Every finding on record at Canterbury Center

Based on observations, resident interview, and staff interview, the facility failed to ensure the rooms are being kept in a clean/comfortable/homelike environment for four (4) of nine (9) rooms throughout the Long-Term Care Survey Process. Room identifiers: #301, #305, #306. Resident identifier: #4. Facility census: 59. Findings included: a) room [ROOM NUMBER] On 07/12/26 at 11:45 AM the following observation was made of room [ROOM NUMBER]'s bathroom: A bed pan was placed on the floor. Also, in the room trash debris was on the floor between and under the beds. Nursing Assistant #24, verified the bed pan should have been off floor and the room cleaned, stating On the weekends house keeping is scheduled one person usually. b) room [ROOM NUMBER] In room [ROOM NUMBER] trash can had trash overflowing under the sink and in bathroom. Nursing Assistant #24 verified the room and bathroom needed cleaned. c) room [ROOM NUMBER] On 07/12/26 at around 12:00 PM, in room [ROOM NUMBER] the state surveyor (SS) observed the trash can had trash overflowing with trash debris and a soiled brief in it. Nursing assistant (NA) #24 verified trash was over flowing and the brief should not have been in there. She stated, I have been running around like crazy today - staffing is a bit low. d) Resident #4 On 07/12/2026 2:00 PM during an interview with the SS Resident #4 stated her bedside table was dirty and never got cleaned. SS observed that the bedside table was soiled and needed cleaning. ON 07/13/26 at 11:12 AM the SS went to Resident #4 room to check on her. She was not in her room. The SS saw a wet floor sign. The floor was dry. The room looked to have been cleaned, but the bedside table was still soiled and needed cleaning. The SS asked Registered Nurse #99 if the bedside table looked soiled to her. She stated, It is soiled and we will get it cleaned.

Based on observations, resident interviews, record review and staff interviews. The facility failed to ensure call lights were answered in a timely fashion to ensure residents needs are met, additionally the facility failed to ensure resident's received treatment and care in accordance with professional standards of practice. Specifically, physician's orders were not followed. For five (5) of (22) residents reviewed during the long term care survey process. Facility census 59.Resident indicators. #8, #39, #41 and #79, #4 Findings include; a)Review of grievance reports: -02/10/26 grievance of long call light times -02/17/26 grievance of long call light times evening and night shifts -03/03/26 grievance of long call light times during the day -03/10/26 grievance of call light are slow to being answered -03/17/26 grievance of long call light times on night and early morning shifts -04/24/26 grievance of long call light time -04/24/26 grievance of long call light time -04/24/26 grievance of long call light time -04/24/26 grievance of long call light time -04/24/26 grievance of long call light time -04/24/26 grievance of long call light time -04/24/26 grievance of long call light time -04/24/26 grievance of long call light time -04/24/26 grievance of long call light time -04/24/2026 grievance of long call light time -04/24/2026 grievance of long call light time -04/24/2026 grievance of long call light time -04/24/26 grievance of long call light time -04/24/26 grievance of slow call light response between 8pm and 12 am and call lights being turned off without assistance until later. -5/12/26 grievance of long call light times -05/26/26 grievances of call light response times are varied across shifts. -06/02/26 grievance of long call light times around meal pass. -06/30/26 grievance of slow call light times b) Review of resident council meeting minutes: -02/10/26 concern of long call light times reported by multiple residents over the past week. -02/17/26 Residents reported long call light times in the evening and night shifts. -03/03/26 multiple residents reported long call light times in the morning and night. -03/10/26 concern that call light times are still slow on some days -03/17/26 residents report long call light times mainly on night and early morning shifts -04/28/26 residents report slow call light response times from 8pm-12am and call lights are being turned off without assistance until later. -05/12/26 residents report call lights go unanswered on the night shift -06/30/26 residents report call light times have been slower than expected this past week on varied shifts and days. On 07/12/26 at around 12:10PM Resident #8 asked for her call light, reporting need someone and I cant find my call light. The State Surveyor (SS) observed the call light was on the floor between the side rail and mattress. The SS turned on call light for resident at this time. At around 12:35 PM, the Activity Director (AD) walked into the room to answer the call light. The SS questioned how long it generally took to answer call lights specifically during meals and on weekends. The AD reported, Usually pretty quick, but her aide was helping another hall. Resident #8 requested call light to be in reach. The AD verified the call light was not in reach and repositioned it. Resident #8 reported to activity director, My call light had been on since 12:10. It is now 12:35 PM. That is a long time. The AD reassured Resident #8 that they would do better at answering. On 07/12/26 at around 12:55 PM the SS observed that the call light for Resident #8 was on. SS was observing for meal service. At 1:15 PM the call light remained on and no staff was observed on the unit. The SS observed that the meal delivery cart was brought to the unit at 12:50 PM. At 12:20 PM Nurse Aide (NA) #24 began meal service and the all light remained on. The SS questioned NA #24 if staff answered call lights during meals, she replied We usually answer, I was in there a couple minutes ago. SS reported to NA #24 that their observation was being done since 12:50 PM with no staff being on the unit until 1:20 PM. NA #24 reported, Oh, I was down another hall passing trays, I am sorry. On 07/12/26 at around 2:10 PM, Resident #39 reported, When I put on my call light it takes a long time, sometimes I wet myself. Like now. They tell me they are short staffed. Most days I try to wait and not bother them. On 07/12/26 at around 1:30 PM during follow up interview, Resident #79 reports, I have only been here since Friday but they need more staff, it takes along time to get a call light answered. They are even telling me they are short staffed On 07/12/26 at around 3:45 PM, Resident #41, was interviewed with her daughter. Resident #41 she reported, It doesn't seem like they have enough staff, seems like there is always one aide on a hall , the nurses try to help but they are busy too d) Resident #4 During an interview with the State Surveyor (SS) on 07/12/26 at 2:00 PM Resident #4 stated that she fell two months ago. She said she fell out of a shower chair. Resident #4 said the facility waited three days to get an x-ray. 07/13/26 1:00 PM Pn 07/13/26 the SS reviewed the medical record of Resident #4 and determined that Resident #4 had a fall on 03/27/26 at 7:45 PM. Further review of the medical record revealed that on 03/29/26 the Physician ordered an X-ray of the right knee, right foot and sacrum due to complaint of pain. The X-ray was obtained for her right knee and foot but not her sacrum. 07/13/26 1:30 PM On 07/13/26 at 1:30 PM the state surveyor asked the Director of Nursing (DON) why Resident #4 did not receive an X-ray for her sacrum as ordered by the physician on 03/29/26. She stated, I am not sure, I will ask the staff and the Nurse Practitioner (NP) and get back to you. On 07/13/26 at 2:32 PM the DON stated to the SS, I could not find out why Resident #4 did not receive the X-ray for her sacrum. I have notified the Physician about the omitted X-ray for Resident #4 back on 03/29/26. I am going to complete a significant change and a pain assessment on Resident #4.

Based on record review and staff interview the facility failed to ensure pharmacist recommendations were acknowledged by the physician. This was true for one (4) of Five (5) residents reviewed for the care area of unnecessary medication. Facility Census: 59. Resident identifiers: #43, #4, #54, and #56. Findings Included: a) Resident #43 The Consultant Pharmacist (CP) completed a Medication Regimen Review (MRR) on 10/21/25. The Consultant Pharmacist (CP) recommended (as Written): The resident was prescribed diclofenac gel 1% to knees twice daily for pain relief. The current order did not specify the amount. Recommended dosing for diclofenac gel.: Upper Extremity: Apply 2g gel each affected area up to 4 times daily (maximum dose per joint is 16g/day) Lower extremity: Apply 4g to each affected are up to 4 times daily(maximum daily dose per joint of 8g/day) Maximum Daily dose (ll joints combined): 32g/day Please update the resident's diclofenac gel 1% order to specify the amount of grams to be applied. The physician did not respond to or acknowledge this recommendation. The CP completed a Medication Regimen Review (MRR) on 11/12/25: The CP recommended (Ttyped as written): The resident is prescribed diclofenac gel 1% to knees twice a daily for relief of pain. The current order does not specify amount. Recommended dosing for diclofenac gel: Upper Extremity: Apply 2g gel each affected area up to 4 times daily (maximum dose per joint is 16g/day). Lower extremity: Apply 4g to each affected are up to 4 times daily(maximum daily dose per joint of 8g/day) Maximum Daily dose (all joints combined): 32g/day Please update Resident's diclofenac gel 1% order to specify amount of grams to be applied. The physician did not respond to or acknowledge this recommendation. During an interview with the Director of Nursing (DON) on 07/14/26 at 9:40 AM, she was asked why the facility had not acted on these pharmacy recommendations. She stated, I do not know, I came here in December 2025. c) Resident #54 A medical record review for Resident #54 revealed monthly drug regimen reviews response without physicians review, actions or rationale. On 07/22/25, the Consultant Pharmacist (CP) recommended the following: Resident is receiving probiotic Florastor twice daily. No noted GI complaints. Could this be considered to stop at this time? No Physician response was noted. During an interview on 07/15/26 at 11:02 AM the Administrator verified that the physician did not review the recommendation or note the action or rationale. d) Resident #56 A medical record review for Resident #56 revealed monthly drug regimen reviews from the CP. 11/19/25 Recommendation from the CP: Federal guidelines for long term care facilities require an evaluation of antipsychotic usage upon admission. This resident was recently admitted with an order for Olanzapine ODT 10 MG two times a day to treat psychosis management. 11/19/25 Recommendation from the CP: Resident is currently receiving Escitalopram and Trazodone for depression. The combined use of more than one antidepressant medication has not been demonstrated to be more effective than a single agent and has potential to increase side effects. During an interview, on 07/15/26 at 11:02 AM, the Administrator verified that the physician did not review the recommendation or note the action or rationale. b) Resident #4 The Consultant Pharmacist (CP) completed a Medication Regimen Review (MRR) on 09/24/25 for Resident #4. The Consultant Pharmacist (CP) recommended to increase Glargine insulin dose or routine Lispro insulin doses to lesson the need for corrective Lispro insulin. This recommendation was not acknowledged by the facility. The CP completed a Medication Regimen Review (MRR) on 10/21/25 for Resident #4. The CP recommended to increase Glargine insulin dose or routine Lispro insulin doses to lesson the need for corrective Lispro insulin. The facility had no evidence reflecting that this recommendation was acknowledged. The CP completed a Medication Regimen Review (MRR) on 11/11/25 for Resident #4. CP recommended increasing the Glargine insulin dose or routine Lispro insulin doses to lessen the need for corrective Lispro insulin. This recommendation was not acknowledged by the facility. State Surveyor (SS) asked DON during an interview on 07/14/26 at 9:40 AM why the facility had not acted on these pharmacy recommendations She stated, I do not know, I came here in December 2025.

Based on observation, resident interview, and staff interview, the facility failed to ensure palatable food. The noon meal on 07/12/26 was served late and cold causing food to be too tough to cut or chew. This was a random opportunity for discovery that had the potential to affect more than a limited number of residents. Resident Identifiers: #47, #9, #19, #44, #37, #28, #2, #36, #25, #11, #4, #43, #78, #14, #57, #60. Facility Census: 59 Findings Included: a) During the first kitchen visit on 07/12/26 at 11:55 AM, kitchen staff reported that due to being short-staffed, no residents would be served in the dining room at the usual time of 12:00PM. A short time later at 12:10 PM, the kitchen was notified that because the state is here the dining room had to be open. The Dietary Manager had already placed usual dining room resident's meal tickets back in the stack for room delivery. Dining room observation on 12:25 PM revealed Resident #47, #9. #19, #44, #37, #28, #2, #36, #25, and #11 were in the dining room at 12:25 PM waiting to be served. At 12:40 pm, The frist trays served in the dining room to Resident #9, #19, and #47. This was 40 minutes late. Resident #47 refused her tray stating she could not cut/chew the meat. At 12:50 PM, It was observed Resident #44 received her tray which was 50 minutes late. At 1:20 PM Resident #11 became very upset and asked several times What is going on here. Am I going to eat or not? By 1:25 PM, she decided to go back to her room but was given the tray that was left sitting on the counter. When staff was asked where the tray came from she stated it was An extra one. The surveyor asked if the tray might be too cold to serve; she stated, Oh, maybe. and went back to check with Resident #11 who stated the tray was too cold to eat. At 1:30 PM Resident #11's tray arrived after it had been sent to her room and then back to the dining room and was given to her to replace the rejected extra tray. Again the surveyor asked the staff if that tray was also too cold. She checked again, confirmed it was cold, and took it to be heated. It was then given to resident # 11 at 1:35PM. Also at 1:30PM Resident #2, #36, #25, #37, and #28's trays arrived after they had been sent to their rooms and then back to the dining room. Resident #37 stated she could not eat her tray as it was cold and stated the meat was too tough,. Resident #37 said, I don't want to break my teeth on that meat. In an interview with the Dietary Manager (DM) on 07/12/26 at 12:10 PM, the DM reported the dining room was originally supposed to be closed for the noon meal due to the facility being short staffed. The change of opening the dining room caused the meals to be served later than scheduled time of 12:00 PM In an interview with the facility Administrator (FA) and the Corporate RN (CRN) on 07/13/26 at 9:00AM, the FA and CRN stated they would have liked to have known about it sooner but acknowledged the noontime meals were served late with cold and tough food in the dining room the previous day. -On 07/12/2026 at around 1:50 PM Resident #78 called this surveyor to room, and reported, I am not sure what this meal is supposed to be but the meat is tough, the mashed potatoes are runny, The surveyor observed the meat was tough to cut and mashed potatoes running on the plate. -On 07/12/2026 at around 1:30 PM Resident # 57, reported, The food is sometimes alright, a lot it is cold, they take along time to pass trays. Today the meat was really tough and gravy was not good. -On 07/12/2026 at around 2:00 PM Resident #14, reported,. I don't like any of the food, the meat is usually too tough to eat. And cold by the time they pass. -On 07/12/2026 at around 2:00 PM, Resident #37 reported, The food is usually not good it is cold half the time because the aides take along time to pass trays. -On 07/12/2026 at around 3:30 PM. Resident #60 reported, The food is usually not too good. Today for instance the meat was really tough, couldn't hardly chew it, and the mashed potatoes were runny.

Based on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. This was true for the facility kitchen and nourishment pantry. This had the potential to affect all residents in the facility. Facility census: 59 Findings included: a) Initial Kitchen Visit: On 07/12/26 at 11:44 AM, during an Initial Brief Tour of the Kitchen, with the Dietary Manager (DM) the DM acknowledged the following:- in the walk in cooler, an opened box of bacon not sealed and left open to air- in the refrigerator, a ketchup container with a hole the corner of the lid exposing the condiment to open air, - in both of the 2 (two) utensil drawers, the scoops were not stored all in the same direction. b) Nourisment room walkthrough: On 07/13/26 at 11:15AM during a walk through in the nourishment room with the Dietary Manager (DM) the DM acknowledged the following: the refigerator thermometer found the temperature inside was 48 degrees. The Dietary Manager stated she would request maintenance to check it. c) Facility Food Storage Policy:On 07/14/26 at 3:00 PM the surveyor reviewed the facility policy labeled HCSG Policy 019, Food Storage: Cold Foods. Procedure number 5 stated: All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. d) Staff Interview:On 07/15/26 at 9:00 AM, the surveyor interviewed the Facility Administrator (FA), Director of Nursing (DON) and the Corporate RN (CRN). The FA, DON, and CRN acknowledged the exposed box of bacon in the walk-in cooler, the open condiment in the refrigerator, the incorrectly stored utensils in the kitchen, and the 48-degree refrigerator temperature in the nourishment room, and they made a list of the findings.

Based on record review, and staff interview, the facility failed to ensure Resident #38 had a person-centered comprehensive care plan developed and implemented to meet his / her other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This practice affected one (1) of (22) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was developed for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident Identifiers: #38. Facility census: 59.Findings included:a) Resident #38Review of the medical records for Resident #38 revealed a preference for no male caregivers in the special instructions. Subsequent review of the comprehensive care plan and physician orders indicated that the instruction for no male care givers was only documented within the special instructions section rather than integrated into the primary care goals or active physicians orders During an interview on at 12:47 PM, the Social Service Director (SSD) verified she has never interviewed Resident #38 about her preferences of care givers. On 07/15/26 at 1:15 PM, an interview with the Director of Nursing confirmed that the directive for No male care givers was not properly reflected in the resident's care plan or physician orders to ensure all staff were alerted to the request.

Based on observation, and staff interview the facility failed to treat each resident with respect and dignity during the lunch dining experience. This was a random opportunity for discovery. Resident Identifier: #54. Facility census: 59 Findings included: a) Resident #54 An observation of meal service on 07/09/26 at 12:40 PM, found Nurse Aide (NA) #66 standing over Resident #54 assisting with his lunch meal. During an interview on 01/12/26 at 12:19 PM the Director of Nursing (DON) verified that staff should assist residents with meals while sitting beside them, not standing over the resident.

Based on resident interview, record review and staff interview, the facility failed to ensure one (1) of one (1) resident received the assistance needed with activities of daily living. Resident identifier: #4. Facility census: 59. a) Resident #4 During an interview with the State Surveyor (SS) on 07/12/26 at 2:00 PM Resident #4 stated she had not had a shower in three (3) weeks. She stated she was supposed to get a shower every Monday and Friday. She became teary-eyed and stated, My hair is greasy and I cannot do it by myself. Resident #4 had capacity to make medical decisions. On 07/13/26 at 12:08 PM the SS spoke with the Director of Nursing (DON), the Clinical Lead Nurse (CLN) and the Administrator (ADM) about Resident #4 stating that she was not getting showers as she would like to. On 07/13/26 at 12:16 PM the CLN gave the SS a copy of Resident #4's bathing documentation from her medical record. It did show that Resident #4 was receiving bed baths instead of showers. On 07/13/26 at 1:30 PM the SS asked the DON, ADM and CLN why Resident #4 was receiving bed baths instead of showers. The CLN stated, I am not sure, but I will check for refusals. On 07/14/26 at 10:18 AM the SS asked the DON, ADM and CLN if they figured out why Resident #4 was not getting showers. The CLN stated. I cannot tell you that she refused these showers. I do not have proof. A review of Resident #4's care plan revealed the following: Focus: Resident requires assistance for ADL (Activities of Daily Living) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting, related to ESRD-Dialysis, Asthma and Diabetes. Goal: Residents ADL care needs will be anticipated and met throughout the next review period. Interventions: Provide resident with substantial/maximal assistance for bathing. Resident #4 was admitted on [DATE] and her base care plan was created on 12/16/24. The base care plan had not been updated regarding her bathing preference. She had capacity and during her interview on 07/12/26. During that interview she stated she preferred showers. On 07/14/26 at 12:49 PM the State Surveyor (SS) spoke with the DON, CLN and ADM about Residents #4 care plan not showing her bathing preference as wanting showers. They stated, We will get her care plan updated to reflect this.

Based on observations, and staff interviews, the facility failed to ensure the resident environment under its control was as free from accident hazards as possible. An observation of Resident #28's room found a spray bottle of disenfectant cleaner on her bedside dresser. Additionally, observations revealed a housekeeping cart and a treatment cart were left unlocked and unattended, and doors to central supply and the service hall were also found unlocked. These failed practices presented random opportunities for discovery and could affect more than a limited number of residents. Facility census: 59. Findings included: a) Resident #28 On 07/13/26 at 2:10 PM, a white/green spray bottle of disinfectant/cleaner was observed sitting on Resident #28's bedside dresser which was witnessed and confirmed by Housekeeping (HK) #82 and #101. HK #82 removed it and took it to the Director of Nursing (DON). During an an intervew with the DON, on 07/13/26 at 2:20 PM, she acknowledged the spray bottle of cleaner was found in Resident #28's room and stated she was going to check with the family to see if they brought it into the facility. On 07/12/26 at around 11:45 AM, the state surveyor (SS) observed an HK cart near the Dining Room (DR) left unattended and unlocked. SS observed the housekeeping (HK) cart for five (5) minutes while residents entered and exited the dining room. Laundry Aide (LA) #107 verified this needed to be locked since residents are coming and going in the dining room. On 07/12/26 at around 11:45 AM the State Surveyor (SS) observed the door to a room at the end of the service hall unlocked with a case of water blocking the entrance. LA #107 verified it needed locked. At around 1:45 PM the door at the end of the service hall remained unlocked with the case of water blocking it from opening fully. The Dietary Manager (DM) verified this door should be locked at all times. On 07/12/26 at around 12:00 PM the Treatment Cart (TC) near the resident lounge was unlocked and unattended. At 12:10 PM Registered Nurse (RN) #69, came to ask if this surveyor needed anything. The SS showed her that the cart was unlocked while residents were coming in and out of the resident lounge and passing by the cart on the unit. The RN verified it should have been locked.

Based upon record review and staff interview, the facility failed to maintain the accuracy of medical records for its residents. Specifically for wanderguards and their tracking and use. This was discovered during the normal long term survey process and has the ability to affect more than a limited number of residents. Resident identifier: #42. Facility census: 59.Findings included:a) Resident #42During a record review of Resident #42's chart performed on [DATE] at approximately 12:00 PM, it was discovered that Resident #42 was still wearing a wonderguard (a device that is placed upon a resident who wanders for safety), but the order had expired. The wanderguard orders were set to expire at the end of [DATE]. It was currently [DATE] and the same wanderguard was still on the resident. The orders included a note to Check placement and function daily and note in the medical administration record (MAR). The staff had been making notes in the MAR as checked but this was filed under an area that showed very the expiration. The Director of Nursing (DON) confirmed the wanderguard on the resident was not expired, but the orders were incorrect and had to be updated and they just did that (updated the orders).

Based on observation and interview the facility failed to ensure the daily nursing posting was completed accurately for two (2) days throughout the long-term care survey process. This was a random opportunity for discovery and had the potential to impact more than an isolated number of residents. Facility census: #59. Findings included:a) Staffing dataAn observation of the facility's posted staffing data on 07/12/26 revealed that the required resident census was not documented for 07/11/26 or 07/12/26.During an interview on 07/12/26 at 11:40 AM Registered Nurse (RN) #69 verified the census was not documented. She stated that she would add the census immediately.

Based on observations and interviews with residents and staff, the facility failed to ensure proper levels of staff were maintained to provide for the residents' needs. This was discovered during the normal Long Term Survey Process, while meeting with the resident council and has the ability to affect more than a limited number of residents. Census 59. Findings included:a) On 07/14/26 at approximately 10:30 AM during a meeting with the resident council, twelve (12) out of thirteen (13) members in attendance brought up that call light response times are very long. When the group was asked how long they thought the average wait time for a call light to be answered, the response was longer than 45 minutes most days. This was the answer given. This has been an area of note in almost every meeting since the beginning of the year. A second surveyor later confirmed this after overhearing a worker telling a resident, I'm sorry we are short staffed and it's taking so long to get to y'all.In a follow up with the Administrator, they confirmed staffing issues and stated they were working to address these concerns through new hiring and better deployment of current staff.

50795 Based on observation and interview, facility staff failed to handle, store, process, or transport linens and laundry in a hygienically clean manner, or clean the laundry machine filters. The facility also failed to follow infection control protocols when handling food trays, and trash. In addition, the facility failed to provide residents with hand hygiene before meals. These failed practices allowed for the potential spread of infection throughout the facility. Facility Census: 59 Findings Include: 1) Handling and storage of clean linen (100 Wing, 300 Wing and 400 Wing): a. During an observation of the 100 Wing linen cart on March 10, 2025, at approximately 7:30 AM, Account Manager (AM) #67 was seen replenishing wall boxes with trash bags. While doing this, she pushed a linen cart out of the way with her foot, causing clean linen from the lower rack of the cart to spill onto the floor. AM #67 was observed picking up the spilled linen and placing it back in the cart. However, RN #62 confirmed that the linen should not have been returned to the cart. RN #62 then removed all the linen from the bottom shelf of the cart and placed it in a used linen bag to be sent back to the laundry. At approximately 7:49 AM, the Director of Nursing (DON) approached and mentioned that staff member AM #67 was being educated on the safe and hygienic handling of clean linen. The DON also stated that she was organizing an in-service training for all staff focused on infection control. b. An inspection of the 300 Wing linen cart on 03/17/25 at approximately 12:16 PM revealed a staff person's sweater, a tube of hand lotion, and a can of air freshener placed on top of the clean linen in the cart. RN #53 was notified of the lapse in infection control, and confirmed that personal items were not supposed to be stored in the linen carts. RN #53 promptly removed the items and notified the DON. c. On 03/10/2024 at 6:17 AM During a check in the Linen Cart on 400 wing hall, there was Nystatin topical powder and a tube of Prevent Ointment found on the middle shelf with the clean linens. During a second check of the linen cart in the 400 hall on 03/17/25 at 12:06pm, personal clothing and a bottle of hand sanitizer was found on the second shelf of the linen cart in the clean linens. In an interview on 03/10/2025 at 6:30 AM, with RN #25 acknowledged the medicines were in the laundry cart and stated they were not to be left there and took them away. In an interview with The CNA # 4 on 03/17/25 at 12:20 PM, She stated the clothing was hers, but she did not have it on her body that day and she had placed the bottle of hand sanitizer on the cart so she could use it as needed. 2) Soiled Briefs Found in trash can in shared Bathroom: On 03/16/25 at 6:50 AM, soiled briefs were found in a trash can in the shared bathroom between rooms [ROOM NUMBERS]. On 03/16/2025 at 12:09PM, during a 2nd check, It was observed soiled briefs in shared bathroom between rooms [ROOM NUMBERS]. In an interview on 03/16/2025 at 12:20 PM with The DON, acknowledged the soiled briefs in the resident's bathroom trash can. She stated she would take care of it. 3) Resident hand hygiene not performed before meals: On 03/10/2025, at 9:00 AM, it was observed, on the 400 hall of the facility, while delivering the residents breakfast trays, CNA # 17 did not offer to wash or sanitize resident #24's hands. In an interview with CNA #17 on 03/10/2025 at 9:05 AM, she stated she did not remember to offer to wash or sanitize resident #24's hands before serving her tray. 4) Dinner food trays left at nurses station overnight: Upon entry to the facility at 5:30 AM on 03/10/2025, It was found that a cart of dinner trays from 03/09/2025 were left in front of the nurse's station overnight. In an interview with the DON on 03/12/2024 at approximately 2:00PM, she stated she was very aware of the dinner trays found at the nurse's station upon survey entry and that they should not have been there. 5) Trash and linen During an observation on 03/10/25 at 5:30 AM the facility had bags of trash and bags of linen on the floor in Hallway 100, 200 and 300. The linen barrels were overflowing in the soiled utility. During an interview on 03/10/25 at 5:46 AM Registered Nurse #9 verified the trash, and linens shouldn't be on the floor. She stated that they just have not had time to take out. 6) Hall 200 lunch tray pass An observation on 03/11/25 at 12:32PM of the noon meal tray pass revealed Nurse Aids placing the dirty plate covers and dirty breakfast trays back on the meal cart with resident lunch trays that were still being passed. An interview with the Infection preventionist verified the dirty items on the clean cart and stated dirty items should never be placed with clean trays. 7) Washing machine filters An observation of the laundry room on 03/18/25 at about 12:40 PM found four (4) of four (4) filters on the washing machine were not cleaned daily as required. During an interview with the laundry supervisor on 03/18/25 at about 12:44 PM, she verified the filters are not cleaned daily, she stated the maintenance men clean them when they clean the drains. 50801

Based on observation, staff interview, and equipment manual review the facility failed to have a clean, sanitized kitchen, store food in the refrigerator, freezer, and dry storage store food in accordance with professional standards for food service safety. The facility also failed to keep the ice machine in safe operating condition. This has the ability to affect all Residents that get their nutrition from the kitchen, also attends food related activities. Facility Census: 61 Findings included: a) Initial Kitchen tour. During the initial kitchen tour with the Kitchen Account Manager on [DATE] at 11:54 AM, an observation found --Walk-in refrigerator - Temperatures not documented -- Walk -in freezer - Temperatures not documented and a large box of cookie dough, open to air. b) Pantry During the resident panty tour on [DATE] at 1:12 PM found the drawer was dirty, littered with sugar, salt, and pepper. The upper cabinet had a box of 12 packs of oatmeal expired in [DATE]. During an interview on [DATE] at 1:20 AM the Infection Preventionist verified that the oatmeal was expired and the drawer was dirty. c) Ice Machines Observation during the kitchen tour on [DATE] at 11:50AM found the ice machine did not have the required water filter as required by the manufacture's guidance On [DATE] at around 1:15 PM, during a tour the Maintenance Director confirmed the ice machine did not have the required water filter.

Based on record review and staff interview, the Facility failed ensure they had sufficient and competent nurse staffing by failing to complete competency evaluations for Nurse Aides. This is true for five of five Nurse Aide charts reviewed. Findings included: Review of staff files on 03/12/25 at 1:57 PM revealed no competency evaluations for the following staff: #28, #1, #2, #33, #63 Interview with Consulting Administrator on 03/12/25 at approximately 2:30 PM revealed that the facility was behind on competencies and that there were no records for competencies in the last year for the following staff: #28, #1, #2, #33, #63

Based on observation and interviews, the facility failed to ensure the resident environment, over which they had control, was as free from accident hazards as possible in regards to water temperatures. This was a random opportunity for discovery. Room Identifiers: Rooms #101, #107, #202, and #302. Facility census:59. Findings Include: a) Resident #1 During an interview on 03/10/25, at 9:13 AM, Resident #1 stated that the water is too hot for her. She stated that she has never been burnt but must ask the staff to make the water temperature cooler. During an inspection of Resident #1s sink water temperature, this surveyor had to pull my hand back from the sink water due to hot temperatures. b) Water Temperatures During an interview and inspection with the Maintenance Director (MD) #56 on 03/10/25 at approximately 10:30 AM the water temperature was found: -- room [ROOM NUMBER], the sink temperature reading was 128 degrees Fahrenheit. MD #56 stated that once the water had been left running for a while, the temperature would drop. -- room [ROOM NUMBER], MD #56 checked the temperature of the water at the sink in room [ROOM NUMBER] and confirmed a reading of 124 Degrees Fahrenheit. -- room [ROOM NUMBER]: MD #56 checked the temperature of the water at the sink in room [ROOM NUMBER] and confirmed a reading of 118 Degrees Fahrenheit. -- room [ROOM NUMBER]: MD #56 checked the temperature of the water at the sink in room [ROOM NUMBER] and confirmed a reading of 119 Degrees Fahrenheit.

50795 Based on observation and interviews, the facility failed to maintain a homelike environment by not providing housekeeping and maintenance services to ensure that residents' rooms were being kept in a clean and sanitary condition. Room Identifiers: #103, #104, #108, #110, #302, #304, #307B, #401, #402, #404 #408, 400 Wing hallway, and Shower Room. Resident Identifier: #47. Facility Census: 59. Findings Include: a) Observation of the facility interior upon survey entry on 03/10/25 at 5:30AM: room [ROOM NUMBER] had approximately 3 foot section of section of unfinished drywall above heads of beds The 400 hallway above the resident's room doors had rips in the wall paper borders room [ROOM NUMBER], unfinished dry wall patches on the wall above the head of both resident's beds - Bathroom between rooms [ROOM NUMBERS] had a yellowish stain around base of toilet, and over-flowing trash can. In an interview on 03/10/25 at approximately 5:45 AM, with RN employee identifier #25, he acknowledged the unfinished drywall on the wall in room room [ROOM NUMBER] above the head of both resident's beds. During an interview with RN #25 on 03/10/25 at 6:00AM, he acknowledged the trash can in the shared bathroom between rooms [ROOM NUMBERS] was overflowing with trash on the floor. He stated the trash can should have been emptied and the floor should have been cleaned. In an interview with RN #25 on 03/10/25 at 6:10 AM, he acknowledged in 408 there were unfinished patches of drywall a four (4) foot long by (3) inch wide, unfinished section of drywall behind the bathroom door - unfinishedhe stated he would report all the resident rooms in need of repair on the 400 hall. b) Further observation of the facility interior on 3/10/2025, between 8:45AM and 11:25AM: Resident room [ROOM NUMBER]: During an inspection on 03/10/25 at approximately 8:45 AM, the bathroom in room [ROOM NUMBER] revealed that the wall behind the commode was bulging, with brown substances in the drywall. Resident room [ROOM NUMBER]: During an inspection on 03/10/25 at approximately 8:49 AM, the bathroom in room [ROOM NUMBER] revealed a toilet bowl with brown spots in it, and the wall behind the commode was bulging, with brown substances in the drywall. RN #8 confirmed that the bathroom needed to be cleaned, and maintenance notified. Resident room [ROOM NUMBER]: During an inspection on 03/10/25 at approximately 8:55 AM, the bathroom in room [ROOM NUMBER] revealed cracked tile and a brown substance around the base of the commode. Resident room [ROOM NUMBER]: During an inspection on 03/10/25 at approximately 8:55 AM, the bathroom in room [ROOM NUMBER] revealed cracked tile and a brown substance around the base of the commode. Resident room [ROOM NUMBER]: During an inspection on 03/10/25 at approximately 9:09 AM, the bathroom in room [ROOM NUMBER] revealed a plastic container with a brown substance in it. In addition the wall behind the commode was bulging, with brown substances in the drywall. RN #8 confirmed that the plastic container should not have been left in the bathroom. RN #8 contacted housekeeping to remove the container. She also stated that maintenance would be notified about the bulging wall. Resident room [ROOM NUMBER]: During an inspection on 03/10/25 at approximately 9:15 AM, the bathroom in room [ROOM NUMBER] revealed that the wall behind the commode was bulging, with brown substances in the drywall. Shower Room: During an inspection of the shower room on 03/11/25 at approximately 11:25 AM, ceiling tiles with a brown substance were observed. RN # 8 confirmed that the ceiling tiles needed to be changed. During a walk-through with the Maintenance Director (MD) #56 on 03/17/25 at approximately 11:30 AM, MD # 56 created a punch list and confirmed that the bathrooms in Rooms #103. #104, #108, #110, #302, and #308 needed to be repaired. In addition, MD #56 also confirmed that the ceiling tiles in the shower room would have to be replaced. c) Resident room [ROOM NUMBER]B: Resident #47 reported their room had spots on the ceiling, and had requested that the ceiling be painted last October (2024). On 03/11/25 at 10:00 AM, a review of resident council meeting minutes dated 10/01/24- under Maintenance category revealed 307-B would like the ceiling painted. Resident council meeting minutes dated for 03/04/25 under Maintenance category revealed Resident #47 (307-B) requested her ceiling be painted. On 03/11/25 at 12:00 PM during resident council meeting, Resident # 47 reported that she has requested that her ceiling be painted due to dark spots on the ceiling. On 03/11/25 at 2:09 PM observation of residents ceiling in her room showed there were several dark spots on the ceiling. On 03/11/25 at 3:44 PM during an interview with the Maintenance Director in regards to the ceiling spots in Resident #47's room. His initial response was She's on my list. He stated that maintenance tries to keep those spots painted. He then went on to state that he was not aware that the ceiling needed painted but was aware the walls in her room did. 50801

Based on observation and interview, the facility failed to uphold the residents' right to be treated with dignity and respect by leaving urinary catheter bags uncovered and prominently displayed. Resident Identifiers: Residents #28 and #58. Facility Census: 59. Findings Include: a) Resident #28 On 03/10/25, at approximately 1:35 PM, Resident #28 was observed in bed. The resident's catheter bag, which was uncovered and half full of urine, was seen dangling off the foot of the bed in plain view of anyone passing by. At approximately 1:37 PM on 03/10/25, Licensed Practical Nurse (LPN) #38 confirmed that the catheter bag needed to be covered. She stated that she would cover the catheter bag immediately. 50801 b) Resident #58 On 03/10/2025 at 11:03 AM, It was observed Resident #58 in his wheelchair rolling down the hall with his catheter bag in his lap. The catheter bag did not have a bag cover. In an interview with Resident #58, on 03/10/2025 at 11:05 AM, he stated he has never been offered a cover for his catheter bag and would like to have one. In an interview with RN #25 on 03/10/2025, at approximately 11:10 AM, he acknowledged Resident # 58 did not have a cover for his catheter bag.

Based on observation and interview, the facility failed to ensure that residents had the opportunity to exercise autonomy over important aspects of her life such as choice regarding waking time and morning care. Resident Identifier: Residents #50 and #52 Facility Census: 59. Findings Include: a) Resident #52 During an interview with Resident #52, on 03/10/25, at 1:51 PM, she expressed her preference for waking up early and having her bed made and morning care completed before breakfast. She noted that she does not receive morning care until after 10:00 AM. A family member present during the interview stated that they have raised this issue with the nursing staff multiple times, but no action has been taken. The resident also mentioned that her roommate receives morning care around 7:45 AM each day, while she does not receive assistance until much later. Observations on 03/11/25 revealed that AM care was provided to Resident #52 at approximately 10:20 AM. During an interview with the Director of Nursing (DON) on 03/10/25, at 10:35 AM, the DON confirmed that the resident has the right to receive morning care at a time of their choosing. The DON stated that she would follow up and ensure that the staff are aware of Resident #52's request to have her bed made and morning care completed before breakfast. A review of the residents Care Plan on 03/11/25 at approximately 3:55 PM revealed the following: FOCUS Provide resident/patient with opportunities for choice Date Initiated: 02/07/25 Created on: 11/27/24 Revision on: 02/07/25 GOAL Resident requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Recent hospitalization , fall at home with fracture, Date Initiated: 02/07/25 Created on: 11/27/24 Revision on: 02/19/25 INTERVENTIONS: Resident prefers to get AM care early, around 7AM. Date Initiated: 03/11/25 Created on: 03/11/25 Created by: DON Further observations and an interview on 03/12/25 at 10:43 AM revealed that the resident had not received her morning care until approximately 10:00 AM. During an interview with Consulting Administrator (CA) #100 on 03/12/25, at approximately 11:05 AM, CA #100 stated that she would ensure the resident's wishes regarding morning care would be honored, after being notified of the resident's complaint. An interview with Resident #52 and a family member on 03/17/25 at approximately 9:00 AM, revealed that the resident's bed had been made and morning care had been completed before breakfast. b) Resident #50 During an observation and interview with Resident #50 on 03/10/25 at 10:18 AM, she was upset about the staff not making her bed. She was trying to get it made and get dressed herself. She stated that she likes getting ready for the day early and having her bed made. She continued to say that staff tell her that they are helping other residents, and no one comes to help her until later in the day. A record review revealed resident #50's preferences for her morning routine were not documented. On 03/11/25 at 10:37 AM during an interview, Resident #50 was up and dressed with her bed made. She stated that she got herself ready and made her own bed. On 03/11/24 at 12:49 PM during an interview the Administrator verified there were no morning preferences documented. She continued to state that instead of looking for her preferences, I will have activities staff go get her preferences on her daily routine now.

The facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. Random opportunity for discovery. Census 59 Findings included: a) 03/17/25 4:50 PM first observation: A sign located at the receptionist window in the lobby stated that survey results are located on the shelf under the television. However, the state survey results were not located on the book shelf nor anywhere else in the lobby during this observation. b) 03/18/25 11:25 AM second observation: The state survey results were not located on the bookshelf nor anywhere else in the lobby during this observation. c) In an interview with the Administrator 03/18/25 at 11:30 AM she did not find the survey book on the bookshelf and went to locate it. She came back and stated she found it in the business office.

45171 45173 Based on record review, staff interview and observation, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The state agency determined these failures placed Resident #39's access to smoking supplies and other residents in an immediate jeopardy situation due to potential of serious injury and/or death as a result of burns or fire-related injuries. The state agency notified the Nursing Home Administrator of the immediate jeopardy at 2:59 PM on 07/13/22. The facility submitted a plan of correction (POC) at 4:48 PM. At 5:00 PM the POC was accepted by the state agency. The state agency verified the POC was implemented by conducting staff interviews and the immediate jeopardy was abated at 9:15 AM on 07/14/22. Upon abatement of the immediate jeopardy at 9:15 AM on 07/14/22, the scope and severity of the deficient practice was reduced to an E. The facility abatement plan of correction included the following: The Nursing Home Administrator(NHA) obtained the lighter from Resident # 39 on 07/13/22 at 2:30pm. The Director of Nursing (DON)/designee conducted a search of all residents including resident rooms on 07/13/22 at 2:45 PM for cigarettes and lighters with no additional corrective action indicated. Reeducation will be provided by the Director of Nurses (DON)/designee to all facility staff on 07/13/22 at 3:59 PM to ensure residents smoking supplies are secured at all times, including lighters. Posttest completed to validate understanding. Any facility staff not available during this time frame will be provided education, including posttest by the DON/designee upon the beginning of next shift to work. New facility staff will be provided education, including posttest during orientation by the DON/designee. The Director of Nursing (DON)/designee will monitor starting on 07/13/22 at 5:00 PM to ensure residents smoking supplies are secured at all times, including lighters daily across all shifts for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter. Results of monitors will be reported by the DON/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. (Typed as written.) Additionally, the facility was found to have an unlocked housekeeping cabinet and an unlocked cabinet in the supply closet as well as an unlocked, unattended medication cart. Resident identifier: #39. Facility Census: 60. Findings included: a) Resident #39 Resident #39, a resident who has not been assessed for smoking, was noted with a pack of cigarettes containing one cigarette and a lighter in the pocket of his pants. The resident was also observed wearing a nicotine patch on his right arm. The facility's policy verified for Centers that allow smoking, patients will be assessed on admission, quarterly, and with change of condition for the ability to smoke safely and, if necessary, will be supervised. The admitting nurse will perform a Smoking Evaluation on each patient who chooses to smoke. The patient will be allowed to smoke only with direct supervision until the interdisciplinary team has evaluated him/her. Smoking supplies will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station. The facility's failure to implement their smoking policy and their non-compliance to ensure the resident environment was free from accident hazards placed the resident in an immediate jeopardy situation where serious injury and/or death was likely occur without intervention. In addition, wearing a nicotine patch while smoking puts this resident at risk for nicotine toxicity. On 07/13/22 at 1:50 PM, during observation of catheter care for Resident #39, Nurse Aide (NA) #11 removed Resident's #39's pants and pulled out a pack of cigarettes containing one (1) cigarette and a lighter from the pants pocket. NA #11 was able to obtain the cigarette pack but the resident refused to give her the lighter. The resident was also observed wearing a nicotine patch on his right arm. Wearing a nicotine patch while smoking puts the resident at risk for nicotine toxicity. Record review found the resident has a Brief Interview for Mental Status (BIMs) score of 2 (two) as of 06/10/22 which indicates severe cognitive impairment. However, the Nurse Practitioner (NP) determined the resident has capacity to make medical decisions on 06/17/22. The resident was admitted to the facility on [DATE] and was ordered a nicotine patch on 06/08/22 for smoking cessation. The Medication Administration Record documents a nicotine patch was administered 16 times on the following dates: --06/08/22 --06/09/22 --06/10/22 --06/11/22 --06/12/22 --06/13/22 --06/14/22 --06/15/22 --06/16/22 --06/17/22 --06/18/22 --06/19/22 --06/20/22 --06/21/22 --07/12/22 --07/13/22 Upon entering the facility, the surveyors were notified this was a non-smoking facility and no residents smoke here. The resident is non-verbal and communicates with head nods and gestures. A review of the discharge summary from (name of the acute care facility) dated 06/07/22 prior to admission to the facility found evidence stating the resident did have a history of tobacco dependence as well as an admission note dated 05/13/22 stating the resident has a past medical history for tobacco abuse. The care plan was reviewed on 07/13/22 and there was no focus area relating to smoking cessation or smoking status. After reviewing the electronic medical record (EMR) and the paper chart, there was no smoking assessment completed by the facility. Without a smoking assessment, the facility had no way of knowing whether the resident would be safe maintining a lighter on his person. The Admissions Welcome Packet was reviewed on 07/13/22. Under the heading of Smoking, the packet states, Some Centers are smoke free while others allow smoking per the following guidelines. You will be informed if the center is smoke free prior to your admission and will be asked to sign an acknowledgement form. If you refuse to sign the form, your admission to the center may be denied. If you are admitted to a center that allows smoking, you will be assessed for smoking safety. Smoking will be permitted only in designated areas. If you are deemed unsafe based on your assessment, smoking supplies will be maintained by staff; and families and visitors are prohibited from giving smoking materials to you. Staff will assist you at specified times throughout the day. On 07/13/22 at 1:59 PM, the Administrator was notified. The Administrator stated, We didn't know he smoked .we are a non-smoking facility .we didn't know he had a nicotine patch .he must have came back from the hospital with it. It should be noted again, the facility had placed a nicotine patch on the resident from 06/08/22 - 06/21/22 and 07/12/22 - 07/13/22. On 07/13/22 at 2:03PM, the Administrator obtained the lighter from the resident. The Administrator stated, We will call the physician, obtain statements and do a smoking assessment. If he can smoke independently then he can smoke. The Administrator was asked about the non-smoking policy? The Administrator states (Name of nursing home corporation) will allow smoking if the resident is able to smoke independently. The resident says he found the cigarettes. On 07/13/22 at 2:12 PM, the Administrator stated, the physician will not permit the resident to smoke until his capacity and BIMS score has been reviewed .if he goes outside he will be escorted 1:1 (one on one). On 07/13/22 at 2:41 PM, the Administrator stated, every room will be searched for cigarettes and lighters .the whole building. On 07/14/22 at 8:42 AM, interviews were completed with a sample of staff: NA #32, NA #34, Licensed Practical Nurse (LPN) #79 and Unit Assistant (UA) #49. The interviews and sign in sheets for the education concluded education was completed regarding smoking supplies. The facility's failure to implement their smoking policy and their non-compliance to ensure the resident environment was free from accident hazards placed more than a limited number of residents in a situation where serious injury and/or death was likely as a result of burns or fire-related injuries. Also, Resident #39 was wearing a nicotine patch while smoking puts the resident at risk for nicotine toxicity. b) Unlocked closet and cabinet On 07/11/22 at 1:00 PM, the clean utility room located in the 400 rooms hallway was opened by the surveyor. The clean utility room did not have a lock on the door. The room contained the emergency eye wash station. On top of the counter were bottles of DBK non-acid disinfectant cleaner and instant hand sanitizer. The DBK non-acid disinfectant cleaner bottle stated to contact poison control if swallowed. The instant hand sanitizer bottle, which did not have a brand name label, stated to contact the physician immediately if the product was ingested. Above the counter was a cabinet with a sign stating, These doors must be kept locked. Inside the cabinet were shampoo, lotion, and mouthwash. These bottles had no emergency treatment instructions. On 07/11/22 at 1:05 PM, Registered Nurse (RN) #76 stated the clean utility room was not locked because it contained the emergency eye wash station. RN #76 stated the non-acid disinfectant cleaner and instant hand sanitizer were housekeeping product, and should not be kept in the unlocked clean utility room. RN #76 also stated the cabinet containing shampoo, lotion, and mouthwash should be locked. On 07/11/22 at 1:12 PM, the housekeeping supply closet was opened by the surveyor. The inside doorknob did have a lock that could be locked. The housekeeping supply closet contained True Kleen Multienzyme Cleaner, Purell soap, and antibacterial hand soap. The True Kleen Multienzyme bottle stated to rinse if on skin or in eyes. The Purell soap container stated to contact the physician or poison control if swallowed. The antibacterial hand soap container, which did not have a brand name, stated to contact the physician or poison control if swallowed. On 07/11/22 at 1:15 PM, the Administrator stated the housekeeping supply closet should be locked. According to the Resident Census and Conditions of Residents provided by the facility on 07/12/22, seven (7) residents were able to ambulate independently, and nine (9) residents were able to ambulate with assistance or assistive devices. According to the DBK non-acid disinfectant cleaner material safety data sheet (MSDS) provided by the facility, after skin contact, all exposed skin area should be rinsed with mild soap and water. After eye contact, the eyes should be immediately rinsed with plenty of water. After ingestion, the mouth should be rinsed, and emergency medical attention should be obtained. According to the True Kleen Multienzyme Cleaner material safety data sheet (MSDS) provided by the facility, the product could cause severe eye damage and skin corrosion or irritation. If ingestion occurred, large quantities of mild or water should be consumed and a physician should be called. According to the Purell soap MSDS provided by the facility, the product could cause eye irritation. In case of contact, the eyes should immediately be flushed with plenty of water for at least 15 minutes and medical advice should be sought. Additionally, if the product was swallowed, the mouth should be rinsed with water and medical attention should be obtained. No further information was provided through the completion of the survey. c) Medication cart On 07/12/22 at 8:40 AM it was observed that the medication cart on the 200 hall was left unattended and unlocked. This was confirmed with Nurse Practitioner (NP) #90 on 07/12/22 at 8:41 AM. 07/12/22 08:40 AM It was observed while walking down the 200 hall the medication cart was unlocked and unattended. This was confirmed with the NP# 90 who was at the nurses station on 07/12/22 at 8:41 AM and she locked the cart.

Based on record review and staff interview, the facility failed to ensure two (2) of three (3) residents with a pressure ulcer received treatments per the there need and physician order. Resident #46 did not receive treatments and a wound culture as ordered by the physician. As a result, the wound worsened. The lack of treatment caused physical harm to Resident #46 whose death certificate stated the cause of death was a Stage IV Sacral Decubitis Ulcer. Resident identifiers: #46 and #33. Resident identifier: #33. Facility census: 60. Findings included: a) Resident #46 Resident #46 was admitted to the facility on [DATE]. The resident expired at the facility on [DATE]. Her cause of death according to the Physician's/Medical Examiner's Certificate of Death, was a Stage IV Sacral Decubitis Ulcer. On [DATE], Resident #46 was admitted to the facility with, according to the admission Nursing Documentation dated [DATE]. One page 17 of 18, a Stage 2 wound to the sacrum was noted on the admission documentation. According to the Skin Integrity Report upon admission the wound to the sacrum was a Stage 3. It was documented on [DATE] as being intact/deep purple 75%, slough 25%, Length 11 centimeters (cm), Width 11 cm, Depth 0.2 cm, no undermining, no tunneling, light serosanguineous drainage, deep purple/maroon, wound edges macerated and no odor, no pain. The next Skin integrity Report over three months later on [DATE] documented as a Stage IV (worsening), Granulation 25%, Necrotic 75%, Length 11.3 cm, Width 11.5 cm, Depth 3.8 cm, undermining 4.7 cm at ,d+[DATE] o'clock on the wound, moderate serosanguineous drainage, macerated surrounding tissue, wound edges macerated, no odor and she has pain. According to the physicians orders dated [DATE] wound care to the sacral wound consisted of the following (this was the order in place at the time of Resident #46's death: --Cleanse sacral wound with wound cleanser, pat dry, apply Santyl ointment on eschar tissue, apply hydrogel on granulation tissue, cover with Allevyn dressing every day. Wound treatment orders to the sacral wound that were discontinued and in effect from [DATE] to [DATE] included: -Cleanse sacrum deep tissue injury (DTI) to open area with wound cleanser, apply hydrogel and optifoam every day, every day shift for DTI with open area. Wound treatment orders to the sacral wound and in effect from [DATE] to [DATE]: -Clean stage 4 pressure ulcer on sacrum with wound cleanser, pat dry, apply santyl ointment and cover with optifoam every day shift for stage 4 AND every 24 hours as needed for stage 4. Wound treatment orders to the sacral wound and in effect from [DATE] to [DATE]: -Sacral wound: Irrigate gently sacral wound with Wound Cleanser. Apply Non Irritating Skin Prep Barrier Wipe X 2 to wound edges. Apply Silvadene Cream to wound bed cover with cut to size of wound bed hydrofera blue (soak with saline and wring out moisture) Cover with adhesive foam dressing of choice, every other day and as needed (prn) soiling. Wound care is very painful medicate prior to wound care. Every day shift, every other day for Sacral Wound Care related to pressure ulcer of sacral region, stage 4 and as needed for Sacral Wound Care related to pressure ulcer of sacral region, stage 4. Wound treatment orders to the sacral wound and in effect from [DATE] to [DATE]. -Wound vacuum (W Vac) to sacral wound setting at 125 millimeters of mercury (mmHg) Change Monday, Wednesday, Friday, one time a day every Mon, Wed, Fri for Sacral wound. Wound treatment orders to the sacral wound and in effect from [DATE] to [DATE]: -Sacral wound: Irrigate gently sacral wound with Wound Cleanser. Apply Non Irritating Skin Prep Barrier Wipe X 2 to wound edges. Apply Silvadene Cream to wound bed cover with cut to size of wound bed hydrofera blue (soak with saline and wring out moisture) Cover with adhesive foam dressing of choice every other day and prn for soiling. Wound care is very painful, medicate prior to wound care. May reinforce with transparent dressing to prevent fecal soiling and contamination every day shift every other day for wound care until W Vac arrives, discontinue when W Vac arrives and as needed for prn soiling, discontinue when W Vac (wound vac) arrives. Wound treatment orders to the sacral wound and in effect from [DATE] to [DATE]. -Wound vac to sacral wound 125mmHg, Change Monday and Thursday and prn for dislodgement every day shift every Mon, Thu for Sacral wound and as needed for dislodgement of the wound vac. Review of the Skin/Wound evaluations to be done weekly found only three (3) of four (4) evaluations were completed in May ([DATE], [DATE] and [DATE]). Only 1 (one) of 4 (four) evaluations was completed in June ([DATE].) According to documentation on the Treatment Administration Record (TAR): the following wound care treatments were not completed as ordered: [DATE] Sacrum [DATE], [DATE] and [DATE]. [DATE] Sacrum [DATE] [DATE] Sacrum [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Sacrum ointment [DATE], [DATE] and [DATE]. [DATE] Sacrum Wound Vac change [DATE] [DATE] Treatments were completed until death on [DATE] A urine culture and a wound culture were ordered on [DATE] for an elevated white blood count (WBC) of 38. According to Registered Nurse #76 and the Director of Nursing, the wound culture was never completed. This was confirmed by RN #76 and the DON on [DATE] at 1:15 PM. The DON acknowledged the documentation of treatments to the wound did not indicated treatments to promote wound healing were consistently provided as ordered by the physician. Review of the resident's Minimum Data Set (MDS) a quarterly with an Assessment Reference Date (ARD) of [DATE] found the resident was not on a turning and repositioning program, and had no pressure relieving devices for her bed or chair. Resident #46 died on [DATE] at the facility, and according to the Death Certificate the immediate cause of death was the Stage IV Sacral Decubitis Ulcer. b) Resident #33 Review of the residents current medical record found orders for treatment to one (1) pressure ulcer: Cleanse stage III to right ischium with wound cleanser, pat dry, cover with calcium alginate, and optifoam dressing every day. Review of the most recent Minimum Data Set (MDS), a quarterly, with an Assessment Reference Date (ARD) of [DATE] found the resident was not on a turning and repositioning program. Review of the current care plan found the pressure ulcer treatment was care planned: Resident readmitted with abrasion to RUE (right upper extremity) and DTI (deep tissue injury) with open areas to right ischium, remains at risk for additional skin breakdown due to frail fragile skin, history of pressure ulcer, impaired sensation, incontinence, limited mobility, moisture/excessive perspiration, Interventions included: Turn and/or Reposition and check skin every 2 hours as determined by tissue tolerance. Shows on Kardex. assist resident in turning and reposition every 2 hrs. Shows on Kardex. On [DATE] at 8:49 AM, the Registered Nurse (RN) coordinator, RN #53 said she did not code the resident as being on a turning an repositioning program. She said no one documents he is turned and repositioned. If they don't document it anywhere, I can't count it. RN #53 provided the surveyor with the requirements required to code a turning and repositioning program: M1200C Turning/repositioning Program, the turning/repositioning program is specific as to the approaches for changing the resident's position and realigning the body. The program should specify the intervention (e.g. reposition on side, pillows between knees) and frequency (e.g. every 2 hours). Progress notes, assessments, and other documentation (as dictated by facility policy) should support that the turning/repositioning program is monitored and reassessed to determine the effectiveness of the intervention. Review of the treatment administration record (TAR) for [DATE] found treatments for: Cleanse stage II located above primary ischium wound with wound cleanser pat dry, Apply Skin Prep Wipe to wound edges X 2 allow to dry fill cavity Calcium Alginate with Ag cover with Allevyn Adhesive dressing QOD (every other day) and prn soiling. Reassess in 2 weeks. Every day shift every other day. The order was written on [DATE]. The treatment was only provided on [DATE]. Six treatment: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] were not provided as directed. The order was discontinued on [DATE]. (The ischium forms the lower and back region of the hip bone.) Cleanse stage III to right ischium with wound cleanser, pat dry, Apply Skin Prep Wipe to wound edges X 2 allow to dry fill cavity with FLEXI GEL Strands cover with Allevyn Adhesive dressing QOD (every other day) and prn (as needed) soiling. Reassess in 2 weeks. This order was in effect from [DATE] to [DATE]. The treatment was provided on [DATE] only. Cleanse stage III to right ischium with wound cleanser pat dry, Apply Skin Prep Wipe to wound edges X 2 allow to dry fill cavity Calcium Alginate with Ag cover with Allevyn Adhesive dressing QOD and prn ( as needed) soiling. Reassess in 2 weeks. This order was in effect from [DATE] to [DATE]. The treatment was provided on [DATE] and held from [DATE] to [DATE]. Cleanse Stage III to right ischium with wound cleanser, pat dry, Apply Skin Prep Wipe to wound edges X 2 allow to dry fill cavity Calcium Alginate with Ag cover with Allevyn Adhesive dressing QOD and prn ( as needed) soiling. Reassess in 2 weeks. This order was in effect from [DATE] to [DATE]. No treatment was provided. Cleanse stage III to right ischium with wound cleanser pat dry, Apply Skin Prep Wipe to wound edges X 2 allow to dry fill cavity with Flexi Gel. Stands cover with Allevyn Adhesive dressing QOD (every other day) and prn ( as needed) soiling. Reassess in 2 weeks. As needed for right ischium wound PRN for 2 weeks. This order was written on [DATE] and discontinued on [DATE]. No treatment was provided. On [DATE] a new order was written to treat the Stage III pressure to right ischium with wound cleanser, pat dry, cover with calcium Alginate and optifoam dressing every day. This treatment has been provided as ordered since [DATE] with no treatment missed. On [DATE] at 8:20 AM, the Director of Nursing said the Stage II pressure ulcer had healed on [DATE]. The DON was asked why treatments were not provided as ordered. The DON said there was some confusion during this time as new staff were hired. The DON reviewed the TAR and said she could not explain all the orders and she didn't know why all the treatments were not provided. According to the TAR for June, the resident only received 4 treatments to the pressure ulcer (ulcers) to the right ischium: [DATE], [DATE], [DATE] and [DATE]. Treatments to the right ischium were ordered every other day, for the Stage II and Stage III pressure ulcers. The resident should have had 15 treatments from [DATE] to [DATE]. On [DATE] at 11:11 AM, Registered Nurse (RN) #76 said the resident never had a Stage II pressure ulcer to the ischium. There was only 1 pressure ulcer the whole time - a Stage III pressure ulcer to the right ischium. They were both just one big pressure ulcer. RN #76 was asked why would nursing staff initial two (2) separate treatments if the resident only had 1 pressure ulcer. RN #76 had no answer. RN #76 could not explain all the changing orders and treatments. At the time of discovery on [DATE], the resident had been sent to the hospital for an unrelated condition and the wound/wounds could not be observed for clarification.

Based on policy and procedure review, incident report review, resident interview, and staff interview, the facility failed to ensure residents were free from verbal, psychological and physical abuse when confronted with resident to resident altercations. This practice caused actual harm to Resident #307 and #5. Resident #307 experienced actual harm, by Resident #8 through verbal and mental abuse, as evidenced by crying shaking, and showing signs of sadness. Resident #5 was experienced actual harm, by Resident #8 through verbal and mental abuse, as evidenced by expressing feealings of fear and being unsafe. The actual harm and immediate jeopardy was further evident by the fact the facility did not report, investigate, nor put protections in place to safeguard residents from Resident #8, who had exhibited numerous incidents of verbal, mental and physical aggression towards residents and staff. The Centers for Medicare and Medicaid Services determined this deficient practice was an immediate jeopardy. State Agency surveyors notified the facility administrator of the immediate jeopardy on 11/04/19 at 12:32 PM. The facility abatement plan was approved through verification of implementation on 11/04/19 at 4:50 PM. The facility's abatement plan included: 1. Resident # 8 no longer resides in the facility. Resident #s 5, 2, 13, 22, and 45 were seen by facility Nurse Practitioner on 10/14/2019 to evaluate residents for emotional and psychological harm. Resident #s 5, 2, 13, 22, and 45 have not experienced any negative outcomes. On 11/1/2019 Resident #5 denied concerns, anxiety, fear related to any additional residents in the facility. Resident # 307 no longer resides in the facility. 2. All residents of the facility have the potential to be affected. On 10/16/19 all incident reports and resident council minutes from 04/01/2019 to current were audited by the Administrator to ensure all potential incidents of abuse, including resident to resident altercations, were thoroughly investigated, reported to the appropriate state agencies, and that protective safeguards were put into place to protect residents from the verbal, mental, and physically aggression of other residents. The Social Worker/designee will interview interviewable residents and the Director of Nursing/designees will conduct body audits of non-interviewable residents by 11/07/2019 to ensure other residents are free from verbal, psychological, and physical abuse when confronted by resident to resident altercations. No other residents are exhibiting verbal, mental, and physical aggression towards residents or staff. 3. By 11/07/2019 all facility staff, including contracted and agency will receive abuse prohibition reeducation by the Director of Social Services/ designee to ensure all residents are 1) free from abuse including verbal, psychological, and physical abuse, 2) that timely reporting to appropriate state agencies occurs, 3) a thorough investigation is conducted, 4) involved residents' reactions are assessed and 5) interventions/safeguards are initiated to protect the residents when confronted by resident to resident altercations, with a post-test to validate understanding. Facility staff, including contracted and agency staff not available during this time frame will receive reeducation including a post-test by the Director of Nurses/designee upon day of return to work. New facility staff, including contracted and agency staff will be provided education with a posttest to validate understanding during orientation by the Director of Nurses/designee. Starting 10/30/2019 all incident reports and resident council minutes will be reviewed by the Administrator/designee and 10% of residents will be interviewed daily including weekends X 2 weeks, then 3X week X 2 weeks, then randomly thereafter to ensure all residents are free from verbal, psychological, and physical abuse when confronted by resident to resident altercations; ensuring timely reporting to the appropriate state agencies, a thorough investigation is completed, involved residents' reactions are assessed and that interventions are initiated to protect involved residents with immediate corrective action. 4. Results of these audits will be reported by the Administrator /designee monthly to the QAPI committee for any additional follow up and/or in-servicing until the issue is resolved and randomly thereafter as determined by the QAPI committee. Upon verification of the implementation of the facility abatement plan, the deficient practice was reduced to a D. Resident identifiers: #307, #2, #5, #13, #45, , #8. Facility census: 62. Findings included: a) Findings for 11/04/19 Interviews with [NAME] residents were conducted on (MONTH) 4, 2019. Residents were asked about their overall feelings in the facility, specifically, if they feel safe. Below are the replies: At 1:55 PM, Resident #5 stated she had been afraid of another resident, who is no longer in the facility. She was referring to resident #8. Resident #5 added that she was verbally abused by resident #8, in the past. She added that she is glad he is out of the facility. Resident #5 did report that resident #45 has threatened her. This was resolved when resident #5 reported this to nursing staff. Resident #5 reported that she feels safe in the facility. At 2:06 PM, Resident #13 was unable to answer questions. She was pleasantly confused and began discussing her birthday, company housing, her husband's death and her six children. At 2:19 PM, Resident #22 stated she is safe. Resident #22 reported resident #8 threw coffee during Bingo, at one point. She added that nothing like that has happened, since. Resident #22 is glad that resident #8 is no longer in the facility. Resident #22 reported Resident #45 has referred to her as a [***] . She does not feel threatened or abused. At 2:28 PM, Resident #2 stated she feels safer without Resident #8 in the facility. She added that when she has reported issues to nursing staff, they assist. At 2:35 PM, Resident #45 was unable to answer questions. She was confused and appeared agitated. During her continual chatting, she said she was happy and sad. She added that she writes books and it is how you are raised. Abuse training has begun for Staff. [NAME] Administrator plans to have all staff trained by (MONTH) 7, 2019. On (MONTH) 4, 2019, several staff members were interviewed, regarding. Below are their replies: At 3:30 PM, Employee #12, Activities Director, reported that the facility has done a lot of education regarding abuse. Employee #12 stated she has been trained to protect the residents, first, if there is an abusive situation. Employee #12 identified step two is to contact her supervisor, regarding the situation. Employee #12 has handled abusive situations with this protocol. Employee #12 added that she would call OHFLAC, if necessary. At 3:40 PM, Employee #84, Licensed Practical Nurse, stated she has not been working for the past few days. She stated that she would report an abusive situation to her supervisor. According to [NAME] Center's inservice sign in sheet, regarding Abuse Policy, Employee #84 has not been trained, as the signature line is empty. At 3:45 PM, Employee #59, Nursing Assistant, reported she has received the inservice. Employee #59 stated she would stop the abusive behavior, initially. She would follow up by reporting to her supervisor. Employee #15, Nursing Assistant, was interviewed with #59. She also had the inservice. She reported she would stop the abuse, then report it to her supervisor. At 3:50 PM, Employee #15, from the Maintenance Department, acknowledged that he has been trained. Employee #15 stated that he would stop the abusive situation and then report it to his supervisor. He added that he would report to OHFLAC, if nobody else was available to report. An employee from the Laundry Department, was interviewed at 3:55. Employee #86 stated she would report the situation to her supervisor. Employee #86 added that she would not get in the middle of that. There is no evidence that Employee #86 has received the Abuse Policy inservice. Employee #72, Clerk, acknowledged the inservice. At 4:00 PM, Employee #72 reported she would try to stop the abuse and report to a nurse. At 4:05, Registered Nurses #82 and #52, stated they would protect the residents, first. #82 stated she would then report to OHFLAC, Adult Protective Services and the Ombudsman. #52, would report to her supervisor and complete a change in condition. At 4:09 PM, Employee #8 from Physical Therapy, stated the most important thing is to protect the residents. That is what Employee #8 would do, before notifying supervisor. At 4:15 PM, Dietary employees #34 and #20 reported they would protect the residents and follow up with notifying supervisor. Employee #34 would then follow up with OHFLAC. At 4:40 PM, DON was made aware of complaints regarding Resident #45. She is aware of issues with this resident. She added that Resident #45 had a Urinary Tract Infection and was treated. In addition, resident #45 had [MEDICATION NAME] discontinued through a gradual dose reduction. They have evaluated the resident and believe she would benefit from [MEDICATION NAME], at her maintenance dosage. DON added that they will be obtaining orders to begin giving her [MEDICATION NAME]. b) Policy and Procedure Review A review of the facility policy and procedure titled WV Abuse Prohibition with effective date of 06/01/96, review date of 10/10/16 and revision date of 11/28/16 was conducted. The policy stated that anyone who witnesses an incident of suspected abuse is to tell the abuser to stop immediately and report the incident to their supervisor immediately. Additionally, the incident is to be reported to OHFLAC (Office of Health Facilities and Certification), APS (Adult Protective Services), and the Ombudsman. If the resident sustains serious bodily injury, the Nursing Home Administrator (NHA) or designee is to be notified and reported within two (2) hours. c) Resident #307 On 10/08/19 at 11:00 AM, a review of an incident report dated 05/18/19 at 6:50 PM stated that Resident #307 was sitting in the common area in front of the Nurses Station. When Resident #8 started yelling racial slurs and calling him (Resident #307) vulgar names. Resident #307 started shaking and crying asking, Why is he call me names? I didn't do anything to him. I don't like to be called names and I don't like to be hollered at. What did I do to him to talk to me like that? Resident #307 was removed from the situation and consoled. The incident report noted resident-to-resident-NO ABUSE. Injury Psych (psychological), harm. An additional incident on 05/19/19 at 14:40 (2:40 PM) Resident #307 was in the common area when another resident (Resident #8) from the adjoining TV room started yelling and cursing and calling him N*****. Resident #307 started crying and expressing feelings of sadness and repeatedly stating why does he say that to me and why does he call me names? What did I do for him to talk to me like that. Resident #307 was harmed by showing signs of emotional distress of crying and being cursed and insulting name calling. d) Resident #2 In an interview with Resident #2 on 10/08/19 at 12:17 PM revealed she had observed Resident #8 yell, cuss and scream at other residents. Resident #2 stated other residents had told her without revealing other residents names, that they were afraid of Resident #8. Resident #2 stated she had seen Resident #8 go after other residents and had stepped in to protect other residents. She stated she is not afraid of Resident #8. e) Resident #5 A review of incident report dated 10/07/19 5:30 PM revealed Resident #5 was confronted by Resident #8 who was sitting on the table next to her. Resident #8 wanted the TV on. Resident #5 stated that the TV was only for Bingo. Resident #8 continued to argue with the other resident who then raised fists at Resident #5 and moved closer. Resident #8 continued to yell at Resident #8 raising fists while staff tried to pulled Resident #8 away. Resident #5 continued to yell and stated that if you hit me you will go to prison. During the Resident Council meeting on 10/08/19 at 2:30 PM Resident #5 stated that Resident #8 continually curses at her and calls her names. Resident #5 stated she does not feel safe and Resident #8 scares her. f) Resident #13 A review of the incident report dated 04/29/19 at 3:30 PM revealed Resident #8 was in dining room and began to yell and scream and threw his glasses, cards and a plastic flower vase which hit Resident #13 in the right side of face. Both residents were removed from the dining room for safety. No injury noted to Resident #13. A nurses note dated 04/30/19 Resident #13 has stayed away from Resident #8. g) Resident #45 A review of incident report dated 10/05/19 at 10:15 PM, Resident #8 was sitting at table coloring in common area. Resident #45 rolled over to the common area and started pecking Resident #8 on the shoulder. Resident #8 turned around and hit R#45 multiple witnessed times with closed fist before staff could separate them. Resident #45 removed from situation and placed in a safe environment while the aggressor #8 continued to pursue other unidentified residents and staff members. The incident report indicated there was no injury. No evidence was found as to the emotional status of this resident after the altercation. No further evidence was presented prior to exiting the facility as to this resident emotional status. h) Resident #8 An incident report on 09/14/19 at 6:14 PM review found the Director of Nursing (DON) was called to the dining room where Resident #8 was yelling and screaming. He was served his food and had asked for a salt and pepper shaker. The aide in the dining room handed him the shakers and he immediately stated to scream that he wanted the glass shakers. He became mad and threw the shakers at the aide leaving a mark on her arm. He continued to yell at residens and staff. The DON told him that he could not eat in the dining room as he was scaring residents. The Dietary Manager (DM) told him that she would serve his meal at the table in the TV lounge. He then grabbed a knife and a fork (plastic) and moved to the table fist raised utensils in his hand. He then moved to the DON and tried to stab with the utensils. The DON told him that he was not able to eat in the dining room in this state and she asked him to leave. In the meantime the DM had called the police. He continued to scream and yell until the police came and continued to call the officer names. The police officers called EMT (Emergency Medical Team) to see if any intervention was possible. Resident #8's guardian came in and talked to the officers. The Guardian stated she would like to have him evaluated by psychiatry. EMT could not take him in and the police officers left. Corrective actions noted on the incident report were to observe closely, try to remove from any triggers that start aggressive behavior. An interview with the DON on 10/08/19 at 3:25 PM found that no investigation of the incidents, witness statements, how other residents and victims were protected from this resident. The DON confirmed they did not follow their policy and procedure to report, investigate and assess resident reactions when the residents were involved and/or were victims of the abuse. The DON stated it would require another person just to notify other agencies and to conduct the investigations.

Based on observation, record review, resident interview, family interview, staff interview and policy review, the facility failed to monitor and intervene to identify weight loss for three (3) of three (3) residents reviewed for the care area of nutrition. Failure to monitor and implement interventions resulted in Resident #72 having an avoidable weight loss resulting in harm. Resident #72 had a 27-pound weight loss in 21 days (22.5% loss of body weight), and a discharge from therapy for lack of progress due to fatigue. Resident identifiers: #72, #2 and #117. Facility census: 59. Findings include: a) Resident #72 Record review began, on 06/06/17 at approximately at 11:32 a.m., revealed Resident #72 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #72's admission weight was noted as 120 pounds. A physician's orders [REDACTED].#72 was to receive honey thick liquids. The nutritional assessment dated [DATE] revealed Resident #72: --Weighed 120 pounds; --Had no swallowing issues; --Was on a regular diet; and --Had a concern noted for intakes to be monitored. Review of the weight log found the following weights: --04/28/17 (admission weight): weight was 120 pounds --05/04/17: weight was 109 pounds; --05/11/17: weight was 104 pounds; and --05/19/17: weight was 93 pounds. Twenty-one (21) days after admission Resident #72 experienced an unexplained 27-pound weight loss or a loss of 22.5% of her total body weight. No weights were documented after 05/19/17. Review of the care plan dated 05/03/17 noted Resident #72 was at risk for altered nutrition with a goal to eat at least 50% of her meals each day. Interventions included: --Speech therapy three (3) times a week; --To alert the dietitian and physician of any significant weight loss; and --To report decreases in meal intake to the physician. Review of the medical record revealed a physician's note dated 05/17/17 specified Resident #72 still weighed 120 pounds which was inaccurate according to the weight log. Resident #72 had two (2) noted weight losses indicating severe weight loss since admission by the date of this physician's note. A discharge note dated 06/01/17 by the physician also noted that Resident #72 still weighed 120 pounds which was inaccurate according to the weight log. Resident #72 had three (3) noted weight losses indicating severe weight loss since admission by the date of this discharge note by the physician. A physician note dated 05/30/17 noted Resident #72 was chronically undernourished. This issue was not addressed by the plan of care. Continued review of the clinical record revealed a progress noted titled Weight Warning written by the Assistant Director of Nursing (ADON) on 06/01/17. The note documented a 27-pound weight loss and that Resident #72 was on calcium and vitamin D as supplements. The record noted, Resident #72 received a dysphagia diet with advanced texture with poor appetite, and the physician and dietician aware of the variance. On 06/05/17 at 12:40 p.m., an observation of the lunch meal was completed. Resident #72 ate approximately 50 percent of her meal. At the time of the observation, a family member was assisting Resident #72 with feeding. Resident #72 was not observed choking. The family member stated that Resident #72 has not eaten well while she was here and has lost about 20 pounds. On 06/06/17 at 8:30 a.m., Resident #72 was observed eating breakfast. The breakfast tray was noted with thin liquids, not honey thick liquids as ordered. Resident #72 ate approximately 50% of her breakfast. An observation of the lunch meal was completed on 06/06/17 at 12:10 p.m. NA #26 delivered Resident #72's lunch tray. Resident #72 ate approximately 50 percent of her lunch. A follow up interview was completed with a family member on 06/06/17 at 12:15 p.m. The family member stated Resident #72 was being discharged home today and stated, Today was her last day in therapy. She wasn't progressing so therapy stopped. We are going to go home and will have people come in there. Review of the Weights and Heights policy found residents are weighed on admission and weekly for 4 weeks, then at the discretion of the interdisciplinary care team. On 06/06/17 at 1:55 p.m., an interview was completed with the Assistant Director of Nursing (ADON) #37. The ADON reported she was familiar with Resident #72. She stated, Residents get weighed monthly after the admission weights unless the registered dietitian (RD) or doctor sign off to do them more often. We would do weights more often if a resident is consistently losing weight. The ADON acknowledged Resident #72 was losing weight. She stated Resident #72 should have been put on weekly weights. She further stated a 5% weight loss in a month would trigger weekly weights. She also stated NAs do the weights. She said, If they see a big discrepancy, they know to get me a follow up weight. If it's a 5-pound weight loss, I would have them re-weigh. The NA's write the weights down on paper and give them to me. I enter them in the computer. I missed putting a request in for weekly weights. I get a weight warning if there is a 5% weight change and then I make a note (with the Weight Warning). Resident #72 was not on a nutritional supplement. Speech was involved with her. We put her on (antidepressant) for weight loss. The only dietary evaluation was on 05/03/17. After the note on (06/01/17 Weight Warning), I would notify the doctor and we would have weighed her again this week. I haven't notified the RD yet. I haven't seen him. She had a problem refusing meals and her appetite wasn't good. I would have told the doctor already. He's here every day. She was on a dysphagia, advanced texture (soft foods) with honey thick liquids. Our system sends out notices after 30 days when weights are put in. It doesn't calculate weight changes with each weight. Weekly weights aren't evaluated as they are entered. Calculations are just done every 30 days. On 06/06/17 at 2:50 p.m., an interview was completed with NA #2. NA #2 stated she was familiar with Resident #72 and (Family member) was always here to feed her. An interview was completed with Therapy Director #81 on 06/06/17 at 3:03 p.m. Therapy Director #81 said, We worked with (Resident #72) in speech, physical and occupational therapy. She didn't progress well. We improved her bed mobility slightly. Services were stopped about a week ago. She wasn't making improvements. She fluctuated, but towards the end declined some. She would fatigue easily. She didn't eat very well. It probably affected her energy level along with her body positioning. On 06/07/17 at 7:05 a.m., an interview was completed with RD #84. RD #84 said There is a weight exception report that can be looked at any time. It should be done monthly. It shows if there has been a significant change. If there is a change in the weekly weights, the nurses would need to let us know. The report looks back 30 days. We make notes on admission and quarterly. If they have a weight issue or a pressure ulcer the system will flag for a monthly note. Reviewed resident's chart. I would have started daily weights with the drops she had. We would start a supplement if we found something that she would like. An interview was completed with Speech Therapist (ST) #79, on 06/07/17 at 9:00 a.m., revealed she was working with Resident #72 on her swallowing. ST #79 said, She came in on thin liquids and nursing downgraded her to honey thick liquids because she was having trouble swallowing. On bad days, she would still have trouble swallowing so I left her on honey thick for the facility staff. Her eating fluctuated. Some days she swallowed well and some days she had a lot of problems where I wouldn't even try to give her anything by mouth. She had a significant decline while she was here. I thought she would be back on thin liquids. At one point, she had to go out for a blood transfusion. By the end of therapy, I think they did a lot in bed because she couldn't get up as much. When I first met her, she was very pleasant and alert. Two weeks ago, she was completely different. She was agitated and wouldn't cooperate. On the last day, she looked better than the last couple weeks. On 06/06/17 at 10:30 a.m., the meal intake documentation for June 2017 was reviewed. It was noted that for breakfast and lunch on 06/01/17; zero percent was eaten. On 06/05/17, 25% of dinner was eaten. The rest of the form was left blank. The May meal intake documentation noted 36 meals with no documentation and 12 meals where no food was eaten. Percentages of food eaten ranged from 25% to 100%. On 06/07/17 at 10:46 a.m., an interview was completed with the Director of Nurses (DoN). The DoN said the Activity of Daily Living (ADL) sheets are audited sometimes between shifts. She stated, I have some NAs who we use to review the sheets. (Resident #72) 's family brought in food. It's hard to know how much she ate. They should have asked how much she ate and written it. She didn't eat much of our food. The facility failed to monitor Resident #72's weight, failed to notify the physician and dietician of the weight loss, failed to consistently document meal intake, failed to order supplements or meal substitutions, failed to continue to monitor weight, failed to follow the facility weight loss policy, and failed to address the weight loss on the care plan. This failure resulted in harm to Resident #72 experiencing an avoidable t27-pound weight loss in 21 days (22.5% loss of body weight), and a discharge from therapy for lack of progress due to fatigue. b) Resident #2 Record review on 06/06/17 at 1:00 p.m. revealed Resident #2 was admitted to the facility on [DATE]. Among the resident's [DIAGNOSES REDACTED]. The resident had a physician order [REDACTED]. Further review of the clinical record at 1:00 p.m. on 06/06/17 revealed the actual recorded weights in the Vital section of the electronic medical record for the resident were as follows: --05/03/17 weight = 152.6 pounds --05/11/17 weight = 152.8 pounds --05/30/17 weight = 134.2 pounds --06/02/17 weight = 139.0 pounds The first recorded weight was 13 days after admission. Subsequent weights did not comply with the ordered weekly weights for the first month following admission. The weight recorded on the initial nutrition assessment was pulled from a previous admission for the resident (09/01/16 = 154.4 pounds). During a 06/06/17 at 2:00 p.m., interview with the ADON #37, she stated the resident had not refused to be weighed per the ordered schedule. On 5/30/17 a Weight Warning was generated by the electronic medical record based on declining weight entries. ADON #37 responded to the warning with the following note: Resident with medications of Vitamin D as a dietary supplement and [MEDICATION NAME] for generalized [MEDICAL CONDITION]/AFIB/pulmonary HTN. admitted with [MEDICAL CONDITION] to LT LE and which has now resolved. Resident admitted with diet Regular diet and then changed to NAS per RD. Resident #2's nutritional care plan dated 04/26/17 was reviewed on 06/06/17 at approximately 2:00 p.m. The care plan established a goal that the resident would maintain a stabilized weight with no significant changes for the next 90 days. The care plan also directed staff to weigh per protocol and alert dietitian and physician to any significant loss or gain. There had been no subsequent nutrition notes since the 04/26/17 initial nutrition assessment despite a significant decline in weight (152.6 pounds to 134.2 pounds / an 18.4 pound loss from 05/03/17 to 05/30/17). Interview with the DON #44 on 06/07/17 at 11:00 a.m. identified diuresis as the primary cause of the weight loss. While diuresis might explain the weight loss, the resident's care plan which directed staff to alert the dietitian and physician had not been implemented. During interview with the Resident #2 on 06/07/17 at 11:30 a.m., she stated she had recently regained her appetite, was no longer in as much pain related to her fractures and found the meals to be tasty. c) Resident #117 During review of the clinical record on 06/06/17 at 11:00 AM., it was noted Resident #117 had an order dated 05/12/17 which stated, Weigh weekly x 4 from date of admission then monthly. Among the resident's [DIAGNOSES REDACTED]. The actual weights recorded in the Vitals section of the electronic medical record for the resident were: --05/17/17 = 195.0 --05/19/17 = 173.0 --06/02/17 = 159.6 During a 06/06/17 at 2:00 p.m. interview with the ADON #37, she stated the resident had not refused to be weighed per the ordered schedule. The first weight was obtained 5 days after admission and subsequent weights did not comply with the ordered weekly weights for the first month following admission. The resident's nutritional care plan developed on 05/17/17 and reviewed on 06/06/17 at 11:00 a.m. stated to, Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. There had been no subsequent nutrition notes to acknowledge the 35 pound weight loss since admission. During interview with Resident #117 on 06/07/17 at 3:00 p.m., she stated that staff had used a hoyer lift for her transfers and a scale was available on the lift. She recalled that she had asked staff to tell her the weight, but she could not recall when or what the weight had been.

Based on record review, family interview, and staff interview, the facility failed to assure the safety of one (1) of eight (8) sampled residents, by not providing adequate supervision to prevent an accident with injury requiring emergency medical intervention. Resident identifier: #57. Facility census: 56. Findings include: a) Resident #57 Review of Resident #57's closed medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. The resident fell in her room on 06/04/08, striking her head and requiring an emergency transport to the hospital for closure of the laceration. The resident's daughter, when interviewed, reported the resident was standing at the sink while a nursing assistant was making her bed when she fell , although her mother was supposed to have the assistance of two (2) staff members when up. The resident's daughter stated she questioned the facility about the lack of assistance at the time of the fall. Documentation on the incident report of the fall stated, "Pt. (patient) was ambulating in walker and CNA (certified nursing assistant), lost balance and fell backwards." While the description of the circumstances surrounding the fall varied between these two (2) sources, both the incident report and the resident's daughter indicated only one (1) staff member was present at the time of Resident #57's fall. A review of Resident #57's care plan revealed a nursing intervention indicating the resident required the assistance of two (2) staff members when getting out of bed. An activities of daily living (ADL) assistance form communicated to the nursing assistants, on 09/26/07 and again on 04/24/08, that the number of staff Resident #57 required for bed mobility, transfers, and toileting as "2+" (two (2) or more). Documentation by the nursing assistants on the ADL flow sheet, for 06/04/08, recorded Resident #57 required maximum physical help or total dependence of staff for bed mobility, transfers, and toileting. The daughter's concern about the lack of adequate staff assistance when the fall occurred (an allegation of neglect) was not reported to the appropriate State agencies, and there was no documentation to indicate the facility conducted a thorough investigation into the daughter's concerns even though the nurses' notes indicated the resident's daughter returned to the facility with the resident and spoke to the director of nursing (DON) about the fall. During an interview with the administrator at 11:05 a.m. on 05/21/09, she acknowledged the daughter had been upset at the fact that there were not two (2) persons assisting Resident #57 at the time of the fall, but the administrator stated there was a nursing assistant in the room and the resident had a walker. She also stated the resident had gotten herself out of bed, although there was no evidence of this, and it was not mentioned in either the nurses' notes or the incident report. The administrator did acknowledge, after reviewing the record, there should have been two (2) nursing assistants present to assist the resident whenever she was out of bed. .