Every finding on record at Buckingham Pavilion

Based on observation, interview, and record review, the facility failed to ensure food items were properly labeled and dated. These failures have the potential to affect all 110 residents receiving food prepared in the facility's kitchen. Findings include:On 12/02/25 at 9:18 AM, V3 (Kitchen Supervisor) stated all food items are labeled with a delivery date, a prepared or opened date and a use by date. V3 stated if the item is labeled by the manufacturer with a use by date printed on the product, then that is the date the kitchen follows and items need to be discarded or used by this date. V3 stated it is everyone's responsibility to label and date food items and it is important for all items to be labeled and dated with use by dates so the staff knows when food should be discarded. V3 said, we have to do this, so the residents do not get sick by eating expired foods. On 12/02/25 at 9:23 AM, the following items were found in the in reach-in refrigerator:1.) Opened package of orange colored cheese slices wrapped in plastic labeled with an open date of 11/30/25. The package was not labeled with a use by date. The cheese slices had printed on the product by the manufacturer best by date of 06/09/26. V3 stated these sliced cheese needs to be used by 06/09/26 because that is what is printed on the product, and that is why the staff did not need to label the package with a use by date once they opened the product because there was a use by date already on there. 2.) Opened 24-ounce glass jar of Gefilte Fish with a white sticker on the lid with the word pureed and open date 11/20/25 handwritten on the sticker. There was no use by date written on the sticker. V3 stated this item comes in shelf-stable but does not in pureed form and that it was pureed on 11/20/25 by the cook. V3 stated it is not labeled with a use by date because they follow the date printed on the product by the manufacturer. V3 pointed to the lid which had a best by date of January 2027 printed on it by the manufacturer. V3 stated that is how long the Gefilte Fish is good for (even after being opened) but that this product would be used up before then. On 12/03/25 at 9:35 AM, the following item was observed in cabinet where spices are stored:1.) Opened large plastic container of [NAME] Pepper labeled with delivery date 06/28/20, opened date 05/10/21. Printed on the container by manufacturer was best by date 03/11/22. On 12/03/25 at 9:42 AM, V3 (Kitchen Supervisor) stated the spice should have been thrown out because it has expired already. On 12/04/25 at 11:36 AM, V27 (Consultant Registered Dietitian) stated opened and prepared food items should be labeled with an open/prepared date and a use by date. V27 stated use by dates vary depending on what the item is, and the kitchen follows the policy on use by date recommendations. V27 stated it is important for items to be labeled with an open and use by date, so the staff is aware of when to discard the item to make sure the kitchen does not serve somebody something that has gone bad, so no one gets sick. V27 stated shelf stable items printed with a best by date on the item by the manufacturer means this item can be used up until the best by date assuming it is not opened before that date. V27 stated once the shelf stable item is opened it needs to be labeled with an opened and use by date and that the use by dates and storage guidelines should be followed per the kitchen policy/guidelines. V27 looked at the kitchen document titled Use by Date Recommendations and stated the cheese slices once opened are good for two weeks, not until 06/09/26. V27 stated if the Gefilte Fish had a best by date of January 2027 printed on the jar that means it is good until January 2027 if the product is not opened but that once the Gefilte Fish is opened it should be used within 5-7 days based on the kitchen guidelines. V27 stated Gefilte Fish would be considered as a higher acid product and therefore be good for 5-7 days after opening. V27 stated white pepper should have been discarded because it expired and /or they are no longer using it in the kitchen. V27 stated there are two residents in the facility who receive nothing by mouth (NPO). On 12/04/25, V1 (Administrator) provided list of diet orders for all residents in the facility. The diet order list indicates there is two residents receiving nothing by mouth (NPO). Facility provided policy titled, Labeling ad Dating Foods Policy dated 10/04/2016 which documents in part, for dry storage room once opened these items are refrigerated and labeled with the date opened and with discard or use by date. Refer to the following chart for use by recommendations. Refrigerated items are labeled with the date received and if not opened, are discarded by the manufacturer's expiration date. If opened, the cold food items is labeled with the date opened and the date by which to discard or use by. Refer to the following chart for the use by recommendations. Facility provided document titled, Use by Date Recommendations (undated) which lists different food items and documents in part, 1.) Canned good - high acid recommended maximum storage if opened 5-7 days, refrigerated.2.) American cheese (sliced) recommended maximum storage if opened 2 weeks refrigerated.3.) Ground spices recommended maximum storage if opened 2-3 years.

Based on observation, interview, and record review, the facility failed to ensure a resident (R101) took their medication, failed to ensure medications remained in their original packaging, failed to keep their medication carts clean and sanitary, failed to discard expired medications, and failed to store a medication per manufacturer recommendation for three out of three medications carts reviewed for medication storage.Findings include: R101's 'Face Sheet' documents in part diagnoses of mild cognitive impairment and disorientation. On 12/02/2025 at 10:11 AM, R101 was oriented to name and city but disoriented to time and situation. There was a small purple pill on top of R101's dresser near the bed. R101 did not know which medication it was and asked surveyor if R101 should take it. R101 asked for water and stated could take it now. Surveyor instructed R101 to hold and called for V4 (Registered Nurse). V4 stated V4 did not leave the medication at bedside and did not know which medication it was. V4 stated when nurses are administering medications, they are to make sure the residents (especially those with cognitive impairments like R101) swallow their medications. V4 grabbed the pill and compared it to those in R101's prescribed medication blister packs. V4 stated it could be Levothyroxine which was scheduled at 6:00 AM. V4 stated V4 was not completely sure and discarded the pill. On 12/03/2025 at 10:18 AM, surveyor reviewed the U-medication cart on the third floor with V11 (Licensed Practical Nurse/LPN). V11 stated the medication cart services 11 residents. In the second drawer of the cart, there were multiple loose pills not in their original packaging. For example, in the first slot there were two white capsules at the bottom of the drawer. The second slot had a yellow round pill, a blue round pill, blue oblong pill, and orange oblong pill at the bottom. The third slot had a yellow round pill, white oval, and square pill outside their packaging. The fourth slot had a yellow round pill. V11 did not know what the medications were. V11 stated the night shift nurse is supposed to be cleaning the carts nightly. On 12/03/2025 at 10:53 AM, surveyor reviewed the 2 South medication cart with V12 (LPN). V12 stated the cart serviced 25 residents. In the second drawer, the first and third slots had white pills not in their original containers. In the third drawer, there were loose pills in the first and third slots. When reviewing the narcotic drawer and bin, there was a bottle of Lorazepam 2 MG (milligram) per ML (milliliter) 30 ML bottle for R104. The packaging read store at cold temperature - refrigerate at 36F to 46F. When asked how long the bottle has been in the drawer, V12 stated the bottle was there when shift started in the morning. V12 stated the bottle has been open since 11/19/2025 and was not sure how long it's been out of the refrigerator. V12 stated each nurse is responsible for keeping their medication carts clean, safe, and sanitary. On 12/03/2025 at 11:14 AM, surveyor reviewed the medication cart for rooms XXX with V13 (Registered Nurse). V13 stated the cart serviced 16 residents. In the third drawer of the cart, there was greater than 30 pills/capsules that were loose and not in their original packaging at the bottom and back of the drawer. There was also different colored powder residue collecting at the back of each of the drawer slots. When reviewing the individualized medication blister packs, there were multiple expired medications for R113. There were ten Hydroxyzine 50 MG blister packs with varying expiration dates of 2/23/2025, 3/26/2025, 5/30/2025, and 9/30/2025. R113 also had two blister packs of Sennoside/Docusate Sodium that expired in 4/09/2024, three blister packs of Gabapentin 400 MG that expired 8/02/2025, and a blister pack of Loperamide 2 MG that expired 10/09/2025. R11 also had a blister pack of Senokot-S that expired 9/25/2025. On 12/04/2025 at 9:42 AM, V2 (Director of Nursing) stated all nurses on all shifts should be checking and maintaining their medication carts. The night shift nurses are responsible for cleaning the carts, but the facility also has a part-time nurse that is responsible for overseeing all medication carts weekly. Regarding the pill at R101's bedside, V2 stated nurses are not to leave medications at bedside. V2 stated when administering medications, nurses are to make sure the resident swallows them. Regarding R104's Lorazepam, V2 stated the nurses are to withdraw the ordered dose and place it back into the fridge for storage. Facility's Administering Medications policy (11/06/2019) documents in part: Medications shall be administered in a safe and timely manner, and as prescribed. Facility's Storage of Medications policy (10/28/2019) documents in part: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals shall be stored in the packaging, containers or other dispensing system in which they are received. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location.

Based on observation, interview and record review the facility failed to keep the door closed and educate visitors on proper Personal Protective Equipment (PPE) to be used when entering a resident room on Contact/Droplet precautions for one (R121) resident, failed to don proper PPE when entering the room of one (R1) resident room with a diagnosis of COVID-19 and failed to ensure clean linen was covered on two second floor linen carts. These failures have the potential to affect 51 residents residing on the second floor. Finding Include: 1. R121 was admitted to the facility on [DATE] with diagnosis not limited to Non-ST Elevation (NSTEMI) Myocardial Infarction Presence of Coronary Angioplasty Implant and Graft, Paroxysmal Atrial Fibrillation, Atherosclerotic Heart Disease of Native Coronary Artery, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 Through Stage 4 Chronic, Acute Diastolic (Congestive) Heart Failure , Chronic Kidney Disease, Stage 3, Coronary Atherosclerosis due to Calcified Coronary Lesion, Atherosclerotic Heart Disease of Native Coronary Artery, Bradycardia, Dizziness and Giddiness, Methicillin Resistant Staphylococcus Aureus Infection, Streptococcal Infection, Specified Bacterial Agents as the Cause of Diseases Classified Elsewhere and Pain In Left Leg. R121's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 13 indicating intact cognitive response. R121's Physician Orders document in part: 11/21/25 Strict contact isolation precautions due to an active infection. Single room, resident alone and not cohorted with a roommate. Resident remains in the room at all times. All services done inside the room. 11/26/25 Vancomycin HCl (Hydrochloric Acid) in NaCl (Sodium Chloride) 1GM (Gram)/250ML (Milliliters)-0.9% Solution Dose: 1000MG/ (milligram) 250ML (intermittent) @ (at) 125 ml/hr. (Hour) every three days 0600 Through: 12/28/2025 For: Bacterial Infection MRSA (Methicillin-resistant Staphylococcus aureus) in nose. R121's Care Plan document in part: Problem: 11/21/25 (Infection/Prevention): Related To: MRSA (nares). Approach: 11/21/25 Nurses - Contact precautions. 12/02/25 Nurses - Droplet precautions Nurse Aide - Droplet precautions. Goal: 11/21/25 to prevent the spread of infection. 11/21/25 Problem: (Infection/Prevention): R1 has Infection and receiving IV (intravenous) antibiotic Related to: dx (diagnosis) of Acute bacterial sinusitis, streptococcal bacteremia, sphenoid sinusitis, MRSA. R121's Hospital Record dated 11/21/25 document in part: Discharge Diagnoses: Sepsis Secondary to Step Anginous Bacteremia with Bilateral bacterial sinusitis, Bilateral bacterial sinusitis of sphenoid/ethmoid with MRSA and Strep anginous and mixed Gram-positive aerobes c/f (consider/rule out) skull base osteomyelitis. Infectious workup completed with BCX (blood Culture), CBC (complete Blood count), imaging. Found to have S. anginous in blood meeting criteria for sepsis. Taken for endoscopic sinus surgery. Found to have MRSA in OR (operating room) cultures with S. anginous. Started on Vancomycin and will need 6-week total course estimated end date 12/28/25. On 12/02/25 at 11:37 AM, observed R121's door posted with signage for Contact Precautions and Droplet Precautions. R121's door was wide open. Surveyor could see from R121's doorway that R121's was lying in bed. Supply of PPE outside R121's door included N-95 face mask, face shield, gowns, gloves. Surveyor knocked on the door, introduced self and asked if it would be okay to enter R121's room. R121's waved his hand and said, come in, come in. I cannot see you. I am blind. On 12/02/25 at 2:06 PM, observed R121's door wide open. Observed V21 (R121's Friend) inside R121's room talking to R121 within close proximity to each other. On 12/02/25 at 2:09 PM, V22 (Registered Nurse) observed R121's door wide opened and stated R121's door should be closed because he is on droplet/airborne precautions and that R121's visitor inside his room should be following the posted guidelines for wearing PPE (Personal Protective Equipment). On 12/02/25 at 2:13 PM, V21 (R121's Friend) stated she is R121's significant other and has visited him every day since he was admitted to the facility. V21 stated R121's door to his room is always wide open, never closed. V21 stated no one has said anything to her about wearing PPE. V21 stated those signs have only been up there for two days. V21 stated when the signs went up, she asked the staff if what he (R121) had was contagious and they said no to her. V21 does not remember the name of the staff who told her that, but she did ask because she was worried for herself. V21 stated the only staff wearing PPE when they go into R121's room are the therapist. V21 stated the nursing staff does not wear anything when they go in and out of R121's room. V21 said, they look just the way they do now walking in the hallway. V21 stated when staff go into R121's room to deliver his meals they also do not wear anything. On 12/02/25 at 2:21 PM, V2 (Director of Nursing) stated R121's family is non-compliant with wearing PPE and she thinks she provided education to V21 about wearing PPE but V21 does not follow the guidelines. V2 stated she does not remember if she documented that the education was done with V21 but if she did it would be documented in the progress notes section of R121's electronic health record (EHR). V2 stated R121 is on contact and droplet precautions due to having MRSA (Methicillin-Resistant Staphylococcus Aureus) in the nares and therefore R121's door should be closed to decrease the transmission through the air. V2 stated because the MRSA is in R121's nares if he sneezes it could be transferred through the air which is why his door should always be shut because it could pass to other residents. On 12/02/25 at 3:30 PM from the doorway surveyor observed R121 in bed with V21 (R121's Friend) sitting on R121's bed next to R121 with no PPE in use. Signage posted on the entry door of R121's room indicated Contact Precautions and Droplet Precautions. On 12/02/25 at 3:31 PM surveyor asked V21 (R121's Friend) to exit the room. Surveyor asked V21 was she aware and receive education that she (V21) should have a mask and a gown on while in R121's room. V21 said the staff never educated her about wearing the gown and a mask. They just put that sign on the door for Droplet Precautions yesterday. I have visited R121 every day since he has been here, and no one has told me that I need to wear a gown and mask until today. I have been coming here not knowing a thing. I found out that R121 has MRSA in the nares and now I may have it. I have a doctor appointment to see if I am infected. V21 then turn and asked R121 how many days have you been here. R121 responded, 12 days. V21 then reentered R121's room without putting on any PPE. On 12/02/25 at 3:35 PM V5 (Registered Nurse) stated if R121 is on droplet precautions anyone that enters the room should wear a mask. I won't be able to answer any question about R121because that is not my resident. I saw V21 (R121's Friend) and I am not sure who she is. On 12/02/25 at 3:40 PM RN V22 (Registered Nurse) stated I think that I have taken care of R121 one time before today. V2 (Director of Nursing) was educating V21 (R121's Friend), not me. On 12/02/25 at 3:44 PM V2 (Director of Nursing) stated R121 came in with an order and I just talk to R121's son that said R121's isolation should be six weeks. We should do another culture. The Contact and Droplet Precaution signage has been on R121's door since he has been here. R121 has MRSA of the nares. V21 (R121's Friend) keep opening R121's door. I talked to V21 and told her you need a mask and gown. I just went there, and she said no mask no gloves. The droplet precautions carry in the air and R121's door should be closed. I educated V21 multiple times. I teach them right away and the family is not complying. Surveyor asked V2 if she has documented the education for the use of PPE and keeping the door closed. V2 responded, I will check. On 12/03/25 at 9:40 AM V2 (Director of Nursing) stated the notes for PPE (Personal Protective Equipment) education for R121's family and visitors, I did not document at that time, I did a late entry. The second time that I saw V21 (R121's Friend) was yesterday. The other time that I saw V21 was in the hallway. R121's son was educated yesterday and on admission. R121's Progress Note dated 12/02/25 6:26 PM document in part: Late entry, upon admission resident's female friend in the room, education about isolation was done, the friend was very upset and screamed to question about the isolation and walked out of the room reluctantly because resident needed to be physically assessed, and the writer requested visitors to follow the isolation. Resident's son was educated for isolation and resident's granddaughter and daughter in law all were educated for the isolation and precaution. R121's Progress note dated 12/02/25 06:49PM document in part: Resident's female friend did not follow the isolation and ignored the door signs, the floor nurse reported to this writer. Spoke with the friend regarding the isolation and following the instruction to protect herself and others, she stated that she is not going to wear the gloves, and she is not going to wear the mask, after teaching. And later she walked out of the room with the gown on, followed this friend to insist her to follow the isolation requirement, this friend yelled at this writer and went to the room, removed her gown and sat next to the resident and stated that she cannot tolerate the gown, she is not going to wear it. Educated this friend about keeping the door closed, this friend was very upset and kept coming out of the room and kept the door open, this writer went to several times to close the door, and this visitor opened the door after. 2. R1's Progress note dated 12/03/25 3:53 AM document in part: Infection/ABT (Antibiotic) MRSA Nares, Streptococcus anginous bacteremia. Isolation: Contact Precaution. R1 was readmitted to the facility on [DATE] with diagnosis not limited to Heart Failure, Adult Failure to Thrive, COVID-19, Diabetes Mellitus, Muscle Weakness, Acute Kidney Failure, Paraplegia, Vascular Dementia, Secondary Malignant Neoplasm of Bone, Lymphedema, Hypo-Osmolality and Hyponatremia, Secondary Malignant, Secondary Hypertension, Synovial Cyst of Popliteal Space [Baker], Right Knee, Adjustment Disorder with Depressed Mood, Acute on Chronic Right Heart Failure, Unilateral Inguinal Hernia, Severe Protein-Calorie Malnutrition, History of Falling, Anemia in other Chronic Diseases, Acute Kidney Failure, Neuromuscular Dysfunction of Bladder and Wedge Compression Fracture of Third Lumbar Vertebra. R1's Physician Orders document in part: 12/01/25 strict contact & droplet isolation precautions due to an active infection. Single room, resident alone and not cohorted with a roommate. Resident remains in the room at all times. All services done inside the room. Three times a day AM, PM, NOC last date: 12/05/25. R1's Care Plan document in part: 12/02/25 Problem: (Infection/Prevention): Related to: MRSA nares, Respiratory infection (COVID). Approach: 12/02/25 Nurses - Droplet precautions Contact precautions. Droplet precautions Contact precautions. Nurses - Airborne precautions Nurse Aide - Airborne precautions. On 12/02/25 at 03:19 PM R1's entry door was observed with signage indicating contact/ droplet precautions with the door closed. On 12/03/25 at 9:49 AM two linen carts were observed in the hallway on the second floor with the flaps open exposing the clean linen. On 12/03/25 at 10:20 AM R1's call light was activated. V25 (Certified Nurse Assistant) was observed with a standard surgical face mask in place. V25 applied a gown, gloves and a face shield then entered R1's room. V25 then exited R1's room after removing the face mask, gown, face shield and gloves. Surveyor asked V25 was she aware that R1 was on isolation due to COVID-19 and what kind of mask should be worn. V25 responded yes, I should have put on the white mask for my own protection. The flaps on the linen carts should be closed. Maybe I left the flap open because I went to answer R1's call light. On 12/03/25 at 2:08 PM V14 (Infection Preventionist) stated R121 is on contact and droplet precautions isolation. The isolation entails before entering R121's room each person must implement PPE (Personal Protective Equipment) precautions, including putting on a mask, gloves, face shield and gown. The family members and visitors are supposed to wear the same PPE when entering R121's room. R121 was admitted to the facility on [DATE]. The isolation signage has been on R121's door since the day he was admitted . The education documentation was when the (V2) Director of Nursing noticed V21 (R121's Friend) did not have PPE on and V2 educated her (V21). I do not know if V21 had visited R121 prior to yesterday (12/02/25). PPE that should be worn for resident with COVID-19 are a gown, N95 mask, face shield and gloves. The purpose of wearing PPE is to prevent the spread of infection. The purpose for wearing the N95 mask is infections can spread. V14 (Infection Preventionist) stated R121 had MRSA of the Nares on admission, and they are placed on contact and droplet precaution. I do some care plans and MDS does them as well. Contact isolation was initiated on 11/21/25. The care plan should have indicated contact and droplet precautions immediately upon admission because contact and droplet precautions are for MRSA of the nares. I would have to check who updated the care plan. Signage titled Contact Precautions document in part: Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Signage titled Droplet Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry or Remove face protection before room exit. On 12/04/25 at 11:01 AM V14 (Infection Preventionist) stated the flaps on the linen carts should always be closed. To prevent the spread of infection. The second-floor census was obtained from the Room/Bed List present to the surveyors on 12/02/25. Policies: Titled Infection Prevention and Control Program dated 05/10/20 document in part: The facilities infection prevention and control program shall include the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement and following accepted national standards. (2) Written standards, which include: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (4) A system for recording incidents identified under the facility's IPCP (Infection Control and Prevention Program) and the corrective actions taken by the facility. Titled Isolation – Categories of Transmission-Based Precautions dated 10/8/16 document in part: Policy Statement: Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation 2. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. 4. The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission-based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. Contact Precautions: 1. Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. 3. The individual on contact precautions will be placed in a private room if possible. 4. Staff and visitors are instructed to wear gloves (clean, non-sterile) when entering the room. 5. Staff and visitors are instructed to wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Droplet Precautions 1. Droplet Precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 microns in size] that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). 2. Residents on droplet precautions will be placed in a private room if possible. 3. Masks will be worn when entering the room. 4. Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions. Titled Linen dated 11/28/17 document in part: Personnel shall handle, store, process, and transport linens so as to prevent the spread of infection. 7. Clean linen shall be kept covered when on linen carts. Titled Contact Precautions dated 11/28/17 document in part: Contact precautions are intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident of environment and requires the use of appropriate PPE, including a gown and gloves before and upon entering the room. Prior to leaving the resident's room the PPE is removed, and hand hygiene is performed. Titled Droplet Precautions dated 11/28/17 document in part: The use of droplet precautions applies when respiratory droplets contain pathogens which can be spread to another susceptible individual. Respiratory pathogens can enter the body via the nasal mucosa, conjunctivae and less frequently the mouth. Appropriate facemasks should be used upon entry into a resident's room with respiratory droplet precautions. Based upon the pathogen or clinical syndrome, if there is a risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, glove and gown as well as goggles should be worn.

Based on observation, interview, and record review, the facility failed to provide a dignified dining experience for one resident (R114) out of a total sample of 23 residents. Findings include: R114's 'Face Sheet' and 'Physician Orders' document in part diagnoses of dysphagia (difficulty swallowing), sialadenitis (inflammation/infection of salivary glands), progressive bulbar palsy (disease that causes gradual weakness in muscles for speaking, swallowing, chewing, and facial expression), osteoarthritis, osteoporosis, and abnormal involuntary movements. R114's 'Physician Orders' document in part orders for pureed diet with honey-thick liquid. R114's 10/14/2025 MDS (Minimum Data Set) assessment and 'Care Plan' documents in part needing supervision or touching assistance when eating. During lunch service on 12/02/2025, R39 and R114 sat at a table across from each other. At 12:19 PM, R39 received a lunch tray. V4 (Registered Nurse), V9 (Activity Aide), and Certified Nursing Assistants (CNAs) were passing lunch trays. At 12:21 PM, V4 sat R93 to the right of R39 and the left of R114. At 12:23 PM, R93 received a lunch tray but R114 remained without one. Staff continued to pass trays to other residents/tables. At 12:27 PM, R39 and R93 were eating lunch but R114 remained without lunch tray. At 12:35 PM, V29 (Housekeeping) pointed to R114 and asked V9 (Activity Aide) what about [R114]? V9 stated nursing staff needed to set up a tray for R114. At 12:37 PM, V4 and V9 rearranged some residents in the dining table. At 12:39 PM, V4 sat R114 at a different table with R16 and R72 who were both eating lunch. At 12:41 PM, staff placed lunch tray in front of R114 but did not set up the meal tray (did not thicken juice). At 12:45 PM, V7 (CNA) sat down next to R114 and provided meal assistance. On 12/04/2025 at 9:36 AM, V2 (Director of Nursing) stated ideally, the staff are to serve all the residents at the same table at the same time. V2 stated those requiring feeding assistance should also not be served last. Facility's 'Food Service and Distribution' policy dated 7/14/2014 do not document procedures or protocol on how to protect residents' dignity while serving resident meals in the dining room. Facility's 11/28/2017 'Resident Rights Policy' documents in part: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside [facility]. Including those specified in this section. [Facility] treats each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. [Facility] protects and promotes the rights of the residents. The resident has a right to be treated with respect and dignity.

Based on interview and record review, the facility failed to update a resident's (R41) care plan to coincide with their requested advanced directive wishes for one out of a final sample of 23 residents.Findings include: On [DATE] at approximately 3:00 PM, V4 (Registered Nurse) stated R41 was DNR (Do Not Resuscitate). R41's IDPH (Illinois Department of Public Health) Uniform Practitioner Order for Life-Sustaining Treatment (POLST) form dated [DATE] documents in part that R41's wishes include NO CPR [cardiopulmonary resuscitation]: Do Not Attempt Resuscitation (DNAR) with selective treatment. R41's Face Sheet and Physician Orders read DNR. However, R41's Care Plan dated [DATE] documents in part that R41 is FULL CODE (attempt resuscitation). On [DATE] at 9:34 AM, V2 (Director of Nursing) stated that residents' care plans should be updated when there are any changes to residents' plan of care. Facility's Health Care Policies Manual ([DATE]), Section 3.1, documents in part that care is subject to related physician orders and the resident's advance directives. Facility's Comprehensive Person-Centered Care Planning Manual ([DATE]) documents in part: [Facility] shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan describes the following: Any services that would otherwise be required under the regulations but are not provided due to the resident's exercise of rights, including the right to refuse treatment. Policy also documents in part that the interdisciplinary team is to review and revise the comprehensive care plan after each assessment.

Based on interview and record review, the facility failed to obtain a new Preadmission Screening and Resident Review (PASRR) after a resident's (R101) PASRR Level II short-term approval ended for one out of a total sample of 23 residents. Findings include: R101's 'Face Sheet' documents in part diagnoses of schizophrenia, bipolar disorder, and depressive episodes. R101's [DATE] 'Notice of PASRR Level II Outcome' documents in part a determination of Short Term Approval without Specialized Services. The short-term approval ended on [DATE]. Surveyor requested for the updated PASRR. On [DATE] at 12:17 PM, V10 (Admissions Director) stated facility resubmitted R101 for assessment and was flagged again for requiring a PASRR Level II evaluation. V10 stated the protocol is if it is an expired Level II PASRR, facility must resubmit for screening. V10 provided R101's Notice of PASRR Level I Screen Outcome dated [DATE] (time of survey). No other PASRR submitted after [DATE] or prior to start of survey. Facility's Health Care Policies Manual ([DATE]), Section 2.10 documents in part: Preadmission screening for individuals with a mental disorder and individuals with intellectual disability. [Facility] shall not admit any new resident with Mental disorder unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, that, because of the physical and mental condition of the individual, the individual requires the level of services provided by [Facility]. Policy does not read procedures related to short-term approvals.

Based on interview and record review, the facility failed to refer residents with newly evident or possible serious mental disorder for Preadmission Screening and Resident Review (PASRR) to the appropriate state-designated authority. This failure affects four (R22, R32, R47, R82) residents in a total sample of 23 residents reviewed. Findings include: On 11/13/2024 at 3:19 PM, V8 (Admissions Director) stated all eligible residents should receive a PASARR screening upon admission. V8 stated the hospital is responsible for completing the Level 1 Pre-Admission Screening and Resident Review (PASARR) prior to a resident's admission to the facility. V8 stated the facility ensures the resident has a Level 1 PASARR prior to admission and the facility is responsible for ensuring that the resident PASARR screening are accurate upon admission into the facility. V8 stated the facility no longer utilizes the OBRA/Omnibus Budget Reconciliation Act screening for the PASARR screenings. V8 stated the facility staff is responsible for inputting resident data into the PASARR screening program. V8 stated based on resident medical records information that is input, a PASARR screening determination is generated in the screening program. V8 stated information such as mental health diagnoses, demographics, and medications are input into the screening program. V8 stated the PASARR determination is then referred to the social services department. V8 stated if information is inaccurately input into the screening program, this could result in an inaccurate PASARR screening report. V8 stated the purpose of the PASARR screening is to ensure the resident's mental health level of care is provided. V8 stated she is unsure of how often residents need to be screened for PASARR screenings. V8 stated she is not sure if a resident should be screened for another PASARR screening if they have a new diagnosis of a mental health condition while residing in the facility. V8 stated the DON/determination of needs score is also provided on the PASARR screening. V8 stated the DON score determines whether the resident is appropriate for the facility. 1.) R22's Face sheet documents that R22 is an [AGE] year-old male admitted to the facility on [DATE] who has diagnoses not limited to: schizophrenia. R22's PASARR screening titled OBRA I Initial Screening is dated 01/07/2012. OBRA I screening documents that there is no reasonable basis for suspecting DD/Developmental Disability or MI/ Mental Illness. There is no documentation to show that R22 was screened for a new Level I PASARR screening or a Level 2 PASARR screening. 2.) R82's Face sheet documents that R82 is a [AGE] year-old female admitted to the facility on [DATE] who has diagnoses not limited to: schizophrenia, bipolar disorder, and depressive episodes. R82's PASARR screening titled Notice of PASRR Level I Screen Outcome dated 11/10/2022, documents that a Level II screening is not required due to no SMI (severe mental illness)/ID (intellectual disability). R82's PASARR screening does not document that R82's diagnoses of schizophrenia and bipolar disorder were included as mental health diagnoses on R82's screening that was submitted to the screening agency. 3.) R47's Face sheet documents that R47 is a [AGE] year-old female admitted to the facility on [DATE] who has diagnoses not limited to: schizoaffective disorder, bipolar type. R47's PASARR screening titled Level I Notice of Determination dated 02/18/2020 documents that R47's PASARR referral type was a private hospital, the determination was withdrawn, and R47 does not require specialized services. Facility document dated 08/08/2019, untitled, documents in part, Coordination includes- (2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. 41356 4.) R32 is [AGE] years old, recent admitted [DATE]. R32 was diagnosed for vascular dementia and psychotic disorder with hallucination dated 10/19/2021 and major depressive disorder dated 12/06/2023. After request for Preadmission Screening and Resident Review (PASRR), facility submitted OBRA 1 - Interagency Certification of Screening Result with 01/27/2020 as date of screening. On 11/13/2024 at 1:11 PM, V14 (Social Service Director) stated that she will coordinate with V8 (Admission Director) if R32 has Preadmission Screening and Resident Review (PASRR) to the new system. R32 needs a new assessment because the OBRA 1 - Interagency Certification of Screening Result was dated 01/27/2020, after which R32 was diagnosed with psychotic disorder with hallucination on 10/19/2021. On 11/13/2024 at 2:32 PM, V8 stated that all residents are required to have Preadmission Screening and Resident Review (PASRR) with the new system. It includes residents with mental illness or not. All residents do not use OBRA assessment anymore. Once Preadmission Screening and Resident Review (PASRR) level 2 is needed, it will be communicated to V14. Understanding the level of care needed related to mental health is important. It is also incorporated in the care plan. V8 stated to check if R32 has an updated Preadmission Screening and Resident Review (PASRR). On 11/14/2024 at 9:32 AM, V1 (Administrator) stated that R32 does not have an updated Preadmission Screening and Resident Review (PASRR). Preadmission screening for individuals with a mental disorder and individuals with intellectual disability policy dated 08/08/2024, reads: Facility will not admit any new resident with mental disorder unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission. 2022 Illinois PASRR Redesign Understanding Your Changing Role in the PASRR Process Improvements to Preadmission Screening and Resident Review (PASRR) processes will be launched by the (state agency) and new partner, (name of company), on March 14, 2022. Updates include the implementation of a new web-based management system, (name of system). Changes are being made to the following processes: o Submission of all PASRR Level I Screens o Review of all PASRR Level I Screens o Completion of PASRR Level II Assessments for Serious Mental Illness (SMI) As of March 14, 2022, OBRA-I is being retired for Level I PASRR use. You will use the Level I Screening Tool found in (name of system).

Based on observation, interviews, and review of records the facility failed to follow their policy in providing privacy to 1 out of 1 resident (R94) when providing bedside care for a total sample of 23 residents reviewed. Findings include: R94 is [AGE] years old, admitted in the facility on 02/06/2024. R94 medical diagnosis includes malignant neoplasm of the brain. On 11/12/2024 at 11:51 AM, while passing the hallway, the door of R94's room was open visually able to see the R94's bed elevated without clothes from waist down. V15 (Certified Nursing Assistant) was seen taking linen on the cart located at the hallway. V15 stated that she was doing patient care as R94 was calling for V15. On 11/12/2024 at 12:29 PM, after finishing bedside care V15 was asked why the door was opened during bedside care with R94? V15 stated that she was taking some things in her linen cart when she opened the door. V15 stated that R94's gown may not be placed on her that could have exposed her visually from the hallway. V15 was asked why privacy curtain was not used? V15 replied that she forgot to use the curtain. V15 stated that putting herself to R94 situation being exposed, she will not feel well and would feel bad that she was exposed. V15 stated the importance of using privacy curtain when taking residents. V15 stated that R94 does not have clothing waist down because R94 had a bowel movement. On 11/13/2024 at 12:51 PM, V1 (Administrator) stated that as far as practicable privacy of residents that are exposed needs to be maintained by using privacy curtain and closing the door. This applies to other residents inside the room and people passing in the hallway. On 11/14/2024 at 10:55 AM, V3 (Wound Coordinator/Acting Director of Nursing/Registered Nurse) stated that privacy curtain is used when a resident is exposed like when changing diaper. The use of privacy curtain also applies to a nursing procedure like performing G Tube (stomach feeding tube) care. When a resident is exposed, not only does the resident lose their privacy but also their dignity. V3 said that she will be embarrassed if she will be on a similar situation as being exposed. Privacy policy dated 09/16/2024, reads: Resident rooms shall be designated and equipped for adequate nursing care, comfort, and privacy of residents. Bedrooms shall be equipped to assure full visual privacy for each resident. Provide each resident with the opportunity for personal privacy and ensure privacy during treatment and care of personal needs.

Based on observations, interview and review of records, facility failed to follow a resident's care plan to ensure the call light was within reach for 1 (R98) out of three residents reviewed for call lights in a sample of 23. Findings include: On 11/12/2024 at 11:41 AM, surveyor observed R98 lying in bed. Surveyor observed R98's call light was on the fall mat and not within reach of the resident. R98 stated that she doesn't even know where her call light is at. On 11/12/2024 at 11:45 AM, surveyor asked V5 (Registered Nurse) to come into R98's room. V5 came in and saw R98's call light on the floor mat. Surveyor asked V5 if R98 can reach her call light. V5 stated that R98 cannot reach her call light safely. Surveyor observed V5 tie R98's call to her side rale. On 11/14/24 at 11:00 AM, V3 (Wound Care Nurse/Registered Nurse) stated she is the currently the acting director of nursing (DON) and helping out V2 (Director of Nursing) because she is out sick. V3 stated call lights are supposed to be within the reach of the residents. V3 stated that if the call lights are not within reach of the residents, care will not be given on time and the resident will have a risk of falling. R98's face sheet documents in part: R98 has a diagnosis of history of falling. R98's care plan documents in part: Reinforce to use call light when needing assistance. Place call light within reach. Facility's call light policy (12/5/2019) documents in part: It is the policy of the facility to maintain a call light system for residents to summon staff.

Based on observation, interview, and record review the facility failed to provide privacy and confidentiality for three (R37, R44, R82) resident's personal medication administration record. Finding include, On 11/12/24 at 9:25 AM, surveyor observed V9 (Registered Nurse) administer R37, R44, and R82's medications. On 11/12/24, at 9:29 AM, V9 prepared R37's medications. V9 stated, Let me go see if R37 wants any medication for constipation. At 9:32 AM, V9 walked away from the medication cart with the computer screen open with R37's personal medication on the lap top screen. V9 returned to the medication cart, then left the cart again to answer the phone at the end of the hallway, the computer screen was open with R37's personal medical information exposed. On 11/12/24, at 9:56 AM, V9 prepared R44's morning medications. V9 walked away from the medication cart to administered R44's medications and left the computer screen open with R44's personal information exposed. On 11/12/24, at 10:01 AM, V9 prepared R82's morning medications. V9 walked away from the medication cart to administer R82's medications and left the computer screen open with R82's personal information exposed. On 11/12/24, at 10:20 AM, V9 stated, I forgot to lock the computer screen, or I could have minimized the screen so no one would have been able to visualize the residents' personal information. On 11/14/24, at 10:30 AM, V3 (Assistant Director of Nursing/Wound Care Nurse) stated, The nurses should lock their computer screens before walking away to provide the resident privacy. If the computer screen is unlocked, anyone, residents, and visitors can see the resident personal information. Policy-Documents in part: Resident Rights -You have the right to privacy over your personal and clinical records

Based on observations, interviews and record reviews, facility failed to follow their policy to ensure routine wellbeing checks are done for 1 (R45) out of three residents reviewed for activities of daily living (ADL) care in sample of 23. Findings include: On 11/12/2024 at 11:21 AM, surveyor observed R45 laying on her back. There was a foul odor coming from R45. R45 stated that she hasn't been changed. On 11/12/2024 at 12:21 PM, surveyor observed V7 (Certified Nursing Assistant) go into R45's room and drop of her lunch meal tray and walk out. R45 was still laying on her back. On 11/12/2024 at 1:01 PM, surveyor observed V7 go into R45 to feed the resident. V7 did not change or turn the resident. R45 was still laying on her back. On 11/12/2024 at 1:30 PM, R45 was still not cleaned up, turned or repositioned. R45 was laying on her back. On 11/12/2024 at 1:35 PM, V7 stated that the last time she changed or repositioned was at 10:00 AM. V7 stated that she is supposed to check on residents and reposition them every two hours. On 11/12/2024 at 1:45 PM, surveyor observed R45's wound. Wound on sacrum is dry and closed. On 11/14/2024 at 11:08 AM, V3 (Wound Care Nurse/Registered Nurse) stated that their policy for wellbeing checks states 'nursing staff shall perform routine checks throughout their shift'. V3 stated that routine checks are every two hours. They are supposed to check their mental status, positioning, and if they need anything. If they are dependent and non-verbal we check if they have soiled themselves and we have to change them at least every two hours. For someone who is dependent and non-verbal, if they are not checked every two hours, they may not get help in a timely manner. If there is a medical emergency, we may not be able to respond on time. V3 stated that R45 has a moisture associate wound which is like a skin tear. V3 stated that if R45 is not checked on frequently then her moisture associated rash or skin tear can get worse. R45's care plan documents in part: R45 has urinary incontinence, fecal incontinence, open lesion moisture associated. Assist with hygiene and general skin care. Keep skin clean and dry. Establish consistent routine checks. R45's physician order sheet documents in part: perineal (diaper dermatitis), frequency: twice a day. Clean with normal saline. Treatment: Zinc oxide/vitamin A&D ointment. R45's Treatment Administration Record for 10/2024 documents in part: perineal (diaper dermatitis), frequency: twice a day. Clean with normal saline. Treatment: Zinc oxide/vitamin A&D ointment. R45's MDS Section H, Bowel and Bladder (10/04/2024) documents in part: R45 always has urinary and bowel incontinence. R45's MDS Section GG, Functional Abilities (10/04/2024) documents in part: when it comes to toileting hygiene, R45 is completely dependent where the helper does all the effort. Facility Wellbeing checks (08/19/2016) documents in part: Nursing staff shall perform routine checks throughout their shift and ensure that any identified needs are addressed in a timely fashion.

Based on observations, interviews, and record reviews the facility failed to follow their enteral tube feeding via pump policy to ensure 1 (R21) resident's enteral nutrition bottles were labeled before administration in a sample of 23 reviewed for enteral tube feeding. Findings include, R21's clinical record document in part, R21 was admitted with the following medical diagnosis Corticobasal degeneration, Gastro-esophageal reflux disease with esophagitis, pneumonitis due to inhalation of other solids and liquids, dysphagia, gastrostomy status, secondary hypertension, anemia, inflammatory disease of prostate, and chronic obstructive pulmonary disease. Physician orders: 11/11/24: Tube feeding: (brand name of feeding solution) 35m/hour continuous via gastric tube. Keep head of bed elevated 30-45 degrees. Assess feeding tube placement, flush with 30 ML (milliliters) before and after medication administration. Monitor for signs of infection on the insertion site. Change gastric tube site dressing with dry 4x4 gauze after site is cleaned with saline gauze. On 11/12/24 at 11:11 AM, surveyor and V6 (Licensed Practical Nurse) observed R21 resting in bed with his gastric tube infusing. The infusing bottle of gastric feeding solution did not bear a label. The feeding bottle did not have the following information: name of the feeding solution, name of resident, date, start time, or rate. There was a second bottle hanging with a clean substance in the bottle, no label or resident's information was present. On 11/12/24 at 11:15 AM, V6 (Licensed Practical Nurse) stated, When I came into work R21's gastric feeding tube was already up and infusing. R21 was readmitted back to the facility yesterday on 11/11/24. The night nurse did not have the feeding bottle of R21's ordered solution available in the one-liter bottle. We did have the formula in the small 8-ounce cartons. The night nurse and I retrieved another feeding one-liter bottle and poured out feeding solution poured in the small eight-ounce cartons of the ordered feeding solution and pulled of the feeding label because the label was not the correct feeding solution. The name of the feeding solution, residents name, date, and time the solution was started, and rate should be on the feeding bottle. The second bottle hanging is R21's water flush bottle. The bottle does not have any information on the bottle. The bottle should have R21's name, date, time, amount of water flush and rate on the bottle. I forgot to place the label on the water bottle. On 1/19/24 at 12:10 PM V3 (Assistant Director of Nursing/Wound Care Nurse) stated, All gastric feeding bottles and water bottles are labeled with the resident's name, room number, date opened, time opened, formula type, rate flow, and water flow rates. If the feeding and water bottles are not labeled, the resident could potentially receive old, spoiled formula and water. The next nurse would not know when or how much feeding formula or water the resident received. That could potentially cause harm to the resident such as weight loss, infection, or wrong formula given. Policy Documents in part: Feeding Tube Administration dated 8/9/24. Administration the prescribed enteral nutrition formula unless approved by the dietician or physician. The type, volume, and rate will be determined by the attending physician or dietitian based on the patient's nutritional requirements. Label the formula with patient's name, date, start time rate.

Based on observation, interviews, and review of records the facility failed to provide dental services for a resident who has difficulty chewing due to lack of upper teeth for 1 out of 1 resident (R56) for a total sample of 23 residents. Findings include: R56 is [AGE] years old, admitted in the facility on 12/16/2023, with diagnosis of chronic kidney disease (stage 4), dependence on renal dialysis. R56 cognition was intact during conversation. R56 can express his thought well. On 11/12/2024 at 11:55 AM, R56 stated that he cannot chew some food because his teeth were extracted prior to coming in the facility two (2) years ago. Until now he does not have any dentures. R56 opened his mouth and does not have any upper teeth visually seen. R56 stated that he has hard time chewing meat because of lack of dentures. On 11/14/2024 at 10:23 AM, V13 (Registered Nurse) stated that R56 does not have dentures for eating. He (V13) does not know if R56 was having difficulty of eating or does not have upper teeth. On 11/14/2024 at 10:39 AM, V3 (Wound Coordinator/Acting Director of Nursing/Registered Nurse) stated that she was not sure if R56 has dentures. Residents that don't have upper or lower teeth need to have dental services. V3 stated, As far as I know if residents have problem on chewing, we send them to the dentist. V3 stated that she will review R56's clinical record to check if R56 was seen by the dentist. V3 after review, stated that R56's clinical record does not document any dental care. Dental Services policy dated 08/08/2019, reads: Facility shall assist residents in obtaining routine and 24-hour emergency dental care. Facility shall provide or obtain from an outside resource routine and emergency dental services to meet the needs of each resident.

Based on interview and record review, facility failed to follow their policy to provide influenza and pneumococcal vaccination and failed to document resident education for the vaccinations for 3 residents (R43, R45, and R98) out of 5 residents reviewed for vaccinations in a sample of 23. Findings include: On 11/13/2024 at 11:19 AM, V4 (Quality Assurance/Infection Preventionist) and surveyor reviewed the immunization status for residents. V4 stated all the immunization records, consent and education provided are documented in the resident's electronic health record. V4 stated that R98 refused their influenza immunization. Surveyor asked V4 if R98 had received education for the influenza vaccine. V4 stated yes but was unable to provide documentation showing influenza education was provided to R98. V4 also stated she did not offer R43 his pneumococcal vaccination because she has not gotten to it yet. V4 was unable to provide a history of R43's pneumococcal vaccination nor any consent or education documentation. Lastly V4 stated that R45 refused her pneumococcal vaccine but was unable to provide any consent or documentation on education for R45 on the benefits of pneumococcal vaccine. On 11/14/2024, at 11:50 AM, V3 (Wound Care Nurse/Registered Nurse) stated, that the purpose of flu and pneumococcal vaccines are to prevent residents from having the flu or pneumonia. If vaccination is not offered, then residents will have a higher risk of catching the flu or pneumonia. Before any vaccination, we provide education and consent. The purpose of education of the vaccination is to help the resident be informed of the benefits and side effects of the vaccination and make an informed decision. If education is not provided, they cannot make an informed decision. R98's immunization record documents in part: No influenza vaccine administered. No documentation of education provided. R43's immunization record documents in part: No pneumococcal vaccine administered. No documentation of education or consent form provided. R45's immunization record documents in part: No pneumococcal vaccine administered. No documentation of education or consent form provided. Facility's Pneumococcal Vaccine policy (11/28/2017) documents in part: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated will be offered the vaccine series. Before receiving pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Residents/representatives have the right to refuse vaccination if refused appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. Facility's Influenza Vaccine policy (11/28/2021) documents in part: All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Prior to the vaccination the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine form and placed in the residence medical record.

Based on observations, interviews, and record review the facility failed to grant access of the residents' electronic health records to the survey team timely. These failures have the potential to affect all 102 residents in determining a thorough review of residents' records to identify or rule out compliance of state and federal regulation. Findings include: On 11/12/2024 at 09:24 AM, V1 (Administrator) was informed and provided documents that the survey team needs to have complete access to resident's electronic health records, and it is important aspect of the survey process. V1 informed the survey team that facility needs to provide laptops because of the platform use by the facility in their electronic health record. At 11:20 AM at the nurse station, V1 was informed that survey team needs access to resident electronic record. At 2:43 PM, V1 was informed that team needs access to resident electronic record. V1 responded that laptops will be available beginning tomorrow (11/13/2024). On 11/13/2024 at 9:20 AM, a follow up with V1 about the laptop to provide for the purpose of the survey. V1 stated that facility does not have available laptops since charger were missing. V1 stated that he will work on it, to provide the survey team with laptops. V1 was made aware of the importance of reviewing resident's records as part of survey process. At 12:59 PM, at the nurse's station, V1 was informed that electronic health record access does not give surveyors complete access. Pointing out that Face Sheets, Medication Administration Records (MAR), Treatment Administration Records (TAR) were not accessible. During this time, the survey team cannot deliberate and discuss privately any resident's record pertinent to the survey. Documentation of resident's record primarily, needs to be requested to V1 in order to access. At 1:02 PM, V1 was again informed that access granted to the survey team was not complete and the need to have privacy in reviewing residents' records without facility staff present. On 11/14/2024 at 09:11 AM, V1 stated that for prospective purposes, the facility needs to procure laptops or provide desktops in the designated room for surveyors to use during survey process. But as of now it is too late to provide equipment due to the late stage of the survey. It was reiterated to V1 that review of the residents' record forms is an integral part of the survey process that will benefit the residents. The survey team was not provided equipment to access resident's record on the designated room assigned by facility for the whole duration of the survey process. Medical Records policy dated 08/08/2019, reads: In accordance with accepted professional standards and practices. Facility shall maintain medical records on each resident that are readily accessible for public health activities, health oversight activities and to avert a serious threat to health or safety.

Based on observation, interview and record review, the facility failed to post the daily nurse staffing data. This deficient practice had the potential to affect 87 residents who reside in the facility. Findings include: During an observation on 12/5/23 at 9:34 AM, the facility's daily staffing information was not observed. On 12/5/23 at 9:34 AM V3 (Receptionist) stated, I started working today at 7AM. I did not complete it and post the facility's daily staffing information. I been off work for the last ten days. I'm not sure the last time the facilities daily staffing information was posted. On 12/5/23 at 9:40 AM, V1 (Administrator) stated, The facility daily staffing sheet is not posted. The receptionist is responsible to post the information. I will have V3 complete the form and post it. On 12/5/23 at 11:30 AM, V2 (Director of Nursing) stated, V3 was gone on vacation for ten days. I am not sure who was responsible to post the daily staffing. Record Review: Per State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities S483.35(g)(2) Posting requirements. The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. Data must be posted as follows: Clear and readable format. In a prominent place readily accessible to residents and visitors. S483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

Based on observations, interviews, and record reviews, the facility failed to use utensils or wear food handling gloves while handling a resident's (R31) food. The facility also failed to ensure food items were properly stored, failed to ensure staff was performing appropriate hand hygiene in between handling dirty and clean kitchen equipment, and failed to air dry the blender and lid after staff washed it in the three-compartment sink having the potential to affect all 85 residents receiving food prepared in the facility's kitchen. Findings include: On 12/05/23 at 9:45 AM, during initial kitchen tour with V10 (Food Service Manager) observed opened bag of potato pancake mix that was not fully closed in dry storage area. The bag had been twisted at the opening but not kept fully closed with a twist tie or clip and it was not wrapped in plastic. Also, observed large 30-pound bag of cornflake crumbs folded over. The top of the bag had been cut all the way across to open the bag, and then folded over but was not fully closed with a twist tie or clip and was not wrapped in plastic. On 12/05/23 at 9:47 AM, V10 stated opened packaged items should be tied closed or covered tightly in plastic to prevent bugs from crawling inside the item. On 12/05/23 at 9:58 AM, observed V11 (Dietary Assistant) working in the dish room placing dirty resident plate ware and silverware into a dishwasher rack and then putting the dishwasher rack into the dishwashing machine. At 10:00 AM, observed V11 walk to the clean side of the dishwasher and pull out the cleaned plate ware and silverware in the dishwasher rack from the dish machine. V11 did not perform any hand hygiene in between handling the dirty and cleaned items. On 12/05/23 at 10:05 AM, V11 stated there is always two staff members working in the dish machine area with the same person always feeding dirty dishes into the dishwasher and then pulling the cleaned rack out of the dishwasher. On 12/06/23 at 11:19 AM, during pureed food preparation observed V14 (Dietary Assistant/Cook) give blender and lid to the dishwasher to clean in the three-compartment sink. At 11:20 AM, the dishwasher turned over the blender and lid on wire rack. At 11:22 AM, V14 took the blender and lid from wire rack, and placed them on the prep counter. Surveyor observed dripping liquid inside the blender pooling at the bottom and liquid on the blender lid. At 11:23 AM, V14 added three cups of water to the blender and ten pieces of cooked baked fish into the wet blender and blended it. V14 did not wait for the blender and lid to air dry. On 12/07/23 at 7:48 AM, V17 (Registered Dietitian) stated during phone interview that any opened bags of food bag should be wrapped in plastic wrap or closed with a clip or rubber band to prevent anything from getting inside such as dust, or anything that could spill from another the shelf. V17 stated after kitchen equipment is cleaned it needs to be left out to air dry and that the item should not be used for food preparation until it is fully dry. V17 stated it is important to let the disinfectant chemicals dry out so that they do not get passed to the food. V17 stated once items come out of the dish machine the items are sanitized and clean. V17 stated the same staff should not be placing dirty items into the dish machine and then pulling out the cleaned items from the dish machine unless that staff member is washing their hands in between. V17 stated if the staff members' hands are not washed it could cause cross contamination and has the potential to cause a food borne illness. On 12/05/23, V1 (Administrator) provided list of residents with diet orders including separate list of two residents who are NPO (Nothing by Mouth). Facility policy provided by V1 titled, Food Storage dated April 2012 documents in part, food storage areas shall be maintained in a clean, safe, and sanitary manner and food items not requiring refrigeration will not be subjected to sewage, or wastewater backflow or contamination by condensation, leakage, rodents, or vermin. Facility Job Description provided by V1 titled Food Service Supervisor undated documents in part, responsibilities as assures proper storage and handling of food and supplies. Facility Job Description provided by V1 titled, Dietary Aide undated document in part, responsibilities as assists in storing food and supplies, adheres to good sanitation and safe procedures and assists in dish and pan washing as assigned. 40061 On 12/05/2023 at 12:09 PM, R31 sat in the dining room for lunch. V21 (Certified Nursing Assistant) asked R31 if (R31) wanted a peanut butter and jelly sandwich. R31 stated yes. At 12:10 PM, V21 brought in R31's lunch tray. V21 unwrapped the peanut butter and jelly sandwich with bare hands, split it into two pieces, and handed it to R31. On 12/07/2023 at 1:15 PM, V29 (Certified Nursing Assistant Supervisor) stated that staff should not handle residents' food with bare hands. Staff are supposed to use the utensils to handle the residents' food. V29 stated V21 should have used a knife and fork to split R31's peanut butter and jelly sandwich.

Based on observation, interview, and record review the facility failed to ensure standardized recipes were followed during pureed food preparation. This failure has the potential to affect 6 residents (R12, R31, R39, R40, R47, R51) out of 85 receiving foods prepared in the facility's kitchen. Findings Include: On 12/06/23 at 11:15 AM, V14 (Dietary Assistant/Cook) stated the pureed consistency should be smooth with no lumps and thick like applesauce. At 11:23 AM, during pureed meal preparation observed V14 add three cups of water and ten pieces of cooked baked fish to the blender before pressing the start button to puree the fish. At 11:26 AM, V14 added an additional one cup water to fish. At 11:27 AM, V14 portioned pureed fish using #8 scoop into individual bowls. There was left over pureed fish in the blender. Surveyor observed the consistency of pureed fish to be thin. Surveyor did not observe V14 reading or looking at a pureed fish recipe before, during or after preparing the pureed fish. On 12/06/23 at 11:35 AM, V14 stated V14 follows recipes and that V14 reviewed them before V14 started preparing the pureed items so V14 knows how much food to use and how much liquid to add. On 12/05/23, V1 (Administrator) provided list of residents with diet orders including separate list of two residents who are NPO (Nothing by Mouth). On 12/06/23 at 3:00 PM, V10 (Food Service Director) provide recipe for pureed fish to surveyor. On 12/07/23 at 9:55 AM, V1 (Administrator) provided policy titled Standardized Recipes and list of residents receiving a pureed diet to surveyor. On 12/07/23 at 8:00 AM, V17 (Registered Dietitian) stated via telephone interview that the menus are reviewed by a Registered Dietitian for nutritional adequacy and the pureed recipes should be followed to meet the nutritional calories needed so the residents are getting adequate nutrition per meal. V17 stated using chicken broth instead of water is used to improve the flavor of the pureed food. Facility recipe titled Pureed Fish lists ingredients for three-ounce portion of fish as 10 portions of fish, 10 Tablespoons of Mashed Potato Flakes and two cups of broth (hot). Recipe instructions documented in part to add small amounts of liquid, blending after each additional until creamy consistency. Facility policy titled Standardized Recipes undated, documents in part purpose is to provide residents with food that is palatable, prepared in a manner to enhance flavor and appearance, and to prepare food in accordance with the resident's diet order. Procedure documents in part the cook will prepare all food items using the recipes. Facility job description for position title Cook undated, documents in part responsibilities included but not limited to prepare food according to written menu with meals and uses standardized recipes. Facility job description for position title Dietary Aide undated, documents in part assists in food preparation as assigned.

Based on observations, interviews, and record reviews the facility failed to provide care in a manner to promote dignity for two residents (R31, R50) reviewed for dignity in a total sample of 18 residents. Findings include: 1.) R31's comprehensive care plan dated 10/16/2023 documents in part that R31 requires one-to-one feeding assistance. On 12/05/2023 at 12:33 PM, R31 sat in the dining room for lunch. V22 (Certified Nursing Assistant/CNA) stood on R31's right side feeding R31. V22 was not at eye level with R31. On 12/07/2023 at 12:03 PM, V2 (Director of Nursing) stated staff must be respectful and be at the resident's eye level during feeding assistance. On 12/07/2023 at 1:15 PM, V29 (CNA Supervisor) stated staff are supposed to sit next to the residents when providing feeding assistance. Staff should not stand over the residents. Reviewed facility's Assistance with Meals policy dated 09/08/2015. It did not document in part how staff should treat residents with dignity while providing meal assistance. 39779 2.) R50 has diagnosis not limited to Diabetes Mellitus, Kidney Failure, Spinal Stenosis, Pure Hypercholesterolemia, Hypertensive Heart Disease, Benign Prostatic Hyperplasia, Heart Failure and Bacterial Pneumonia and Acute Hypoxia. On 12/06/23 at 10:35 AM V6 (CNA) was observed pulling R50 down the hallway backwards in a shower chair. V6 then approached the front of the shower chair and pushed R50 into the shower room backwards in the shower chair. On 12/06/23 at 10:45 AM V6 (CNA) exited the shower room pulling R50 backwards in the shower chair down the hallway into R50's room. On 12/06/23 at 11:48 AM V6 entered the nursing station. The surveyor asked V6 at 10:35 AM was she (V6) pulling V50 backwards in the shower chair to the shower room and V6 responded yes. The surveyor then asked V6 at 10:45 AM when she (V6) exited the shower room did, she (V6) pulls R50 backwards down the hallway in the shower chair to R50's room and V6 responded yes to lay him (R50) back in bed and get him dressed. When the surveyor asked V6 the proper way to transport R50 in the shower chair or wheelchair V6 began explaining that R50 is transferred using the mechanical lift. I pull the residents that can't get control of themselves backwards. When I try to push R50 he can't hold himself. I pulled R50 backwards so that he would not fall out of the shower chair. On 12 07/23 at 08:58 AM R50 stated I can't walk, and it takes two people to get me up out of the bed. I received a shower yesterday. Surveyor asked R50 how the staff transports him to the shower room and R50 responded they do both push me forward and pull me backwards in the shower chair. On 12/07/23 at 09:20 AM V2 (Director of Nursing) stated When staff are transporting a resident in a wheelchair or shower chair pushing or pulling them, either way is not good. My understanding is the shower chair is not very sturdy. I will in-service V6 (CNA) on another practice for transporting the residents. If the resident is in the shower chair, we should not push the shower chair it is not sturdy and should not be used for long distance transport. To my understanding the shower chair is plastic and it does not matter if you push or pull it, it is not for long distant transfer. When pulling the resident in the shower chair there would be an issue of dignity and a safety issue. Policy: Titled Quality of Life - Dignity dated 08/14/09 document in part: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Titled Policy on Resident Rights dated 11/28/17 document in part: (a) Residents rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside BP (the facility). (1) BP treats each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on interviews and record reviews, the facility failed to clarify a physician's order for one (R51) resident out of a total sample of 18 residents reviewed for medications. Findings include: R51's face sheet documents in part medical diagnosis of Huntington's Chorea. R51's physician order sheet documents in part an order for Olanzapine 5 MG (Milligram) half a tablet along with 10 MG tablet to equal 12.5 MG by mouth daily for Huntington's Chorea. Order dated 05/17/2023. After Visit Summary and prescription dated 03/03/2023 documents in part that R51's Olanzapine dose increased from 10 MG to 12.5 MG at that time. Physician's Progress Notes document in part a note from V30 (R51's Neurologist and Movement Disorder Specialist) dated 09/08/2023 for a follow-up evaluation. It documents in part to increase Olanzapine to 15 MG at night. Reviewed the corresponding After Visit Summary and prescription from V30 dated 09/08/2023. They document in part Olanzapine 5 MG tablet take one tablet by mouth nightly. Take with the 10 MG pill of Olanzapine for a total of 12.5 MG nightly. On 12/07/2023 at 10:38 AM, surveyor asked V13 (Nurse) regarding R51's current dosage for Olanzapine. V13 stated Olanzapine 12.5 MG. Surveyor showed V13 the prescription, After Visit Summary, and V30's progress note from 09/08/2023. V13 stated the order was confusing and did not know which dosage R51 was supposed to receive. V13 stated facility will have to call V30 to clarify which dosage R51 is supposed to be on for Olanzapine. Reviewed R51's progress notes from 09/08/2023 to 09/30/2023. No documentation that facility clarified the order with V30. Facility's Medication Administration policy last updated July 2017 does not document in part procedures to clarify medication orders that are not well-defined.

Based on observation, interview and record review the facility failed to follow the current plan of care and utilize a mechanical lift during transfer from bed to wheel chair for 1 of 3 (R1) residents reviewed for menchanical lifts. This failure resulted in R1 being sent to the hospital where he was assessed and recieved treatment for [REDACTED].' Findings include: R1 was admitted to facility on 1/6/11 with [DIAGNOSES REDACTED]. R1 is alert and oriented x3. Review of facility nurses notes document on 7/7/15, late entry for 7/6/15 at 11:45 p.m. 'Observed water all over R1's bedroom floor. Deemed necessary and safest to move R1 to a different room for the night until water can be cleaned up. Explained to R1that it would be unsafe for both R1 and staff members to receive and provide care in her room. R1 said 'just give me my bedpan and turn off the light. I 'll be ok, nothing will happen to me.' Explained to R1 possible dangers, if she stays in the room. R1 said 'I don't care just give me my bedpan. Explained to R1 we will transfer with the mechanical lift, R1 does not want the lift to be used. R1 insist staying in bed.' Six staff members present to help transfer R1 safely onto wheel chair. Informed R1 of the procedure and transferred R1 safely onto wheelchair. No c/o pain at this time. R1 still shouting and telling staff that she wants to stay in her room. Transferred R1 safely to a different room and bed. Placed R1 in comfortable position, call light within reach.' 7/7/15 late entry 7/7/15 at 4:00 a.m. 'R1 sleeping comfortable. Pain medication given two tablets at 2:30 a.m. for generalized pain with good results.' On 7/7/15 at 8:40 a.m. 'R1 complains of general body pain with movement, acetaminophen 500mg two tablets given at 8:00 a.m. Left message for Z1, attending physician.' 10:30 a.m. 'Z1 called back with order for laboratory test, chest X-ray and of both upper arms. ' 11:40 a.m. 'R1 stated feeling pain all over her body due to being transferred last night. R1 was being transferred from bed to different room with assist of six staff members, (CNA's) and nurses. R1 noted with ecchymosis of left foot and toes.' 11:50 a.m. 'Called and left a message with Z2 (POA) power of attorney to update regarding R1's pain all over the body.' 2:00 p.m. 'Z1 aware of X-ray results, order to send R1 to local hospital.' 2:50 p.m. 'Call transport company for transfer to hospital.' 3:00 p.m. 'Vital signs checked.' 4:10 p.m. 'R1 transported to hospital. ' 4:40 p.m. 'Left message with Z2, to update on R1's status, awaiting call back.' 6:45 p.m. 'Updated Z2 regarding R1 ' s condition and hospitalization .' 11:15 p.m. 'Spoke with hospital (ER) emergency room , R1 will stay at hospital overnight.' On 7/8/15 at: 12:20 p.m. ' R1 readmitted with bilateral humeral and right tibia/fibula fractures.' On 7/9/15 at 4:15 p.m. order to send R1 to hospital (ER) for evaluation due to elevated temperature. ' 10:00 p.m. ' R1 admitted to hospital with [DIAGNOSES REDACTED]. 10:10 p.m. ' Z2 (POA) power of attorney called and updated that R1 was admitted .' On 7/14/15 at: 7:30 p.m. 'R1 readmitted to facility, sling on right arm and immobilizers on both legs.' 11:55 p.m.'R1 complained of pain to right foot, pain medication given as ordered.' Facility 'Endurance/Functional Ability Assessment' documents: On 6/4/15 ' R1 does not ambulate, has limitations to upper and lower extremities. Needs moderate to maximum assist with transfers and minimal to moderate with (ADL ' s) activities of daily living. R1 ' s limitations affect R1 ' s ADL abilities. ' Facility ' Fall Risk Evaluation ' for R1 documents 5-6 which is less than ten, R1 not at risk fall. Facility ' Condensed Minimum Data Set ' (MDS) documents on 6/03/15 under: ADL Self-performance: Transfer 3. Extensive assistance ADL Support provided: Transfer 3. Two+ person physical assist. ADL Self-performance: Locomotion on unit 4. Total dependence Functional Limitation in (ROM) range of motion: Upper extremity 1. Impairment on one side. Functional Limitation in (ROM) range of motion: Lower extremity 2 Impairment on both sides. Facility ' Care Plan ' documents for R1 under: Present weight is: 163 pounds Physical and Psychosocial needs: Mechanical lift for transfers .On 7/14/15 at: 2:45 p.m. E4 (RN) registered nurse stated 'R1 had an electrical bed, thought it will be better to move R1 out of the room. We explained the need to move and use mechanical lift to mover R1 out of the room. R1 said no. Six of us transferred R1 to the wheel chair and to the new room, R1 wanted to stay in the room and not transfer. They did some test and when results came back and Z1 (attending physician) said it would be best if R1 was transferred to the hospital. ' 3:00 p.m. E12 (CNA) stated ' Room was flooded had to move R1 out of the room last week. I supported R1's back with my hands; R1 did not want to be transferred. ' 3:30 p.m. ' I supported R1 by the thighs. The mechanical lift was offered but R1 refused. Six of us were in the room to transfer R1. R1 refuses everything, so all it was being said by R1 was no to the transfer. ' On 7/15/15 at 3:00 p.m. E14 (RN) stated 'The team discussed and made the decision to transfer R1. E15 9 (CNA) grabbed R1 from the torso to the wheel chair. R1 was explained the need to be moved. R1 refused the mechanical lift. We have to use the mechanical lift if indicated for resident safety and staff.' On 7/16/15 at 6:30 a.m. E15 (CNA) stated 'All of us moved R1; three on the right and three on the left side. We moved R1 ' s feet to the sitting position and transfer R1 at the count of three. Then we maneuver R1 in the bed slowly and gently at the count of three. R1 refused to use the mechanical lift. ' 6:45 a.m. E16 (CNA) stated 'We gently transferred R1, no mechanical lift was used, R1 refused the lift. We moved R1 gently from the bed to the wheel chair. R1 didn ' t fall. ' 11:30 a.m. E5 (QA) quality assurance stated 'I feel bad for R1 and my staff for what happened. The thing is that they usually use the mechanical lift and that night R1 refused. Hard to say what could have been done different.' 12:30 p.m E3 (DON) director of nursing stated 'If CNA's don't know the resident, they should ask the nurse or look at the care plan for transfers, under (ADL's) activities of daily living. Total assist needs a mechanical lift if they can't bear weight; with twopeople, it depends if one to two. For trensfers the gait belt will hold the resident and the CNA hold the gait belt on the sides. The CNA's must be in the day room and supervise residents at all times, if not then someone to check the monitor at the nursing station.' 2:15 p.m. Z1 (attending physician) stated 'My understanding is the fractures apparently occurred from moving R1. The working hypothesis is that they transferred R1. The mechanical lift is the preferred method. R1 had pain and they were able to identify the fractures. It normally takes four to six weeks to heal. This impacted R1's routine, main activities of daily living and needing more assistance than before.' On 7/15/15 at 11:30 a.m. R1 stated 'I ended up with a broken arm and I am left handed, at present I can ' t raise my in left arm. I was fearful that I was going to be hurt, I have muscle weakness, and I hope I can move my arm and leg. They got me into a wheel chair and put me into another bed. They made me go out of the bed. I have a mechanical lift and they didn ' t use it because it was late at night, I tried to tell them not to pull me. They put arms/hands under my arms and legs. ' Facility 'Lifting and Movement of Residents' not dated documents under: Policy Interpretation and Implementation 2. Manual lifting of residents shall be kept to a minimum when feasible. 3. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Facility 'Safe Lifting and Movement of Resident: Manual transfer' not dated documents under: Purpose: the purposes of this procedure are to safely transfer a resident. General Guidelines: When moving a resident who cannot assist you, ensure adequate staff are present to lift the resident.