Every finding on record at Belle Fountain Nursing & Rehabilitation Center

Based on observation, interview and record review the facility failed to ensure staff implemented safe repositioning techniques during incontinence care for one resident (R107) of two residents reviewed for accidents and supervision resulting in R107 falling from the bed and sustaining a dislocated shoulder. Findings include: On 4/26/26 at 10:53 AM, R107 was interviewed and reported they had experienced a fall a few days prior during bed care. R107 said there was only one staff member present providing care when two staff were required. In addition, R107 said that during the attempt to change the pad underneath them, they were rolled onto their left side, which was their weakened side due to a recent stroke, and subsequently fell out of the bed. R107 said they are not sure if CNA F pushed them too hard or if they fell from being turned with too much force. R107 said since the fall they have had pain in the left arm and left knee.On 4/27/26 at 3:00 PM, Certified Nurse Aid (CNA) F was interviewed and reported on 4-24-26 the night of the incident, R107 indicated their pad was wet. While attempting to change the pad, CNA F said they rolled R107 away from them, at which time the resident fell out of the bed. When queried regarding proper technique, CNA F said they were not trained on the correct method of rolling a resident prior to the incident, and acknowledged they later learned the resident should have been rolled toward the staff member to ensure safety.On 4/28/26 at 9:03 AM, R107 was interviewed and reported they were transferred to the hospital on 4/26/26 after results from prior x-ray were received. They repeated imaging at the hospital confirmed a dislocated left shoulder. The resident further reported ongoing pain in the left arm and left knee following the fall.On 4/28/26 at 12:06 PM, the Director of Nursing (DON) was interviewed and confirmed that two staff should have been utilized to provide care for R107. The Corporate Nurse Registered Nurse (RN) B was present and said staff are trained when they are hired on the proper way to turn a resident, which is toward the staff person. On 4/28/26 at 12:40 PM, during an interview with the DON, RN B and the Nursing Home Administrator (NHA) the DON said staff are expected to follow the care plan interventions, including rolling residents toward staff and utilizing two-person assistance when indicated by the Kardex. The DON said R107 was evaluated for a mobility bar but there is no indication for a mobility bar since they are now utilizing a bariatric mattress. The NHA had no additional information to contribute. Review of R107 Electronic Medical Records (EMR) revealed resident was admitted on [DATE] with the diagnosis as follows: HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION (stroke), TRANSIENT CEREBRAL ISCHEMIC ATTACK, DYSPHAGIA, OROPHARYNGEAL PHASE, CHRONIC KIDNEY DISEASE, RESPIRATORY FAILURE and MUSCLE WEAKNESS. Review of R107 Minimum Data Set (MDS) date 4/22/26 revealed resident Brief Interview for Mental Status was 13 out of 15 indicating cognitively intact. Review of progress note dated 4/26/2026 22:19 Nursing - Progress Note stated, resident had a positive x ray results for left dislocated shoulderThe document provided by the facility did not address repositioning of a resident.

Based on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 04/26/2026 at 8:32 AM observed an inoperable water fountain in the front entrance of the building lobby indicating possible stagnant water. The electric plug was observed unplugged and hanging. On 04/26/2026 at 10:36 AM observed an inoperable water fountain in the hearth room indicating a possible stagnant line.On 04/26/2026 at 11:06 AM observed a therapy tub in the spa room A hall. An interview with Housekeeping/Laundry Supervisor (HLS) K at this time found they were not sure if it is used or not.On 04/26/2026 at 11:16 AM observed a shower room converted to a clean linen room in the spa room E hall. The hand sink faucet and shower head were observed on. On 04/26/2026 at 11:19 AM observed a shower room converted to a clean linen room in the spa room D hall. An interview with HLS K found it is not used as a shower room. The hand sink faucet and shower head were observed on. On 04/26/2026 at 11:27 AM an interview with HLS K found the water fountains were turned off during covid and have not been turned back on.On 04/26/2026 at 1:36 PM an interview with Nursing Home Administer (NHA) and phone interview with Maintenance Director (MD) I was conducted. When asked about control measures regarding water management, MD I indicated they do water temperature checks weekly, and yearly testing for Legionella. When asked if chlorine monitoring is done, NHA indicated they do not test for free chlorine in the domestic cold or hot water supply that residents use and that they only receive and review the water reports from their municipality. When asked about decorative fountains, MD I indicated they have one that is closed for the season currently. MD I indicated when the fountain is opened it is treated and treatment is done on a need be basis. When asked if there are control limits in place, NHA stated the facility would change their course of action depending on Legionella test results. MD I indicated they did have a positive Legionella test in the kitchenette a few months ago and changed the faucet and line set per the recommendation. When asked if the process is written out, NHA indicated the processes are in TELS for controls in place. When asked if aerators are cleaned, MD I indicated they are changed on a need be basis. On 04/26/2026 at 2:31 PM MD I arrived at the facility and an interview was conducted. When asked about unoccupied rooms, MD I stated they run faucets in unoccupied rooms weekly. When asked if the shower rooms that were converted to clean linen rooms are flushed, MD I indicated they are flushed when taking water temperatures but are not on a regular cycle. MD I indicated they go to different areas every week to take water temperatures. When asked about the water fountains that are inoperable, MD I stated the water fountains were unplugged and turned off at the valve during covid and have not been turned back on.Record review of the facility provided document titled [NAME] Fountain Nursing & Rehabilitation Center Legionella Water Management Program dated 2/2019 states, The purpose of the water management program is to identify areas in water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. The policy includes the components of the plan, including The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including . 3. Filters 4. Aerators 5. Showerheads and hoses . 7. Hot Tubs 8. Fountains.Record review of the facility provided document titled Maintenance and Monitoring of Water Systems dated March 2022 states, Where practicable, the following engineering measures will be incorporated into the design and operation of the system.The design should eliminate dead legs and other areas of stagnant water.Record review of the facility provided policy titled Legionella Policy/Procedure - Environmental dated last reviewed 2/4/2025 states procedure steps including, 2. Building Water Systems: The WMT will describe and assess the Facility's water system. The assessment will identify where Legionella could grow and spread, which may include . hot and cold water tanks; water heaters; pipes, valves and fittings; water filters; water faucets; aerators . hot tubs and saunas; decorative fountains. Step three includes, 3. Control / Maintenance Measures: The facility will implement control measures to reduce the potential for the growth and spread of Legionella as identified in the Legionella Management Plan. Control measures will include, but are not limited to: A. Routine testing of chlorine levels . C. Monitoring and flushing pipes in rooms and/or areas of the building that are not in use .A record review of the facility provided document titled Water Management Program Plan includes a date of February 12, 2026. The plan does not include identified areas where Legionella could grow and spread, or a description of control measures taken.According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. Eliminate dead legs, which are sections of no- or low-water flow.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 4/26/2026 at 8:51 AM observed residue on the shelving surface of the food storage racks in walk in cooler. An interview with Dietary Manager (DM) H at this time found the shelves are cleaned. When asked how often, DM H indicated weekly or monthly.On 4/26/2026 at 8:53 AM observed the stand mixer with a plastic cover over it. When asked if the mixer is used, DM H indicated yes. Upon removal of the cover, brown buildup was observed accumulated on the upper portion of the mixer above the mixing bowl. DM H stated they would get someone to clean it.On 4/26/2026 at 9:15 AM observed red residue buildup on the inside nozzle of the juice gun. An interview at this time regarding cleaning of juice gun found the nozzle is ran through the dishwasher daily.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 4/26/2026 at 8:56 AM an interview with DM H regarding the high temperature dishwasher found the wash gauge on the dishwasher is unreliable. DM H indicated the rinse gauge moves throughout the cycle but the wash gauge stays the same. The dish machine was run through two full cycles and the wash gauge was observed remaining at 140 F during both cycles, while the rinse gauge fluctuated to 180 F. DM H indicated the kitchen staff rely on the rinse gauge to assess temperatures.According to the 2022 FDA Food Code section 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature, (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than: (1) For a stationary rack, single temperature machine, 74oC (165oF); Pf.On 4/26/2026 at 9:06 AM observed the drain line from the prep sink in the kitchen extend into the janitor sink and terminate below the flood level rim creating an improper air gap.On 4/26/2026 at 9:09 AM observed the kitchen three compartment sink drain line directly connected to the wastewater line.On 04/26/2026 at 12:02 PM an interview with DM H regarding the three-compartment sink found they had talked to the Maintenance Director (MD) I. MD I indicated the drain line was replaced three years ago and the previous maintenance director did not believe an air gap was necessary.On 04/26/2026 at 1:03 PM observed the drain line behind the ice machine in the dining room extend behind the cabinet unit. No air gap was visible from the drain line.On 04/26/2026 at 1:17 PM an interview was conducted with MD J from a neighboring facility. When asked about the three-compartment sink, MD J indicated there had been an air gap previously and the drain line was changed because a new grease trap had to be installed.On 04/26/2026 at 1:19 PM an interview was conducted with MD J regarding the drain line behind the ice machine. When asked about the ice machine in the dining room, MD J indicated it was newly installed by maintenance, and the drain line would not be visible unless the cabinets were taken out.On 04/26/2026 at 3:00 PM MD I arrived to the facility and an interview was conducted regarding the three-compartment sink drain line. MD I indicated they had put an air gap in previously and it was taken out.On 04/26/2026 at 3:03 PM in an interview with MD I when asked about the ice machine drain line that is hidden, MD I indicated they had not seen the air gap before, and the ice machine had been installed before they got here.According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 4/26/2026 at 9:18 AM observed the two-door cooler in the kitchen with chipped and worn paint on multiple storage rack surfaces. Paint was observed peeling from edges in high use areas of the rack leaving exposed metal. According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment, (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. On 4/26/2026 at 9:41 AM observed a container of a thickening agent in medication refrigerator with a facility marked date of 4/13 and a manufacturer expiration date of July 2026. A sign on the refrigerator door stated, No food is to be kept in medication refrigerators.

Based on observation, interview and record review the facility failed to develop and implement written comprehensive advance directives (Cardiopulmonary Resuscitation/CPR, Artificial Nutrition/Peg Tube, Artificial Hydration/ IV, and Diagnostic Testing) for six (R4, R6, R7, R9, R64, and R70) of 14 residents reviewed for advance directives, resulting in the missed opportunity to grant life sustaining or life withholding decisions known by the resident or legal representative.Findings include:R64 On [DATE] at approximately 9:00AM, R64 was observed in their room in bed. On [DATE] at approximately 9:30AM, R64 was queried regarding their advance directives. R64 said they did not recall making a choice or decision upon admission but would not want chest compressions if their heart or breathing would stop. A record review was conducted and revealed R64s most recent admission to the facility was on [DATE] with diagnoses that included fracture of the right femur, acute kidney failure, pain, dementia, delirium, and urinary tract infection. A review of R64's physician orders revealed an order dated [DATE] which read, Adv. Directive: Full Cardiopulmonary Resuscitation (CPR). Section C of the Minimum Data Set with an Assessment Reference Date of [DATE] revealed R64 scored 12/15 on the Brief Interview for Mental Status assessment – indicative of moderate cognitive impairment. A social work progress note dated [DATE] revealed in part, Advanced directives reviewed & (and) discussed. Education provided on difference between full code & DNR (Do Not Resuscitate) status, put in place of FULL CDE [sic] status per (R64) wishes. There was no other documentation in the electronic health record (EHR) to support the decision made by the resident. R6 On [DATE] at approximately 10:00AM, R6 was observed in their room in bed. R6 was alert and communicated appropriately during the interview. A record review was conducted and revealed R6's most recent admission to the facility was on [DATE] with diagnoses that included pressure ulcer of sacral region, chronic kidney disease, heart failure, anxiety disorder, depression, chronic respiratory failure, chronic obstructive pulmonary disease, sleep apnea, and type II diabetes. Section C of the Minimum Data Set with an Assessment Reference Date of [DATE] revealed R6 scored an 11/15 on the Brief Interview for Mental Status assessment – indicative of moderate cognitive impairment. There was no active physician order related to advance directives. R6's demographic sheet (Face Sheet) listed the code status as Full Cardiopulmonary Resuscitation. A social work progress note dated [DATE] revealed in part, Advanced Directives reviewed and & discussed. Education provided on difference between FULL CODE & DNR. Voiced understanding. Put in place of FULL CODE status per (R6) wishes. There was no other documentation in the EHR to support the decision made by the resident. R70 On [DATE] at approximately 10:00AM, R70 was observed in their room. R70 was alert and communicated appropriately during the interview. A record review was conducted and revealed R70s most recent admission to the facilty was on [DATE] with diagnoses that included metabolic encephalopathy, adjustment disorder with mixed anxiety and depressed mood, dementia, delirium, respiratory failure, acute kidney failure, heart failure, type II diabetes, and obesity. A review of R70's physician orders revealed an order dated [DATE] which read, Adv Directive: Full Cardiopulmonary Resuscitation (CPR). Section C of the Minimum Data Set with an Assessment Reference Date of [DATE] revealed R70 scored 11/15 on the Brief Interview for Mental Status assessment – indicative of moderate cognitive impairment. A social work progress note dated [DATE] revealed in part, Advanced Directives reviewed & discussed. Education provided on difference between DNR & FULL CODE status. Voiced understanding. Put in place of FULL CODE status per wishes. There was no other documentation in the EHR to support the decision made by the resident. R7 Record review of R7 electronic medical record revealed that R7 was identified as Full Code. However, further review of medical records revealed no documented evidence that the resident nor responsible party had been educated regarding advanced directives, including the right to formulate advanced directives and accept or refuse treatment. Further review revealed no signed consent, advance directive documentation, or other supporting documentation identifying how the resident's Full Code status had been determined. Review of R7 Electronic Medical Record (EMR) revealed resident was admitted on [DATE] with the diagnosis as follows: FRACTURE OF LOWER END OF RIGHT TIBIA, FRACTURE OF SHAFT OF RIGHT FIBULA, PARANOID SCHIZOPHRENIA, CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE and DYSPHAGIA. Review of Minimum Data Set (MDS) for R7 with date of [DATE] for Brief Interview for Mental Status (BIMS) noted R7 was 15 out of 15 cognitively intact. R9- On [DATE] at 11:27 a.m. R9 was observed in the dining room. R9 presented as alert and oriented to person and place with confusion. R9 was able to participate in simple conversation and make basic needs known. Review of the clinical record revealed R9 was initially admitted into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, post-traumatic stress disorder, and chronic developmental disorder. According to the quarter Minimum Data Set (MDS) assessment dated [DATE], R6 had moderate cognitive impairment (BIMS-12) and required max assistance with most activities of daily living. According to the resident profile in the electronic medical record, R9 has a court appointed legal guardian. Review of the advance directive form in the electronic medical record dated [DATE] documented a Full Code status that was signed by R9. There was no revised written evidence that showed the legal guardian was informed or agreed with the code status. R4- On [DATE] at 2:48 p.m. R4 was observed in the bedroom with the spouse present at the bedside. R4 presented as alert, oriented to person, place, and situation. R4 was also able to make needs known. Review of the clinical record revealed R4 was admitted into the facility on [DATE] with diagnoses that included chronic respiratory failure, end stage renal dialysis, atrial fibrillation, and chronic obstructive pulmonary disease. According to the admission MDS assessment dated [DATE], R4 was cognitively intact (BIMS-14) and required max assistance with most activities of daily living. R4 does not have a legal representative and makes decisions independently. According to the resident profile in the electronic medical record documented R4 was a Full Code. There was no written evidence that showed the R4 was informed or agreed with the code status. On [DATE] at 4:17 p.m. R4 was interviewed again queried if the facility presented an advance directive upon admission. R4 stated, What's that? R4 was informed an advance directive was a written plan to let the facility know what to do if there was an emergency such as CPR or a peg tube. R4 said someone spoke about it a while ago but didn't say anything about wanting a peg tube. On [DATE] at 9:45 a.m. Social Service Director D was interviewed and said the Corporate Social Worker G instructed a written advance directive did not have to be used if residents are a full code. The advance directive for full code is documented in the medical record but there is no written documentation. A code status (Full Code or DNR) is only discussed, and a pamphlet is given to the resident or legal representative upon admission. On [DATE] at 3:32 p.m. Corporate Social Worker G was interviewed via telephone and said written advance directives for full code status used to be used but it was determined it was not required per policy. Corporate Social Worker G did acknowledge pieces were missing (peg tug, IV hydration, diagnostic testing) to thoroughly formulate an advance directive. Review of the facility's policy titled Advance Directives- Code Status revision date [DATE] documented in part the following: It is the policy of the facility that the resident has the right to formulate an advance directive, including the right to accept or refuse medical treatment. Upon admission, the facility will inquire if the resident has executed a written advance directive related to their code status. If the resident is incapacitated or unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative.

Based on observation, interview and record review the facility failed to ensure dignity was maintained for one resident (R38) of one resident reviewed for dignity.Findings include:On 4/26/26 at 8:35 A.M. upon entering the facility walking past R38's room, the resident was observed in the first bed in a supine position (position lying on the back with face upward), with brief and entire upper thighs exposed in full view of the survey team and hallway traffic. The R38's arms were extended to the sides of the bariatric bed, and each exposed leg was positioned at the end of each corner of the bed. The resident's body was not covered and due to the resident's size (480 pounds) and the position of the bed, the resident's brief and body parts were seen from the hallway.In addition to the earlier observation R38 remained in the first bed without a Privacy curtain being pulled or a change of rooms. R38's body was within full view of the hallway showing an exposed brief and no covering of the lower extremities on 4/26/26 at 1:09 P.M., and on 4/27/26 at 8:00A.M.,3:02 P.M. and 4:45 P.M.R38 was readmitted to the facility on [DATE], with diagnoses of defect of end plate of vertebrate, acute and chronic respiratory failure with hypoxia, adult sexual abuse, morbid obesity, undeferential schizophrenia, developmental disorder, seizure, obstructive sleep apnea, and developmental delay.According to [NAME] Data Set (MDS) dated [DATE] R38 had a Brief intellectual mental status (BIMs) of 12 of 15 with moderately cognitive impairment (ability to think) and was dependent on staff for toileting, dressing, shower/bathe, rolling left and right, sitting to lying and lying to sitting on the side.On 4/28/26 at 1:30 P.M. during an interview with Unit Manager (UM) L concerning the observations of the resident's brief and exposed body parts from the hallway, UM L attempted to defend R38's exposed body part as being the resident's rights. During the interview with UM L was asked would a reasonable individual like yourself would want their body and brief to be on displayed to male visitors, other staff and residents entering or walking the hallway? The manager responded no. UM L was then asked had the facility attempted to address the resident's exposure from the hallway by implementing privacy interventions? UM L responded, no and that the resident had been educated on covering her lower extremities and staff tried to check on the resident frequently. UM L was asked how the facility ensured R38 understood the education when the resident had a diagnosis of developmental delay and sometimes could not express herself. UM L had no response.On 4/26/26 at 4:25 P.M., review of the facility's policy titled: Dignity dated 9/21/2023 stated in part.* Demeaning practices and standards of care that compromise dignity is prohibited. * Staff are expected to promote dignity and assist residents. *Staff are expected to treat cognitively impaired residents with dignity and sensitivity.

Based on observation, interview, and record review the facility failed to provide age-appropriate meaningful activities for one cognitively intact (R85) of four residents reviewed for activities, resulting in boredom, lack of interest in facility life, and loss of dignity.Findings include:R85-On 4/26/2026 at 11:23 a.m. R85 was observed resting in bed watching television. R85 presented as alert, oriented to person, place, and time and able to make all needs known. R85 has been observed participating in out of room activities, however R85 said they don't bother going to activities anymore due to there not being enough activities of interest to do. R85 stated, They (facility) no longer offer live entertainment or out the facility trips. It's spring and we should be planting a little garden or building a bird feeder. Instead, they have us doing ( kiddie shit) making me feel like an asshole. We should be having activities we enjoy. R85 pointed to the closet door of the bedroom. There was a [NAME] that had cartoon stickers and glitter placed on it. Next to the [NAME], there was a paper plate with cotton balls, stickers, and glitter. R85 said the activities seemed to have changed once the Activities Director took on an additional job and did not seem to have time to plan better activities. R85 was also the Resident Council President.On 4/26/26 at 1:18 p.m. Activities Aide M was observed approaching residents asking if they wanted to attend the activities sand art and a movie. The sand art activity was not listed on the monthly (April) activities calendar. Activities aide was queried who decided on the movie that was going to be watched and why sand art was added as an activity. Activities Aide M said the movie was decided by the Activities Director. The sand art activity was just added today. The aide was queried about residents choosing the movie. Activities Aide M asked, Was it inappropriate that we picked the movie? On 4/27/26 at 10:54 a.m. Activities Director AD C was interviewed and queried about activities occurring not being on the calendar. Activities Director C said it was added at the last minute. Activities Director C was queried about the movie that was selected by the Activities Director and not the residents. AD C said one resident selected the movie and another resident was ok with the choice. No other residents were asked. AD C was queried about the age appropriateness of paper plate, glitter, and cartoon stickers crafts. AD C stated, I choose activities from a website and try to choose activities that lower functioning residents could do. I am also staff challenged. I do not offer an alternative activity for higher functioning residents. I just wait until something is suggested and try to do it. On 4/28/26 at 3:05 p.m. the Nursing Home Administrator (NHA) was interviewed and shown the art that was in R85's room. The NHA said the art was not age appropriate and that things can be improved in the department.Review of the clinical record revealed R85 was initially admitted into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, muscular sclerosis, and congestive heart failure. According to the quarter Minimum Data Set assessment dated [DATE], R85 was cognitively intact (BIMS-15) and required total two-person assistance with most activities of daily living. Review of the Activities/Recreation care plan, date initiated 6/21/24 documented in part the following: Resident can make their own decisions as to which programs they would like to attend. The resident is alert and complete their own assessment. Interventions: Assure that the activities the resident is attending are compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed, Compatible with individual needs and abilities; and age appropriate.

Based on observation, interview and record review, the facility failed to ensure adequate monitoring of antibiotic use for one resident (R64) of five residents reviewed for antibiotic stewardship, resulting in the potential for the resident to experience unnecessary medication side effects or outcomes. Findings include: On 4/27/2026 at approximately 9:20AM, R64 was observed in their room in bed. R64 was asked about their antibiotic use for a urinary tract infection (UTI). R64 responded, they say I'll always have to take it because I'll always have a UTI. When asked if they had any current symptoms of a UTI such as burning with urination, R64 said no. A record review was conducted and revealed R64s most recent admission was on 3/14/2026 with diagnoses that included fracture of the right femur, acute kidney failure, metabolic encephalopathy, chronic obstructive pulmonary disease, dementia, and urinary tract infection. Section C of the Minimum Data Set with an Assessment Reference Date of 3/20/2026 revealed R64 scored 12/15 on the Brief Interview for Mental Status assessment - indicative of moderate cognitive impairment. A review of R64's March and April 2026 Medication Administration Record (MAR) revealed the following antibiotic orders:Levofloxacin Oral Tablet 750 MG - start date 3/15/2026: Give one tablet by mouth one time a day every 2 days for UTI for 4 days. Administered on 3/15/2026 and 3/17/2026. Nitrofurantoin Macrocrystal Oral Capsule 50 MG - start date 3/24/2026: Give 1 capsule by mouth one time a day for chronic UTI's. No stop date- prophylactic. Held 3/31/2026 to 4/1/2026 and discontinued 4/6/2026. Administered 3/24/2026 through 3/31/2026. Nitrofurantoin Macrocrystal Oral Capsule 50 MG - start date 3/31/2026: Give 1 capsule by mouth two times a day for UTI for 5 days. Administered on 3/31/2026 and discontinued 3/31/2026. Nitrofurantoin Macrocrystal Oral Capsule 100 MG - start date 4/1/2026: Give 1 capsule by mouth two times a day for UTI for 5 Days. Administered 4/1/2026 through 4/4/2026 and discontinued on 4/6/2026. Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 MG - start date 4/11/2026: Give 1 tablet by mouth two times a day for UTI for 2 days. Administered 4/11/2026 and 4/12/2026. Macrodantin Oral Capsule 50 MG - start date 4/12/2026: Give 1 capsule by mouth two times a day for prophylactically for UTI. Administered 4/12/2026 and 4/13/2026. Discontinued 4/13/2026. Macrodantin Oral Capsule 50 MG - start date 4/14/2026: Give 1 capsule by mouth two times a day for prophylactically for UTI - no stop date per attending Nurse Practitioner as prophylactic. Administered 4/14/2026 through 4/21/2026. Discontinued on 4/21/2026. Bactrim DS Oral Tablet 800-160 MG - start date 4/22/2026: Give 1 tablet by mouth one time a day for UTI prophylaxis - no stop date. Administered 4/22/2026 through current date. A nursing progress note dated 3/15/2026 revealed in part, ABX (antibiotic) started this shift D/T (due to) new admission for UTI. Resident denies nay [sic] pain or discomfort with urination.A nursing progress note dated 3/15/2026 revealed in part, Continues on oral ABX for UTI, no s/s (signs or symptoms) of infection noted to right hip. No c/o (complaints of) pain or discomfort. The patient did experience 3 episodes of diarrhea this shift. None of the bowel regime medications were given. Provider made aware of loose stools and writer is awaiting response for next steps r/t diarrhea.A nursing progress note dated 3/16/2026 revealed in part, Resident continues on ABX for UTI. No c/o pain or any discomfort with urination. Resident did state that she had a loose stool. Imodium given with + results.A nursing progress note dated 3/27/2026 revealed in part, Continues on prophylactic ABX for UTI. Resident has no urinary complaints.Physician progress notes dated 3/16/2026, 3/18/2026, 3/27/2026, 3/31/2026, and 4/24/2026 revealed no mention of the UTI, antibiotic usage, or monitoring of the medication.Further review of the R64's electronic health record revealed that no urinalysis with urine culture laboratory testing had been ordered since R64's admission date of 3/14/2026.On 4/27/2026 at approximately 4:15PM, a telephone interview was conducted with R64's Attending Physician E (AP E). When queried about the numerous antibiotic orders and adjustments, the antibiotic with no stop dates, and lack of laboratory monitoring, AP E said that his nurse practitioner was adjusting the doses; that he does not want to test unless there are signs and symptoms and that R64 has chronic retention of urine and a history of UTI's. On 4/28/2026 at approximately 11:30AM, an interview was conducted with the Director of Nursing (DON). The facility's corporate nurse consultant (CN G) was also present for the interview. The DON was queried regarding the numerous antibiotic orders and adjustments, the antibiotic with no stop dates, and lack of laboratory monitoring. The DON reported that medications are reviewed within the EHR system for any alerts and corrections are then made. The DON further said that they noticed on 4/27/2027 there was no stop date for the Bactrim and notified the provider. CN G added that the continued use of the antibiotics will keep the resident from going to the hospital and that no stop date is necessary for the prophylactic antibiotic. A policy titled, Antibiotic Stewardship Program originally dated 10/31/2017 was provided by the facility and revealed in part, Recommendations and interventions of an effective antibiotic stewardship program are designed to ensure that residents who meet criteria for infection receive the right antibiotic, at the right dose, at the right time, and for the right duration. The document also revealed, The facility follows the CDC's (Centers for Disease Control) core elements for antibiotic stewardship which includes diagnostic testing required to be completed per McGreer's criteria prior to initiation of antibiotic orders, orders for antibiotics will include name, dose, route, frequency of the antibiotic as well as indication for use and stop date. Finally, the document revealed, Actions to improve antibiotic use: reduction in prescribing antibiotic prophylaxis for the prevention of urinary tract infections.

This citation pertains to intake 2581458.Based on observation, interview and record review the facility failed to protect the resident's right to be free from verbal abuse from staff for one resident (R906) out of five residents reviewed for abuse, this failure resulted in the resident experiencing feelings of distress and emotional harm.Findings Include:Review of a Facility Reported Incident dated July 28,2025 revealed an allegation of a staff to resident verbal abuse incident.Record review of R906's electronic medical record revealed admission into the facility on 7/18/25 with a pertinent diagnosis of trochanteric fracture of left femur (thigh). Further review of revealed resident scored 15 out of 15 (intact cognition) on a Brief Interview of Mental Status (BIMS) on 8/4/25. Review of Kardex (Care Notes) dated 8/7/25, R906 required ADL (Activities of Daily Living) assist x1 staff.During an interview on 8/6/25 at 10:57 AM with R906 it was reported that while attempting to get in her wheelchair, Licensed Practical Nurse (LPN) A entered the room and questioned, What are you doing? R906 stated they explained their actions and that the nurse then called them a 'liar.' The resident further stated that when they were escorted to the restroom and returned, LPN A moved the wheelchair, causing the resident's leg to strike the shower chair. The resident reported experiencing significant pain and began to cry. The resident reported that LPN A pretended (mocked resident) to cry, referred to them as a cry baby, and stated that they would not receive their pain medication if they did not stop crying. R906 then verbalized that Certified Nursing Assistant (CNA) B had witnessed the incident. The incident of verbal abuse occurred nine days prior to the State Agency survey. However, at the time of the interview, R906 was observed with tears and stated, I felt bullied and degraded.Record review of Incident Report dated 7/26/25 and signed by CNA B documented, I walked in when the nurse (LPN A) was taking her *the resident * to the bathroom still arguing. The resident started crying, the nurse began to make fun by fake crying herself. Attempts were made during the survey to contact LPN A and CNA B without success.Record review of Exhibit 6 (interview between Social Worker C and R906), dated 7/27/25, documented, The nurse was mocking the resident on crying. Resident stated, 'The nurse told me to stop crying or I won't give you your medicine.' Record review of Separation of Employment for LPN A, dated 7/30/25 and signed by the Nursing Home Administrator documented LPN A was terminated for patient abuse and violation of company policies/procedures.During an interview on 8/7/25 at 3:15 p.m. with NHA, it was reported that the facility investigation revealed that LPN A had verbally abused R906.Record review of facility's Abuse policy dated 5/24/23 documented, Verbal Abuse: Use of oral, written, or gestured communication or sounds to residents within hearing distance regardless of their age, ability to comprehend, or disability. To Include but not limited to harassment, mocking, insulting, ridiculing, yelling or hovering with the intent to intimidate, threatening, etc.

Based on interview and record review the facility failed to ensure adequate supervision to prevent a fall for one resident (R904) out of three residents reviewed for falls.Findings include:On 8/7/25 at 9:00 a.m., during an interview with R904, it was reported that on 7/30/25 staff let the resident fall from the bed to the floor while removing a bed pan.Record review of Nursing Progress Notes dated 7/30/25 at 2:18 a.m. documented, CNA notified writer that resident had a witnessed fall, resident was getting taken off of bedpan and CNA (Certified Nursing Assistant) lowered resident to the floor. The writer observed resident lying on her left side on the floor.Review of electronic medical records revealed that the resident was admitted into the facility on 7/7/25 with a pertinent diagnosis of fracture of left ulna (lower arm). An additional review revealed on 7/31/25 that R904 had scored 15 out of 15 (intact cognition).Review of the care plan dated 7/16/25 indicated that R904 required two people for assistance with bed mobility. Review of the Kardex (care notes) R904 was a two person assist with bed mobility.A phone interview was conducted on 8/7/25 at 1:15 p.m. with CNA E. CNA E said while independently assisting the resident with the removal of a bedpan, the resident was moved away from the staff member. The resident's gown was grasped to help prevent the fall, but following the direction of the resident, CNA E released the gown, and the resident fell to the floor.During an interview on 8/7/25 at 1:30 PM, the Assistant Director of Nursing (ADON) D said resident (R904) required two staff members when assisting the resident off a bed pan. It was further reported that the staff member should have referred to the Kardex when giving care to ensure the resident had two staff members to properly reposition the resident in bed and not roll the resident away from staff. The ADON confirmed R904 was identified as a two person assist.According to the Repositioning policy dated 4/24/25, documented when repositioning a resident verify assistance needed per Kardex. Obtain additional assistance as indicated. When turning back to side- position resident so that when turned they are in the middle of the bed.

Based on observation, interview, and record review, the facility failed to: 1. Ensure pans were cleaned and air dried before stacking; 2. Properly date-label food in the kitchen; 3. Ensure food items past the use-by-date were not stored with active food; 4. Store cartons of milk in a manner to avoid splash from mop water; and 6. Adequately clean the air gap basin. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: During the initial tour of the kitchen on [DATE] at 8:45 AM with Dietary Manager (DM) A, the following was observed: 1. Two wet ,d+[DATE] pans and one ,d+[DATE] pan soiled with food debris were observed nestled and stored with clean pans in the clean pot/pan storage area. 2. Inside of the three-door cooler contained, a.) two opened 16-ounce containers of chicken base and one opened 16-ounce container of vegetable base which were not labeled with an expiration date; b.) a box with 15 four-ounce containers of apple juice which all expired [DATE]; and c.) an opened bag, containing approximately 15 hot dogs, labeled with an opened date of [DATE] but not labeled with an expiration date. 3. Inside of the walk-in cooler, a milk crate, full of eight-ounce cartons of milk, was stored directly on the cooler floor. DM A said the case of milk should be 12 inches off the floor. On [DATE] at 12:00 PM, during a return visit to the kitchen the following was observed in the dry food storage room, opened and not labeled with an expiration date, a pack of spaghetti and bag of polenta. On [DATE] at 9:10 AM, during a return visit to the kitchen, two sheet pans stacked with clean pans in the cook's area were observed soiled with food debris. On [DATE] at 9:20 AM, the air gap basin for the two-compartment sink, used to clean produce and thaw meat, was observed with Maintenance Director (MD) B and DM A. The drain in the basin was partially covered with peas and carrots. The inside perimeter and sink drainpipe had a build-up of some type of brown and black residue. MD B stated, We pour bleach (in the basin), but we don't clean it. DM A stated, It looks dirty. On [DATE] at 1:23 PM, the Nursing Home Administrator (NHA) said the air gap basin needs a good scrubbing because it does not look clean. Food should not be stored on the floor (in the kitchen). The NHA added that she was a little surprised about the concerns identified in the kitchen because the kitchen was recently audited. The NHA stated, That's a problem for me. A review of the 2013 FDA Food Code documented the following: - Section ,d+[DATE].11, entitled, Safe, Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under S ,d+[DATE].12, honestly presented. - Section ,d+[DATE].11 Food Storage. A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. - Section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. - Section ,d+[DATE].13, Nonfood-Contact Surfaces: Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

Based on observation, interview, and record review, the facility failed to ensure an adequate supply of emergency food was available. Findings include: On 3/10/25 at 12:00 PM, an observation and interview regarding the facility's emergency food supply was conducted with Dietary Manager (DM) A. A section in the dry food storage room was delineated by a sign that read, EMERGENCY FOOD DO NOT TOUCH!! DM A stated, They (kitchen staff) have been told not to use the emergency food. DM A said emergency food items were obtained from a commercial food supply company and provided a list of emergency foods that should be on hand. The emergency food supply list was compared to the foods currently available in the emergency food area, and the following items were not available: chicken noodle soup, cheese sauce, and green beans. DM A provided a policy titled, Disaster and Emergency Planning for Food Service, dated 2/3/23, that documented in part the following: The facility provides a disaster and emergency plan to ensure that the food service department will have on hand adequate food, water and disposable supplies to ensure that meals are prepared and served to our residents and staff. On 3/12/25 at 1:23 PM, the Nursing Home Administrator (NHA) said the kitchen should audit the emergency food and ensure emergency food is in place.

Based on observation, interview, and record review the facility to ensure the foley catheter bag (bags used to collect urinary drainage from Foley catheters) was not resting on the floor for one (R37) of three residents reviewed for catheter/UTI (urinary tract infection) potentially resulting in the spread of infections and dislodgement. Findings include: On 3/10/25 at 2:03 p.m. R37 was observed in bed asleep. The bed was in a low position (approximately 4-6 inches from the floor). R37 was also observed with a catheter in which the catheter bag was observed resting on the floor wedged between the floor mat and wheel of the bed. Review of the electronic medical record documented R37 was admitted into the facility on [DATE] with diagnoses that included neuromuscular dysfunction of bladder and repeated fall. According to the admission Minimum Data Set assessment dated [DATE], R37 was cognitively intact (BIMS=13) and required dependent two-person assistance with most activities of daily living. R37 was also admitted with a foley catheter. Review of the Alteration of Elimination care plan dated 2/21/25 documented: Problem: (R37) has an alteration in elimination r/t: indwelling foley catheter. Intervention: Secure catheter with securement device. Provide a barrier for foley catheter when (R37) choses to lay on the floor mat or the bed in lowest position. Review of the physician's orders dated 3/2/25 documented: Maintain foley catheter and provide care every shift. On 3/12/25 at 11:10 a.m. Unit Manager (UM) E was queried about the improper positioning of R37's catheter bag. UM E said the nurse aides are responsible for ensuring catheter bags are hung properly on the bed and not supposed to be on the floor. There is a white pan that is supposed to be under the catheter bag so it wouldn't be on the floor when the bed is in a low position. UM E was not able to explain why the barrier was not applied. On 3/12/25 at 1:26 p.m. the Director of Nursing (DON) was informed R37's catheter bag was on the floor and said there should have been a white basin under the catheter bag to prevent it from being on the floor. Review of the facility's policy titled Catheter Care dated 8/24/23 documented in part the following: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care .

This citation pertains to intakes MI00150118 and MI00150053. Based on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADLS) in a timely manner for one resident (R23) of three reviewed for ADL care. Findings include: On 3/10/2025 at 10:59 a.m. and on 3/12/2025 at 1:36 p.m. R23 was observed sitting in a wheelchair with facial hairs, greasy unkempt hair, and long dirty untrimmed fingernails. R23 during an interview verbalized wanting to get shaved, hair washed and combed, and nail care. R23 confirmed no one asked to assist with nail care, shaves and grooming of the hair on scheduled shower days. R23 was unable to recall the last day a shower was given and unable to recall scheduled shower days. According to the electronic medical record, R23 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses of congestive heart failure, major depressive disorder, dementia, chronic kidney disease stage 3, chronic obstructive pulmonary disease, and osteoarthritis. R23 quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R23 had moderately impaired cognition and required one person assistance with all ADLs. A care plan revised on 2/14/2025 for Activity of Daily Living had an ADL self-care performance deficit related to muscle weakness, required one person assist with bathing/shower, dressing, and Personal hygiene. On 3/12/2025 at 1:50 p.m. Unit Manager (UM) C Confirmed the Resident scheduled shower days were Monday's and Thursday's afternoon and should have been shaved and had nail care at that time. On 3/12/2025 at 1:30 PM, the DON reported that all residents should receive nail care and shaves if it is the resident's preference.

Based on observation, interview, and record review, the facility failed to ensure a care plan for a communication deficit was developed and implemented for one resident (R282) of nineteen residents reviewed for care plans. Findings include: On 3/10/2025 at 10:40 a.m., R282 was observed in room, alert and sitting on the bed with multiple sheets of writing paper and three ink pens on the bed side table. During an interview, R282 stated, If you are talking to me, you have to write it down because I cannot hear you. R282 pointed to the right ear and stated, This hearing aid I have is useless and I can't hear with it. On a handwritten note, R282 was asked how the hearing loss affects your communication and interaction with others. R282 stated, I avoid being around a crowd of people because I cannot communicate and interact with them. I wish I can try (Name Brand) for hearing aids, maybe they would work better. My ears have ringing sounds sometimes and I cannot hear my phone calls. On 3/12/2025 at 9:29 a.m. Unit Manager (UM) C said while walking to the resident's room that R282 did not wear a hearing aid and did not need any communication device or writing material to aid in communication. UM C walked in R282's room and attempted to communicate with the resident. R282 gestured to the right ear hearing aid and indicating not being able to hear and to use the writing paper. UM C said the resident did say the family would bring a hearing aid that the resident was using at home. UM C was unable to recall when and who brought in the hearing aid. R282 said the hearing aid probably needed new batteries and it had been about three weeks since the batteries were changed. According to the electronic medical record review, R282 was initially admitted to the facility 9/10/2018 and readmitted on [DATE] with diagnoses of depression, anxiety disorder, heart failure, type two diabetes, and hearing loss. R282's Admission Minimum Data Set Assessment (MDS) with a reference date of 9/17/2018 indicated R282 had intact cognition with a BIMS (brief interview for mental status) score of 13/15. Review of the 3/10/2025 Activity of Daily Living (ADL) care plan documented, R282 has an ADL self-care performance deficit. Resident will reach highest practicable physical, mental and psychosocial well-being, and will continue to participate in ADLs daily .Encourage the resident to participate to the fullest extent possible with each interaction. Resident required two persons assist with ADLs and transfers. Review of the medical record revealed, R282 had no communication interventions. On 3/12/2025 at approximately 10:00 a.m. UM C was asked should there be a care plan to further care for the resident hearing deficit. UM C said Yes and reviewed R282's medical record and confirmed there was not a hard of hearing care plan noted. On 3/12/2025 at 10:14 a.m. the Director of Nursing (DON) was queried if there should be interventions for residents with hearing deficit. The DON said, Yes, and reviewed R282's medical record and said the care plan was created on 3/8/2025 and resolved on 3/10/2025. The care plan was resolved without a reason and it must have been the MDS nurse (assess residents care areas) who resolved it. The DON confirmed because there was no hard of hearing care plan, there wouldn't be a Kardex (aid in the resident's care) for the CNAs to use to provide care for the R282 and would affect the resident's care and interaction with others. On 3/12/2025 at approximately 10:20 a.m. during an interview, MDS Nurse K stated, The hard of hearing care plan was resolved on 3/10/2025 because the care plan was not completed, so I resolved it and just had not been back to complete it and I should have. Resolving the care plan did not allow staff to review and provide care to the resident. (R282) is hard of hearing and a lack of communication would have a negative impact on the resident's care and ability to communicate. On 3/12/2025 at approximately 3:30 p.m. a care plan policy was requested but was not provided prior to exiting the facility at approximately 4:30 p.m.

This citation pertains to intake MI00148212, MI00149641, and MI00149668. Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergency or routine care and unmet care needs. This deficient practice had the potential to affect all residents who resided in the facility. Findings include: On 1/27/2025 at 12:30 P.M., the Master Schedule for Nurses during the period of 01/01/2025 - 1/26/25, was reviewed for RN coverage for the facility. The following dates revealed there was no consecutive 8 hour scheduled RN coverage: January 12, 2025, Census 72 January 19, 2025, Census 77 January 25, 2025, Census 71 On 1/28/2025 at 2:25 P.M. the Director of Nursing (DON) was interviewed and the schedules dated (1/12/25, 1/19/25, and 1/25/25) were reviewed. The DON confirmed that RNs did not work of those days. When asked how the facility ensured there was daily 8-hour RN coverage the DON replied, We just hired RNs to assist with coverage. The DON agreed there needs to be daily eight consecutive hours of RN coverage and acknowledged there was a problem with staffing. A review of the facility's policy titled, Staffing dated 11/3/2023, was reviewed. However, the policy provided did not address RN coverage for at least 8 consecutive hours a day, 7 days a week.

Based on interview and record review the facility failed to ensure that one (R506) of three residents reviewed for unnecessary medications had a specific diagnosis for use, clinical indications for use, or a valid informed consent for the use of psychotropic medications (drugs that affects brain activities with mental processes and behaviors). Findings include: According to R506's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with diagnoses that included multiple falls and traumatic ischemia of muscle (muscle tissue not receiving enough blood due to a physical injury) and diabetes. On 9/11/24 a progress note documented by Social Worker (SW) J indicated R506 had a Brief Interview of Mental Status (BIMS) score of 15/15, indicating no cognition impairment. A Behavioral Care and Psychiatric Service form for Consultation Request, Consent, And Authorization To Treat dated 9/11/24 indicated R506 had declined treatment and Did NOT consent to Psychiatric treatment or services. On 9/16/24, a progress note indicated that Physician K gave a nursing order for Seroquel 25 milligrams (mg) three times a day (Seroquel is an antipsychotic medication). There are no additional progress notes, no corresponding physician note, no diagnosis, or clinical indications for use of psychotropic medication. On 9/17/24 SW J documented; Resident was started on Seroquel yesterday. No diagnosis to support. Notes indicate resident has been pleasantly confused. Resident denies anxiety, hallucination, or delusions. Resident expressed they did not want to be on Seroquel when explained to them and resident continued to decline psychiatric services. Nurse was informed and contacted the physician to get Seroquel discontinued per the resident's wishes and there was no indication of the need. On 9/25/24, a progress note indicated that Physician K gave a nursing order to increase the Seroquel to 50 mg three times a day. There are no additional progress notes, no corresponding physician note, no diagnosis, or clinical indications for use of psychotropic medication. On 9/26/24, SW J documented that R506 was started on Seroquel for hallucinations and that the resident was logged for AIMS (abnormal involuntary movement scale) test to be done, evaluation, and proper diagnosis. On 9/26/24, (10 days after R506 was initially prescribed Seroquel) a consent for use of psychoactive medications was signed by SW J as a verbal order from R506's family member (FM) H. On 11/21/24 at 9:15 A.M., FM H was asked about R506's use of Seroquel. FM H said they were not the resident's Durable Power of Attorney (DPOA) and did not consent to anything. FM H said they had informed the social worker to contact Family Member I about obtaining consent for those things. FM H could not say what occurred afterwards. On 11/21/24 at approximately 10:00 A.M., FM I said they were informed by the physician at the hospital that the resident had been prescribed Seroquel and did not understand the reason for the medication. FM I said the resident was taken off the Seroquel while at the hospital on 9/29/24. On 11/21/24 at 12:00 P.M., SW J said that R506 had declined the use of psychoactive medications upon admission and again on 9/17/24. The nurse manager, Licensed Practical Nurse (LPN L) and the physician (Physician K) were notified, but the physician still wanted the resident to be on Seroquel. SW J said she had explained the use of Seroquel to FM H and did not recall that they (FM H) were not the resident's DPOA. SW J reviewed R506's EHR and said, We should not be starting Seroquel for anxiety. I don't know what happened. On 11/21/24 at approximately 12:15 PM the Nursing Home Administrator (NHA) was asked about the use of Seroquel for R506 and acknowledged that the facility's policy for use of psychotropic medication was not followed in this instance. On 11/21/24 at 1:00 PM the Director of Nursing (DON) said that after reviewing R506's EHR a meeting was held for further review with staff and education was being provided to follow facility policy. According to the facility's 'Psychotropic Medication Use' last revised on 1/10/2024 in part reads: It is the policy of the facility to only prescribe psychotropic medications when it is necessary to treat a specific diagnosed condition and the medication is deemed beneficial to the resident. The facility will identify when a resident is prescribed a psychotropic medication and will obtain informed consent from the resident or authorized representative for each psychotropic medication ordered. Residents who use psychotropic medications will receive gradual dose reductions, unless clinically contraindicated, in efforts to discontinue the medication when appropriate -The medical practitioner in conjunction with the Interdisciplinary Team shall evaluate and document the situation to identify and address any contributing and underlying causes of the acute condition and verify the need for a psychotropic medication -For any Resident taking a psychotropic medication, the Social Service employee or designee will obtain informed consent from the resident and/or authorized representative using the 'Psychotropic Medication Consent' UDA in PCC (point click care) - If the Resident and/or the authorized representative refuses to consent to the psychotropic medication, the physician/medical pratitioner will be notified so the medication can be disontinued.

This citation pertains to intake MI00146645. Based on interview and record review, the facility failed to maintain complete and accurate medical records for one (R801) of three residents reviewed for medical records, resulting in R801's INR results not accurately documented or maintained in the resident's Electronic Health Record (EHR) resulting in the potential for an unclear picture of the resident's blood clotting times and health care needs. Findings include: The State Agency received a complaint that the facility did not monitor a resident that was receiving warfarin for anticoagulation therapy side effects. R801: According to the Electronic Health Record (EHR) R801 admitted to the facility on [DATE] with diagnoses that included history of pulmonary embolism (blood clot in the lungs). On 8/1/24 the physician ordered warfarin 7.5 mg (milligrams) daily at bedtime. The order summary for warfarin included a black box warning (the strictest and most serious type of warning that the FDA gives a medication that alerts consumers when a serious adverse or special problem occurs, particularly those that may led to death or serious injury). The black box warning indicated that warfarin can cause major or fatal bleeding. The physician ordered to review the Warfarin Flowsheet every nightshift in assessments. The Warfarin Flowsheet included the resident's INR results. An INR blood test is used to monitor clotting times in people taking warfarin to check how well your blood clots. A normal INR range is 0.8 to 1.1 if you're not taking anticoagulant medications such as warfarin. R801's Medication Administration Record (MAR) reflected the order and had the following documentation: Review Warfarin Flowsheet every night shift. Must be reviewed and updated daily. R801's EHR only had one completed Warfarin Flowsheet dated on 8/8/24. On 8/8/24 the INR was 1.98. On 9/5/24 at 1:30 PM the Director of Nursing (DON) acknowledged that R801 only had one completed Warfarin Flowsheet in their EHR. The DON said, We realized that we did not completely document all the resident's INR results in the Warfarin Flowsheet. We immediately did an education for all the nurses. We did complete INR tests for the resident but did not document all of them correctly in the medical record. At this time the DON produced two additional INR lab results for R801 that were not part of the resident's EHR. The DON acknowledged that R801's INR lab results were not in the resident's EHR. The DON said, I got the INR results from the lab. They faxed it over today. On 7/31/24, R801 had an INR lab result of 2.78. This result was documented on the MAR. There was no corresponding Warfarin Flowsheet. On 8/5/24, R801 had an INR lab result of 1.98. This result was not documented on the MAR and there was no corresponding Warfarin Flowsheet. On 9/9/24 at 8:00 AM during a phone interview, the physician said the resident did not have the Warfarin Flowsheets up-to-date but that the INR blood tests were being done and reviewed through the lab. According to the facility's Lab Results policy last revised on 8/18/23, in part reads: The facility must provide or obtain laboratory services when ordered * For facilities and laboratories integrated with the electronic health record PointClickCare (PCC), laboratory results will display in PCC under the resident ' s results tab, and unreviewed laboratory results can also be accessed under the Clinical Dashboard and under the Clinical Lab/Rx Results Dashboard in PCC. * For facilities and laboratories not integrated with electronic health record PointClickCare (PCC), laboratory results may be faxed to the facility or retrieved from the laboratory's website. Those results will be uploaded into the resident ' s electronic health record in PCC under the documents tab.

This citation pertains to intake MI00146645. Based on interview and record review, the facility failed to develop or implement a care plan for anticoagulant administration (warfarin, a blood thinner) for two (R801 and R802) of three residents reviewed for care plans resulting in R801 and R802 not having a care plan for monitoring anticoagulation therapy side effects and the potential for healthcare needs to go unmet. Findings include: The State Agency received a complaint that the facility did not monitor a resident that was receiving warfarin for anticoagulation therapy side effects. R801: According to the Electronic Health Record (EHR) R801 admitted to the facility on [DATE] with diagnoses that included history of pulmonary embolism (blood clot in the lungs). On 8/1/24 the physician ordered warfarin 7.5 mg (milligrams) daily at bedtime. The order summary for warfarin included a black box warning (the strictest and most serious type of warning that the FDA gives a medication that alerts consumers when a serious adverse or special problem occurs, particularly those that may led to death or serious injury) that indicated warfarin can cause major or fatal bleeding. The physician ordered to review the warfarin flowsheet every nightshift in assessments. The flowsheet included information to monitor the use of warfarin administration and anticoagulation therapy. The Minimum Data Set (MDS) dated [DATE] indicated that R801 was receiving anticoagulant medication daily. A review of the resident's care plans revealed there was no care plan or interventions for monitoring the side effects for the risk of bleeding due to warfarin administration or anticoagulation therapy. On 9/5/24 at 1:30 PM the Director of Nursing (DON) acknowledged that R801 did not have any care plan or interventions regarding the use of warfarin or anticoagulation therapy. The DON said the facility did not have any policy specifically for the use of anticoagulants. The policy for care plan implementation was requested. R802: According to the R802's EHR the resident admitted to the facility on [DATE] with diagnoses that included history of Atrial Fibrillation (A-fib, irregular rapid heart beat that commonly causes poor blood flow and blood clot formation). The resident was prescribed warfarin 12.0 mg daily at bedtime. The order summary for warfarin included a black box warning. The physician ordered to review warfarin flowsheet every nightshift in assessments. The Minimum Data Set (MDS) dated [DATE] indicated that R802 was receiving anticoagulant medication daily. A review of the resident's care plans revealed there was no care plan or interventions for monitoring the side effects for the risk of bleeding due to warfarin administration or anticoagulation therapy. On 9/5/24 at approximately 4:15 PM the DON acknowledged that R802 did not have a care plan for the use of anticoagulants. According to the facility's Care Plan policy last revised on 8/25/23, read in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

This citation pertains to intakes MI00144980 and MI00145055. Based on observation, interview, and record review, the facility failed to ensure expired food was not stored with active food stock resulting in the potential for food borne illness to affect all residents who consume food from the kitchen. Findings include: The State Agency received a complaint that a resident was served a sandwich with mold on the bread. During a tour of facility's kitchen on [DATE] at 11:20 AM with Registered Dietitian (RD) A, Kitchen [NAME] (KC) B, and Dietary Aide (DA) C the following was observed in the active food stock area; -two 8-packs of hamburger buns were opened and undated with small amounts of white fuzzy substance in a circular pattern on the bottom of the buns. Six additional 8-packs of hamburger buns did not have delivery date or use by date on them. -two 8-packs of hot dogs buns were unopened, undated, and had small amounts of white/grayish fuzzy substance in a circular pattern on the buns. Six additional 8-packs of hamburger buns did not have delivery date or use by date on them. Inspection of the refrigerator revealed the following; -approximately one dozen of pre-made breakfast biscuits in a zip-lock bag with a use-by date of [DATE]. -approximately one dozen of breakfast sausages in an undated zip-lock bag. -three pre-made 6 inch-subs were in an undated zip lick bag. -a clear tub with a creamy substance was labeled as 'pancake batter use by [DATE]'. -an opaque cream colored tub was labeled as 'vanilla pudding use by [DATE]'. On [DATE] at approximately 11:30 AM, KC B said the all food items should have an opened dated and a use-by date on them. KC C and DA C removed all the hamburger buns, hot dog buns, and the expired items in the kitchen's refrigerator from the active stock area. Upon inquiry both KC B and DA C said they were aware of a resident being served a sandwich with mold on the bread. On [DATE] at 2:00 PM the Nursing Home Administrator acknowledged that she had been made aware that a resident had been served a sandwich with visible mold on the bread. According to the facility's Food Storage policy replaced on [DATE] in part reads as follows; It is the responsibility of the Dietary Staff and supervisors to ensure that food is stored, labeled and used within the recommended time guidelines to prevent food borne illness. C. Guidelines for food labeling and dating must be adhered to by all food service personnel and closely monitored by the food service manager. 7. Arrival dates should be placed on all foods removed from the case at the time of delivery. 12. Leftover foods must be immediately frozen, labeled and dated for later use. If refrigerated, the food must be discarded within 72 hours .

This citation pertains to intakes: MI00144232, MI00144376, MI00144543, and MI00144585. Based on observation, interview, and record review, the facility failed to ensure call lights were answered promptly for four residents (R810, R811, R812, and R805) reviewed for accommodation of needs resulting in various unmet health care needs. Findings include: Review of multiple complaints reported to the State Agency (SA) included allegations that call lights were not answered timely (beyond half an hour and longer). Observations on 6/5/24 at 2:00 PM revealed that three call lights were on for the A/B hall (R810, R811, and R812). It is unknown when the call lights were originally activated by the residents. Resident 810 On 6/5/24 at 2:10 PM R810's call light remained on. R810 was observed seated on the edge of the bed with the call light in hand. R810 said she needed assistance to go to the bathroom and the call light had been on for over 15 minutes. R810 said, It takes a long time for them to answer the call light. Usually over a half hour and sometimes over an hour on the night shift. At 2:20 PM, R810 was assisted to the bathroom by Nurse Unit Manager Registered Nurse (RN) B. According to R810's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with multiple diagnoses that included chronic obstructive pulmonary disease and falls. R810 was identified to have intact cognition. Resident 811 On 6/5/24 at 2:13 PM R811's call light remained on. R811 was seated in a wheelchair next to her bed. R811 said she had been up in her chair since breakfast and wanted to go back to bed, but her bed had not been made up. R811's bed did not have a linen on it. R811 said she asked to go back to bed right after lunch and no one had come back to help her. R811 said, I've had my call light on for hours. Someone comes in turns the light off and says they will come back to put me in bed, but no one has done it. So, I keep putting my call light back on. At 2:30 PM RN B entered the resident's room, turned the call light off. RN B returned with linen and made the resident's bed. RN B said she would get another staff person to assist the resident back to bed. The call light remained off. The resident was observed to be assisted back to bed at approximately 2:45 PM. According to R811's EHR the resident admitted to the facility on [DATE] with multiple diagnoses that included Down's syndrome and a fall with fracture to the upper extremity. A Minimum Data Set (MDS) dated [DATE] indicated R811 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15/15, had impairment to one side of the upper extremity, and required substantial to moderate assistance for mobility. Resident 812 On 6/5/24 at 2:15 PM R812's call light remained on. R812 was lying in bed and said she needed the bedpan immediately. I've had the call light on for a long time. They are very slow to answer the call lights here. I usually just give up and go in the bed, but I'm really trying to hold it until someone comes and answers my light. You should be here at night. They never answer the call light. At 2:33 PM RN B came into the room turned the call light off and then left the room without putting the resident on the bedpan. RN B said she was going to get a Certified Nursing Assistant to help place the resident on the bed pan. The resident was observed to be assisted with placement on the bed pan at approximately 2:40 PM by a CNA. According to R812's EHR the resident admitted to the facility on [DATE] with multiple diagnoses that included fall with fracture to the lower extremity. A MDS dated [DATE] indicated R812 had intact cognition with a BIMS score of 14/15 and required extensive assistance from staff for all mobility, including rolling side to side. On 6/5/24 at approximately 2:40 PM RN B confirmed she was the nurse unit manager for A/B hall and was asked about staffing for the day shift on A/B hall. RN B reported there were three Certified Nursing Assistants (CNAs) scheduled on the A/B hall for the day shift and that was 'normal staffing'. When asked why the nurse manager had answered most of the call lights by herself she said, The CNAs are all busy. We all answer call lights. RN B did not explain why she turned the call lights off before she met the resident's needs. Resident 805 On 6/5/24 at 2:48 PM the resident was observed in her room seated in her wheelchair. R805 said she called the SA to file a complaint because she had to wait over two hours for someone to answer her call light on 5/14/24 and 5/15/24. R805 said, I was swimming in pee and in severe pain. R805 said she had resorted to calling '911' on her cell phone because no one had answered her call light for over two hours on the night shift. R805 reported the police came to the facility but did not transport her to the hospital because the nurse had given her a pain pill prior to their arrival. According to R805's EHR the resident admitted to the facility on [DATE] with multiple diagnoses that included chronic pain. A MDS dated [DATE] indicated R805 had intact cognition with a BIMS score of 12/15, had impairment to both sides of the lower extremities and required extensive assistance from staff for all mobility. During an interview with the Director of Nursing (DON) on 6/7/24 approximately 11:00 AM she said that all staff were responsible to answer the call lights and staff should leave the call light on until the resident's needs were met. According to the facility's 'Call Light Accessibility and Timely Response' dated 8/16/2023 reads in part: - Staff members who see or hear an activated call light are responsible for responding, regardless of their assignment. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. Process: . - Turn off the call light when the resident's request is met.