Every finding on record at Bradley Home Infirmary/Pavilion

Based on observation, review of facility documentation, facility policy and interview, the facility failed to ensure that the kitchen was maintained in a clean and sanitary manner. The findings include:Based on observation, review of facility documentation, facility policy and interview, the facility failed to ensure that the kitchen was maintained in a clean and sanitary manner. The findings include:Initial tour of the facility kitchen with the Dietary Director on 8/23/26 beginning at 7:33 AM identified the following.Observation of the food prep areas, refrigerator and freezer units, dishwashing area, 3 Bay sink area, food storage areas, cooking and steam table areas, juice and ice areas identified the kitchen flooring had a significant amount of dirt, debris, and staining among. Observation of the floorboards along supporting walls had a thick shiny debris that transitioned from gray to brown to black and appeared to be splattered and adhered to these areas.Observation identified a deep fryer located near the range cooking area appeared to have white partics floating on top of a black liquid which the Dietary Director identified as cooking grease. Debris was noted on the fryer, and around a partial wall the Dietary Director identified a grease drain located within the fryer. Black flying winged insects were observed above the drain during the observation. Observation of the cooking range area also identified debris and grime on the cooking range as well as inside and outside of the ovens.Observation of the facility walk-in refrigerator identified a large metal baker's rack which contained a large metal tray not observable due to its height from the floor. The tray was located directly under the refrigerator compressor fans which were actively blowing during this observation. Observation of the metal tray identified 7 large filets of fish that appeared partially frozen, with no date or labeling. Observation of the refrigerator also identified dirt and debris throughout the flooring areas.Observation of the soiled dishware and dishwashing area identified several small areas of black debris that appeared uniform in size located throughout the flooring of the area. Additional observation of the black debris identified what appeared to be inactive/dead insects, which appeared to be the same type as active black flying winged insects observed throughout the kitchen.Observation of the area directly across from the 3 bay sink identified a second large floor drain with a small amount of debris that appeared to be small vegetable pieces located on the top of a metal grate covering the drain. A large yellow mop bucket was observed to the right of the drain. 5 active flying winged insects were over the drain and one resting on the large yellow bucket.Observation of 2 metal prep tables and shelving, to the right of the cooking area and steam table, identified multiple open containers. Observation of the shelving identified a large open paper container of table salt, an open paper box of light brown sugar, and an open paper box of baking soda. Observation of one of the two metal prep tables identified a one-gallon container of 1% low fat milk that appeared half full located next to a metal container. The Dietary Director identified the container as beverage thickener, which was open with the lid sitting next to the milk. Observation directly across from this prep table identified a second metal prep with 2 white glue type traps located directly on top of one another and positioned underneath the table. Further observation identified 2 large black masses on the traps. Further observation identified the black masses were multiple inactive black winged insects located on multiple areas of the glue traps. Observation of one of the 2 glue traps observed identified a total of 37 inactive black winged insects. An attempt was made to obtain a count of the 2nd larger mass however the mass was much larger and not fully visible due to its position. Interview with the Dietary Director directly following these observations identified that the kitchen is spot cleaned daily however a dietary staff member was responsible for doing a once weekly kitchen cleaning that included sweeping, mopping, sweeping of the walk-in refrigerator and cooler, and thorough cleaning of all of the kitchen equipment. The Dietary Director further identified that a deep cleaning was done at least quarterly of all the kitchen areas and surfaces. A request was then made to provide documentation of both the daily and weekly cleaning for the last three months as well as the quarterly cleaning done.Review of the daily cleaning logs for 6/2026, 7/2026, and 8/2026 failed to identify a daily schedule for any areas of the kitchen. Review of the logs identified several unreadable scribbles under each of the items. The logs also identified individual items were each assigned to be cleaned once weekly (i.e. clean catch drain of juice machine and clean drain of coffee machine on counter; wipe down and clean can opener, wipe down counter by dock door, etc.) was scheduled to be done once weekly on a set day rather than cleansed and sanitized daily. The review of the logs failed to identify a cleaning schedules for weekends, and failed to have any documentation related to specific staff who completed the cleanings with the date and time the cleaning tasks were completed.Observation of kitchen during a follow up tour with the Dietary Director on 8/24/2026 at 7:14 AM identified the kitchen areas observed on 8/23/26 appeared unchanged from the previous observations. Review of a kitchen weekly cleaning log for 8/2026 identified that Dietary Aide #1 completed a full cleaning of the kitchen on 8/24/26. Observation of kitchen during a follow up tour with Dietary Director on 8/25/26 at 8:00 AM identified that identified the kitchen areas identified on 8/23/26 appeared unchanged from the previous observations. Observations and interview with Dietary Aide #1 on 8/25/26 at 8:30 AM identified that while she had started the weekly cleaning list for the kitchen and signed off that all the tasks were completed, she had actually not completed a full cleaning of the kitchen. Dietary Aide #1 identified that she had swept and mopped the walk-in cooler and started to sweep and mop areas of the kitchen flooring, but due to an issue with the facility dishwasher, she had been placed in charge of handwashing all of the dishware for the facility and was unable to address the task on the cleaning list. Dietary Aide #1 also identified that she was the primary person responsible for completing the weekly cleaning but also had other job responsibilities as she also was a dietary aide in the facility.A review of the quarterly deep cleaning logs identified that the last full deep cleaning of all areas of the kitchen was 2/2026. Review of the deep cleaning schedule identified that the meat slicer was last deep cleaned on 2/11/26, the oven was last deep cleaned on 2/2/26, and the walk-in freezer was last deep cleaned on 2/5/26. Further review of the logs identified that the deep fryer was last strained of leftover food and debris on 5/27/26 and failed to identify any actual deep cleaning or draining of the deep fryer, including changing of cooking grease in 2026.Interview with the Dietary Director on 8/25/26 at 8:45 AM identified that she was aware there was an ongoing issue related to cleanliness in the kitchen. The Dietary Director identified she had several staff that were out on leave and that she had been running the kitchen with limited staffing. The Dietary Director further identified that she was aware that one person completing a full weekly cleaning was not enough to upkeep the kitchen cleanliness and that she had also been coming in one extra day a week for 8 hours to try to address the cleanliness and sanitation issues but was unable to identify any specific areas she had addressed. The facility policy on the dietary cleaning schedule directed at it was the responsibility of the dietary department to maintain all areas of the facility's kitchen and related areas in a clean and sanitary manner. The policy further directed that the food service director was responsible to identify, assign, monitor, and manage declining list of their department. The policy also directed that the food service director would monitor and manage daily, weekly, and monthly cleaning schedules by reviewing the cleaning schedules and reviewing that the work had been completed. The food service director should also constantly look for and identify new areas needing attaching and then add those to the cleaning schedule as necessary. The policy also directed that the food service director would retrain individual employees on proper cleaning and sanitizing of specific areas that may not have been completed properly.

Based on observation, review of facility documentation, facility policy and interviews, the facility failed to ensure that the dishwasher was operating within the manufacturer's recommendations and facility policy to ensure proper sanitization temperatures. The findings include:Observation during initial tour of the kitchen with Dietary Director on 8/23/26 beginning at 7:33 AM identified the following related to dishwasher rinse temperatures. Observation of 3 wash and rinse cycles for the dishwasher identified that while the initial wash cycles registered at or above 160 F, two of the three rinse cycles registered below 180 F. Observation of a point above the wash and rinse temperature gauges located on the front of the dishwasher identified the minimum wash temperature was 160 F and the minimum rinse temperature was 180 F. Following the third attempt the rinse temperature registered above 180 F. Review of the dishwasher Temperature Log for 8/2026 identified that on 8/21/26, the rinse temperature in the afternoon registered at 170 F and in the evening registered at 171 F. Further review of the log identified that on 8/22/26 the afternoon rinse temperature was 170 F, and the evening rinse temperature was 173 F. Interview with the Dietary Director immediately following these observations and review of the log identified that she was not aware of any issues related to rinse temperatures for the dishwasher and that she had not worked the prior 2 days. The Dietary Director further identified that while the dishwasher identified minimum wash and rinse temperatures, she had instructed staff to follow the directions of the National Sanitation Foundation (NSF) and referenced an instructional sheet she had posted near the dish machine area. The Dietary Director further identified that the document directed for hot water sanitizing machines a reading of 160 F was sufficient and an indication that the dishware was sanitized. The Dietary Director also identified that the only equipment in the kitchen that had regular preventative maintenance was the facility ice machine which was serviced monthly. Review of documentation and observations of kitchen during a follow up tour of kitchen with Dietary Director on 8/24/26 at 7:14 AM identified continued issues related to dishwasher temperatures. Multiple observations were made of the wash and rinse temperatures. Initial observation identified a wash temperature at 160 F, and with subsequent washing dropping to 155 F over 5 cycles. Rinse temperatures did not reach above 170 F despite multiple wash/rinse cycles. The Dietary Director sent a temperature gauge through the dishwasher (which measures temperatures inside of the dish machine during both wash and rinse cycles). Observation of the temperature on exit was 165.9 F. Further observation of the dish machine and dish machine area also identified a large silver box, which the Dietary Director identified a booster heater for the dish machine. The Dietary Director identified that the Maintenance Director had replaced parts within the booster heater within the last year and since that time there had been no issues with any dishwasher wash or rinse temperatures. Following a request of the facility dishwasher policy and the manual or instructions for the dish machine, the Dietary Director reiterated that the facility followed the NSF recommended field evaluation procedures for commercial dishwashers. Review of the NSF recommendation procedures with the Dietary Director identified that hot water sanitizing machines use a temperature reading of 160 F at dish level, however the same recommendations also directed that the facility should follow close adherence to manufacture's dishwasher identified minimum temperatures of 160 F for wash and 180 F for rinse. Following review of the NSF recommendations, the Dietary Director was unable to identify what the facility policy directed regarding the dishwasher or what the manufacturer's instructions were, and identified she began following the NSF recommendations due to local public health inspections which directed her that use of the NSF recommendations were appropriate for the facility. The Dietary Director then identified that she would request service on the machine and switch over to paper products until service was completed. Interview with Maintenance Director on 8/24/26 at 7:34 AM identified that the Dietary Director was responsible for all calls regarding any maintenance or service for kitchen equipment. The Maintenance Director further identified that he completed a repair to the booster heater by replacing the heating element 2 years ago. The Maintenance Director further identified that the dishwasher was from 1998, and he was not aware of any manual or instructions for its use anywhere in the building. The Maintenance Director identified if the dishwasher had an issue, the Dietary Director would request he look at it, but for small issues only. The Maintenance Director also identified that he was not aware of any preventative maintenance for the kitchen and that the Dietary Director has that responsibility. Follow up observation and interview with the Dietary Director on 8/25/26 at 8:45 AM identified that the dishwasher was not in service, and that the dishware of the facility was being handwashed in the 3 bay sink area. The Dietary Director identified that following service of the dishwasher, an issue was identified in the pipes leading to the dishwasher and the service technician confirmed the dishwasher temperatures were low. The Dietary Director directed that the facility would be following policy and handwashing all dishware until the issue was resolved. Following multiple requests, the facility provided the instruction manual for the dishwasher. A review of the instruction manual identified the minimum wash temperature was 160 F and the minimum rinse temperature was 180 F. The facility policy on the dishwasher directed that the purpose of the policy was to ensure proper sanitary dishwashing with high temperature and low temperature dish machines. The policy further directed that conventional high temperature machines must reach a water temperature in accordance with the manufacturer's specifications for wash and final sanitizing rinse. The policy also directed that dietary staff would record dish machine temperatures on the dish machine temperature log before they begin the dishes from each meal service and any unusual or substandard readings should be reported immediately to the food service director and or cooking supervisor and that corrective action should be taken immediately. Corrective action included discontinuing use of the dishwasher, waiting 10 minutes and recheck temperatures, and if temperatures remain substandard discontinue use of the dish machine and report the concern to the food service director and/or maintenance director. The policy also directed if no contact was made with either the food service director or the maintenance director, staff were to discontinue use of the dish machine and manually wash all equipment and wares.

Based on observation, review of facility documentation, facility policy and interviews, the facility ensure that dietary staff were educated and in-serviced on a new sanitization method including the manufacturer's instructions and facility policy regarding use. The findings include:During an initial tour of the facility kitchen with Dietary Director on 8/23/26 beginning at 7:33AM, observation identified several red buckets throughout the kitchen that did not contain chemical sanitizer. Interview with the Dietary Director immediately following these observations identified the facility had recently switched to a premixed quaternary chemical sanitizing spray for sanitizing food contact surfaces and prep areas. The Dietary Director further identified that dietary staff still used the quaternary chemical sanitizer that required dilution with water that went into the red buckets in the 3-bay sink for pot sanitizing, but the red buckets for cleaning food contact surfaces were no longer being used. Review of the chemical sanitizing spray instructions on the spray bottle identified that for food contact surface sanitization, the spray required contact on a hard nonporous surface for at least one minute to reach 200 parts per million (PPM) to be effective. Interview with the Dietary Director on 8/25/26 at 8:10 AM identified that the facility had recently changed over from quaternary chemical sanitizer that staff would dilute with water into red buckets to a premixed quaternary sanitizing spray sometime in July 2026 and that the facility had not ever used a premixed sanitizing spray prior to that time. The Dietary Director identified that the spray arrived in cases of 6 - 32 oz bottles and she would pull one bottle from the shipping box and check the sanitizing spray with a chemical test strip to ensure it read between 200 and 400 PPM. The Dietary Director identified she would only check one bottle per shipping box and did not track the information. The Dietary Director also identified that she had not provided any instruction to the staff on how to use the sanitizing spray and identified that she believed that the sanitizer needed to be sprayed and then left to air dry in order to sanitize the area that it was being used. The Dietary Director was not sure if the spray should be left to air dry before or after wiping down the area sprayed. Following review of the instructions on the chemical sanitizing spray bottle with the Dietary Director, she identified she had not read any of the instructions on the chemical sanitizing spray and had not provided education to any of the dietary staff regarding its use. The Dietary Director also identified when staff previously used the chemical sanitizer buckets, the staff would wipe down the areas they were cleaning and then left these areas to air dry prior to use, and she assumed the spray worked in the same way. The Dietary Director also identified that she was responsible for ensuring that all the dietary staff were educated on how to use any new sanitizing products utilized in the kitchen to ensure that food preparation areas were sanitized appropriately. The facility policy on sanitizer buckets directed that the purpose of the policy was to provide guidelines and directions relating to proper sanitizing bucket use to maintain sanitary conditions of work areas and equipment. The policy further directed if prepared or purchased sanitizer sprays were used, dietary staff were to follow the manufacturer's instructions explicitly. The policy also directed that cloths that were used with any prepared sanitizers must be stored in sanitizer buckets between uses and refilling of sanitizer buckets would still apply. The policy further directed that sanitizer buckets used for cloth storage would be filled with a quaternary based sanitizing solution and that the solution would be checked to ensure that the sanitizing level was at the correct PPM, logged, and that the sanitizer buckets would be emptied, cleaned and refilled with shift changes, when the sanitizer solution became cloudy or soiled, and after sanitizing raw poultry or meat surfaces.

Based on observation, review of facility documentation, facility policy and interview, the facility failed to have an effective pest control program to ensure that food storage, preparation, and service areas were free of pests. The findings include:During an initial tour of the facility kitchen with Dietary Director on 8/23/26 beginning at 7:33 AM, initial observations identified a significant amount of active black flying winged insects throughout multiple areas. Multiple active black flying winged insects were observed flying through the kitchen food preparation area around the stove and ovens, steam table, dry storage area, ice machine area, dishwashing area, and the 3 bay sinks. Several active black flying winged insects were also observed above a large floor drain, which was located next to a partial wall directly on the opposite side food cooking area. Observation of the cooking area included a large commercial fryer, industrial range, flat top cooking surface, and commercial ovens. Across from the cooking area, a large steam table which had several breakfast items was also observed at the same time as the black flying winged insects were observed above the drain, approximately 4-6 feet from the cooking area and steam table, respectively. Observation of the soiled dishwashing area identified several small areas of black debris that appeared uniform in size located throughout the flooring of the area. Additional observation of the black debris identified what appeared to be inactive/dead insects, which appeared to be the same type as the black flying winged insects observed throughout the kitchen. Observation of the area directly across from the 3 bay sink identified a second large floor drain with a small amount of debris that appeared to be small vegetable pieces which were located on the top of a metal grate covering the drain. A large yellow mop bucket was observed to the right of the drain. Five active black flying winged insects were over the drain and one resting on the large yellow bucket. Observations throughout the kitchen identified several white glue type insect traps directly on top of one another. Observation of 2 traps located directly on top of one another and positioned underneath a metal prep table, to the right of the cooking area and steam table, identified 2 large black masses on the traps. Further observation identified the black masses were multiple inactive black flying winged insects located on multiple areas of the glue traps. Observation of one of the 2 glue traps observed identified a total of 37 inactive black flying winged insects. An attempt was made to obtain a count of the 2nd larger mass however the mass was much larger and not fully visible due to its position. Interview with the Dietary Director immediately following these observations identified that the black flying winged insects had only been present for approximately 4-5 weeks and that the facility had monthly pest control services to address the issue. Interview with Maintenance Director on 8/24/26 at 7:34 AM identified he was aware of issues with the black flying winged insects in the kitchen and that the Dietary Director was responsible for addressing any pest issues in the kitchen. The Maintenance Director further identified that pest control by an outside company was last performed on 8/6/26 but the technician did not have enough contact paper traps per the Dietary Director, and she said additional traps would be brought for the kitchen with next monthly visit in 9/2026. The Maintenance Director further identified that the Dietary Director addressed all service and pest control issues in the kitchen, including any calls that would be needed for additional pest control issues. Observation of kitchen during a follow up tour of kitchen with Dietary Director on 8/24/26 at 7:14 AM identified continued insect activity and black flying winged insects were observed in the dishwasher area, 3 bay sink area, and floor drains previously identified on 8/23/26. Review of pest control invoice logs identified the facility kitchen was treated for pests on 1/8, 2/5, 3/5, 4/2, 5/7, 6/4, 7/2, and 8/6/26. Further review of the logs identified drain treatment for drain flies in the kitchen was provided on 6/4 and 7/2/26. Interview with Pest Control Person #1 (Owner of Company) on 8/24/26 at 8:23 AM identified that Pest Control Person #2 was the technician who provided pest control services to the facility for the past several years, however he was familiar with the issues. Pest Control Person #1 identified that multiple treatments were done for the black flying winged insects however the issue was ongoing due to issues with sanitation and cleanliness. Pest Control Person #1 identified that the flying winged insects were drain flies and that the source of the infestation was related to drains in the facility that contain organic matter that allow flies to breed. Pest Control Person #1 identified that the facility had been instructed multiple times that drains needed to be addressed (cleaned) as pest control only kills adult flies, not eggs or larvae and once drains are addressed, the flies would eventually go away. Pest Control Person #1 identified that the insect larvae life cycle progressed from eggs to adults in 7 days and that Pest Control Person #2 was only contracted to visit the facility once a month. Person #1 also identified that the drains in the kitchen had been treated chemically multiple times, but the treatment only addressed the adult flies, not any larvae or eggs. Pest Control Person #1 identified that the facility must thoroughly clean the kitchen drains to address the pest issue. Interview with Pest Control Person #2 on 8/24/26 at 12:09 PM identified he was the pest control technician assigned to the facility and conducted monthly visits. Pest Control Person #2 identified that the facility had an ongoing issue with drain flies that were primarily in two areas which included a basement bathroom located outside of the facility and the facility kitchen. Pest Control Person #2 identified he had educated the facility multiple times that the drains in the kitchen had to be cleaned with steam and heat due to the life cycle of the drain fly however that this treatment was costly. Pest Control Person #2 also identified he instructed kitchen staff that an alternative treatment using a product called Biogel, a biological degrading agent, could be applied to the kitchen drains, however the treatment had to be applied every night, or it would have no impact. Pest Control Person #2 identified that he also provided fruit fly glue traps to monitor the drain fly activity but were only used to monitor activity and not as a pest control measure. Pest Control Person #2 identified he provided the facility a one-gallon bottle of Biogel to apply to the drains sometime in the past year but based on the pest activity and no staff had ever requested additional bottles, that the treatment was either not being applied at all or not being applied nightly. Observation of kitchen during a follow up tour of kitchen with Dietary Director on 8/25/26 at 8:00 AM identified continued pest activity and black flying winged insects were observed in the dishwasher area, 3 bay sink area, and floor drains previously identified. Observation and interview with the Dietary Director on 8/25/26 at 8:45 AM identified that she was aware there was an ongoing issue related to drain flies however she felt that the monthly pest control visits were sufficient and that she was not aware any additional treatment could be provided. The Dietary Director further identified that she had not inquired if any additional treatment could be done due to the amount of activity and reiterated the activity had only worsened in the last 4-5 weeks. The Dietary Director identified she would speak with the Administrator regarding additional pest control measures including addressing the facility drains. Observations during this interview, which occurred in the Dietary Director's office, located directly across from the kitchen in an office space, identified 2 active black flying winged insects present above the Dietary Director's desk throughout the interview. The facility policy on pest control directed the purpose of the policy was to establish procedures for preventing, identifying, reporting, and addressing pest activity at the facility to maintain a clean, safe, and sanitary environment for residents, employees, and visitors. The policy also directed that dietary staff would be responsible to maintain clean food preparation and storage areas, properly store food, and promptly report any evidence of pest activity. The policy further directed that the facility would have scheduled monthly pest services performed by a qualified test service provider and that additional pest control services would be scheduled when pest activity was identified or recommended by the pest control provider. The policy also directed the facility would take reasonable measures to prevent pest activity which included maintaining clean and sanitary conditions, properly storing food and supplies, and that routine monitoring would include the kitchen, dining areas, and storage rooms. The policy further directed that for food service areas, food and supplies would be stored in a manner that prevented pest access and contamination, and any food suspected of being contaminated by pests would be removed and discarded. The policy also directed that pest control treatments in the kitchen, dining, or food storage areas would be coordinated with a dietary department to prevent contamination of food, equipment, and food contact surfaces.

Based on review of the clinical record, facility documentation, facility policies, and interviews the facility failed to ensure ongoing tracking, monitoring and review of antibiotic use (antibiotic stewardship) and for 2 of 2 residents (Resident #9 and 18) reviewed for prophylactic antibiotic use, the facility failed to ensure ongoing tracking, monitoring and review of the effectiveness, benefits, and risks of the use of prophylactic antibiotic including documentation in the clinical record. Further, the facility failed to complete regular reporting of antibiotic use to medical providers for residents on prophylactic antibiotics. The findings include:1. During a review of the facility's infection control program with RN #1 (Infection Control Nurse) on 8/24/26 9:01 AM a request was made to provide all documentation related to tracking and monitoring of antibiotic use for all residents of the facility who required antibiotic treatments for infections in the facility for 2026. Review of the documentation provided identified a document (72 Hour Antibiotic Time-Out) for multiple residents of the facility. A review of 6 residents included with the documentation identified the following: A 72 Hour Antibiotic Time-Out form completed for Resident #27 on 1/10/26 identified the ordered Azithromycin was changed from 500 mg to 250 mg for 4 days and was started on 1/7/26. The form further identified that a stop date of 1/12/26 (5 days after the 1/7/26 start date) and that the antibiotic was started for symptoms of cough, congestion and wheezing. The form identified that Resident #27 was still having symptoms and that signs and symptoms were improving. Further review of the form included questions under the section (Antibiotic Appropriateness) which asked: Does the resident meet McGeer's Criteria? which was left blank and failed to identify a specific diagnosis related to the need for antibiotic therapy A 72 Hour Antibiotic Time-Out form completed for Resident #20 on 3/12/26 identified the resident was started on Augmentin 500-125 mg for 5 days. The form identified the antibiotic was started due to a skin/wound/cellulitis issue that included symptoms of pain, edema and erythema, without a culture. The form further identified that the resident met McGeer's criteria and that the resident was still having symptoms and that signs and symptoms were improving. Further review of the form failed to identify any additional information or documentation related to a specific diagnosis related to the need for antibiotic therapy, including the location of the skin issue, type of issue, or duration. A 72 Hour Antibiotic Time-Out form completed for Resident #10 on 5/2/26 identified the resident was started on Doxycycline 100 mg for 10 days on 4/29/26 with a stop date of 5/9/26 for symptoms of cough and congestion. The form identified that Resident #10 met McGeer's criteria. Review of the form failed to identify specific diagnosis related to the need for antibiotic therapy. A 72 Hour Antibiotic Time-Out form completed for Resident #36 on 5/17/26 identified the resident was started on Cipro 500 mg on 5/14/26 for 7 days with a stop date of 5/21/26. The form further identified that the resident had a urinary tract infection (UTI) diagnosed on [DATE] which was positive for E-coli with increased confusion with incontinence. The form further identified that the resident met McGeer's criteria and was still having symptoms and that signs and symptoms were improving. A 72 Hour Antibiotic Time-Out form completed for Resident #24 on 7/22/26 identified the resident was started on Macrobid 100 mg for 7 days on 7/19/26 with an end date of 7/26/26 for a urinary tract infection that was E coli positive. Symptoms included dysuria and increased frequency and the form further identified that the resident met McGeer's criteria and was no longer having any symptoms. Review of a separate 72 Hour Antibiotic Time-Out form completed for Resident #24 dated 7/24/26 (2 days after the initial form) identified the resident was started on Zithromax 250 mg on for 4 days on 7/21/26 and ending on 7/26/26 (5 days later). The form further identified the reason the antibiotic was prescribed was related to a UTI, no cultures were done, and the pathogen was related to bronchitis with signs and symptoms that included nasal congestion, wheezing, cough, decreased appetite, and fatigue. The form also identified that Resident #24 met McGeer's criteria, that the resident was still having symptoms, and that signs and symptoms were improving. Further review of the 72 Hour Antibiotic Time-Out forms completed for Resident #10, 20, 24, 27 and 36 identified that all the forms contained a section to be completed by the attending provider with the following questions: Antibiotic prescribed is appropriate. Antibiotics should be discontinued. Change antibiotic to:_____________. Change antibiotic route to: IV, PO. Change duration of antibiotics to: ___________ days of therapy. End date:____. Transmission based precautions: standard, contact, droplet, airborne, none. Other:_________. Review of the forms identified the provider sections were left blank for all residents reviewed. Further review of the forms also failed to identify if the antibiotic therapy was completed for all the residents, if additional interventions were required, and any documentation that signs and symptoms resolved following initiation of antibiotic therapy. Interview with RN #1 on 8/25/26 at 7:00 AM identified that she did not have any other tracking or monitoring data for any residents that required antibiotics for 2026, and that she did not use any standardized method for tracking and monitoring other than the 72 Hour Antibiotic Time-Out form for all residents who required antibiotics in the facility. RN #1 identified she was not involved in determining if a resident was appropriate for antibiotics or providing assistance to the providers in choosing an appropriate antibiotic. RN #1 identified she would typically be notified of an antibiotic start by a staff nurse or during morning report and would research when the antibiotic was started based on that information. RN #1 identified that she would know that she would need to complete the 72 Hour Antibiotic Time-Out form 3 days after the antibiotic was started. RN #1 further identified once she completed the time out form no further documentation or tracking regarding antibiotic use was completed by her, but she would make a mental note when residents started antibiotics based on when she completed the 72 Hour Antibiotic Time-Out form and would periodically review the electronic medical record to determine if the resident had completed the antibiotic course. RN #1 identified she did not have a set standard regarding timeframe or specific residents she would review and did not track any other information including prophylactic antibiotic orders or if any residents were not responsive to antibiotics or required any change in antibiotic treatment. RN #1 identified she was not aware that she should be tracking this information. The facility policy on antibiotic stewardship directed that the Infection Preventionist was responsible for tracking antibiotic use and monitor adherence to evidence-based criteria including: 1. Documentation related to antibiotic selection and use. 2. Tracking antibiotics used to review patterns of use and determination of the impact of the antibiotic stewardship interventions. 3. Monitoring for clinical outcomes such as rates of C difficile infections, antibiotic resistant organisms, or adverse drug events. 4. Reporting of communicable disease by state law. 5. Assisting prescribing practitioners in choosing the right antibiotic using antibiotics (recommend using the AHRQ toolkit) 6. Provide reports related to monitoring of antibiotic usage and resistance data to the QAPI committee. The facility policy on the infection control program directed surveillance data was used to measure effectiveness of the infection prevention control program. The policy also directed the infection prevention program was coordinated and overseen by the Infection Preventionist. The policy further directed that outcome surveillance collected data that indicated the presence of infections, communicable diseases, and antibiotic usage among residents and compared the data to standard definitions and criteria. The policy also directed that regarding antibiotic stewardship, culture reports, sensitivity data, and antibiotic usage reviews were included in surveillance activities and that clinical criteria and standardized definitions of infections would be used to help recognize and manage infections. 2. Resident #9 was admitted to the facility in December 2023 with diagnoses that included dementia, cerebrovascular accident, and cerebral infarction. The nurse's note dated 12/8/23 at 5:21 PM identified Resident #9 transferred from the residential care home to the facility at 8:30 AM related to a decline in health and ADL's with the family's consent. A urine sample was obtained for a urinalysis (UA) and culture and sensitivity (C&S). An active physician's order dated 12/8/23 directed to administer Macrobid (an antibiotic used to treat bladder infections and lower urinary tract infections) 100 mg in the morning for prophylaxis. The order note dated 12/8/23 identified this order was outside of the recommended dose or frequency: Macrobid Oral Capsule 100 mg give 1 capsule by mouth in the morning for prophy- This dose failed a general dose range check based on drug inputs and/or the patient information provided. This drug`s dose should be adjusted based on renal function. Manual screening was required. The initial medical evaluation visit dated 12/14/23 at 10:30 AM identified Resident #9 needed care in skilled level and had a history of dementia. hypertension, hyperlipidemia, GERD. osteoarthritis, UTI, The quarterly MDS dated [DATE] identified Resident #9 had severely impaired cognition, was frequently incontinent of bladder and always incontinent of bowel and was taking medication from the following high-risk drug classes; antibiotic and diuretic. The care plan dated 6/25/26 identified Resident #9 had an alteration in bladder with potential for alteration in bowel related to decreased motility, with interventions that included continuing prophylactic antibiotic for UTI. Review of the MAR July through August 2026 identified Macrobid 100 mg was administered in accordance with the physician's order. Review of the clinical record failed to identify the following documentation: a planned stop/review date, intended duration, renal and hepatic considerations, evaluation of reversible UTI causes, non-antibiotic strategies, evidence supporting the use of a prophylactic antibiotic, a periodic review of prophylactic antibiotic use, and Resident #9's response to the prophylactic antibiotic. Review of the clinical record and facility documentation with the Infection Preventionist (RN #1) on 8/23/26 at 1:48 PM failed to identify antibiotic tracking and regular reporting on antibiotic use to the medical providers was being completed. Interview with RN #1 on 8/24/26 at 6:28 AM identified that Resident #9 had a history of recurrent UTIs, was comfort measures, and was already taking Macrobid for prophylaxis upon admission. Resident #9's family was very involved in his/her care, and they requested that Resident #9 remain on the prophylaxis antibiotic, but RN #1 did not recall providing education to Resident #9 or his/her resident representative on non-antibiotic approaches or the use of long-term prophylactic antibiotics, including the risks. RN #1 indicated that Resident #9's prophylactic antibiotic regimen was overseen by the facility's medical providers, and he/she had not had any consultations with specialty providers such as Urology or Infectious Disease. RN #1 identified that Resident #9's past medical history of recurrent UTI's and cystitis were the evidence-based indications for continuing prophylactic antibiotic use, and that she had taken for granted that when the medical providers completed their regulatory reviews and medication reconciliations that the prophylactic Macrobid was reviewed then. RN #1 further identified that she sees Resident #9 daily, and that Resident #9 had not had any UTIs or experienced side effects while taking the prophylaxis antibiotic, but she had not been formally monitoring or tracking Resident #9's prophylactic antibiotic use as part of the antibiotic stewardship program or reviewing Resident #9's prophylactic antibiotic use with the prescribing medical providers or the IDT. RN #1 indicated that moving forward she would reeducate Resident #9's resident representative on the use of long-term antibiotics, begin monitoring and tracking Resident #9's prophylactic Macrobid, and reviewing the data with the medical providers. Interview with the DNS on 8/24/26 at 7:34 AM identified that she was aware that Resident #9 was on prophylactic Macrobid and believed the necessity of the antibiotic use was being reviewed when the medical providers completed their medication reviews during their medical visits or a change in condition. Monitoring and tracking as part of the Antibiotic Stewardship program was not being completed for Resident #9. The DNS indicated that moving forward medical providers and the IP would review the use of prophylactic antibiotics more comprehensively as part of the 60-day review. The DNS further indicated that she was not sure if education had been provided to Resident #9 or his/her resident representative on the long-term use of antibiotics. The DNS further indicated that she would expect education to include a discussion of risks and benefits of long-term antibiotic use, alternative options, discussions on discontinuing the antibiotics, and the risk of antibiotic resistance. 3. Resident #18 was admitted to the facility in October 2025 with diagnoses that included dementia and a history of UTIs. The APRN Note dated 11/28/25 at 8:00 AM identified Resident #18 was evaluated for ongoing confusion and reaching at objects and hallucinating. Resident #18 denied focal urinary symptoms, new urinalysis results for review, given there were no signs of acute urosepsis, await culture. No empiric antibiotics at this time. Risperdal that was initiated by psych and continued to be on hold pending likely treatment for UTI. Previously, Resident #18 was evaluated on 11/26/25 for follow-up on 72-hour UTI monitor per staff. At that time, Resident #18 was having hallucinations, reaching in the air for things that were not there, and his/her family reported increased confusion. A straight catheter urinalysis (UA) and culture and sensitivity (C&S) were ordered to rule out underlying infection as cause of altered mental status. The nurses note dated 11/29/25 at 2:23 PM identified Resident #18's urine culture result was reported to the medical APRN with orders to administer Bactrim DS Oral Tablet 800-160 mg every 12 hours for >100,000 E. coli in urine for 7 Days. The nurses note dated 12/4/25 at 1:52 PM identified Resident #18 was being treated for a UTI, at present. Per conversation with Resident #18's representative, Resident #18 has had 4 UTIs in the last few months which have resulted in multiple falls, injuries, and behavioral disturbances like hallucinations. Resident #18 has returned to baseline mentation with current treatment. Discussed with the Medical Director if a prophylactic antibiotic would be appropriate, Macrobid once daily ordered. A current physician's order dated 12/25/25 directed to administer Macrodantin (an antibiotic used to treat bladder infections and lower urinary tract infections) 50 mg daily related to other symptoms and signs involving cognitive functions and awareness and UTI prophylaxis. The quarterly MDS dated [DATE] identified Resident #18 had moderately impaired cognition, was frequently incontinent of bladder and bowel, and was taking medication from the following high-risk drug classes: antidepressant, anticoagulant, antibiotic and diuretic. The care plan dated 7/30/26 identified Resident #18 was at risk for UTI secondary to history of chronic UTI, with interventions that included prophylactic antibiotic for UTI and to administer the antibiotic as ordered and labs as ordered. Review of the MAR July 2026 through August 2026 identified Macrodantin 50 mg was administered in accordance with the physician's order. Review of the clinical record failed to identify the following documentation: a planned stop/review date, intended duration, renal and hepatic considerations, evaluation of reversible UTI causes, non-antibiotic strategies, a periodic review of prophylactic antibiotic use, and Resident #9's response to the prophylactic antibiotic. Review of the clinical record and facility documentation with RN #1 on 8/24/26 at 1:11 PM failed to identify antibiotic tracking and regular reporting on antibiotic use to the medical providers was being completed. Interview with RN #1 on 8/24/26 1:11 PM identified Resident #18 was transferred to this facility from another skilled nursing facility and had a few UTIs there, and following the UTI in November of 2025, he/she was started on the Macrodantin prophylactically. RN #1 did not recall providing education to Resident #18 and his/her resident representative on the use of long-term prophylactic antibiotics, including the risks or non-antibiotic approaches. RN #1 indicated that Resident #18's prophylactic antibiotic regimen was overseen by the facility's medical providers, and he/she had not had any consultations with specialty providers. RN #1 identified that she had taken for granted that when the medical providers completed their regulatory reviews and medication reconciliations that the prophylactic Macrodantin was reviewed at that time. RN #1 further identified that Resident #18 had not had any UTIs or experienced side effects while taking the prophylaxis antibiotic, but she had not been formally monitoring or tracking Resident #18's prophylactic antibiotic use as part of the antibiotic stewardship program or reviewing Resident #18's prophylactic antibiotic use with the prescribing medical providers or the IDT. RN #1 indicated that moving forward she will reeducate Resident #18's family on the use of long-term antibiotics, begin monitoring and tracking Resident #18's prophylactic Macrodantin, and review the data with the medical providers. Interview with the DNS on 8/24/26 at 4:16 PM identified that Resident #18 was living independently a year ago but was sent to another skilled nursing facility. The DNS further identified that while Resident #18 was at the other facility he/she had horrible UTIs that resulted in falls with injuries and hallucinations. The DNS indicated that after Resident #18's most recent UTI with hallucinations, in November of 2025 at this facility, she discussed putting Resident #18 on Macrodantin prophylactically, with the previous Medical Director and educated Resident #18 and his/her family on the risks of long-term use of an antibiotic. Since Resident #18 has been on the antibiotic, he/she has not had any UTIs. The DNS indicated that it did not cross her mind that residents on prophylactic antibiotic treatment regimens should also be tracked as part of the Antibiotic Stewardship Program, but moving forward she would ensure that the necessity for use of the prophylactic antibiotic would be reviewed during the medical providers 60-day medical visits and medication review, and the IP would be included in that process. Interview with the Medical APRN (APRN #1) on 8/25/26 at 10:06 AM identified that she had begun working at the facility in May of 2026 and she was not the original prescribing provider for Resident #9 or 18's prophylactic antibiotics. APRN #1 indicated she had not completed any reevaluation for the necessity of Resident #9 or 18's prophylactic antibiotics nor had she participated in a QAPI or Medical Staff meeting, and she did not know if a review of prophylactic antibiotics was completed at that time. Interview with the Medical Director (MD #1) on 8/25/26 at 10:08 AM identified that the decision to implement prophylactic antibiotics for the management of recurrent UTIs was individualized based on an individual resident's risk verses benefit analysis, with the goal to minimize risk, promote comfort, and quality of life. MD #1 indicated that he did not have immediate access to Resident #9 and #18's clinical record, but both Residents #9 and #18 were doing well on their respective prophylactic antibiotics, had no recurrent UTIs since prophylactic treatment was initiated, and no side effects had been reported or identified. MD #1 further indicated that the Urology community also supports the use of prophylactic antibiotics in certain cases to optimize quality of life. MD #1 identified that the use of antibiotics was reviewed during the Medical Staff meetings as part of the Antibiotic Stewardship Program, but he was not sure if Resident #9 and #18's specific cases were reviewed during those meetings. MD #1 further identified that since Residents #9 and 18 were doing well and have not had any acute UTIs in the setting of the prophylactic antibiotics, he would not alter the treatment unless the resident developed a UTI while on the treatment, as that would be an indicator that antibiotic resistance was developing. The Antibiotic Stewardship policy directs that antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics in the facility's residents. Training and education would include emphasis on the relationship between antibiotic use and gastrointestinal disorders, opportunistic infections (C. difficile, Candida albicans, etc.), medication interactions, and the evolution of drug-resistant pathogens. The Antibiotic Stewardship-Review and Surveillance of Antibiotic Uses and Outcomes policy directs that antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form. The data would be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics would undergo review by the IP or designee, review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with appropriate use of antibiotics. All resident antibiotic regimens will be documented on the facility approved antibiotic surveillance tracking form. The information gathered would include resident, medical record number, unit and room, date of symptoms, name of antibiotic, start date of antibiotic, pathogen identified, site of infection, culture, stop date, total days of therapy, outcome, and adverse events. The Antibiotic-Prophylaxis policy directs that its purpose is to prevent infections when evidence based antibiotic prophylaxis was indicated and to minimize unnecessary antibiotic exposure, C difficile, and adverse drug reactions in antimicrobial resistance. Antibiotic prophylaxis may be initiated only for clearly documented clinical indications, the prescriber must document the indication, selected antibiotic, dose, duration, allergies, renal considerations, and planned stop/review dates, prophylaxis should be reviewed routinely and discontinued when the indication no longer exists. Examples of appropriate indications include certain surgical dental procedures when guideline-based prophylaxis is indicated, selected residents with recurrent urinary tract infections when a qualified clinician determines that prophylaxis is appropriate after evaluation of reversible causes and non-antibiotic strategies, and other narrowly defined indications according to current specialty guidelines. Prescribing requirements include verifying allergy history, reviewing recent cultures and antibiotic exposure, considering renal/hepatic function in drug interactions, using the narrowest appropriate agent, specifying the duration and stop date, and obtaining cultures when clinically appropriate rather than treating colonization. Monitoring included monitoring for allergic reactions, adverse effects, C difficile infection, drug interactions, and emergence of resistant organisms. Pharmacy/infection prevention should periodically review prophylactic antibiotic use, and tracking antibiotic days of therapy and indications as part of the facility's antimicrobial stewardship program. Documentation should include clinical indication, evidence supporting prophylaxis, medication /dose/route, start date and intended duration, stop/review date, culture information when applicable, and resident response and adverse effects.

Based on observation, review of the clinical records, facility documentation, facility policy, and interviews for 4 of 4 residents (Residents #22, 25, 27 and 34) reviewed for restraints, the facility failed to ensure individualized assessments and reassessments were completed per the facility policy for residents utilizing bed and chair alarms. The findings include:1. Resident #22 was admitted to the facility in October 2019 with diagnoses that included Alzheimer's disease, vertigo, and overactive bladder. The quarterly MDS dated [DATE] identified Resident #22 had severely impaired cognition, was able to express ideas and wants, understood verbal content, normally utilized the following mobility devices: a walker and a wheelchair, required partial/moderate assistance with toilet transfers and walking 10 feet and 50 feet with 2 turns, and used a bed alarm and chair alarm daily. The care plan dated 6/4/26 identified Resident #22 was at risk for falls related to osteoarthritis, vitreous degeneration, lumbago with sciatica, SVT, pulmonary hypertension, Alzheimer's disease, and overactive bladder. Interventions included toileting every 2 hours and as needed, keeping the call light within reach, and utilizing a bed/chair alarm (initiated on 9/15/24 and revised on 5/28/25). A physician's order dated 8/7/26 directed to use a bed and chair alarm at all times when in bed/chair, check placement and function every shift. Review of the clinical record failed to identify a documented assessment, according to the Fall Prevention Alarms policy, for the need of the bed/chair alarm, including the resident's ability to respond appropriately to the alarm, if the resident would benefit from the alarm, and reassessments after a fall, significant change, or repeated alarm activation. Interview with the DNS on 8/24/26 at 3:58 PM identified that currently there was no standardized assessment being completed on residents prior to implementing a bed/chair alarm as a fall prevention intervention. The DNS further identified that prior to implementing a bed/chair alarm education was always provided to the resident and resident representative, in the event that the resident or family did not want to use the alarm, a different intervention would be implemented. Subsequent to surveyor inquiry, the DNS indicated that the facility identified the need to complete and document initial and on-going assessments for the use of the bed/chair alarms to ensure criteria were being met for the intervention. The DNS further indicated that Resident #22 had sustained a fall with a major injury on 8/23/25, had a history of falls, did not use the call bell, had continued to attempts to ambulate independently without his/her walker, had poor safety awareness, and a lack of awareness for the need for assistance. Other fall prevention interventions that were in place for Resident #22 were frequent rounding, placement in the common area, diversional activities, offering snacks and drinks, offering puzzles, offering to ambulate, and toileting after meals, after waking and times when he/she would potentially get up. 2. Resident #25 was admitted to the facility in January 2025 with diagnoses that included CHF, irritable bowel syndrome with diarrhea, and overactive bladder. A physician's order dated 1/20/26 directed the use of a bed/chair alarm at all times when in bed/chair, check function and placement every shift. The quarterly MDS dated [DATE] identified Resident #25 had moderately impaired cognition, was able to express ideas and wants, understood verbal content, normally utilized the following mobility devices: a walker and a wheelchair, required partial/moderate assistance with toilet transfers and walking 10 feet and 50 feet with 2 turns, and a bed alarm and chair alarm were not used. The care plan dated 8/6/26 identified Resident #25 was at risk for falls related to weakness, history of falls, poor safety awareness, and forgetfulness. Interventions that included keeping frequently used items within reach, keeping walkways/pathways/room free of clutter, and using a bed/chair alarm (intervention initiated on 11/6/25). Review of the clinical record failed to identify a documented assessment, according to the Fall Prevention Alarms policy, for the need of the bed/chair alarm, including the resident's ability to respond appropriately to the alarm, if the resident would benefit from the alarm, and reassessments after a fall, significant change, or repeated alarm activation. Interview with the DNS on 8/24/26 at 3:58 PM identified that currently there was no standardized assessment being completed on residents prior to implementing a bed/chair alarm as a fall prevention intervention. The DNS further identified that prior to implementing a bed/chair alarm education was always provided to the resident and resident representative, in the event that the resident or family did not want to use the alarm, a different intervention would be implemented. Subsequent to surveyor inquiry, the DNS indicated that the facility had identified the need to complete and document initial and on-going assessments for the use of the bed/chair alarms to ensure criteria were being met for the intervention. The DNS further indicated that Resident #25 had sustained a fall with a major injury on 8/31/25, had repeated falls, did not use the call bell, did not use his/her walker as prescribed, overestimated his/her limits to get up on his/her own, had periods of altered mental status, and liked to [NAME] around his/her room without calling for assistance. Other fall prevention interventions that were in place for Resident #25 included frequent rounding, offering snacks and drinks, offering puzzles, offering to ambulate, toileting after meals, after waking and times when he/she would potentially get up, and the facility offered to put a card table in the resident's room so Resident #25 could have his/her papers in close proximity, but the family declined. 3. Resident #27 was admitted to the facility in March 2025 with diagnoses that included dementia, urinary retention, and a history of falls. A physician's order dated 3/18/26 directed to utilize a bed/chair alarm while in the bed/wheelchair every shift. The quarterly MDS dated [DATE] identified Resident #25 had moderately impaired cognition, was able to express ideas and wants, understood verbal content, normally utilized the following mobility devices: a walker and a wheelchair, required partial/moderate assistance with toilet transfers, was able to wheel 150 feet in a manual wheelchair, and used a bed alarm and chair alarm daily. The care plan dated 7/21/26 identified Resident #27 was at risk for falls related to decreased mobility, history of falls, and weakness, with interventions that included keeping frequently used items and the call light within reach and the placement of a bed alarm while in bed (initiated on 7/8/25). Review of the clinical record failed to identify a documented assessment, according to the Fall Prevention Alarms policy, for the need of a bed/chair alarm, including the resident's ability to respond appropriately to the alarm, if the resident would benefit from the alarm, and reassessments after a fall, significant change, or repeated alarm activation. Interview with the DNS on 8/24/26 at 3:58 PM identified that currently there was no standardized assessment being completed on residents prior to implementing a bed/chair alarm as a fall prevention intervention. The DNS further identified that prior to implementing a bed/chair alarm education was always provided to the resident and resident representative, in the event that the resident or family did not want to use the alarm, a different intervention would be implemented. Subsequent to surveyor inquiry, the DNS indicated that the facility had identified the need to complete and document initial and on-going assessments for the use of the bed/chair alarms to ensure criteria were being met for the intervention. The DNS further indicated that Resident #27 had sustained a fall with a major injury on 11/18/25, had a history of falls, did not use the call bell and had a lack of awareness for the need for assistance. Other fall prevention interventions that were in place for Resident #27 included frequent rounding, PT/OT services placement in the common area, diversional activities, watching movies in the common area, offering snacks and drinks, offering to ambulate, keeping his/her bed low to the floor, and toileting after meals, after waking and times when he/she would potentially get up. The Fall Prevention Alarms policy directs that the facility assess for the need of bed/chair alarms to reduce the risk of unassisted bed exits and falls, and to promote resident safety while maintaining dignity, mobility, and least-restrictive care. Indications include individualized assessments that identify a risk of falling or unsafe bed exit, the resident has demonstrated repeated unsafe attempts to leave the bed, and the alarm is part of the resident's care plan and is clinically appropriate. Alternatives before/alongside the alarm include scheduled toileting, pain management, appropriate bed height, call bell placed within reach, adequate lighting, frequently used items within reach, rounding/observation, appropriate footwear, mobility assistance, and environmental modifications. Assessments include an assessment of the resident's fall history, cognition, mobility, toileting needs, medications, behavior, and ability to respond appropriately to the alarm, to determine whether the alarm actually benefits the individual resident, and reassessing after a fall, significant change in condition, repeated alarm activation, or change in mobility/cognition. Remove the alarm when the risk/clinical indication no longer exists or when it is ineffective or causing unintended consequences; reassess after discontinuation. 4. Resident #34 was admitted to the facility in May 2026 with diagnoses that included difficulty walking and cognitive communication deficit. The Morse Fall Scale dated 5/8/26 identified Resident #34 was at high risk for falls. The admission MDS dated [DATE] identified Resident#34 was severely cognitively impaired, required one person assist with bed mobility, transfers, had an unknown fall history and utilized bed and chair alarms daily to monitor and alert staff when movement was detected. Physician's order dated 5/15/26 directed to utilize a bed and chair alarm at all times while in bed and chair, check placement and function every shift. The care plan dated 5/21/26 identified Resident #34 was at risk for falls due to poor safety awareness and cognitive memory loss. Interventions included redirection as needed and utilize bed and chair alarms at all times, monitoring placement and function every shift. Resident #34 was subsequently admitted to the hospital from [DATE] through 5/26/26 for diagnosis and treatment of pneumonia. Physician's orders dated 5/26/26 directed bed and chair alarms for safety, check placement and function every shift. Resident #34 was subsequently admitted to the hospital from [DATE] through 8/22/26 for diagnoses that included cirrhosis of the liver and urinary tract infection. Physician's order dated 8/23/26 directed bed and chair alarms for safety, check placement and function every shift. Review of physician and nursing progress notes dated 5/8/26 through 8/24/26 lacked documentation of any falls, failed interventions or initial assessment supporting the need for a position change alarm when implemented or its continued use. Observation on 08/23/26 between 1:30 PM and 2:20 PM identified Resident #34 sitting in a recliner chair with a chair alarm pad in place beneath him/her and made no attempts to get up. Interview and review of the clinical record with the DNS on 8/23/26 at 2:34 PM identified the use of positioning devices is a last resort intervention when other measures were ineffective. The DNS indicated the interdisciplinary staff discuss the implementation and continued use during meetings but an initial assessment is not documented. The DNS further identified criteria for removal included improved impulsivity in attempts to get up, functional status becomes independent and residents' are alert and oriented and do not want the device. The DNS could not show attempts to reduce the use of and eventual discontinuation of a positioning device in the absence of a documented assessment, tracking and re-assessment. Interview with NA #3 identified on 8/24/26 at 6:07 AM identified she was new to the facility and assigned to the 11:00 PM to 7:00 AM shift and worked with Resident #34 since his/her readmission to the facility. NA #3 indicated Resident #34 was very confused with poor safety awareness and attempted to get up often during the shift usually because he/she needs incontinent care or requested an adjustment in clothing. Once the task is complete, Resident #34 will go back to sleep. Interview with RN #1 and clinical record review on 8/24/26 at 6:10 AM identified Resident #34 was confused with poor safety awareness and that every intervention was attempted prior to the initiation of the positioning alarms. RN #1 also indicated the implementation and continued use of the positioning alarms were discussed between the interdisciplinary team and should be documented in the progress notes. RN #1 was unable to provide documentation of failed interventions, any falls, or assessment for the implementation of and continued use for the positioning alarms. Observation on 8/24/26 between 6:20 AM and 7:30 AM identified Resident #34 lying in bed with a bed alarm pad in place beneath him/her and made no attempts to get up. Observation on 8/25/26 between 8:10 AM and 8:45 AM identified Resident #34 sitting in a recliner chair with a chair alarm pad in place beneath him/her with staff at bedside during a meal making no attempts to get up. Review of the facility policy for Fall Prevention Alarms dated 6/2023 identified the policy was to be followed to assess the need for bed/chair alarms to reduce the risk for unassisted bed exits and falls and promote resident safety. Indications for use include an individualized assessment identifying the risk of falling or unsafe bed exit, demonstration if repeated unsafe attempts to leave the bed and the alarm is part of the resident's care plan and clinically appropriate. Alternatives to be initiated before and alongside the alarm include scheduled toileting, pain management, appropriate bed height, ensuring the call bell is within reach, adequate lighting, ensuring frequently used items are within reach, rounding and observation appropriate footwear, mobility assistance, environmental modifications. The assessment should include a fall history, cognition, mobility, toileting needs, medications with behavior and ability to respond appropriately to the alarm. Determine whether the alarm benefits the individual resident, reassess after fall significant change of condition, repeated alarm activation or change in mobility or cognition The device is to be implemented after obtaining an appropriate practitioner order according to facility policy and applicable regulations, educate the resident and family representative when appropriate, place the alarm according to manufacturer instructions, test the alarm after installation and routinely thereafter, ensure staff can hear and receive the alarm with a resident is located and ensure the alarm does not create a tripping entanglement or other safety hazard. Staff are to respond promptly to every activation, determine why the resident is attempting to get out of bed, address the underlying need rather than simply resetting the alarm and document clinically significant findings and interventions. Care planning should include documentation for the reason of use, resident specific goals, interventions attempted, monitoring and include the intervention in the resident comprehensive care plan when indicated. Discontinuation of the alarm occurs when the risk or clinical indication no longer exists, when it is ineffective or causing unintended consequences reassess after discontinuation.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #16 and 20) reviewed for vaccinations, the facility failed to ensure that the residents were offered and/or provided education to consent or refuse the influenza and pneumococcal vaccinations. The findings include.During a review of the facility infection prevention program as part of an annual recertification survey on 8/24/26 at 9:01 AM, a request was made to RN #1 (Infection Control Nurse) to provide documentation for influenza and pneumococcal vaccinations or signed refusals with education for a list of 5 sampled residents (Resident #13, 16, 17, 20, and 24). Although requested, the facility failed to provide documentation that Resident #16 or his/her resident representative was provided education or offered the pneumococcal vaccination. Although requested, the facility failed to identify documentation that Resident #20 or his/her resident representative was provided education or offered the pneumococcal vaccination. Review of the clinical record documentation identified Resident #20 received the influenza vaccination on 10/22/25. Further review of the clinical record failed to identify documentation that Resident #20 or his/her resident representative had been provided education on or provided consent to receive the influenza vaccination. Review of the clinical record failed to identify documentation that Resident #20 or his/her resident representative had provided education or offered the pneumococcal vaccination. Interview with RN #1 on 8/25/26 at 7:00 AM identified that following a review of the vaccinations, she realized she did not offer Resident #16 or 20 the pneumococcal vaccination. Additionally, RN #1 identified that she routinely did not obtain signed consents or refusals for vaccinations and rather would review risk versus benefit with the resident or resident representatives by phone and may have forgotten to document education and consent for Resident #20's influenza vaccination. RN #1 identified that the consent for any vaccine should be documented and it was her practice to review risk versus benefit with all residents. The facility policy on influenza vaccinations identified that prior to the vaccination the resident or the resident's legal representative would be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education should be documented in the medical record. The policy also directed that a resident's refusal of the vaccine should be documented on the informed consent for the influenza vaccine and placed in the resident's medical record. The policy on pneumococcal vaccinations directed that all residents would be offered pneumococcal vaccinations to aid in preventing pneumonia and pneumococcal infections. The policy further directed that prior to or upon admission, residents were assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, were offered the vaccine after admission to the facility unless medically contraindicated or the resident had completed the current recommended vaccine series. The policy also directed that before receiving the pneumococcal vaccination, the resident or legal representative would receive information in education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education would be documented in the residents medical record. The policy also directed that residents and representatives had the right to refuse the vaccination. If refused, appropriate information would be documented in the resident's medical record indicating the date of the refusal of the pneumococcal vaccination.

Based on clinical record reviews, facility documentation, facility policy and interviews for three (3) of three (3) sampled residents (Residents #1, #2 and #3) who were reviewed for the use of antipsychotic medication, the facility failed to ensure the resident's targeted behaviors were being monitored. The findings include:1. Resident #1's diagnoses included bipolar disorder, depressive episodes and Alzheimer's disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) indicating Resident #1 had some memory recall deficits. The Resident Care Plan dated 12/23/25 identified Resident #1 received an antipsychotic medication related to a diagnosis of bipolar disorder. Interventions included observing for target behaviors of excessive crying and suicidal ideation. A physician's order initiated on 11/25/25 directed to administer Aripiprazole 5 mg by mouth in the morning for bipolar disorder and on 1/13/26 Aripiprazole was decreased to 2 mg. A physician's order dated 1/21/26 directed to increase the Aripiprazole back to 5 mg at bedtime. Review of the January 2026 and February 2026 Medication Administration Records failed to reflect documentation targeted behaviors were monitored every shift related to the use of the Aripiprazole. 2. Resident #2's diagnoses included schizophrenia, major depressive disorder and anxiety disorder. A physician's order dated 6/9/25 directed to administer Clozaril 25 milligram (mg) and 50 mg to equal a total dose of 75 mg to be given by mouth daily at bedtime for schizophrenia. The annual Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating Resident #2 had no memory recall deficits. The Resident Care Plan dated 11/25/25 identified Resident #2 received psychotropic medication related to diagnoses of schizophrenia and depression. Interventions included observing for target behaviors of paranoia, delusions, and hallucinations. Review of the January 2026 and February 2026 Medication Administration Records failed to reflect documentation targeted behaviors were monitored every shift related to the use of the Clozaril. 3. Resident #3's diagnoses included dementia with behavioral disturbances and cognitive communication deficit. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) indicating Resident #3 had some memory recall deficits. A physician's order dated 11/21/25 directed to administer Rexulti one (1) mg by mouth one (1) time a day related to dementia with behavioral disturbances. The Resident Care Plan (RCP) dated 12/2/25 identified that Resident #3 utilizes psychotropic medication related to diagnoses of dementia and depression. Interventions included observing for targeted behaviors. Review of the January 2026 and February 2026 Medication Administration Records failed to reflect documentation specific targeted behaviors were monitored every shift related to the use of the Rexulti. Interview with the psychiatric Advanced Practice Registered Nurse (APRN) on 2/3/26 at 10:19 AM identified all residents on antipsychotic medications should have behavior monitoring put into place upon the initiation of the medications to ensure specific targeted behaviors are monitored so the resident was treated appropriately. Interview and clinical record review with the Director of Nursing (DON) on 2/3/26 at 1:30 PM identified targeted behavior monitoring should have been put into place every shift for Residents #1, #2 and #3 upon the initiation of the antipsychotic medications. Review of the Psychotropic Medication Use policy (undated) directed, in part, that psychotropic medication management is an interdisciplinary process that requires adequate monitoring for efficacy and adverse consequences to include expressions or indications of distress and resident complaints, behaviors and symptoms. Documentation must include that behavioral interventions (non-pharmacological) were attempted but not successful, and these interventions were deemed clinically contraindicated. Residents receiving psychotropic medications are monitored and the response to treatment is documented. Monitoring may include behavior flow sheets, progress notes and medication administration records. Review of the Behavioral Assessment Intervention policy dated 6/2023 directed, in part, that if the resident is being treated for altered behavior or mood, the interdisciplinary team will observe for changes in the individual's behavior, mood and function. If antipsychotic medications are used to treat behavioral symptoms, the interdisciplinary team will monitor their indication. The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for a change in condition, the facility failed to ensure a complete and accurate clinical record to include an antipsychotic medication was transcribed correctly and signed off as administered. The findings include:Resident #1's diagnoses included bipolar disorder, depressive episodes and Alzheimer's disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) indicating Resident #1 had some memory recall deficits. The Resident Care Plan dated 12/23/25 identified Resident #1 received an antipsychotic medication related to a diagnosis of bipolar disorder. Interventions included observing for targeted behaviors of excessive crying and suicidal ideation. A physician's order dated 11/25/25 directed to administer Aripiprazole 5 mg by mouth in the morning for bipolar disorder and on 1/13/26 the Aripiprazole was decreased to 2 mg. A physician's order dated 1/13/26 directed to administer a one-time dose of Aripiprazole 2 mg in the morning on 1/14/26. A physician's order dated 1/21/26 directed to increase the Aripiprazole back to 5 mg at bedtime. The nurse's note dated 1/20/26 at 6:57 PM identified the Director of Nursing was notified by staff that Resident #1 had been found around 4:24 PM by a nurse aide with the call bell cord wrapped around his/her neck. The note indicated the cord was immediately removed, no marks were noted to the neck, no distress was noted, Resident #1 was unable to verbalize why the cord was around his/her neck, one-to-one constant observation was immediately implemented, the psychiatric Advanced Practice Registered Nurse (APRN) was in-house and assessed Resident #1 and Resident #1 was sent to the Emergency Department for evaluation. The note identified Resident #1 returned to the facility the same day with a letter stating he/she was not a harm to self or others and the one-to-one constant observation continued. Review of the January 2026 Medication Administration Record identified the one-time dose of Aripiprazole 2 mg had been signed off as administered at 9:00 AM on 1/14/26, however documentation failed to identify the Aripiprazole 2 mg had been administered at 8:30 PM on 1/14/26 and 1/15/26. Interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #3, on 2/3/26 at 12:20 PM identified she did not administer the 1/14/26 dose of Aripiprazole 2 mg to Resident #1 at 8:30 PM because the 7AM-3PM nursing supervisor, Registered Nurse (RN) #2, had communicated to her the Aripiprazole 2 mg was administered on the 7AM-3PM shift, as the provider had ordered a one-time dose at 9:00 AM and the Aripiprazole was to be administered at 8:30 PM daily starting on 1/15/26. LPN #3 explained she left a note for RN #2 to review the order in the morning, and she did not sign off. LPN #3 identified she should have written a note to explain why the 8:30 PM had not been signed off as administered. Interview with RN #2 on 2/3/26 at 12:40 PM identified although she transcribed the 1/14/26 order directing to administer Aripiprazole 2 mg daily at bedtime, Resident #1 had already received the Aripiprazole at 9:00 AM on 1/14/26 so the order was supposed to go into effect on 1/15/26 at 8:30 PM and the order should not have shown up on the Medication Administration Record to administer on 1/14/26 at 8:30 PM. RN #2 indicated she transcribed the order incorrectly. RN #2 identified she should have ensured the order was entered correctly before signing it. Interview with the 3-11PM charge nurse, LPN #2, on 2/3/26 at 12:49 PM identified although she did not sign off the Aripiprazole on 1/15/26 at 8:30 PM, she did administer the medication. LPN #2 indicated she was responsible for ensuring all of her documentation was completed and correct before she leaves. Interview and clinical record review with the Director of Nursing (DON) on 2/3/26 at 1:30 PM identified RN #2 should have ensured she transcribed the Aripiprazole 2 mg order on 1/14/26 correctly, and then checked the order again before signing it, and although a medication error was not made, the resident could have been given double the dose. The DON explained staff are expected to sign off on all medications and treatments for the residents and ensure that documentation was complete and accurate, and if medications or treatments are not administered staff should be writing a note to indicate the reason. Review of the Charting and Documentation policy dated 07/2017 directed, in part, that all services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Although requested, a policy on Transcription of Physician's Orders was not available

Based on review of the clinical record, facility documentation, facility policies, and interviews, for one (1) of three (3) sampled residents (Resident #1) who required staff assistance for ambulation, the facility failed to provide adequate supervision during ambulation with a rolling walker, which resulted in a fall with a right femoral neck fracture requiring surgical intervention. The findings include:Resident #1's diagnoses included dementia, lack of coordination, abnormal posture, and generalized weakness. The amended quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 7), short and long-term memory recall deficits and was dependent on staff for transfers in and out of the bed and chair and for ambulation with a rolling walker. The fall risk assessment completed 11/21/25 identified Resident #1 was at high risk of falls. The Resident Care Plan dated 11/21/25 identified Resident #1 had a self-care deficit and was at risk for falls due to weakness, decreased mobility, and history of falls. Interventions directed assistance of one (1) with transfers in and out of the bed and the chair, and assistance of one (1) with ambulation using a rolling walker. The physician's order dated 11/21/25 directed an assist with one (1) during mobility of forty-five (45) to seventy-five (75) feet as tolerated and to provide rest breaks as needed. The nurse's note dated 12/1/25 at 6:57 PM identified RN #1 (the 3 PM to 11 PM Nursing Supervisor), was called to the area where Resident #1 sustained a witnessed fall. While ambulating, Resident #1 was observed looking back at another resident, then lost his/her balance and fell, landing on his/her right side. Resident #1 was assessed by RN #1 and complained of discomfort to his/her back that subsided during the assessment. Neurological checks were normal, and Resident #1 had full range of motion at all extremities. Resident #1 was assisted to his/her feet and ambulated back to his/her room. Resident #1 complained of discomfort to the right upper leg. The family and the Advanced Practice Registered Nurse (APRN) were notified. The APRN directed an x-ray to the right hip and right upper femur which was scheduled for the following morning. The nurse's note dated 12/2/25 at 8:29 AM identified RN #2 (the 7 AM to 3 PM Nursing Supervisor), assessed Resident #1 and noted Resident #1 had increased confusion, was slow to respond verbally, and denied pain. The APRN was notified and directed a transfer to the ED for follow-up. The hospital record dated 12/5/25 identified Resident #1 sustained a closed fracture of the right hip and underwent a surgical procedure for an Open Reduction and Internal Fixation (ORIF) of the right hip insertion of the femoral neck on 12/3/25. The nurse's note dated 12/5/25 at 4:46 PM identified Resident #1 was readmitted to the facility. Review of the facility's summary report dated 12/9/25 indicated Resident #1 was walking with a staff member when Resident #1 turned to look at another resident then fell onto his/her right side sustaining a femoral neck fracture of the right side. An interview with NA #1 on 1/5/26 at 12:45 PM identified she worked the 3:00 PM to 11:00 PM shift on 12/1/25 and was responsible for providing care to Resident #1. NA #1 identified that Resident #1 required assistance of one (1) staff member and use of a gait belt during ambulation. NA #1 reported that on 12/1/25 between 5:30 PM and 6:00 PM, she was assisting Resident #1 from the dining room back to the resident's room when another resident seated in a wheelchair nearby required assistance. NA #1 stated she left Resident #1 standing in the hallway and instructed the resident to remain there while she went to assist the other resident, who was out of NA #1's line of sight. When NA #1 returned, Resident #1 was actively walking toward his/her roommate and another staff member. As NA #1 approached, Resident #1 turned to look at another person nearby, lost his/her balance, and fell onto his/her right side. NA #1 confirmed she was not holding onto Resident #1 at the time of the fall, did not have a gait belt with her, did not apply a gait belt to the resident, and did not remain with the resident during ambulation as required. NA #1 further stated she should have seated Resident #1 to ensure safety before leaving to assist another resident. Interview with Director of Nursing (DON) on 1/5/26 at 1:45 PM identified that although there was no provider order for a gait belt to be used while staff assisted Resident #1 with transfers and ambulation, a gait belt should have been used. The DON identified that if a resident refused application of a gait belt, the refusal should have been documented. According to the physician's orders directing an assist of one (1) for ambulation, NA #1 should not have left Resident #1 standing alone in the hallway. The DON further identified that NA #1 failed to follow the facility's policy for ambulation. Review of the facility ambulation with walker policy identified assistance with the use of a walker during ambulation will be provided to residents as indicated by the MD order. The policy further identified if the Resident began to fall, the staff should draw the resident close to the staff member's body, support the resident, and gently and slowly lower the resident to the floor by sliding the resident down the staff member's leg. Attempts to interview OT #1 were unsuccessful.

Based on the tour of the Dietary Department, observations, facility documentation, facility policy, and interviews, the facility failed to ensure the Dietary Department served food at temperatures outside of the danger zone and failed to ensure foods reheated by nursing staff were served at safe temperatures. The findings included: 1. Observation of the tray line on 3/6/2025 at 11:42 AM identified a test tray was placed on the only Pavilion meal delivery cart at 12:02 PM and the cart was brought through the dining room onto the nursing unit. The meal delivery cart was observed to be a Bunn rack and was covered with a zippered clear plastic cover that went over the top of the Bunn rack and zipped along the front corners of the rack. The meal plates on the trays inside the rack were covered with clear hard plastic covers that did not contain warming pellets. All meal trays were delivered to the residents by Nurse Aide (NA) #2. Interview with the Assistant Food Service Director (Asst Food Service Dir) on 3/6/2025 at 12:05 PM identified that for breakfast meal service, all residents ate in their rooms, and the Cambro meal delivery cart (insulated meal delivery cart) was used because it had room to hold all trays. The Asst Food Service Dir indicated that for the lunch meal service, some residents ate in their room, but most ate in the dining room, so there wasn't a need for the Cambro meal delivery cart for delivering the meals. On 3/6/2025 at 12:15 PM the test tray was the last tray served on the nursing unit, was brought to the nursing unit kitchenette, and the following temperatures were obtained: Sweet potatoes: surveyor- 107.6 degrees Fahrenheit, Asst Food Service Dir- 105 degrees Fahrenheit Chopped spinach: surveyor- 114.5 degrees Fahrenheit, Asst Food Service Dir- 114 degrees Fahrenheit Pork: surveyor- 97.2 degrees Fahrenheit, Asst Food Service Dir- 95.6 degrees Fahrenheit Interview with the Asst Food Service Dir on 3/6/2025 at 12:16 PM identified the food temperatures were low. Observation on 3/7/2025 at 11:48 AM identified a test tray was placed on the only Pavilion meal delivery cart and the cart was brought through the hallway of the Residential Care Home (RCH), through the double doors into the hallway of the Pavilion and delivered to the nursing unit. The meal delivery cart was a Cambro meal delivery cart with a door that closed and latched in the front. The meal plates on the trays inside the cart were within a blue, hard plastic, heated pellet thermal container which fully enclosed the meal plate. The Asst Food Service Dir and Registered Nurse #1 assisted the NAs in delivering the meal trays. The test tray was the last tray served on the nursing unit. On 3/7/2025 at 11:52 AM the test tray was brought to the nursing unit kitchenette on the unit and the surveyor observed the Asst Food Service Dir obtain temperatures of the test tray food which identified safe food temperatures. Interview with the Food Service Director and Asst Food Service Dir on 3/7/2025 at 12:00 PM identified after the low temperature food readings of the test tray on 3/6/25, they decided to initiate the blue heated pellet thermal system for the meal plates and to use the Cambro meal delivery cart rather than the Bunn rack with zippered cover for delivery of meal trays during lunch. Review of the Food Transportation policy identified food would be maintained at a temperature outside the food safety danger zone of 41 to 135 degrees Fahrenheit. Plates and bowls would be covered by foil, plastic wrap, snap-on covers or domes during transportation and holding, and trays would be placed into covered carts for delivery. 2. Observation on 3/6/2025 at 12:11 PM identified NA #2 brought Resident #24's tray into the kitchenette to reheat the food per Resident #24's request. Interview with NA #2 on 3/6/2025 at 2:00 PM identified she asked residents if they needed any items or their food reheated when delivering meal trays, and if a resident requested food to be reheated, she would use the microwave in the kitchenette to heat the food for 40 to 50 seconds. NA #2 identified there was not a thermometer in the kitchenette to check food temperatures, instead, she tried not to overheat food. NA #2 further identified that she reheated food less during breakfast when meal trays were delivered in the Cambro meal delivery cart, and more often for meals delivered on the Bunn rack. Observation of the kitchenette on 3/7/2025 at 9:15 AM identified a thermometer with alcohol wipes for cleaning was located in the drawer furthest from the door on the left side of the room. Interview with NA #5 on 3/7/2025 at 9:30 AM identified she reheated food as requested by residents and tried not to overheat food to prevent residents from burning their mouth. She indicated she reheated food for 25-30 seconds at a time, or longer, as requested. NA #5 identified she did not have a thermometer for checking the temperature of the food but instead would place her hand above the food to gauge how warm the food was. Interview with the Food Service Director on 3/7/2025 at 11:47 AM identified that nursing staff were permitted to reheat food for residents. She identified the food was reheated in the microwave in the kitchenette, food was to be heated until the temperature was 165 degrees Fahrenheit and verified by the thermometer in the kitchenette, and after reheating the food, the food was to sit for at least 1 minute before being served. The Food Service Director further identified she provided the DNS with a new thermometer the previous day. Review of the On-Unit Food Reheating policy, identified, foods may be reheated by facility staff only using the nourishment kitchen's microwave and provided thermometer. Further identified was reheated foods must reach an internal temperature of 165 degrees Fahrenheit for 15 seconds, microwaved food must be let to rest for at least 1 minute, and to prevent injury reheated foods must be retested to ensure the temperature has reduced to approximately 135 degrees Fahrenheit prior to serving to the resident.

51183 Based on observations, review of the clinical record, facility policy and interviews for 1 of 2 residents (Resident #10) reviewed for skin conditions and 1 of 1 residents (Resident #11) reviewed for Urinary Tract Infections (UTI), the facility failed to revise resident care plans (RCP) after changes in condition occurred. The findings include: 1. Resident #10 was admitted to the facility in August of 2023 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), hypoosmolality and hyponatremia (excess water in the body and low sodium levels) and chronic kidney disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), required set up assistance for eating, supervision for bed mobility, and partial/moderate assistance for toileting and transfers. The RCP dated 1/16/25 identified Resident #10 was at risk for impaired skin integrity. Interventions included ensuring properly fitting shoes, observing feet for redness or skin breakdown with care, treatments as ordered, observing for edema, warmth, induration, redness, drainage, updating the physician as needed, observing skin for breakdown with care, redness, excessive moisture, raised areas, open areas and drainage. A nurse's note dated 2/25/25 at 10:27 PM by RN #6 identified an area of purpura to Resident #10's left lower shin opened with a scant amount of bleeding and a dressing was applied. A progress note dated 2/28/25 at 10:15 AM by Advanced Practice Registered Nurse (APRN) #1 identified a new wound to the left shin which was suspected of having a traumatic etiology as it was located on the extensor surface. Review of the clinical record identified there were no revisions to the RCP to include the new wound to the left lower shin or protective/preventative interventions. 2. Resident #11 was admitted to the facility in June of 2022 with diagnoses that included Dementia, falls and UTI. The Quarterly MDS assessment dated [DATE] identified Resident #11 as severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 4), was independent with bed mobility, required supervision for transfers, and required partial/moderate assistance for toileting. The RCP dated 1/30/25 identified potential for activities of daily living/self-care deficit related to weakness and confusion. Interventions included vital signs as needed, labs as ordered, observing for changes in mental status and observing for UTI: abdominal/flank/back pain/discomfort, fever, changes in urine color, clarity or odor. A progress note dated 2/24/25 at 3:00 PM by APRN #1 identified dark concentrated urine with a history of UTI and that urinary frequency had subsided significantly with medication. A Physicians order dated 2/24/25 directed 72-hour monitoring for UTI and monitoring for dysuria for 3 days. A urine culture dated 2/25/25 identified greater than 100,000 colonies per milliliter of Klebsiella Pneumoniae in the urine. A physician's order dated 2/27/25 directed to administer Sulfamethoxazole -Trimethoprim (antibiotic) tablet 800-160 milligrams twice a day for a UTI for 7 days. Review of the clinical record identified the RCP was not revised to include the confirmed UTI, monitoring or treatment. Subsequent to surveyor inquiry, the RCP was revised to include an actual UTI and antibiotic treatment. Interventions included to encourage fluids, provide peri care, intake and output as needed, medication as ordered, labs as ordered, observe for signs and symptoms of UTI: mental status changes, fever, dysuria, frequency, urgency, increased incontinence, abdominal/flank/back pain/discomfort, toilet every 2 hours and as needed, prompt incontinent care. Interview with LPN #1 on 3/6/25 at 12:44 PM identified the facility interdisciplinary team (IDT) should update RCPs. Interview with the Director of Nursing Services (DNS) on 3/7/25 at 9:20 AM identified LPN #1 (MDS Coordinator) is responsible for updating RCPs and that RCPs should be updated after clinical meetings, risk meetings, after changes in condition and quarterly by the IDT. Review of the Care Plan policy dated 6/23, directed, in part, care plans will be updated at a minimum of quarterly when the resident has an MDS to be completed. The MDS Coordinator is responsible for ensuring all new items, wounds, falls, etc. are care planned.

Based on clinical record review, review of facility policy, and interviews for 1 of 1 resident (Resident #14) reviewed for choices, the facility failed to honor a resident's right to choose. The findings include: Resident #14 was admitted to the facility in September of 2024 with diagnoses that included dementia, chronic kidney disease, muscle weakness, and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13), independent with eating, oral hygiene and toileting, required supervision or touching assistance for personal hygiene and was independent for bed mobility and transfers. The MDS identified that Resident #14 and his/her family participated in assessment and goal setting. The MDS did not identify Resident #14 with a swallowing disorder, coughing or choking during meals or when swallowing medications, or complaints of difficulty or pain with swallowing. The Resident Care Plan dated 1/2/25 identified Resident #14 was at risk for an alteration in nutrition related to changes in oral intake. Interventions included a no added salt diet, low cholesterol, soft and bite sized texture (level 6), mildly thick liquid (level 2) consistency, availing menu alternative, references at prescribed textures and monitoring and documenting oral intake. A Physicians order dated 2/20/25 directed a no added salt diet (NAS), low cholesterol, soft and bite sized texture (level 6), mildly thick liquid (level 2) consistency. Interview with Resident #14 on 3/5/25 at 11:45 AM identified that he/she was forced , by the facility, to drink thickened liquids and eat foods that were different from what his/her spouse ate. Resident #14 indicated that he/she was accompanied by his/her spouse for meals and had a difficult time enjoying meal times because of the diet he/she was served. Resident #14 identified that he/she had radiological and swallowing tests done in October of 2024 which identified he/she was at risk of aspiration and was subsequently started on thickened liquids. Resident #14 identified he/she developed diarrhea, due to the thickener, which caused frequent trips to the bathroom. Resident #14 indicated that he/she understood the consequences of not adhering to the recommended diet but preferred to not follow the recommendation. Resident #14 further indicated that the facility provided him/her thickened liquids and soft foods despite multiple discussions and requests to be placed on a regular diet and thin liquids. Resident #14 indicated that he/she is of advanced age and is most concerned about having a quality of life and would like his/her wishes to be honored by the facility. An Advanced Registered Nurse Practitioner's (APRN) note dated 2/4/25 by APRN #1 identified that Resident #14's spouse, who was also his/her first emergency contact person, had approached her requesting that Resident #14 be placed on palliative comfort measures only (CMO) to liberalize fluids. The note further indicated that the responsible party/power of attorney (POA) would need to be involved. The note identified that Resident #14 was readmitted to the facility due to cognitive and physical decline and he/she was being monitored for dysphagia and diarrhea possibly related to the thickener used in fluids. A Physician ' s order dated 12/11/24 directed to administer 2 milligrams of Loperamide Hydrochloride by mouth every 24 hours as needed for Diarrhea. Interview with Social Worker (SW) #1 on 3/5/25 at 12:20 PM identified that she was aware of Resident #14's food complaints. SW #1 identified that Resident #14 was started on thickened liquids due to choking concerns. SW #1 indicated that APRN #1 was responsible for addressing CMO requests and indicated she had no discussions with APRN #1 regarding Resident #14's food complaints. SW #1 identified there had been no meeting with the facility interdisciplinary team, Resident #14, or Resident #14 ' s family to discuss goals of care. Review of the clinical record failed to identify documentation of a meeting or collaboration between the facility interdisciplinary team, Resident #14, or Resident #14 ' s family to discuss goals of care Review of the clinical record identified Resident #14 was his/her own decision maker and did not have a named representative or POA. Interview with APRN #1 on 3/7/25 at 12:15 PM identified that she had a meeting with Resident #14 and his/her spouse to discuss the risks versus benefits of stopping the dysphagia diet and further discussed a CMO status. APRN #1 indicated that she did not think Resident #14, or his/her spouse were capable of making decisions because they lacked the insight to understand the benefit of the Speech and Language Pathologists (SLP) recommendations. APRN #1 identified that she thought Resident #14's daughter was Resident #14 ' s legal decision maker but indicated that she had not contacted or reached out to Resident #14's daughter to discuss goals of care. APRN #1 indicated that the facility did not want to cause harm to Resident #14 by advancing his/her diet per his/her request. APRN #1 identified that she informed the DNS and the nursing supervisor of Resident #14's and his/her family ' s requests for a transition to CMO and diet change. APRN #1 further indicated that it was the facility's responsibility to make decisions based on goals of care. Interview with the DNS on 3/7/25 at 1:00 PM, identified that the facility did not advance Resident #14's diet because a diet change would be unsafe. The DNS further identified that Resident #14's daughter requested a waiver in order for Resident #14 ' s diet to be changed but the facility did not provide any form of waiver. The DNS indicated that Resident #14 was not appropriate for a CMO status since he had not experienced a decline. Interview with SLP #1 on 3/10/25 at 9:20 AM identified that Resident #14 voiced concerns regarding the dysphagia diet recommendation. SLP #1 identified that Resident #14 received SLP services in October of 2024, was discharged in November of 2024, and no further referrals had been made after the November discharge. Facility's Residents [NAME] of Rights identified that residents have a right to refuse treatment . and residents rights would be honored. Review of facility policy titled, Palliative Care, identified, in part, that, the physician and staff will identify individuals who desire or are likely candidates for palliative care, for example, those with a known terminal illness or end-stage condition (that is, a condition that has resulted in substantial functional dependency, impairment and/or medical instability and continued decline anticipated, regardless of whether medical treatments are rendered.

Based on clinical record review, review of facility policy, and interviews for 1 of 3 residents (Resident #14) reviewed for elopement, the facility failed to develop a comprehensive care plan for a resident at risk of elopement. The findings include: Resident #14 was admitted to the facility in September of 2024 with diagnoses that included dementia, chronic kidney disease and hypertension. An Elopement Risk assessment dated [DATE] identified Resident #14 was at low risk for elopement. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 6), required assistance for eating, supervision or touching assistance for personal hygiene and was independent for bed mobility and transfers. The MDS identified that Resident #14 ambulated with a walker. Resident Care Plan dated 10/9/24 identified Resident #14 had cognitive loss related to dementia. Interventions included reorienting and supervising as needed, giving choices regarding care, asking questions, rephrasing as needed for confusion or agitation and use of task segmentation to support short term memory deficits. A Nursing progress note by RN #1 on 10/15/24 at 7:00 PM identified that Resident #14 was exit seeking multiple times, was redirected by staff, and a new order for a Wander guard (monitoring device applied on residents who wander and are risk of elopement) to the walker was obtained for safety. An Advanced Practice Registered Nurse (APRN) progress note by APRN #1 dated 10/21/24 identified Resident #14 presented with periods of confusion, disorientation, exit-seeking and wandering behaviors. The note further identified that Resident #14 was often looking for his wife, who lived on the assisted living side of the facility, and that Resident #14 had a Wander guard in place. Review of the clinical record identified there was no repeat Elopement Risk assessment performed for Resident #14 until 12/31/24. An Elopement Risk assessment dated [DATE] identified Resident #14 was at risk for elopement. Observation of Resident #14 on 3/4/25 at 11:00cAM and 3/5/24 at 11:51 AM, identified a Wander guard attached to Resident #14's walker. Review of the RCP failed to identify a basic or comprehensive care plan with interventions directing care for Resident #14's elopement/wandering risk. Interview with LPN #1 (MDS Coordinator) on 3/6/25 at 12:31 PM identified that she was not notified in October of 2024 that a Wander guard was ordered for Resident #14 due to wandering behavior but was made aware in December of 2024 during Resident #14's quarterly MDS assessment. LPN #1 indicated that she forgot to develop an RCP with interventions directing care for Resident #14 ' s wandering behavior. Subsequent to surveyor inquiry, LPN #1 revised the RCP to identify Resident #14's Wander guard order with interventions to check placement every shift and for a Wandering assessment to be performed quarterly and with any change. Interview with the DNS on 3/7/25 at 9:16 AM identified that LPN #1 was responsible for updating RCPs and that RCPs are updated quarterly and with changes in condition. The DNS further identified that LPN #1 should have updated the RCP when the Wander guard was applied in October of 2024. Review of facility policy titled, Care Plans, identified, in part, that the care plan will be developed no later 7 days after the completion of the comprehensive MDS. The RCP of each resident is completed and reviewed by the 21st day after admission and quarterly thereafter at the Resident Care Conference. RCPs can also be revised, as needed at any time, on an interim basis. The MDS coordinator is responsible for ensuring that all new items, wounds, falls etc., are care-planned.

Based on clinical record review, review of facility policy, and interviews for 1 of 1 resident (Resident #14) reviewed for choices, the facility failed to identify and promote individualized care for a resident who voiced goals of care requests. The findings include: Resident #14 was admitted to the facility in September of 2024 with diagnoses that included dementia, chronic kidney disease, muscle weakness, and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13), independent with eating, oral hygiene and toileting, required supervision or touching assistance for personal hygiene and was independent for bed mobility and transfers. The MDS identified that Resident #14 and his/her family participated in assessment and goal setting. The MDS did not identify Resident #14 with a swallowing disorder, coughing or choking during meals or when swallowing medications, or complaints of difficulty or pain with swallowing. The Resident Care Plan dated 1/2/25 identified Resident #14 was at risk for an alteration in nutrition related to changes in oral intake. Interventions included a no added salt diet, low cholesterol, soft and bite sized texture (level 6), mildly thick liquid (level 2) consistency, availing menu alternative, references at prescribed textures and monitoring and documenting oral intake. Interview with Resident #14 on 3/5/25 at 11:45 AM identified that he/she was forced , by the facility, to drink thickened liquids and eat foods that were different from what his/her spouse ate. Resident #14 indicated that he/she was accompanied by his/her spouse for meals and had a difficult time enjoying meal times because of the diet he/she was served. Resident #14 identified that he/she had radiological and swallowing tests done in October of 2024 which identified he/she was at risk of aspiration and was subsequently started on thickened liquids. Resident #14 identified he/she developed diarrhea, due to the thickener, which caused frequent trips to the bathroom. Resident #14 indicated that he/she understood the consequences of not adhering to the recommended diet but preferred to not follow the recommendation. Resident #14 further indicated that the facility provided him/her thickened liquids and soft foods despite multiple discussions and requests to be placed on a regular diet and thin liquids. Resident #14 indicated that he/she is of advanced age and is most concerned about having a quality of life and would like his/her wishes to be honored by the facility. An Advanced Registered Nurse Practitioner's (APRN) note dated 2/4/25 by APRN #1 identified that Resident #14's spouse, who was also his/her first emergency contact person, had approached her requesting that Resident #14 be placed on palliative comfort measures only (CMO) to liberalize fluids. The note further indicated that the responsible party/power of attorney (POA) would need to be involved. The note identified that Resident #14 was readmitted to the facility due to cognitive and physical decline and he/she was being monitored for dysphagia and diarrhea possibly related to the thickener used in fluids. A Physician ' s order dated 12/11/24 directed to administer 2 milligrams of Loperamide Hydrochloride by mouth every 24 hours as needed for Diarrhea. Interview with Social Worker (SW) #1 on 3/5/25 at 12:20 PM identified that she was aware of Resident #14's food complaints. SW #1 identified that Resident #14 was started on thickened liquids due to choking concerns. SW #1 indicated that APRN #1 was responsible for addressing CMO requests and indicated she had no discussions with APRN #1 regarding Resident #14's food complaints. SW #1 identified there had been no meeting with the facility interdisciplinary team, Resident #14, or Resident #14 ' s family to discuss goals of care. Review of the clinical record failed to identify documentation of a meeting or collaboration between the facility interdisciplinary team, Resident #14, or Resident #14 ' s family to discuss goals of care. Review of the clinical record identified Resident #14 was his/her own decision maker and did not have a named representative or POA. Interview with APRN #1 on 3/7/25 at 12:15 PM identified that she had a meeting with Resident #14 and his/her spouse to discuss the risks versus benefits of stopping the dysphagia diet and further discussed a CMO status. APRN #1 indicated that she did not think Resident #14, or his/her spouse were capable of making decisions because they lacked the insight to understand the benefit of the Speech and Language Pathologists (SLP) recommendations. APRN #1 identified that she thought Resident #14's daughter was Resident #14 ' s legal decision maker but indicated that she had not contacted or reached out to Resident #14's daughter to discuss goals of care. APRN #1 indicated that the facility did not want to cause harm to Resident #14 by advancing his/her diet per his/her request. APRN #1 identified that she informed the DNS and the nursing supervisor of Resident #14's and his/her family ' s requests for a transition to CMO and diet change. APRN #1 further indicated that it was the facility's responsibility to make decisions based on goals of care. Interview with the DNS on 3/7/25 at 1:00 PM, identified that the facility did not advance Resident #14's diet because a diet change would be unsafe. The DNS further identified that Resident #14's daughter requested a waiver in order for Resident #14 ' s diet to be changed but the facility did not provide any form of waiver. The DNS indicated that Resident #14 was not appropriate for a CMO status since he had not experienced a decline. Although requested, a policy on the provision of social services was not provided.

Based on clinical record reviews, review of polices and interviews for 6 of 9 residents (Resident #3, #8, #9, #12, #22 and #26) reviewed for medication administration, the facility failed to ensure the residents had identification bands during medication administration and for 3 of 9 residents (Residents #8, #12, #22), the facility failed to follow safe medication administration practices when identifying the right resident through electronic health record picture. The findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, vascular dementia, and anxiety disorder. 2. Resident #8 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, diabetes mellitus type 2, hearing loss and depressive disorder. 3. Resident # 9 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, depressive disorder, and vascular dementia. 4. Resident #12 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, pick's disease (neurodegenerative disease), and aphasia (inability to speak). 5 Resident #22 was admitted to the facility on [DATE] with diagnoses that included dementia, myositis (inflammation in muscles), and mononeuropathy of lower limb (nerve damage). 6. Resident #26 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, depressive disorder, and schizophrenia. Observation and interview of medication administration with LPN #1, on 5/8/23 from 4:30 PM through 6:16 PM, identified Residents #3, #8, #9, #12, #22, #26 had no identification bands on his/her person. In addition to the residents not having identification bands. Further observation of the LPN #1's medication administration on 5/8/23 from 4:30 PM to 6:16 PM identified Residents #8, #12, #22 had no electronic health record picture identification in the facility software system. LPN #1 indicated at the time of the observation she knew the residents. Interview and policy review with the DNS on 5/11/23 at 11:45 AM with the DNS indicated the nurse on the unit had reported missing identification bands and that she had instructed the night shift staff to check for resident identification bands. The DNS also indicated she could not confirm that all residents now have identification bands. Additionally, the DNS identified the policy for Administration of Medications, item #5 notes the nurse identifies residents by name and by the facility identification system in place identification bracelet, photo, etc.). The DNS revised the policy at the time of the interview by handing writing a notation which directed the nurse may get a second staff member to ID the resident.

47490 Based on record reviews, review of policy and staff interviews for 7 of 7 sampled residents (Resident #6, Resident #9, Resident #10, Resident #16, Resident #21, Resident #24, and Resident #26) reviewed for clinical documentation, the facility failed to maintain an accurate medical record regarding residents' alcohol consumption during recreational activities. The findings included: 1. Resident #6's diagnoses included Altered Mental Status, Alzheimer's Disease, Transient Cerebral Ischemic Attack, Obstructive Sleep Apnea and Supraventricular Tachycardia. An Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 as severely cognitively impaired and required extensive assistance with one person for bed mobility, transfers, and toilet use. Additionally, the MDS identified Resident #6 required limited assistance with one person for dressing and set up assistance for eating. An RCP dated 5/10/23 identified Resident #6 was at risk for bleeding related to Aspirin use with interventions to obtain laboratory as ordered, provide medications as ordered, check neurological status as needed, observe for mental status changes, monitor for difficulty with speaking, walking, weakness, fainting, headaches, seizures, and light sensitivity. 2. Resident #9's diagnoses included vascular dementia, Atrial Fibrillation, major depressive disorder, Heart Failure, and diabetes mellitus. A quarterly MDS assessment dated [DATE] identified Resident #9 was cognitively intact and required no assistance with transfers, dressing, and eating. Additionally, the MDS identified Resident #9 required set up assistance with bed mobility and toilet use. The RCP dated 5/4/23 identified Resident #9 was at risk for bleeding related to use of Xarelto anticoagulation therapy with interventions to obtain laboratory as ordered, provide medication as ordered, check neurological status as needed, observe for mental status changes, monitor for difficulty with speaking, walking, weakness, fainting, headaches, seizures, and light sensitivity. 3. Resident #10's diagnoses included Altered Mental Status, aphasia, Gastrointestinal Hemorrhage, Transient Cerebral Ischemic Attack, and chronic pancreatitis. An Annual MDS assessment dated [DATE] identified Resident #10 was cognitively intact and required supervision with one person for bed mobility and transfers, and with set up only for eating. Additionally, the MDS identified Resident #10 required limited assistance with one person for dressing and toilet use. The RCP dated 3/27/23 identified Resident #10 was at risk for bleeding related to Aspirin use and history of gastrointestinal bleeding with interventions to obtain labs as ordered, provide medication as ordered, check neurological status as needed, observe for mental status changes, monitor for difficulty with speaking, walking, weakness, fainting, headache, seizures, and light sensitivity. 4. Resident #16's diagnoses included Unspecified Dementia, Chronic Kidney Disease Stage 3, Alzheimer's disease, hypertension, and muscle weakness. The RCP dated 10/23/22 identified Resident #16 had cognitive loss related to Alzheimer's disease, psychotropic medication usage and cognitive communication deficit with interventions to cue, reorient and supervise as needed, observe for changes in cognition, redirect and reassure as needed, and observe for side effects and effectiveness of psychotropic medications per protocol. A quarterly MDS assessment dated [DATE] identified that Resident #16 was severely cognitively impaired and required limited assistance with one person for bed mobility, and required extensive assistance with one person for transfers, dressing, and toilet use. Additionally, the MDS identified Resident #16 required supervision with one person for eating. 5. Resident #21's diagnoses included essential hypertension, Cognitive Communication Deficit, Left Bundle Branch Block, repeated falls, and macular degeneration. An Annual MDS assessment dated [DATE] identified Resident #21 was severely cognitively impaired and required extensive assistance with one person for dressing, required set up only for eating and toilet use, and required no assistance with bed mobility or transfers. The RCP dated 5/10/23 identified Resident #21 was at risk for cardiac/respiratory distress related to hypertension and left bundle branch block with interventions to observe for signs and symptoms of mental status changes, and observe for a facial droop, one-sided weakness, slurred speech, difficulty ambulating, complaints of numbness, tingling and headache. 6. Resident #24's diagnoses included hypertension, Chronic Obstructive Pulmonary Disease, Congenital Stenosis of Aortic Valve, unspecified dementia, and Chronic Respiratory Failure with Hypoxia. An Annual MDS assessment dated [DATE] identified Resident #24 was severely cognitively impaired and required extensive assistance with one person for bed mobility, transfers, dressing and toilet use. Additionally, the MDS identified Resident #24 required set up only for eating. The RCP dated 4/24/23 identified Resident #24 had altered respiratory status related to Chronic Obstructive Pulmonary Disease and Respiratory Failure with Hypoxia with interventions to administer medications/puffers as ordered, maintain a clear airway, monitor for changes in orientation, and monitor for increased restlessness, anxiety, and air hunger. Additionally, the RCP identified to monitor for signs and symptoms of respiratory distress and abnormal breathing patterns. 7. Resident #26's diagnoses included hyperglycemia, Schizophrenia, Acute Respiratory Failure with Hypoxia, repeated falls, and muscle weakness. The RCP dated 1/2/23 identified Resident #26 was at risk for hyperglycemia related to disease process with interventions to monitor for signs and symptoms of hyperglycemia such as increased thirst and hunger, frequent urination, weight loss, fatigue, dry skin, poor wound healing, and muscle cramps. Additionally, the resident care plan identified to monitor for labored breathing, monitor vital signs, and check fasting blood sugar as ordered. A quarterly MDS assessment dated [DATE] identified Resident #26 was cognitively intact and required supervision with one person for bed mobility, transfers and toilet use, and limited assistance with one person for dressing. Additionally, the MDS identified Resident #26 required set up only for eating. Interview with the ADNS on 5/9/23 at 10:38 AM identified that some residents do participate in wine drinking at happy hour. The ADNS further identified that the facility policy for alcohol use identified that residents have the right to participate. Interview with Registered Pharmacist (RPH) on 5/9/23 at 2:42 PM identified that certain amounts of alcohol consumption with insulin and anticoagulation use could cause thinning of the blood, and the combination could potentially lower blood sugar. Additionally, the RPH indicated that someone who was on anticoagulation medication should have physician oversight with alcohol usage. Interview with MD #2 on 5/9/23 at 2:52 PM identified that he was aware of the facility serving alcohol at recreation and happy hour to residents. MD #2 further identified that if residents were not in a controlled setting, then he would have been concerned about the amount of alcohol consumption while on anticoagulation therapy and insulin. MD #2 further identified that since it was a controlled setting with residents being monitored by trained nursing staff, and receiving limited alcohol, he was not concerned for any adverse effects with medications. Interview with the DNS on 5/9/23 at 3:22 PM identified that with the current policy there were no mechanisms in place to assess residents for appropriateness of alcohol consumption or to determine interactions with medications. The DNS also identified that there should be a resident assessment done prior to allowing residents to consume alcohol, and a care plan with interventions. A facility policy dated 5/2023 for alcohol use identified that a resident would be able to consume alcohol if they are not taking medications that would interact poorly with medication and do not have a medical condition that needs to have special considerations. An interview with the DNS on 5/11/23 at 4:00 PM identified Resident #6, #9, #10, #16, #21, #24, and #26, who participate in recreational alcohol use have physician orders and care plans in place as of 5/10/23. The DNS further identified that although there are no completed assessments within the resident's medical record to determine alcohol consumption appropriateness.

Based on clinical record reviews, review of policy and interviews for 1 of 3 residents ( Resident# 5), reviewed for nutrition, the facility failed to meal supplement to the resident as directed by the physician and for 1 of 3 resident (Resident #11) reviewed for weight loss, the facility failed to follow a recommendation for weekly weights and the facility policy for weight management for a resident at risk for nutritional problems and for (Resident #12) reviewed for weight loss, the facility failed to consistently monitor weekly weights as ordered for a resident identified with significant weight loss. The findings included: 1. Resident # 5's diagnoses included dementia, major depressive disorder, and anxiety disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident # 5 as severely cognitively impaired, and required oversight, encouragement or cueing when eating. The Resident Care Plan dated 2/23/2023 identified the potential for alteration in nutrition related to a decrease in oral intake. Interventions directed to encourage adequate intake of foods and fluids, provide food and fluid preferences as available, and offer 240mls of Ensure following meal intake of 50% or less. A physician's order dated 9/23/22 directed to give 8oz of Ensure when Resident #5 consumed less than 50% of her meal. Observation on 5/8/23 at 6:13PM identified Resident # 5 consumed less than 50 percent of his/her dinner and the resident was not offered Ensure supplement as ordered by the physician. An interview and clinical record review with Dietician #1 on 5/11/23 at 11:15AM identified Resident #5 should receive 8oz of Ensure to supplement her/his meals when intake is less than 50%. Interview Dietician # 1 on 5/11/23 at 11:15 AM with the ADNS identified a physician's order dated 9/23/22 for 8oz of Ensure to be given for meal supplement for consuming less than 50 percent of his/her meal had not been transcribed by staff on the Medication Administration Record Interview with APRN #1 at 2:08 PM on 5/11/23 identified her expectation is that all physician's orders were to be followed. 2 a Resident #11's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, dementia, Paroxysmal Atrial Fibrillation, and Acute Kidney Failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was severely cognitively impaired and required extensive assistance with two persons for bed mobility, transfers, and toilet use. Additionally, the MDS identified Resident #11 required extensive assistance with one person for eating and dressing. The Nutritional Quarterly Assessments (completed by the dietician) dated 1/11/23 and 3/30/23 identified Resident #11's plan of care included weekly weights. The care plan dated 4/6/23 identified Resident #11 as at risk for fluid volume overload related to hypertension and history of edema. Interventions directed to encourage the resident to follow therapeutic diet, update dietician as needed, and obtain weights as ordered and as needed. However, the Electronic Medical Record (EMR) for Resident #11 failed to identify weekly weights was ordered for January 2023 to March 30, 2023. The facility weight book dated 1/2023 through 5/2023 for Resident #11 failed to identify weekly weights were obtained according to the dietician's recommendation. Interview and record review with the Registered Dietician (RD #1) on 5/11/23 at 12:20 PM identified Resident #11 had a recommendation for weekly weights, and indicated she would have expected the weekly weights to be obtained. RD #1 further identified she had communicated to the DNS and ADNS about weights not being obtained for residents including Resident #11. RD #1 also identified that she was not responsible for obtaining physician's orders for weights and indicated the licensed staff was responsible for weight which management was aware at the time. Additionally, RD #1 identified recommendations are communicated directly to the licensed staff, ADNS and DNS. Interview and record review with the DNS on 5/11/23 at 1:02 PM identified RD #1 communicated her/his recommendations verbally to the licensed staff including the DNS. The DNS further identified the licensed staff was responsible for obtaining physician's order for weekly weights for Resident #11. The DNS also identified that she would have expected the weekly weights to be obtained for Resident #11 according to RD #1's recommendations. Additionally, the DNS failed to identify weekly weights and a physician order for Resident #11 from January 2023 through March 30, 2023. b. The clinical record identified Resident #11's weight on 2/1/23 was 154.6 pounds (lbs.), weight on 3/1/23 was 155 lbs., and weight on 4/5/23 was 133.6 lbs. which indicated a weight loss of 21.4 lbs. The Nutritional Quarterly Assessments (completed by the dietician) dated 1/11/23 identified Resident #11's most recent weight was 138.1 lbs., and the assessment dated [DATE] identified the resident's most recent weight was 155 lbs. which identified a weight gain of 16.9 lbs. Interview and record review with RD #1 on 5/11/23 at 12:20 PM identified Resident #11's weight was consistent and stable. RD #1 indicated she was not aware of Resident #11's weight of 133.6 lbs. on 4/5/23. RD #1 further identified that she was unsure if the weight was accurate, and she would have expected to be notified by staff with a re-weight to determine accuracy to address any concerns. Additionally, RD #1 also identified that although she was unable to assess Resident # 11 for weight loss without additional weights, she was able to identify Resident #11's meal intakes have been averaging 50-75%, the resident had no abnormal laboratory, nutritional supplement currently administered, and the resident's body mass index was considered overweight with no concerns at this time. Interview and record review with the DNS on 5/11/23 at 1:02 PM failed to identify documentation of weight refusals, contraindications or reweight within the Electronic Medical Record and the facility weight book for Resident #11's weight of 133.6 lbs. on 4/5/23. The DNS also identified that she would have expected the licensed staff to reweigh Resident #11 according to facility policy and notify RD #1. Facility policy dated 6/13/22 for Obtaining Weights notes residents are to be reweigh for discrepancies of 3 lbs. or more and directed the licensed staff to report any weight loss/gain to dietitian. 3. Resident #12's diagnoses included Pick's Disease, vascular dementia, aphasia, hypothyroidism, and diabetes mellitus Type 2. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 was severely cognitively impaired and required extensive assistance with two persons for bed mobility, transfers, dressing, and toilet use. The MDS further identified Resident #12 also required extensive assistance with one person for eating. A physician's order dated 1/3/23 for Resident # 12 directed to start weekly weights on 1/10/23 for decreased by mouth (PO) intake. The Admission Nutrition assessment dated [DATE] identified Resident #12's plan of care included weekly weights. The Resident Care Plan (RCP) dated 1/6/23 identified Resident #12 had potential for alteration in nutrition related to decreased PO intake as evidenced by weight loss with significant decrease for 180 days. Interventions included weekly weights, monitoring and documenting food and fluid intakes daily, obtain laboratory as ordered, provide supplements and nutrition consult as needed. The Advanced Practice Registered Nurse (APRN #1)'s progress noted dated 1/8/23 identified Resident #12 had poor by mouth intake and weekly weights were pending. Interview with APRN #1 on 5/10/23 at 1:57 PM identified Resident #12 had weekly weights ordered and she would have expected the facility staff to follow the order as directed and communicate any weight loss. Interview and record review with the DNS on 5/10/23 at 2:07 PM identified she would have expected for Resident #12's weekly weights to be obtained as ordered. The DNS further identified the order was supposed to start on 1/10/23 and weights would have been entered in either the Electronic Medical Record (EMR) or in facility weight book. The DNS also identified that although weekly weights were obtained on 1/12/23 and 1/31/23; (a total of 19 days between both dates), and on 2/22/23; (a total of 22 days from last date weighed) she could not provide documentation or evidence to identify weekly weights were done. Additionally, the DNS identified Resident #12's weight should have been obtained on 3 different occasions but were not. Facility policy on Obtaining Weights dated 6/13/22 identified residents shall have their weights obtained in a timely manner and the charge nurse and/or supervisor are responsible for accuracy of weights obtained. 47491

Based on staff interviews and record review for 1 sampled resident (Resident #9) reviewed for alcohol use, the facility failed to ensure a comprehensive care plan was implemented for a resident who consumed alcohol during recreational activities. The findings include: Resident #9's diagnoses included vascular dementia, atrial fibrillation, Major Depressive Disorder, heart failure and diabetes mellitus. A quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #9 as cognitively intact and required no assistance with transfers, dressing, and eating. Additionally, the MDS identified Resident #9 required set up assistance with bed mobility and toilet use. The care plan dated 5/4/23 identified Resident # 9 at risk for bleeding related to use of Xarelto (anticoagulation therapy). Interventions included to obtain laboratory blood work as ordered, provide medications as ordered, check neurological status as needed, observe for mental status changes, and to monitor for difficulty with speaking, walking, weakness, fainting, headaches, seizures, and light sensitivity. Interview with the Assistant Director of Nursing Services (ADNS) on 5/9/23 at 10:38 AM identified Resident #9 participate in recreational activities involving wine drinking and indicated the resident has the right to participate. Interview with the Registered Pharmacist (RPH) on 5/9/23 at 2:42 PM identified that alcohol consumption while on anticoagulation therapy could thin the blood and would require physician oversight. Interview with Medical Doctor (MD #2) on 5/9/23 at 2:52 PM identified he was aware that the facility served alcohol during recreational activities to residents. MD # 2 further identified Resident #9 was educated on the pros and cons of alcohol usage. Additionally, MD #2 identified he was not concerned for adverse effects with Resident #9's anticoagulation therapy and alcohol usage because the setting was controlled and monitored by the licensed nursing staff. Interview and record review with the DNS on 5/9/23 at 3:22 PM identified Resident #9 did not have a care plan with interventions for alcohol use during recreational activities. The DNS further identified there should have been a care plan with interventions in the medical record for licensed staff to review. The DNS also identified that without the care plan in place, licensed staff would not know what interventions to follow for Resident #9 alcohol consumption. A facility policy (no date) for resident care plans identified the facility will develop a comprehensive care plan for residents to identify problems, risks, needs and strengths with approaches and interventions that include measurable objectives that will be evaluated for effectiveness. Subsequent to inquiry, interview with the DNS on 5/11/23 at 4:00 PM identified Resident #9's medical record was updated to include a physician order and care plan for participation in recreational activities with alcohol usage as of 5/10/23.

Based on clinical record review and staff interview for one resident (Resident # 8) reviewed for at risk for pressure ulcer, the facility failed to accurately assess and stage the resident's pressure ulcer. The finding include: Resident # 8's diagnoses included acute kidney failure, Urinary Tract Infection (UTI), type 2 diabetes mellitus and hypertension. Resident # 8 was admitted to the facility on [DATE]. The admission MDS assessment dated [DATE] identified the resident was cognitively intact, required limited one-person physical assistance with bed mobility, transfers, and personal hygiene. The assessment also noted the resident was at risk for pressure ulcer and noted one stage 2 pressure ulcer. The physician's order dated 5/1/23 directed to apply air boots to left foot while in bed every shift. The care plan at risk for skin breakdown secondary diabetes mellitus dated 5/7/23 included interventions to apply air boot to left foot in bed, to check placement of boot while in bed, to off load heels every shift and assess wound with measurement weekly and notify dietician when needed. A review of the facility wound documentation with the Infection Preventionist on 5/9/23 at 10:12 AM identified Resident # 8 had a facility acquired unstageable left heel pressure ulcer that developed a blister upon return from the hospital. The blister area was not identified by the facility within 48 hours of the resident's readmission. The physician's order dated 5/12/23 directed to apply left heel Santyl External ointment 250 units/gram daily to Left heel topically one time a day. Additionally, directed to apply ointment [NAME] thick edge to edge on the eschar/ scabbing only followed by calcium alginate then a foam dressing. Interview RD #1 on 5/11/23 identified she was unaware the resident had a pressure ulcer on the resident's left heel until 17 days after 4/24/23 when the pressure ulcer was identified. Interview with the Infection Preventionist on 5/11/23 at 11:20 AM identified she could not provide evidence that the dietician had been notified of the resident pressure ulcer on the heel before 5/11/23.

Based on clinical record review, observations and interviews for one sampled resident, R#33, who was at risk for skin impairment, the facility failed to assess the resident's risk accurately on admission, and/or failed monitor the resident's skin condition, and/or failed to implement measures to prevent skin breakdown according to professional standards. The findings include: Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission Minimum (MDS) data set [DATE] indicated the resident was without cognitive impairment, required extensive to total assistance with activities of daily living, had limitations in range of motion to the lower extremities, transferred via a mechanical lift, was frequently incontinent, had intact skin and utilized a pressure reducing device in the chair and on the bed. A Pressure Risk assessment dated [DATE] noted that the resident scored 6, with a score of 8 indicative of high risk for skin breakdown. The care plan dated 11/9/11 indicated the risk for impaired skin integrity related to decreased mobility. Interventions included peri care after each incontinent care and whenever necessary, total assistance with toileting every two hours and to monitor for skin break down. Nurse's narrative notes dated 11/10/11 reported that R#33 had problems with positioning. Nurse's narrative note dated 11/16/11 during the 7 AM to 3 PM shift reflected that R#33 was treated with A and D ointment to a reddened area on the buttocks. On 11/19/11 nurse's narrative notes reflected that R#33's buttocks were "excoriated" and measured 3 X 3 cm with no depth. The note further indicated that [MEDICATION NAME] was applied to the coccyx area. Observation on 1/31/12 and 2/1/12 noted that the resident utilized a triangular styled sponge covered with lamb's wool while in a bedside chair. Observation on 2/2/12 at 9 AM noted that the resident's pressure reducing mattress was covered with an egg crate, followed by a mattress pad and a soaker pad. Observation on 2/2/12 at 10:39 AM with RN#2 noted that the R#33's buttocks were reddened, and there was also a reddened area to the lower back. Interview with RN #1 at 9:45 AM on 2/2/12 reflected that the plan of care did not include turning and repositioning or the use of pressure reducing devices. RN #1 stated "I missed it." Interview with the DNS on 2/2/12 at 9:50 AM identified that R#33's Pressure Skin Assessment did not accurately reflect the resident as the resident was incontinent and not continent, therefore the score of 6 was inaccurate. The interview also reflected that utilization of a sponge with sheep skin overlay and egg crate were not beneficial to the resident as they were not pressure reducing equipment. Further interview noted that weekly body assessments were not being performed by the licensed staff. According to National Pressure Ulcer Advisory Panel Guidelines for Prevention 2007, bed bound and chair bound persons whose ability to reposition is impaired are at risk for pressure ulcer. Merck Manual 2008,directed that old fashioned"egg crate" mattresses offer no advantage and sheepskin should be avoided as a treatment for [REDACTED].