Every finding on record at Blue Ridge Care Center LLC

Based on observations, record review, staff interviews, review of the facility's policies titled Medication Administration; Insulin Pens, Prefilled, and package insert titled, Instructions for Use Insulin Lispro KwikPen injection, for subcutaneous use the facility failed to ensure accurate administration of medications for three of 25 medication opportunities observed, resulting in a medication error rate of 12%. This deficient practice had the potential to negatively impact residents (R) leading to complications of current health status. Findings include:Review of facility policy titled, Medication Administration revised 1/8/2026 revealed item 10. Ensure that the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right documentation Further review of item 17. Administer medication as ordered in accordance with manufacturer specifications.Review of the facility policy titled, Insulin Pens, Prefilled, reviewed 1/2026, revealed the following Procedure for insulin pen administration: 1) Attach disposable needle tip to insulin pen; 2) Dial up correct units of insulin per MD order; 3) Use an alcohol pad to clean the injection site; 4) Firmly depress the needle into the injection site; 5) Inject insulin into resident by pushing down on the dial; 6) Unattach disposable needle and dispose of properly in biohazard container.The policy did not include instructions to prime the insulin pen prior to dialing the prescribed dose or instructions to maintain the insulin pen in place at the injection site for 5 to 10 seconds following administration.Review of package insert titled, Instructions for Use Insulin Lispro KwikPen injection, for subcutaneous use revised July/2023 revealed instructions for priming the insulin pen prior to each injection as follows: Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Further review of the instructions included Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and '0' is seen in the Dose Window. The instructions further directed during administration, under Step 11: Insert the Needle into your skin. Push the Dose Knob all the way in. Continue to hold the Dose Knob in and slowly count to 5 before removing the Needle.Observation on 08/14/2026 at 11:32 AM on the C-Station Unit, Licensed Practical Nurse (LPN) BB was observed reviewing and administering medication to R10. LPN BB administered Tramadol HCl 50 mg, 1/2 tablet by mouth, before administering Methocarbamol (Robaxin) 750 mg. R10's physician orders included: (1) Tramadol HCl 50 mg, give 1/2 tablet by mouth every 6 hours as needed for pain, with instructions to administer only after Robaxin if ineffective; and (2) Methocarbamol (Robaxin) 750 mg, give one tablet by mouth every 8 hours as needed for muscle spasms, with instructions to administer before Tramadol. During the observation, LPN BB stated, The resident has orders for a muscle relaxer but is asking for the pain medication.Observation on 08/14/2026 at 12:06 PM on the C-Station Unit, LPN CC was observed preparing and administering Insulin Lispro to R11. LPN CC dialed a dose of 10 units on the insulin pen without first priming the pen. LPN CC then injected the insulin into R11's left upper arm. Following the injection, LPN CC immediately removed the needle and did not hold the insulin pen in place at the injection site. Insulin was observed coming from the injection site, and LPN CC wiped the insulin away.Observation on 08/14/2026 at 12:17 PM on the C-Station Unit, LPN CC was observed preparing and administering Insulin Lispro to R12. LPN CC dialed a dose of 14 units on the insulin pen without first priming the pen. LPN CC then injected the insulin into R12's abdomen. Following the injection, LPN CC immediately removed the needle and did not hold the insulin pen in place at the injection site. Insulin was observed coming from the injection site, and LPN CC wiped the insulin away.Interview on 08/14/2026 at 12:24 PM with LPN CC revealed that, when asked about priming an insulin pen prior to administration, LPN CC stated that she did not know what priming meant and requested an explanation. After the priming procedure was explained, LPN CC stated, If you want me to do that, I can. LPN CC further stated, I have not received any in-services on insulin pens or insulin pen administration. I do not know the policy on insulin pen administration. Regarding the length of time the insulin pen should be held at the injection site, LPN CC stated, I believe it is 5 seconds. When asked whether she held the insulin pen in place for 5 seconds during the administrations observed, LPN CC stated, I believe so.Review of R10's Medication Administration Record (MAR) on 08/14/2026 revealed LPN BB documented administration of Tramadol HCl 50 mg at 11:39 AM, and Methocarbamol (Robaxin) 750 mg at 1:27 PM.Interview on 08/14/2026 at 2:33 PM with LPN BB revealed LPN BB stated that she did not read the complete instructions associated with R10's medication orders. LPN BB stated that she should have administered the Methocarbamol (Robaxin), a muscle relaxant, before administering Tramadol HCl, as directed by the physician's orders. LPN BB further stated that she would contact the Nurse Practitioner (NP) to determine what action should be taken because the medications had been administered in an order that was not prescribed.Interview on 08/25/2026 at 10:07 AM with LPN Staff Education DD revealed that insulin pen administration was included in the facility's staff education. LPN DD stated that, during insulin pen training, staff are instructed to use the insulin pen per manufacturer's instructions for administration. She stated that staff are instructed to waste 2 units prior to dialing the prescribed dose to remove air from the pen, then dial the prescribed dose and verify the dose prior to administration. She further stated that staff are instructed to hold the insulin pen in place at the injection site for up to approximately 10 seconds after injection.Interview on 08/25/2026 at 10:24 AM with the Director of Nursing (DON) revealed that the facility's expectation is for medication administration errors to remain below 5%, with the DON's personal expectation being zero medication errors. The DON stated that nurses are expected to follow the five rights of medication administration and follow the physician's orders exactly. Regarding insulin pen administration, the DON stated that the facility had previously used insulin vials and that insulin pens were new to the facility. The DON stated that nurses are expected to prime the insulin pen with 2 units prior to dialing the prescribed dose. The DON further stated that nurses are expected to hold the insulin pen in place at the injection site for 5 to 10 seconds following administration.

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Hand Hygiene, Infection Prevention and Control Program, and general guidelines titled Resident Care Equipment Cleaning and Disinfection the facility failed to ensure staff followed infection prevention and control practices related to hand hygiene, cleaning and disinfection of resident care equipment, and the handling, containment, and disposal of soiled materials. This deficient practice had the potential to increase the risk of cross-contamination and transmission of infection. The facility census was 166.Findings Include:Review of the policy titled, Hand Hygiene revised 1/8/2026 indicated that All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.Review of the facility's policy titled, Infection Prevention and Control Program, revised 1/8/2026, revealed that This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Further review revealed under item 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.Review of the facility's general guidelines titled, Resident Care Equipment Cleaning and Disinfection with a date of January 2026 revealed under item 2: Equipment shared between residents will be cleaned and disinfected prior to use. Item 3 further indicated: Facility approved disinfection wipes will be used with the appropriate disinfection time posted on the disinfection wipes.Observation on 08/12/2026 at 1:36 PM of perineal care with Certified Nursing Assistant (CNA) AA in the Nursing Unit, 400-hall, revealed that the resident (R) had a bowel movement and required a brief change. Following completion of the perineal care, CNA AA exited the resident's room wearing gloves and carrying the soiled brief and soiled linens. The soiled brief, which contained fecal material, was entangled within the soiled linens. CNA AA walked approximately five steps into the hallway to a mobile soiled linen container equipped with a cloth bag and lid and placed the soiled linens into the container.CNA AA then opened a clear plastic bag that was tied to the side/top of the mobile linen container by untying the bag. The clear plastic bag already contained a soiled brief. CNA AA separated the soiled brief from the soiled linens and placed it into the clear plastic bag, then retied the bag. CNA AA then returned to the resident's room while wearing the same gloves used for handling of the soiled brief and linens.Upon returning to the resident's room, CNA AA removed and discarded the gloves and performed hand hygiene. CNA AA then donned a new pair of gloves while in the hallway and pushed the mobile linen container down the hallway to the soiled utility room. The clear plastic bag containing the soiled briefs and the cloth linen bag were observed to be full when transported to the soiled utility room for disposal.Interview on 08/12/2026 at 2:00 PM following the observation of perineal care, revealed that CNA AA stated she wears gloves when transporting soiled linen through the hallway because she is handling contaminated items. CNA AA stated that she is unable to bring the soiled-linen container into the resident's room. CNA AA further stated that she wears gloves when carrying trash or handling other items she considers dirty. Regarding the clear plastic bag attached to the side of the soiled-linen container that contained a soiled brief, CNA AA stated that she understood it was acceptable to keep a bag containing soiled briefs attached to the side of the linen container as long as the bag was tied. CNA AA stated that she untied the bag, placed the additional soiled brief inside, and retied the bag. CNA AA further stated that she waits until the bag is full before transporting it to the soiled utility room because the soiled utility room is a distance from the resident rooms.Observation on 08/12/2026 at 2:54 PM revealed multiple clear bags containing soiled briefs with visible stool stored at the bottom of a linen cart on the Nursing Unit, 500-hall. The bags were observed in contact with a wheelchair located in the hallway. Observation on 08/13/2026 at 11:39 AM and again at 12:01 PM revealed an open, clear plastic bag containing soiled briefs attached to the side of a linen cart on the Nursing Unit, 300-hall. The open bag was observed in contact with a resident's door. Three observations during medication administration on 08/14/2026 at 10:50 AM, 10:59 AM, and 11:12 AM with Licensed Practical Nurse (LPN) BB revealed that LPN BB used the same blood pressure (BP) machine and cuff to obtain blood pressure readings for R13, R14, and R15. Following the blood pressure measurement for R13 at 10:50 AM, LPN BB did not clean or disinfect the BP cuff or machine prior to using the equipment on R14 at 10:59 AM. Following the blood pressure measurement for R14, LPN BB did not clean or disinfect the BP cuff or machine prior to using the equipment on R15 at 11:12 AM.Interview on 08/14/2026 at 11:32 AM with LPN BB revealed that LPN BB stated the BP machine and cuff do not need to be cleaned or disinfected unless visibly soiled or when a resident has a condition requiring additional precautions, such as contact precautions.Observation on 08/18/2026 at 4:07 PM revealed a CNA exiting the shower room on the Nursing Unit, 300-hall, while wearing gloves and pushing a resident seated in a shower chair down the hallway.Observation on 08/19/2026 at 11:27 AM revealed what appeared to be a clean, unused brief resting directly on top of a soiled linen cart on the [NAME] Unit, 700-hall. The brief was not contained in a bag or other protective covering. The soiled linen cart had a clear plastic bag attached to its side that was open and contained trash. Observation on 08/19/2026 at 11:28 AM revealed multiple trash bags stored on the floor inside a resident's room on the [NAME] Unit, 700-hall. The bags were positioned next to the trash receptacle and were observed in contact with the resident's wheelchair. The contents of the bags could not be determined. Observation on 08/25/2026 at 2:41 PM revealed an open, clear plastic bag containing soiled briefs attached to the side of a linen cart on the [NAME] Unit, 900-hall. The open bag contained multiple loose, soiled briefs that were not individually bagged.Review of the electronic medical record (EMR) revealed that R13 was admitted to the facility on [DATE] and pertinent diagnoses including but not limited to malignant neoplasm of brain, and chronic diastolic (congestive) heart failure.Review of the EMR revealed that R14 was admitted to the facility on [DATE] and pertinent diagnoses including but not limited to local infection of the skin and subcutaneous tissue, unspecified bacterial pneumonia, and pressure-induced deep tissue damage of the sacral region.Review of R14's care plan dated 08/14/2026, revealed that R14 was on Enhanced Barrier Precautions (EBP) related to a Foley catheter and PICC line. The care plan directed direct-care staff to utilize gowns and gloves for personal care and to monitor the resident for signs and symptoms of infection. The care plan further identified that R14 had a PICC line and was receiving IV medications related to an infection, with interventions to monitor the IV site for signs and symptoms of infection.Review of the EMR revealed that R15 was admitted to the facility on [DATE] and pertinent diagnoses including but not limited to displaced bimalleolar fracture of left lower leg, and peripheral vascular disease.Review of R15's care plan dated 08/10/2026, revealed that R15 was identified as at risk of infection. The care plan included the goal that the resident will remain free from infection-related complications through the next review date, with interventions to administer medications as ordered, encourage the resident to follow infection-control practices, and notify the physician/Nurse Practitioner as needed.Interview on 08/25/2026 at 10:07 AM with LPN Staff Education DD revealed that staff are instructed to clean BP cuffs and machines when equipment is used for more than one resident. LPN DD stated incontinence briefs are to be placed in a bag, tied, removed from the resident's room, and taken to the soiled utility room. LPN DD stated that soiled briefs should not be collected on the bottom of the linen cart. She also stated that staff should not wear gloves in the hallways and that care involving contaminated materials should be completed in the resident's room.Interview on 08/25/2026 at 10:24 AM with the Director of Nursing (DON) revealed that BP cuffs should be sanitized between each resident encounter. The DON stated that staff should not wear gloves in the hallways unless an emergency occurs and that equipment should be assembled and disassembled in the resident's room. Regarding disposal of incontinence briefs, the DON stated that briefs should be bagged and tied off and that it is not acceptable to collect trash or briefs on the bottom of the linen cart. The DON stated that the facility expects staff to follow infection-control practices when handling and disposing of contaminated materials.Interview on 08/25/2026 at 11:14 AM with Infection Control Registered Nurse (RN) revealed that BP monitors used for more than one resident should be wiped down with the facility's purple-top disinfectant wipes between resident use. Infection Control RN stated that gloves should not be worn in the hallway except for limited circumstances, such as an emergency involving blood or other potentially infectious material. She further stated that soiled materials should be contained in a bag and should not be stored in a manner that places them in contact with resident equipment or other surfaces. Infection Control RN stated that soiled bags should ideally be disposed of immediately. Regarding incontinence briefs, she stated that a clean brief should not be placed on a soiled linen cart and that clean and soiled materials should not be mixed.

Based on observations, staff interviews, and review of the facility policy titled, Food Storage, the facility dietary staff failed to label and date opened food items and failed to properly discard expired milk. The facility census was 163 and 162 residents were receiving an oral diet. Findings include:Review of the facility policy titled Food Storage revealed under B. Refrigerated Storage: . Label all opened items with the date opened and use by date (per facility policy or manufacture guidance). The policy also revealed under 6. Labeling Requirements: All opened, repackaged, or leftover items must include date opened/prepared and use by/discard date.1. Observation on 12/5/2025 at 8:40 am revealed the kitchen had two walk-in refrigerators and the walk-in refrigerator to the far left had a five-pound bag of shredded cheddar cheese that had been open and stored with no open date.During an interview on 12/5/2025 at 8:40 am, the Dietary of Dietary (DOD) confirmed that the bag of shredded cheddar cheese had been open and had no open date. The DOD stated that she expected dietary staff to label and date any food item after opening. The DOD revealed that all dietary staff were responsible for ensuring that opened food items were properly labeled and dated but that she was ultimately the person responsible for checking on opened food items. The DOD stated that she checked the walk-in refrigerator first thing in the morning and throughout the day but had not done the task yet for the day.Observation on 12/5/2025 at 9:05 am of the spice/condiment rack in the food preparation area that was used by the dietary cooks revealed a one gallon container of teriyaki sauce that had been opened and had no open date.During an interview on 12/5/2025 at 9:05 am, the DOD confirmed that the gallon container of teriyaki sauce had been opened and stored with no open date. The DOD revealed that the staff member that opened the item was responsible for writing the open date on the container. The DOD stated that she usually followed behind staff to ensure all opened items had been labeled and dated and this was over looked.2. Observation on 12/5/2025 at 8:42 am of a full crate of eight-ounce chocolate milk cartons revealed they had a sell by date of [DATE]. Further observation revealed that this crate of expired milk was located next to the other stacks of milk crates.During an interview on 12/5/2025 at 8:42 am, the DOD confirmed that the crate of chocolate milk cartons had a sell by date of [DATE], and that this crate was located next to all the other stacks of milk crates and did not have a do not use sign. The DOD revealed that when milk cartons were expired, the crate was to be moved away from the other milk crates and was generally place near the door of the walk-in refrigerator with a sign do not use. The DOD stated that all staff were responsible for reviewing expiration dates. The DOD stated that she noticed the crate of chocolate milk had expired but forgot to move that crate away from the other crates of milk and forgot to place the do not use sign on it.

Based on observations, staff interviews, and review of the facility policy titled, Dishwasher Temperature, the facility failed to demonstrate a properly functioning dish machine to sanitize dishware to prevent food borne illness. The facility census was 163 and 162 residents were receiving an oral diet.Findings include:Review of the facility policy titled Dishwasher Temperature revealed for low temperature dishwashers (chemical sanitization) the wash temperature shall be 120 degrees Fahrenheit (F) and the sanitizing solution shall be 50ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse.Observation on 12/5/2025 of the facility dish machine was first conducted at 9:10 am until 9:30 am. The facility has a large conveyor belt type dish machine and was a low temperature machine that used a chemical for sanitizing dishware. Dietary aide FF assisted with demonstrating the use of the dish machine. Dietary aide FF placed several empty dish racks on the conveyor belt and observation of the temperature gauges located on the front of the dish machine revealed that they were not functioning as no temperature for either the wash cycle or the rinse cycle were registering. As the empty dish racks come through the dish machine to the sanitize and rinse side, the Director of Dietary (DOD) assisted with testing the concentration of the sanitizing solution using a white colored paper test strip. The test strip was to change to a shade of black to indicate the concentration level of the sanitizing solution. The DOD dipped the test strip into the sanitizing solution and the test strip remained white in color which indicated no sanitizer was being dispersed inside the dish machine to sanitize dishware. Dietary aide FF opened one of the doors to the inside of the dish machine and took a test strip to see if the sanitizing water deeper inside would register the concentration of the sanitizing solution, the test strip remained white in color which was confirmed by dietary aide FF and the DOD. Dietary aide FF looked at all of the chemical buckets under the dish machine and also looked at all of the plastic tubing that went from the chemical buckets into the dish machine, looking for any obstructions. Dietary aide FF changed the sanitizing bucket for new and placed the tubing in the bucket. Dietary aide FF place empty dish racks through the machine to get the chemical running again. The DOD again took a white paper test strip and tested the sanitizing solution concentration and the test strip remained white in color to indicate no sanitizing solution was being dispersed inside the dish machine. Dietary aide FF attempted to test the sanitizing solution again from deep inside the dish machine and the test strip remained white in color to indicate no sanitizing solution.During an interview on 12/5/2025 at 9:20 am, the DOD revealed that the temperature gauges were working this morning and not sure why they are not working now. The DOD stated that dietary staff were having no problems with the dish machine up until this demonstration. Continued interview with the DOD revealed that the dish machine was recently repaired a few weeks ago and had a contract repair company assist with the repairs. The DOD revealed that the dish machine was not operational for a few days waiting for a part that the repair man had to order. The DOD stated that once the new part was installed, there had been no issues with the dish machine until this moment. During the interview, the DOD contacted the facility maintenance and also contacted dish machine repair company for assistance in getting the dish machine to work properly. The DOD stated that dietary staff would serve resident meals using paper and plastic products until the dish machine was repaired.Observation on 12/5/2025 at 9:50 am of the dish machine again, but with the Director of Maintenance (DOM), he confirmed that the temperature gauges were not registering any temperatures for the wash or rinse cycles while the dish machine was running. The DOM tested the sanitizing solution using the white paper test strips, the test strip remained white in color which the DOM confirmed indicated no sanitizing concentration could be determined. The DOM confirmed that the dish machine had recent repair work and had been working properly.On 12/5/2025 at 12:12 pm, the [NAME] President of Operations (VPOO) stated that the dish machine was fixed and wanted to show that the dish machine was in proper working order.Observation on 12/5/ 2025 at 12:15 pm of the dish machine revealed that the temperature gauges were working, the wash cycle had a temperature of 120 degrees F and rinse had a temperature of 140 degrees F. The DOM tested the sanitizing solution using the white paper test strip, the test strip remained white in color indicating no sanitizer chemical was being dispersed inside the dish machine.Observation on 12/5/2025 at 12:16 pm of the VPOO testing the sanitizing solution using the white paper test strip revealed that the test strip remained white in color indicating no sanitizing solution.Interview on 12/5/2025 at 12:20 pm with the DOM regarding the temperature gauges and how they started working and the DOM revealed that he tried a few things and they suddenly started to work again.Observation on 12/5/2025 at 12:23 pm of the DOM testing the sanitizing solution revealed the test strip continued to indicate no sanitizer solution could be detected.Observation on 12/5/2025 at 12:25 pm, the DOM looked at all of the plastic tubing from the chemical buckets to the dish machine, and the DOM shook/agitated each plastic line to ensure there were no obstructions.Observation on 12/5/2025 at 12:30 pm the DOM tested the sanitizing solution using the white paper test strip and this time the test strip registered a shade of black which indicated the sanitizing concentration was about 75 parts per million (ppm) which indicated that the dish machine was dispersing sanitizing solution to sanitize dishware.

Based on observations, family and staff interviews, record review, and review of the facility's policy titled, Promoting/Maintaining Residents Dignity, the facility failed to protect the privacy of health information for one of three residents (R) (R19) reviewed for privacy. Specifically, the facility posted instructions on R19's wall that disclosed birthday, gender, medical identification, and picture. The deficient practice had the potential to place R19 at risk of a diminished quality of life in an environment that promotes the maintenance or enhancement of each resident's dignity.Findings include:Review of the facility policy titled, Promoting/Maintaining Residents Dignity dated 1/8/2025 documented under Policy: It is the practice of this facility to protect and promote resident rights and threat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident individually. Under the section Compliance Guidelines: .12. Maintain resident privacy. A review of the electronic medical record (EMR) for R19 revealed he had a diagnosis of but not limited to paraplegia, unspecified (loss of motor function below injury).A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for R19 revealed in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 00, which indicates severe cognitive impairment.Observations on 12/5/2025 at 8:49 am and on 12/6/2025 at 9:00 revealed R19 had a posting titled, R19 Shower Day on the wall that disclosed private medical information.A telephone interview on 12/5/2025 at 11:28 am with a family member of R19 revealed she was not aware that the posting disclosed personal medical information and was not sure why it would be posted on the wall.In an observation and interview on 12/6/2025 at 11:46 with the Unit Manager (UM) AA confirmed that the poster should not be there and was unsure why rehabilitation services would post medical information.An interview on 12/6/2025 at 2:11 pm with the Director of Nursing (DON) revealed no staff should be posting residents medical information that may compromise the Health Insurance Portability and Accountability Act (HIPAA).

Based on staff interviews, record review, and review of a policy titled, Use of Psychotropic Medication(s), the facility failed to ensure as needed psychotropic medication were ordered and limited to 14 days for one of five residents (R) (R 123) reviewed for un-necessary medications, The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.Findings include:Review of the policy titled Use of Psychotropic Medication(s) date implemented 1/8/2025 revealed the Policy was to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Under the section titled Policy Explanation and Compliance Guidelines under number 16 revealed psychotropic medications used as needed are limited to no more than 14 days unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond 14 days and documentation is included from the physician or prescriber for the rationale to extend the time period and indicate a specific duration.Review of the electronic medical record (EMR) revealed R123 was admitted to the facility with pertinent diagnoses including but not limited to depression, anxiety, diabetes mellitus type two, long term use of insulin, and urinary tract infection.Review of R123's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/29/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates R123 was cognitively intact.Review of R123's care plan revealed the use of antianxiety, antidepressant, or hypglycemic medications were not addressed.Review of the EMR revealed physician's orders for R123 included but were not limited to Alprazolam tablet 0.25 milligrams (mg), give one tablet by mouth every 12 hours as needed for anxiety. Start date was 11/10/2025 and the end date was documented as indefinite.Review of the November 2025 Electronic Medication Administration Record (eMAR) revealed Alprazolam was administered on November 13, 14, 15, 16, 23, 24, 25, and 29 of 2025. Two doses were administered after the 14th day of this order.Review of the December 2025 eMAR revealed Alprazolam was administered on December 1, 2, and 4 of 2025. Three doses were administered after the 14th day of this order.12/7/2025 at 11:34 am during an interview with Licensed Practical Nurse (LPN) GG, she revealed that all PRN antipsychotic and psychotropic medication orders are limited to 14 days. During a review of R123's EMR with LPN GG, she confirmed and verified Alprazolam 0.25 mg was ordered as needed by the Nurse Practitioner and the stop date on the order was documented as indefinite.During an interview on 12/7/2025 at 12:09 pm with the Director of Nursing (DON), she confirmed and verified alprazolam 0.25 mg was ordered for R123 on November 10, 2025, and confirmed and verified the order was transcribed into the computer with a stop date of indefinite. She stated she thought the Nurse Practitioner was writing an order for this medication with a 14-day duration but instead the Nurse Practitioner herself entered the order in the EMR and marked the stop date as indefinite. She reviewed the November 2025 eMAR and verified and confirmed that R123 was given alprazolam on the 25th and 29th of November 2025 which was 15 and 19 days after the order was written. She reviewed the December 2025 eMAR and she verified and confirmed R123 was given alprazolam on December 1, 2, and 4 of 2025, which was 21, 22, and 24 days after the order was written on November 10, 2025. The DON stated her expectation was that stop dates for psychotropic medications be on a time frame of less than 14 days.

Based on observation, record review, staff interviews, and review of the facility policy's titled, Comprehensive Care Plans, Oxygen Administration, and Use of Psychotropic Medications, the facility failed to develop a person-centered comprehensive care plan for four of 48 sampled residents (R) (R71, R90, R21, and R123) out of 48 sampled residents. Specifically, the facility failed to develop a care plan for R71 related to an indwelling urinary catheter, failed to develop a care plan for R21 and R90 related to oxygen, and failed to develop a care plan for R123 related to psychotropic medication. The deficient practice had the potential to cause R71, R90, R21, and R123 not to receive necessary care and services. Findings include: Review of the facility policy, Comprehensive Care Plans dated 1/8/2025 revealed under Policy: It is the policy of this facility to develop and implement a comprehensive person- centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Review of the facility policy Oxygen Administration dated 1/8/2025 revealed under Policy Explanation and Compliance Guidelines: . 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders. Review of the facility policy Use of Psychotropic Medications dated 1/8/2025 revealed under Policy Explanation and Compliance Guidelines: . 14. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. 1. R71 was admitted to the facility with diagnosis that included but not limited to retention of urine. Review of the 11/22/2025 admission Minimum Data Set (MDS) for R71 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition, dependent with all Activities of Daily Living (ADLs), and has an indwelling urinary catheter. Review of the electronic medical record (EMR) for R71 revealed there was not a care plan in place for an indwelling urinary catheter. Review of the physician orders for R71 revealed orders dated 11/18/2025 for Foley catheter (a thin, flexible tube inserted into the bladder through the urethra to provide continuous urine drainage): Resident to have continued use of indwelling Foley size 16 french coude (a slightly curved tip on medical devices) due to urinary retention, Foley catheter care daily and PRN (as needed) every day shift and as needed, Maintain Enhanced Barrier Precautions (EBP) at all times due to Foley catheter, change drainage bag on admission and monthly on night shift, change catheter every month and prn, and Foley to gravity drainage at bedside. Secure catheter at all times and change securing device PRN. Interview on 12/7/2025 at 9:58 am with MDS Coordinator CC confirmed there was no care plan in place for the indwelling foley catheter for R71. She stated that there should be one in place since the admission assessment was completed on 11/22/2025 and the comprehensive care plan should be completed. MDS Coordinator CC stated that she relied on nurses, interviewing and observing residents, and reviewing the residents medical records to identify areas that should be in an individualized care plan. She stated that Certified Nurse Assistants (CNAs) will not know how to provide care with no guide to go by and that it was her responsibility to ensure care plans were completed so they had knowledge of specific care for residents. 2. Review of the admission Record for R90 revealed diagnoses that included, but were not limited to, epilepsy, unspecified, not intractable, without status epilepticus, acute respiratory distress, and pneumonia, unspecified organism. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/5/2025, for R90 revealed that Section O (Special Treatments, Procedures, Programs) documented that the resident received oxygen therapy while a resident. Review of the care plan for R90 revealed no focus areas, goals, or interventions related to oxygen use. Review of the physician orders for R90 revealed an order dated 8/13/2025 to apply oxygen at two liters per minute (LPM) via nasal cannula (NC) for oxygen saturation below 90 percent and call the physician immediately after placement for further orders, as needed. In a concurrent observation and interview on 12/6/2025 at 1:05 pm, Licensed Practical Nurse (LPN) DD confirmed that R90 was receiving oxygen at four LPM. She confirmed there were no focus areas or interventions for oxygen on the resident's care plan and stated she was unsure whether oxygen should be included on the care plan. In an interview on 12/6/2025, MDS Coordinator CC confirmed that the use of oxygen was documented on the Quarterly MDS dated [DATE] for R90. She confirmed there were no focus areas or interventions for oxygen on the care plan and stated the use of oxygen should be on the care plan, since it was documented on the MDS assessment. She stated she was unsure why the oxygen had not been added to the care plan and would add it. In an interview on 12/6/2025 at 1:50 pm, the Director of Nursing (DON) stated the resident's care plan should include the use of oxygen if it was documented on the MDS assessment. 3. Review of the EMR revealed R21 was admitted to the facility with pertinent diagnoses that included but were not limited to shortness of breath and unspecified asthma, uncomplicated. Review of R21's five-day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/7/2025 revealed a BIMS score of 3, which indicates R21 had severe cognitive impairment. Section O, (Special treatments, Procedures and Programs), revealed R21 received oxygen therapy on admission intermittently and as a resident. Review of R21's care plan revealed no care plan was developed addressing oxygen use. Observation and interview on 12/6/2025 at 3:30 pm with Licensed Practical Nurse (LPN) GG, she confirmed and verified R21 was using oxygen via NC, and the flow meter was set on 2 LPM. She stated R21 was on continuous oxygen and had been on continuous oxygen since her admission to the facility on 9/3/2025. During a review of the care plan for R21 with LPN GG, she confirmed and verified the care plan did not address R21 using oxygen. She stated the care plan should address oxygen use. Interview with the Director of Nursing (DON) and MDS Coordinator CC on 12/6/2025 at 3:50 pm in the DON's office, they verified and confirmed the care plan for R21 did not address R21's oxygen use at all. They both stated the care plan should address the residents' use of oxygen. The DON She stated her expectation of care plans was that they were completed and included oxygen use for residents who used oxygen. 4. Review of the EMR for R123 revealed she was admitted to the facility with pertinent diagnoses that included but not limited to depression (unspecified), anxiety, type 2 diabetes mellitus, and long term (current) use of insulin. Review of R123's quarterly MDS assessment with an ARD of 10/29/2025 revealed in section N (Medications) under the section titled High Risk Drug Classes Use and Indication the documentation indicated that R123 was taking and an indication was noted during the previous seven days of the MDS Assessment, antianxiety, antidepressant, antibiotic, antiplatelet, and hypoglycemic (including insulin) medications. Review of R123's care plan revealed no focus area, goals, or interventions were developed to address the use of antianxiety, antidepressant, and hypoglycemic medications. During an interview on 12/7/2025 at 11:51am with LPN II revealed that she expected interventions related to psychotropic medications would be on the care plan. During an interview on 12/7/2025 at 12:09 pm with the DON, she confirmed and verified there were no interventions documented on R123's care plan to address her use of antidepressants, psychotropic medications, or insulin. She stated there should be interventions listed. She revealed her expectation was that the care plan be present. During an interview on 12/7/2025 at 12:37 pm with LPN JJ in the DON's office, she confirmed and verified R123's care plan did not have interventions for antidepressant medications, psychotropic medications, or insulin listed. She stated her normal process was to review residents' diagnoses and medications, then use a template for each type of medication to develop a care plan for each. She stated that when residents were admitted from an acute care hospital for rehab the care plan is developed by another nurse, MDS Coordinator CC, but once the resident changed to long term care (LTC) she reviewed the care plan and updated it as necessary. She stated she was not sure why this care plan did not get updated. During an interview on 12/7/2025 at 12:43 pm in the DON's office with MDS Coordinator CC, she stated they had care plans specific for each medication which they developed within the proper time frame after the MDS assessment was completed. She stated she was not sure why this did not happen for R123. Cross-Reference F695

Based on observations, staff and resident family interviews, record review and review of the facility policy titled, Nutritional and Dietary Supplements, the facility failed to provide one of 48 sampled residents (R) (R15) a nutrition supplement as ordered.Findings include:Review of the facility policy titled Nutritional and Dietary Supplements revealed that the facility will provide nutritional and dietary supplements to each resident, consistent with the residents' assessed needs.Review of the admission record revealed R15 was admitted to the facility with a medical diagnosis of but not limited to unspecified protein calorie malnutrition.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that R15 had a Brief Interview for Mental Status (BIMS) score of one out of 15, indicating cognition is severely impaired.Review of the electronic medical record (EMR) revealed R15 had a physician order for a frozen nutritional supplement with meals for supplemental related to unspecified protein malnutrition. The supplement was ordered 11/20/2025.Observation on 12/6/2025 at 1:35 pm of R15's lunch meal tray revealed no nutritional supplement was provided. Continued observation of the lunch meal tray revealed that besides the meal plate, R15 was offered a glass of iced tea and a cup of Italian ice.During an interview on 12/6/2025 at 1:35 pm with R15's family member, they confirmed that R15 was not provided with any nutritional supplement with the lunch meal. R15's family member stated that R15 had received a frozen nutritional supplement a few times and really enjoyed it. During an interview and observation on 12/6/2025, the Director of Dietary (DOD) confirmed that R15 was not provided with a frozen nutritional supplement. The DOD revealed that the dietary department is currently out of the frozen nutritional supplement and had ordered more to be delivered but their food supplier was waiting for more to come as well. The DOD was not aware that R15's physician order was for the frozen nutritional supplement to be given at meals. The DOD thought R15's nutritional supplement was to be given between meals.During a telephone interview on 12/6/25 at 2:35 pm the facility's registered dietitian (RD) confirmed that the DOD did notify her that their food supplier was out of the frozen nutrition supplement. The RD revealed that R15 had tried liquid nutrition supplements in the past and disliked them. Continued interview with the RD revealed that R15 should have at least been offered a regular cup of ice cream to provide some additional calories since the frozen nutrition supplement was unavailable.

Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure oxygen was administered as ordered by the physician for two of 14 residents (R) (R90 and R21) receiving oxygen. This deficient practice had the potential to place R90 and R21 at increased risk of respiratory complications.Findings include: Review of the facility's policy titled Oxygen Administration, dated 1/8/2025, revealed the Policy section stated Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The Policy Explanation and Compliance Guidelines section included, 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders are obtained as soon as practicable when the situation is under control. 1. Review of the admission Record for R90 revealed diagnoses that included, but were not limited to, epilepsy, unspecified, not intractable, without status epilepticus, acute respiratory distress, and pneumonia, unspecified organism (5/2/2025). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R90 revealed that Section GG (Functional Abilities and Goals) documented that the resident was dependent on staff for all ADLs (activities of daily living), and Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen while a resident. Review of the physician orders for R90 revealed an order dated 8/13/2025 to apply oxygen at two liters per minute (LPM) via nasal cannula (NC) for oxygen saturation below 90 percent (%), and call the physician immediately after placement for further orders, as needed (PRN). Continued review revealed an order dated 11/1/2024 for vital signs every Wednesday, 3-11(3:00 pm to 11:00 pm) shift. Review of the Medication Administration Record (MARS) for R90 dated October 2025, November 2025, and December 2025 revealed no documentation of oxygen saturations below 90%. Review of the Progress Notes for R90 revealed no documentation of respiratory distress, oxygen saturations below 90%, or the use of oxygen from 10/1/2025 through 12/5/2025. In a concurrent observation and interview on 12/6/2025 at 1:05 pm, Licensed Practical Nurse (LPN) DD confirmed that R90 was receiving oxygen at four LPM. She further confirmed the physician's order for R90 was for oxygen at two LPM via a NC for oxygen saturation below 90 percent, and to call the physician immediately after placement for further orders as needed. She confirmed there was no documentation of the resident's oxygen saturation being below 90 percent. She stated she had not received a report of any changes in the resident's orders or status. In an interview on 12/6/2025 at 1:10 pm, Registered Nurse (RN) EE stated that oxygen should be administered according to the physician's orders. She stated that the nurse should check the oxygen settings during rounding and ensure that oxygen was being administered as ordered. In an interview on 12/6/2025 at 1:50 pm, the Director of Nursing (DON) stated that nurses should follow physician orders when administering oxygen and should check the oxygen settings and physician orders for administration each shift. She stated that if oxygen was not administered in accordance with the physician's orders, a resident could experience adverse effects. 2. Review of the electronic medical record (EMR) revealed Resident (R) 21 was admitted with pertinent diagnoses including but was not limited to shortness of breath and unspecified asthma, uncomplicated. Review of R21's five-day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/7/2025 revealed a Brief Interview for Mental Status (BIMS) of 3, which indicates R21 had severe cognitive impairment. Section O, Special Treatments, Procedures and Programs, revealed R21 received oxygen therapy on admission intermittent and as a resident. Review of R21's care plan revealed no care plan was developed addressing oxygen use. Review of the EMR revealed physician's orders for R21 included but was not limited to: a. Change oxygen concentrator set up (NC tubing and water) and clean oxygen concentrator filter with soap and water weekly on Wednesdays (as applicable for filter present). Open back vented area and wipe with name of corporation approved wipes, every day and shift every Wed. (Wednesday) for hypoxia (low oxygen level) and as needed. b. Apply oxygen 2 liter a minute via nasal cannula for oxygen saturation below 90%. Call physician immediately after placement for further orders. As needed for hypoxia. Review of the November 2025, Electronic Medication Administration Record (eMAR) for R21 revealed: pulse oximeter readings between 11/25/2025 -11/30/2025 were between the range of 93 to 98 percent. There was no documentation to indicate if the pulse oximeter readings were taken on room air or on oxygen. Review of the December 2025, eMAR for R21 revealed the pulse oximeter readings between 12/1/2025 to 12/5/2025 ranged between 93 to 98 percent. There was no documentation to indicate if the pulse oximeter readings were taken on room air or on oxygen. On 12/5/2025 at 11:40 am, R21 was observed sitting up in bed wearing oxygen via NC. Further observation revealed the oxygen concentrator had a place for a filter in the back of the concentrator, but no filter was present. There was no oxygen in use signage on the doorway. On 12/6/2025 at 11:14 am, R21 was observed to be sitting up in bed wearing oxygen via NC, further observations of the oxygen concentrator revealed there was no filter located on the back of the concentrator in the indented area, there was no oxygen in use signage on the doorway. On 12/6/2025 at 3:25 pm, R21 was observed resting in bed wearing oxygen via NC the oxygen concentrator was observed to have no filter, there was no oxygen in use signage on doorway. Observation and interview on 12/6/2025 at 3:30 pm with Licensed Practical Nurse (LPN) GG, she confirmed and verified R21 was wearing oxygen via NC at two LPM. She stated R21 was on continuous oxygen and had been on oxygen continuously since her admission to the facility. She confirmed and verified there was no filter located on the back of the concentrator, she stated there should be a filter and it should be cleaned or replaced every week. She confirmed and verified there was no oxygen in use sign on the doorway and stated there should be a magnetic sign on the door frame. She confirmed and verified R21 had physician orders for the filter to be cleaned and/or replaced on Wednesdays, oxygen was ordered at two LPM via NC if the oxygen saturation is below 90 percent and to call the physician immediately after placement for further orders as needed for hypoxia, she stated this order was an order for as needed oxygen not continuous oxygen. She stated that once the resident was determined to need oxygen the nurse should reach out to the physician for new orders. Further review of the eMAR with LPN GG, she confirmed and verified the oxygen saturations recorded on the November 2025 and the December 2025 eMAR were all above 90 percent and no nurse documented administration of oxygen on either eMAR. She stated that no one documented it because the order was an as needed order not continuous and R21 was wearing oxygen continuously. During an interview on 12/6/2025 at 3:45 pm with the DON in her office, she confirmed and verified R21 had an as needed order for oxygen at two LPM via NC. She confirmed and verified the November 2025 and December 2025 eMARs had oxygen saturations documented and they were all greater than 90 percent and the documentation did not specify if the reading was on room air or oxygen. She verified and confirmed no nurse documented on the November 2025 and December 2025 eMAR that oxygen was applied for R21. She verified and confirmed there was an order for the filter of the concentrator to be washed each Wednesday. The DON stated her expectation of staff was that if a resident was requiring oxygen for oxygen saturations of 90 percent or less, was to follow the physician orders. She stated she expected staff to change/wash filters on the oxygen concentrator every Wednesday. She stated she expected staff to apply the oxygen in use signage to the door frame of each resident's room in which oxygen was in use. She stated she expected staff to document in the eMAR when oxygen was ordered as needed i administered to the resident.

Based on observations, staff and family interviews, and review of the facility menu, the facility failed to serve the lunch meal as written on the menu for one of 48 sampled residents (R) (R15).Findings include:R15 was admitted to the facility with a medical diagnosis of but not limited to unspecified protein calorie malnutrition.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R15 had a Brief Interview for Mental Status (BIMS) score of one out of 15, indicating cognition is severely impaired.Review of the electronic medical record (EMR) revealed R15 had a physician order for a regular diet, regular texture, regular consistency.Review of the facility Week 2 Saturday lunch meal revealed residents were to be served chicken parmesan, spaghetti, tomato sauce, Italian mixed vegetables, garlic roll. margarine, Italian ice, and whole milk.Review of R15's lunch meal tray slip revealed he was to receive three ounce chicken parmesan, one half cup mashed potatoes, four ounces Italian vegetable blend, one each garlic bread, one each margarin, one each salt, one each pepper, two each sugar packet, four fluid ounce apple juice, eight fluid ounce ice tea, six fluid ounce coffee. Handwritten in ink on the ticket was, fried chicken, no sauce, noodles, no gravy.Observation on 12/6/2025 at 1:35 pm of R15 lunch meal tray revealed R15 was served plain steamed chicken thigh, Italian mixed vegetable, garlic bread, eight ounces ice tea, and cup of Italian ice.During an interview on 12/6/2025 at 1:35 pm with R15's family member, they confirmed that R15 was not served the chicken parmesan as indicated on the lunch meal tray slip. R15's family member stated that they visited with R15 daily and were present for most meals. R15's family member stated that R15 was often not served what was indicated on the meal tray slip.During an interview and observation on 12/6/2025 at 2:05 pm, the Administrator viewed the lunch meal and meal tray slip that R15 received and confirmed that they were not served the chicken parmesan and were served plain steamed chicken instead for lunch. The Administrator stated that even though R15 preferred not to have any sauces or gravy, R15 should have been served the chicken parmesan.During an interview and observation on 12/6/2025 at 2:10 pm, the Director of Dietary (DOD) viewed the lunch meal tray served to R15 and confirmed that R15 was not served chicken parmesan that was stated on the meal tray slip or as written on the posted menu. The DOD stated that R15 should have been served the chicken parmesan without any sauce or gravy. The DOD revealed that the cooks usually set aside a few pieces of chicken parmesan without sauce for those residents that preferred no sauces.

Based on observations, staff interview, record review, and review of the facility policy titled, Catheter Care, the facility failed to follow proper infection control practices related to hand washing during catheter care for one of seven residents (R) (R71) with indwelling urinary catheters. The deficient practice had the potential to cause R71 increased risk for urinary tract infections. Findings include:Review of the facility policy titled Catheter Care dated 1/8/2025 revealed under Compliance Guidelines . 7. Perform hand hygiene.R71 was admitted to the facility with diagnoses that include but is not limited to, retention of urine.Review of the 11/22/2025 admission Minimum Data Set (MDS) assessment for R71 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition, is dependent with all Activities of Daily Living (ADLs), and has an indwelling urinary catheter, Review of the Person-Centered Comprehensive Care Plan for R71 revealed no care plan in place for an indwelling urinary catheter. Review of the physician orders for R71 revealed orders dated 11/18/2025 for Foley (a thin, flexible tube inserted into the bladder through the urethra to provide continuous urine drainage): Resident to have continued use of indwelling Foley size 16 french coude (a slightly curved tip on medical devices) due to urinary retention, Foley catheter care daily and PRN (as needed) every day shift and as needed, Maintain Enhanced Barrier Precautions (EBP) at all times due to Foley catheter, change drainage bag on admission and monthly on night shift, change catheter every month and prn, and Foley to gravity drainage at bedside. Secure catheter at all times and change securing device PRN.Observation on 12/5/2025 at 12:07 pm of R71 in bed with his eyes closed revealed an indwelling urinary catheter in place. Urinary bag noted below bladder at bedside facing door with no privacy bag, but the door remained shut. Draining clear yellow urine. No sediment noted.Observation on 12/6/2025 at 8:12 am of R71 in bed with eyes closed revealed an indwelling urinary catheter remained in place. Bag was on the left side of the bed below the bladder and was covered with a dignity bag. There was clear yellow urine in the tubing with no sediment noted. Observation and interview on 12/6/2025 at 11:25 am of Certified Nursing Assistant (CNA) BB performing catheter care on R71 revealed prior to entering the room, she sanitized her hands and stated that she double gloved so that when, or if, her gloves became soiled, she could remove the soiled pair. During this time CNA BB put on two pair of gloves. Upon entering the room, CNA BB did not clean the bedside table but set up two pans of water, one with soap and water, and one with rinse water. She placed a clean washcloth in both pans. CNA BB took a washcloth from the pan with soap water and cleaned the catheter tube around the site of insertion, then using a separate, clean area of the washcloth she cleaned around the insertion site of the catheter tube at the meatus (opening to penis). She then removed one pair of gloves from her double-gloved hands, discarded them in a plastic bag, took the washcloth from the rinse water pan and repeated the same process to rinse. CNA BB, wearing the same gloves used to rinse, took the towel and dried the tubing and genital area. Wearing the same gloves, CNA BB pulled the covers up over R71 and ensured he was comfortable and stated that this was how she performed incontinent care. CNA BB did not wash or sanitize her hands throughout the catheter care process when going from dirty to clean and she did not put on new gloves.Review of the Catheter Care Audit form revealed 11. Did NA (Nursing Assistant) remove gloves and wash hands or use hand sanitizer? If new gloves were applied remove gloves and wash hands? 12. Were hands washed after each direct resident contact for which hand washing is indicated by professional practice?Review of the Education Sign In Form with the topic of Peri-Care dated August 2025 revealed CNA BBs name on the list as participating.

Based on interview and record review, the facility failed to revise their CLIA (Clinical Laboratory Improvement Amendments) certificate within 30 days after new ownership. The facility does not have a current CLIA certificate appropriate for the level of testing it conducts after approximately seven months of ownership.Findings include:Review of the CLIA Certificate of Waiver with Effective Date of 5/6/2024 and Expiration Date of 5/5/2026 is in the name of the previous owner hospital.Review of the CLIA Certificate of Compliance with Effective Date of 8/19/2023 and Expiration Date of 8/18/2025 is in the name of the previous laboratory service owner. In an interview on 7/8/2025 at 12:21 pm with the facility's Administrator, they stated, We are still operating under that (Previous Owner) waiver as part of the transition. The new owner purchased the facility from the hospital in January 2025.On 7/8/2025 the State CLIA Department was consulted, and they confirmed the following, The facility is out of compliance and should request a revised CLIA certificate using the attached CMS-116 application. Facilities are required to notify CLIA STATE agencies within 30 days of ownership changes. The facility was provided with CMS-116 application on 7/9/2025.

Based on record review, observations, and resident and staff interviews, the facility failed to provide bath linen in good condition on seven of nine hallways (C hall, 600 hall, 200 hall, 400 hall, 500 hall, 800 hall and 900 hall).Findings include:On 7/7/2025 beginning at 10:55 am, during a brief tour of C hall, one linen cart revealed no towels or washcloths, a second linen cart has a torn washcloth and a few hand towels in disrepair. On 7/7/2025 at 11:22 am, in the secured hall, a staff member came out of room [ROOM NUMBER] with an arm full of linens, some washcloths tattered, and said, they were not dirty, I promise and put them in soiled laundry bin. On 7/7/2025 at 11:26 am, on the 600-hall linen cart had 10 wash cloths, a few were tattered and 13 bath towels.During an interview on 7/7/2025 at 11:37 am, Resident R12 said, they tore up larger towels and made it into washcloths when the new company took over. I had a few yesterday that were torn.During an interview with R11, on 7/8/2025 at 10:14 am, R11 said, the facility cut up towels to washcloth size and showed four tattered washcloths taken from their drawer.During an observation on 7/9/2025 at 10:23 am, a Certified Nursing Assistant (CNA) on 200 hall had two ripped washcloths in her hand coming out of room [ROOM NUMBER].During an interview on 7/9/2025 at 10:37 am with CNA JJ, they said, on the 900 hall, we sometimes don't have linens, or they are torn and shredded. We only got new linens today because State is in the building. I can't change residents until after 11:00 am because all we have are rags, just torn washcloths and no towels. During an interview on 7/10/25 at 1:09 pm, R13 took 2 torn and shredded washcloths from her shelf and displayed them on her bed.During an interview on 7/10/2025 at 1:10 pm, R15 shared the Resident Council Minutes and June 2025 minutes revealed the facility still did not have enough towels and wash cloths.Review of the grievance log revealed a Resident Council Grievance filed on 4/30/2025 from R15 that area of concern: residents complained about linen shortage that happens daily and occurs on all units. Actions/approaches: the Administrator was present at the meeting and informed residents that extra linen has been ordered to address this issue.During a telephone interview on 7/10/2025 at 2:30 pm with the Environmental Service Supervisor (EVS), they said, We have tried to get the linen par up. Families have taken towels to cut up and making washcloths out of them.An interview on 7/10/2025 at 2:38 pm with the Administrator revealed that families had torn and shredded the bath towels. The families and residents were taking linen into their rooms and storing it, then the staff went in and took the linens out of the rooms. The laundry techs said the CNAs grab linens and they worked from back towards the front to divvy it up fairlyOn 7/10/2025 at 2:39 pm, the Surveyor shared with the EVS, the Administrator, and the Regional Director of Operations pictures of torn and shredded washcloths found in R13's room that day. The Administrator and Regional Director of Operations both said, We should never use anything that's cut up.

Based on observations, staff interviews, and review of the facility policy titled, Food Storage, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility had expired food in storage areas reserved for resident snacks. This practice affected two of three units (Middle Unit and the Nursing Unit) observed in the facility for resident food storage. Findings include:Review of the facility policy titled Food Storage with a date of January 2025 revealed under 5. Storage Guidelines. D. Perishable and Leftover Foods, Label with preparation date and discard date (typically within 3-7 days based on item type). Observation on 7/7/2025 at 11:30 am of the snack cabinet for residents on the Nursing Unit revealed the cabinet contained an unopened loaf of bread that had an expiration date of 4/24/2025. The bread was hard and had areas of green discoloration in several areas.An interview, on 7/7/2025 at 11:33 am with Certified Nursing Assistant (CNA) II revealed the bread should have been discarded back in April of 2025.Observation on 7/7/2025 at 11:45 am of the residents' refrigerator used for snacks on the Middle Unit revealed the refrigerator contained three wrapped turkey sandwiches with a use by date of 7/4/2025 and three cups of covered apples with a use by date of 7/4/2025.An interview on 7/7/2025 at 11:50 am with CNA HH revealed the sandwiches and apples should have been discarded on 7/4/2025. The CNA threw the sandwiches and apples in the trash.

Based on observations, staff interviews, and review of the facility policy titled, Hand Hygiene, the facility failed to ensure proper hand hygiene during the lunch meal in the Nursing Unit Main Dining Room for three of 14 residents (R) (R4, R5, and R6). The deficient practice had the potential to cause foodborne illnesses for residents eating in the Nursing Unit Main Dining room.Findings include:Review of the facility policy titled Hand Hygiene with an effective date of January 2025 revealed under Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Under Guidelines: . 5) Use an alcohol-based hand rub for the following situations: . o) Before and after assisting a resident with meals.On 7/7/2025 at 12:49 pm, Certified Nursing Assistant (CNA) AA entered the Nursing Unit Dining Room, sat down without performing hand hygiene and started to assist R4 to eat. CNA AA touched the spaghetti on R4s fork with her bare hands and then brought that fork up to R4s mouth for them to eat the now contaminated food. Using the same hand, CNA AA twirled her own hair and itched her own head, then continued to assist R4 to eat. At 12:51 pm, CNA AA took their cell phone out of their pocket and checked it, then went back to assisting R4 with their lunch meal. At 12:52 pm, CNA AA touched her face, did not use any method of handwashing, and continued assisting R4 to eat. At 12:53 pm, CNA AA got up and changed the tv station to cartoons, then sat down to assist R4 with meal with no handwashing. At 12:54 pm, CNA AA put salt and pepper on R4s spaghetti, then continued to assist R4 with his meal. At 12:55 pm, CNA AA touched her head again and scratched her head several times, then used the same dirty hand to feed R4 with no hand hygiene. At 12:58 pm, a CNA handed CNA AA a pair of gloves to wear while assisting R4 to eat, but instead of putting on the gloves, CNA AA walked away from the R4 to pass out another tray, with no hand hygiene, and CNA AA then proceeded to cut up R5's spaghetti.On 7/7/2025 at 1:02 pm, without hand hygiene, CNA AA moved to assist R5 to eat. At 1:09 pm, CNA AA left R5 and put their hands on their hips, walked to another table, and came back to R4 to assist them briefly, then went to assist R6 to eat with no hand hygiene in between. At 1:10 pm, CNA AA touched their own face with her right hand that she had been using to feed the residents. At 1:11 pm, CNA AA went back to R4 to assist with their drink. There was no observed hand hygiene between assisting R4, R5, or R6.On 7/7/2025 at 1:27 pm, CNA AA returned to the Nursing Unit dining room, and within seconds left the dining room to get another meal cart. At 1:29 pm, CNA AA returned to the dining room with the last meal cart. No hand hygiene was observed before passing out meal trays or between passing out meal trays.During an interview on 7/7/2025 at 1:33 pm with CNA AA, they revealed most of the feeders (dependent diners) eat in this dining room. CNA AA said, If I have an itch I scratch it, but that is not good infection control. I should use hand sanitizer in the dining room. With R5, I didn't use hand sanitizer, I did have gloves, but I didn't wear them.During an interview on 7/10/2025 at 9:49 am with the Manager of the Nursing Unit Licensed Practical Nurse (LPN) KK, LPN KK said, staff should wash hands, grab trays, set them up, open everything and offer bites and drinks in between. I would do handwashing when you stop and then wash hands before I start to feed someone again. I would wash again after I touched my face or hair. I would never touch food on a fork. Don't touch food with bare hands. Between residents, you need to wash your hands. If you did not have clean hands, you could contaminate food and make the residents sick.During an interview on 7/10/2025 at 10:01 am with the Director of Nursing (DON) regarding handwashing or hand hygiene, they said, The staff should use hand sanitizer before serving or feeding. During an interview on 7/10/2025 at 2:50 pm, the Administrator and the Regional Director of Operations both said there should have been handwashing between passing trays, and before you fed anyone, or it would be an infection control issue.

Based on observations and resident and staff interviews, the facility failed to promote dignity for one of 14 residents (R) (R 6) who ate in the main dining room. Specifically, R6 was seated at a table with inappropriate height.Findings Include:1. Observation on 7/7/2025 at 12:43 pm, at the second table, two of six residents had meal trays and were eating. R6 was seated at that table, but R6 was upset about not having food and Certified Nursing Assistant (CNA) AA moved R6 to the third empty table that was also upper lip height. Observation on 7/7/2025 at 12:59 pm, R6 was observed sitting in a lowered seat wheelchair eating independently with her upper lip at table height. Observation on 7/7/2025 at 1:18 pm, R6 was seated at a single table at eye level. R6 introduced herself.Interview on 7/7/2025 at 1:33 pm, CNA AA said R6 eats all her food, but her upper lip is almost at table height. R6 should be seated at a smaller table so she can see her food.During an interview with the Director of Nursing (DON) on 7/10/2025 at 10:01 am, she said, We heard through the grapevine that this was a problem on Monday, so we started to fix it on Tuesday. We gave you the policies already for Dignity.During an interview with the Administrator on 7/10/2025 at 2:50 pm, she said R6 should be seated at an adjustable table height, a small table. It's harder for anyone to eat when they cannot see the plate. This is a dignity issue, as she should either be seated with other residents, or if at a table alone, she should be seated at a smaller table. We have adjustable table heights, and we should have adjusted it for her or put her at the smaller table if she was sitting alone.During an interview with the Regional Director of Operations on 7/10/2025 at 2:53 pm, stated, R6 should sit at a smaller table so she can see her food.

Based on observations, staff interviews, record review, and review of the policy titled, Oxygen (O2) Administration, the facility failed to maintain a clean O2 concentrator filter consistent with professional standards of practice for two of 23 residents (R) (R56 and R119) who use O2. The deficient practice had the potential to cause respiratory distress for R56 and R119. Findings include: A review of the facility policy titled Oxygen Administration dated 5/12/2022 and revised on 11/16/2022 revealed in the section titled Care of Concentrator Equipment, number five revealed remove and wash the air filter every seven days, documenting on resident's Medication Administration Record (MAR), Change oxygen (O2) tubing every seven days, documenting on resident's MAR, Wash concentrator with WellStar approved cleaning solution, Change humidifying water bottle weekly, Replace facility approved storage bag once a month or (as needed) PRN, and Check connections and flow setting to assure resident oxygenation every shift and PRN. Review of the electronic medical record (EMR) revealed that R56 was admitted to the facility with diagnoses including, but not limited to chronic obstructive pulmonary disease (COPD), and emphysema. Review of R56's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicates R56 had moderate cognitive impairment with no physical or verbal behaviors exhibited, dependent with extensive assistance for activities of daily living (ADLs) with two-person assistance. Review of R56's care plan dated 4/11/2024 indicated a respiratory problem. Goals included but were not limited to exhibiting no shortness of breath during the next 90 days. Interventions included but were not limited to providing humidification, monitoring for changes in symptoms that may indicate worsening respiratory status, notifying provider of changes, ensuring that supply is available at all times, change tubing per protocol, change O2 Concentrator Set up (nasal cannula (NC) tubing and water) and clean O2 concentrator filter with soap and water weekly on Wednesday and PRN, and administer oxygen therapy as ordered: Oxygen at two liters via nasal cannula at all times. Review of the EMR revealed that the Physician's Orders for R56 included but were not limited to changing the oxygen concentrator setup (NC tubing and water) and cleaning the oxygen concentrator filter with soap and water weekly on Wednesday, as needed, and open back vented area, and wipe with WellStar approved wipes weekly. Review of the EMR for R56 medication orders revealed oxygen is administered at two liters via nasal cannula per physician orders. Observation on 5/21/2024 at 3:18 pm revealed R56's O2 concentrator filter (in rear of unit) was covered with a thick, white substance. Observation on 5/22/2024 at 12:30 pm revealed that R56's O2 concentrator filter was covered with a thick, white substance. Observation on 5/22/2024 at 5:00 pm revealed that R56's O2 concentrator filter was covered with a thick, white substance. Observation and interview on 5/22/2024 at 5:05 pm with the Dementia Unit Manager (UM) HH confirmed the O2 concentrator filter for R56 was covered with a thick, white substance. The Dementia Unit Manager HH revealed that the O2 concentrator maintenance was conducted on the third shift (11:00 pm to 7:00 am), every Wednesday, and as needed per the physician order. However, R56's MAR revealed the O2 concentrator was clean as ordered. She verified and confirmed that the filter was covered with a thick, white substance. She stated that in her professional opinion the filter did not appear to have been cleaned during the previous third shift as indicated on the MAR. Review of the EMR revealed R119 was admitted to the facility with diagnoses including, but not limited to acute respiratory failure with hypoxia. Review of R119's MDS assessment dated [DATE] revealed a BIMS score of six, which indicated R119 had a severe cognitive impairment. R119 requires partial and moderate assistance with ADLs with one or two-person assistance. Review of the care plan dated03/21/2024 for R119 indicated a problem with receiving oxygen therapy. Goals included but were not limited to exhibiting no shortness of breath during the next 90 days. Interventions included but were not limited to providing humidification, monitoring for changes in symptoms that may indicate worsening respiratory status, notifying the provider of changes, ensuring that supply is always available, changing tubing per protocol, and administer oxygen therapy as ordered. Review of the the Physician's Orders for R119 included but were not limited to changing the oxygen concentrator setup (NC tubing and water) and cleaning the oxygen concentrator filter with soap and water weekly on Wednesday, as needed, and open back vented area, and wipe with WellStar approved wipes weekly. Review of the medication orders for R119 were listed but not limited to oxygen is administered at two liters via nasal cannula per physician orders. Observation on 5/21/2024 at 3:24 pm revealed R119's O2 concentrator filter (rear of unit) covered with a thick, white substance. Observation on 5/22/2024 at 12:28 pm revealed that R119's O2 concentrator filter was covered with a thick, white substance. Observation on 5/22/2024 at 5:05 pm revealed that R119's O2 concentrator filter was covered with a thick, white substance. Observation and interview on 5/22/2024 at 5:17 pm with Dementia Unit Manager HH revealed the O2 concentrator filter for R119 was covered with a thick, white substance. Dementia Unit Manager HH revealed that the O2 concentrator maintenance was conducted on the third shift, every Wednesday, and as needed per the physician order. She verified and confirmed that the filter on R119's O2 concentrator was covered with a thick, white substance. She stated that in her professional opinion that this filter did not appear to have been cleaned on the previous third shift as indicated on the treatment administration record (TAR). Interview on 5/22/2024 at 2:36 pm with a Certified Nursing Assistant (CNA) CC, she stated that the Licensed Practical Nurse (LPN) was responsible for assisting residents with their respiratory care needs, which included cleaning the oxygen concentrator filters. Interview on 5/22/2024 at 3:06 pm with LPN JJ verified that the nurse assigned to that resident's hall was responsible for maintaining and cleaning the O2 machine filter, ensuring the nebulizer machine was stored properly when not in use, and keeping the O2 tubing in a bag when not in use. Interview on 5/23/2024 at 9:43 am with the Director of Nursing (DON), she revealed that her expectations of staff caring for residents who receive O2 therapy was that the nurses assigned to these residents were to ensure the O2 concentrators were thoroughly cleaned and the filters were cleaned each week and as needed. She stated that the third shift nurse was responsible for cleaning the O2 concentrator and filters weekly and documenting their activities, but all nursing was responsible to check and make sure the equipment was clean and free of debris.

Based on observation, staff interview, and review of facility documents titled Food Storage and Distribution and Department Policy and Procedure, the facility failed to ensure that the piping under one of one hood and over the stove was without rust and failed to ensure cleanliness of this area underneath the hood over the stove in the kitchen. Findings include: The initial kitchen tour began on 10/1/22 at 8:55 a.m. with the Certified Dietary Manager (CDM) and revealed the following: The pipes that were underneath the hood over the stove were with white sediment on them and with brown corrosion looking material observed on them and not maintained well. During an interview with the CDM on 10/14/22 at 10:10 a.m. it was reported that she expected the area to be cleaned with the hood cleaning that is done once a quarter. Dietary Manager, CDM acknowledged what was seen in the kitchen in regard to pipes over the hood in need of cleaning/repair, but was unable to identify who exactly was responsible for checking to assure that the pipes over the hood in the kitchen were clean and well maintained. A kitchen tour began on 10/20/22 at 9:34 a.m. with the Maintenance Director revealed that he had an email that stated they are changing out the pipes next summer, but the pipes will be addressed to see if they could get a company to put stainless steel in the pipes instead of what they had now, and he further mentioned that it was in next year budget to get all of the rusted pipes replaced. Review of document titled Food Storage and Distribution was dated 2/10/22 and revealed It is the facility policy to store and distribute food and food products in a manner that ensures maintenance of safety and potency while also reducing the likelihood of preventable injury.

Based on observation, record review, and staff interview, the facility failed to individualize and/or implement a resident-centered care plan for six of 41 sampled residents (R) (R#97, R#45, R#70, R#117, R#20, and R#486) related to: activities for R#97; Activities of Daily Living (ADL) for R#45; and related to the restorative services for (R#70) (R#117) (R#20) and (R#486). Findings include: 1. Review of R#97's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the staff did not assess his activity preferences. Review of R#97's care plan revealed a care plan description for a need for customary routine choices to be met with the goal that the resident will have preferences for customary routine offered by staff. The approaches listed in the care plan included participating in favorite activities, participating in religious activities or practices, reading books, newspapers, or magazines, and that the resident enjoys listening to music that he likes. It further noted that he likes to be around animals and enjoys his favorite activities. During an observation on 10/18/22 at 11:12 a.m. and 2:29 p.m.; and 10/19/22 at 9:38 a.m., 11:15 a.m. and 3:11 p.m., R#97 was observed in bed, lights off and privacy curtain closed. Further observation revealed that the television was on at each of these times, but no provision of activities by staff were noted. During an interview and observation on 10/18/22 at 11:12 a.m. with R#97, he stated that he was bored. R#97 if he ever left the room for activities or had activities in the room. R#97 stated that he did not know that the facility had activities. Observation of the room revealed resident did not have an activity calendar on his side of the room. During interview with Certified Nursing Assistant (CNA) NN on 10/19/22 at 12:46 p.m., she stated that R#97 gets up out of bed into a Geri-chair but only stays up for a short period of time because he screams to go back to bed. CNA further stated that other than watching television, R#97 does not engage in any activities. During interview with the Activity Director (AD) on 10/19/22 at 2:26 p.m., she stated that she had two activity assistants and that they are responsible for ensuring that each resident has a current activity calendar. She stated that the assistants are responsible for informing and inviting resident to the group activity on each unit. The AD also stated that the activity assistants were responsible for providing 1:1 activities for residents who do not attend the group. After reviewing R#97's record, the AD further stated the resident has not had an initial or follow up activity assessment completed since admission. During an interview on 10/19/22 at 2:43 p.m. with Activity Assistant SS she revealed that she provides 1:1 activity with residents on the unit who are bedbound and does that attend group activities. She stated that the facility has group activities daily at 10:00 a.m. and 2:00 p.m. She stated that she goes to the resident's room and invites them to the activities and the CNAs on the unit assist resident to group activities. She stated that the scheduled activities are not announced because the residents have a calendar in their rooms and there is a big activity calendar near the dining room. Activity Assistant SS verified that R#97 did not have an activity calendar on his side of the room and agreed that calendar posted on resident's roommates' side of the room is not visible to R#97. Activity Assistant SS stated that the only interaction that she has with R#97 is going by his room from time to time and socializing with him. She confirmed that the resident does not attend group activities. Review of Activity Log Reports printed from the computerized system revealed that R#97 had not attended a group activity after 8/3/22 and did not have any one-to-one activities documented since admission. This was verified with the AD on 10/19/22 at 2:26 p.m. A review of the facility's policy titled Activities with a revision date of 7/8/21 Policy: A. Residents have the right to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility. B. To provide an activities program with services which are suited to the resident's needs, abilities, and interests. Activities provided to residents are appropriate to their needs and capacity to participate. Residents benefit from the activities which are in accordance with their interests. Appropriateness of activities is determined by a consideration of needs. C. Activities are provided in individual and group settings for both ambulatory and nonambulatory residents. 2. Review to the clinical record for R#45 revealed the most recent quarterly MDS assessment dated [DATE] revealed she required total assistance for baths and extensive assistance for personal hygiene. Review of the care plan dated 5/6/21 indicated that R#45 requires assistance with ADLs. Approaches include resident needs extensive assist with bed mobility, dressing, and personal care. Observation and interview with R#45 on 10/18/22 at 11:00 a.m., 10/19/22 at 9:46 a.m. and 4/11/18 at 9:33 a.m. and 11:03 a.m. after a.m. care was provided, revealed that fingernails on both hands are long and untrimmed. She asked surveyor to cut them for her. R#45 told surveyor that she does not desire her fingernails to be that long. She further stated that a girl once came around to trim and polish her nails, but no one comes around to do that anymore. On 10/19/22 at 12:36 p.m. during an interview with CNA NN, she stated the activity department is responsible to trim and polish resident fingernails and confirmed that they do not provide care for residents nails. During an interview with Director of Nursing (DON) on 10/19/22 at 3:01 p.m. she stated that the CNAs are responsible to ensure that all residents nails are cleaned, trimmed, and filed when they are providing showers. She further stated that the activity departments staff assists the CNAs, at times, with polishing nails but the responsibility of nail care is the responsibility of the CNAs. 3. Review of R#70's clinical record revealed that he had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his Quarterly MDS assessment dated [DATE] revealed that he had had functional limitation in (Range of Motion) ROM on one side of the upper and lower extremities. Review of the care plan, initiated 5/27/22, revealed an intervention of Resident is on Restorative Nursing Program (RNP) for Passive Range of Motion (PROM) and Splint. Observations on 10/18/22 at 9:14 a.m., 10/19/22 at 9:53 a.m., 11:38 a.m. and 12:26 p.m. revealed R#70 was not able to completely extend his fingers on his left hand and he did not have any splint or orthotic device in place. Observation of R#70's room revealed signage above his bed with pictures of orthotic devices that read: Daytime left-hand splint ON: after breakfast, OFF after lunch, On (2:00 p.m.), Off after dinner. Passive (ROM) before putting on. Nighttime: Left hand palm protector on at bedtime. Check skin daily for irritation, clean hand splint daily with Sani-cloth, wash palm protector with soap and water and air dry, wash hand with mild soap and water and dry well, Contact Occupational Therapist (OT) with any questions or concerns. Review of nursing notes dated 8/23/22 at 7:05 p.m. revealed that R#70 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Restorative Task revealed the following restorative plan of care - Passive ROM: Passive ROM for knees, ankles and hip flexing and extension. Active range of motion seated in (wheelchair) marches, kicks. Active ROM with (Right Lower Extremities) and (Left Lower Extremities). Active ROM and Active ROM with (Left Lower Extremities) as tolerated . (Physical Therapy) to improve (Left Lower Extremities) function. Splint/Brace: Monitor (Left Lower Extremities) positioning device with application per schedule. During an Interview with Registered Nurse (RN) Unit Manager FF on 10/19/22 at 10:27 a.m. she stated that the restorative CNA was pulled to work another hall today and there was not another restorative CNA scheduled to work. She further stated that the CNAs on the floor were responsible for following the restorative plan of care when the restorative CNA was not available. During an interview on 10/19/22 at 10:40 a.m. with CNA NN, she stated that the CNAs are responsible for doing ROM with ADL care for all residents. She stated that if residents have splints or braces that the CNAs are responsible to ensure that they are applied. She further stated that she was trained by the therapy department to apply the devices. The facility staff put a note in the closet to let us know about the resident's care. She stated that she does not think there are any resident on the hall who require splints at this time. During an interview on 10/19/22 at 10:53 a.m. with LPN OO, he stated that that the restorative and Physical Therapy aides are responsible to perform ROM and apply splints for resident requiring them. He further stated that if the restorative aide is pulled to another floor, the nurses or the CNA is responsible for following the restorative plan of care. He stated that activities and the CNA is responsible to perform the nail care for residents. During an interview with Therapy Manager PP on 10/19/22 at 11:13 a.m. revealed that resident has been on therapy case load and was discharged from skilled services with a restorative plan of care. He further stated that R#70 is not currently receiving skilled services and that the restorative aide should be following the plan of care outline by the therapist. During an interview with DON on 10/19/22 at 3:07 p.m. She stated that the restorative plan of care is developed by the therapy department and the Unit Managers are responsible for inputting the plan of care into the electronic record for the restorative aide to follow. DON stated that currently the facility has 52 residents on the restorative program and has 1 full time restorative aide during the week and 1 restorative aide on the weekend. She further stated that not all the resident receives restorative every day. During an interview with Occupational Therapist on 10/20/22 at 10:20 a.m. she stated and verified that R#70 should be wearing the left-hand splint during the day, every day. She went into the R#70's room and stated that resident does not have the splint on. Splint observed lying in the room on the bedside table. She stated that the nursing staff should apply the splint after breakfast, and it should have already been on at the time of the observation. 4. Review of R#117's clinical record revealed that she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of her care plan, initiated 4/14/22 revealed a care plan description titled Active Assist Range of Motion (AAROM) program/ Restorative with a goal to prevent further ROM loss and an intervention, please see resident for AAROM to bilateral LE for ankle pumps, knee flex/ext, hip flex/ext, hip abd /add x 15 reps each. BUE to tolerance for shoulder flex, elbow flex/ext, finger flex/ext x 10 - 15 reps. Observation and interview with R#117 on 10/18/22 at 11:30 a.m. Resident stated that she no longer receives skilled therapy but is supposed to receive exercises to her arms and legs by therapy, but she is not receiving the services. Resident further stated that her arms and legs are getting stiffer and weaker due to not having the exercises. R#117 stated that her daughter was at the facility earlier today and exercised her legs because the staff at the facility will not do it. Interview with R#117 10/19/22 at 10:07 a.m. resident stated that the staff did not exercise her legs or hands on 10/18/22. She further stated that she is getting so weak. She further stated that her daughter is going to New York and will be away for a week so she will not probably receive any exercises until her daughter returns. R#117 stated I don't know why they don't do what they are supposed to do. Interview with r on 10/19/22 at 2:56 p.m. Resident lying in bed. Resident does not have splints in place. Resident stated that no one has been in her room to perform exercises today. During an interview with Therapy PP, on 10/19/22 at 11:13 a.m. revealed that R#117 has been on therapy case load and was discharged from skilled services with a restorative plan of care. He further stated that resident is not currently receiving skilled services and that the restorative aide should be following the plan of care outline by the therapist. Therapist stated that resident is a long-term resident at the facility and has been on the therapy caseload but is not currently receiving skilled services. He further stated that resident was discharged from therapy with a restorative plan of care that should be followed. A review of the Restorative Roster revealed R#117 that from 8/1/22 through 10/18/22 R#117 had her restorative plan of care documented as the service being provided only 11 days in that period. 5. Observations on 10/18/22 at 11:10 a.m., 10/18/22 at 3:20 p.m., and 10/19/22 at 10:15 a.m. revealed R#20 dressed and sitting in a wheelchair. Resident's right upper extremity (RUE) was positioned closed to body and right hand was clinched into a fist. Resident's right lower extremity (RLE) was positioned in a bent sitting position. Observations revealed two signs posted on the wall above the head of the bed with instructions to apply RUE splint in the morning and remove at bedtime and to apply right knee brace when out of bed. Observations revealed one splint and one knee brace lying on the bedside table. A review of the Restorative Nursing Treatment Plans dated 2/10/22 and signed by the OT, the PT and CNA GG revealed a treatment plan of: Frequency five to seven times per week 1: PROM to RUE 2: RUE weight bearing on rail in hallway with trunk flexion and extension from wheelchair focusing on RUE elongation 3: RUE splint on and clean. Goals: maintain RUE PROM and prevent contractures. Frequency five to seven times per week 1: Please stretch RLE into extension 20-30 second holds for three to five repetitions 2: Place orthotic on for tolerance for maximum of nine hours Goals: Maintain RLE ROM, maintain right knee orthotic four to nine hours per day A review of the care plan included: Description: PROM lower extremity Goal: Maintain ROM and maintain right knee orthotic for four to nine hours a day. Interventions: Stretch RLE into extension 20-30 seconds hold three to five repetitions and place orthotic on for minimum of four hours and maximum of nine hours Description: PROM weight bearing and splint Goal: Maintain RUE PROM and contractures. Interventions: PROM to RUE weight bearing on rail in hallway with trunk flexion/extension on RUE elongation hold on rail by restorative aid and RUE splint on. A record review of the Restorative Roster with date range of 7/19/22 through 10/19/22 revealed restorative nursing services were not provided for a minimum of five days a week every week. An interview on 10/19/22 at 1:20 p.m. CNA GG revealed she is scheduled Monday through Friday to provide restorative nursing services. She revealed she was reassigned on this date to cover CNA duties on 200 Hall. She further revealed she is reassigned to cover CNA hall duties as often as three days a week. She reveals there is one weekday CNA and one weekend CNA trained to provide restorative nursing services in her absences. She further reveals there are days that the CNA assigned to the residents are responsible for providing restorative nursing services due to all restorative CNAs being unavailable. She further revealed any staff that provides restorative nursing services charts in the EMR as completed, refused or other if not provided. She revealed she feels that she is unable to adequately provide ordered restorative services to all residents and she revealed there are currently 53 residents with restorative nursing plans. She revealed she feels that all residents do not receive restorative nursing services in her absences due to the CNAs do not have time to provide restorative services in addition to all other cares. An interview on 10/19/22 at 1:40 p.m. with the DON revealed there are two CNAs trained to provide restorative nursing services and one CNA that is cross trained to provide restorative nursing services if needed. She revealed it is her expectation that the CNAs assigned to the floor provide restorative nursing services if a restorative CNA is unavailable. She revealed it is her expectation for all staff providing restorative nursing services should document services provided every shift in the EMR. Record review of the care plan for R#20 with the DON verified care plan goals and interventions were not followed. Record review of Restorative Roster with date range of 7/19/22 through 10/19/22 with the DON verified that restorative nursing services were not provided for a minimum of 5 days a week every week for R#20. 6. Observations on 10/18/22 at 10:40 a.m., 10/18/22 at 3:10 p.m., and 10/19/22 at 9:15 a.m. revealed R#486 lying in bed on left side. Observations revealed left upper extremity (LUE) positioned close to body in a bent position with hand clenched. Observations revealed one splint lying on the bedside table. Observations revealed a sign on the wall above the head of the bed with instructions to apply splint on left forearm (LFA) in the morning and remove at bedtime. Resident's speech is unclear. A review of the Restorative Nursing Treatment Plans dated 4/20/22 and signed by the OT, the PT and CNA GG revealed a treatment plan of: Frequency five times per week Plan: 1: PROM to LUE as tolerated 2: Monitor LUE resting hand splint as tolerated to wearing schedule Goals: Maintain PROM of LUE A review of the care plan revealed Description: PROM Goal: Will maintain PROM LUE Interventions: PROM to LUE as tolerated (restorative nursing) Hand splints as tolerated (restorative nursing) A record review of the Restorative Roster with date range of 7/19/22 through 10/19/22 revealed restorative nursing services were not provided for a minimum of five days a week every week. An interview on 10/19/22 at 1:20 p.m. CNA GG revealed she is scheduled Monday through Friday to provide restorative nursing services. She revealed she was reassigned on this date to cover CNA duties on 200 Hall. She further revealed she is reassigned to cover CNA hall duties as often as three days a week. She reveals there is one weekday CNA and one weekend CNA trained to provide restorative nursing services in her absences. She further reveals there are days that the CNA assigned to the residents are responsible for providing restorative nursing services due to all restorative CNAs being unavailable. She further revealed any staff that provides restorative nursing services charts in the EMR as completed, refused or other if not provided. She revealed she feels that she is unable to adequately provide ordered restorative services to all residents and she revealed there are currently 53 residents with restorative nursing plans. She revealed she feels that all residents do not receive restorative nursing services in her absences due to the CNAs do not have time to provide restorative services in addition to all other cares. An interview on 10/19/22 at 1:40 p.m. with the DON revealed there are two CNAs trained to provide restorative nursing services and one CNA that is cross trained to provide restorative nursing services if needed. She revealed it is her expectation that the CNAs assigned to the floor provide restorative nursing services if a restorative CNA is unavailable. She revealed it is her expectation for all staff providing restorative nursing services should document services provided every shift in the EMR. Record review of the care plan for R#486 with the DON verified care plan goals and interventions were not followed. Record review of Restorative Roster with date range of 7/19/22 through 10/19/22 with the DON verified that restorative nursing services were not provided for a minimum of five days a week every week for R#486.

Based on observation, record review and staff interviews, the facility failed to ensure that activities of daily living (ADL) were provided for two of 41 sampled residents (R) (R#45 and R#68) related to nail and hair care. Findings include: 1. Review to the clinical record for Resident R#45 revealed the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she required total assistance for baths and extensive assistance for personal hygiene. Review of the care plan dated 5/6/21 indicated that R #45 requires assistance with ADLs. Approaches include resident needs extensive assist with bed mobility, dressing, and personal care. Observation and interview with R#45 on 10/18/22 at 11:00 a.m., 10/19/22 at 9:46 a.m. and 4/11/18 at 9:33 a.m. and 11:03 a.m. after a.m. care was provided, revealed that fingernails on both hands are long and untrimmed. She asked surveyor to cut them for her. R#45 told surveyor that she does not desire her fingernails to be that long. She further stated that a girl once came around to trim and polish her nails, but no one comes around to do that anymore. On 10/19/22 at 12:36 p.m. during an interview with Certified Nursing Assistant (CNA) NN She stated the activity department is responsible to trim and polish resident fingernails we don't do it. During an interview with Director of Nursing (DON) on 10/19/22 at 3:01 p.m. she stated that the CNAs on the floor are responsible to ensure that all residents nails are cleaned, trimmed and filed when they are given their showers. She further stated that the activity departments staff assist the CNAs at time with polishing nails but the responsibility of nail care is the responsibility of the floor staff. A review of the facility's policy titled Shower/Tub Bath, Sub-Category - Personal Care with an effective date August 2007 revealed a required action 1.5 - Trim the resident's toenails or fingernails as instructed by your supervisor. 2. A review of the policy titled, Shower/Tub Bath under Purpose, stated to define a process to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. On 10/18/22 at 10:36 a.m. R#68 observed lying in bed with eyes closed, hair noted to be oily with pimples on forehead. Observation on 10/19/22 at 1:39 p.m. of R#68 who was in bed awake with television on. R#68 hair remains oily and greasy to touch. On 10/19/22 at 11:24 a.m. Staff JJ stated that the resident receives a bath Mondays and Thursdays on the evening shift (3: 00 p.m.-11:00 p.m.), a bath schedule was observed hanging on the wall in the breakroom, the bath schedule did not indicate shampoos to be included during bath/showers. Review of quarterly MDS assessment dated [DATE] Section G revealed that R#68 is totally dependent on staff for all aspects of her personal hygiene which includes combing hair. During an observation on 10/20/22 at 10:15 a.m., R#68 was in bed awake with television on. R#68 hair continued to look oily and greasy. An interview on 10/19/22 at 11:25 a.m. with Unit Manager (UM) II, revealed a bath system in the electronic medical record was labeled Bath Roster where the resident has received bed baths on 10/3/22, 10/6/22, 10/10/22, 10/13/22, 10/14/22 and 10/17/22. UM II further reveals that R#68 did not go to beauty shop for hair shampoos, and that they use a shampoo cap for her hair, however she was not sure when the last time she had received a shampoo of her hair.