #292 concerns by the daughter in the hallway. The GNA #9 advised she assisted the resident to the bathroom. During an interview on 12/06/24 AM at 0950, the Resident's daughter reported no nurse came in to care for her mother for about an hour. LPN #13 was the first nurse that came into her room after the Resident vomited. During a review of staff clock time reports it was revealed that RN #3 clocked out at 08:03 AM and LPN #13 clocked in at 08:34 AM to fill her role as the nurse in the middle hall.

Based on interview and record review, it was determined the facility failed to ensure the required staff members were present for each of the monthly Quality Assurance (QA) Committee meetings. This was evident during a review of the Quality Assurance and Performance Improvement (QAPI) program during the recertification survey. The findings include: On 12/11/24 at 9:59 AM, an interview with the Nursing Home Administrator (NHA) was conducted to review the facility's quality assurance activities. Copies of the attendance sheets for the past 6 months' QA meetings were requested. On 12/11/24 at 3:31 PM, a review attendance sheets for the following months revealed: - May: no Director of Nursing (DON), Infection Preventionist (IP), Medical Director (MD) - June: no DON and IP - July: no DON, IP and MD On 12/12/24 at 7:44 AM, the NHA and the General Manager (GM) were notified of the concern related to the required members of the QA committee attending the meeting.

Based on observations and interview, it was determined the facility failed to ensure that the location of the most recent state survey results and plan of correction were posted in a place readily accessible to residents, family members and visitors. This was evident during the facility's recertification survey. The findings include: The surveyor's observations of the facility on 12/05/24 at 8:00AM and 12/6/24 at 7:30AM did not reveal any posted notification indicating where the recent state survey results and plan of correction were located. On 12/09/24 at 07:56 AM in an interview, the Nursing Home Administrator confirmed that the facility failed to post a sign indicating where the most recent survey inspection was located. The Administrator stated I will take care of that right now After the surveyor's intervention, on 12/09/24 at 09:54 AM the surveyor observed a sign which revealed the location of the recent state survey inspection results, posted in a place easily accessible to any person, on a table in front of the nurse's station.

Based on review of the facility policy and interviews it was determined that the facility failed to ensure that grievance forms were accessible. This was found to be evident for 1 (Resident #244) out of 1 Resident reviewed for the grievance policy. The findings include: A review of a formal complaint MD00203191 filed with the Office of Healthcare Quality was conducted on 12/05/24 at 10:00 AM. The complainant stated that verbal grievances were filed by the Social Service Director on behalf of the complainant and Resident #244. The complainant also reported that a request to receive a copy of the written grievances was denied in accordance with the facility's policy. On 12/05/24 at 10:32 AM review of grievance forms confirmed Resident #244 had 2 investigated grievance forms. During an interview conducted on 12/05/24 at 11:10 AM, the Social Service Director stated that she filed the grievances on behalf of the complainant and Resident #244. The Social Service Director stated that the complainant requested a copy of the grievance forms investigated, however the request was denied because the grievance forms were an internal document not for the public view which was in accordance with the facility's policy. This Surveyor requested a copy of the grievance policy. On 12/05/24 at 11:19 AM, the Surveyor reviewed the facility's grievance policy which stated in Action Step #5 section c stated The SSC (Social Service Coordinator) / designee will: Make grievance reports readily accessible to residents, family, and team members. During an interview conducted on 12/05/24 at 12:22 PM, the Surveyor and Nursing Home Administrator (NHA) reviewed the grievance policy provided by the Social Service Director. The NHA confirmed that the facility's grievance policy stated that the facility would make the grievance policy accessible to residents, family, and team members. The NHA further stated that she would educate the Social Service Director on the facility's grievance policy.

Based on record review and interview, it was determined that the facility failed to provide evidence that an advance directive was offered to the residents. This was evident for 2 (Resident #22 and #37) of 4 residents reviewed for advance directives during the recertification survey. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. A Medical Orders for Life-Sustaining Treatment (MOLST) is a medical order form that documents a patient's wishes for end-of-life care. A Brief Interview for Mental Status (BIMS) is a brief cognitive screening measure that focuses on orientation and short-term word recall. On 12/5/24 at 7:45 AM, a review of Resident #22 and Resident #37's paper charts revealed capacity forms that were completed on 11/14/24 which indicated that they were both capable. Further review of their paper and electronic health records revealed no evidence that an advance directive was offered to the residents. On 12/5/24 at 8:13 AM, during an interview with the Social Worker, she stated that Resident #22 and Resident #37 had no advance directives in the charts. The Social worker also discussed the process when the facility had new admission, she stated that she made sure the resident was seen within 24 hours and if it was a Friday admission, she saw the resident on a Monday. She added that she checked the capacity and went over the home situation to have an idea of the discharge planning. She also stated that she checked if BIMS was conducted by nursing staff and redid if needed. She also checked the MOLST and asked the resident if they had an advance directive and if the resident had one, she would ask the family to bring to the facility and followed up the resident representative after a week, if there was none, she stated that she asked the resident to complete a surrogate form to determine the decision maker. She further stated that she offered the residents or the resident representatives to formulate an advance directive, however, she confirmed that she did not document it in the medical records. On 12/6/24 at 7:36 AM, a record review revealed that the Social worker documented these progress notes to the following residents after surveyors' intervention: - Resident #37, 12/5/2024 13:42 Discussed Advance Directives with resident. Resident states he/she has informally appointed his/her son but has not put anything in writing. Resident accepted a copy of the advance directives to review with his/her son. - Resident #22, 12/5/2024 13:46 Spoke with resident about advance directives. Resident states he/she believes he/she has documents but will discuss with family. Resident declined a copy of the advance directives. On 12/12/24 at 10:20 AM, the facility was made aware of the concern with advance directives during the exit meeting.

Based on observation and interviews with residents and staff, it was determined that the facility failed to respect a resident's dignity. This was evident in 1 (Resident #8) out of 6 residents observed for dignity. The findings include: During an observation on 12/04/24 at 12:41 PM Resident #8 was observed sitting in a wheelchair with another resident at the dining room table. Resident #8 was slumped forward asleep with a stream of drool draining from the resident's mouth onto the resident's lap. A plate of food was sitting in front of the resident on the dining room table and no food had been eaten. During continued observation on 12/04/24 at 12:52 PM Resident #8 was observed sitting in a wheelchair asleep. No assistance was being provided by the staff. The surveyor attempted to awaken the resident by saying the resident's name but received no response. A Geriatric Nursing Assistant (GNA) #9 came over to assist. The GNA had to say the resident's name loudly and shake the resident's shoulders to awaken. The resident appeared groggy and would not hold his/her head up. The GNA stated that she would take the Resident to his/her room. During an observation on 12/05/24 at 12:38 PM Resident #8 was observed slumped over sleeping in his/her wheelchair at lunch, no food had been delivered yet. The resident was sitting at a table in the corner alone and had wet spots on his/her shirt from drool. During an observation on 12/05/24 at 12:41 PM Resident #8 was slumped over sleeping. No attempts to awaken or any other assistance had been given to the resident. No food had been delivered to the Resident. During the continued observation the Surveyors returned to the dining room at 12:47 PM. The Resident was still slumped forward asleep. The Resident now had a plate of food in front of him/her. The Surveyors left the dining room and located the Assistant Director of Nursing (ADON). The Surveyors explained their concern with the ADON. The Surveyors and the ADON returned to the dining room and found the Resident still asleep, slumped forward and his/her food was untouched. The ADON woke the Resident by calling his/her name loudly and shaking his/her shoulders. The Resident responded but appeared groggy with difficulty lifting his/her head. There was visible drool on the napkin that lay on the Resident's lap. The ADON stated, This is unacceptable. The ADON advised the surveyors that she would have someone to sit with the resident during his/her meals.

Based on surveyor review of the clinical record and staff interviews, it was determined that the facility staff failed to follow the physicians orders for laboratory tests and medications and to initiate treatment to residents in a timely manner. This finding was identified in 7 of 28 residents selected in stage 2 reviews. (Residents #92, #48, #70, #140, #145, #23 and #74). This finding was determined to cause harm to resident #92. The findings include: 1). Based on surveyor review of the clinical record and staff interviews, it was determined that the facility staff failed to obtain a laboratory test as ordered and in a timely manner, to evaluate and to provide timely and appropriate treatment for [REDACTED]. The findings were determined to cause harm to the resident and include: On [DATE], review of the closed clinical record revealed that Resident #92 was admitted to the facility on [DATE] for rehabilitation services following a hospitalization due to a fall at home, associated with generalized weakness and frailty. The resident had a history of [REDACTED]. His discharge [DIAGNOSES REDACTED]. Based on review of the admitting physical exam, performed by the attending physician in the nursing facility on [DATE], the physician noted that the resident's prognosis and rehabilitation potential were "good" with a projected discharge within 30 days. Review of the admission orders [REDACTED]. The CBC and CMP tests were done and the results were reported the next day on [DATE]. However, according to documentation on the Treatment Administration Record (TAR) dated [DATE], the "urine (was) not collected." There was no other information in the clinical record regarding the failure to collect the residents urine for the laboratory tests as ordered on [DATE]. The CBC test results from [DATE] revealed an abnormally high WBC (white blood count) of 11.1 (the normal reference range is 3XXX,[DATE].3). A high or elevated WBC can indicate the presence of infection. Review of the previous hospital laboratory tests done on [DATE], the day before the resident's discharge to the facility, revealed that the WBC was within normal range at 6.9. Based on the elevated WBC of 11.1, the physician gave a telephone order on [DATE] for a "CBC next week Wednesday," which was scheduled for [DATE]. In addition to this laboratory order on [DATE], the physician gave a new order for "psych(iatric) consultation (secondary to) agitation." However, based on review of the hospital medical records, the nurse's admission note dated [DATE], and the physician's admitting history and physical exam, there was no evidence that the resident had a past medical history of [REDACTED]. A change in behavior, specifically in the elderly, can indicate the presence of an infection. Additionally, a speech therapist evaluated the resident on [DATE] because the resident was "observed coughing on thin liquids." The speech therapist obtained orders for treatment of [REDACTED]. However, based on review of the hospital medical records, the nurse's admission note dated [DATE], and the physician's admitting history and physical exam, there was no evidence that the resident had a past medical history of [REDACTED]. A change in functional status, such as swallowing ability, can be related to a change in condition. Continued review of the clinical record, through the days to the next week's scheduled CBC laboratory test on [DATE], revealed that the resident had decreased food intake, confusion was noted, and he displayed agitative behaviors as evidenced by taking off his clothes and pulling down his pants, despite the start of psychoactive medication for agitation on [DATE]. On [DATE], the CBC test was done and the results reported, which revealed the WBC was increasingly higher at 19.3 in comparison to 11.1 on [DATE]. The attending physician visited the resident the same day and noted the abnormal WBC result. The physician then ordered another WBC laboratory test for the "next lab day." Based on an interview with the Director of Nursing (DON) on [DATE] at approximately 11:00 AM, the facility's routine lab days are Monday, Wednesday, and Friday. Therefore, the WBC laboratory test, as ordered by the physician on [DATE], was scheduled to be done on Friday, [DATE]. Additionally, review of the physician's progress note and written orders on [DATE] revealed that a urinalysis with culture and sensitivity test was ordered again, intended to evaluate for a possible urinary tract infection. Based on record review and interviews with the DON as aforementioned, the urinalysis with culture and sensitivity test, initially ordered when the resident was admitted to the facility, had not been done since ordered a week prior. There was no information in the clinical record regarding the failure to collect the urine for the laboratory tests as ordered on [DATE] to date on [DATE]. Based on record review, the WBC laboratory test was done and the result reported as scheduled on Friday [DATE], which revealed that the WBC was increasingly higher at 22.1 in comparison to 19.3 on [DATE]. The physician was notified and gave new orders for a chest X-ray and urinalysis with culture and sensitivity "via straight cath next lab day." Based on interview with the DON as aforementioned, the urinalysis with culture and sensitivity test, re-ordered on [DATE], still had not been done because staff could not obtain the urine due to the resident's incontinence. Therefore, staff received another order on [DATE] to obtain the urine by catheterization, scheduled for the next lab day which was Monday [DATE]. The chest X-ray was done on [DATE] and the results were negative. However, continued review of the clinical record revealed that the resident's condition worsened on [DATE] as evidence by decreased oral intake, fever (elevated temperature of 100.9 degrees F), change in mental status and lethargy. The physician was notified and gave a series of new orders for: a STAT (immediate) urinalysis with culture and sensitivity via straight cath, stool for [MEDICAL CONDITION] (a laboratory test to evaluate for bowel infection), and to [MEDICATION NAME](an antibiotic) 500mg twice daily for 10 days, and Tylenol 650mg every 4 hours as needed for temperature greater than 100 degrees F. A following order from the physician on [DATE] stated to send the resident to the hospital emergency room for further evaluation. Based on a nursing entry and the physician's telephone order near 3:00 PM on [DATE], the resident's family member was called and stated that they did not want the resident sent to the hospital, after which the physician's orders [REDACTED]. The STAT urinalysis with culture and sensitivity was done and the results of the urinalysis reported to the facility at 10:00 PM on [DATE], which indicated a urinary tract infection. Review of the record revealed that [MEDICATION NAME] was started on [DATE], although the first dose was not given until the next day on [DATE] at 4:00 AM, despite the availability of the drug in stock supply at the facility. Continued review of the nursing notes and the physician orders [REDACTED]. The laboratory test result for [MEDICAL CONDITION] was reported negative and the urine culture and sensitivity test result was still pending from the laboratory on this date. The laboratory report for the urine culture and sensitivity was received at the facility the next day on [DATE] at 12:00 PM. The results showed the resident had [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) infection in the urine and that this infection was resistant to the antibiotic, Cipro. However, by this time on [DATE], a nursing note entered at 6:15 AM stated that the resident was found deceased at 5:45 AM. Review of the Certificate of Death completed by the attending physician stated that the cause of death was urosepsis, a systemic [MEDICAL CONDITION] response of the body to infection. 2). Based on resident record review and staff interviews, it was determined that the facility staff failed to follow physican orders for resident #48. The findings include: Resident #48 was admitted on [DATE] after a surgical repair of a right [MEDICAL CONDITION]. The resident is alert and needs assistance for activities of daily living. a. review of the resident's medical record revealed [REDACTED]. These medications have a high risk of constipation as a side effect. Further review revealed that the resident developed constipation on [DATE]. A Fleet's enema was given once with large amounts of stool eliminated. On [DATE], the resident complained of abdominal pain. An abdominal x-ray was ordered to rule out a bowel obstruction. It revealed that the resident did not have a bowel obstruction but a large amount of stool present (constipation). The physician ordered another Fleet's enema. Further, record review revealed the night nurse noted on [DATE] that the resident's appetite had been poor and was noted with "episodes of loose stool" which was the result of the enema given. The resident's abdomen "remain(ed) slightly distended". With ongoing constipation, further assessment and interventions should be initiated to prevent constipation. However, no comprehensive assessment and no new interventions were provided to manage the constipation. On [DATE], the night shift nurse documented that the resident complained of "constipation and dry mouth". The nurse encouraged the resident to drink more fluids and noted that the resident was able to "pass small amount of stool" but "abdomen is tender in the lower left quadrant". The nurse also noted "blood in toilet due to swollen hemorrhoid". This information was passed on to the day shift nurse for follow up. No additional medication or other intervention was noted to relieve the resident's constipation. Review of the nursing note revealed that the day shift staff did not inform the physician in a timely manner for the above change in condition until noon. By then the resident had emesis and visual hallucinations. The nurse documented that the resident had one episode of emesis described as "greenish in color", "stomach a little distended, has loose stool". The resident was seeing things, defined as a "hallucination" by the nurse. The physician ordered another abdominal x-ray and to check the stool for [MEDICAL CONDITION] (a contagious stool infection with diarrhea common) and discontinued [MEDICATION NAME] and [MEDICATION NAME] (pain medications). A psychiatric consultation was also ordered. No further assessment or intervention for constipation was documented. In the evening of [DATE] at 9 PM, the nurse documented that the resident continued to have a distended abdomen with "nausea, hypoactive bowel sound". The abdominal x-ray result came back and revealed a large amount of stool (less than 4 days ago). The nurse obtained an order for [REDACTED]. Further review found no documentation when the Fleet enema was received and no documentation that the Fleet enema was given as ordered. The facility staff failed to ensure a timely administration of the Fleet enema and failed to conduct a comprehensive assessment and provide adequate interventions for the resident's ongoing constipation problem. b. In addition, the resident's laboratory test revealed an elevated BUN and creatinine, an indication for dehydration. The physician ordered IV (intravenous) fluid in the evening of [DATE]. On [DATE], the resident continued having "visual disturbance" and the physician ordered a head MRI which revealed "right posteria cerebral artery ischemic". On [DATE], The resident was then sent to a hospital by 911. With these changes in conditions, the nursing staff failed to follow up the [MEDICAL CONDITION] test ordered on [DATE] to rule out a stool infection. No result of the [MEDICAL CONDITION] test ordered on [DATE] was found in the record. An interview of the assistant director of nursing on [DATE] at 4 PM revealed that the staff obtained the stool sample on [DATE], but did not send the stool sample to the laboratory until 4 days later on [DATE]. By then, the resident was already sent to the hospital for the change in condition. Following surveyor's intervention, the assistant director of nursing obtained the stool test result done on [DATE] which indicated a positive result of [MEDICAL CONDITION] infection. Review of the hospital record revealed that the resident was admitted with [DIAGNOSES REDACTED]. The facility staff failed to ensure that a laboratory test was performed timely to facilitate the physician evaluation and treatment when the resident had a significant change in condition. 3). Based on resident record review and staff interviews, it was determined that the facility staff failed to provide a pain patch as ordered for resident #70. The findings include: Resident #70 is newly admitted in [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. One of the narcotics is a [MEDICATION NAME] to be applied every 3 days since [DATE]. Review of the MAR (medication administration record) revealed no documentation that the [MEDICATION NAME] was administered as ordered. The findings include: On [DATE], the resident was scheduled to have the [MEDICATION NAME] (a narcotic) applied, but the medication was not available. The staff delayed one day to administer the pain patch for the resident. However, on the next scheduled date of [DATE], the staff failed to apply the patch. The patch was not applied until [DATE]. There was no explanation for this delay. Further review revealed that the staff failed to administer the pain patch on another scheduled date of [DATE]. The pain patch was not applied until [DATE]. An interview of the assistant director of nursing on [DATE] at 2 PM revealed no further information. In addition, review of the narcotic sheet for the pain patch revealed that the facility was missing the [MEDICATION NAME] record from ,[DATE] to [DATE]. Refer to F431 for details. 4). Based on resident record review and staff interviews, it was determined that the facility staff failed to follow the physician order [REDACTED]. The findings include: Resident #140 was admitted to the facility on [DATE] after hospitalization for a knee infection and jaw abscess. review of the resident's medical record revealed [REDACTED]. Review of the resident's laboratory tests revealed a history of a low potassium level and the physician has been monitoring the potassium level and adjusting the dosage in the past. Low blood potassium can cause muscle problems, fatigue, and heart problems. High blood potassium could be toxic and even lethal. It is important to perform laboratory tests and monitor symptoms to ensure a therapeutic level of blood potassium (K). Review of the physician orders [REDACTED]. Surveyor review of the record on [DATE] revealed no result of the repeat potassium level which should have been done on [DATE]. An interview of the assistant director of nursing on [DATE] at 4 PM confirmed that the laboratory test was not done. Review of the record on [DATE] revealed that the staff obtained an order on ,[DATE] to test the blood potassium level on [DATE]. However, the result could not be found in the record. An interview of the staff nurse #4 on [DATE] at 11 AM revealed additional information. The nurse called the laboratory company and was told it was faxed days ago. The test result was not located in the record and the nurse had to request another faxed copy which did reveal a normal potassium level of 3.8 mMOL/L. 5). Based on surveyor review of the clinical record and interviews of the facility staff, it was determined that the facility staff failed to follow physician's orders [REDACTED]. The findings include: For background information on resident #145 refer to F272. On [DATE], review of the clinical record revealed resident #145 was being administered KCL 40 mEq three times a day for a supplement. A laboratory blood test performed on [DATE] revealed that the K level was 2.9 mMOL/L, a critically low level. A call was made to the attending physician who gave an order to "give extra dose KCL 40 mEq Po (by mouth) at 2 PM today". Review of the MAR for ,[DATE] revealed that the dose was administered at 2 PM as ordered. However, the scheduled dose for the three times a day is also at 2 PM. There is a line drawn through that 2 PM dose as it was not administered. The resident did not receive the extra dose of KCL as ordered. On [DATE] at 9:30 AM, an interview with the acting DON revealed that the extra dose was not administered as ordered. 6). Based on surveyor review of the clinical record and interviews of the facility staff, it was determined that the facility staff failed to follow the physician's orders [REDACTED]. The findings include: On [DATE], review of the clinical record revealed resident #23 is in the facility for rehabilitation after a hospitalization . At the time of hospitalization a new [DIAGNOSES REDACTED]. On admission on [DATE] an order was written by the physician to have a HgbA1C to be drawn in 1 month after admission. A HGBA1C (hemoglobin A1C) is a blood test performed to determine if the glucose level is optimally and carefully regulated and averages the blood glucose over ,[DATE] weeks. This test is a good indicator of long-term glycemic control. There is no evidence this laboratory test was performed since admission. On [DATE] at 1 PM, an interview of the acting DON revealed that the HGBA1C was never performed. 7). Based on surveyor review of the closed record and interviews of the facility staff, it was determined that the facility staff failed to follow the attending physician's orders [REDACTED]. The findings include: On [DATE], review of the clinical record revealed resident #74 had a hospitalization in August and returned to the facility on [DATE]. On [DATE], a physician's orders [REDACTED]. every day. This order was transcribed to the MAR indicated [REDACTED] ,[DATE] shift 600 ml ,[DATE] shift 400 ml. ,[DATE] shift 200 ml. This means each shift was allowed to give this much fluid to the resident, totaling 1200 ml. There was also a place to document exactly how much fluid the resident actually received during each shift. However, there is no evidence of how much fluid the resident received on each meal tray. Usually the dietician reviews the fluid restriction and informs the kitchen how much fluid to place on the tray and then how much fluid the staff can use each shift to administer medications or free fluid during the day. On [DATE], the ,[DATE] shift documented administering 200 ml. of fluid, the ,[DATE] space is blank, and the ,[DATE] shift documented 200 ml. On [DATE] the ,[DATE] shift documented administering 300 ml. On [DATE] at 8:45 AM, a new order was written by the dietician for clarification on the fluid restriction. It revealed that the resident should have no bedside water and that nursing could have 180 ml. per day for medication pass. However, this order was then transcribed on the MAR indicated [REDACTED]. for med pass / daily". The amount was not broken down into how much the resident could receive each shift. Record review revealed on [DATE] during the ,[DATE] shift the resident received 400 ml. of fluid, over the 180 ml. available for nursing all day. The ,[DATE] shift on [DATE] documented administering 60 ml. of fluid and then the following shifts of ,[DATE] and ,[DATE] have only initials, no documentation of amount of fluid administered. On [DATE] at 10 AM, an interview of the dietician revealed that she had contacted the kitchen and notified them of the specific amount of fluids to be placed on each tray. She also stated that she had written the order for nursing to use only 180 ml per 24 hours. On [DATE] at 9 AM, an interview of LPN #1 revealed he had transcribed the order and mistakenly added the zero to change the nurses amount from 180 ml. to 1800 ml. In addition, a narcotic medication ([MEDICATION NAME]) was dicontinued on [DATE]. However, record review revealed that when the resident went to the hospital on [DATE] for a change in mental status, the [MEDICATION NAME] was observed on the resident in the emergency room and was removed by the emergency room physician at that time. No additional information was offered.