Every finding on record at Cherry Ridge

Based on observations, record reviews, and interviews, the facility failed to provide necessary care and services in accordance with the professional standards of practice for 2 (#1 and #78) of 2 residents reviewed for respiratory care. The facility failed to properly store a nebulizer mask, AutoPAP mask, and a nasal cannula when not in use.Findings: Review of the facility's Policy and Procedure for Respiratory Therapy – Prevention of infection revised November 2011 revealed the following in part: Purpose The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. Steps in Procedure Infection Control Considerations Related to Oxygen Administration: 8. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Infection Control Considerations related to medication nebulizers/continuous aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. Infection Control Considerations related to CPAPs/ BiPAPs, etc: 6. Provide clean bag for proper storage of mask when not in use (date and initial bag) Resident 78 Review of the medical record for Resident #78 revealed an admission date 07/17/2026. Resident #78 had diagnoses that included acute respiratory failure with hypoxia, lobar pneumonia, unspecified organism, bronchiectasis with (acute) exacerbation, dysphagia, pneumonitis, hypertensive heart disease with heart failure, anemia, and unspecified asthma. Review of the admission MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated no cognitive impairment for daily decision making. Review of the July 2026 physician orders revealed an order dated 07/23/2026 for Ipratropium-albuterol solution 0.5 mg-3mg (2.5mg base)/3 ml administer 1 vial inhalation via nebulization TID x 5 days. Review of the July 2026 EMAR revealed documentation Resident #78 received Ipratropium-albuterol breathing treatments as ordered. On 07/27/2026 at 10:40 a.m., observation of Resident #78 revealed he was lying in bed with head of bed elevated 45 degrees. Resident #78 received humidified oxygen at 2 lpm via nasal cannula. Observation of Resident #78's room revealed an uncovered nebulizer face mask sitting on nebulizer machine on dresser beside bed. Observation of Resident #78's room on 07/27/2026 at 4:30 p.m., revealed the nebulizer mask was uncovered lying on top of the nebulizer machine on dresser beside his bed. On 07/28/2026 at 8:45 a.m., S2DON was informed Resident #78's nebulizer face mask was observed uncovered lying on top of nebulizer machine on 07/27/2026. S2DON confirmed Resident #78's nebulizer tubing and face mask should be stored in a plastic bag when not in use. Resident 1 Review of the medical record for Resident #1 revealed an admission date of 08/05/2021. Resident #1 had diagnosis of obstructive sleep apnea. Review of the July 2026 physician orders for Resident #1 revealed an order dated 08/16/2023 for AutoPAP at 4-20 CmH20 via facemask during sleep hours. Further review of the orders revealed an order dated 06/18/2026 to check oxygen saturation every shift on Saturdays and as needed for shortness of breath. If oxygen saturation reading is less than 88% begin oxygen at 1.5 liters. Review of the annual MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 12 which indicated moderate cognitive impairment for daily decision making. Further review of the MDS revealed the resident had shortness of breath with exertion and received oxygen therapy. Review of Resident #1's careplan revealed he had sleep apnea, used an AutoPap at 4-20 CmH20 via facemask during sleep hours, and received oxygen therapy related to shortness of breath. Observations of Resident #1's room on 07/27/2026 at 4:20 p.m., and 07/28/2026 at 7:45 a.m. revealed the AutoPAP mask was uncovered on the bedside table. Further observation on 07/28/2026 at 8:26 a.m. revealed the AutoPAP mask was uncovered on the bedside table, and the oxygen nasal cannula was draped over the oxygen concentrator uncovered. On 07/28/2026 at 8:45 a.m. an observation with S2DON of Resident #1's room revealed the AutoPAP mask was on the bedside table uncovered and the oxygen nasal cannula was draped over the oxygen concentrator uncovered. At this time S2DON confirmed the AutoPAP mask and nasal cannula should have been stored in a bag when not in use.

Based on observations and interviews the facility failed to provide a safe, sanitary, functional, and comfortable environment by having 1) a shower room and a storage closet room door unlocked on the secured unit, and 2) an air conditioner unit in a resident's room not properly secured to the wall for 1 (#6) of 4 residents reviewed for environment. Findings: Hall 1: On 07/27/2026 at 11:45 a.m., observation of the secured memory care unit revealed the door to the shower room and the storage closet were unlocked. Observation of the shower room revealed there were 2 one-gallon jugs of Dial hair and body soap (1 full and the other was 1/3 full) sitting on the shower chair in the shower. There was a grey laundry barrel, and a black trash barrel both were covered with a lid that had a sign stating, return to the proper closet after emptying. There was also an unlocked cabinet that was open that contained 4 twin blade disposable razors, bottle of mouth wash, bottles of deodorant, boxes of gloves, and multiple clothes were hanging on a large clothing rack. Observation of the storage closet revealed there were 3 regular mattresses, 2 air loss mattresses, 2 stand up walkers, several wheelchairs, and wheelchair parts. On 07/27/2026 at 12:00 p.m., interview with S2DON confirmed the doors to the shower room and storage room on the secured memory care unit should be locked. Resident 6 On 07/27/2026 at 9:10 a.m., 07/28/2026 at 8:00 a.m., and 3:45 p.m. observations of Resident #6's room revealed the air conditioner unit was not secured properly to the wall. Further observation revealed the unit did not have side panels or insulation around the unit and light from the outside could be visualized on the sides of the air conditioner unit. On 07/28/2026 at 4:00 p.m. observation of Resident #6's air conditioner unit with S3Maintenance Director and S2DON revealed the unit was not secured properly to the wall. On 07/28/2026 at 4:10 p.m. S2DON confirmed Resident #6's air conditioner unit was not secured properly to the wall.

Based on record reviews and interviews, the facility failed to ensure the physician addressed irregularities identified by the pharmacist for 2 (#2 and #41) of 5 residents reviewed for unnecessary medications. The physician failed to provide a handwritten clinical rationale for the denial of a gradual dose reduction for Resident #2 and failed to address gradual dose reduction recommendations by the consultant pharmacist for Resident #41.Findings: Resident 2 Review of the medical record for Resident #2 revealed an admission date of 02/05/2026. Resident #2 had diagnoses that included traumatic subarachnoid hemorrhage, heart disease, muscle wasting and atrophy, depression, anxiety, hypothyroidism, and dementia. Review of the significant change MDS assessment dated [DATE] revealed Resident #2 had severe cognitive impairment for daily decision making and required assistance with ADLs. Resident #2 received antipsychotic and antianxiety medications. Review of Resident #2's care plan revealed potential for social isolation due to depression, and the resident was at risk for side effects due to antipsychotic drug use. Further review of the care plan revealed an approach was to administer medications as ordered. Review of the February 2026 physician orders for Resident #2 revealed an order dated 02/05/2026 for Seroquel 25 mg, 1 tablet by mouth at bedtime, and an order dated 02/06/2026 for Lexapro 10 mg, 1 tablet by mouth every day. Review of the Pharmaceutical Consultant Report – Psychoactive Gradual Dose Reduction form dated 02/11/2026 revealed the pharmacist recommended a dose reduction for Seroquel 25 mg at bedtime, and Lexapro 10 mg every day. Further review of the report revealed the physician denied a dose reduction and failed to provide a handwritten valid clinical rationale for the denial of the dose reduction. On 07/29/2026 at 11:30 a.m. interview with S2DON confirmed the physician denied a dose reduction for the medications and failed to provide a handwritten valid clinical rationale for the denial of the dose reduction. Resident 41 Review of the medical record for Resident #41 revealed an admission date of 05/22/2026. Resident #41 had diagnoses that included Alzheimer's disease, depression, polyneuropathy, sleep disorder, anxiety disorder, and unspecified dementia, moderate, with agitation. Review of the admission MDS assessment dated [DATE] revealed a BIMS was not completed. Resident #41's cognitive status for daily decision making was severely impaired. Resident #41 had problems with short term and long term memory. Further review revealed Resident #41 was dependent on staff assistance with ADLs. Resident #41 received antipsychotic medication, antianxiety medication, antidepressant medication, and anticonvulsant medication. Review of the July 2026 physician orders revealed an order dated 05/31/2026 for Seroquel 200 mg tablet give 1 tablet by mouth twice a day, and an order dated 05/29/2026 for Trazadone 100 mg tablet give 1 tablet by mouth at bedtime. Review of the Pharmaceutical Consultant Report- Psychoactive Gradual Dose Reduction forms dated 06/04/2026 and 07/07/2026 revealed the consultant pharmacist requested a dose reduction for Seroquel 200 mg twice a day, and Trazadone 100 mg at bedtime. Further review of the forms revealed the physician did not address a gradual dose reduction for Seroquel and Trazadone. On 07/29/2026 at 10:00 a.m. interview with S2DON confirmed the physician did not address a gradual dose reduction for Seroquel and Trazadone.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good personal hygiene for 1 (#60) of 1 resident reviewed for ADL care. Findings:Review of the medical record for Resident #60 revealed an admission date of 08/11/2016 with diagnoses that included cerebral infarction, muscle weakness, hemiplegia and hemiparesis affecting non dominant side, memory deficit and depression.Review of the annual MDS assessment dated [DATE] revealed a BIMS score of 11 which indicated Resident #60 had moderately impaired cognitive skills of daily decision making. Further review revealed Resident #60 required set up or clean-up assistance with personal hygiene.Review of Resident #60's care plan revealed he required assistance with grooming.Observation on 07/27/2026 at 9:36 a.m. revealed Resident #60 was in bed in his room, and he had whiskers on his lower face. Interview at this time revealed he received a bath every morning and he would like to be shaved. Further interview revealed the CNAs have not offered to shave him since last week.Observation on 07/28/2026 at 1:08 p.m. revealed Resident #60 was in bed in his room, and he continued to have whiskers on his lower face. Interview at this time revealed he was not offered to be shaved this morning during his bath. An interview with S4CNA on 07/29/2026 at 7:00 a.m. revealed she bathed Resident #60 at the end of her shift on 07/28/2026. She reported she did not shave the resident on 07/28/2026. She reported he did not ask to be shaved.An interview with S2DON on 07/29/2026 at 2:50 p.m. confirmed Resident #60 needed to be shaved. Further interview confirmed the CNAs should offer to shave residents during their baths.

Based on record review and interview, the facility failed to ensure a resident with an order for psychotropic medication PRN was not subjected to chemical restraints for 1 (#41) of 5 residents reviewed for unnecessary medications. The facility failed to ensure Resident #41's PRN order for psychotropic medications was limited to 14 days.Findings:Review of the medical record for Resident #41 revealed an admission date of 05/22/2026. Resident #41 had diagnoses that included Alzheimer's disease, depression, polyneuropathy, sleep disorder, anxiety disorder, and unspecified dementia, moderate, with agitation. Review of the admission MDS assessment dated [DATE] revealed a BIMS was not completed. Resident #41's cognitive status for daily decision making was severely impaired. Resident #41 had problems with short term and long term memory. Further review revealed Resident #41 was dependent on staff assistance with ADLs. Resident #41 received antipsychotic medication, antianxiety medication, antidepressant medication, and anticonvulsant medication. Review of the July 2026 physician orders revealed an order dated 05/23/2026 for Lorazepam (Ativan) concentrate 2mg/ml administer 0.5 ml po q 2 hours PRN for anxiety/agitation, and an order dated 07/01/2026 for Ativan 1 mg tablet give 1 tablet by mouth TID prn restlessness/anxiety. Review of the Pharmaceutical Consultant Report- Psychoactive Gradual Dose Reduction form dated 06/04/2026 revealed the consultant pharmacist requested a specific duration/stop date for Ativan 0.5 ml every 2 hours PRN. Further review of the form revealed the physician did not provide a duration/stop date for the Ativan order. Review of the Pharmaceutical Consultant Report- Psychoactive Gradual Dose Reduction form dated 07/07/2026 revealed the consultant pharmacist requested a specific duration/stop date for Ativan 0.5 ml every 2 hours PRN and for Ativan 1 mg TID PRN. Further review of the form revealed the physician did not provide a duration/stop date for either of the Ativan orders. On 07/29/2026 at 10:00 a.m., interview with S2DON confirmed Resident #41 had orders for Ativan PRN for greater than 14 days. S2DON further confirmed the physician had not provided a duration/stop date for either Ativan orders.

Based on observations of the medication administration, record review, and interview, the facility failed to ensure that it was free from a medication error rate of 5% or greater. The facility had a 5.26% medication error rate with 2 medication errors out of 37 opportunities. Findings: Resident #40 Observation of the medication pass for Resident #40 on 06/03/2025 at 7:15 a.m. revealed S3Licensed Practical Nurse (LPN) administered one eye medication, Dorzolamide 2%, 1 drop in each eye. Review of the physician orders for Resident #40 revealed an order for the glaucoma eye medication Brimonidine 0.2, 1 drop in both eyes three times daily at 8:00 a.m., 1:00 p.m. and 6:00 p.m. This medication was not administered. Review of the Medication Administration Record for Resident #40 revealed that S3 LPN documented that she administered Brimonidine eye medication at 7:15 a.m., at the same time as she administered Dorzolamide eye medication. Resident #67 Observation of the medication pass for Resident #67 on 06/03/2025 at 7:57 a.m. revealed S4LPN administered 8 medications. Review of the physician orders for Resident #67 revealed an order for the anti-depressant medication, Venlafaxine, extended release 24 hour capsule, 37.5 milligram (mg), 1 capsule every morning. This medication was not administered. Interview with S4LPN on 06/03/2025 at 11:40 a.m. confirmed that she did not administer the medication Venlafaxine (Effexor) 37.5mg during medication pass for Resident #67 this morning as ordered. Interview with S2Director of Nursing (DON) on 06/03/2025 at 12:45 p.m. confirmed she was aware of the omission of the medication Venlafaxine for resident #67. Further interview with S2DON revealed that she was unaware of eye medication omission for Resident #40. Explained to S2DON that 2 medication errors (omission) were made during the medication pass resulting in a medication error rate greater than 5%.

Based on observation, record review and interview, the facility failed to maintain an infection control program to help prevent the development and transmission of communicable diseases and infections by failing to implement its policy for enhanced barrier precautions for 2 (#50 , #57) of 3 (#50, #57, #77) residents reviewed for transmission based precautions. Findings: Review of the Enhanced Barrier Precautions (EBPs) policy dated August 2022 revealed in-part: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing). 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. 9. Staff are trained prior to caring for residents on EBPs. 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 11. PPE is available outside of the resident rooms. Resident #50 On 06/02/2025 at 2:00 p.m., an observation of Resident #50 revealed an ace wrap dressing noted to his left shin and foot. There were metal rods was a black knob and metal rods protruding from the ace wrap on the anterior aspect of left shin. Resident #50 reported he has a device implanted to try to increase the circulation in his foot. Observation of Resident #50's door revealed there was no signage indicating a need for EBP. Further observation revealed there was no PPE available outside Resident #50's room. Record review revealed Resident #50 was admitted to the facility on [DATE]. Resident #50's diagnoses included but not limited to the following: Type 2 diabetes mellitus, history of osteomyelitis left ankle foot, status post amputation toes left foot, and stage 2 pressure ulcer sacral region. On 06/03/2025 at 11:06 a.m. an interview with S2Director of Nursing (DON) revealed Resident #50 should have been on Enhanced Barrier Precautions related to his wounds. S2DON confirmed the facility did not implement their enhanced barrier precautions policy by failing to place signage and PPE near the door of Resident # 50's room. Resident #57 On 06/02/2025 at 9:09 a.m. and 06/03/3035 at 8:55 a.m., observation of Resident #57 revealed a dressing on his right foot. Observations of Resident #57's door revealed there was no signage indicating EBP. Further observations revealed there was no PPE available outside Resident #57's room. Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses that included but not limited to the following: osteomyelitis ankle and foot acquired absence of right great toe, type 2 diabetes mellitus with diabetic neuropathy, and type 2 diabetes mellitus with diabetic neuropathy. On 06/03/2025 at 10:50 a.m., an observation conducted with S2DON outside Resident # 57's room revealed there was no signage indicating Resident #57 was on EBPs. Further observation revealed there was no PPE available outside Resident #57's room. S2 DON revealed Resident #57 should be on EBP related to right foot wound. S2DON confirmed the facility did not implement their enhanced barrier precautions policy by failing to place signage and PPE near the door of Resident # 57's room.

Based on observations, record reviews, and interviews, the facility failed to ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for 2 (#73 and #23) of 3 (#73, #23, and #13) residents reviewed for positioning and mobility. Findings: Resident #23 Record review revealed Resident # 23 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to embolism of unspecified cerebellar artery, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and reduced mobility. Review of most recent quarterly Minimum Data Set (MDS) data revealed as Brief Interview of Mental Status (BIMS) score of 9 which indicated moderate cognitive impairment. Review of June 2025 active orders revealed an order for a hand roll to right hand for contracture management and remove every shift to wash and dry thoroughly inside hand and replace. Every shift- day shift, evening shift, night shift. On 06/02/2025 at 4:36 p.m., Resident #23 was observed in bed with a contracture noted to right hand. No hand roll or brace was observed to the right hand. On 06/03/2025 at 3:21 p.m., Resident #23 was observed in a wheelchair at the bedside. His right hand was contracted with no hand roll in place. Resident #23 reported he does not have a hand roll for his right hand and staff does not place anything in his right hand. On 06/04/2025 at 8:12 a.m., Resident #23 was observed in the dining room eating breakfast with assistance. Right hand did not have a hand roll in place. Interview with S3 Licensed Practical Nurse (LPN) confirmed Resident # 23 should have a hand roll in place at all times other than when the hand is being cleaned. On 06/04/2025 at 9:08 a.m., an interview with S2Director of Nursing (DON) confirmed a hand roll to the right hand of resident #23 should have been in place as ordered. Resident #73 Review of the medical record for Resident #73 revealed an admission date of 07/10/2024 with diagnoses that included cerebral infarction, aphasia, right hand contracture, type 2 diabetes mellitus, and flaccid hemiplegia of the right dominant side. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed no Brief Interview for Mental Status score due to Resident #73's communication barriers. The MDS documented that Resident #73 was rarely or never able to be understood or understand others. Resident #73 was always incontinent of bowel and bladder and totally dependent upon staff for care. Review of the current Physician's Orders revealed no orders related to Resident #73's right hand contracture. Review of the Occupational Therapy Discharge summary dated [DATE] documented the presence of a right hand contracture, left hand grip strength within functional limits, and a goal of the use of a right hand orthotic. On 06/03/2025 at 2:26 p.m., it was observed that Resident #73 did not have an orthotic device in place to the right hand. On 06/04/2025 at 8:23 a.m., it was noted that Resident #73 did not have an orthotic device in place to the right hand. On 06/03/2025 at 2:08 p.m., an interview was conducted with S5Occupational Therapist (OT). S5OT confirmed that a recommendation was made for a palm protector to be placed in Resident #73's right hand. S5OT advised that once a recommendation is made, the nursing department is to ensure that the recommendation is implemented. On 06/04/2025 at 8:26 a.m., an interview was conducted with S3Licensed Practical Nurse (LPN) who advised that she has not noted a palm protector in place to Resident #73's right hand. On 06/04/2025 at 8:37 a.m., an interview was conducted with S6Certified Nursing Assistant (CNA) who advised that there is no order in place related to the use of a palm protector to the right hand. On 06/04/2025 at 8:43 a.m., an interview was conducted with S2Director of Nursing (DON) who confirmed that therapy recommendations are to be entered by the nursing department. S2DON was informed that the therapy recommendation for Resident #73 was not entered or implemented.

Based on record review and interview, the facility failed to electronically transmit encoded, accurate and complete Minimum Data Set (MDS) data to Centers for Medicare and Medicaid (CMS) in a timely manner for 2 (#30,#79) of 2 (#30, #79) residents reviewed for the completion of a 14 day discharge assessment. Findings: Record review revealed Resident #30 was admitted to the facility on [DATE] and discharged on 01/25/2025. The discharge assessment for 01/25/2025 was noted as being in process and had not been transmitted. Record review revealed Resident #79 was admitted to the facility on [DATE] and discharged on 01/03/2025. A discharge assessment for 01/03/2025 had not been completed therefore a discharge assessment had not been transmitted within 14 days. On 06/04/25 at 12:33 p.m., an interview with S7MDS coordinator confirmed Resident #30 was discharged on 01/25/2025 and Resident #79 was discharged on 01/03/2025. The discharge assessments had not been transmitted within 14 days of discharge for Resident #30 or Resident #79.

Based on observations, record reviews, and interviews, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice by not having signage on the outside of the residents' room door to indicate oxygen was in use for 2 (#13, #60) of 2 (#13, #60) residents reviewed for oxygen. Findings: Review of the facility's Oxygen Administration policy and procedure, revised January 2025, revealed the following, in part: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the Procedure 2. Place an Oxygen in Use sign in a designated place outside resident room. Resident #13 Review of the medical record for Resident #13 revealed an admission date of 05/09/2025 with diagnoses that included the following: chronic obstructive pulmonary disease, major depressive disorder, fracture of unspecified part of left clavicle, subsequent encounter for fracture with routine healing, displaced intertrochanteric fracture of left femur, osteoporosis without current pathological fracture, bipolar disorder, and heart failure. Review of the admission Minimum Data Set assessment (MDS) dated [DATE] revealed the resident has a Brief Interview for Mental Status (BIMS) score of 14, which indicates the resident is cognitively aware and able to make daily decisions. Further review revealed the resident needs assistance with all activities of daily living. Review of the physician's orders dated June 2025 revealed administer continuous oxygen at 2 liters per nasal cannula. Review of the current plan of care for Resident #13 revealed the resident had oxygen therapy related to ineffective gas exchange, respiratory illness, give medications as ordered by the physician, and observe for signs and symptoms of respiratory distress. On 06/02/2025 at 9:20 a.m. and 06/03/2025 at 12:50 p.m., observations of Resident #13 revealed she was in the bed and received oxygen at 2 liters per nasal cannula. Observations of the outside of the resident's door revealed there was no sign to indicate the resident received oxygen therapy. On 06/04/2025 at 9:25 a.m. observation of the outside of resident #13's door with S4Licensed Practial Nurse (LPN) revealed there was no signage to indicate the resident was on oxygen. On 06/04/2025 at 1:30 p.m. S2Director of Nurses (DON) confirmed the signage for oxygen use was not on the outside of Resident #13's room. Resident #60 Review of the medical record for sampled Resident #60 revealed an admission date of 03/28/2025 with diagnoses of acute and chronic respiratory failure, chronic obstructive pulmonary disease, interstitial pulmonary disease, hypertensive heart disease with heart failure, and chronic kidney disease, stage three. Review of the physician's orders dated June 2025 revealed administer continuous oxygen at 4 Liters per nasal cannula. Review of the admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 which indicates the resident is independently cognitively aware and able to make daily decisions. Review of the current care plan for Resident #60 revealed the resident had oxygen therapy related to ineffective gas exchange, respiratory illness, give medications as ordered by the physician, and observe for signs and symptoms of respiratory distress. On 06/02/2025 at 9:25 a.m. and 06/03/2024 at 12:55 p.m., observations of Resident #60 revealed she was in the bed and received oxygen at 4 Liters per nasal cannula. Observations of the outside of the resident's door revealed there was no sign to indicate the resident received oxygen therapy. On 06/04/2025 at 9:20 a.m. observation of the outside of resident #60's door with S4LPN revealed there was no signage to indicate the resident was on oxygen. On 06/04/2025 at 1:30 p.m.,S2DON confirmed the signage for oxygen use was not on the outside of Resident #60's room and it should have been.

Based on observation, record review, and interviews, the facility failed to ensure the resident was treated with dignity and respect for 1 (#2) of 1 (#2) sampled residents who complained of a long call light response. The facility failed to ensure resident #2's call light was answered in a timely manner, after the resident had requested assistance from staff on 08/11/2024. Findings: Review of the medical record revealed resident #2 was admitted to the facility on [DATE] with diagnoses including a colostomy. Further review revealed that resident #2 had a documented brief interview for mental status score of 14. A score of 13-15 indicated that resident #2 was cognitively intact with daily decision making skills. On 08/12/2024 at 10:23 a.m., an interview with resident #2 revealed he had used his call light three times on 08/11/2024 and requested staff assistance with the emptying of his colostomy bag. Review of the [NAME]-Care Report (a reporting system by which the facility obtained all nurse call activity) revealed a maximum response time of 32:34 (thirty two minutes and 34 seconds) on 08/11/2024. On 08/14/2024 at 11:56 a.m., S1Administrator was notified of resident #2's complaint of a long call light response on 08/11/2024. After reviewing the [NAME]-Care Report with S1Administrator, she confirmed a maximum wait time of 32:34 was too long of a response time.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing and to prevent infection for 1(#3) of 2 (#1 and #3) sampled residents reviewed for pressure ulcers. The facility failed as evidence by resident #3 not having a dressing covering her sacral wound, in accordance with the physician's orders. Findings: Review of the medical record revealed resident #3 was admitted to the facility on [DATE]. Resident #3's documented diagnoses included obesity, cerebral infarction, and an unstageable pressure ulcer of the sacrum. Review of the medical record revealed a physician's order dated 07/11/2024. Review of the order revealed that staff were to cleanse resident #3's sacral wound with wound cleanser, pat the wound dry, and apply Calcium Alginate to the wound bed. Further review of the order revealed to cover the wound with a silicone dressing, to change the dressing every other day and as needed. Upon entering resident #3's room on 08/12/2024 at 11:00 a.m., S4Certified Nursing Assistant (CNA) was observed repositioning the resident in bed. During the observation, a visual inspection of resident #3's skin with S4CNA revealed resident #3 had an open wound to her sacrum. Observation revealed there was no dressing covering the wound, therefore leaving it opened and exposed with feces inside of the wound bed. S4CNA revealed that she had bathed resident #3 at 9:30 a.m. and observed that resident #3 did not have a dressing in place at that time. She revealed that she had notified the nurse (referring to S5Licensed Practical Nurse) (LPN) of resident #3 not having a dressing on her sacrum. On 08/12/2024 at 11:28 a.m., S3Wound Care Nurse (WCN) was notified of the finding and the interview with S4CNA. S3WCN revealed that she was not aware of resident #3's sacral dressing being off. She confirmed that resident #3 should have had a dressing in place to cover the sacral pressure ulcer. On 08/12/2024 at 11:30 a.m., S1Administrator and S2Assistant Administrator were notified of the above findings. On 08/12/2024 at 11:35 a.m., S5LPN was notified of the interview with S4CNA. S5LPN revealed that she did not recall anyone notifying her of resident #3's sacral dressing being off.

Based on observation and interview, the facility failed to maintain all mechanical equipment in a safe operating condition by having a large buildup of grease in the deep fryer. Findings: On 05/28/2024 at approximately 12:30 p.m., an observation of the kitchen revealed one large gas deep fryer. Further observation revealed the deep fryer had a lower compartment that housed the fryer's internal components. Observation of the lower compartment revealed a large, thick buildup of grease and grease splatters throughout the compartment and in direct contact with the fryer's internal components. S4Dietary Manager was present during the observation and confirmed the deep fryer was not in safe working condition and needed to be cleaned. On 05/30/2024 at 3:02 p.m., S1Administrator and S9Administrator-In-Training were notified of the observation of the deep fryer.

Based on observations and interviews, the facility failed to prepare and distribute food in accordance with professional standards for food service safety. The facility failed to ensure 1) that all staff operating the three compartment sink and dishwasher could test for the proper amount of sanitizer, and 2) contamniated serving utensils did not come in contact with the food on the steam table. According to interview with S4Dietary Manager (S4DM), there were 72 residents who received meals served from the kitchen. Findings: During a tour of the kitchen with S4DM on 05/28/2024 at 8:35 a.m., an observation revealed S5Dietary Worker in the dishwashing room. She was observed placing dishes in the three compartment sink. Further observation revealed water in all three individual compartments of the sink. S5Dietary Worker removed a test strip from the Auto-Chlor (Test strips used to test for chemical sanitizer levels) bottle. S5Dietary Worker dipped the test strip into the water of each of the compartments. S5Dietary Worker revealed that she was checking the water with the test strip and if it (referring to the test strip) turned purple, the water was warm enough. Observation of the test strip revealed there was no color change to indicate the sanitizer level. S6Dietary Worker was present in the dishwashing room and was observed preparing dishware for the dishwashing machine. S6Dietary Worker revealed that when she used the strips (Referring to test strips used to check the sanitizer level), she was to check the temperature of the water. She pointed to one of the dishwasher's hose that was located at the top of the dishwashing machine and revealed she could see the water that contained the sanitizer coming out of the hose. S6Dietary Worker confirmed that she did not check the machine's water during the rinse cycle to determine the amount of sanitizer in the water. S4DM was present in dishwashing room during the observations and interviews with S5Dietary Worker and S6Dietary Work and confirmed the dietary staff needed further training on the testing for sanitation of the three compartment sink and the dishwashing machine. During an observation of the lunch service on 05/28/2024 at 11:45 a.m., S5Dietary Worker was observed using a pair of tongs to retrieve sliced turkey from a pan that was located on the steam table. When attempting to pick the meat up, she dropped the tongs in the pan with the handle submerged in the gravy and in direct contact with the sliced turkey. S5Dietary Worker had held the tongs with her bare hands. S5Dietary Worker picked the tongs up from the gravy with the same bare hands and continued with the meal service. Further observation revealed S7Dietary Worker retrieved the rolls from a different pan on the steam table. After handling the tongs with her bare hands, S7Dietary Worker was observed placing the tongs including the handles, on top of the rolls. The handle of the tongs were on top of and in direct contact with the rolls. S4DM was present in the kitchen during the meal service and was notified of the observations and interviews with S5Dietary Worker and S7Dietary Worker. S4DM confirmed that S5Dietary Worker should have replaced the dropped tongs and S7Dietary Worker should not have placed the tong handles on top of an in direct contact with the rolls. On 05/30/2024 at 3:02 p.m., S1Administrator and S9Administrator-In-Training were notified of the observations during the lunch meal service.

Based on observations, interview and record reviews, the facility failed to honor and accommodate food preferences for 5 (#4, #17, #22, #39, #47) of 6 (#4, #6, #17, #22, #39, #47) residents investigated for dining concerns. The failed practice was evidenced by residents not being provided condiments with their meals. Findings: Resident #39 Record review revealed resident #39 had a quarterly Minimum Data Set (MDS) assessment completed on 05/03/2024. Section C (cognitive patterns) of the MDS revealed a Brief Interview of Mental Status (BIMS) was completed with a score of 13 which indicated she was cognitively intact. Further review of active physician orders for May 2024 revealed an order for resident #39 to receive a regular diet. On 05/28/2024 at 09:18 a.m., observation revealed resident #39 was served pancakes with no syrup. During an interview at this time with resident # 39, she reported she was agitated and she stated enough was enough. Resident # 39 complained about the kitchen staff rarely providing the necessary condiments to go with the food served. Resident # 39 reported she had to ask for condiments the majority of the times when she ate meals in her room. Resident #17 Record review revealed a quarterly MDS assessment data was collected on 04/19/2024. Section C (cognitive patterns) revealed resident #17 had a BIMS score of 12 which indicated mild cognitive impairment and had the ability to make her wants and needs known. Further review of active physician orders for May 2024 revealed an order for resident #17 to receive a regular diet. On 05/28/2024 at 09:24 a.m., an observation and interview with resident #17 was conducted in her room as she was being served breakfast. She was served bacon and pancakes with no syrup. Resident #17 reported she wanted syrup with her pancakes and she frequently had to ask for condiments such as salt, pepper and ketchup because it was not provided on her meal tray. Resident #17 reported she normally ate in her room. Resident #4 Record review revealed resident #4 had a quarterly MDS assessment completed on 03/24/2024. Section C (cognitive patterns) of the MDS revealed a BIMS was completed with a score of 15 which indicated she was cognitively intact. Further review of active physician orders for May 2024 revealed an order for resident #4 to receive a regular renal diet. On 05/28/2024 at 09:27 a.m., an observation and interview was conducted in resident #4`s room. Resident #4 reported she never got condiments with her meals. Resident #47 Record review revealed resident #47 had a quarterly MDS assessment completed on 04/12/2024. Section C (cognitive patterns) of the MDS revealed a BIMS was completed with a score of 15 which indicated he was cognitively intact. Further review of active physician orders for resident #47 revealed an order for resident #47 to receive a regular diet with no concentrated sweets. On 05/30/2024 at 1:10 p.m., an interview was conducted with resident #47 in his room. Resident #47 was alert and oriented. He reported he was not served condiments with all of his meals served in his room. Resident #22 Record review revealed resident #22 had a quarterly MDS assessment completed on 03/01/2024. Section C (cognitive patterns) of the MDS revealed a BIMS score of 15 which indicated she was cognitively intact. Further review of active physician orders revealed an order for resident #22 to receive a regular diet. On 05/30/2024 at 1:00 p.m., an interview was conducted with resident #22 in her room. Resident #22 was alert and oriented. Resident #22 reported condiments were not always on her tray when meals were served. Resident # 22 reported she occasionally ate meals in her room and it was a problem if she had to wait for condiments to be delivered after her food was dropped off in her room. On 05/30/2024 at 11:30 a.m. an interview was conducted with S2 Director of Nurses (DON). S2DON confirmed all residents should have been served condiments with their meals in accordance with their diet ordered.

Based on record reviews and interviews, the facility failed to ensure resident's drug regimens were free from unnecessary psychotropic medications for 2 (#24 and #219) of 5 (#12, #16, #24, #54, #219) residents reviewed for unnecessary medications. The facility failed to ensure 1) lab work was obtained for resident #24 while receiving a psychotropic medication and 2) a psychotropic medication was used only when there was an acceptable diagnosis documented in the medical record for resident #219. Findings: Resident #24 Review of the medical record for resident #24 revealed an admitted [DATE] with diagnoses including esophageal obstruction, diabetes mellitus, depression, bipolar, psychosis, and dementia. Review of the May 2024 physician orders revealed an order dated 05/01/2022 for Seroquel (antipsychotic) 25 milligrams (mg) to be administered by mouth at hour of sleep. Further review of the May 2024 orders revealed an order dated 10/26/2022 to obtain Glycated Hemoglobin (HbA1c) annually in February. Review of the current care plan revealed antipsychotic drug use related to diagnosis of bipolar and to obtain lab work as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) which indicated intact cognitive skills for daily decision making. Review of the medical record revealed no documented evidence of a HbA1c obtained in February 2024 as ordered. Interview with S2Director of Nursing (DON) on 05/29/2024 at 3:00 p.m. confirmed there was no documentation of the HbA1c obtained for resident #24 in February 2024. Interview with S2DON on 05/30/2024 at 1:10 p.m. confirmed the facility should obtain the HbA1c when a resident was administered Seroquel. 19256 Resident #219 Review of the medical record for resident #219 revealed the resident was admitted on [DATE] with diagnoses of hypertension, insomnia, restless legs syndrome, atherosclerotic heart disease, osteoarthritis, neuropathy, and osteoporosis. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 10 on the Brief Interview for Mental Status (BIMS) which indicated moderately impaired cognitive skills for daily decision making. Review of the physician orders for May 2024 revealed an order dated 05/10/2024 for Geodon (antipsychotic) 20 mg at bedtime daily. Review of the record revealed the following care plan: antipsychotic drug use, at risk for side effects - takes Geodon. An interview with S8Assistant Director of Nursing on 05/30/2024 at 9:50 a.m. confirmed the resident did not have a diagnosis documented in the clinical record for receiving Geodon. An interview with S2Director of Nursing on 05/30/2024 at 1:10 p.m. confirmed the resident did not have an acceptable diagnosis documented in the clinical record for receiving the antipsychotic medication, Geodon.

Based on record review, observations and interviews the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene for 1 (#5) of 2 (#5, and #14) residents investigated for assistance with activities of daily living (ADL). The failed practice was evidenced by resident #5 having long and dirty fingernails. Findings: Resident #5 Record review revealed resident #5 was admitted to the facility on [DATE] with diagnoses that included hypertension, chronic obstructive pulmonary disease, seizure disorder, and congestive heart failure. Further review of the record revealed a Minimum Data Set (MDS) assessment completed on 04/05/2024. The assessment revealed resident #5 had a brief interview of mental status (BIMS) score of 15 which indicated he had no cognitive impairment. Further review of the MDS data, under section G - ADL assistance, revealed resident #5 required assistance with all activities of daily living with at least one person assistance. On 05/28/2024 at 2:52 p.m. an interview and observation with resident #5 revealed he had long fingernails with black grime observed underneath the nails. Resident #5 reported staff came by a couple of weeks ago and soaked his fingernails in warm water and reported they would be back to trim his nails but no one returned to trim his nails. Resident #5 reported he asked staff to cut them again on a different day but the person he asked never returned to trim his nails. On 05/29/2024 at 3:34 p.m., an observation of resident #5 revealed he had long fingernails with black grime observed underneath the nails. On 05/29/2024 at 10:20 a.m., an observation of resident #5 was conducted in his room with S3Licensed Practical Nurse (LPN). Observation revealed resident #5 had long fingernails with black grime observed underneath the nails. S3LPN confirmed resident #5 was in need of nail care. On 05/30/2024 at 11:32 a.m., S2Director of Nurses (DON) was informed of resident #5 having long dirty fingernails and S2DON agreed nail care should have been provided.

Based on observations, record reviews, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 (#1 and #2) of 2 (#1 and #2) residents observed during pericare. The failed practice was evidenced by staff not performing proper hand hygiene after providing pericare for residents #1 and #2. Findings: Resident #1 Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Resident #1's documented diagnoses included in part, bullous pemphigoid, long term (current) use of non-steroid anti-inflammatories (NSAID), contracture of muscle, multiple sites, age-related osteoporosis without current pathological fracture, abnormal posture, and a comminuted proximal humeral head fracture left. Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #1 had a brief interview for mental status score of 08. A score of 08-12 indicated that resident #1 had mild cognitive impairment with daily decision making. Review revealed Resident #1 required extensive assistance with one person physical assist with toilet use, dressing, personal hygiene, total dependence with one person assist with bathing, and Resident #1 had impairment to both the upper and lower extremities. During an observation of pericare on 10/31/2023 at 1:50 p.m., S6Certified Nursing Assistant (CNA) gathered the supplies that were needed for the pericare procedure for Resident #1. S6CNA donned a pair of clean disposable gloves and began cleaning resident #1's perineal area. Resident #1 was then repositioned on her right side. Observation revealed feces on the resident's buttocks. S6CNA continued with the pericare procedure. After completing the procedure, S6CNA retrieved a clean brief and place in on the Resident #1. S6CNA did not remove her dirty, contaminated gloves, and she did not perform hand hygiene after providing pericare for Resident #1. S6CNA placed a clean brief on Resident #1 while wearing the contaminated gloves. S6CNA then retrieved a large pillow from the end of the bed and repositioned Resident #1 by using the pillow. S6CNA was observed touching the resident's bed linens and body using the same pair of contaminated gloves worn during pericare. Resident #2 Review of the Resident t #2's medical record revealed the resident was admitted to the facility on [DATE]. The resident's documented diagnoses included in part, muscle wasting left upper arm, right upper arm, need for assistance with personal care, age-related osteoporosis with without current pathological fracture, bowel and urinary incontinence, and muscle weakness (generalized). Review of the Minimum Data Set, dated dated dated [DATE] revealed Resident #2 had a documented brief interview for mental status score of 03. A score of 00-07 indicated that Resident #2 was severely cognitively impaired with daily decision making. Further review revealed resident #2 required extensive assistance with two+ persons physical assist with bed mobility, extensive assistance with one person physical assist with dressing, and limited assistance with one person assist with personal hygiene. Review further revealed Resident #2 had impairment on one side of the upper and lower extremities. During an observation of pericare on 10/31/2023 at 1:30 p.m., S6CNA gathered the supplies needed for the pericare procedure for resident #2. S6CNA then donned a clean pair of disposable gloves and began to clean urine from Resident #2's perineal area and buttocks. After the pericare procedure was finished, S6CNA removed the resident's soiled brief. She then retrieved a clean brief from resident's bedside table while wearing the contaminated gloves and placed the brief on resident #2. S6CNA then retrieved a large pillow from the foot of resident #2's bed and used the pillow to reposition the resident's body. She then touched the Resident #2's clothing and bed linens using the same pair of dirty and contaminated gloves she had used to provide pericare for Resident #2. On 10/30/2023 at 3:30 p.m., S1Administrator, S2Administrator in Training (AIT), and S3 Director of Nursing (DON) were notified of the findings during the pericare procedures for Residents #1 and #2. S3DON confirmed that S6CNA did not perform pericare for resident #1 and resident #2 in a sanitary manner that would help prevent cross contamination.

Based on observations, record reviews and interviews, the facility failed to ensure that all alleged violations involving abuse or mistreatment are reported immediately to the administrator of the facility for 1 (#1) of 3 (#1, #2, and #3) residents who reported an allegation of alleged abuse. The facility failed to ensure an allegation of abuse related to Resident #1 was reported immediately to the administrator by an employee that was made aware of the allegation of alleged abuse. Findings: Review of resident #1's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, bullous pemphigoid, long term (current) use of non-steroid anti-inflammatories (NSAID), contracture of muscle, multiple sites, age-related osteoporosis without current pathological fracture, and abnormal posture. Review of the quarterly minimum data set (MDS), dated [DATE], revealed Resident #1 had a brief interview for mental status score of 08. A score of 8-12 indicated that resident #1 had mild cognitive impairment with daily decision making. Further review of the (MDS) revealed Resident #1 required extensive assistance with one person physical assist with toilet use, dressing, personal hygiene, and total dependence with one person assist with bathing. Further review also revealed resident #1 had impairment to both her upper and lower extremities. An Observation on 10/30/2023 at 9:30 a.m., revealed Resident #1 lying in bed, in her room. Further observation revealed resident #1's arms and hands were contracted. During an interview, Resident #1, reported that S5CNA/Former Employee had broken her arm. Resident #1 reported that S5CNA/Former Employee had been rough with her and she had pulled on her left arm when getting her dressed. Resident #1 further reported that she (Resident #1) had pain in her left arm after S5CNA/Former Employee had pulled on her left arm. During a telephone interview with S5CNA/Former Employee on 10/30/2023 at 1:05 p.m., S5CNA/Former Employee reported that upon her return to work on a Wednesday, she (S5CNA/Former Employee) could not recall the exact date, Resident #1 had reported that she (S5CNA/Former Employee) had broken her left arm and left leg. S5CNA/Former Employee revealed that she reported Resident #1's complaint to S4LPN. During an interview with S4LPN on 10/30/2023 at 2:23 p.m., S4LPN revealed that on Wednesday, 10/11/2023, S5CNA/Former Employee had reported to her (S4LPN) that the resident #1 had complained of pain in her arm. S4LPN reported that she had asked resident #1 if she was hurting and resident #1 reported yes, that her arm was hurting, but did not say which arm. S4LPN further revealed that resident #1 had reported to her (S4LPN) that S5CNA/Former Employee had had been rough with resident #1, pulled resident #1's arm, and that resident #1 had reported that she had been having pain in her arm since the incident had occurred. S4LPN confirmed that she did not immediately report to S1Administrator the allegation of alleged abuse involving resident #1 and S5CNA/Former Employee, upon S4LPN first becoming aware of the allegation on 10/11/2023. On 10/31/2023 at 3:15 p.m., S1Administrator was notified of the findings. S1Administrator confirmed S4LPN should have immediately notify her (S1Administrator) on 10/11/2023 when S4LPN first became aware of the allegation of alleged abuse involving Resident #1 and S5CNA/Former Employee.

Based on record review, observations, and interviews, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#52) of 3 (#52, #54, and #70) residents reviewed for nutrition. Resident #52 was not assisted with his meals in a timely manner while other residents at his table were provided their meals. Findings: Review of the medical record for resident #52 revealed the resident was admitted on [DATE] with diagnoses of extrapyramidal and movement disorder, anxiety disorder, reduced mobility, lack coordination, muscle weakness, right wrist drop, need for assistance with personal care, cognitive communication deficit, Huntington's disease, and encephalopathy. Review of the Minimum Data Set, dated dated dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance with eating, bed mobility, transfer, dressing, toilet use and personal hygiene. Observation on 05/15/2023 at 12:02 p.m. revealed resident #52, resident #63, resident #29 and resident #62 were sitting at the table. S5CNA (Certified Nursing Assistant) was assisting resident #63 with eating, S6Certified Nursing Assistant was assisting resident #29 with eating and resident #62 was eating her lunch meal. Resident #52 was sitting at the table with no food or drink. Observation on 05/15/2023 at 12:18 p.m. revealed S4Licensed Practical Nurse started to assist resident #52 with eating. Observation on 05/16/2023 at 8:02 a.m. revealed resident #52, resident #29, and resident #54 were sitting at the table. S5CNA was assisting resident #29 with eating and resident #54 was eating. Resident #52 was sitting at the table without with his meal. An interview on 05/17/2023 at 1:15 p.m. with S4LPN (Licensed Practical Nurse) confirmed on Monday, 05/15/2023, and Tuesday, 05/16/2023, resident #52 waited without his meal at the table while the other residents were eating. S4LPN confirmed resident #52 should have been provided his meal at the same time as the other residents at the table. An interview on 05/17/2023 at 1:55 p.m. with S2Director of Nursing confirmed resident #52 should be provided his meal at the same time as the other residents at his table.