Every finding on record at Citizens Care and Rehabilitation Center of Frederi

Based on interviews and record review, it was determined that the facility failed to ensure that residents received their meals at a safe and palatable temperature. This deficient practice has the potential to affect all residents. During an initial tour of the facility on 3/16/26, several residents reported that the facility's food was typically cold for hot foods. A review of the facility's food service temperature logs for January 2026 was conducted on 3/17/26 at 2:02 PM. The review revealed missing internal cooking temperatures for: lunch and dinner on 1/4/26, lunch and dinner on 1/5/26, dinner on 1/6/26, lunch and dinner on 1/7/26, lunch and dinner on 1/8/26, lunch and dinner on 1/9/26, lunch and dinner on 1/10/26, lunch and dinner on 1/11/26, lunch and dinner on 1/12/26, lunch and dinner on 1/13/26, lunch and dinner on 1/14/26, lunch and dinner on 1/15/26, lunch and dinner on 1/16/26, dinner on 1/19/26, dinner on 1/20/26, dinner on 1/21/26, dinner on 1/22/26, lunch and dinner on 1/23/26, lunch and dinner on 1/24/26, lunch and dinner on 1/25/26, lunch and dinner on 1/26/26, dinner on 1/27/26, dinner on 1/28/26, and breakfast, lunch, and dinner on 1/30/26, as well as lunch and dinner on 1/31/26.The review also lacked documentation for the holding and serving temperatures for breakfast on 1/8/26, 1/9/26, 1/15/26, and 1/16/26. A random review of the holding temperatures for Lunch and Dinner on the Memory Care, Rehab, 2nd, and 3rd floor units showed the following: seasoned potato wedges at 129 degrees F on 2/3/26; lemon butter angel hair at 125 degrees F on 2/6/26; mashed potatoes at 115 degrees F and chicken alfredo with broccoli at 126 degrees F on 2/7/26; grilled ham and cheese sandwich at 119 degrees F; no recorded holding temperature for dinner on 2/15/26; lasagna at 120 degrees F on 2/17/26; beef strongnoff at 128 degrees F & Egg noodles at 133 degrees F on 2/21/26; sweet and spicy glazed chicken stir-fry at 117 degrees F on 2/22/26; and fish sticks at 129 degrees F on 2/26/26.A review of the facility's policy titled food safety management system noted that cold foods must be held and served at a temperature of 40 F or below and Hot foods must be held and served at a temperature of 140 F or above. However, an earlier review revealed that some hot foods were served below 135 F.During an interview on 3/17/26 at 2:32 PM, staff #17, the dietary general manager, stated that the cooks were expected to check internal food temperatures to ensure safety, and that servers were also responsible for checking the holding temperatures of each meal before service. If the reading was below the acceptable temperature, they were to reheat the food before serving it to residents. Staff #17 confirmed that holding and serving temperatures were missing from the log for some days.

Based on observations, record reviews, and interviews, it was determined that the facility failed to serve residents meals according to a predetermined menu that reflected their preferences. This was evident in 2 out of 3 dining observations during the survey. The findings include:1)While observing the second-floor unit tray line on 3/18/26 at 11:51 AM, the surveyor requested a test tray. The tray contained a meal ticket for Resident #38, which listed the following food items to be served: pureed bread, pureed mandarin oranges, magic cup (a fortified nutritional frozen dessert designed for individuals needing extra calories and protein), pureed Salisbury steak, gravy, cheddar mashed potatoes, and pureed summer squash and carrot medley. However, ongoing observation did not reveal that Resident #38's tray contained pureed bread, pureed mandarin oranges, and a magic cup. In an interview with the Dietary General Manager on 3/18/26 at 12:51 PM, he reported that the facility was out of Magic Cup, and it was replaced with regular ice cream for the Resident. During a subsequent interview with the Registered dietitian on 3/18/26 at 1:36 PM, she reported that Resident #38 was to receive a magic cup during lunch for malnutrition. She added that it had more calories than ice cream and expected it to be provided to the Resident daily at lunch.2) A breakfast observation on 3/19/26 at 8:17 AM on the 2nd floor, Unit showed Resident #5 eating breakfast in his/her room. On the Resident's meal tray was a ticket listing all the food items: Smart Balance buttery spread, double chocolate chip muffin, fresh banana, cranberry juice, orange juice, and scrambled eggs.However, continued observation failed to show that Resident #5's tray included a double-chocolate chip muffin and a fresh banana. Staff #19, a speech therapist, was in the resident's room and confirmed that resident #5 did not receive a fresh banana with his/her breakfast tray. The double chocolate chip muffin was replaced with a plain muffin.3) An observation of breakfast on 3/19/26 at 8:25 AM included Resident #114, eating in his/her room. The observation noted from the Resident's meal ticket was that s/he was to receive grits, Smart Balance buttery spread, orange juice, pancakes, and turkey sausage. However, the observation did not show that Resident #114 received grits on his/her tray. In an interview on 3/19/26 at 8:49 AM, staff #19 confirmed that Resident #114 was missing grits from his/her breakfast tray.

Based on observation, medical record review, and interview it was determined that the facility failed to maintain a medication error rate of less than 5%. This was based on 2 errors out of 32 opportunities for error during the medication observation task and involved 2 (Resident #179 and #53) out of the 3 resident's observed. The findings include: 1) On 3/19/26 at 9:14 AM surveyor observed nurse #12 prepare and administer medications to Resident #179. Several of the medications prepared were packaged in a sealed white bag which included the name, dosage and quantity of the medications in the bag. Additionally, each of the medications in the white bag were individually packed with identifying information. The nurse proceeded to pop the pills out of the individual containers into a medicine cup. Surveyor retained the white bag and the individual pill containers after the nurse was finished with them and prior to disposal. During the observation Nurse #12 reported Allopurinol 100 mg was one of the medications. Prior to entering the resident's room surveyor and the nurse counted the number of pills in the cup. The total number of pills was 14, which included 13 different medications, one of which the dosage required two pills. Surveyor noted at this time that one of the tablets was only half a pill. Nurse #12 was not sure which medication was the half a tablet, indicating she had not noticed as she was popping them out of the packaging. After administering the medication to the resident Nurse #12 signed off on the Medication Administration Record that 13 medications were administered, including Allopurinol 100 mg. After the observation, review of Resident #179's medical record revealed the resident had an order, in effect from 3/12/26 until it was discontinued on 3/18/26, for Allopurinol Oral Tablet 100 mg Give 0.5 tablet by mouth one time a day. This order indicated that staff would administer a half tablet of this medication. Further review, of both the white bag and the individual package of the Allopurinol, revealed written underneath Allopurinol TAB 100 MG was (0.50x100MG=50 MG). Thus, indicating this was the half tablet observed during the medication pass. Further review of the medical record revealed a new order, dated 3/18/26 for Allopurinol Oral Tablet 100 mg give 1 tablet by mouth one time a day. On 3/19/26 at 10:42 AM after reviewing the packaging with the surveyor, Nurse #12 confirmed the Allopurinol was the half tab and that she gave 50 mg. After confirming the new order was for Allopurinol 100 mg Nurse #12 indicated she would give the resident another 50 mg to give the full dose. On 3/19/26 at 11:00 AM surveyor provided the packaging of the Allopurinol to the Assistant Director of Nursing (ADON #15) and asked what the dosage was. The ADON stated: 100 mg. Surveyor then asked the ADON to read the packaging again, at which time the ADON stated: 50 mg. Surveyor then reviewed the medication error related to the wrong dose being administered due to recent change in the order to 100 mg. 2) On 3/20/26 at 8:21 AM surveyor observed Nurse #13 prepare and administer medication to Resident #53. Nurse #13 accessed a container of Reguloid powder and proceeded to use a small plastic spoon to obtain one spoonful of the powder which was placed in a small drink cup. When surveyor asked how much powder was being used, Nurse #13 responded, one teaspoon. Water was added to the powder, and the nurse reported it was 120 ml of water. The nurse administered the Reguloid to the resident. Reguloid is psyilium fiber used to treat constipation. Metamucil is also psyilium fiber used to treat constipation. After the observation surveyor reviewed resident #53's medical record and found an order for Metamucil give 1 Tablespoon by mouth one time a day for constipation. There are three teaspoons in a tablespoon. On 3/20/26 at 11:09 AM surveyor asked ADON #15 how they expect staff to measure out a powder. ADON indicated she would need to check on that and would get back to the surveyor. On 3/20/26 at 11:42 AM the ADON reported that staff should be using the medicine cup to measure powders. Surveyor reviewed the concern that the nurse did not use a measuring cup and that the nurse had reported he was giving a teaspoon, but the order is for a tablespoon. The ADON reported she had spoken with Nurse #13 and was aware that the nurse did not use the measuring cup. On 3/20/26 at 1:46 PM: Nurse #13 acknowledged that he only gave a teaspoon rather than a tablespoon and stated, I misread the order.

Based on interviews and record reviews, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADLs) received showers. This was evident for 1 (Resident #2) of 1 resident reviewed for ADLs. The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to collect information on each Resident's strengths and needs. This information informs Resident care planning decisions.An interview with Resident #2 on 3/17/26 at 7:58 AM indicated that there were a few showers, and they did not happen regularly. A review of Resident #2's MDS assessment dated [DATE] indicated that the Resident was completely dependent on staff for assistance with showers. A further review of the shower schedule for the unit where Resident #2 lived showed that he/she was scheduled for 2 showers per week, totaling 8 showers per month.Further review of the GNA (Geriatric Nurse Assistant) shower documentation for Resident #2 from January 1 to January 23, 2026, and from February 1 to February 28, 2026, was completed. The review revealed that between January 1-23, 2026, Resident #2 received four partial baths (washing a resident in bed with a basin of water, soap, and a washcloth without washing the hair and usually focusing on cleaning the face, underarms, hands, and perineal area) on days he/she was scheduled for showers. Additionally, three partial baths were recorded in February. The review did not show any evidence that Resident #2 received showers in January or February 2026.During an interview on 3/20/26 at 10:32 AM, staff #9, a Unit manager, reviewed Resident #2's GNA shower documentation for January 1-23, 2026, and February 1-28, 2026, with the surveyor. The interview lacked supporting evidence that Resident #2 received showers on the days she was scheduled to have them.

Based on record review, observation and interviews, it was determined that the facility failed to ensure medical orders were put in correctly and the nurses documented accurate administration of oxygen use. This was evident for 1 (Resident #15) of 5 resident reviewed for respiratory care. The findings include:Resident #15 was admitted into the facility in late 2019. Current diagnosis included but was not limited to respiratory failure with hypoxia.Hypoxia is a critical condition where body tissues are deprived of adequate oxygen, causing symptoms like shortness of breath, confusion, headaches, and rapid heart rate. Treatment involves oxygen therapy and addressing the underlying cause.On 3/16/26 at 11:46 AM, Resident #15 was observed sitting on the wheelchair watching TV in his/her room. Oxygen was on flowing at a rate of 2 L/min connected to a nasal cannula. However, the nasal cannula was not on the resident and was observed coiled up on the resident's bed.A review of Resident #15's medical record was conducted on 3/17/26 at 3:21 PM. The review revealed the order for oxygen to be administered continuously at 2 l/min every shift with a start date of 12/30/25. The review also revealed interventions in the care plan for oxygen to be administered 2 L/min continuously at bedtime initiated on 9/24/25, and as needed related to shortness of breath that was initiated on 6/29/20. There was no documentation found in the care plan to indicate that oxygen was to be administered continuously every shift.Resident #15 was interviewed about his/her oxygen use on 3/17/26 at 3:30 PM. The resident answered, only at night, when asked when s/he puts on the nasal cannula for oxygen administration.On another observation of Resident #15 on 3/18/26 at 1:09 PM. The resident was sitting in room watching TV with no oxygen being administered. Immediately after the observation, Resident #15's administration record was reviewed and revealed that the day shift nurse (Nurse #10) had signed off the order that oxygen was administered continuously for day shift on 3/18/26.On 3/18/26 at 1:12 PM, Nurse #10 was interviewed regarding Resident #15's oxygen use. Nurse #10 stated, S/he's on 2 Liters of oxygen when in bed. During the day, s/he's not on oxygen. When asked about the resident's order for oxygen, he indicated he was not sure and would have to review it on the computer. Upon reviewing the resident's medical record, he confirmed that the order was for continuous administration and that he had signed this order for his shift. Nurse #10 stated, I guess I wasn't paying attention. He also reported that the resident goes around the unit with a wheelchair with no oxygen tank/no oxygen use.In an interview with the Assistant Director of Nursing (Staff #15) on 3/19/26 at 9:50 AM, the finding above was discussed and she indicated that it was already discussed with her by the nursing staff. Staff #15 reported that Resident #15 was hospitalized in December of 2025 and when the resident returned to the facility, the oxygen order was put in as continuous rather than as needed. The concern was discussed that nurses are signing the administration record for the oxygen as being administered continuously since 12/20/25 every shift but confirmed that the resident only utilized oxygen at bedtime. Staff #15 verbalized understanding and acknowledged the concern.

Based on record observations, record reviews and interviews, it was determined that the facility failed to ensure staff donned appropriate personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP). This was evident for 2 (Residents #121 and #75) of 7 residents reviewed for infection control and for 1 (Resident #116) of 2 residents reviewed for urinary catheters/UTI. The findings include:Enhanced Barrier Precautions are infection-control measures designed to decrease the spread of infections in nursing homes. They involve wearing gowns and gloves during high-contact resident care activities such as dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting for residents with infections or colonization of MDROs (multi-drug-resistant organisms), central lines, urinary catheters, feeding tubes, tracheostomies, or any skin openings that need dressing. A gastrostomy tube (G-tube) is a tube inserted into the stomach through an opening in the stomach wall. It is used to deliver medications, liquids, and liquid food. A tracheostomy is an opening (stoma) in the neck that connects directly to the trachea, providing an airway for patients with breathing problems. 1) A review of Resident #121's medical record showed that he/she had a G-tube feeding tube and a tracheostomy. An observation on 3/16/26 at 10:13 AM noted signage on Resident #121's door indicating the resident was on EBP, which required wearing gowns and gloves during high-contact resident care activities. Continued observation showed a cart filled with PPE supplies placed outside Resident #121's room. Further observation on 3/16/26 at 10:22 AM showed Staff #5, a registered nurse in Resident #121's room, providing oral hygiene to Resident #121. Staff #5 was noted with gloves; however, she did not wear a gown. The surveyor questioned the staff about the Resident's G-tube feeding at that time. Staff #5 reported that she had just turned it off and flushed it with water before providing oral care. Staff #5 confirmed that she did not wear a gown before performing either task for Resident #121. During an interview on 3/16/26 at 2:34 PM, staff #5 was asked what the EBP signage on Resident #121's door meant. She explained that it indicated to wear gloves, and since Resident #121 did not have an active infection, there was no need to wear gowns. 2) An observation on 3/16/26 at 12:06 PM showed signage on Resident #75's door that indicated that the Resident was on EBP precautions, which meant staff were required to wear gowns and gloves during high-contact Resident care activities. The observation also noted PPE in a cart at the door of the Resident's room. Continued observation noted staff #5 in Resident #75's room performing a dressing change on the Resident's G-Tube site. Staff #5 wore gloves and a mask, but the observation did not show that she wore a gown. In an interview on 3/16/26 at approximately 2:40 PM, staff #5 stated that she did not fully understand the meaning of the EBP signage on Resident #75's door. An interview with the Infection Preventionist Nurse on 3/19/26 at 7:24 AM indicated that all staff members were expected to know what EBP means and which PPE to wear when providing direct care activities to Residents, as training had been provided. 3) Resident #116 was admitted into the facility in mid-2025 with diagnosis that included urinary retention and encounter for fitting and adjustment of urinary device. During an observation of the resident on 3/16/26 at 11:34 AM, the resident indicated that s/he had a urinary catheter. A urine collection bag was secured on the resident's bed frame, supply of gloves was available by the doorway in the resident's room, but there were no available gowns in or outside the room. There was also no signage found to indicate that the resident was on EBP. A review of Resident #116's medical record on 3/17/26 at 9:20 AM revealed an order for EBP that was indicated for urinary catheter with a start date of 9/6/25. On 3/17/26 at 4:04 PM, A geriatric nursing assistant (GNA #7) was observed transferring Resident #116 and reported that she was about to give the resident a shower. GNA #7 was wearing a pair of gloves but did not have a gown on. The findings above were discussed with the nurse unit manager (Staff #6) on 3/17/26 at 4:10 PM. Staff #6 confirmed that Resident #116 was on EBP due to the use of urinary catheter and indicated that she would get the EBP signage and PPE supplies for the resident's room. On 3/17/26 at 4:13 PM, Staff #6 confirmed there was no signage found in or outside Resident #116's room. At this time, GNA #7 stepped out of the resident's room as she needed to get supplies for the resident. GNA #7 confirmed that she was not wearing a gown and indicated that it was because none was available. Staff #6 explained to GNA #7 that gowns and gloves are required to be worn when conducting high contact activities (including transferring, showering, and bathing) with the resident. The facility's infection preventionist nurse (Staff #11) was interviewed on 3/18/26 at 12:04 PM. Staff #11 reported the facility's process when a resident is put on EBP. She noted that other than the medical order and signage, the EBP information would also be in the Kardex (Kardex was explained as a GNA's tool to reference resident medical information including special precautions like EBP). She also reported that putting up the signage on the resident's door and installing the PPE supply station was primarily her responsibility, but the unit managers and weekend supervisors also had access to the materials needed. The concern was discussed with Staff #11 that Resident #116 did not have a signage for EBP, PPE supplies not readily available for staff to use, and GNA #7 was observed conducting high contact activities with the resident without the appropriate PPE. Staff #11 reported that GNA #7 was not a new employee and that a recent staff training on infection control including EBP was conducted in February 2026, where GNA #7 had also attended. Staff #11 indicated that she would reeducate GNA #7 when she returns to work and acknowledged the concern.

Based on observation and interviews, it was determined that the facility failed to treat residents with respect and dignity, as evidenced by failing to knock and request permission before entering residents' rooms. This was evident for 1 (Resident #75) of 1 resident reviewed for dignity. The findings include:An observation was made during an interview on 3/16/26 at 12:28 PM with the representative of Resident #75 in the resident's room. Staff #3 and #4, both nursing assistants, entered the resident's room with a lunch tray. The observation did not show that both staff members knocked or announced their entry, and waited for permission before entering the resident's room. In a later interview on 3/16/26 at 12:35 PM, both staff #3 and #4 confirmed they did not knock on Resident #75's door before entering and added that they should have done so. During an interview on 3/19/26 at 9:45 AM, the Assistant Director of Nursing stated that she expected her staff to knock on residents' doors or announce their presence before entering residents' rooms if their hands were full.

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure residents with or at risk of developing pressure ulcer/injuries receive appropriate services for treatment and prevention. This was evident for 2 (Resident #10 and #108) of 3 residents reviewed for pressure injuries. The findings include:1) Review of Resident #10's medical record revealed the resident was admitted to the facility in December 2025. The resident was seen weekly by a wound specialist for the treatment of pressure ulcers and skin tears. One of the pressure ulcers was a stage IV ulcer to the left heel. A stage IV pressure ulcer involves full-thickness skin and tissue loss with exposed or directly palpable muscle or bone in the ulcer. 1a)There was an order, in effect from 2/4/26 until it was discontinued on 2/18/26, to clean the left heel stage IV ulcer with normal saline, apply mupirocin ointment and cover with a dressing every day and evening shift. Mupirocin ointment is a medication that treats skin infections caused by bacteria. Review of the Medication Administration Record (MAR) for February 2026 revealed an area for staff to document that the dressing to the left heel was completed. Nursing staff documented a 9 on the following occasions when the dressing change was due:-2/6 evening-2/7 day-2/9 day-2/10 evening-2/11 day-2/15 evening Review of the chart codes revealed a '9' indicates 'other/see nurse notes', indicating the dressing change was not completed on those six occasions. Review of the nursing note failed to reveal documentation as to why the dressing changes were not performed on these occasions. These notes were just a repeat of the actual dressing change order. On 3/18/26 at 2:15 PM Nurse #14 confirmed that a '9' indicates the dressing change was not completed for some reason and to see the nursing notes. Surveyor reviewed the concern that the nursing notes just repeated the order. Nurse #14 then proceeded to check the nursing notes, then stated,you're right, just repeats the order, should have said why not completed. On 3/18/26 at 3:39 PM surveyor reviewed the above dates with the ADON #15 and that the corresponding notes just re-iterate the order, and that no documentation was found to indicate why the dressing change had not occurred on these occasions. As of time of survey exit on 3/20/26 at 4:00 PM no additional documentation was provided to indicate the dressing change was completed as ordered for the six occasions identified in February. 1b) On 3/18/26 review of Resident #10's medical record revealed the wound specialist saw the resident on 3/11/26. This note revealed that Bacterial Fluorescence Imaging showed bacteria in the periwound area of the left heel wound. The note included a recommendation for changing the dressing to alginate calcium with silver once daily and as needed. Silver has antibacterial properties. On 3/18/26 further review of the medical record revealed the current order, in effect since 2/18/26, for the left heel was to clean with normal saline, apply plurogel and cover with border dressing every day shift. Plurogel assists with maintaining a moist wound healing environment. Further review of the medical record failed to reveal documentation to indicate the 3/11/26 recommended change to the dressing order was implemented or addressed with the primary care physician. On 3/18/26 at 3:56 PM interview with Nurse #16 revealed that she attends rounds with the wound specialist. The wound specialist makes recommendations verbally, which Nurse #16 writes down, and then the wound specialist also puts the recommendations into her note. Nurse #16 reported that at the end of rounds she (Nurse #16) puts the orders into the system. Nurse #16 confirmed that what is written in the wound specialist note would be translated into an order. Surveyor then reviewed the 3/11/26 wound specialist note which included a recommendation that the dressing be changed to silver alginate, but review of the orders failed to reveal documentation to indicate the order was changed. Nurse #16 then asked,that's not [his/her] current order? And went on to state there were some problems with the wound specialist's notes last week and indicated that she missed the order change. On 3/20/26 at 3:20 PM surveyor reveiwed the concern with the ADON regarding the failure to ensure wound specialist orders were implemented. 2) Resident #108 had been Residing in the facility since 2009. Current diagnosis included but was not limited to dementia, hemiplegia and hemiparesis following a stroke affecting the left side. Hemiplegia is a severe form of paralysis affecting one side of the body while Hemiparesis is weakness or reduced movement on one side of the body. On 3/16/26 at 12:02 pm, Resident #108 was observed laying in bed equipped with an air mattress. A control box by the foot of the bed indicated that the air mattress was set to 4 bars for firmness with static pressure. On 3/17/26 at 9:32 AM, the resident was again observed in bed, and the air mattress setting remained the same. Resident #108's medical record was reviewed on 3/17/26 at 11:36 AM. The review revealed an assessment dated [DATE] that indicated the resident was at 'high risk' of developing pressure ulcer/injuries. The review also revealed the air mattress order that indicated the setting should be on 3 bars for firmness with alternating pressure on a 15-minute cycle. This order was scheduled every shift for the nurse to monitor for proper function and inflation. A subsequent review of Resident #108's medical record was conducted on 3/17/26 at 3:38 PM. The review revealed the order for proper function and inflation (that indicated the specific air mattress setting) was signed by the day shift nurse for 3/17/26. However, immediately after this review, on 3/17/26 at 3:39 PM, the resident was again observed in bed with the air mattress still set at 4 bars for firmness with static pressure. On 3/17/26 at 3:46 PM, the evening shift nurse (Nurse #8) confirmed the observation of Resident #108's air mattress setting and indicated that the bed previously had an audible alarm/beep, but she was not sure what was wrong with it. The findings were discussed with the Unit Manager (Staff #6) on 3/17/26 at 3:50 PM. A review of Resident #108's air mattress order was conducted with Staff #6 and she confirmed that it should be on alternating pressure at 3 bars for firmness. Staff #6 indicated that she wanted to see the control box herself and asked the surveyor to accompany her to the resident's room. On 3/17/26 at 3:55 PM, Nurse #8 was observed in Resident #108's room, in the process of changing the air mattress setting. As the mattress was set to the correct setting, the control box started to beep/alarm. Both Nurse #8 and Staff #6 confirmed that the mattress was holding air but did not know why it was beeping and indicated that may be the reason someone had changed the setting. The concern was discussed with Staff #6 that nurses are signing the order but failed to ensure the resident's air mattress was functioning and inflated appropriately. Staff #6 reported that she was putting in a maintenance request to check Resident #108's air mattress immediately.

Based on interview and review of facility reported incident (FRI) investigation documentation it was determined the facility failed to thoroughly investigate incidents of missing property, this was evident for 1 (Resident #1) of 2 residents reviewed for facility reported incidents. The findings include:On 0/14/25 at 1:23 PM, a review of facility reported incident #2613495 revealed on 8/28/25 at 3:00 PM, the resident's representative reported to facility staff that Resident #1 was missing an unknown amount of money. During a follow-up interview, Resident #1 reported that about $500 was missing from the lock box (safe) the resident kept in his/her room.The facility's self-report documented Resident #1 resided in the facility for long term care since October 2019, and had multiple diagnoses which included vascular dementia, depression, anxiety and cognitive communication deficit, was followed by psychiatric services and was seen by his/her primary care physician for recently exhibited increased confusion.Review of the facility's investigative documentation revealed interviews were conducted with facility staff, however, continued review of their investigation found no documentation to indicate interviews had been conducted with any residents.The facility failed to do a thorough investigation into the alleged misappropriation of Resident #1's funds by failing to interview residents who potentially may have been victims or may have seen or heard something relevant to the incident.On 1015/25 at 9:44 AM, during an interview, the Nursing Home Administrator (NHA) confirmed the facility's investigation did not include resident interviews. At that time, the NHA indicated resident interviews would have been conducted if residents wandered in and out of the resident's room, however, Resident #1 kept the door to his/her room closed, that residents did not wander into the resident's room and Resident #1 had the only key to his/her lock box. The concerns with the facility failing to conduct resident interviews during an investigation were then discussed with the NHA, who acknowledged the concerns at that time.On 10/16/25 at 11:51 AM, the above concerns were discussed with Staff #8, Chief Operating Officer who indicated resident interviews were not conducted because the facility staff knew Resident #1 very well, that the resident stayed in his/her room, and had the only keys to his/her lock box which s/he on him/herself at all times. Staff #8 acknowledged the concerns at that time and indicated the facility had not fully explored all possibilities of what could have happened.

Based on review of the medical record and interview it was determined the facility staff failed to ensure all prior MOLST forms in the resident record were voided as per the MOLST instructions. This was evident for 1 (#6) of 3 residents reviewed for Quality of Care.The findings include:Maryland MOLST (Maryland Orders for Life Sustaining Treatment) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a patient's wishes about medical treatments. Per the MOLST instructions: Updating the Form: The MOLST form shall be voided and a new MOLST form prepared when there is a change to any of the orders. If modified, the physician, NP, or PA shall void the old form and complete, sign, and date a new MOLST form. Voiding the Form: To void this medical order form, the physician, NP, or PA shall draw a diagonal line through the sheet, write VOID in large letters across the page, and sign and date below the line. A nurse may take a verbal order from a physician, NP, or PA to void the MOLST order form. Keep the voided order form in the patient's active or archived medical record. Resident #6's electronic medical record (EMR) was reviewed on [DATE] at 8:12 AM. The Miscellaneous section revealed 5 scanned voided copies of MOLSTS dated: [DATE] - Attempt CPR - per resident, [DATE] - Attempt CPR per Surrogate decision maker, [DATE] - No CPR option A2 with changes to page 2, [DATE] - No CPR Option B with changes to Page 2, [DATE] - No CPR, Option B with changes to Page 2.The EMR also contained the scanned copies of the original (un-voided) MOLST for the same dates as well as the most recent MOLST dated [DATE]. An interview was conducted with the facility Administrator on [DATE] at 11:30 AM. She was made aware of the above findings. She indicated that the paper record contained the original MOLST forms all of which, except for the most recent, were voided as per the MOLST instructions. She was made aware that Resident #6's EMR contained the voided and un-voided (active) copies of each MOLST form. The Corporate Nurse was made aware of the above concerns on [DATE] at 12:15 PM.

Based on observation, interview, and review of the facility policy, the facility failed to ensure all food in the freezer, refrigerator, and dry storage was labeled, dated, and not expired as well as failed to ensure newly washed dishes were allowed to properly air dry and staff wore the appropriate hair coverings. These failures had the potential to affect all 158 residents in the facility who consumed food from the kitchen. Findings include: Review of the facility's policy titled, Food Safety Product Labeling and Dating Guidelines, dated [DATE], revealed .Sodexo policy does not specify a date marking label. An establishment can choose to be as precise as needed in date marking if the parameters set forth within the Sodexo policy are met. A date marking system may use calendar dates, days of the week, color-coded marks, or other effective means to comply with policy and the food code . All managers and food employees need to be trained and understand the operation's date marking policy and the dating/labeling system they use . Review of the facility's policy titled, Hair Restraints, dated [DATE], revealed Consumers are particularly sensitive to food contaminated by hair. Hair can be both a direct and indirect vehicle of contamination. Food employees may contaminate their hands when they touch their hair. A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair. Our guidelines below are taken from the FDA Food Code. Food employees should wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, which are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. During an observation on [DATE] at 8:43 AM, the following observations in the kitchen were identified and verified by the Dietary Manager (DM). 1. The walk-in freezer contained two bags of chicken with no use-by-dates. The bags were frozen to the tray due to some kind of spill. There was also one box of hamburgers not sealed shut. Two bags of sausage had no labeling and dating. One bag of Cod was outdated with an expiration date of [DATE]. One bag of pork patties was outdated with an expiration date of [DATE]. One metal container had no labeling and dating and the DM had no idea what the container contained. There was also one package of food that had no labeling and dating and the DM had no idea what the package contained. 2. The walk-in refrigerator contained one bag of salami with an expired date of [DATE], boiled eggs expired with a date of [DATE], tuna with an expiration date of [DATE], fortified pudding, feta cheese, and cut potatoes expired on [DATE]. Cut potato slices had an expiration date of [DATE]. Two bags of bologna and beef/mac not sealed shut. 3. The dry Storage room contained one bag of dried cranberries that had no labeling, dating, and was not sealed shut. 4. The Robot Coupe was not allowed to airdry before the lid was attached. The inside of the container was wet. There were also six metal pans that were stacked wet and not allowed to airdry. 5. The kitchen contained four hot boxes that transfer food to the kitchens on the units. They were dirty and sticky on the outside with dried food and crumbs. Observation and interview on [DATE] at 8:43 AM with the DM revealed the DM did not have a hair covering. When asked what he was doing, the DM stated, I was putting food in the walk-in refrigerator. When asked why he did not have a hair covering, the DM did not answer. He then stated, He was not handling food. Observation and interview on [DATE] at 8:55 AM with Dietary Aide (DA)2 revealed that he had a hairnet, but only the top of his hair was covered. When questioned, DA2 stated, My hair must have fallen out. Observation and interview on [DATE] at 11:25 AM with DA1 revealed that she did not have a hairnet. When asked why, DA1 stated, I was told if my hair is under a quarter of an inch, I do not have to wear a hairnet. Interview with the General Manager (GM) on [DATE] at 11:09 AM revealed, My expectations of the kitchen is that the staff follows food safety, quality, and have consistency. Training must be completed. Issues need to be noted and handled. During an interview with the Administrator on [DATE] at 11:33 AM revealed, The kitchen needs to be in compliance with regulations and wear hair coverings. All food should be labeled and dated. The kitchen needs continuous training.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure infection control measures were appropriately implemented and maintained hand hygiene related to blood glucose testing for four of four residents (Resident (R) 35, R16, R77, and R14) who were observed during testing. Also, the facility failed to ensure wound care was performed in a manner to prevent infection for R115. These failures placed the residents at risk for infections and a decrease in quality of life. Findings include: 1. Review of the facility's policy titled, Glucometer Disinfection reviewed 10/14/24 indicated, Policy Explanation and Compliance Guidelines .5. Procedure: a. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes. b. Wash hands.e. Put on gloves. f. Obtain capillary blood glucose sampling according to facility policy. g. Remove and discard gloves, perform hand hygiene prior to exiting room. i. Retrieve a disinfectant wipe from container. j. Using wipe, clean to remove heavy soil, blood and,/or other contaminants left on the surface of the glucometer. k. After disinfecting, place glucometer on foil barrier and allow the glucometer to air dry. l. Discard disinfectant wipe in waste receptacle. m. Perform hand hygiene. a. Review of the Face Sheet located in the Admissions tab of the electronic medical record (EMR) revealed R16 was admitted to the facility in June 2018 with diagnoses of dementia and type 2 diabetes with long term use of insulin. Review of the Orders Summary located in the Orders tab of the EMR revealed, Blood Glucose check two times a day and dated 03/21/22. Observation on 12/16/24 at 10:24 AM revealed Licensed Practical Nurse (LPN) 7 completed a blood glucose test on R16. LPN7 did not wash her hands before putting on her gloves. LPN7 entered the residents room with the glucometer, lancet, alcohol wipe, and test strips in her uniform pockets. The glucometer was then placed on the nightstand with no barrier. The procedure was completed, and the dirty glucometer was placed on the medicine cart and then cleaned and put away. LPN7 did not wash her hands after cleaning the glucometer. b. Review of the Face Sheet located in the Admissions tab of the EMR revealed R35 was admitted to the facility in April 2022 with diagnoses of dementia and type 2 diabetes with diabetic chronic kidney disease. Review of the Orders Summary located in the Orders tab of the EMR revealed, Blood Glucose check before each meal and dated 04/01/22. Observation on 12/16/24 at 11:50 AM revealed LPN8 completed a blood glucose check on R35. A plastic container contained multiple lancets (20), alcohol wipes, and test strips was observed. When the procedure was completed, LPN8 put the dirty glucometer on top of all the clean lancets in the plastic container and brought to the medicine cart. Hand hygiene was not performed during the procedure. c. Review of R77's undated Face Sheet located under the Profile tab in the EMR revealed R77 was admitted to the facility in August 2022 with the diagnosis of type 2 diabetes mellitus. Review of R77's Physician's Orders located under the Orders tab in the EMR revealed an order dated 10/01/24 which stated, Novolog Flex Pen Solution Ped-injector 100 Unit/ML [unit per milliliter] Inject as per sliding scale: if 0-70 Call MD [medical doctor]; 71 - 150 = 0; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401+ Call MD [Medical Doctor] subcutaneously before meals related to Type 2 Diabetes Mellitus . During an observation on 12/16/24 at 4:42 PM, LPN1 cleaned the glucometer after it was used to obtain R77's blood sugar. LPN1 wiped the glucometer with the Micro Kill wipe and did not wear gloves when cleaning the glucometer with the Micro Kill wipe. d. Review of R14's undated Face Sheet located under the Profile tab in the EMR revealed R14 was admitted to the facility in August 2022 with the diagnosis of type 2 diabetes mellitus with hyperglycemia. Review of R14's Physician's Orders located under the Orders tab in the EMR revealed an order, dated 09/18/24, which stated, Novolog Flex Pen Solution Ped-injector 100 Unit/ML [unit per milliliter] Inject as per sliding scale: if 0-70 Call MD [medical doctor]; 71 - 150 = 0; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401+ Call MD subcutaneously before meals related to Type 2 Diabetes Mellitus . During an observation on 12/16/24 at 4:36 PM, LPN1 cleaned the glucometer after it was used to obtain R14's blood sugar. LPN1 wiped the glucometer with the Micro Kill wipe and did not wear gloves when cleaning the glucometer with the Micro Kill wipe. The interview with the Director of Nursing (DON) on 12/19/24 at 10:09 AM revealed, My expectations of the nursing staff is that they have all equipment on the medicine cart and enter the resident room with all supplies. Place a barrier down and place supplies on the and proper hand hygiene is to be used. Interview on 12/19/24 at 10:36 AM with LPN8 revealed, I was nervous. I know that I am supposed to wash my hands before putting on gloves. During an interview with the Administrator on 12/19/24 at 11:48 AM revealed, I expect that nursing follows policy and does what they are supposed to do. Training is essential to maintain infection control. During an interview on 12/19/24 at 11:52 AM, the Infection Preventionist (IP) nurse stated, The nurse is to wear gloves while cleaning the glucometer. They are to place a piece of foil on the top of the medication cart and place the glucometer on it after they have cleaned it while they are waiting for it to dry. 2. Review of the Admission Record located in the Profile tab of the EMR revealed R115 was admitted to the facility in November 2021 with diagnoses that included dementia and malnutrition. Review of the quarterly MDS located in the MDS tab of the EMR with an ARD of 11/21/24 revealed, R115 had a BIMS score of six out of 15 which indicated he/she was severely impaired in cognition and had one stage for pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) that was facility acquired. Review of a 12/18/24 Wound Clinic Provider visit note, located in the Miscellaneous tab of the EMR revealed, The wound measures 0.6cm x 1.3cm x 0.3cm with undermining at 9 o'clock which was 3.8cm. Wound progress at goal, duration of the wound is >431 days. The objective is to maintain healing. The tissue is a little more robust. Give it more time since changing the chair cushion and recommend [he/she] get into bed in the afternoon between lunch and dinner (but [he/she] is unlikely to comply). Review of the Order Summary located in the Orders tab of the EMR dated, 11/20/24 revealed, LT [left] HIP STAGE IV PRESSURE WOUND: Clean with NS [normal saline], cut thin small strip of Methylene Blue Foam, moisten with NSS [normal saline solution], wring out, then tuck into undermining every day. During a wound care observation on 12/19/24 at 11:41 AM with the Treatment Nurse (TN), she was observed to have brought in the wound care supplies into the room and laid them on the overbed table while she washed her hands and applied gloves. The wound care supplies were still packaged. After she applied her gloves, she carried the supplies over to the resident and laid them on the bed. She opened the vial of normal saline and poured it onto the gauze and proceeded to clean around the wound. She then obtained a clean gauze and cleaned the inside of the wound and then with the same gauze, she cleaned around the outside of the wound. The TN did not remove her gloves or perform hand hygiene before obtaining the methylene blue foam which was moistened in normal saline. She placed the foam into the wound bed using a sterile Q-tip. After she finished providing the foam, without changing her glove or performing hand hygiene, she opened the foam dressing and applied it to the wound. Without removing her gloves and performing hand hygiene, she picked up her soiled supplies off the resident's bed and proceeded out of the room before being stopped. During an interview on 12/19/24 at 11:54 AM, the TN was asked when you should change gloves and perform hand hygiene during wound care. The TN stated, They are to be changed when going from soiled to clean. The TN was asked about using the moistened gauze inside the wound and then around the wound on the skin. The TN stated she should have obtained clean moistened gauze instead of using the soiled gauze. The TN confirmed that she knew about the changing of the gloves from soiled to clean but was nervous. 32513 43050

Based on observations, interviews, record review and review of facility policy, the facility failed to ensure expired insulin pens were discarded from five medication carts (respiratory care unit (RCU) cart two, second floor long-term care unit (LTC) medication carts one, second-floor LTC medication cart two, third floor LTC medication cart medication cart one, and memory care medication cart one) of nine medication carts reviewed. This failure placed residents at risk of ineffective medication. Findings included. Review of the facility policy titled, Medication Administration, dated [DATE] revealed, . Ensure that the open date is documented on the vial or pen .Check the expiration date prior to administration to ensure it is within the usage date. Expired insulin should be immediately discarded. Vials and pens without an open date recorded should be discarded . 1. Review of RCU cart two on [DATE] at 3:35 PM with Licensed Practical Nurse (LPN)3 revealed, a Lantus (long-acting) insulin pen for R117 which had an orange label on the side of the pen which indicated, Do Not Use After [DATE]. In addition, an Aspart (Novolog-a short-acting) insulin pen which also had an orange label which indicated that the pen was Opened on [DATE]. The pharmacy label on the medication package for both medications read, Discard after 28 days. Further review of RCU cart two with LPN3 revealed that R124 had a Lantus insulin pen which indicated that the insulin pen was opened on [DATE]. The pharmacy label showed that the medication was to be discarded after 28 days. LPN 3 confirmed that the insulin pens had been used for both R117 and R124 and should have been discarded. 2. Review of the second-floor LTC cart two on [DATE] at 3:48 PM, with LPN4 revealed a Humalog (short-acting) insulin pen for R72 which had an open date of [DATE]. The label indicated that the insulin pen was to be discarded after 28 days. LPN4 confirmed that the Humalog insulin had been used for R72 and should have been discarded. 3. Review of the second-floor LTC cart one on [DATE] at 3:53 PM with LPN6 revealed a Novolog insulin pen which had an open date of [DATE]. The label on the package showed that the insulin pen was to be discarded in 28 days. LPN6 confirmed that the insulin pens had been used and they should have been discarded in 28 days. 4. Review of the third-floor LTC cart one with LPN1 revealed a Humalog insulin pen for R130 with an open date of [DATE]. The label on the package indicated that the insulin pen was to be discarded in 28 days. In addition, R130 had a second Humalog pen which showed no open date or expiration date on the pen. LPN confirmed that both pens had been used and should have been labeled when opened and discarded after 28 days. Further review of the third-floor LTC cart one with LPN1 revealed an Aspart insulin pen for R77 which had an open date of [DATE]. LPN1 confirmed that the insulin pen should have been discarded on [DATE]. 5. Review of the memory care medication cart one on [DATE] at 4:27 PM with Unit Manager (UM)1 revealed, R158 had a Novolog insulin pen with an unreadable open date. UM1 confirmed that the insulin pen should have been thrown out as the date was unreadable. During an interview on [DATE] at 4:51 PM the Director of Nursing (DON) was asked what his expectation was in regard to labeling insulin pens when opened and not using them past the expiration date. The DON stated, My expectation would be that prior to administration via the insulin pen, the medication would be observed for the correct open date. If outdated and expired, the insulin pen should be discarded and a new insulin pen obtained.

Based on record review, interview, and facility policy review, the facility failed to review and revise a comprehensive care plan to reflect the resolution developing of pressure ulcers and non-pressure wounds for one of four residents (Resident (R)155) out of 39 sampled residents. This failure created an increased risk for R155 to receive care and services not appropriate for their current clinical condition. Findings include: Review of R155's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R155 was admitted to the facility on [DATE] with diagnosis of malignant neoplasm of the pancreas, chronic respiratory failure with dependence on ventilator, tracheostomy, gastrostomy, pressure ulcer of other site, unstageable, pressure ulcer of other site, Stage 3, and non-pressure chronic ulcer of other part of right foot and left foot with fat exposed. Review of R155's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/11/24 coded the resident as having a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated R155 was moderately cognitively impaired. R155 was also coded as being a risk for developing pressure ulcers, and having one Stage 2, two stage 3, one Stage 4, and one unstageable pressure ulcers that were present on admission. Review of the VOHRA Wound Physicians .Wound Evaluation & [and] Management Summary located under the MISC [Miscellaneous] tab in the EMR and dated 11/06/24 through 12/18/24 revealed R155 was admitted to the following wounds; non-pressure wounds to the left 1st, 4th, and 5th toes and right 4th and 5th toe and tongue areas. R155 also had pressure wounds to the left and right plantar foot Stage 3, Sacrum Stage 2, left ear Stage 4, and right lateral foot unstageable areas. On the wound note, dated 11/13/24, the right 4th toe and sacrum wounds were healed. On the wound note, dated 11/25/24, the pressure wound to the left plantar foot was healed and a new pressure wound to the right heel Stage 3 was noted. On the wound note, dated 12/04/24, the non-pressure wounds to the right and left 5th toe were healed, and the addition of the right buttock Stage 2 was noted. On the wound note, dated 12/11/24, the non-pressure wound to the right 5th toe reopened and the pressure wound to the right plantar foot Stage 3 was healed. Review of the Comprehensive Care Plan located under the Care Plan tab in the EMR and dated 11/26/24 revealed on admission skin impairments as follows: Arterial wounds: left first, fourth and fifth toes, right buttock [sic] Pressure wounds right lateral foot, and left ear [sic] Non-pressure tongue and face . Under the Focus area of the care plan dated 11/05/24 revealed [R155] has the potential for skin impairment to limited mobility [sic] with interventions of Body check by GNA [geriatric nursing assistant] with AM [morning] care qd [every day]. Body check by nurse q [every] week/ Use left sheet to prevent shearing. Turn and Position q 2-3 hours. Mattress: Static pressure redistribution. Keep HOB [head of bed] raised to lowest comfortable angle for resident. Use pillows to prevent skin to skin contact prn [as needed]. Offload pressure areas. There was no documentation of the wounds to the right 4th toe, sacrum, and the left and right plantar foot was healed and the addition of new pressure wounds to the right heel and to the right buttock. During an interview on 12/19/24 at 11:50 AM, the Unit Manager (UM)2 stated, It [care plan] only has the wounds listed that [R155] was admitted with. I did not update the care plan when a wound healed, or another was found. The Director of Nursing confirmed the care plan was to represent the care the resident was receiving in the facility, and this care plan did not show this. Review of the undated facility's policy titled Care Plan Revisions Upon Status Change provided by the facility stated, .The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change . The care plan will be updated with the new or modified interventions .

Based on interview, record review, and review of the facility policy, the facility failed to ensure a Level II PASARR (a more in-depth preadmission screening and resident review) was obtained, as required for one resident (Resident (R)58) of three sampled residents in a total sample of 39. This failure placed the resident at risk of not receiving specialized services for serious mental illness. Findings included: Review of the facility policy titled, Resident Assessment-Coordination with PASARR Program, dated 2024 revealed, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs .All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening .PASARR Level I- initial pre-screening that is completed prior to admission. If the Level I Screen is negative-permit admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. If the Level I screening is positive-necessitates a PASARR Level II evaluation prior to admission .PASARR Level II is a comprehensive evaluation by the appropriate stated-designated authority and cannot be completed by the facility which determines whether the individual has MD [mental disorder], ID [intellectual disorder] or related condition, and determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs . Review of the Admission Record located in the Profile tab of the electronic medication record (EMR) revealed, R58 was readmitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and anxiety. Review of an 11/21/2021 Care Plan located in the Care Plan tab of the EMR revealed, [R58] has a diagnosis of Depression, Anxiety, Bipolar disorder & PTSD. [he/she] has behaviors such as yelling out, cursing until [he/she] goes back to bed or is changed. Interventions included, not limited to, Monitor for responses to loud noises related to possible response from PTSD and Behavioral health consults as needed; e.g. psychologist, psychiatrist. Review of the quarterly Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 12/05/24 revealed R58 had a Brief Interview of Mental Status (BIMS) score of three out of 15 which indicated he/she was severely impaired in cognition and had no behaviors. Review of the Level I PASARR located in the Miscellaneous tab revealed R58 had a Level I PASARR which was dated 06/01/22. The Level I further indicated that If two of three boxes are marked (under mental illness) then a Level II PASARR would be required. During an interview on 12/18/24 at 12:22 PM, Social Worker (SW)1 was asked if a Level II PASARR had been done for R58 in 2022. SW1 stated, The Level I PASARR (in the EMR) was from his psychiatric hospital stay in 2022. SW1 further stated, Counseling doesn't feel it would be helpful to R58 has [his/her] BIMS score is low. In addition, the VA [Veterans Administration] would not provide any further counseling when [he/she] was readmitted after his psychiatric hospital stay. SW1 was asked about the section of the PASARR Level 1 where it indicated that R58 met two of the three requirements to have a PASARR Level II evaluation, in 2022. SW1 reviewed the section and confirmed that R58 should have had a PASARR Level II evaluation.

Based on observation, interview, and facility policy review, the facility failed to accurately check the insulin pen that was being used to administer insulin to one of three resident (Resident (R) 14) administered insulin out of six residents being observed during the medication administration task. This failure had the potential for bloodborne pathogens to infect residents by using a reusable insulin pen to a resident other than the resident that it had been ordered for. Findings include: Review of the facility's policy titled Medication Administration .Insulin Administration dated 06/21/17 and provided by the facility stated, .Pens must be used only for a single resident and must never be shared . During an observation of medication administration on 12/16/24 at 4:50 PM, Licensed Practical Nurse (LPN)1 was observed in getting a new Novolog Insulin Pen from the Unit Manager (UM)3 which was obtained from the Cubex. LPN1 administered R77 with two units of Novolog insulin subcutaneously as ordered by the physician. LPN1 went to the next resident which was R14. LPN1 applied the alcohol prep to R14's left upper quadrant of R14's abdomen and uncapped the Novolog Insulin Pen. Before LPN1 was able to stick R14's abdomen with the insulin pen, the surveyor requested the nurse to stop and LPN1 was asked to return to the medication cart. LPN1 stated, When you stopped me, I thought that I should have asked my supervisor for a new insulin pen instead of using this one. During an interview on 12/19/24 at 11:52 AM, Unit Manager (UM)3 stated, Each person has their own individual pen. I expect the nurse to use one pen at a time for each person. On 12/19/24 at 11:55 AM, the Director of Nursing (DON) was notified of LPN1 attempting to use an insulin pen of Novolog on R14 that was used to administer insulin to R77. The DON confirmed insulin pens are only to be used on one resident and each resident should have their own pen.

Based on record review, interview and facility policy review, the facility failed to develop a comprehensive care plan regarding a condom catheter for one of one resident (Resident (R)155) out of 39 sampled residents. This failure to develop a care plan increased the risk for care to be incomplete and/or inconsistent related to R155 having a condom catheter. Findings include: Review of R155's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R155 was admitted to the facility on [DATE] with diagnosis of chronic kidney failure, Stage 3, malignant neoplasm of the pancreas, chronic respiratory failure with dependence on ventilator, tracheostomy, and gastrostomy. Review of R155's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/11/24 coded the resident as having a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated R155 was moderately cognitively impaired. Review of R155's Physician Orders located under the Orders tab in the EMR revealed an order dated 11/13/24 for Maintain size 35mm [millimeter] Condom Catheter. Review of R155's Comprehensive Care Plan located under the Care Pan tab in the EMR revealed no documentation of R155 having a condom catheter. During an interview on 12/19/24 at 11:50 AM, with the Director of Nursing (DON) and Unit Manager (UM)2 stated, The condom catheter is not on the care plan. Asked if the condom catheter should have been placed the on the care plan after the order was received and UM2 stated, Yes, it should have been added to the care plan. The DON confirmed the care plan was to represent the care the R155 was receiving in the facility, and this care plan did not show this. Review of the undated facility's policy titled Comprehensive Care Plan revealed revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .

Based on interview, record review, and review of facility policy, the facility failed to ensure that the education of benefits and risks of immunizations for pneumonia and influenza was provided after refusals for the vaccinations for three residents (Residents (R) 36, R20, and R80) of five sampled residents reviewed for immunizations. This failure placed the residents at risk for pneumonia and influenza. Findings included: Review of facility policy titled, Pneumococcal Vaccine, dated 08/01/2024 revealed, .Prior to offering a pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization with the education documented in the clinical record . Review of facility policy titled, Influenza Vaccination, dated 09/01/2024 revealed, . Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be offered a copy of CDC's (Center for Disease Control) current vaccine information statement relative to the influenza vaccination .The resident's medical record or staff's medical file will include documentation that the resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal. According to the CDC (Centers for Disease Control) at www.cdc.gov recommends Complete series: PCV 13 at any age & PPSV 23 at [AGE] years of age or older and then at five years. Together, with the patient, vaccine providers may choose to administer PCV20 to adults greater than [AGE] years of age who have already received PCV13 or PPSV 23 at or after age [AGE] years. 1. Review of the Face Sheet' located in the Admissions tab of the Electronic Medical Record (EMR) revealed R36 was admitted to the facility on [DATE] and was [AGE] years old. Review of the Immunizations tab of the EMR revealed R36's son (who is the responsible party), refused the pneumococcal conjugate vaccine (PCV 20) and no documented education was provided. 2. Review of the Face Sheet' located in the Admissions tab of the EMR revealed R20 was admitted to the facility on [DATE] and was [AGE] years old. Review of the Immunizations tab of the EMR revealed R20's sister (who is the responsible party), was called and voicemail left on 11/27/24 for consent to administer the influenza and PCV 20, with no return call. The facility did not follow up on the phone call and documentation on education was not provided. 3. Review of the Face Sheet' located in the Admissions tab of the Electronic Medical Record (EMR) revealed R80 was admitted to the facility on [DATE] and was [AGE] years old. Review of the Immunizations tab of the EMR revealed R80's sister (who is the responsible party) agreed to the vaccine, but R80 refused the vaccine and did not receive documentation on education for the influenza vaccine. The facility made no attempt to contact the sister for assistance with the resident receiving the vaccine. During an interview on 12/19/24 at 2:24 PM, the Infection Preventionist (IP) stated, I do not know why the Vaccination Information Sheets (VIS) all say no education was provided. My concern is that I do not always know that I am getting the vaccine refusals. I need to review my process for immunizations. Interview on 12/19/24 at 2:58 PM with the Administrator revealed, My expectation for immunizations is that the IP is reviewing the vaccines and refusals and providing education on the risk and benefits of receiving those vaccines. Education has to be provided and documented in the resident's records.

Based on documentation review and staff interview, it was determined the facility failed to include in their COVID-19 Staff Vaccination Policy a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who were not fully vaccinated for COVID-19. This was evident during a complaint survey and has the ability to affect all residents. The findings include: On 2/15/22 at 11:40 AM, a review of the facility ' s COVID-19 Vaccination Policy was conducted. Review of the policy revealed that, as of September 1, 2021, the facility expected all staff and contractors to either be fully vaccinated for COVID-19 or have an approved exemption as an accommodation. Further review of the vaccination policy failed to include a process for ensuring the implementation of additional precautions the facility would take to mitigate the transmission and spread of COVID-19 for staff who were not fully vaccinated that included staff with medical and religious exemptions. Additional precautions could have included social distancing, wearing of additional PPE (personal protective equipment) or weekly testing. Interview of the Corporate RN (staff #7) on 2/15/22 at 1:45 PM, revealed that all staff and contractors that work at the facility were 100% vaccinated with the exception of 4 staff members that either had a religious or medical exemption. At that time, it was discussed with Staff #7 the content of the policy and the areas that were missing additional information. The Nursing Home Administrator was made aware on 2/15/22 at 2:45 PM.

Based on medical record review, and interview with staff, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice as evidenced by failure to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include On 9//3/21 at 9 :15 AM, Resident # 5 medical records were reviewed. This review revealed that the resident was admitted to the facility in April 2021 for rehabilitation and with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical records revealed a physician order, dated 4/22/21, for [MEDICATION(S)] Kwik Pen Solution inject per sliding scale two times a day for diabetes. Review of the medication administration records (MAR) revealed that, on 4/23/21, the resident had finger sticks at 6 AM and 6 PM to check the blood sugar level per physician order. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the corporate nurse, on 9/3/21 at 11:30 AM, she acknowledged that it was not done and that she had no further explanation for it. During the survey exit, on 9/7/21 at 3:00 PM, the concern regarding the failure to follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on medical record review and staff interview, it was determined that facility staff failed to honor a resident' s right to formulate a Do Not Resuscitate (DNR) advance directive and performed CPR (cardiopulmonary resuscitation) against the resident's stated written request. This was evident for 1 of 5 residents (Resident # 43) reviewed for Advance Directives during the survey, and the deficiency was cited to the level of actual harm. The findings include: Facility Reported Incident MD 887 was reviewed on [DATE]. The Incident Report stated that, on [DATE], CPR (Cardio [MEDICAL CONDITION] Resuscitation) was initiated on Resident # 43 and discontinued when it was determined that the resident had formulated a DNR (Do Not Resuscitate) advanced directive. The patient subsequently expired. Cardiopulmonary Resuscitation (CPR) refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased. A DNR directive instructs health care providers not to perform (CPR) if a patient stops breathing or if their heart stops beating. The facility CPR policy was reviewed on [DATE]. The Facility's CPR policy states that CPR should be administered in accordance with a resident's MOLST. Resident # 43's medical record was reviewed on [DATE]. Review of the record revealed that a [NAME]land Medical Order for Life Sustaining Treatment (MOLST) was completed on [DATE]. The MOLST is a portable and enduring medical order form covering options for CPR and other life-sustaining treatments. Resident # 43's MOLST was coded to reflect that the resident's health care agent, as named in the resident's advanced directive, requested that CPR not be attempted if cardiac and/or [MEDICAL CONDITION] arrest were to occur. A healthcare agent is a person designated and authorized by an advance directive to make a treatment decision for another person in the event the other person becomes unable to make necessary health care decisions. On [DATE], A Facility Investigation Summary Form, completed on [DATE], was reviewed. The Investigation Summary Form stated that, on [DATE] at 6:50 PM, Registered Nurse (RN) Supervisor # 7 phoned the Director of Nursing (DON) and informed him/her that Resident # 43 had expired. The form noted that, on [DATE] at approximately 3:15 PM, the Memory Care Unit Manager reported to the DON that Registered Nurse (RN) # 2 had informed him that RN # 1 had performed CPR on Resident # 43. In a statement RN # 1 wrote that she/he may have performed CPR on the resident. RN# 1's employee file was reviewed on [DATE]. This review revealed that RN # 1's employment was terminated on [DATE] due to her/his job performance. The Memory Care Unit Manger was interviewed on [DATE] at 12:30 PM. The Memory Care Unit Manager stated that RN # 2 came into her/his office on [DATE] and informed her/him that RN # 1 had performed CPR on Resident # 43. RN # 1 was contacted on [DATE] at 12:58 PM. RN # 1 declined interview. RN # 2 was interviewed on [DATE] at 1:08 PM and stated: RN # 3 and I were sitting at the nurse's station. Geriatric Nursing Assistant (GNA) # 3 came running to our unit from Memory Care to get the backboard and he/she told us to call a Code Blue. (A backboard aids in the administration of cardiopulmonary resuscitation by creating a flat, rigid surface to use under the person in need of care. A Code Blue indicates an emergency and is announced in a facility when an individual's breathing or heart stops). We were already on the phone with RN Supervisor # 7. We told her/him about the code blue and then we went running over there. We got there at the same time as RN Supervisor # 7. He/she went to the nurse's station to get Resident # 43's chart and we went to the resident's room. When we went to the room, RN # 3 and I saw Resident # 43 on the floor and RN # 1 doing chest compressions on top of him/her. RN Supervisor # 7 told RN # 1 to stop CPR because Resident # 43 was a DNR. RN # 3 was interviewed on [DATE] at 2:00 PM. RN # 3 stated that, on [DATE], GNA # 3 ran to their unit and requested that they call a Code Blue. RN # 3 stated that he/she and RN # 2 ran to The Memory Care Unit to respond to the Code Blue. When RN# 3 arrived at the resident's room he/she saw that Resident # 43 was on the floor and that RN # 1 was doing chest compressions. RN # 3 stated that RN Supervisor # 7 had arrived on the unit at the same time as he/she had and checked Resident # 43's medical record. RN Supervisor # 7 told RN # 1 to stop compressions because the resident was a DNR. GNA # 3 was interviewed on [DATE] at 1:07 PM. GNA # 3 stated that, on [DATE], s/he had gone into Resident # 43's room to give him/her a bath. GNA # 3 stated: I got my basin, undressed Resident # 43 and began to give him/her a bath. His/her eyes began to roll back and forth in his/her head, he/she became less responsive and his/her breathings slowed down. I stopped and got RN # 1. RN # 1 came into the room, looked at the resident and left to get a pulse oximetry monitor. When she/he left the room, Resident # 43 turned completely white, his/her lips turned white and his/her eyes didn't roll back forward. I ran out of the room and shouted that I needed the nurses. RN # 1 ran into the room, jumped on his/her chest and started CPR. RN # 4 went to get the crash cart (a crash cart is a wheeled container carrying medicine and equipment for use in emergency resuscitations). There was no backboard on the crash cart, so they asked me to go get one. I ran to the Short-Term Rehab Unit to get a backboard and to asked them to call a code. When I came back into the room, RN # 1 had pulled Resident # 43 onto the floor and was still doing chest compressions. RN Supervisor # 7 arrived and told RN # 1 to stop CPR because Resident # 43 was a DNR, and we could only perform comfort measures. RN Supervisor # 7 asked us to put Resident # 43 back onto the bed. When we put him/her back into the bed, I noticed that he/she was not breathing anymore. RN Supervisor # 7 was interviewed on [DATE] at 12:45 PM. RN Supervisor # 7 stated that around 6:00 PM on [DATE] she/he heard that a resident was in distress. RN Supervisor # 7 stated: When I ran to the unit, I went straight to the chart, and opened the chart. I went to the rack and got the chart. When I opened the chart, I realized that Resident # 43 was a DNR, so I went to the room. When I went to the room, I saw Resident # 43 lying on the floor and I saw RN # 1 struggling to put the backboard underneath the patient. I told her/him no, don't do that, that patient is a DNR. I told her/him that we need to put Resident # 43 on the floor and put some oxygen on him/her. The Director of Nursing and the Chief Nursing Officer were made aware of the findings on [DATE] at 10:38 AM and confirmed that facility staff had failed to honor Resident # 43's DNR advance directive.

Based on an anonymous complaint, reviews of a closed medical record, hospital record, and the facility investigation, and resident interview, it was determined that the facility failed to administer a resident the correct medications which in turn lowered the resident's glucose levels to a critical level which required admission to the hospital. This resulted in an a past non-compliance actual harm level citation. This was evident for 1 of 5 residents (Resident #1) reviewed during a complaint survey. The findings include: Review of anonymous complaint MD 961 on 10/23/2015 revealed an allegation Resident #1 was given another resident's medication. Review of Resident #1's closed medical record revealed nursing documentation dated 07/26/2015 at 6:30 PM that indicated Resident #1 was found unresponsive by the nursing staff with a finger stick blood sugar result of 32 mg/dl (normal 70 - 120 mg/dl). The nursing staff administered medications to treat Resident #1's [DIAGNOSES REDACTED] that included glucose gel and 1 mg (milligram) of [MEDICATION NAME] ( a glucose solution administered to elevate a resident's blood sugar levels). Resident #1's family and physician were notified. Resident #1 was sent by 911 ambulance to the local hospital. Further review of Resident 31's closed medical record failed to reveal a [DIAGNOSES REDACTED].#1 suffered from high or low glucose levels. Further review of Resident #1's closed medical revealed a physician note, dated 07/26/2016 at 6:45 PM, that detailed Resident #1 was sent to the local hospital for [DIAGNOSES REDACTED] (low blood sugars) and that Resident #1 was not receiving any hypoglycemic medications but Resident #1's roommate does receive oral hypoglycemic medications. Review of Resident #1's hospital record revealed Resident #1 received several injections of [MEDICATION NAME], D 50 by intervenious injection, and was started on a intervenious D 10 solution (a continuous glucose solution), Resident #1 required being transferred to the hospital ICU (Intensive Care Unit) for further management because Resident #1's finger stick glucose levels would drop into the 20's mg/dl. The hospital record noted Resident #1 was not a diabetic. Further review of Resident #1's hospital record revealed a laboratory result that indicated Resident #1 had plasma concentrations of the medication [MEDICATION NAME] (an oral medication to treat elevated levels of blood glucose as seen in diabetic residents) in his/her blood stream. In an interview with Resident #1 on 10/23/2015 at 11:49 AM, Resident #1 stated he/she was given the wrong medication that lowered his/her blood sugar and that he/she became unconscious. Resident #1 stated he/she did not realize what had happened and that he/she could not recall much during the several days he/she spent in the hospital. Resident #1 stated the hospital staff told him/her he received the wrong medication. The surveyor determined the facility staff failed to administer Resident #1 the correct medication which in turn lowered the resident's glucose levels to a critical level which required admission to the hospital. This medication error harmed the Resident #1 by having to go to the hospital and being admitted to the ICU for several days. The facility completed the corrective action and provided documentation that education of the nursing staff regarding proper medication administration was completed on 07/30/2015.

Based on a complaint, reviews of a medical record and staff interview, it was determined that the facility staff failed to provide a resident with a safe environment during care, and to prevent the resident from falling out of a shower chair onto the floor and suffering an injury. This occurred for 1 of 16 residents reviewed during a complaint survey. The findings include: Review of resident #1's medical record, on 02/10/2014, revealed that resident #1 is totally dependent upon the facility staff for all aspects of care and is unable to protect himself/herself from any accidents. Review of complaint MD 565, on 02/10/2014, revealed an allegation that resident #1 suffered a fall during a shower, struck his/her head, and suffered lacerations which required transportation to the hospital for suture and stapling to the face and scalp on 01/07/2014. Review of resident #1's care plans, on 02/10/2014, revealed that resident #1 uses a Broda chair for ambulation on the nursing unit to prevent resident #1 from falling. A Broda chair is a specialized wheel chair that reclines but still allows resident #1 to ambulate, by using his/her feet, on the unit. In an interview on 02/11/2013 at 12:25 pm, GNA #1 stated that he/she was showering resident #1 on 01/07/2014, while resident #1 was sitting on the facility shower chair. GNA #1 stated that he/she was in the process of drying resident #1 and then stood behind resident #1 to dry resident #1's hair. GNA #1 stated that resident #1 has a tendency to lean forward. In addition, per incident injury documentation on 12-9-13, resident #1 "bends over often, puts head on rails, head on dining room table." In this incident as well, GNA #1 stated that resident #1 leaned forward and fell out of the shower chair. The facility shower chair was a standard chair that does not have any devices to protect a resident from falling out of the chair. Resident #1 suffered lacerations to his/her face and scalp which required a trip to the hospital for suturing and stapling. In conclusion, during a shower on 01/07/2014, GNA #1 failed to provide resident #1 with a safe environment, failed to prevent resident #1 from sliding out of the shower chair onto the floor and sustaining lacerations to the face and scalp, which required a trip to the hospital for suturing and stapling.