Every finding on record at Chatham Glen Healthcare and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure medications were administered as ordered by physician for 2 of 7 residents reviewed for medication management (Residents #24 and #90), and failed to ensure the intravenous (IV) catheter dressing was changed for 1 of 4 residents reviewed for intravenous therapy (Resident #140). Findings include: 1) During an observation on 2/19/2026 at 8:13 AM, Staff G, Licensed Practical Nurse (LPN), administered Diltiazem HCI (Hydrochloride) ER (Extended Release) 240 mg (milligram) capsule to Resident #24. Electronic health record showed Resident #24's blood pressure documented as 118/54 mmHg (millimeter of mercury) and pulse as 56 beats per minute. Review of Resident #24's physician order dated 12/31/2025 read, Diltiazem HCI ER Coated Beads 240 MG capsule extended release 24 hr [hour], Give 1 capsule by mouth one time a day for HTN [hypertension] hold if SBP [systolic blood pressure] is less than 110 or HR [heart rate] less than 60. Administer whole, do not crush, split or chew. During an interview on 2/20/2026 at 8:05AM, the Director of Nursing stated, Staff should follow parameters and notify the provider when the parameters are not followed. Medication should be given as ordered, unless the provider is aware and gives the order for the medication to be given out of parameters. During an interview on 2/20/2026 at 9:09 AM, Staff G, LPN, stated, I did not see the parameters for the blood pressure medication for [Resident #24's name]. I should always follow parameters. 2) During an observation on 2/19/2026 at 9:24 AM, Staff H, LPN, poured one Enteric Coated Aspirin 81 milligram into the medication cup for Resident #90. Staff H crushed the medication and mixed it with chocolate pudding. Staff H was requested to review the physician order prior to entering Resident #90's room to administer the medication. During an interview on 2/19/2026 at 9:37 AM, Staff H, LPN, stated, Enteric Coated medication should not have been crushed. Review of Resident #90's physician order dated 2/25/2026 read, Aspirin Tablet Delayed Release, Give 81 mg by mouth one time a day for cardiac maintenance monitor for bleeding/bruising and notify provider with any concerns. Do not crush, cut or chew. During an interview on 2/19/2026 at 12:30 PM, the Director of Nursing stated, Delayed Release medication should not be crushed. The nurse should contact the provider to change the order. Review of the facility policy and procedures titled Medication Administration with the last review date of 5/30/2025 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 17. Administer medication as ordered in accordance with manufacturer specifications. c. Crush medications as ordered. Do not crush medications with do not crush instructions. 3) During an observation on 2/17/2026 at 9:51 AM, Resident #140 had an intravenous midline catheter on her left upper arm. The dressing was peeling away and there was dried blood at the insertion site. The dressing was dated 2/12/2026 (Photograph evidence obtained). Review of Resident #140's intravenous team note dated 2/7/2025 at 7:55 PM read, 14 cm [centimeters] midline placed in left basilic vein. + [positive] blood return. Flushed NS [normal saline], skin prep, bio patch, stat lock and Tegaderm [clear dressing]. Review of Resident #140's physician order dated 2/11/2026 read, Change (midline) transparent dressing every 7 days and PRN [as needed] if soiled or dislodged every night shift Wed [Wednesday] for infection control. Review of Resident #140's physician order dated 2/17/2026 read, Normal Saline Flush Solution 0.9% (Sodium Chloride Flush), Use 10 ml [milliliter] intravenously every 12 hours for patency. Review of Resident #140's Medication Administration Record (MAR) documented normal saline flush was administered on 2/17/2026 at 9:00 AM and 9:00 PM, and on 2/18/2026 at 9:00 AM. During an observation on 2/17/2026 at 12:27 PM, Resident #140 IV dressing was peeling away and there was dried blood at the insertion site. The dressing was dated 2/12/2026. During an interview on 2/17/2026 at 12:45 PM, Staff A, LPN, stated that the dressing had to be changed if soiled. During an interview on 2/18/2026 at 9:45 AM, Staff B, LPN, stated, I just flushed the IV [intravenous] line and seen the blood, but did not think to change the dressing. During an interview on 2/28/2025 at 1:45 PM, the Director of Nursing stated, The dressing should be changed as written by the physician every 7 days and should be changed if contaminated. It should have been changed when blood was observed and the dressing was contaminated. Review of the facility policy and procedures titled PICC/Midline/CVAD Dressing change with the last review date of 5/30/2025 read, Policy: It is the policy of this facility to change peripherally inserted catheter (PICC), midline or central venous access device (CVAD) dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes.

Based on observation, interview, and record review, the facility failed to ensure medications were securely stored in 2 of 4 halls. Findings include: 1) During an observation on 2/17/2026 at 10:31 AM, Resident #3 was sitting in her wheelchair in her room next to her bed. On top of her bed, there was Hydrocortisone Cream 1% and Zinc Oxide Ointment. During an interview on 2/17/2026 at 10:31 AM, Resident #3 stated, I use the creams preventively for my back because at times my back will itch. During an interview on 2/17/2026 at 11:52 AM, Staff I, Licensed Practical Nurse (LPN), stated, Residents are not to keep medication in their rooms. It should be secured in the medication cart. During an interview on 2/19/2026 at 12:40 PM, the Director of Nursing stated, Medications should be stored in a lock box. 2) During an observation on 2/17/2026 at 10:06 AM, there was a pill and powdered substance on the floor in Resident #42's room. During an observation on 2/17/2026 at 10:24 AM, there was a medication on the floor, crushed into pieces and powder, in Resident #143's room. During an interview on 2/17/2026 at 12:03 PM, Staff C, LPN, identified the items observed in Resident #42's room as medication and a powder medication for the patient's [Resident #42's] buttocks. The process is to call out the medication and stay with the resident until the medication is consumed by the resident before moving on to the next medication pass. it probably happened during the night shift. During an interview on 2/17/2026 at 12:06 PM, Staff C, LPN, identified the substance in Resident #143's room and stated, This is a pill medication. The morning staff did not inform me of medication being on the floor. 3) During an observation on 2/17/2026 at 10:01 AM, there were one bottle of Blink tears dry eye lubricating eye drops (active ingredient: Polyethylene glycol) and one bottle of nail polish removal (active ingredient: Acetone) on Resident #18's bedside table (Photograph evidence obtained). During an interview on 2/17/2026 at 10:01 AM, Resident #18 stated, I use the eye drops any time that my eyes feel dry. I've used the eye drops when I got up this morning around 7 AM. I was never told that I could not have the eye drops or the fingernail polish remover in my room. During an interview on 2/17/2026 at 12:50 PM, Staff A, LPN, stated, No medication or nail polish remover can be left at the bedside. 4) During an observation on 2/17/2026 at 9:46 AM, there was one bottle of Systane Lubricant eye drops (active ingredients: polyethylene glycol 400 (0.4%) and propylene glycol (0.3%)) on Resident #15's bedside table. During an interview on 2/17/2026 at 9:46 AM, Resident #15 stated, My wife brought those [eye drops] in and I use the drops if I need to. I used the eye drops last night. During an interview on 2/17/2026 at 12:57 PM, Staff A, LPN, stated, No medications including saline eye drops can be left at the bedside. What happens is the families bring these medications in and don't tell us. During an interview on 2/18/2026 at 1:45 PM, the Director of Nursing stated, No medication can be left at the bedside unsecured. Review of the facility policy and procedures titled Medication Storage with the last review date of 5/30/2025 read, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication room according to the manufactures' recommendation and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines. 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerator, medication rooms) under proper temperature controls. b. only authorized personnel will have access to the keys to locked compartments.

Based on observation, interview, and record review, the facility failed to ensure staff used personal protective equipment (PPE) appropriately while providing wound care for 1 of 1 residents observed for wound care (Resident #13) to prevent the possible spread of infection and communicable diseases.Findings include: During an observation on 2/20/2026 at 8:15 AM, Staff F, Licensed Practical Nurse (LPN), started providing wound care for Resident #13. Staff F performed hand hygiene and donned gloves. Wound care supplies were separately stored and labeled with Resident #13's name in plastic bags. Staff F removed 4x4 gauze, collagen, Santyl and iodoform packing strip. Staff F cleaned scissors with alcohol and let the scissors dry prior to cutting iodoform packing strip. Staff F performed hand hygiene and donned gown and gloves. Staff F did not tie top of the gown and shoulders were not covered. Staff F proceeded to adjust Resident #13 in the bed on his left side. Staff F adjusted her gown at the shoulders and then removed old dressing from coccyx region and disposed of the old dressing. Staff F adjusted her gown on shoulders and then removed the contaminated gloves, and adjusted shoulders of the gown again while walking to the sink. Staff F performed hand hygiene and donned clean gloves and then adjusted the shoulders of the gown again, having the clean gloves on. Staff F proceeded to complete the wound care by applying the Santyl, packing the wound and applying the dry clean dressing (DCD).Review of Resident #13's physician order dated 2/18/2026 read, Santyl External Ointment 250 unit/gm [gram] (collagenase). Apply to coccyx topically as needed for soiled or dislodged and apply to coccyx topically every day shift for wound care. Irrigate wound with Dakins, pat dry, sprinkle collagen flakes to wound bed, then, apply nickel thick layer of Santyl into wound bed. Lightly pack w/ [with] iodoform packing strip and cover w/ DCD. Monitor for ss [signs and symptoms] or worsening. Notify MD [Medical Doctor] w/ any concerns.Review of Resident #13's physician order dated 1/30/2026 read, Enhanced barrier precautions due to wounds every shift.During an interview on 2/20/2026 at 8:45 AM, Staff F, LPN, stated, I realized what I did after the second time that I adjusted the gown. I should not do that.During an interview on 2/20/2026 at 9:00 AM, the Director of Nursing stated the gown should be tied to prevent staff from adjusting with contaminated glove and cross contamination.Review of the facility policy and procedures titled Personal Protective Equipment with he last review date of 5/30/2025 read, Policy: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to resident, visitors, and other staff. Policy Explanation and Compliance Guidelines: Indications/considerations for PPE use: B. Gowns: i. Wear gowns to protect arms, exposed body areas, and clothing from contamination with blood, body fluids, and other potentially infectious material. ii. Gowns should fully cover torso from neck to knees, arms to end of wrist, and wrap around the back. Fasten in back at neck and waist.

Based on record review and interview, the facility failed to ensure residents' Minimum Data Set (MDS) assessments were accurate for 2 of 6 residents reviewed for medication management (Residents #75, and #122). Findings include:1) Review of Resident #122's physician order dated 9/28/2025 read, Furosemide Oral Tablet (Furosemide), Give 20 mg [milligram] by mouth every 12 hours for fluid retention. Order Status: Active. Review of Resident #122's Medication Administration Record for January 2026 documented Furosemide was administered from 1/20/2026 to 1/31/2026.Review of Resident #122's quarterly MDS assessment dated [DATE] revealed the resident was not taking diuretics under Section N- Medications.During an interview on 2/19/2026 at 12:37 PM, the Director of MDS stated, [Resident #122's name] diuretic medication section had been coded incorrectly and needed to be corrected.2) Review of Resident #75's physician order dated 8/12/2025 read, Wellbutrin SR [Sustained Release] Oral Tablet Extended Release 12 hour (Bupropion HCI [Hydrochloride]), Give 150 mg by mouth every 12 hours for Depression, Administer whole, do not crush split or chew. Order Status: Active. Review of Resident #75's Medication Administration Record for January 2026 documented Wellbutrin SR was administered from 1/20/2026 to 1/31/2026.Review of Resident #75's MDS assessment dated [DATE] documented the resident was not taking antidepressant under Section N- Medications.During an interview on 2/19/2026 at 12:37 PM, the Director of MDS stated, [Resident #75's name] antidepressant medication section had been coded incorrectly and needed to be corrected.Review of the facility policy and procedures titled MDS 3.0 Completion with the last review date of 5/30/2025 read, Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specific by the State.

Based on record review and interview, the facility failed to ensure the arbitration agreement granted the right to rescind the arbitration agreement within 30 calendar days for 3 of 3 residents reviewed for arbitration (Residents #58, #148, and #149). Findings include: Review of Resident #58's Arbitration Agreement signed on 10/11/2024 did not include the right to rescind the agreement within 30 days after signing the agreement.Review of Resident #148's Arbitration Agreement signed on 2/16/2026 did not include the right to rescind the agreement within 30 days after signing the agreement. Review of Resident #149's Arbitration Agreement signed on 2/9/2026 did not include the right to rescind the agreement within 30 days after signing the agreement.During an interview on 2/19/2026 at 2:59 PM, the Administrator stated, We used to have another arbitration agreement and we changed software. The agreement should say the resident has the right to rescind within 30 days.Review of the facility policy and procedure titled Binding Arbitration Agreements with the last review date of 5/30/2025 read, Policy Explanation and Compliance Guidelines: 2. The agreement must: c. Explicitly grant resident or his or her representative right to rescind the agreement within 30 calendar days of signing it.

Based on record review and interview, the facility failed to ensure the attending physician documented their rationale related to pharmacy recommendations for 2 of 5 residents reviewed for unnecessary medications, Residents #52 and #72. Findings include: 1) Review of Resident #72's Pharmacist's Recommendation to Prescriber dated 4/25/2024 showed it read, Findings/Recommendation: This resident is receiving a low dose antipsychotic regimen, Quetiapine Tab [tablet] 25 mg [milligram]- Give 25 mg by mouth at bedtime for paranoia . Recommendation: please consider a taper or discontinuation at this time. If reduction or tapering is clinically contraindicated, please indicate rationale below . Prescriber's Response: Disagree. The form did not contain the prescriber's rationale. Review of Resident #72's Pharmacist's Recommendation to Prescriber dated 6/23/2024 showed it read, Findings/Recommendations: This resident has an order for Vitamin C Tab 500 mg- Give 500 mg by mouth one time a day for age related deficiency . Recommendation: Please consider discontinuation of Ascorbic Acid for supplement . Prescriber's Response: Disagree. The form did not contain the prescriber's rationale. Review of Resident #72's medical records did not reveal any rationale provided by the provider for the pharmacist's recommendations on 4/25/2024 and 6/23/2024. 49656 2) Review of Resident #52's Pharmacist's Recommendation to Prescriber dated 8/22/2024 showed it read, Findings/Recommendation: This resident has current orders that might present a potential drug interaction: Omeprazole cap 20 mg- give 20 mg by mouth two times a day for GERD [Gastroesophageal Reflux Disease] administer whole do not crush chew or cut., in addition to Sucralfate. Recommendation: Please consider discontinuation of Sucralfate at this time, unless clinically contraindicated. If concomitant therapy is still warranted at this time, please indicate reason . Prescriber's Response: Disagree. The form did not contain the prescriber's rationale. Review of Resident #52's medical records did not reveal any rationale provided by the provider for the pharmacist's recommendation on 8/22/2024. During an interview on 9/19/2024 at 11:26 AM, the Director of Nursing (DON) stated, I just spoke to the pharmacist, and they will be changing the forms so that the physicians know they must include a rationale. Since it just said comments, I would not think I had to write anything in that section. I did not find any rationale for the action of the physician for [Resident #52's name] and [Resident #72's name]. Review of the facility policy and procedure titled Addressing Medication Regimen Review Irregularities with the last review date of 5/6/2024 showed it read, Policy: It is the policy of this facility to provide a Medication Regimen Review (MRR) for each resident in order to identify irregulates and respond to those irregularities in a timely manner to prevent the occurrence of an adverse drug event . Policy Explanation and Compliance Guidelines . 4 d. The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration for 2 of 4 reviewed for medication administration, Residents #481 and #101, and during wound care for 1 of 6 residents reviewed for skin conditions, Resident #13 to prevent from possible spread of infection and communicable diseases. Findings include: 1) During an observation on 9/18/2024 at 9:03 AM, Staff B, Licensed Practical Nurse (LPN), opened the medication cart and realized she had no liquid protein in the medication cart. Staff B went to the medication room and used the keypad to open the door. Staff B returned to the medication cart and began to open and pour the liquid protein into a medication cup without performing hand hygiene. Staff B's pen fell on the floor and Staff B picked up the pen. Staff B opened the bottom drawer and removed a Sani wipe container with a purple top and sanitized the pen and her hands with the wipe without using gloves. Staff B proceeded to pour medication for Resident #481. Staff B did not have Miralax on hand in the medication cart. Staff B entered Resident #481's room leaving the oral medication locked in the medication cart and handed the liquid protein to the resident. The resident refused the medication. During an interview on 9/18/2024 at 9:36 AM, Staff B, LPN, stated, I did not realize I did not do hand hygiene when I came back from the medication room. I thought I did. 2) During an observation on 9/18/2024 at 9:59 AM, Staff D, Registered Nurse (RN), poured medications for Resident #101. Staff D did not have iron in her medication cart and went to the medication room to get the medication. Staff D opened the medication room door using the keypad. Staff D returned to the medication cart and opened and poured the iron into the medication cup without performing hand hygiene. Staff D was crossing the hallway and when another staff member exited a room and called Staff D for help, stating a resident had fallen. Staff D entered Resident #12's room with Resident #101's medication in her hand. Staff D exited Resident #12's room and without hand hygiene or disposing the medication entered Resident #101's room and administered the medication. During an interview on 9/18/2024 at 10:18 AM, Staff D, RN, stated, I should have done hand hygiene after coming back from the medication room and when I exited the resident's room before entering another resident's room. During an interview on 9/18/2024 at 10:47 AM, the Director of Nursing stated, Nursing staff should have performed hand hygiene when they return from the medication room since they are touching the keypad and the door to open the room. Staff should not walk into another resident's room with another resident's medication. Staff should hand the medication to another employee or just get rid of the medication and redraw the medication needed. 3) During an observation on 9/19/2024 at 7:25 AM, Staff E, Wound Care Nurse, LPN, entered Resident #13's room and donned personal protective equipment. Staff E removed the dressing from Resident #13's right foot. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene. Staff E cleaned the wound and removed her gloves and donned new pair of gloves without performing hand hygiene and applied the treatment. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene and applied a dressing to the resident's right foot wound. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene, repositioned the resident and removed the sacrum dressing. Resident #13 had a bowel movement. Staff E cleaned Resident #13's bowel movement. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene and proceeded to clean the sacrum wound. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene and applied the treatment. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene and applied the dressing. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene and proceeded to remove the left foot wound dressing. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene. Staff E cleaned the wound and changed her gloves without performing hand hygiene in between. Staff E applied the treatment to the wound. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene and applied the dressing to the resident's left foot. During an interview on 9/19/2024 at 7:56 AM, Staff E, LPN, stated, I know I should have used hand sanitizer in between removing my gloves. Yesterday, he had the hand sanitizer bottle in the room, but he did not have it today. During an interview on 9/19/2024 at 1:04 PM, the Director of Nursing (DON) stated, Staff should preform hand hygiene in between wound care steps and when they remove their gloves hand hygiene should be done. Review of the facility policy and procedure titled Hand Hygiene with the last review date of 5/6/2024 showed it read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . Policy Explanation and Compliance Guidelines . 6. Additional Considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on observation, interview, and record review, the facility failed to ensure accurate documentation of nutritional supplement administration and percentage of supplement consumed for 1 of 9 residents reviewed for nutrition, Resident #43. Findings include: Review of Resident #43's admission record revealed the resident was admitted on [DATE] with diagnoses including combined systolic (congestive) and diastolic (congestive) heart failure (primary diagnosis), respiratory failure, orthostatic hypotension, pulmonary embolism without acute core pulmonale, essential (primary) hypertension, muscle weakness, abnormalities of gait and mobility, protein-calorie malnutrition, hyperlipidemia, atherosclerotic heart disease of native coronary artery without angina pectoris, peripheral vascular disease, gastro-esophageal reflux disease without esophagitis, osteoarthritis, and pleural effusion. Review of Resident #43's physician order dated 9/6/2024 showed it read, Mighty Shake with meals for protein supp [supplement] 1 carton= 4 oz [ounces]. During an observation on 9/17/2024 at 9:10 AM, Resident #43 was eating his breakfast. There was no Mighty Shake on the resident's meal tray. During an observation on 9/17/2024 at 1:05 PM, Resident #43 received a lunch tray with a Mighty Shake on the tray. At 1:34 PM, the meal tray with unopened Mighty Shake carton was removed and returned to the tray return cart. During an observation on 9/18/2024 at 9:10 AM, Resident #43 was eating his breakfast on his bedside table. There was no Mighty Shake on the resident's tray. During an observation on 9/18/2024 at 12:52 PM, Resident #43 received a lunch meal tray with no Mighty Shake on the resident's tray. During an interview on 9/18/2024 at 1:10 PM, Staff A, Certified Nursing Assistant (CNA), stated, The Mighty Shake was not on the tray. It should have been on the tray, but it was not there. During an interview on 9/18/2024 at 1:17 PM, Staff B, Licensed Practical Nurse (LPN), stated, The nurse is responsible for documenting if the Mighty shake was drunk by the resident with his meals. I documented how much of the shake he drank in the MAR [Medication Administration Record]. Review of Resident #43's Medication Administration Record (MAR) showed the resident consumed 100% of Mighty Shake on 9/17/2024 at 8:00 AM, 9/17/2024 at 12:00 PM, and 9/18/2024 at 8:00 AM. During an interview on 9/19/2024 at 7:48 AM, the Director of Nursing stated, The amount consumed by a resident need to be accurately documented in the resident's record. The Mighty Shake shouldn't be documented with the amount consumed if the resident didn't receive it. I expect the nursing staff to be documenting accurately. Review of the facility policy and procedure titled Documentation in Medical Record last reviewed on 2/21/2024, showed it read, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines . 4. Principles of documentation, include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. i. False information shall not be documented.

Based on observation, interview, and record review, the facility failed to ensure residents received nutritional supplements for 1 of 9 residents reviewed for nutrition, Resident #43 (Photographic evidence obtained). Findings include: Review of Resident #43's admission record revealed the resident was admitted on [DATE] with diagnoses including combined systolic (congestive) and diastolic (congestive) heart failure (primary diagnosis), respiratory failure, orthostatic hypotension, pulmonary embolism without acute core pulmonale, essential (primary) hypertension, muscle weakness, abnormalities of gait and mobility, protein-calorie malnutrition, hyperlipidemia, atherosclerotic heart disease of native coronary artery without angina pectoris, peripheral vascular disease, gastro-esophageal reflux disease without esophagitis, osteoarthritis, and pleural effusion. Review of Resident #43's physician order dated 9/6/2024 showed it read, Mighty Shake with meals for protein supp [supplement] 1 carton= 4 oz [ounces]. During an observation on 9/17/2024 at 9:10 AM, Resident #43 was eating his breakfast. There was no Mighty Shake on the resident's meal tray. During an observation on 9/17/2024 at 1:05 PM, Resident #43 received a lunch tray with a Mighty Shake on the tray. At 1:34 PM, the meal tray with unopened Mighty Shake carton was removed and returned to the tray return cart. During an observation on 9/18/2024 at 9:10 AM, Resident #43 was eating his breakfast on his bedside table. There was no Mighty Shake on the resident's tray. During an observation on 9/18/2024 at 12:52 PM, Resident #43 received a lunch meal tray with no Mighty Shake on the resident's tray. During an interview on 9/18/2024 at 1:10 PM, Staff A, Certified Nursing Assistant (CNA), stated, The Mighty Shake was not on the tray. It should have been on the tray, but it was not there. During an interview on 9/18/2024 at 1:20 PM, the Registered Dietitian (RD) stated, I am familiar with the resident. I reviewed his weight loss and nutritional needs. I ordered Vitamins, protein, and Mighty Shakes. He should be getting the Mighty Shakes on his tray as ordered. The RD reviewed the order in Resident #43's medical record and stated, He [Resident #43] should be getting the Mighty Shake with each meal. The dietary staff should be putting it on the tray, and it comes from the kitchen. I don't think it would cause harm if he didn't get it. His weight is becoming stable, but he needs to be getting his shakes. During an interview on 9/18/2024 at 1:25 PM, the Certified Dietary Manager stated, The dietary aide is responsible for putting the Mighty Shakes on the tray with the meals. During an interview on 9/19/2024 at 7:48 AM, the Director of Nursing stated, I expect the nursing staff to be following physician orders. Review of the facility policy and procedure titled Nutritional and Dietary Supplements last reviewed on 5/15/2024, showed it read, Policy: It is the policy of this facility that nutritional and dietary supplements will be used to complement a resident's dietary needs in order to maintain adequate nutritional status and resident's highest practicable level of well-being. Definitions . Nutritional Supplements refers to products that are used to complement a resident's dietary needs such as calorie or nutrient dense drinks, total parenteral products, enteral products and meal replacement products (e.g. Ensure, Glucerna, Promote). Policy Explanation and Compliance Guidelines . 8. Nutritional supplements are to be provided to residents within 45 minutes of either a resident's request of less depending on the facility's scheduled time for meals.

Based on observation, interview, and record review, the facility failed to post the accurate nurse staffing data for the facility on a daily basis. Findings include: During an observation while conducting the initial tour of the facility on 9/16/2024 at 9:10 AM, there was no nurse staffing data on the receptionist desk, posted on the wall, in the reception area or at the nursing stations. During an interview on 9/16/2024 at 9:20 AM, the Administrator stated, I'm not sure what you are looking for. We have a list on each unit of all the staff for the day. I don't have the information you are looking for posted. During an observation on 9/16/2024 at 3:03 PM, the nurse staffing data was displayed on the counter at the receptionist desk, indicating the facility census for 9/16/2024 as 111. During an interview on entrance conference conducted on 9/16/2024 at 9:14 AM, the Administrator stated the resident census for 9/16/2024 was 110. Review of the facility's daily census dated 9/16/2024 showed total residents of 110. During an interview on 9/16/2024 at 3:05 PM, the Administrator stated, The posting is posted up front each day, but it was not there this morning when you asked me about it. It should have been there, and it should be accurate. During an interview on 9/18/2024 at 8:04 AM, Staff C, Certified Nursing Assistant/Staff Coordinator, stated that she coordinated the federal staffing posting and it wasn't posted at shift change for 9/16/2024. Review of the facility policy and procedure titled Nurse Staffing Posting Information last reviewed on 8/23/2024, showed it read, Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name, b. The current date, c. Facility's current resident census, d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses, ii. Licensed Practical Nurse/Licensed Vocational Nurses, iii. Certified Nurse Aides. 2. The facility will post the Nurse Staffing Sheet at the beginning of each shift. 3. The information posted will be: a. Presented in a clear and readable format. b. In a prominent place readily accessible to residents and visitors.

Based on observation, interview and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety in the dry storage food area and in the walk-in freezer in the main kitchen. Findings include: During the initial tour of the kitchen dry good storage area conducted with the Certified Dietary Manager on 5/22/23 at 9:25 AM, a plastic scoop was observed in the oatmeal storage bin lying on top of the oatmeal and a small metal scoop was observed in the brown sugar storage bin on top of the brown sugar. During a tour conducted with the Certified Dietary Manager on 5/22/23 at 9:30 AM of the facility's walk-in freezer, there was a container of fried chicken with the cover opened on the corner, a partially used bag of lasagna sheets not fully closed and a partially used bag of preformed cookie pucs [formed, uncooked cookie dough] not fully closed. During an interview conducted on 5/24/23 at 9:47 AM the Certified Dietary Manager stated that her expectation for food stored in the freezer be labeled, dated and fully closed and that no scoops should be kept on top of the food in the dry food storage bins. 39371 Review of policy and procedure titled Food Safety Requirements implemented 3/18/23 read, Policy: It is a policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with the delivery of the food to the residents. Elements of this process including the following: .b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including the growth of microorganisms 8. Additional strategies to prevent foodborne illness include, but are not limited to: .d. Proper refrigeration of meat, poultry, and pasteurized dairy products.

Based on observation, interview, and record review the facility failed to implement comprehensive resident centered care plan interventions for 2 (Resident #9, #338) of 12 residents review for accidents and pressure ulcers. Photographic evidence obtained. Findings include: 1) During an observation on 5/22/2023 at 10:03 AM Resident #9 was lying in bed, one fall mat was placed on the floor on the right side of the bed while the left side of the bed there was no fall mat on the floor. During an observation on 5/23/2023 at 9:00 AM Resident #9 was lying in bed, one fall mat was placed on the floor on the right side of the bed while the left side of the bed there was no fall mat on the floor. During an observation on 5/24/2023 at 8:30 AM Resident #9 was lying in bed, one fall mat was placed on the floor on the right side of the bed while the left side of the bed there was no fall mat on the floor. During an observation on 5/24/2023 at 12:30 PM AM Resident #9 was lying in bed, one fall mat was placed on the floor on the right side of the bed while the left side of the bed there was no fall mat on the floor. During an interview on 5/24/2023 at 1:38 PM Staff B, License Practical Nurse (LPN) stated, I am not sure why [Resident #9's name] only has one fall mat maybe its due to her side table being placed on the side with no floor mat. If the Kardex (Certified Nursing Assistant Point of Care system for the comprehensive care plan] states bilateral floor mats, staff should ensure it is followed. During an interview on 5/24/2023 at 2:25 PM Director of Nursing stated, Staff are expected to follow what is documented on the Kardex. Review of Resident #9's admission record documented an admitted [DATE] with diagnoses to include muscle weakness, altered mental status, abnormal posture, presence of right artificial hip joint, and dementia. Review of Resident #9's comprehensive care plan with a revision date of 10/14/2022 read, Focus [problem]. I am at risk for falls related to decreased mobility, weakness, unsteady gait, and medication contributors. Interventions. Bilateral floor mats at bedside while in bed. Review of the policy and procedure titled Comprehensive Care Plans with implemented date of 10/24/2022 read, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 47275 2.) During on observation on 05/22/2023 at 8:27 AM, Resident #338 was lying on his back in bed, without bilateral heels off loaded [allow weight of the leg to 'settle' into an offloading device such as pillow, wedge or boot]. During an observation on 05/23/2023 at 9:28 AM Resident #338 was lying in bed watching television without bilateral heels off loaded. During an observation on 05/24/2023 at 11:02 AM Resident #338 was lying in bed watching television without bilateral heels off loaded. During an observation on 05/24/2023 at 1:45 PM Resident #338 was lying in bed visiting with family. Bilateral heels were not off loaded. During an interview on 5/24/2023 at 10:00 AM Resident #338 stated, They do not put anything on my feet, or under my heels while I am lying in bed. During an interview on 5/24/2023 at 1:55 PM Staff C, Licensed Practical Nurse stated, It is the responsibility of the Certified Nursing Assistants (CNA's) and the nurses to make sure the care plan is being followed. Review of Resident #338's physician's orders dated 5/20/2023 read Offload Bilateral heels while in bed every shift for Prophylaxis. Review of Resident #338's care plan dated 5/20/2023 read Risk for skin breakdown related to decreased mobility. Administer skin treatment as ordered. Minimize pressure to boney prominences.

Based on interview and record review the facility failed to submit the Minimum Data Set (MDS 3.0) discharge summary in a timely manner for 1 (Resident #21) of 4 residents reviewed for discharge. Findings include: Review of Resident #21's MDS 3.0 summary assessment titled Discharge-return not anticipated was completed on 1/12/2023 and was accepted on 5/23/2023. Section A Identification Information read F. Entry/discharge reporting 10. Discharge-return not anticipated. A200. discharge date [DATE]. Review of Resident #21's admission record documented Resident #21 was discharged on [DATE]. During an interview on 5/24/2023 at 8:40 AM Staff D, MDS Coordinator, stated, It was completed [MDS 3.0 Discharge-return not anticipated] on 12/16/2022 and locked as of yesterday [5/23/2023]. This happened due to the way it had been set up, the report was not setup to be send to CMS and the correction was made yesterday. The assessment had been done in a timely manner just not submitted. Upon request of a policy and procedure for MDS 3.0 and discharge assessments, the Director of Nursing stated, The facility does not have a policy for MDS 3.0, we follow the Resident Assessment Instrument (RAI) Manual guidelines.

Based on observation, interview, and policy and procedure review, the facility failed to ensure food was labeled, dated, stored, and monitored in accordance with professional standards. Findings; During the initial tour of the kitchen conducted on 1/10/2022 beginning at 9:17 AM with the Certified Dietary Manager (CDM) an observation of the walk-in cooler showed several outdated containers of leftovers to include a container labeled green beans dated 1/3/2022, a container of rice dated 1/1/22, and a container of black-eyed peas dated 1/1/22. There were containers of raw tomatoes and whole lemons observed with bruising, oozing brownish and/or white discoloration to the produce. During an interview on 1/10/2022 at 9:30 AM the CDM confirmed the food products that are considered a left-over should have been discarded timely. The CDM stated the produce should not remain in the cooler when they have discoloration or a break in the outer skin. Review of policy and procedure titled, Date Marking for Food Safety dated 3/18/2020 with a revision date of 2/22/21 read, The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. Review of the policy and procedure titled, Food Safety Requirements dated 2021, no month was documented, with a revision date of 2/22/21 read, Food will also be stored, prepared and served in accordance with professional standards for food service safety. 3. c. iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded. Review of https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basic/leftovers-and-food-safety#_Store review and printed on 1/20/22 read, Store Leftovers Safely - Leftovers can be kept in the refrigerator for 3 to 4 days or frozen for 3 to 4 months.

Based on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for the maintenance of a Peripherally Inserted Central Catheter (PICC) for 1 of 3 residents, Resident #371. Findings: Review of the admission record for Resident #371 documented the resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 1/10/22 at 10:15 AM Resident #371 had a PICC located in the anterior elbow covered with a stockinet. The PICC site had dried, crusty, red to dark red blood visible through the transparent dressing. The date written on the dressing was partially illegible with only 12/ at 8 PM visible. During an interview on 1/10/2022 at 10:17 AM Resident #371 stated that he was still receiving medication through his PICC line and confirmed that the dressing has not been changed. Resident #371 stated, I have not seen them change the dressing. I have not refused to have the dressing changed. During an observation on 1/10/2022 at 2:03 PM the PICC line dressing located on the anterior elbow site had dried, crusty, red to dark red blood visible through the transparent dressing. The date written on the dressing was partially illegible with only 12/ at 8 PM visible. During an interview on 1/11/2022 at 9:58 AM Resident #371 stated, I just received my PICC medication. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Normal Saline Flush Solution 0.9% 10 ml [milliliters] every 8 hours for patency. Change IV [intravenous] tubing and caps every 72 hours. Monitor IV for redness, swelling, bleeding and pain. Notify MD [Medical Doctor] if any are present. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/6/2022 read under Section C500 for a Brief Interview for Mental Status (BIMS) a score of 11 (moderate cognitive impairment). Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Treatment Administration Record (TAR) for December 31, 2021 through January 11, 2022 documented the PICC line dressing change was not provided per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 1/11/2022 at 10:12 AM Staff C, Regional Nurse Consultant (RNC) stated intravenous site dressings were changed depending on their admitted , they are changed in 24 hours, and I think, again every 3 days, but I am not sure of that. During an observation on 1/11/2022 at 10:12 AM the RNC confirmed the date on the PICC dressing site on the left anterior elbow read 12/ at 8:00 PM and the rest was not legible. Review of the comprehensive care plan for Resident #371 read the patient is receiving antibiotic therapy related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions include IV (PICC) dressing changes as ordered, observe IV PICC insertion site for sign and symptoms of redness, infection and infiltration. Review of the policy and procedure titled, Midline Dressing Changes with a review date of October 2019 read: Policy: Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter related infections associated with contaminated, loosened or soiled catheter-site dressing. General Guidelines: 1. Change midline catheter dressing 24 hours after insertion if placed with gauze, every 7 days or if it is wet, dirty, not intact, or compromised in any way. 4. Use a sterile, transparent, semi-permeable membrane (TSM) or gauze dressing. If gauze dressing is used, cover the gauze dressing with a TSM dressing and change the dressing every 48 hours.

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene for 2 of 4 residents, Residents #369 and #371, in a total sample of 28 residents. Findings: Review of the admission record for Resident #369 documented the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 1/10/22 at 10:16 AM Resident #369 was sitting in her wheelchair, had a sling on her right upper arm, long facial hair was observed to her upper lip and chin, and her hair was greasy. During an interview on 1/10/22 at 10:17 AM, Resident #369 stated she was admitted to the facility last Wednesday,1/5/2022 and had not had a shower or a bed bath since coming to the facility, no one offered to give me a shower or a bed bath. I would love to have them remove the hair on my face and give me a shower. During an observation on 1/11/2022 at 8:30 AM Resident #369 was in bed, there was a sling to her right upper arm, facial hair to her upper lip and chin, and greasy hair. During an observation on 1/12/2022 at 9:22 AM Resident #369 was in bed, there was a sling to her right upper arm, facial hair on her upper lip and chin, and greasy hair. During an interview on 1/12/2022 at 9:22 AM, Resident #369 stated, I still did not get a shower. I hope they will give me a shower today and cut my facial hair. I told my daughter to bring in scissors so they can cut my facial hair, because I do not want to be shaved. During an interview on 1/13/2022 at 10:12 AM, Resident #369 stated, I sat up in a chair in the bathroom yesterday and had a sponge bath, but I wished they would have washed my hair. During an interview on 1/12/2022 at 10:03 AM Staff E, Certified Nursing Assistant (CNA) stated she was assigned to Resident #369. She was aware of the shower schedule for Resident #369 then stated the resident has a sling on her arm that cannot be removed, so therapy will give her a shower today. During an interview on 1/13/2022 at 10:02 AM, the Director of Therapy stated, Occupational Therapy (OT) does provide showers at times. He verified that the OT notes dated 1/12/2022 for Resident #369 confirmed the resident received only a sponge bath, not a shower. A request was made for documentation of the resident not being able to have a shower, none was provided. Review of the shower schedule revealed Resident #369 was scheduled for showers every Wednesday and Saturday on the day shift. Review of the Minimum Data Set (MDS) Assessment Reference Date (ARD) 1/11/2022, Section C500 read a Brief Interview for Mental Status (BIMS) score of 15, (intact cognitive response). Section G read Resident #369 was required extensive assistance of two persons for physical assistance with bed mobility, dressing, toilet use, personal hygiene and total dependence for bathing with two person assistance. Review of the Initial care plan read: Staff and I believe that I am capable of increased independence with at least one activities of daily living (ADL) prior to returning to the community. Goal: I will have ADL's completed and hygiene needs met daily through next review. 2. Review of the admission record for Resident #371 documented the resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 01/10/22 at 10:40 AM Resident #371 was in bed, awake, alert, oriented to name, time and place. The resident was observed with facial hair, food debris on his teeth, and a dark colored substance under the nail beds of both hands. During an interview on 1/10/2022 at 10:40 AM Resident #371 stated that he has been at the facility for about two and half weeks and has not had a shower but once. My last shower was two weeks ago, the staff said they would check into it, but nothing happened. I don't know why they would not even give me a bed bath and I cannot brush my teeth because I cannot stand up. During an observation on 1/11/2022 at 9:02 AM Resident #371 was in bed, awake, and alert. The resident was observed with facial hair, food debris on his teeth, and a dark colored substance under the nail beds of both hands. During an interview on 1/11/2022 at 9:02 AM Resident #371 stated, I wished they could shave me and give me a shower. I would never pass on a shower if they offered. During an interview on 1/11/2022 at 10:02 AM Staff B, Certified Nursing Assistant (CNA) stated, I don't really know about the residents because I do not work in this unit all the time. I check the CNA shower book to find out if they are scheduled for a shower. If a resident refuses a shower, I will try to offer at a later time because I work 12 hours. If they still refuse, the resident signs a refusal form. I do not know when Resident #371 is scheduled for a shower, I would have to check the shower book. During an interview on 1/12/2022 at 9:39 AM Resident #371 stated, I am disappointed, the girl was in a hurry and did not shave me. Review of the shower schedule for Resident #371 read the resident's shower days were every Wednesday and Saturday on the day shift. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/6/2022 read under Section C500 for Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive impairment). Section G read Resident #371 requires extensive assistance of two person assistance for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and total dependence on bathing. During an interview on 1/11/2022 at 10:12 AM Staff C, Regional Nurse Consultant (RNC) confirmed that Resident #371 has facial hair and there is a dark colored substance underneath his fingernails. Review of the comprehensive plan of care dated 1/2/2022 for Resident #371 read Focus: I am capable of increased independence with my activities of daily living (ADL) prior to returning to the community. Goal: Have ADL's completed and hygiene needs met daily. Interventions dated 1/2/2022 include - Assist with oral hygiene as needed. Report any decline in ADL capabilities to MD/PT/NP [Medical Doctor, Physical Therapist, Nurse Practitioner] as needed. Encourage patient to do as many ADL tasks for themselves as possible.