Every finding on record at Calvin Community

Based on clinical record review, staff interview, policy review, and Resident Assessment Instrument manual the facility failed to develop a comprehensive care plan that included behaviors/interventions for residents receiving psychotropic medications( anti-anxiety, antipsychotic, and antidepressants) for 4 of 5 residents reviewed (Residents #3,#6, #2, and #44). The facility reported a census of 55 residents. Findings include: 1.The MDS completed 11/3/25 revealed Resident #3 with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Diagnoses include major depressive disorder, recurrent, and moderate. The MDS indicated the use of antianxiety and antidepressant medications. The Physician Orders for Resident #3 listed the resident received Trazadone (start date 10/28/25) and Wellbutrin (antidepressants) (start date 10/27/25) daily. The Care Plan, last revised on 11/19/25 , noted Resident #3's use of an antidepressant with a goal of the resident's use of medication will result in maintenance in the resident's functional status. Interventions included administering medication as ordered and monitor and report labs as indicated by the physician. The Care Plan failed to identify targeted behaviors of depression Resident #3 was being treated or monitored for. The Care Plan lacked resident-specific non-pharmacological interventions staff may utilize for the resident. 2. The Quarterly MDS completed 10/17/25 revealed Resident #6 with a BIMS of 3, indicating severe cognitive impairment. Diagnoses include dementia, anxiety disorder, depression, and delusional disorders. The MDS indicated the use of an antipsychotic and antidepressant medication. The Physician Order Report for Resident #6 listed Seroquel (antipsychotic) daily (start date 10/14/25) and Sertraline(antidepressant) daily (start date 12/09/25). The Physicians order also included an order for Melatonin every night for treatment of insomnia with start date of 7/14/25. The Care Plan, last revised 10/8/2525, noted Resident #6's use of an antidepressant with a goal the resident will not exhibit signs of drug related sedation, hypotension, or anticholinergic symptoms. Interventions included administering medication as ordered, monitoring resident's functional status, and pharmacy consultation as indicated. The care plan included the resident received antipsychotic medication with additional interventions of AIMS (abnormal involuntary movement test )every 6 months or more often if indicate, attempt a gradual dose reduction according to recommendations, monitor resident's behavior and response to medication. The Care Plan itself failed to identify resident-specific targeted behaviors that Resident #6 was being treated or monitored for. The Care Plan lacked resident-specific non-pharmacological interventions staff may utilize for the resident. 3.The MDS completed 12/1/25 revealed Resident #2 with a BIMS of 15, indicating intact cognition. Diagnoses include anxiety and major depressive disorder, severe, with psychotic symptoms. The MDS indicated the use of antianxiety and antipsychotic medications. The Physician Order Report for Resident #2 listed the following medication orders: Mirtazapine 15 mg daily (antidepressant) (start date of 11/24/25); Venlafaxine 150 mg daily (antianxiety/antidepressant) (start date 11/24/25); and Aripiprazole 5 mg daily (antipsychotic) (start date 11/25/25). The Physicians Order Report documented the resident admit date as 11/24/25. The Care Plan, last revised on 12/12/25, noted Resident #2's use of an antidepressant with a goal the resident will not exhibit signs of drug related sedation, low blood pressure, or anticholinergic side effects (such as dry mouth, constipation, and confusion). Interventions included administering medication as ordered, monitoring resident's functional status, and pharmacy consultation as indicated. The Care Plan failed to identify targeted behaviors of depression Resident #2 was being treated or monitored for. The Care Plan lacked resident-specific non-pharmacological interventions staff may utilize for the resident. The Care Plan failed to identify the use of the antipsychotic, possible medication side effects, resident-specific targeted behaviors to monitor, and resident-specific non-pharmacological interventions. 4.The Quarterly MDS completed 12/5/25 revealed Resident #44 with a BIMS of 3, indicating severe cognitive impairment. Diagnoses include depression and stroke. The MDS indicated the use of an antidepressant medication. The Physician Order Report for Resident #44 listed Sertraline 125 mg daily (antidepressant). The Care Plan, last revised 12/11/25, noted Resident #44's use of an antidepressant with a goal the resident will not exhibit signs of drug related sedation, low blood pressure, or anticholinergic side effects (such as dry mouth, constipation, and confusion). Interventions included administering medication as ordered, monitoring resident's functional status, and pharmacy consultation as indicated. Review of the Behavior Analysis Report, from 6/1/25-12/17/25, showed staff documentation of observed resident behaviors. During the above timeframe, staff documented Resident #44 displaying episodes of cursing/screaming, grabbing, hitting, kicking, scratching, and rejecting cares. Interventions staff documented on the report included back rub, calm environment, one-on-one, position change, and redirection. The Care Plan itself failed to identify resident-specific targeted behaviors of depression Resident #44 was being treated or monitored for. The Care Plan lacked resident-specific non-pharmacological interventions staff may utilize for the resident. During an interview on 12/17/25 at 4:00 PM, the Director of Nursing reported resident-specific targeted behaviors should be identified on resident Care Plans. During an interview on 12/18/25 at 10:30 AM, the MDS Coordinator explained they initiate and update resident Care Plans with scheduled assessments. With regards to psychotropic medications, such as antidepressants or antipsychotics, the MDS Coordinator acknowledged adding the use of these to Care Plans. They do not address resident-specific targeted behaviors or interventions as this is more psycho-social and out of their area of expertise. During an interview on 12/18/25 at 11:35 AM, Staff A, Director of Social Services, explained they provide limited input to resident Care Plans. They do not enter information related to resident-specific behaviors or non-pharmacological interventions. The policy Care Planning-Interdisciplinary Team, revised March 2022, documented the following: a.Comprehensive, person-centered Care Plans are based on resident assessments and developed by an Interdisciplinary Team (IDT); b.The IDT includes but is not limited to: resident attending physician; registered nurse with responsibility for the resident; other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident. The 2024 Resident Assessment Instrument 3.0 Version 1.1.9.1 October 2024, pages N-5 and N-6, High-Risk Drug Classes: Use and Indication, documented the following: As part of all medication management, it is important for the interdisciplinary team to consider non-pharmacological approaches. Educating the nursing home staff and providers about non-pharmacological approaches in addition to and/or in conjunction with the use of medication may minimize the need for medications or reduce the dose and duration of those medications. With regards to care planning, target symptoms and goals for use of these medications should be established for each resident. Progress toward meeting the goals should be evaluated routinely. Possible adverse effects of these medications should be well understood by nursing staff. Educate nursing home staff to be observant for these adverse effects. Implement systematic monitoring of each resident taking any of these medications to identify adverse consequences early.

Based on observation, clinical record review, staff interviews and policy review, the facility failed to use proper hand hygiene and infection control practices during medication administration and wound care and further failed to use full Enhanced Barrier Precautions (EBP) during wound care for 1 of 1 residents reviewed (Resident #38) for pressure ulcers. The facility reported a census of 55 residents. Findings include:During a continuous observation on 12/17/25 beginning at 7:25 AM, observation of Staff B, Registered Nurse (RN) administer medications to residents on the 3rd floor. Staff B administered medications to a resident after taking a blood pressure and heart rate reading with a wrist blood pressure cuff that contained both plastic and cloth. Staff B did not sanitize her hands or the shared wrist blood pressure cuff before or after the medications were administered. Staff B then prepared medications for a separate resident and administered the medications, she did not sanitize her hands before or after. Staff B then prepared medications for three other residents, without sanitizing her hands before or after the administration of medications for the residents. Staff B used the wrist blood pressure cuff on another resident, without sanitizing the equipment before or after. Staff B was observed to touch several surface areas in between medication administrations, including resident wheelchairs, hands of residents, clothing of residents, the medication cart, the wall railing and the inside of cups used to place medications to bring to the residents for administration. During an interview 12/17/25 at 11:55 AM, the Director of Nursing (DON) stated an expectation of staff is to sanitize or wash their hands in between resident medication administration. The DON stated shared equipment should be cleaned/sanitized in between residents, if the equipment can be cleaned. Review of the facility policy Administering Medications, revised April 2019, documented staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility policy Hand Hygiene with Alcohol based hand rub, dated 3/2/23, documented when hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands before preparing or handling medications. Review of the facility policy Infection Control Policy, with a review date of 5/16/23, documented the Infection Control policy will include environmental cleaning and disinfection, including cleaning/disinfection of resident care equipment, including shared equipment. 2. Resident #38's MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) unable to be conducted as resident is rarely/never understood. Facility matrix provided on 12/15/25 revealed R#38 with a Stage 3 pressure wound (tissue damage that results in full thickness tissue loss). Observation on 12/17/25 at 1:15 PM, revealed Staff B, Registered Nurse with gloved hands and no gown on, removed an old dressing from a wound on R#38's right foot, cleansed the wound, removed her gloves, and with no hand hygiene completed applied new gloves, applied ointment to the wound, and a dressing. Interview on 12/17/25 at 1:25 PM, the Director of Nursing stated R#38 wound care did not require Enhanced Barrier Precautions (EBP) (use of gown and gloves) with wound care as the wound was not a chronic, non-healing wound. Centers for Disease Control Enhanced Barrier Precautions signage posted in facility hallway revealed the following: a. Wear gloves and a gown for the following high-contact resident care activities: wound care, any skin opening requiring a dressing. Interview on 12/18/2025 at 12:56 PM, Staff B confirmed she did not complete hand hygiene after cleaning the wound and before applying the treatment, just changed gloves. Interview on 12/18/2025 at 1:55 PM, the Assistant Director of Nursing stated an expectation of staff to change gloves and complete hand hygiene after cleaning a wound and before applying the new treatment.

Based on clinical record review, staff interview and policy review, the facility failed to complete a discharge summary, including a recapitulation of stay, and failed to provide a discharge summary to the resident/family for 1 of 1 residents reviewed for discharge (Resident #65). The facility reported a census of 55 residents. Findings include:The admission Minimum Data Set (MDS) dated [DATE] documented Resident #65 admitted to the facility on [DATE] and had diagnoses to include fractures and other multiple trauma. Review of the clinical record for Resident #65 revealed the resident discharged from the facility on 9/23/25. The clinical record lacked a discharge summary and a recapitulation of stay for Resident #65 and further lacked documentation a discharge summary was provided to the resident and/or the family. The clinical record did not contain a signed discharge summary. During an interview 12/17/25 at 4:00 PM, the Assistant Director of Nursing (ADON) stated he is the one, along with the unit manager, who completes the discharge summary, which includes the recapitulation of stay, for residents who discharge from the facility. The discharge documents are printed and the resident and/or family sign the discharge summary and a copy of this is placed in the clinical record for the discharged resident. The ADON acknowledged the recapitulation of stay was not completed for Resident #65 and a discharge summary was not fully completed or signed. The ADON stated an expectation these forms are completed and signed for each resident discharged from the facility. Review of the facility document Discharge Checklist, undated, documented the unit manager will complete discharge summary/transition of care, print of discharge summary/transition of care and place in discharge folder, once discharge summary/transition of care is signed by the resident/family, upload all discharge paperwork into the electronic health record before giving the folder to the resident. The DON/ADON will complete discharge recapitulation/discharge summary in electronic health record observations.

Based on observation and staff interviews, the facility failed to provide services to protect the resident from accident or hazards by transporting a resident in a wheelchair without foot pedals (Resident #48 ). The facility reported a census of 55. Findings include: The Minimum Data Set (MDS) assessment completed 11/28/25 revealed Resident #48 with a Brief Interview for Mental Status score of 15, indicating intact cognition. Diagnoses include heart failure and vascular dementia. The MDS noted Resident #48 utilizes a wheelchair independently. The Care Plan, last updated 11/21/25, documented Resident #48 requires assistance with ambulation. Interventions include the use of a wheelchair for longer distances, such as going to the dining room.During an observation on 12/17/25 at 12:20 PM, Staff B, Registered Nurse, pushed Resident #48 from the nursing station to the dining room, which is over 100 feet, without foot pedals. Staff B did not assess if the resident had foot pedals attached to the wheelchair. Once staff started pushing the wheelchair, Resident 48# immediately lifted their feet off the ground and held them up until they reached the final destination. The resident's feet were noted to be dangling very close to the floor. During an interview on 12/17/25 at 12:25 PM, Staff B confirmed Resident #48 did not have foot pedals on their wheelchair. Staff B acknowledged pedals should have been used when pushing the resident in their wheelchair. During an interview on 12/17/25 at 4:00 PM, the Director of Nursing (DON) states foot pedals should be on wheelchairs when staff push residents. The DON noted staff education regarding the use of foot pedals was reviewed during October '25 nursing staff meeting. The Facility Administrator explained they do not have a specific policy regarding transporting or assisting residents in wheelchairs.

Based on observation, staff interviews and policy review, the facility failed to store medications in a safe manner when the medication cart was unlocked and not within eyesight of the Registered Nurse (RN) responsible for the cart. The facility reported a census of 55 residents. Findings include:During a continuous observation on 12/18/25 beginning at 10:00 AM, observed the medication cart located by the elevator on 3rd floor unlocked. Two residents were near the unlocked medication cart and a male person, appeared to be a visitor to the facility, retrieved a cup from the medication cart and the water pitcher and poured a glass of water, touching the unlocked medication cart. A staff person was not by the medication cart or within eyeshot of the medication cart. At 10:04 AM Staff C, Licensed Practical Nurse (LPN), walked down the hallway from the opposite end of the hallway and by the cart and locked the cart. During an interview 12/18/25 at 10:05 AM, Staff C stated he locked the medication cart as he walked by the cart, however it was not his medication cart today, he locked it as he noticed it was unlocked. Staff C stated the medication cart is Staff B's cart this morning, Registered Nurse (RN), and Staff B was in another room with a resident. During an observation on 12/18/25 at 10:10 AM, Staff B, RN, came out of a resident room and acknowledged she left the medication cart unattended and unlocked. During an interview on 12/18/25 at 10:11 AM, the Director of Nursing (DON) reported an expectation that all medication carts are locked, especially when unattended and out of view of staff. Review of the facility policy Administering Medications, revised April 2019, documented during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide.

Based on observation, facility policy, and the Food and Drug Administration (FDA) food code the facility failed to prepare food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness when a staff member failed to cover facial hair (beard and mustache) while preparing food. The facility reported a census of 55 residents. Findings include: Observation on 12/17/25 at 10 AM, Staff D, [NAME] prepared food for 2 residents on a pureed diet for the lunch meal. Staff D had facial hair including beard and mustache, not covered by net. Interview on 12/18/2025 at 12:31 PM the Administrator (ADM)stated if you could grab a hand full of beard it would be expected that the facial hair should be covered in the kitchen. The ADM stated the facility had not had an issue before with staff and facial hair and not thought about it. Facility Uniforms/Hair Restraints policy directed all employees shall wear protective hair covering in the form of a hairnet or facility hat. The FDA Food Code (Section 2-402.11) requires food employees to wear effective hair restraints-such as hats, hair coverings, nets, and beard restraints-to prevent hair from contacting exposed food, clean equipment, and single-service items. These must be worn in food preparation areas, but are generally not required for staff only serving wrapped items.

Based on electronic health record (EHR) review, resident interview, and staff interview, the facility failed to document and update resident records related to a change in medical condition due to an urinary tract infection (UTI) for 1 of 17 records reviewed (Resident #10). The facilty reported a census of 55. Findings include: The Minimum Data Set (MDS) Assessment completed 12/1/25 revealed Resident #10 with a Brief Interview for Mental Status score of 13, indicating intact cognition. The MDS noted the resident is frequently incontinent. The Physician Order Report documented the use of Ciprofloxacin (Cipro), an antibiotic, starting 12/13/25 and ending on 12/23/25. The rationale for its use was noted as other injury of unspecified body region. The EHR failed to identify the rationale for Cipro use. No documentation found explaining resident symptoms, discussions with a Care Provider prior to the antibiotic use, or accepting and initiating orders for additional testing. During an interview on 12/16/25 at 3:15 PM, Resident #10 acknowledged the use of an antibiotic due to a UTI. Resident #10 recalled notifying nursing staff about UTI symptoms, specifically increased frequency, urgency and burning.During an interview on 12/16/25 at 3:50 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) both acknowledged the lack of documentation regarding the use of Cipro. The DON obtained a screenshot of a text conversation between facility nursing staff and the Advanced Registered Nurse Practitioner (ARNP). Nursing requested an order for a urine analysis for Resident #10 due to frequency and burning. The ARNP agreed. This text conversation occurred on 12/11/25. The Facility Administrator explained they do not have a specific policy regarding EHR documentation.

Based on electronic health record (EHR) review and staff interviews, the facility failed to transcribe and initiate a physician order for Sertraline on 1 of 5 residents reviewed for medications (Resident #44). The facility reported a census of 55.Findings include: The MDS completed 12/5/25 revealed Resident #44 with a BIMS of 3, indicating severe cognitive impairment. Diagnoses include depression and stroke. The MDS indicated the use of an antidepressant. Review of scanned Visit Progress Notes from the medical providers revealed the following: 1. The Advanced Registered Nurse Practitioner (ARNP) documented on 7/1/25 the use of an antidepressant Sertraline 75 mg daily. The ARNP noted Resident #44 often combative with cares and wrote a new order to increase Sertraline to 100 mg daily. The scanned Progress Note was acknowledged by the signature of an unidentified facility staff member2. The facility's Medical Director documented on 7/22/5 the Sertraline was to be increased to 100 mg but current orders show at 75 mg3.The ARNP documented on 8/7/25 the current order of Sertraline at 75 mg with Resident #44 having episodes of pinching and hitting staff. New order written to increase the Sertraline to 100 mgThe EHR Progress Note dated 7/2/25 at 11:16 AM showed facility nursing staff acknowledged the ARNP visit on 7/1/25 and documented new orders. Sertraline Order History Report revealed the following doses:1.50 mg daily ordered on 6/2/26 2.75 mg daily ordered on 6/25/25 3.100 mg daily ordered on 8/7/25 4.125 mg daily ordered on 10/8/25During an interview on 12/18/25 at 145pm, the Assistant Director of Nursing (ADON) explained non-emergent orders from ARNP routine visits are obtained from their dictated visit notes. These are typically received approximately 1-2 days later. Facility nursing staff will transcribe new orders into the EHR and print out for ARNP signature. The ADON acknowledged the order to increase Sertraline to 100 mg on 7/1/25 was missed by the previous unit manager. The Facility Administrator explained they do not have a specific policy regarding transcribing or initiating physician orders.

Based on staff interviews, family interviews, observation and record review, the facility failed to update individual Care Plans for 3 of 19 reviewed (Residents #20, #22, and #38). The facility failed to revise Care Plans for R#20 for Hospice services and failed to update R#22, R#28 for wanderguard (device to alert/inhibit elopements). The facility reported a census of 52 residents. Findings include: 1. The Signature Change Minimum Data Set (MDS) dated [DATE] documented Resident #20 diagnoses included cancer and malignant neoplasm of prostate, secondary malignant neoplasm of bone. The Brief Interview for Mental Status (BIMS) was scored 12 out of 15 which indicated moderate cognitive impairment. The Care Plan last reviewed/revised 01/22/25 documented resident diagnosis cancer with metastasis. The Care Plan did not document that Resident #20 received hospice services. During an interview on 1/21/25 at 3:30 PM Resident #20 reported to received hospice services which included nursing staff and massage therapist visits. During an Interview on 1/23/25 at 2:25 PM with MDS coordinator, Nurse Staff A, reported the Significant Change MDS was completed on 11/22/24 due to resident choice for hospice. Staff A relayed the Care Plan should have been updated to include hospice services. The facility policy titled, Resident Assessments, revised 3/2022 documented the resident assessments are used to develop, review and revise the residents comprehensive care plan. 50500 2. The Quarterly MDS dated [DATE] documented Resident#22 with a BIMS score of 3 which indicted severe cognitive impairment. Diagnoses on the MDS included unspecified dementia. The MDS documented no wandering behaviors exhibited with no wander/elopement alarm in use. The Care Plan reviewed/revised on 1/7/25 included a problem statement indicating wandering behaviors with the placement of an elopement alarm. The Care Plan documented the wanderguard intervention start date as 10/29/24. During electronic record review, the Progress Note dated 11/28/24 documented Resident#22 exhibited active wandering behaviors with the placement of a wanderguard at this time. During an interview on 1/23/25 at 2:15 PM, Staff C, Unit Manager, explained Resident#22 had not shown exit-seeking behaviors prior to the incident on 11/28/24. Resident#22 had not worn a wanderguard alarm prior to the incident on 11/28/24. Staff C was not aware the Care Plan had the implementation date for the wanderguard as 10/29/24. During an interview on 1/23/25 at 2:25 PM, Staff A reported Care Plans updated as needed based on current information obtained during daily nurse meetings, such as placing or removing wanderguard alarms. Staff A reviewed Resident#22's Care Plan and acknowledged the wanderguard implementation date as 10/29/24. Staff A could not explain the discrepancy with the date on the Care Plan with the actual wanderguard placement date in November. The facility policy titled, Resident Assessments, revised 3/2022 documented resident assessments are used to develop, review, and revise resident comprehensive care plans. 3. The Quarterly MDS dated [DATE] documented Resident#38 with a BIMS score of 9, which indicated moderate cognitive impairment. The Care Plan reviewed/revised on 1/21/25 included a problem statement which indicated wandering behaviors with the placement of an elopement alarm. The Care Plan documented the wanderguard intervention start date as 10/10/24. During continuous observations from 1/22/25 thru 1/23/25, Resident#38 did not have wanderguard on her person. The whiteboard located on the third-floor nurses station listed out resident with active Wanderguards. Resident#38 was not on the list. The Progress Note dated 11/5/24 documented the wanderguard was initiated upon Resident#38's admission to the unit in October. Upon completion of the Elopement Evaluation, Resident#38 had shown no signs of elopement and the wanderguard was removed. The Progress Note dated 11/6/24 further documented the lack of elopement behaviors and removal of the wanderguard. During an interview on 1/23/25 at 2:25 PM, Staff A reported Care Plans updated as needed based on current information obtained during daily nurse meetings, such as placing or removing wanderguard alarms. Staff A acknowledged the presence of the wanderguard interventions on the current plan and noted that Resident#38 does not wear a wanderguard. Staff A relayed the Care Plan should have been updated in November when the wanderguard was removed. The facility policy titled, Resident Assessments, revised 3/2022 documented resident assessments are used to develop, review, and revise resident comprehensive care plans.

Based on observation and staff interviews, the facility failed to maintain dignity for 1 of 17 residents reviewed (Resident#2). The facility reported a census of 52. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident#2 with a Brief Interview for Mental Status score of 1, which indicated severe cognitive impairment. Diagnoses on the MDS included anxiety, paranoid personality disorder, Alzheimer's Disease, and Parkinson's Disease. The MDS revealed Resident#2 utilized a manual wheelchair independently with staff supervision, but moderate to maximum staff assistance for upper/lower body dressing and bathing. During an observation on 1/23/25 at 8:25 AM, Resident#2 sat in a shower chair, in the hallway, outside of the shower room door. Resident#2 wore a short sleeved top and a blanket over his lower body. The blanket was pulled up to the upper thigh area leaving Resident#2's groin exposed for an unknown amount of time. At 8:33 AM, an unidentified employee checked on Resident#2 and pulled the blanket up to the waist area. In an interview on 1/23/25 at 10:15 AM, Staff B, Certified Nursing Assistant, explained staff will undress and transfer Resident#2 into a shower chair to prep for a shower. This included providing a blanket for the lower body not only for warmth but also for dignity as Resident#2 is not wearing pants or undergarments. Staff B reported Resident#2 preferred to wait outside the shower room until it's time. If waiting in another location, Resident#2 may self-propel out of the area, thus delaying the shower. In an interview on 1/23/25 at 10:30 AM, the Director of Nursing (DON) acknowledged Resident#2 typically waited outside the shower room on. The DON voiced an expectation that Resident#2 should be covered appropriately while in the hallway waiting for his shower.

Based on clinical record review and staff interview, the facility failed to accurately code the federally mandated Minimum Data Set (MDS) assessment for 1 of 17 residents reviewed in the sample (Resident#24). The facility reported a census of 52. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident#24 indicated the use of a diuretic and an anti-platelet. The MDS did not document the use of an anticoagulant. The Care Plan reviewed/revised on 1/21/25 for Resident#24 included a problem statement documented Resident#24 was prescribed anticoagulant therapy. Interventions included administering anticoagulants as ordered by the physician and to monitor/report labs as ordered by the physician. The Care Plan also included the diagnosis of chronic atrial-fibrillation, which is commonly treated with the use of anticoagulants. The Medication Administration Record for the months of November 2024 and December 2024 revealed Warfarin, a type of anticoagulant, was prescribed and administered to Resident#24 for the entirety of both months. In an interview on 1/23/25 at 2:25 PM, Staff A, Licensed Practical Nurse, acknowledged the MDS did not reflect the use of an anticoagulant even though it was actively prescribed.

Based on clinical record review, staff interview, and policy review the facility failed to refer one of one residents with a negative Level I result for the Pre-Admission Screening and Resident Review (PASRR), who were later identified with newly evident or possible serious mental disorder or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination (Residents #17). The facility reported a census of 51 residents. Findings include: The annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 identified the resident not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The assessment documented the resident entered the facility on 2/8/22. The MDS documented diagnoses that included non-Alzheimer's dementia, anxiety disorder, depression, and bipolar disorder. The MDS indicated the resident took an antipsychotic, antidepressant, and hypnotic medications during the 7 day lookback period. The MDS documented the resident had disorganized thinking, inattention, and no other behaviors. The care plan revised 3/25/24 identified Resident #17 had diagnoses of bipolar disorder, mood disturbance, depression and generalized anxiety disorder. The care plan revealed the resident took antidepressant and antianxiety medications. The care plan directed staff to monitor the effectiveness of the medications and document target behaviors. Review of the clinical record revealed a Notice of Negative Level I Screen Outcome dated 2/28/22. The Level I screen documented Resident #17 had diagnoses of anxiety disorder and depression, but had no major mental illness such as bipolar disorder (manic depression). The PASRR required no further screening required unless the resident had a suspected major mental illness of intellectual or developmental disability or had a significant change in treatment needs. Review of the electronic health record diagnosis list revealed Bipolar disorder added on 9/19/22. The nurse practitioner progress note dated 9/26/23 revealed the resident had diagnoses of bipolar disorder. The clinical record lacked documentation the resident had been referred for a Level II evaluation and determination when he had a new/change in mental health diagnoses In an interview 3/27/24 at 11:30 AM, the Social Services (SS) Director reported she checked Resident #17's medical record documents and the Maximus website, and confirmed Resident #17 last had a PASRR completed 2/28/22. When she checked the resident's chart, she found he had a new medication added, so she resubmitted a request for a PASRR review to Maximus on 3/27/24 at 11:26 AM. The Social Services Director reported the nursing staff were supposed to let her know whenever a resident had a new medication or psychiatric diagnoses added so she could submit information for a PASRR review, if applicable. The SS Director reported the PASRR process being worked on by staff at the facility. In an email from the Administrator on 3/27/24 at 2:47 PM, the Administrator wrote the facility did not have a policy for PASRR but would work on it. The Administrator wrote nursing had been educated on the importance of informing the SS Director when there had been a significant change or medication change for a resident in order for SS to update the PASRR. The SS Director now attended the morning clinical meetings.

Based on observations, staff interviews, and facility policy review the facility failed to access temperatures of food before serving the meal to the residents to ensure hot food for 11 of 52 residents reviewed. The facility reported a census of 52. Findings: On 1/19/23 at 9:50 AM observed the preparation of pureed meal for five (5) residents on pureed diets by Staff H, Director of Food Services: a. 15 ounce (oz.) of ground seasoned meat added with five (5) buns and broth to the robo-coup mixed to pudding like consistency for five (5) residents, one (1) cup servings b. 28 steak fries, five (5) fries per serving (relayed by the dietary manager) was added to the vita-mixer and pureed to pudding consistency with milk for five (5) one (1) cup servings of potatoes c. Five (5) six-ounce servings of chicken noodle soup had been pureed for five (5) six-ounce servings of soup. Staff H moved the pureed food to the food warmer oven in aluminum containers. The oven indicated a temperature of 170 degrees . On 1/19/23 at 10:30 AM Staff H, reported a maid rite sandwich (seasoned ground beef), chicken noodle soup, fries, and apricots as the lunch menu. Staff H, relayed the kitchen prepared the meals for the health center and the Assisted Living facility. Staff H explained that the kitchen sent the health center their food to the second floor and third floor at around 11:45 AM. The health center served the meals to their residents from steam tables in the kitchenettes next to the second and third floor dining rooms. On 1/19/23 at 11:44 AM witnessed the food arrive at the second-floor kitchenette on a cart with food covered in aluminum containers. Staff G, Dietary AIde, moved the food from the cart in the aluminum containers to the steam table. The food included: a. Seasoned ground meat b. chicken noodle soup c. steak fries d. pureed meat with a bun (1 serving in a bowl, in an aluminum container) e. pureed potatoes (1 serving in a bowl, in an aluminum container) f. pureed soup (1 serving in a bowl, in an aluminum container) Staff G prepared the residents ' plates without assessing the meals temperature. On 1/19/23 at 11:50 PM, Staff F, Dietary Cook, acknowledged that the food should be tempted and left to retrieve a thermometer. Staff G present served and relayed that she had not been taught to temp the food prior to serving it. Staff G agreed to temp the food when a food thermometer retrieved by Staff F. On 1/19/23 at 11:54 AM observed Staff G check the food temperatures revealing the following: a. seasoned ground meat-------temperature 140 b. chicken noodle soup----------temperature 147 c. steak fries---------------------temperature 108 d. pureed meat with a bun ---- temperature 98 e. pureed potatoes --------------temperature 98 f. pureed soup ------------------temperature 98 On 1/19/23 at 11:56 with Staff F voiced the temperatures should be higher. On 1/19/23 at 12:02 PM Staff G relayed that she did not know the food should have its temperature checked before serving. Staff G explained that she did not receive any education on that process and has not checked the food ' s temperature before serving. Staff G served the food to second-floor residents. Staff G agreed to temp the food left at the end of serving. On 1/19/23 at 12:15 observed Staff G check the following food temperatures: a. seasoned ground meat-------temperature 140 b. chicken noodle soup----------temperature 130 c. steak fries------------------------temperature 100 pureed food was served, none left On 1/19/23 at 1:05 PM with Staff H acknowledged that the dietary staff lacked education. Staff H verified that the food temperatures should be checked before serving and if not high enough then the food could be reheated. Staff H acknowledged that the staff needed education. The undated facility provided policy titled Food Temp Procedure and Policy directed the following: a. food tempted and recorded prior to leaving the main kitchen b. food is tempted and recorded after arrival and placement into the steam table c. hot food must hold at 135 degrees or above d. If temp is unacceptable, instructions to call the Food Service Director or cook for instructions. The food would be replaced or corrected.

Based on observations, clinical record reviews, and staff interviews, the facility failed to update the Care Plan for one of three residents reviewed (Resident #15) following a change in condition. The facility reported a census of 52 residents. Findings included: Resident #15's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. The MDS included diagnoses of Alzheimer's disease and osteoporosis without a current pathological fracture. The MDS indicated that Resident #15 required total dependence on staff assistance for eating, dressing, toilet use and bathing. The MDS included additional information that Resident #15 required extensive staff assistance with positioning and transfers. The MDS listed that Resident #15 had an unhealed venous/arterial ulcer. The Care Plan with the goal target date of 11/30/22 identified the resident with the problem of being at stage 4 pressure ulcer to the left elbow. The Care Plan did not identify that Resident #15 had a pressure ulcer to her coccyx area. The Weekly Pressure Ulcer Record identified a date of onset as 11/30/22 of a pressure ulcer to Resident #15's coccyx. As of 1/3/23 Resident #15 continued to have a stage II (2) pressure ulcer to her coccyx that measured 1.3 cm (centimeters) long, 0.8 cm wide and 0.1 cm deep. On 1/13/23 the wound measured 0.9 cm long, 0.9 cm wide, and 0 cm deep. Resident #15's wound bed appeared pink and clear, with the surrounding skin mildly red. During an observation of care on 1/18/23 at 9:50 AM, Staff I, Certified Nurse Aide (CNA), and Staff J, CNA, used the correct technique to properly provide peri care and reposition the resident. During the observation, the surveyor witnessed two open areas, one on the coccyx and one on her right buttock, both appeared nearly healed without signs of infection. During an observation of wound care 1/19/23 at 9:04 AM, Staff K, Licensed Practical Nurse (LPN) and Staff A, CNA, provided the correct technique to cleanse the wound and treatment to Resident #15's left elbow. The site appeared nearly healed without signs of infection. A review of the radiology report dated 5/13/22 identified that Resident #15 had a non-displaced fracture of the distal ulna (bone that is part of the wrist). The Care Plan Problem with a start date of 8/31/22, and an end date of 11/30/22, indicated that Resident #15 had a fractured left wrist with appropriate interventions. The Care Plan lacked identification of the wrist fracture until 8/31/22. During an interview on 1/19/23 at 12:56 PM, Staff E, LPN, reported that Resident #15 had a fracture of her left wrist in May 2022 and the problem should have been identified on the Care Plan within a week after the fracture occurred. During an interview on 1/19/23 at 2:26 PM, Staff D, LPN, reported that Resident #15 had a fracture to her wrist in May 2022 and the MDS coordinator should have added the problem of the fracture to the Care Plan within a week after it occurred.

Based on record review and resident, family, and staff interviews, facility staff failed to respond in a timely manner (15 minutes) when residents activated their call lights for seven of seven residents reviewed. The facility reported a census of 48 residents. Findings include: During a confidential group interview on 08/02/21 01:30 PM 4 of 5 residents present stated the facility had long call light response times. The residents reported it took staff up to 30 to 45 minutes to provide assistance after they had turned on their call light. Two residents reported it took longer on weekends or during care and meal times. Both reported they had accidents while waiting for assistance. On 8/2/2021 at 11:14 AM a family member reported her loved one had often waited up to 30 minutes for staff to answer their call light, especially on weekends with less staff scheduled. Review of call light reports dated 7/15/21 to 7/31/21 revealed call light response times greater than 15 minutes for the following: 1. Resident #9: 6 times with response time ranging from 16 to 76 minutes 2. Resident #15: 4 times with response time ranging from 19 to 34 minutes 3. Resident #26: 14 times with response time ranging from 15 to 70 minutes 4. Resident #33: 17 times with response time ranging from 16 to 36 minutes 5. Resident #37: 1 time with response of 25 minutes 6. Resident #42: 1 time with response of 29 minutes Review of the Resident Council Notes dated 5/24/21 revealed residents had reported concerns with call light response times of 40-50 minutes. The Resident Council Notes documented the residents' concerns were directed to the Health Center Director of Nursing (DON). On 8/5/21 at 1:19 PM, the DON stated she expected staff to respond to resident call lights within 15 minutes. The DON stated they had no call light policy. On 8/5/21 at 1:40 PM, the Assistant Director of Nursing stated he checked call light reports whenever he had resident or family concerns to confirm issues, then followed up with staff. The ADON stated he expected staff answer call lights within 15 minutes.

Based on clinical record review, staff interviews, and policy review, the facility failed to provide a bedhold notice for 2 of 2 residents reviewed (Resident #44 and #6). The facility reported a census of 48 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 5/23/21, Resident #44 discharged from the facility to the hospital on 5/23/21. Review of the Census List revealed Resident #44 discharged from the facility to the hospital on 5/23/21. The clinical record lacked documentation of any explanation of the bed hold notification to the resident or the resident's representative when the resident discharged to the hospital 5/23/21. During an interview 8/4/21 at 3:30 PM, Staff C, Registered Nurse reported she looked for a bedhold notice given to Resident #44. On 8/5/21 at 1:25 PM, the MDS Coordinator reported she could not locate a bedhold notice issued to Resident #44 on 5/2021. 2. The MDS dated [DATE], documented Resident #6 discharged from the facility to the hospital on 6/30/21 . Review of Resident Progress Notes revealed the facility sent Resident #6 to the hospital on 6/30/21 at 4:30 PM and returned to the facility on [DATE] at 5:25 PM. The clinical record lacked documentation that showed staff gave the resident or the resident's representative any explanation or notification of bed hold when the resident discharged to the hospital 6/30/21. During an interview 8/5/21 at 1:58 PM, Staff C, Registered Nurse reported she could not locate a bedhold notice for Resident #6. She stated the facility's standard of practice required staff to provide a notification of bed hold to all residents upon discharge. An undated Admission Agreement packet revealed under section 483.12 Admission, Transfer, and Discharge Rights, regarding notice of bed hold policy. The nursing facility must provide written notice at the time of transfer to the resident or resident's representative which specified the duration of the bed hold policy whenever a resident transferred to the hospital or left for the facility for therapeutic leave.

Based on interview, record review, and facility policy review, the facility failed to ensure staff followed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 48 residents at the time of the survey. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 04/30/21, Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 15 of 15 points possible on the Brief Interview for Mental Status (BIMS) test, which indicated Resident # 6 displayed intact cognitive abilities. The MDS revealed the resident required [CONDITION(S)] treatments, had the ability to communicate verbally, and required limited assist of one staff for bed mobility, surface-to-surface transfers, ambulation (walking), dressing, toilet use and personal hygiene. The MDS also documented Resident #6 required set up assist only for eating and experienced occassional bowel and bladder incontinence. The care plan last revised on 07/14/21 documented Resident #6 required staff assist to meet all Activities of Daily Living (ADL) needs. The care plan directed staff to complete a weekly head-to-toe skin observation with the resident's routine shower, and assist her with routine bathing. The care plan lacked any information, care requirements, or staff directives related to the resident's [CONDITION(S)] catheter site. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Progress Notes printed on 08/05/21 revealed the following: a. On 03/24/21, staff showered the resident that shift. b. On 06/05/21, the resident's fistula dressing came off; staff cleansed the area with normal saline and applied a sterile dressing. c. On 04/10/21 staff noted the resident took an evening shower with no skin issues noted. The Point of Care ADL report printed on 08/04/21 revealed staff showered the resident on 2 of the 7 bathing opportunities between 04/03/21 and 07/27/21. During an interview on 08/02/21 at 10:50 AM, Resident #6 stated her [CONDITION(S)] port became infected when it got wet when staff gave her showers. She reported she ended up in hospital for 10 days with an infection and had to have her [CONDITION(S)] port surgically changed. After that, she said she arranged for a bath every other Saturday with Staff E and then gave herself a sponge bath at other times. During an interview on 08/04/21 at 12:13 PM, Staff E stated she had assisted Resident #6 with baths since she began working on the 3rd floor. Staff E reported when Resident #6 first admitted to the 3rd floor she was assigned to do showers on the evening shift, but then Resident #6 decided to change to morning baths. Staff E logged into her computer to show where she charted baths or showers. On 08/05/21 at 01:35 PM, the Assistant Director of Nursing (DON) verified the facility expected staff to follow physician orders. On 08/05/21 at 1:58 PM, Staff C agreed the facility expected staff to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on clinical record review and resident and staff interviews, the facility failed to ensure assessments before and after hemodialysis treatments for one of one resident reviewed that required [CONDITION(S)] (Resident #6 ). The facility reported a census of 48 residents. Findings include According to the Minimum Data Set (MDS) assessment tool dated 04/30/21, Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 15 of 15 points possible on the Brief Interview for Mental Status (BIMS) test, which indicated Resident # 6 displayed intact cognitive abilities. The MDS revealed the resident required [CONDITION(S)] treatments, had the ability to communicate verbally, and required limited assist of one staff for bed mobility, surface-to-surface transfers, ambulation (walking), dressing, toilet use and personal hygiene. The MDS also documented Resident #6 required set up assist only for eating and experienced occasional bowel and bladder incontinence. Resident # 6's care plan, updated on 07/14/21, identified the resident required [CONDITION(S)] services and directed staff to complete a head-to-toe physical assessment prior to leaving for [CONDITION(S)] and upon return from [CONDITION(S)]. The care plan also directed staff to monitor and record fluid intake, obtain routine weights, observe for changes in cognition, observe for hyper/[CONDITION(S)], [CONDITION(S)], and syncopal ([CONDITION(S)]) episodes, observe for peripheral/sacral [CONDITION(S)], dyspnea, and distended neck veins. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Progress Notes report from May and June of 2021 demonstrated that Resident #6 received pre-[CONDITION(S)] assessments on 11 of 17 [CONDITION(S)] days and received post-[CONDITION(S)] assessments on 12 of 17 [CONDITION(S)] days. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On the Medication Administration History report printed 08/04/21, pre and post [CONDITION(S)] day pain scale and [CONDITION(S)] site/catheter observations were completed on [CONDITION(S)] days from the moment Resident #6 returned from the Hospital on 07/09/21. Pre and Post [CONDITION(S)] vital signs were started on 07/12/21 per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviews: a. On 08/03/21 at 10:30 AM, Resident # 6 reported staff members did not consistently complete assessments (inspecting the [CONDITION(S)] access site, checking vital signs, and/or gathering any pertinent data related to the resident's general condition before and after [CONDITION(S)] treatments. b. On 08/05/01:35 PM the Assistant DON confirmed the facility's expectation that staff provide pre and post assessments on [CONDITION(S)] days by the nurse. He also confirmed that even if the physician did not write a specific order to conduct pre and post [CONDITION(S)] assessments, the nurse would still be expected to provide those assessments. c. On 08/05/21 at 1:58 PM, Staff C agreed nurses are supposed to provide pre and post assessments on [CONDITION(S)] days and they should do so whether or not the physician wrote an order that directed those assessments. The Facility Assessment Tool, reviewed 06/30/21 under section 1.4 Decisons Regarding Care for Residents with Conditions Not Listed Above (List above does not include [CONDITION(S)]). Admissions to [NAME] Community are reviewed using an interdisciplinary approach involving social work, nursing, and any other entity that may be required to meet the needs of the potential resident. If [NAME] Community determines that the staff is able to meet the needs of the potential resident; appropriate supplies, training, etc. are secured prior to the admitted . This includes special equipment needs, dressing supplies, dietary accommodations or feeding supplies, medications or therapies. Staff may make a face to face visit to personally assess and advise regarding admission. Under Category 2: Special Treatments and Conditions, the facility allows for 0-2 [CONDITION(S)] residents.

Based on record review and staff interview, the facility failed to ensure the required staff attended facility Quarterly Assurance Performance Improvement (QAPI) committee meetings for 2 of 5 reviewed meetings. The facility reported a census of 48 residents. Findings include: In an interview on 08/05/21 at 12:50 PM, the Director of Quality Assurance Performance Improvement (QAPI) reported she started in April 2021. She stated there had been a time when the facility had not held any QAPI meetings. They held their last meeting on 07/22/21. In an interview on 08/05/21 at 02:38 PM, the Director of QAPI provided the sign-in sheets she could locate and speculated there may have been meetings where the administrator did not attend, but she knew the facility missed a quarterly meeting before she started working there in April. Facility records show the QAPI meeting attendance form dated July 2020 recorded the following members in attendance QAPI nurse, pharmacist, dietician, social worker, medical director, and DON. Facility records show the QAPI meeting attendance form dated August 2020 recorded the following members in attendance medical director, dietician, QAPI nurse, DON, and ADON. The facility could provide no records to indicate a January 2021 quarterly QAPI meeting occurred as required.

Based on observation, clinical record review, resident and staff interview, the facility failed to ensure two of twelve residents observed were properly covered during cares. (Resident #20 & #30) The facility census was 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], identified Resident #20 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required the extensive assistance for bed mobility, toilet use and transfers and extensive assistance for dressing. During observation on 10/16/19 at 9:45 a.m., Staff E, certified nurse aide, CNA and Staff F, CNA, utilized an EZ stand to assist the resident to stand. Staff [NAME] removed the resident's pants and brief and used a washcloth to cleanse the resident's buttocks area. The resident stood next to the bed with his backside exposed and facing a window with the curtains open. Staff A, licensed practical nurse, LPN, donned a pair of gloves, applied collagen particles/powder and A & D ointment to the residents buttock and requested Staff [NAME] and Staff F for a clean brief, but there were none readily available. Staff lowered the resident onto the bed. At 9:57 a.m., Staff [NAME] obtained a clean brief and additional washcloths. At 9:59 a.m., Staff F used the EZ stand and stood the resident up by the bed, with his bottom exposed toward the window. Staff [NAME] cleansed the resident's bottom and Staff A applied collagen particles/powder and A & D ointment to the resident's buttock. Staff F replaced the resident's brief and pants. Staff [NAME] and Staff F transferred the resident to the recliner. During interview on 10/16/19 at 10:05 a.m., the resident reported he did not know the curtains by the window was open when staff provided cares and applied the skin treatment to his bottom. The resident reported it bothered him when the curtains remained open and he had his bottom exposed. During interview on 10/16/19 at 10:30 a.m., Staff A, LPN, reported she expected staff to close the curtain before providing cares or a treatment. 2. The MDS assessment dated [DATE], documented Resident #30 had [DIAGNOSES REDACTED]. During observation on 10/15/19 at 7:07 a.m., Staff B, CNA, removed the resident's brief. At 7:10 a.m., Staff B left the room to get help leaving the resident in bed fully exposed. At 7:12 a.m., Staff C, CNA arrived with Staff B to provide assistance. Staff B gathered supplies and stated she had to wait for a nurse to observe. The resident laid in bed uncovered while staff gathered supplies and waited for the nurse. At 7:15 a.m., Staff D, Registered Nurse, RN arrived and the resident remained uncovered. At 7:29 a.m., the resident remained uncovered while Staff B and Staff C applied the resident's [NAME] hose. At 7:32 a.m., or 25 minutes later, staff dressed the resident with his briefs and slacks. During interview on 10/15/19 at 8:15 a.m., Staff D stated she would expect staff to not leave the resident exposed when not in the room. During interview on 10/16/19 at 11:15 a.m., the Director of Nursing (DON) stated it would be expected for staff to avoid unnecessary exposure of the resident.