Every finding on record at Clarksville Nursing Center

Based on record review, resident and staff interviews and observations, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 of 15 (Resident #1, Resident #2, Resident #3) reviewed for environment, in that: The facility failed to ensure water temperatures in the resident showers in 2 of 3 of the facility communal showers located on 100 hall and 300 hall was kept at a comfortable temperature for residents. The third shower, located on 200 hall, was inoperable due to construction. This could place residents at risk of unsanitary or uncomfortable conditions by not having hot water available for showers. The findings were: 1.Record review of Resident #1's face sheet dated 04/14/2026 revealed a [AGE] year-old male admitted [DATE] with diagnosis that included cerebrovascular disease with left side hemiplegia (a condition affecting blood flow to the brain with left sided paralysis), Diabetes Type II (a chronic condition where the body resists insulin or fails to produce enough insulin, causing high blood sugar), Hypertension (high blood pressure), Hyperlipidemia (high levels of fats in the blood), Bipolar disorder (a chronic mental health condition characterized by intense, fluctuating mood swings), anemia (a blood disorder characterized by insufficient health red blood cells), major depressive disorder (a mental health condition characterized by persistent sadness, loss of interest and low energy) and anxiety (a mental health condition characterized by persistent, excessive worry and fear that interferes with daily life). Record review of Resident #1's quarterly MDS dated [DATE] revealed Resident #1 had no hearing or communication deficits and a BIMS Score of 15 that indicated intact cognition. The quarterly MDS assessment revealed limited range of motion in upper and lower extremities, used a wheelchair for mobility, was independent in eating, bathing, bed mobility, and transfers, required set-up assistance with toileting and maximum assistance in upper / lower body dressing. In an interview on 04/14/2026 at 10:25 a.m., Resident #1 stated that he received a regular shower, but the shower over here is not worth a crud and the water is either hot or cold! Resident #1 presented clean, odor free and appropriately dressed. Resident #1 was independent in showering and could recall if he had reported this concern to a staff member. 2. Record review of Resident #2's face sheet dated 04/14/2026 revealed a [AGE] year-old male admitted [DATE] with diagnosis that included Chronic Obstructive Pulmonary Disease (a progressive lung disease causing chronic airway / breathing damage), Hypertension (high blood pressure), Parkinson's Disease (a progressive nerve disorder that causes tremors, stiffness and slowness in movements), Peripheral Vascular Disease (a progressive circulation disorder characterized by narrowed or blocked blood vessels) and dementia (a decline in cognitive function to include memory loss, confusion, and personality changes that impairs daily life). Record review of Resident #2's comprehensive significant change MDS dated [DATE] revealed Resident #2 had no hearing or communication deficits and a BIMS Score of 15 that indicated intact cognition. The comprehensive MDS assessment revealed Resident #2 utilized a wheelchair for mobility, was independent in eating, bed mobility and required moderate assistance in toileting, bathing, upper / lower body dressing. and transfers. In an interview on 04/14/2026 at 10:37 a.m., Resident #2 stated that he received a regular shower, but the water does not stay warm enough for the entire shower time. Resident #2 was clean, odor free and appropriately dressed. Resident #2 stated he would comment about the water during the showers but could not recall specifically who he had mentioned it to. 3. Record review of Resident #3's face sheet dated 04/14/2026 revealed a [AGE] year-old male admitted [DATE] with diagnosis that included Congestive Heart Failure (a progressive condition where the heart muscle is too weak to pump blood efficiently causing fluid buildup in the lungs and body), Atherosclerotic Heart Disease (a condition where plaque buildup hardens and narrows the arteries supplying the heart, restricting blood flow), Hypertension (high blood pressure), Hyperlipidemia (high levels of fats in the blood), Diabetes Type II (a chronic condition where the body resists insulin or fails to produce enough insulin, causing high blood sugar), and Osteoporosis (a disease characterized by weak, brittle bones and structural changes that increases the risk of fractures). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed Resident #3 had no hearing or communication deficits and a BIMS Score of 15 that indicated intact cognition. Further review of this quarterly MDS assessment revealed Resident #3 utilized a wheelchair and/or walker for mobility, was independent in eating, toileting, bathing, bed mobility, transfers, upper body dressing and lower body dressing. In an interview on 04/14/2026 at 10:42 a.m., Resident #3 stated, the water is not as hot as [he] would like, but it is usually just warm. Resident #3 was independent in showering and stated he did not report that the water was not as hot as he would like it to be. Observation on 04/14/2026 at 10:30 a.m. of water temperatures taken in the shower room on 300 hall revealed that after turning the shower on and waiting for 3 minutes the shower temperature remained at 85 degrees Fahrenheit. On 04/14/2026 at 11:00 the water temperature of the 300-hall shower reached 108 degrees Fahrenheit after 5 minutes of running the shower, then dropped down to 85 degrees Fahrenheit. Review of the facility Grievances and the Resident Council minutes for the past three months did not reveal any concern about the water temperature in the showers. Observation on 04/14/2026 at 11:30 a.m. of water temperatures taken in the shower room on 100 hall revealed that after turning the shower on and waiting for 3 minutes the shower temperature reached 103.5 degrees Fahrenheit, and then immediately dropped in temperature to 95 degrees Fahrenheit. On 04/14/2026 at 12:00 p.m., the water temperature in 100 hall shower, revealed the water temperature reached 105 degrees Fahrenheit after running the water for 3 minutes and the temperature immediately dropped below 95 degrees Fahrenheit. In an interview on 04/14/2026 at 10:13 a.m., CNA A stated there are times when the water is shut off for repair and noted that the Maintenance Director would give the staff a heads up to allow time for showers to be completed. CNA A stated there was never a time when the hot water was off for extended periods of time. CNA A stated that she lets the water run for a bit to reach a good temperature for the residents. CNA A stated that some residents would like the water to be hotter, but the water is warm enough to complete the shower. In an interview on 04/14/2026 at 10:28 a.m., CNA B stated that she has not had any trouble with the water temperatures and that there is enough hot water to last throughout the entire shower. Stated she has not had any resident complain to her that the water was not hot enough. CNA B stated she adjusts the water temperature as needed. In an interview on 04/14/2026 at 11:05 a.m., LVN C stated that once in a while, a resident would tell her the water does not get as hot as they would like it, but never that the water temperature was cold. LVN C stated if this occurred all of the time, she would complete a maintenance work order and notify the Maintenance Director personally. In an interview on 04/14/2026 at 12:30 a.m., the Maintenance Director stated he was not aware that the water temperatures in the 200 hall and 300 hall showers were not reaching and maintaining a comfortable temperature and that he did not keep a record of the water temperatures for the two functioning communal showers. The Maintenance Director stated that the facility water heater went out on 03/30/2026 and he ordered a new water heater which arrived on 04/03/2026, but it did not arrive with the appropriate parts to fit the current pipes. The Maintenance Director stated he ordered the new parts which arrived on 04/08/2026 and they were installed on 04/08/2026. He stated the current water heater required time for the water to run to heat up properly because the design of the water heater did not keep the water hot in the pipes and consequently, the recycler had to push hot water into the shower pipes at each use. The Maintenance Director stated he ordered new fittings on 04/13/2026 which should take care of this delay once installed. The Maintenance Director reported that his standard practice is to maintain water temperatures in resident restrooms between 108 degrees and 112 degrees and confirmed that the water temperatures failed to maintain this temperature range. He further stated that he was aware the water circulator was out of service, which he identified as a contributing factor and that he had not been routinely taking or documenting shower water temperatures and acknowledged the importance of ensuring residents received adequately heated showers. In an interview on 04/14/2026 at 12:52 p.m., the DON stated that she does not monitor the water temperature in the showers at all and noted that if an aide were to notify her that the water was cold, she would just tell the Maintenance Director. The DON stated she has not received any complaints about the shower water being cold. The DON stated that during the time when the 300-hall water heater was broken, residents were showered on an alternate hall to accommodate and ensure a warm shower was provided. The DON stated she was not exactly sure of the acceptable water temperature for the showers and that the adverse effect on resident's if a warm shower was not provided it could affect their psychosocial well-being. In an interview on 04/14/2026 at 1;15 p.m., the Administrator stated that she was not aware that the shower water temperatures were not monitored and that she would expect them to be monitored weekly and as needed if complaints were received. The Administrator stated she was aware that the water heater on 300-hall had been replaced but was not aware that the showers were not maintained at the proper temperature. The Administrator stated that residents are at risk of receiving cold showers if the temperatures are not monitored routinely and stated that she will ensure the Maintenance Director monitors and records shower temperatures weekly for appropriate temperatures. A policy for water temperatures for showers was requested on 04/14/2026 at 11:32 a.m., and the Administrator stated they do not have a policy for water temperatures for showers. Texas Administrative Code Ch 26, 554.360, revealed the generally accepted safe range for resident bathing is 100 - 120 and maximum water temperature should not exceed 120 to prevent scalding although the potential for injury can occur below 100 depending on the individual's condition and length of exposure. State Operations Manual, dated 08/08/2024 revealed Safe Temperature for bathing to be 100 degrees or below although burns can occur even at water temperatures below 100 degrees Fahrenheit, depending on an individual's condition and length of exposure. There is no identified recommended temperature for with potential for injury or burns at 120 degrees.

Based on interviews and record reviews, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 4 of 5 residents (Resident #2, Resident #7, Resident #8, and Resident #11) reviewed for trauma-informed care.The facility did not ensure the care plans of Resident #2, Resident #7, Resident #8, and Resident #11, who had histories of trauma, identified possible triggers and interventions.This failure could place residents at an increased risk for severe psychological distress due to re-traumatization.1.Record review of Resident #2's face sheet, dated 12/10/25, reflected Resident #2 was a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included PTSD (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Record review of Resident #2's quarterly MDS, dated [DATE], reflected Resident #2 made himself understood and understood others. Resident #2's BIMS score was 9, which indicated his cognition was moderately impaired. Resident #2 had a diagnosis of PTSD and depression. Record review of Resident #2's comprehensive care plan, revised 07/31/25 reflected Resident #2 had a history of trauma that may have a negative effect related to PTSD. The care plan interventions included: monitor for signs and symptoms of depression, anxiety, sleep disturbances and substance abuse issues. The care plan did not address triggers. Record review of Resident#2's comprehensive trauma screening, dated 01/17/25, reflected it did not address triggers. During an interview on 12/10/25 at 10:00 a.m., Resident #2 stated he had a diagnosis of PTSD. Resident #2 stated he had not identified any triggers within the facility and there was nothing that bothers him. Resident #2 stated however he did get spooked when he was woken up. 2. Record review of Resident #7's face sheet, dated 12/10/25, reflected Resident #7 was a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included PTSD (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), anxiety, depression, and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) with hallucinations (sensory experiences, like seeing hearing or feeling things that are not real). Record review of Resident #7's quarterly MDS, dated [DATE], reflected Resident #7 sometimes made himself understood and usually understood others. Resident #7's BIMS score was 8, which indicated his cognition was moderately impaired. Resident #7 had a diagnosis of PTSD anxiety, depression, and psychotic disorder with hallucinations. Record review of Resident #7's comprehensive care plan, revised 09/16/25 reflected Resident #7 used psychotropic medications, mood stabilizer, antidepressants, antianxiety, antipsychotics related to PTSD, major depression disorder, and psychotic disorder with hallucinations. The care plan intervention included: administer medication as ordered, and monitor/document for side effects and effectiveness. The care plan did not address Resident #7's history of trauma to include potential triggers for re-traumatization. Record review of Resident #7's comprehensive trauma screening, dated 11/08/24, reflected it did not address triggers. During an interview on 12/10/25 at 10:07 a.m., the Social Worker stated the comprehensive trauma screening was completed by her on admission. The Social Worker stated she did not ask about the triggers when completing the comprehensive trauma screening. The Social Worker stated she had never been told to ask about triggers unless the resident or family volunteered the information. The Social Worker stated the care plan should indicate whether the resident had triggers or not. After reviewing Resident #2 and #7's electronic medical records, the Social Worker stated neither resident had triggers noted and to her knowledge Residents #2 and #7 did not have any triggers. The Social Worker stated it was important to ensure triggers were identified to prevent re-traumatization. During an interview on 12/10/25 at 10:42 a.m., Resident #7's family member stated he had a diagnosis of PTSD. Resident #7's family member stated he had no significant triggers; however, he does have dreams about his PTSD. Resident #7's family member described it as lookbacks from being in the Vietnam war. During an interview on 12/10/25 at 11:07 a.m., CNA G stated she provided care to Resident #2. CNA G stated to her knowledge Resident #2 did not have any trigger or a diagnosis of PTSD. CNA G stated it was important to know resident's triggers to look out for the warning signs. During an interview on 12/10/25 at 11:32 a.m., CNA H stated she was Resident #7's aide for the 6a-6p shift. CNA H stated to her knowledge Resident #7 did not have any triggers or a diagnosis of PTSD. CNA H stated if the resident did or did not have triggers it should be documented in his chart. CNA H stated it was important to know resident's triggers to prevent re-traumatization. During an interview on 12/10/25 at 5:48 p.m., the MDS Coordinator stated the care plan should indicate whether the residents have triggers or not. After reviewing Resident #2 and #7's electronic medical records, the Social Worker stated neither resident had triggers noted and to her knowledge Residents #2 and #7 did not have any triggers. The MDS Coordinator stated it was important to know resident's triggers to prevent traumatization. During an interview on 12/10/25 at 6:54 p.m., the DON stated she expected triggers to be identified on the care plan. The DON stated the Social Worker and MDS Coordinator were responsible for ensuring the triggers were identified and documented in the resident's chart. The DON stated the Administrator was responsible for monitoring and overseeing PTSD/triggers. The DON stated it was important to know resident's triggers to help better care for the resident. An attempted telephone interview on 12/10/25 at 7:30 p.m., with the Administrator was unsuccessful. Record review of Resident #8's face sheet dated 12/10/2025 revealed a [AGE] year-old female originally admitted [DATE] and readmitted [DATE] with diagnoses including post-traumatic stress disorder, cerebral palsy (a neurological condition from brain damage affecting movement, posture and coordination), schizoaffective disorder (a mental illness blending symptoms of psychosis like hallucinations & delusions with mood disorders and mood swings), mild intellectual disabilities, and anxiety (a feeling of unease, worry or fear). Record review of Resident #8's comprehensive MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition and active diagnosis of PTSD. Further review of Resident #8's comprehensive MDS dated [DATE] revealed Resident #8 utilized a wheelchair for mobility, was independent in eating, required moderate assistance in bathing, maximum assistance in toileting, bed mobility, transfers and total assistance in upper and lower body dressing. Record review of Trauma Assessment Screening form (date not obtained) revealed no identified triggers or description of PTSD event. Record review of Resident #8's care plan with target date of 02/02/2026 revealed Resident #8 was identified as having a history of trauma that may have a negative effect. The care plan did not identify the type of trauma experienced and provided no interventions to ensure Resident #8's needs were being met. During an interview on 12/09/2025 at 11:25 a.m., Resident #8 appeared hesitant to discuss her trauma history with surveyor and was unable to provide further information regarding triggers for care. During a phone interview on 12/11/2025 at 2:20 p.m., Resident #8's family member stated that the trauma stemmed from her former marriage where she experienced an abusive family member. Resident #8's family member stated that Resident #8 appears content in the facility and that a possible trigger could be an aggressive male or a male that resembled her family member. During an interview on 12/10/2025 at 10:11 a.m., the Social Worker stated that she completes the trauma assessment on admission on ly for residents and stated that the trauma assessment does not ask for triggers. The Social Worker stated that identification of triggers specific to each resident would be important to know to help avoid exacerbation of trauma / PTSD. The Social Worker stated she does not ask each resident specifically what the triggers are, but she does explore the PTSD, document concerns and refer to psychological care services for on-going management. During an interview on 12/09/2025 at 9:58 a.m., CNA A stated that she is aware Resident #8 has some outbursts at times but has not been informed of any trauma triggers to be mindful of. During an interview on 12/09/2025 at 3:09 p.m., LVN B stated that she is aware Resident #8 receives medication for mood and behavior management, but is not aware of specific areas of concern related to trauma. During an interview on 12/09/2025 at 3:20 p.m., CNA C stated she works well with Resident #8 and knows that she becomes upset at times but she can easily calm her down. CNA C stated she has not been advised of specific concerns for Resident #8 related to PTSD and that she could not recall if she has received training for PTSD in the past year. During an interview on 12/10/2025 at 1:55 p.m., LVN D stated that she knows Resident #8 receives psychological services and behavior medications but she was not aware of what Resident #8's trauma is related to or what triggers to watch for. During an interview on 12/10/2025 at 6:54 p.m., the DON stated she expects triggers to be identified on the care plan however she feels her staff know the residents well enough that no harm has come from not having this information available for all staff. The DON stated that the Social Worker and the MDS Nurse are responsible for completing the Trauma Informed Care Assessment and stated it is important that triggers are identified to ensure quality of care for the residents affected by PTSD. The DON stated she and the Administrator are ultimately responsible for ensuring assessments are completed. Record review of Resident #11's face sheet dated 12/10/25 indicated he was a [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses PTSD, Dementia (cognitive decline that affects daily life caused by brain cell damage), major depressive disorder (persistent sadness, loss of interest, fatigue, and change in sleep/appetite), diabetes mellitus (chronic metabolism condition marked by high blood sugars), and presbyopia (natural age-related loss of eye's ability to focus on nearby objects). Record review of Resident #11's quarterly MDS dated [DATE] indicated he could make himself understood and was able to understand others. The MDS also indicated he had a BIMS score of 15 which meant his cognition was intact. The MDS also indicated he was independent with all ADLs. Record review of Resident #11's care plan dated 02/22/22 indicated he had a history of trauma that may have a negative effect related to his diagnosis of PTSD due to military history with a goal of staff assist Resident #11 in avoiding his triggers. The care plan did not indicate what Resident #11's triggers were. Record review of Resident #11's comprehensive trauma screening assessment dated [DATE] completed by the Social Worker indicated he had a documented diagnosis of trauma but the assessment did not indicate if Resident #11 had triggers nor what the triggers were. During an interview on 12/10/25 at 10:25 AM the Social Worker said Resident #11 had triggers that consisted of him not liking loud noises. The Social Worker said yesterday (12/09/25) the facility had fire drills and she felt like she should have gone to Resident #11 and let them know there was going to be loud noises [KS1] and that she maybe should have stayed with Resident #11 to comfort him. The Social Worker said the staff would know what Resident #11's triggers were because he was very vocal and would let them know. The Social Worker said there were no triggers on Resident #11's care plans but there should have been triggers included in his care plan to prevent more trauma. During an interview on 12/10/25 at 11:34 AM CNA H said she did not know about Resident #11 having PTSD, but he provided his ADLs for himself. CNA H said she was not aware of him having PTSD, but he would talk with her if he needed anything. CNA H said all staff should be aware if residents had a diagnosis of PTSD to prevent problems. Record review of the facility's policy titled Trauma Informed Care dated 10/24/22 indicated. it is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experience and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. 4. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. 6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident care plan.

Based on observation, interview, and record review, the facility failed to ensure that it was free from a medication error rate of 5 percent or greater. The facility had a medication error rate of 8.82 %, based on 3 errors out of 34 opportunities, which involved 3 of 5 residents (Residents #15, #26, and #27) reviewed for medication administration. 1. The facility failed to ensure LVN K administered insulin correctly for Resident #15. 2. The facility failed to ensure RN B administered Aspirin 325 mg (a common strength of the nonsteroidal anti-inflammatory drug (NSAID) used for pain/fever relief (headaches, colds, arthritis) and, at the doctor's direction, for heart/stroke prevention by reducing blood clots) as ordered by the physician for Resident #26 on 12/08/25. 3. The facility failed to ensure RN B administered Cyanocobalamin 2500 mcg (medication used to maintain the health of your metabolism, blood cells, and nerves) as ordered by the physician for Resident #27 on 12/08/25. These failures could place residents at risk of not receiving the intended therapeutic benefit of their medications or receiving them as prescribed by the physician's orders. Findings included: 1. Record review of Resident #15's face sheet, dated 12/10/25, reflected Resident #15 was a [AGE] year-old male, admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Type 2 diabetes mellitus (lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels), stroke, and high blood pressure Record review of Resident #15's quarterly MDS assessment, dated 11/26/25, indicated Resident #15 made himself understood and understood others. Resident #15's BIMS score was 15, which indicated his cognition was intact. The MDS indicated he received insulin over the 7-day look-back period. Record review of Resident #15's comprehensive care plan dated 08/16/23 indicated Resident #15 had diabetes mellitus. The care plan interventions were for staff to check his blood sugars, give diabetes medication as ordered, observe for adverse side effects and/or complications such as hypoglycemia. Record review of the physician order summary report, dated 10/23/25, reflected Resident #15 had an order for: -NovoLog Flex Pen Subcutaneous Solution Pen injector 100 units per milliliter (Insulin Aspart) Inject 20 units subcutaneously before meals for diabetes. -NovoLog Flex Pen Subcutaneous Solution Pen injector 100 units per milliliter (Insulin Aspart) Inject as per sliding scale: if 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 -450 = 10 units if over 400, contact primary physicians. Subcutaneously before meals and at bedtime, related to diabetes. During an observation and interview on 12/08/25 at 10:53 a.m., LVN K took Resident #15's blood sugar with a reading of 292. LVN K prepared Resident #15's Novolog by removing the pen cap, placing a needle onto the pen, and turning the dose knob to 24 units. LVN K administered the medication to Resident #15's right arm. LVN K did not prime (removing the air from the needle and cartridge) the insulin pen by turning the dose knob to 2 units before turning the dose knob to 24 units. LVN K said she was unaware she needed to prime the insulin before administering Resident #15's insulin. LVN K said after being questioned that she could see the importance of priming the insulin pen to ensure the resident received the correct dosage of insulin, which could have led to uncontrolled diabetes. 2. Record review of Resident #26's face sheet dated 1210/25, indicated a [AGE] year old female who admitted to the facility on [DATE] with diagnoses which included heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), high blood pressure, kidney failure ( a condition in which one or both of your kidneys no longer work on their own), and diabetes mellitus type 2 (also known as diabetes, a chronic disease that occurs when the body has high blood sugar levels. Record review of Resident #26's annual MDS assessment dated [DATE], indicated Resident #26 understood and was understood by others. The MDS assessment indicated Resident #26 had a BIMS score of 11, indicated her cognition was moderately impaired. The MDS assessment indicated Resident #26 had received an antiplatelet medication within the last 7 days of the look-back period. Record review of Resident #26's comprehensive care plan revised on 09/03/25, indicated Resident #26 was taking an anticoagulant related to her disease process of high blood pressure, heart issues, and kidney disease. The care plan interventions were for staff to give diabetes medication as ordered by the doctor. Record review of Resident #26's order summary report dated 06/01/25, indicated Resident #26 had an order for the following: Aspirin Oral Tablet 325 MG (Aspirin). Give 1 tablet by mouth in the morning for the heart. During an observation on 12/09/25 at 9:59 a.m., RN B checked the MAR for Resident #26 and then gave 1 tablet of Aspirin 81mg. During an interview on 12/09/10 at 12:58 p.m., RN B said she gave Resident #26, 1 tablet of Aspirin 81 mg. She said that since the order read to give 1 tablet of Aspirin 325mg, but she gave 1 tablet of Aspirin 81mg, she gave the wrong dose. She said she pulled the wrong bottle, and the risk could affect her clotting factor. 3.Record review of Resident #27's face sheet dated 12/10/25, indicated an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included vitamin B deficiency (occurs when your body lacks sufficient B vitamins, leading to symptoms like extreme fatigue, weakness, pale skin, mood changes (depression, irritability), numbness/tingling, mouth sores, and cognitive issues (memory problems, confusion), and dementia (a loss of mental functions that is severe enough to affect your daily life and activities). Record review of Resident #27's quarterly MDS assessment dated [DATE], indicated Resident #27 understood and was understood by others. The MDS assessment indicated Resident #27 had a BIMS score of 05, indicating his cognition was severely impaired. The MDS assessment did not indicate Resident #27 had received Cyanocobalamin. Record review of Resident #27's comprehensive care plan revised on 08/25/25, indicated Resident #27 had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to dementia. The care plan interventions were for staff to give medication as ordered by the doctor. Record review of Resident #27's order summary report dated 05/30/25, indicated Resident #27 had an order for the following: Cyanocobalamin Tablet 1000 MCG. Give 2.5 tablets by mouth in the morning for the supplement; take 2.5 tabs to equal a 2500 mcg dose. During an observation on 12/09/25 at 10:07 a.m., RN B checked the MAR for Resident #27 and then gave 2.5 tablets of Cyanocobalamin 500 Mcg. During an interview on 12/10/10 at 12:47 p.m., RN B said she gave Resident #27, 2.5 tablets of Cyanocobalamin 500 Mcg. She said that since the order read to give 2.5 tablets of Cyanocobalamin 1000 Mcg, she gave 2.5 tablets of Cyanocobalamin 500 Mcg, she gave the wrong dose. She said the failure was she gave the wrong ordered dosage, and he did not receive the therapeutic dose he needed. During an interview on 12/10/25 at 7:00 p.m., the DON said she expected nurses to give insulin and other medication correctly. The DON said she expected the nurses to read the MAR and give medication as ordered. The DON said she was not sure of what the policy said on insulin pen administration, but after reading the manufacturer's insert on insulin pens, she said she would do an in-service about priming the insulin pens before each use. She said if the pen was malfunctioning, then a resident might not receive the correct dose of insulin, which could make their blood sugar level rise, and if they did not receive the ordered dose, they may not be receiving the therapeutic dose. During an attempted phone interview on 12/10/25 at 7:30 p.m., the Administrator was unsuccessful. Record review of the undated facility's Licensed Nurse Skills Review indicated #1 Perform hand hygiene, #2 Check the physician's order for insulin, #5 Prepare injection: attach the needle, remove the needle cap, check the flow of delivery (air shot) with a 2 unit prime every time and then select the dosage. Record review of the facility's policy titled, Medication-Treatment Administration and Documentation Guidelines, revised 04/06/23, indicated To provide a process for accurate, timely administration and documentation of medication and treatment. Fundamental information: medications are administered according to the manufacturer's guidelines unless otherwise indicated by physician orders. Process: #1 Verify labels accurately reflect the physician's orders on the electronic medical administration record before administering residents' medications and treatment, #2 verify administration accuracy by checking the medication with the MAR three times, #4 administer the medication according to the physician's order. Record review of the manufacturer's policy titled Insulin Aspart Recombinant Novolog, indicated, Insulin was a fast-acting type of insulin. Insulin is one of many hormones that help the body turn the food we eat into energy. To use the flex pen or flex touch pen: #1 wash your hands, #2 primed the pen by removing the air from the needle and cartridge, Select 2 units when turning the dose knob, #3 hold the pen with the needle pointing up then gently tap the cartridge holder to collect the air bubbles at the top, #4 press the push button until it stops you should see a zero in the dose window, #5 you should see insulin at the needle tip if you do not see anything repeat the priming steps but not more than six times if there is still no answer do not use the pen.#6 turn the dose selector, be careful not to press the button #7 insert the needle into your skin and press the push button all the way in for at least 6 seconds. Keep pressing until the needle has pulled out from the skin. This will make sure that you have received the full dose.

Based on observations, interviews, and record reviews, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 9 of 9 confidential residents reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and had an appetizing temperature on 12/09/25. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.Findings included: During a confidential resident group meeting 9 residents stated the food was lousy and cold. During an observation and interview on 12/09/25 at 12:16 p.m., lunch tray was sampled by the Dietary Manager and six surveyors. The sample tray consisted of chili bake which was lukewarm, carrots which were lukewarm, and salad was brown, soggy and withered. The Dietary Manager stated the chili bake and carrots was good to her, and salad was alright. During an interview on 12/10/25 at 4:37 p.m., CNA L stated residents had stated the food was not that great. CNA L stated she was unable to recall the resident's name. CNA L stated when they complained she would try to season the food with the salt and pepper that was given on the tray or offer the resident an alternative. CNA L stated she did not report the complaints to anyone. CNA L stated residents not eating their food could potentially cause weight loss. During an interview on 12/10/25 at 4:51 p.m., the ADON stated no residents complained to her about food being cold or bland but if so, she would offer the resident an alternative. The ADON stated all food complaints would be reported to the DON and Dietary Manager. The ADON stated it was important to ensure food was palatable and had an appetizing temperature to ensure the residents get the nutrition they need. During an interview on 12/10/25 at 6:08 p.m., the Dietary Manager stated she has not had any complaints regarding food being cold or food tasting bland in the last several months. The Dietary Manager stated food complaints were usually brought to her verbally and an alternative would be offered. The Dietary Manager stated she monitored meal service daily including random tray sampling. The Dietary Manager stated it was important to ensure food was palatable and had an appetizing temperature to prevent weight loss. During an interview on 12/10/25 at 6:54 p.m., the DON stated she expected food to be the appropriate temperature and seasoned for palatability. The DON stated the Administrator was responsible for monitoring and overseeing. The DON stated it was important to ensure food was palatable and had an appetizing temperature to keep up their nutrition and quality of life. An attempted telephone interview on 12/10/25 at 7:30 p.m., with the Administrator was unsuccessful. Record review of the facility's policy titled Dietary Services Manager's Responsibility revised 01/2013 indicated. The Dietary Service Manager or designee is responsible for ensuring proper preparation of food by methods that conserve nutritive value, flavor and appearance. 2. The dietary service manager or designee should taste all foods prior to serving. 3. The dietary service manager or designee should see that all meals are presented in a manner that enhances plate appearance.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed. The facility did not ensure:1. Food items were labeled and dated.2. Hair restraints were worn. 3. The kitchen staff had a Soap dispenser located in a place that did not prevent the staff contaminating the clean dish rack. These failures could place residents at risk for foodborne illness.Findings included: During the initial tour observation and interview with the Dietary Manager on 12/08/25 beginning at 11:02 a.m., the following was revealed: 1. Two cans of cut sweet potatoes undated. During an observation on 12/08/25 at 11:05 a.m., the soap dispenser was located over the clean dish rack next to the three-compartment sink. During an observation on 12/08/25 at 11:10 a.m. [NAME] O, [NAME] P and Dietary Manager hairnet were not covering her entire head while she prepared the lunch meal. There was loose hair sticking out. During an interview on 12/10/25 at 5:09 p.m., Dietary Aide F stated all staff were responsible for labeling and dating. Dietary Aide F stated hair nets should always be worn while in the kitchen and cover the entire head without loose hair sticking out. Dietary Aide F stated these failures could potentially put residents at risk for food borne illness and cross contamination. During an interview on 12/10/25 at 5:18 p.m., [NAME] Q stated all staff were responsible for labeling and dating. [NAME] Q stated hair nets should always be worn while in the kitchen and hairnets were supposed to cover the entire head without loose hair sticking out. [NAME] Q stated these failures could potentially put residents at risk for foodborne illness and cross contamination. An attempted telephone interview on 12/10/25 at 5:21 p.m., with [NAME] O was unsuccessful. An attempted telephone interview on 12/10/25 at 5:25 p.m., with [NAME] P was unsuccessful. During an interview on 12/10/25 at 6:08 p.m., the Dietary Manager stated cleanliness was important in the kitchen, so staff were not spreading germs or contaminating anything. The Dietary Manager stated she was responsible for making sure the kitchen was cleaned appropriately. The Dietary Manager stated all food should be dated by the date received. The Dietary Manager stated hair nets should be worn while in the kitchen and covering the entire head without loose hair sticking out. The Dietary Manager stated the soap dispenser should not be over the clean dishes. The Dietary Manager stated she had reported to the department head about moving the soap dispenser. The Dietary Manager stated she was unable to recall names. The Dietary Manager stated she was responsible for monitoring and overseeing daily walk throughs and when there was an isolated issue that staff were verbally in service. The Dietary Manager stated these failures could potentially put residents at risk for cross contamination and foodborne illness. An attempted telephone interview on 12/10/25 at 6:22 p.m., with the Dietitian was unsuccessful. During an interview on 12/10/25 at 6:54 p.m., the DON stated food items should be dated. The DON stated hair nets should be worn while in the kitchen and covering the entire head without loose hair sticking out. The DON stated the soap dispenser should not be over the clean dish rack. The DON stated the Administrator was responsible for monitoring and overseeing. The DON stated these failures could potentially put residents at risk for cross contamination and foodborne illness. An attempted telephone interview on 12/10/25 at 7:30 p.m., with the Administrator was unsuccessful. Record review of the facility's policy titled Dietary Services Manager's Responsibility revised 01/2013 indicated. The Dietary Service Manager or designee is responsible for ensuring proper preparation of food by methods that conserve nutritive value, flavor and appearance.6. The dietary service manager or designee must ensure that dietary staff practice hygienic food handling techniques at all times. Record review of the facility's policy titled Dry Food and Supplies Storage revised 11/15/17 did not address dating food that was in its original container.

Based on interview and record review, the facility failed to ensure residents the right to participate in the development and implementation of his or her person-centered plan of care for 1 of 6 residents (Resident #47) reviewed for care plans.The facility failed to invite and include the input of Resident #47 and/or the resident's representative as members of the interdisciplinary team in Care Plan Conference meetings.This failure could place residents at risk of not receiving the interventions, treatments, and care necessary for the resident to reach their highest practicable physical, mental, and psychosocial well-being by not involving the resident and/or the resident's representative in Care Plan Conference meetings. The findings included:Record review of Resident #47's face sheet, dated 10/12/2025 revealed a [AGE] year-old female admitted [DATE] with diagnoses including cerebral infarction (occurs when a blood clot blocks an artery in the brain, cutting off oxygen and nutrients leading to brain tissue death) with Right sided weakness, hypertension (high blood pressure), dysphagia (difficulty swallowing), aphasia (difficulty speaking), and visuospatial deficits (difficulties with processing and interpreting visual information).Record review of Resident #47's comprehensive MDS dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Further review of Resident #47's comprehensive MDS dated [DATE] revealed Resident #47 presented with upper and lower extremity range of motion impairment, required a wheelchair for mobility, set-up assistance in self-feeding, was dependent in toilet hygiene, bathing and transfers, required moderate assistance in upper body dressing and maximum assistance in lower body dressing, and bed mobility. A record review of Resident #47's care plan revealed the care plan was initiated on 11/05/2025 and completed on 11/24/2025. The record did not include an invitation for Resident #47 and/or the Responsible Party to the care plan meeting or a signature sheet of attendees.During an interview on 12/08/2025 at 1:03 p.m., Resident #47 stated she talks a lot with the therapy staff but has not attended or been informed of a Care Plan Conference meeting with the Social Worker, Activity Director or nursing staff. Resident #47 stated she signed her own paperwork when she was admitted to the facility. During an interview on 12/11/25 at 9:09 a.m., Resident #47's family member stated that she was not invited to or informed of a Care Plan Meeting since Resident #47 was admitted . Resident #47's family member stated she was visiting Resident #47 on 12/10/25 when she was approached by the Social Worker to go to a meeting to discuss concerns the family member had addressed to the nurses over the previous weekend.During an interview on 12/10/25 at 5:20 PM, the MDS Nurse stated that a Care Plan review was completed 11/24/25. The MDS Nurse stated neither the resident nor the family members were present at the review. The MDS Nurse stated that she believes the Social Worker is responsible for inviting the resident or the family to the meetings. The MDS Nurse stated that failure to include residents in their plan of care could result in them not being fully aware of their medications, treatments and rights.During an interview on 12/10/2025 at 5:23 p.m., the Social Worker stated that a Care Plan meeting was held this morning with Resident #47's family members. The Social Worker stated that this was an impromptu meeting when she was notified that the family had some concerns and that they were present in the facility. The Social Worker stated that she is responsible for informing and inviting residents and/or responsible parties to the Care Plan conference meeting which should be completed within three weeks of admission. The Social Worker stated a Care Plan review was already completed for Resident #47 and she failed to invite the resident or responsible party to the review meeting. The Social Worker stated that she should have notified Resident #47 of the care plan review meeting, that it is important to involve the Resident in the meetings to ensure he/she is aware of all aspects of his/her care and failure to include them could result in missing some important concerns about care.During an interview on 12/10/25 at 6:54 p.m., the DON stated that a baseline care plan should be completed within 72hours of admission and a full care plan should be completed by day 21 of the resident's stay. The DON stated she expects the Interdisciplinary Team Members to include the Social Worker and MDS Nurse to ensure the resident and/or their Responsible Party participate in the care plan conference meeting either in person or by phone if necessary to ensure they are informed of the care plan findings and involved in the plan of care. The DON stated adverse effect of residents or their representative not attending and participating in review meetings would be that decisions could be made that the resident and/or representative were not aware of or were not congruent with their wishes.An interview was attempted on 12/10/25 at 7:31 p.m. with the Administrator, however she was not available for interview.Review of facility policy titled Care Plan Guidelines, Revised 05/06/2016, revealed, 1. Meetings will be conducted within 21 days of admission, 2. The meetings will be scheduled by the Social Worker, and 3. The Social Worker will send out invitation letters to the resident, family member, responsible party.

Based on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Residents #15 and #19) reviewed for Medicare/Medicaid coverage. 1. The facility failed to ensure Resident #15 was given a NOMNC (is a notice that indicates when your care is set to end from a skilled nursing facility when discharged from skilled services prior to his covered days being exhausted. 2. The facility failed to ensure Resident #19 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. These failures could place residents at risk of not being aware of changes to services provided. Findings include: 1. Record review of Resident #15's face sheet, dated 12/10/25, reflected Resident #15 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included transient cerebral ischemic attack (stroke). Record review of Resident #15's quarterly MDS assessment, dated 11/26/25, reflected Resident #15 made himself understood and understood others. Resident #15's BIMS score was 15, which indicated his cognition was intact. Record review of Resident #15's SNF Beneficiary Notification Review reflected Resident #15 received Medicare Part A skilled services on 07/20/25, and the last covered day of Part A services was 08/15/25. The facility/provider initiated the discharge from Medicare Part A services when benefits were not exhausted. It was reflected that a NOMNC was not completed which would have informed Resident #15 about the termination, including the reason and his right to appeal the decision. 2. Record review of Resident #19's face sheet, dated 12/10/25, reflected Resident #19 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of Resident #19's quarterly MDS assessment, dated 10/13/25, reflected Resident #19 usually made herself understood and usually understood others. Resident #19's BIMS score was 8, which indicated her cognition was moderately impaired. Record review of Resident #19's SNF Beneficiary Protection Notification Review indicated Resident #19 was receiving Medicare Part A services starting on 10/07/25, and the last day covered of Part A services was 10/13/25. It was reflected that a SNF ABN was not completed, which would have informed Resident #19 of the option to continue services at the risk of out-of-pocket. During an interview on 12/10/25 at 8:59 a.m., the MDS Coordinator stated she was responsible for ensuring Resident #19 was issued a SNF ABN. The MDS Coordinator stated Resident #19 had 93 skilled benefit days remaining. The MDS Coordinator stated she was unaware a SNF ABN and NOMNC should be issued. The MDS Coordinator stated the previous MDS Coordinator would have been responsible for ensuring Resident #15 was issued a NOMNC. The MDS Coordinator stated Resident #15 had 73 skilled benefit days remaining. The MDS Coordinator stated the form should have been issued if the resident had skilled benefit days remaining and was being discharged from Part A services and continued in the facility. The MDS Coordinator stated the Regional Operations Director was responsible for monitoring and overseeing. The MDS Coordinator stated it was important for the residents to receive the form so they would know how many days they had left and what they were responsible for. An attempted telephone interview on 12/10/25 at 5:00 p.m., with the Regional Operations Director was unsuccessful. During an interview on 12/10/25 at 6:54 p.m., the DON stated she expected the SNF ABN and NOMNC to be given when the resident had skilled benefit days remaining and was being discharged from Part A services and continued in the facility. The DON stated it was important for the residents to receive the forms to inform them about their care. An attempted telephone interview on 12/10/25 at 7:30 p.m., with the Administrator was unsuccessful. Record review of the facility's policy titled Beneficiary Notices of Non-Coverage revised 05/30/2018 indicated. it is the intent of named company to abide by the Federal regulations that pertain to issuance of Advanced Notification of Non Coverage when it is believed that Medicare will not pay for services or items not meeting the criteria for skilled care that is no longer reasonable or necessary, or is considered custodial care. the purpose of this guide is to ensure that the correct form(s) for each situation are delivered in timely manner. SNFABN (1) Beneficiary drops to a non-skilled of care and benefits have not exhausted and remains in the facility. Notice of Medicare Non-coverage (1) Beneficiary drops to a non-skilled of care and benefits have not exhausted and remains in the facility.

Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans.The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #1 to address the resident's communication deficit.This failure could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs.The findings were:Record review of Resident #1's face sheet dated 12/10/2025 revealed a [AGE] year-old female originally admitted [DATE] and readmitted [DATE] with diagnoses including aphasia (difficult speaking), slurred speech, legal blindness, cerebral infarction (occurs when a blood clot blocks an artery in the brain, cutting off oxygen and nutrients leading to brain tissue death) with right sided weakness, and hypertension (high blood pressure).Record review of Resident #1's comprehensive MDS dated [DATE] revealed a BIMS Score of 9 indicating moderate cognitive impairment, had unclear speech, was sometimes understood and understands others. Further review of Resident #1's comprehensive MDS assessment dated [DATE] revealed Resident #1 presented with upper and lower extremity range of motion impairment, was bedfast (did not get out of bed during assessment period), and was totally dependent in all activities of daily living to include eating, dressing, toileting, bathing, transfers and mobility.Record review of Resident #1's comprehensive care plan with target completion date 11/07/2025 revealed there was not a care plan addressing the resident's communication deficit.During an interview and observation of Resident #1 on 12/08/2025 at 2:05 p.m. and on 12/09/2025 at 12:01 p.m., Resident #1 responded to surveyor questions with head nods and facial expressions only, with no attempt at verbal communication.During an interview on 12/09/2025 at 9:58 a.m., CNA A stated that Resident #1 does not speak and will use head nods to communicate her needs.During an interview on 12/10/2025 the Social Worker stated that she does feel Resident #1 has a communication problem and will use head nods, hand gestures and facial expressions to communicate. The Social Worker stated that she is responsible for completing the communication section of the MDS, but that the MDS Nurse is responsible for completing the care plan focus problems based off the Care Area Assessment Summary. The Social Worker stated that the risks for not identifying communication deficits on the care plan could mean the resident's needs are not being met.During an interview on 12/10/2025 at 3:00 p.m., the MDS Nurse stated that Resident #1's last care plan review was completed 11/12/2025 and the Interdisciplinary Team members did not catch that communication was not identified in the plan of care. The MDS Nurse stated that failure to identify communication deficits in the plan of care could result in the resident's needs not being met if the staff do not know how to communicate properly with her.During an interview on 12/10/2025 at 6:54 p.m., the DON stated that the care plan for Resident #1 should have included a communication focus problem with appropriate interventions specific to this resident. The DON stated she expects the Interdisciplinary Team members to accurately complete a plan of care reflecting the resident needs. The DON stated that she is ultimately responsible for the accuracy and completeness of the care plans.An interview was attempted on 12/10/25 at 7:31 p.m. with the Administrator, however she was not available for interview.Record review of the facility policy titled Comprehensive Care Plans, Revised 09/04/2024, revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the resident's comprehensive assessment.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish based on the comprehensive assessment and consistent with the resident's needs and choices for 1 of 2 residents (Resident #48) reviewed for activities of daily living. The facility failed to provide communication assistance to effectively communicate with staff for Resident #48. This failure could place residents at risk for decline and diminished quality of life.Findings included: Record review of Resident #48's face sheet dated 12/10/25 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses Down syndrome (genetic condition leading to developmental delays), epilepsy (neurological condition marked by recurrent seizures), and cognitive communication deficit (struggle in communication due to cognitive problems). Record review of Resident #48's admission MDS dated [DATE] indicated he usually understood others and could usually make himself understood. The MDS also indicated he had a BIMS score of 99 because he was unable to complete the assessment and he had moderately impaired cognition. The MDS also indicated Resident #48 required set up assistance with eating, maximal assistance with bathing, supervision with toileting and transfers, and was independent with bed mobility. Record review of Resident #48's care plan dated 10/28/25 indicated Resident has a communication deficit: nonverbal status related to severe intellectual disabilities with interventions to Ensure availability and functioning of adaptive communication equipment: Communication/Message Board. Record review of the facility's undated document titled Communication with non-oral communication devices or sign language indicated Resident #48 required a communication board for communication. During an observation and interview on 12/08/25 at 3:05 PM Resident #48 was lying in bed and slightly smiled when asked questions but did not respond to surveyor. There was no communication tools noted, and roommate was unaware of any ever being used. During an observation and interview on 12/09/25 at 10:22 AM Resident #48 had no communication board in the room. Surveyor attempted to ask questions to Resident #48 but could not get Resident #48 to nod yes or no for any questions. During an observation and interview on 12/10/25 at 4:03 PM CNA N said Resident #48 was more hands on than verbal. CNA N said Resident #48 understood what the staff said, but he did not communicate back except for scrunching his nose. CNA N said Resident #48 had never had a communication board that she was aware of. CNA N said if Resident #48 had a communication board, it would have been in his bedside drawer. CNA N and surveyor looked in the bedside dresser drawers as well as bedside nightstand and no communication board was noted. CNA N said it would have been nice to have a communication board to tell if Resident #48 was hurting and where he was hurting or to know what type of food he really likes. During an interview on 12/10/25 at 4:14pm LVN D said she had never seen a communication board in Resident #48's room. If he had one, it would be located by the bed. LVN D said Resident #48 should have an order or a care plan if he was supposed to have one. LVN D showed the surveyor the care plan, and it was noted in the care plan that Resident #48 should have had a communication board as adaptive communication device. LVN D said no one had mentioned anything about a communication board to her. LVN D said she would speak with the DON and let her know right away so the facility could get a communication board in place. During an interview on 12/10/25 at 5:43 PM Resident #48's family member said she visits Resident #48 once a week and she felt like the staff did a good job taking care of him. She said she had never seen a communication board in Resident #48's room but she wished Resident #48 had a communication board. During an interview on 12/10/25 at 7:11 PM the DON said the facility ordered a communication board and it was in the facility especially for him prior to his admission on [DATE]. The DON said she was responsible as well as CNAs should have been responsible for ensuring the communication board was always available but no one ever notified her of the communication board being missing. The DON said the failure placed a risk for the resident not being able to communicate his needs. Record review of the facility undated policy Communication and Interpersonal Skills indicated:Communication- exchanging information with others. The process could be sent or received through verbal or by non-verbal means.Non-verbal communication is communicating without using words. Non-verbal can use behavior, body language, facial expressions, and attitudes or emotions. Example, resident pointing to a cup of water. The policy did not indicate use of a communication board.

Based on interview, observation, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status and is offered sufficient fluid intake to maintain proper hydration and health for 2 of 5 residents (Resident #13 and Resident #19) reviewed for nutrition. 1.The facility failed to ensure Resident #13 had water in his cup to drink on 12/08/25 and 12/09/25. 2. The facility did not ensure Resident #19 was given a shake as ordered by the physician. This failure could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization.Findings included: 1.Record review of Resident #13's face sheet dated 12/10/25 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses diabetes mellitus (condition that causes the blood sugar to be elevated), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), obstructive and reflux uropathy (a blockage of urine flow, causing backup and kidney damage, pain, and infection), and muscle weakness. Record review of Resident #13's admission MDS assessment dated [DATE] indicated he understood others and was able to make himself understood. The MDS also indicated he had a BIMS score of 11 which meant he had moderate cognitive impairment. The MDS also indicated he was dependent on staff for toileting and bathing, he required moderate assistance with bed mobility and required set-up assistance with eating. The MDS also indicated he was on a mechanically altered diet that required change in texture of food or liquids. Record review of Resident #13's care plan revised on 12/05/25 indicated Resident #13 was on a no restrictions, mechanical soft, and with nectar thickened liquids diet with a goal to maintain adequate hydration and interventions to provide nectar thickened liquids as ordered. Record review of Resident #13's order summary report dated 12/10/25 indicated he had orders for: 1)Restrictions diet Mechanical Soft texture, Mildly Thick-Nectar consistency with a start date of 12/03/25 and no end date. 2) This resident is at risk for malnutrition due to sepsis (medical emergency related to the body response to a severe infection) with a start date of 11/25/25 and no end date. During an observation and interview on 12/08/25 at 11:35 AM Resident #13 was sitting up in his wheelchair visiting with a family member and had no water in his room. He said the facility made axle grease (which was what he called thickened liquids) but they did not leave any in the room for him to drink. Resident #13 said he never had water except on his food trays and he was worried because he had a urinary tract infection while in the hospital. Resident #13 said he was not offered fluids any other times. During an observation on 12/09/25 at 10:38 AM the physical therapist was in Resident #13's room working with him, but he continued to have no water in his room to drink. During an observation on 12/10/25 at 8:38 AM Resident #13 was out of his room but he did not have any water at his bedside. During an interview on 12/10/2025 at 11:33 AM CNA H said the dining room sends out fluids with their meals, and the nurse gives them fluids with their medications. She said she was told that they cannot leave thickening fluids in their room. She said if Resident #13 asked for fluids in between those times, she would have to go to the nurse and ask her to give her some thickened fluids. She said she would ask him if he wanted a drink, and he would drink it. She said she felt they could stay hydrated on their own if fluids were left in the room. CNA H said the failure placed residents at risk for dehydration. During an interview on 12/10/2025 at 2:10 PM, LVN M said the dietary staff does not deliver the thickened liquids to them at snack times. She said today (12/10/25) was the first time she had seen them being delivered. During an interview on 12/10/25 at 7:14 PM the DON said it was not their policy to have the water at the bedside all the time because it could change consistency. The DON said the facility staff used to leave the thickened water at the bedside and the company changed it to where the staff were not supposed to leave it. The DON said the CNAs were supposed to bring out water for residents daily at 10:00 AM, 2:00 PM, and 8:00 PM for hydration. The DON said the failure placed Resident #13 at risk of not having water when he wants it, but he has not had an issue with dehydration. An attempted telephone interview on 12/10/25 at 7:30 p.m. with the Administrator was unsuccessful. Record review of the facility policy Hydration Fluid Maintenance dated October 2010 indicated: Anticipated Outcome 1. The facility will have a comprehensive program to provide adequate opportunity for fluid intake to each resident. Risk factors for a resident becoming dehydrated are: Coma/decreased sensorium (sensory apparatus) Fluid loss and increased fluid needs (e.g., diarrhea, fever, uncontrolled diabetes) Fluid Restriction Functional impairment that makes it difficult to drink, reach fluid or communicate fluid needs.10. There will be no water pitcher at bedside for residents who have ordered Fluid Restrictions, Thickened liquids and NPO. For residents, on thickened liquids containers of pre-thickened liquids may be kept at bedside in a resident's personal refrigerator or a small cooler. 2. Record review of Resident #19's face sheet, dated 12/10/25, reflected Resident #19 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of Resident #19's order summary report, dated 12/10/25, reflected ensure two times a day for supplement with a start date 10/24/25. Record review of Resident #19's quarterly MDS assessment, dated 10/13/25, reflected Resident #19 usually made herself understood and usually understood others. Resident #19's BIMS score was 8, which indicated her cognition was moderately impaired. Resident #19 was independent with eating. Resident #19 has not had 5% weight loss or more in the last month or loss of 10% or more in the last 6 months. Record review of Resident #19's comprehensive care plan, revised on 11/18/25, reflected Resident #19 was at risk for nutritional and hydration related to Alzheimer's, dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), BIMS score, and recent acute illness. The care plan interventions included: provide, serve diet as ordered, and provide ensure as ordered. During an observation, interview and record review on 12/08/25 at 12:25 p.m., Resident #19 did not receive a shake with her lunch meal. The meal ticket reflected 4 oz of a nutritious shake. Resident #19 stated she was supposed to get a milk shake with her meals. During an interview on 12/08/25 at 3:02 p.m., CNA E stated the nurse must check the trays prior to passing them out to the residents to make sure the residents received the right diet. CNA E stated the DON had stepped away and the dietary staff stated it was ok to take the tray to Resident #19. CNA E stated it was important for residents to receive their milk shake to prevent weight loss. During an interview on 12/09/25 at 12:51 p.m., Dietary Aide F stated she was responsible for ensuring the milkshake was on the tray prior delivering to the residents. When asked why she did not ensure a milkshake was placed on a tray, Dietary Aide F stated, it was a mistake. Dietary Aide F stated it was important for residents to receive their milk shake to prevent weight loss. During an interview on 12/10/25 at 6:08 p.m., the Dietary Manager stated the aide was responsible for ensuring the residents receive the milkshake. The Dietary Manager stated she monitored meals by watching meal service daily. The Dietary Manager stated there has not been any issues in the past 3 months regarding residents not receiving the correct diet. The Dietary Manager stated it is important to ensure the residents were on the correct diet to prevent weight loss. During an interview on 12/10/25 at 6:54 p.m., the DON stated she expected the physician diet order to be followed. The DON stated she did not check Resident #19's tray prior to CNA E giving it to her. The DON stated the CNA E should have waited on her to come back before delivering the tray. The DON stated she monitored by weekly and random dining room rounds to ensure diet orders were followed. The DON stated there have been issues in the past, but staff were immediately in-serviced verbally. The DON stated it was important to receive the correct diet to give extra nutrition. An attempted telephone interview on 12/10/25 at 7:30 p.m., with the Administrator was unsuccessful. Record review of the facility's policy titled Menu Planning Guidelines and Procedure revised 07/12/24 indicated. Menus will be followed and served as written.

Based on observation, interviews, and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 1 resident (Resident #15) reviewed for insulin administration. The facility did not ensure LVN K administered Resident #15's Novolog (insulin medication) according to the manufacturer's instructions on 12/08/25. This failure could place residents at risk of medical complications and prevent them from receiving the therapeutic effects of their medications. Findings included: Record review of Resident #15's face sheet, dated 12/10/25, reflected Resident #15 was a [AGE] year-old male, admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Type 2 diabetes mellitus (lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels), stroke, and high blood pressure Record review of Resident #15's quarterly MDS assessment, dated 11/26/25, indicated Resident #15 made himself understood and understood others. Resident #15's BIMS score was 15, which indicated his cognition was intact. The MDS indicated he received insulin over the 7-day look-back period. Record review of Resident #15's comprehensive care plan dated 08/16/23 indicated Resident #15 had diabetes mellitus. The care plan interventions were for staff to check his blood sugars, give diabetes medication as ordered, observe for adverse side effects and/or complications such as hypoglycemia. Record review of the physician order summary report, dated 10/23/25, reflected Resident #15 had an order for -NovoLog Flex Pen Subcutaneous Solution Pen injector 100 units per milliliter (Insulin Aspart) Inject 20 units subcutaneously before meals for diabetes. -NovoLog Flex Pen Subcutaneous Solution Pen injector 100 units per milliliter (Insulin Aspart) Inject as per sliding scale: if 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 -450 = 10 units if over 400, contact primary physicians. Subcutaneously before meals and at bedtime, related to diabetes. During an observation and interview on 12/08/25 at 10:53 a.m., LVN K took Resident #15's blood sugar with a reading of 292. LVN K prepared Resident #15's Novolog by removing the pen cap, placing a needle onto the pen, and turning the dose knob to 24 units. LVN K administered the medication to Resident #15's right arm. LVN K did not prime (removing the air from the needle and cartridge) the insulin pen by turning the dose knob to 2 units before turning the dose knob to 24 units. LVN K said she was unaware she needed to prime the insulin before administering Resident #15's insulin. LVN K said after being questioned that she could see the importance of priming the insulin pen to ensure the resident received the correct dosage of insulin, which could have led to uncontrolled diabetes. During an interview on 12/10/25 at 7:00 p.m., the DON said she expected the nurse to take the resident's blood sugar and give the ordered dose of insulin. The DON said she did not know right off hand what the policy said on the administration of the insulin pen. The DON said she was unaware that the insulin pen needed to be primed before administering the insulin dose. She said she did a random medication pass, which included insulin administration, and she did not notice any issues. After reviewing the manufacturer's package insert, the DON said it was important to properly prime the insulin pen to prevent blood sugar issues. She said she would do an in-service on the proper way to prime the insulin pens. During an attempted phone interview on 12/10/25 at 7:30 p.m. with the Administrator was unsuccessful. Record review of the undated facility's Licensed Nurse Skills Review indicated #1 Perform hand hygiene, #2 Check the physician's order for insulin, #5 Prepare injection: attach the needle, remove the needle cap, check the flow of delivery (air shot) with a 2 unit prime every time and then select the dosage. Record review of the manufacturer's insert titled Insulin Aspart Recombinant Novolog, indicated that insulin is a fast-acting type of insulin. Insulin is one of many hormones that help the body turn the food we eat into energy. To use the flex pen or flex touch pen: #1 wash your hands, #2 primed the pen by removing the air from the needle and cartridge, Select 2 units when turning the dose knob, #3 hold the pen with the needle pointing up then gently tap the cartridge holder to collect the air bubbles at the top, #4 press the push button until it stops you should see a zero in the dose window, #5 you should see insulin at the needle tip if you do not see anything repeat the priming steps but not more than six times if there is still no answer do not use the pen.#6 turn the dose selector, be careful not to press the button #7 insert the needle into your skin and press the push button all the way in for at least 6 seconds. Keep pressing until the needle has pulled out from the skin. This will make sure that you have received the full dose.

Based on observation and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 25 residents (Resident #11) observed for medication storage. 1. The facility failed to ensure Resident #11 did not have hydrocortisone cream and Neosporin on his bedside table and dresser. These failures could place residents at risk for not receiving drugs and biologicals as needed, or overmedicating, .Findings include: Record review of Resident #11's face sheet dated 12/10/25 indicated he was a [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses PTSD (post-traumatic stress disorder), Dementia (cognitive decline that effects daily life caused by brain cell damage), major depressive disorder (persistent sadness, loss of interest, fatigue, and change in sleep/appetite), diabetes mellitus (chronic metabolism condition marked by high blood sugars), and presbyopia (natural age-related loss of eye's ability to focus on nearby objects). Record review of Resident #11's quarterly MDS dated [DATE] indicated he could make himself understood and was able to understand others. The MDS also indicated he had a BIMS score of 15 which meant his cognition was intact. The MDS also indicated he was independent with all ADLs. Record review of Resident #11's care plan dated 09/20/25 indicated he had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to Parkinsons with interventions to administer medications per physician orders and monitor. Record review of Resident #11's order summary report dated 12/10/25 indicated:Hydrocortisone External Cream 1 % (Hydrocortisone (Topical)) Apply to affected area topically every 12 hours as needed for itching apply thin layer to affected area with a start date of 10/30/2024 and no end date. The order summary report did not indicate an order for Neosporin. During an observation and interview on 12/09/2025 at 10:26 AM, Resident #11 had hydrocortisone cream 1% on his bedside table. Resident #11 said he used the hydrocortisone cream for places on his arm when he scratches, he said one of the nurses gave it to him. During an observation on 12/10/2025 at 8:42 AM, Resident #11 was out of the room and had hydrocortisone 1% cream in his room on his nightstand. During an interview on 12/10/2025 at 3:58 PM, LVN M said the facility did not have an order for anyone who kept medications at bedside. LVN M said Resident #11 should not have the hydrocortisone medication at his bedside. LVN M said the failure placed a risk for Resident #11 or any other resident getting the medication, eating it, using too much of the medication, getting the medication in their eyes, or putting the medication in the wrong place. LVN M said all the staff was responsible for ensuring there was no medications in the residents' room. During an interview on 12/10/2025 at 7:08 PM, the DON said she found the hydrocortisone 1% cream and a tube of Neosporin cream in Resident #11's room when she went to clean it out. The DON said Resident #11 had been told over and over that he could not have medications in his room. She said she expected the medications to be stored in the medication cart or the medication rooms. The DON said the staff make rounds daily and all staff was responsible for ensuring the medications was not in Resident #11's room. The DON said the failure placed a risk to having other residents coming in Resident #11's room and ingest it or Resident #11 could have taken or used too much. An attempted telephone interview on 12/10/25 at 7:30 p.m., with the Administrator was unsuccessful. Record review of the facility policy Medication Storage dated 1/20/21 indicated: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.

Based on observations, interviews, and record reviews, the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 of 5 (Resident #19) residents reviewed for special eating equipment and assistance when consuming meals. The facility failed to ensure Resident #19 had a physician's ordered cup with lid for drinking fluids. This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem.Findings included:Record review of Resident #19's face sheet, dated 12/10/25, reflected Resident #19 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of Resident #19's order summary report, dated 12/10/25, reflected regular texture, thin consistency, fortified foods, and cup with lid and straws with every meal with a start date 10/07/25. Record review of Resident #19's quarterly MDS assessment, dated 10/13/25, reflected Resident #19's usually made herself understood and usually understood others. Resident #19's BIMS score was 8, which indicated her cognition was moderately impaired. Resident #19 was independent with eating. Resident #19 has not had 5% weight loss or more in the last month or loss of 10% or more in last 6 months. Record review of Resident #19's comprehensive care plan, revised on 11/18/25, reflected Resident #19 was at risk for nutritional and hydration related to Alzheimer's, dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), BIMS score, and recent acute illness. The care plan interventions included: provide, serve diet as ordered, and provide ensure as ordered. During an observation and interview on 12/08/25 at 12:25 p.m., Resident #19 did not receive a lid with her cup. Resident #19 stated she did not know if she needed a lid or not. During an interview on 12/08/25 at 3:02 p.m., CNA E stated the nurse must check the trays prior to passing them out to the residents to make sure the residents received the right diet. CNA E stated the DON had stepped away and the dietary staff stated it was ok to take the tray to Resident #19. CNA E stated it was important for Resident #19 to receive a lid on her cup to prevent spillage. During an interview on 12/09/25 at 12:51 p.m., Dietary Aide F stated she was responsible for ensuring a lid was on the cup prior to delivering to Resident #19. When asked why she did not ensure a lid was on the cup, Dietary Aide F stated, it was a mistake. Dietary Aide F stated it was important for Resident #19 to receive a lid on her cup to prevent spillage. During an interview on 12/10/25 at 6:08 p.m., the Dietary Manager stated the aide was responsible for ensuring the residents receive a lip on their cup. The Dietary Manager stated she monitored meals by watching meal service daily. The Dietary Manager stated there has not been any issues in the past 3 months regarding residents not receiving the correct diet. The Dietary Manager stated it is important to ensure the residents receive a lid on the cup to prevent spillage which could cause a dignity issue. During an interview on 12/10/25 at 6:54 p.m., the DON stated she expected the physician diet order to be followed. The DON stated she did not check Resident #19's tray prior to CNA E giving it to her. The DON stated the CNA E should have waited on her to come back before delivering the tray. The DON stated she monitored by weekly and random dining room rounds to ensure diet orders were followed. The DON stated there have been issues in the past, but staff were immediately in-service verbally. The DON stated it was important to receive the correct diet to prevent spillage. An attempted telephone interview on 12/10/25 at 7:30 p.m., with the Administrator was unsuccessful. Record review of the facility's policy titled Menu Planning Guidelines and Procedure revised 07/12/24 indicated. Menus will be followed and served as written.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #13) room reviewed for infection control practices and enhanced barrier precautions. 1) The facility failed to ensure the Treatment nurse used the proper handwashing technique while providing wound care for Resident #13. 2) The facility failed to ensure the Treatment Nurse disinfected her scissors during wound care when she cut the dirty dressing and then cut the clean dressing with the contaminated scissors. These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the residents' quality of life.Findings included: Record review of Resident #13's face sheet dated 12/10/25 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses diabetes mellitus (condition that causes the blood sugar to be elevated), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), obstructive and reflux uropathy (a blockage of urine flow, causing backup and kidney damage, pain, and infection), and muscle weakness. Record review of Resident #13's admission MDS assessment dated [DATE] indicated he understood others and was able to make himself understood. The MDS also indicated he had a BIMS score of 11 which meant he had moderate cognitive impairment. The MDS also indicated he was dependent on staff for toileting and bathing, he required moderate assistance with bed mobility and required set-up assistance with eating. Record review of Resident #13's care plan dated 11/26/25 indicated he had a pressure ulcer and was at risk for infection, pain, and a decline in functional abilities with a goal to be free from infection and interventions to provide wound care per physician's order and keep dressing clean, dry, and intact. During an observation on 12/10/2025 at 3:15 PM the Treatment Nurse provided wound care to Resident #13's right heel. The Treatment nurse performed the wound care using aseptic technique. Prior to initiating wound care the Treatment Nurse performed hand hygiene using the sink in Resident #13's bathroom. When the Treatment Nurse turned off the water faucet, she used her bare hand/wrist. The Treatment Nurse was also observed between glove changes turning the faucet off with her bare hand/wrist and again at the completion of wound care prior to exiting the room the Treatment Nurse turned the water faucet off using her bare hand/wrist. During the wound care procedure the Treatment Nurse cleaned her scissors prior to the start of the procedure, but removed the soiled dressing from the patient's right heel using scissors, placed the dirty scissors back on the clean surface, and failed to clean or disinfect the scissors prior to being used to cut clean dressings before the clean dressings were applied to the open wound. During an interview on 12/10/25 at 3:52 PM the treatment Nurse said she felt as though she washed her hands excessively and she usually used the hand sanitizer in between glove changes. The Treatment Nurse said she should have turned the water off with her paper towel instead of her hand because she was re-contaminating her hands. The Treatment Nurse said she also failed to clean the scissors after she cut the dirty dressing off and before cutting the clean dressing. The Treatment Nurse said the failure placed a risk for recontamination or infection. During an interview on 12/10/2025 at 7:17 PM DON said her expectation was for the treatment nurse to use a paper towel to turn the water off and clean scissors between clean and dirty surfaces. The failure placed a risk for infection. An attempted telephone interview on 12/10/25 at 7:30 p.m. with the Administrator was unsuccessful. Record review of the facility policy Hand Hygiene dated 2/20/22 indicated: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.5. Hand hygiene technique when using soap and water:a. Wet hands with water. Avoid using hot water to prevent drying of skin.e. Dry thoroughly with a single-use towel f. Use clean towel to tum off the faucet. Record review of the facility policy Cleaning and Disinfecting Portable Equipment dated 5/4/21 indicated: Anticipated Outcome: It is the policy of this facility to follow infection control principles to prevent spread of infection through contact with portable equipment in the resident's care environment.2. Staff shall follow environmental infection control principles for cleaning and disinfecting the equipment.a. Each user is responsible for routine cleaning and disinfection. b. Cleaning shall be performed daily and between residents. c. Hard surfaces shall be cleaned with a cloth dampened with an approved cleaner/disinfectant (spray the cloth not the device) or a disposable pre-moistened cloth. Allow surfaces to air dry before reuse. (Follow manufacturer's instructions when selecting cleaning/disinfection products.).

Based on interview, and record review the facility failed to treat each resident with respect and dignity that promoted maintenance or enhancement of quality of life for 1 of 14 residents reviewed for resident rights. (Resident #12) 1. The facility failed to treat Resident #12 with dignity and respect witnessed by Resident #43 when CNA D told Resident #12 Oh no ma'am, we are not fixing to do this because I am not going to be the one on 03/25/24 with an attitude and rude tone . These failures could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings included: 1. Record review of a face sheet dated on 09/17/2024 reflected Resident #12 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of slurred speech (weakness in the muscles used for speech, which often causes slowed or slurred speech), anxiety disorder unspecified (a diagnosis given when someone experiences clinically significant anxiety but doesn't meet the criteria for a specific anxiety disorder), muscle weakness (lack of muscle strength), and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (a common after-effect of stroke that causes weakness on one side of the body). Record review of the quarterly MDS assessment dated [DATE] reflected Resident #12 had a BIMS score of 10, which indicated mild cognitive deficit. Resident #12 required maximal assistance for ADLs such as bed mobility, transfer, and toileting. Record review of a care plan dated 02/15/2024 titled ADL assistance reflected Resident #12 had an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner. The intervention for Resident #12 revealed the staff was to provide shower, shave, oral care, hair care, and nail care (prefers longer nails) per schedule and when needed with ADL's. Prefers nails long. Won't use hand splint/roll or let you paint fingernails right hand. During an interview on 09/16/204 at 10:47 a.m., Resident #43 said CNA D was rude to Resident #12. Resident #43 said Resident #12 tried to tell CNA D she was hurting her and grabbed her hand. CNA D grabbed Resident #12 hand an told her, Oh no ma'am you are not going to put your hands on me. Resident #43 said after that happened, she reported the incident to ADM and DON, and they took care of the situation. Resident #43 said the ADM and DON informed Resident #12 that she did not have to worry about anyone being mean to her here. Resident #43 said she thought CNA D does not work here anymore and she had not been back in their room since that incident. During an interview on 09/16/2024 at 3:17 p.m., Resident #12's family member stated there was an incident and she received information from the facility that a staff member had a bad attitude was rude to my mother. Resident #12 family member said she did not remember the details. During a phone interview on 09/17/24 1:32 p.m., CNA D said yes, I remember the incident with Resident #12. I weigh about 115 pounds. I wear a gait belt and it fits really loose, because I am so small. Resident #12 was very irritated that day I came in to work for someone else. I guess when I bent over to reposition her the metal part of the gait belt hit her and it made her upset. I apologized to her. Her oxygen nasal cannula was off and I was trying to put her stuffed animals back close to her and put her oxygen nasal cannula back on her face. She jerked the oxygen nasal cannula out of my hand and scratched me and I told her no ma'am; we are not going to do that, I am not going to be the one you put hands on today. CNA D said that was her first encounter with Resident #12. CNA D said she notified her charge nurse of the incident. CNA D said the nurse gave Resident #12 medication to relax her and after that she never went back into her room. CNA D said the facility fired her, so why are you calling me about the incident. CNA D said she was upset that day when she came in, because she was not informed by the facility staff that 5 residents on the hall, she was supposed to worked had Covid. During an interview on 09/18/2024 at 8:59 a.m., Resident #12 laid in bed awake. Resident #12 said she remembered CNA D. Resident #12 said CNA D hurt her feelings by the way she talked to her. Resident #12 said CNA D did not hit her. Resident #12 said she does feel safe at the facility. During an interview on 09/18/2024 at 9:10 a.m., LVN C said she knew CNA D. LVN C said when she worked with her, CNA D was a good aide. LVN C she had never heard CNA D be rude to staff or residents. LVN C said CNA D talked loud, but she was a good worker. LVN C said she was not there the day the incident occurred with CNA D and Resident #12. During an interview on 09/18/2024 at 9:32 a.m., CNA F said she remembered working with CNA D. CNA F said she had not witnessed CNA D be mean to the residents. CNA F said she had heard a couple of the residents said that CNA D had been rude to them. CNA F said Resident #43 told her that CNA D was rude, but she could not remember who the other resident was. CNA F said she had not seen CNA D be aggressive or mean toward the residents. During an interview on 09/18/2024 at 9:49 a.m., DON said CNA D does not work here anymore. DON said the facility had an investigation about the incident with CNA D and Resident #12 witnessed by Resident #43. DON said Resident #12 and Resident #43 agreed the incident was not abuse. DON said after spoke to the nurses at the facility; they agreed that CNA D had a bad attitude. DON said CNA D worked at the facility as a shower aide before she started to work as needed. DON said since CNA D came back to work for facility; she complained about where she worked. DON said she tried to keep the same staff with the same residents, because everyone was like family there. DON said she got rid of CNA D, because of her constant bad attitude; not from the incident with Resident #12 particularly. DON said she does not need a bad attitude in her building. DON said she believed CNA D was rude to Resident #12 and Resident #43 and both residents said she was rude that day. During an interview on 09/18/2024 at 2:30 p.m., DON said she thought an attitude with a resident was not acceptable. DON said she believed bedside manners was better than medication given to a resident. DON said we should watch what we say and how we treat people. DON said the incident could probably affected Resident #12's dignity. DON said Resident #12 had trouble with communication, so she does not know the extent the incident effected Resident #12. During an interview on 09/18/2024 at 2:39 p.m., ADM said, the facility let CNA D go, because if she was going to have a bad attitude and the resident felt that she was expressing that negative attitude to them, then she was not a good fit for this facility. ADM said she was sure the incident with CNA D made Resident #12 feel sad and she thought the incident shocked Resident #12. ADM said they had never had an incident like that happened at the facility. ADM said the incident could had infringed on Resident #12's dignity, but more than that she thought her feelings were hurt. ADM said the negative effect that incident could had on Resident #12 was it could had made her sad or upset. Review of a Resident Rights facility policy dated 02/20/2021 reflected, .All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex sexual orientation, or gender identity or expression.The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. These rights include the resident's right to .a dignified existence self-determination, and communication with and access to persons and services inside and outside the facility . Review of a Promoting/Maintaining Resident Dignity policy 02/16/2020 indicated, .It is the practice of the facility to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect.All staff members are involved in providing care to residents to promote and maintain resident dignity .

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident #24) reviewed for PASRR Level I screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #24. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (PTSD with an onset date of 04/16/21) was present upon Resident #24's re-admitted on 05/17/2024. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #24. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, after a new diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), with an onset date of 08/28/24. The facility did not complete a 1012 form to update the PASRR Level 1 with the new diagnosis until surveyor intervention on 09/17/2024. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #24's face sheet, dated 09/17/24, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. He was most recently readmitted to the facility on [DATE]. His diagnoses included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), with an onset date of 08/28/24, and post-traumatic stress disorder (a mental health condition that was caused by an extremely stressful or terrifying event), with an onset date of 04/16/21. Record review of Resident #24's quarterly MDS assessment, dated 08/06/24, indicated he had a BIMS score of 15, which indicated intact cognition. He also took an antidepressant medication during the assessment window. Record review of Resident #24's PASRR Level 1 Screening, printed on 07/07/23, indicated that in Section C Mental Illness was marked as no, which indicated Resident #24 did not have a mental illness. During an interview on 09/17/24 at 02:25 PM, Social Worker A said that Resident #24 was marked as negative for mental illness on his PASRR Level 1 screening. She said he had recently received a major depressive disorder diagnosis on 08/27/24. She said she did not know that PTSD could be a PASRR positive diagnosis. She said she was going to fill out a 1012 form to notify the local health authority of the resident's diagnosis change. During an interview on 09/18/24 at 02:14 PM, the Administrator said the PASRR Level 1 screening should have been marked yes for mental illness so the local health authority could evaluate him. She said it was possible he could have received PASRR services since August 28, 2024. Record review of the facility's policy, Preadmission and Screening Resident Review (PASRR) Rules, last revised July 2023, stated: .It is the intent of Advanced Health Care Solutions to meet and abide by all state and federal regulations that pertain to resident preadmission and screening resident review (PASRR) rules . .Referring Entity completes a PL1 . .if negative: .If the resident has a qualifying MI (mental illness) diagnosis and the NF feels the resident should be positive they should talk to the referring entity and ask them to correct the PL1 or complete the 1012 .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 6 residents reviewed for care plans. (Resident #28) The facility failed to implement Resident #28's signed physician order dated 03/31/2024 for occupational therapy to evaluate Resident #28 for a coffee lid. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. Findings included: 1. Record review of a face sheet dated on 09/17/2024 indicated Resident #28 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of exudative age-related macular degeneration, left eye, stage, (a severe form of the disease that occurs when abnormal blood vessels grow under the retina and leak fluid and blood), muscle weakness (generalized) (lack of muscle strength), unsteadiness on feet (might occur due to vestibular problems, nerve damage to the legs, and neurological conditions, such as spondylosis), unspecified lack of coordination (can be a symptom of ataxia, a neurological condition that causes problems with muscle control) and cognitive communication deficit (a difficulty with communication that's caused by a disruption in cognition). Record review of the quarterly MDS assessment dated [DATE] reflected Resident #28 had a BIMS score of 9, which indicated mild cognitive deficit. Resident #28 was independent for ADLs such as eating and toileting but required setup with transfers. Record review of a care plan dated 10/03/2023 titled Visual function (impaired) indicatedreflected, Resident #28 has impaired visual function and was at risk for falls, injury, and a decline in functional ability. The intervention for Resident #28 monitor/document/report to the physician the following signs and symptoms of acute eye problems: change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky pupils, complaints of halos around lights, double vision, tunnel vision, blurred vision, or hazy vision. Care plan date 09/19/2023 titled Falls indicated Resident #28 has the potential for falls related to severely impaired eyesight, generalized weakness, impaired coordination, anxiety, and history of falls while at home. Record review of Resident #28's nurses notes dated 03/30/2034 indicated Resident #28 had reported to the nurse, she had spilled a cup of coffee and received a small blister on her finger that did not require treatment. Resident #28 was educated on letting staff get her coffee. There were no witnesses to the incident. Record review of Resident #28's signed physician order dated on 03/31/2024 indicated Resident #28 was referred to occupational therapy for an evaluation for a lid to be place on coffee cup. Record review on Resident #28's Interdisciplinary Patient Screen dated 09/17/2024 indicated Resident #28, Patient was referred for screening in March 2024 and therapy was notified nursing recommended a screening for a cup lid, because of spill incident. Patient was screened by occupational therapy and based of observation and lack of any significant incident since no adaptive lid at this time. During observations on 09/16/2024 at 12:10 p.m., Resident #28 was eating lunch in dining area independently. Staff setup Resident #28's tray and told her where everything was on the tray before resident started to eat her meal. During an interview and observation on 09/17/2024 at 8:41 a.m., Resident #28 was observed transferred self from her wheelchair to her bed independently. Resident #28 said she did not remember telling anyone about incident where she spilled coffee on herself. Resident #28 said Honey, I'm blind and always spilling stuff on myself. Resident #28 said if there were staff in the dining room, she would let them get coffee for her. She said if there were no staff in the dining room and she wanted coffee then she would get it herself. She said there was 2 types of coffee containers, one had a pump on top and she had to wait on staff because she could not use it, but the other one had a lever, and she could use that fine. She said if she wanted coffee then she would go to get it, but she would let staff get it if they were there. She said she did not have a lid for her coffee but would not use one if she did. During an interview on 09/17/2024 at 9:10 a.m., COTA G was asked about Resident #28 orders for Refer to occupational Therapy to assess for a lid for a coffee cup. COTA G said Resident #28 had therapy before, but therapy had not received an order for a lid for a coffee cup evaluation, so there was no assessment performed. During an interview on 09/17/2024 at 9:20 a.m., The DON said if therapy does not have the assessment performed for an evaluation for the lid on the coffee cup, then the facility does not have one. DON said she did not know about the evaluation order and Resident #28 has not had any issues since the day she said she spilled the coffee. During a phone interview on 09/17/2024 at 10:06 a.m., MD said he expected the facility to follow his orders. MD said if the resident did not like the coffee cup lid he ordered, the facility could cancel the order for the coffee cup lid, but he wanted the orders followed. During an interview on 09/17/2024 at 10:54 a.m., LVN E said Resident #28 told her she spilled coffee on her finger earlier that day and had not told reported it to staff. LVN E said she asked Resident #28 why she did not report the incident to staff about she had spilled coffee on her finger. LVN E said Resident #28 told her she felt like it was not a big deal, and she felt like it was not important, but she told her friends about the (coffee spill) incident and they told Resident #28 she should have told the nurse, so she told LVN. E LVN E said she educated Resident #28 on when things happened in the future let staff know, so they can take care of it. LVN E said her intervention was to educate Resident #28 and to notify occupational therapy to maybe get a coffee cup with a lid. LVN C said all nurses were responsible to make sure doctor orders were followed. LVN E said she did not write an order for occupational therapy to evaluate Resident #28 for a cup with a lid; that was an intervention. LVN E said if she wrote an order, it was a mistake; it was supposed to be an intervention. During an interview on 09/18/2024 at 9:10 a.m., LVN C said when a nurse received an order from the doctor the nurse was responsible for following through with the order. LVN C said when doctor orders are put into point click care therapy were able to access the orders the nurse applied to the computer system. LVN C said the nursing staff usually informed therapy about the new doctor's orders verbally. LVN C said when a nurse wrote an order for an evaluation for therapy, it would be therapy responsibility to follow and initiate the order. LVN C said a signed doctor order should be followed. During a phone interview on 09/18/2024 at 9:49 a.m., the DON said the MD did not write the order for occupational therapy evaluation. LVN E called another MD for the order, but it was not an order. The DON said LVN E wrote an intervention. The DON agreed MD signed the order. The DON said the facility intervention was for Resident #28 coffee spill was to educate the resident on getting assistance with the coffee. The DON said when the nurses put in doctor orders, she expected the nurses to follow the orders. DON said she does believe when a true doctor order was wrote, the orders should be followed, but that was not a doctor order; it was an intervention. During an interview on 09/18/2024 at 2:30 p.m., the DON said she expected the nurses to follow doctor's orders. The DON said not, following doctor orders could affect the residents in several different ways. DON said all signed doctor orders should be followed. During an interview on 09/18/2024 at 2:39 p.m., ADM said she expected the nurses to follow doctor's orders. ADM said not following doctor's orders could potentially cause issues for the resident, if the facility does not follow the doctor orders. ADM said when an order was signed by the doctor, she expected the staff to follow signed doctor's orders. Record review of a facility's Comprehensive Care Plans policy dated 02/10/2021, indicated .to meet the resident's physical, psychosocial and functional needs is developed and implemented for each residents .the care planning process will .include an assessment of the resident's strengths and needs .incorporate the resident's personal and cultural preferences .the services that are to be refurnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . Record review of a facility's Following Physician Orders policy dated 02/10/2021 indicated . for consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: follow facility procedures for verbal or via telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administrator record .

Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 2 residents (Resident #147) reviewed for respiratory care and services. The facility failed to change the filter on an oxygen concentrator machine that were in use for Resident #147 on 09/16/24. This failure could place residents at risk for developing respiratory complications. Findings included: Record review of Resident #147's face sheet, dated 09/17/24, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included heart failure (a chronic condition in which the heart is unable to pump blood effectively), and shortness of breath. Review of Resident #147 MDS reflected they did not have an OBRA MDS assessment completed at the time of this visit. It was not yet due to be completed. During an observation and interview on 09/16/24 at 9:53AM, Resident #147 was lying in bed in his room. He had oxygen in place via a nasal cannula. The oxygen concentrator filter was dirty with a thick layer of white/gray material on the surface. Resident #147 said he usually wore oxygen. During an observation on 09/16/24 at 12:18 PM, Resident #147 was lying in bed in his room. He had oxygen in place via a nasal cannula. The oxygen concentrator filter was still dirty with a thick layer of gray/white material. During an observation on 09/16/24 at 03:06 PM, Resident #147 was lying in bed in his room. He had oxygen in place via a nasal cannula. The oxygen concentrator filter was dirty with a thick layer of gray/white material. During an interview on 09/18/24 at 11:24 AM, LVN B said she had taken care of Resident #147 on 09/16/24. She said she did not check the concentrator filter on the machine during her shift. She said the filters were normally checked weekly. She said she had worked full-time at this facility for only the past few weeks. She said the risk to Resident #147 was that he could get sick or suffer respiratory distress. She said he had been admitted over the past weekend. During an interview on 09/18/24 at 11:26 AM, LVN C, Hall Manager, said she had worked on 09/16/24 and went into Resident #147's room a few times. She said the nurses were supposed to check the concentrator filters once a week on night shift on Wednesdays. She said that Resident #147 had been recently admitted over the weekend, and it was possible that the filter had not been changed from the last time the concentrator was used. She said some of the concentrators did not take filters, so the nurses sometimes forgot to check the filter. She said she did not think the resident could get sick from the dirty filter because the machine would shut off before the resident would get sick. She said even though the machine was working on 09/16/24 with the dirty filter, she did not think the resident would get sick. She said if the machine shut off, then she would be worried about respiratory distress. During an interview on 09/18/24 at 01:44 PM, the ADON said the nurses were supposed to check the filters every week when the tubing was changed. She said she expected the nurse that had pulled the concentrator out of storage to look at it and check the filter. She said the risk to the resident could be that he could get sick from the dirty filter. During an interview on 09/18/24 at 01:53 PM, the DON said the nurses checked and changed filters every Wednesday. She said she did not catch it on Monday before this surveyor checked it. She said the risk to the resident could be sickness. During an interview on 09/18/24 at 02:14 PM, the Administrator said she expected the staff to keep the filter clean and change it per policy. She said the risk to the resident could be sickness. Record review of the facility's policy, Oxygen Administration, last reviewed 01/05/20, stated: .Concentrator 1. Clean filter weekly 2. Remove filter from back of concentrator 3. Rinse filter with water 4. Shake off excess water. Replace filter .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen and the facility's only dining room. The facility failed to ensure that a canister of oatmeal was closed properly in an airtight container after opening. The facility failed to ensure that dirty rags were stored in proper containers prior to being taken to the laundry. The facility failed to ensure that the walls and floors inside the kitchen were properly cleaned. The facility failed to ensure the toaster was cleaned after each use per facility protocol. The facility failed to ensure that trash was properly disposed of. The facility failed to ensure that the kitchens fryer was properly cleaned and the oil changed. The facility did not ensure the ice scoop was not left in the ice bucket during the lunch meal service. These failures could place residents at risk of cross-contamination and foodborne illness. Findings included: 1. During an observation on [DATE] starting at 09:35 a.m.: o approximately three dirty towels/rags with a hardened dried brown/orange color/ substance on them were piled on top of the stainless shelf near the dishwasher, o the kitchen stainless steel shelves and cabinets had food splatters, o the toaster had a build-up of crumbs, o there was an empty, open sugar canister with a thick brown substance built up on the bottom inside corners, o the walls of the mixer had food splattered on them o the fryer had crumbs floating in the grease and piled around the sides, o there were food crumbs, thick dust, and dirt on the floors near the baseboards in the kitchen area and across the lids of the canister storage units, o the oatmeal canister had approximately an inch of the plastic covering missing exposing it to the air, o there was water leakage under the 3 compartment washing sinks, o the wall air conditioning unit had thick dust and dirt and it was blowing towards the food preparation area, o the trashcan lid located near the hand washing sink was broken, o the liner inside the trash can was not properly placed and had trash spilling out of the bag inside the can and the trash overflowed onto the floor, o the steam table had brown murky water in the bottom with two cups of coffee covered in saran wrap sitting directly in the discolored water, o the steam table had a large pile of dusty chalk like ashy substance built up touching the bottoms of the pans, o the walk-in cooler located in the kitchen area contained expired chocolate pudding dated [DATE], expired unlabeled canister of stewed tomatoes dated [DATE] and a carton of Vanilla Shake expired on ,d+[DATE] o the Freezer contained an undated opened box of uncovered egg pasta sheets o the two large trash cans on rollers stationed in the hall area of the kitchen had trash overflowing onto the floor with flies crawling on top of the trash and lids During an observation on [DATE] at 11:40 a.m., the Dietary Manager returned to the kitchen and did not wash her hands before filling a large pan with water for cooking. During an interview on [DATE] at 10:00 a.m., the Dietary Manager said the grease was changed twice weekly on Thursday and Sunday. The Dietary Manager said the grease was not changed yesterday because the cook did not come to work. During an interview on [DATE] at 10:30 a.m., the Dietary Manager said that she went behind the staff to ensure that the kitchen was being cleaned and that everyone was doing the tasks as assigned. The Dietary Manager said that she expected a deep cleaning of the kitchen to be done weekly except for sweeping the floors and wiping down the walls which should be done at the end of each shift/mealtime. The Dietary Manager said that the dirty towels should be taken to the laundry to be washed but laundry services had refused to wash the kitchen towels, and someone had to take them home to be washed. The Dietary Manager expected all open containers to be securely closed with a lid. The Dietary Manager said the toaster should be cleaned after each use. The Dietary Manager said she expected the trash liners to be placed properly inside of the trash can and that all trash be placed inside of the trash can with an appropriately fitted lid. During an interview on [DATE] at 2:24 p.m., Administrator said that there was a kitchen cleaning schedule and that she expected the Dietary Manager to check behind the staff to ensure that these tasks were completed. The Administrator said that she expected the kitchen to be swept and walls wiped down daily. The Administrator said the kitchen staff emptied the grease from the fryer twice weekly on Thursday and Sunday. The Administrator said that she expected for anything in the pantry to be securely covered with a proper lid, trash cans to have liners properly placed to catch the trash and for dirty towels to be in a separate bin and then taken to housekeeping for washing. Record review of the Food Safety and Sanitation Plan policy, revised [DATE], indicated . Fundamental Information All bulk food items that are removed from original containers into food grade containers must have tight fitting lids, and must be properly labeled. The policy further states 13. Personal Hygiene Practices E. after eating, drinking, or smoking . 2. During a dining observation on [DATE] between 11:43 AM - 12:26 PM the dietary staff provided the staff in the dining room with a bucket and an ice scoop. The CNA, in the dining room, filled the bucket with ice without removing the ice scoop. The Social Worker removed the ice scoop, that was buried under the ice, without wearing gloves. The Social Worker and CNA took turns using the ice scoop to fill up drinking glasses, leaving the ice scoop in the ice bucket in between uses. Several nurses and the ADON were assisting during the lunch observation and filled up several cups of ice, leaving the ice scoop inside the ice bucket. During a dining observation on [DATE] between 12:16 PM - 12:32 PM the staff in the dining room took turns filling cups with ice and leaving the ice scoop in the ice bucket. The DON observed the staff passing out ice and instructed the staff to place the ice scoop into a cup. D During an interview on [DATE] at 1:46 PM, CNA A stated the ice scoop should not have been left in the ice bucket while passing ice during the lunch meal. CNA A stated she normally placed the ice scoop in a glass. CNA A stated during the lunch meal on [DATE] she noticed the ice scoop was in the ice bucket and placed it in a cup. CNA A stated it was important to ensure the ice scoop was not left in the ice bucket, so germs did not get on the ice. During an interview on [DATE] at 1:55 PM, LVN C stated the ice scoop should not have been left in the ice bucket. LVN C stated the ice scoop should have been placed in a cup. LVN C stated it was important to ensure the ice scoop was not left in the ice bucket because it could have contaminated the ice. During an interview on [DATE] at 2:05 PM, the ADON stated she was also the infection control preventionist. The ADON stated the ice scoop should not have been left in the ice bucket. The ADON stated the ice scoop was normally placed in a cup. The ADON stated the staff was nervous, so it was probably missed. The ADON stated it was important to ensure the ice scoop was not left in the ice bucket for infection control. During an interview on [DATE] at 2:16 PM, the Social Worker stated she believed it was okay to leave the ice scoop inside the ice bucket. The Social Worker stated the ice scoop was normally left in the ice bucket during meals. During an interview on [DATE] at 4:12 PM, the DON stated the ice scoop should not have been left in the ice bucket while passing ice during meals. The DON stated she expected the staff to ensure the ice scoop was placed in a bag or a cup. The DON stated it was important to ensure the ice scoop was not left in the ice bucket because it was infection control. During an interview on [DATE] at 4:32 PM, the Administrator stated the ice scoop should not have been left in the ice bucket. The Administrator stated education was provided the staff. The Administrator stated it was important to ensure the ice scoop was not left in the ice bucket for infection control. Record review of the Safe Ice Handling policy, revised [DATE], revealed Scoops must be stored outside of the ice in a manner which protects them from contamination.

47006 Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 2 of 13 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) and 1 of 1 dining room reviewed for physical environment. 1. The facility did not ensure room [ROOM NUMBER] had clean floors and walls. 2. The facility did not ensure the bathroom in room [ROOM NUMBER] had no holes and the sheetrock was in good repair. 3. The facility failed to repair scratches in the paint on the wall behind the head of the bed and on the wall next to the bed in room [ROOM NUMBER]A. 4. The facility failed to ensure the wallpaper in the dining room was in good repair. This failure could place the residents at risk for decreased quality of life and infection due to unsanitary conditions. The findings included: 1. During an observation on 08/14/2023 at 10:24 AM, the dining room had crinkled, floral, boarder wallpaper that had fallen off the wall and was held together by clear tape. During an observation on 08/15/2023 at 11:16 AM, the dining room had crinkled, floral, boarder wallpaper that had fallen off the wall and was held together by clear tape. During an observation on 08/16/2023 at 1:08 AM, the dining room had crinkled, floral, boarder wallpaper that had fallen off the wall and was held together by clear tape. During an interview on 08/16/2023 at 3:32 PM, the Maintenance Director stated he was responsible for ensuring the wallpaper was in good repair. The Maintenance Director stated he was unaware the wallpaper in the dining room was taped and crinkled. The Maintenance Director stated he was unsure who could have taped the wallpaper. The Maintenance Director stated it was important to ensure the wallpaper was in good repair because it was the resident's home, and they would want it to look nice. 2. During an observation on 08/14/2023 between10:31 AM - 10:36 AM, room [ROOM NUMBER] had the following issues: 1. The bathroom had a hole in the sheetrock under the sink that was approximately 12 inches in diameter. 2. The sheetrock located under the sink was warped and uneven. 3. The floors had blackish-brown dirt-like spots and streaks under the closet and near the door to the bathroom. 4. The walls in the corner of room near the bathroom were dirty with brownish liquid stains and a piece of white trash stuck on the wall behind the trashcan. During an observation on 08/15/2023 at 11:22 AM, room [ROOM NUMBER] had the following issues: 1. The bathroom had a hole in the sheetrock under the sink that was approximately 12 inches in diameter. 2. The sheetrock located under the sink was warped and uneven. 3. The floors had blackish-brown dirt-like spots and streaks under the closet and near the door to the bathroom. 4. The walls in the corner of room near the bathroom were dirty with brownish liquid stains and a piece of white trash stuck on the wall behind the trashcan. During an observation on 08/16/2023 at 1:12 PM, room [ROOM NUMBER] had the following issues: 1. The bathroom had a hole in the sheetrock under the sink that was approximately 12 inches in diameter. 2. The sheetrock located under the sink was warped and uneven. 3. The floors had blackish-brown dirt-like spots and streaks under the closet and near the door to the bathroom. 4. The walls in the corner of room near the bathroom were dirty with brownish liquid stains and a piece of white trash stuck on the wall behind the trashcan. During an interview on 08/16/2023 at 3:36 PM, Housekeeper D stated she was responsible for cleaning room [ROOM NUMBER] during the survey. Housekeeper D stated she cleaned the room and the bathroom. Housekeeper D stated she wiped the walls and high touch areas, swept, and mopped daily. Housekeeper D stated resident rooms were deep cleaned once a month and were on a schedule. Housekeeper D stated she was unsure what day room [ROOM NUMBER] should have been deep cleaned but she believed it had already been completed for the month. Housekeeper D stated the damage to the walls in the bathroom was reported to the Maintenance Director. Housekeeper D stated the facility recently switched mops and it was harder to clean the black stuff off the floor. Housekeeper D stated it was important to ensure the room was cleaned daily to prevent infection and ensure the building remained clean and looked how she would have wanted it to look if she was living at the facility. During an interview on 08/16/2023 at 3:44 PM, the Environmental Services Supervisor stated the housekeepers were responsible for cleaning the resident's rooms and she was responsible for inspecting it. The Environmental Services Supervisor stated room [ROOM NUMBER] should have been deep cleaned at the beginning of the month. The Environmental Services Supervisor stated the walls and flooring should have been cleaned daily. The Environmental Services Supervisor stated she expected staff to ensure the rooms were cleaned daily. The Environmental Services Supervisor stated the buffer machine has been down for approximately the last 3 weeks. The Environmental Services Supervisor stated the brownish-black areas on the floor were from stripping and waxing. The Environmental Services Supervisor stated she noticed the flooring in room [ROOM NUMBER] was not looking good and had made plans to clean it within the week. The Environmental Services Supervisor stated it was important to ensure the rooms were cleaned daily for the health of the residents and she would not have wanted the residents to live in anything she would not have lived in herself. During an interview on 08/16/2023 at 3:52 PM, the Maintenance Director stated he was aware the bathroom in room [ROOM NUMBER] needed to have been fixed. The Maintenance Director stated he worked on a lot of things at the facility and had not gotten to it yet. The Maintenance Director stated several bathrooms in the facility needed a complete remodel because it was an old building. The Maintenance Director stated he did not have adequate time to complete the issues that needed to be addressed. The Maintenance Director stated it was important to ensure the bathrooms were in good repair and the walls did not have holes because it was the resident's home, and it should have looked nice. During an interview on 08/16/2023 at 4:32 PM, the Administrator stated environmental services was responsible for ensuring resident rooms were kept clean and the Maintenance Director was responsible for ensuring the facility was in good repair. The Administrator stated she expected housekeeping staff to ensure cleanliness and report any issues that needed repaired to the Maintenance Director so he could have followed up. The Administrator stated it was important to ensure the facility was cleaned and in good repair to ensure a clean and sanitary environment for the residents. 3. During an observation on 08/14/2023 at 10:53 AM, there were scratches in the paint behind the head of the bed and on wall next to the bed by the head of the bed in room [ROOM NUMBER]A. The paint was peeled down and the areas were rough when touched. During an observation on 08/15/2023 at 3:39 PM, there were scratches in the paint behind the head of the bed and on wall next to the bed by the head of the bed in room [ROOM NUMBER]A. The paint was peeled down and the areas were rough when touched. During an observation on 08/16/2023 at 10:00 AM, there were scratches in the paint behind the head of the bed and on wall next to the bed by the head of the bed in room [ROOM NUMBER]A. The paint was peeled down and the areas were rough when touched. During an interview on 08/16/2023 at 10:03 AM, CNA A said if a room needed to be repaired, she would report it to the charge nurse, and the charge nurse would fill out a maintenance form. CNA A said she was aware room [ROOM NUMBER]A had scratched off paint on the wall behind the head of the bed and on the side wall. CNA A said she had reported to the charge nurse that room [ROOM NUMBER]A had scratched off paint on the walls. CNA A said it was important for the residents' rooms to not have scratched off paint because she did not want for chipped paint to go in the residents' beds, and because it was the residents' home. During an interview on 08/16/2023 at 10:05 AM, Housekeeper B said she had noticed the scratched off paint on the walls in room [ROOM NUMBER]A, and she had reported it to her supervisor (the Environmental Services Supervisor). Housekeeper B said the Environmental Services Supervisor told her she was going to notify the Maintenance Director. Housekeeper B said it was important for the residents' rooms to not have scratches on the walls because the facility was the residents' home, where they lived. During an observation and interview on 08/16/2023 at 11:05 AM, the Maintenance Director said he repainted the rooms quarterly, unless he was told a room needed to be repainted. The Maintenance Director said if something needed to be repaired, he was told verbally, or the staff could log it in the Maintenance Book. The Maintenance Director said nobody had told him room [ROOM NUMBER]A had scratched off paint on the walls. The Maintenance Director said it was important for the residents' rooms to be in good repairs to show that he cared about them and because the facility was their home. During an interview on 08/16/2023 at 1:29 PM, the Administrator said the Maintenance Director was responsible for ensuring the building was in good repairs. The Administrator said if the walls had scratched off paint the staff should report it to the Maintenance Director for it to be repaired. The Administrator said she expected the Maintenance Director to repair things when they were reported to him. The Administrator said it was important for the residents' rooms and the building to be in good repair for the well-being of the residents. During an interview on 08/16/2023 at 1:46 PM, the DON said the Maintenance Director was responsible for fixing the residents' rooms. The DON said she was not aware that room [ROOM NUMBER]A had scratches to the paint on the walls. The DON said if a CNA noticed the walls were scratched, they should notify the DON or the Administrator, or log it in the Maintenance Book. The DON said it was important for the residents' rooms to be repaired because the facility was their home. During an interview on 08/16/2023 at 1:57 PM, the Environmental Services Supervisor said Housekeeper had notified her Resident #17's walls needed to be repaired, and she had told the Maintenance Director. The Environmental Services Supervisor said she did not remember exactly when she had reported it to the Maintenance Director. The Environmental Services Supervisor said it was important for the residents' rooms to be repaired because the facility was their home. Record review of the facility's 2 Maintenance Books with maintenance request forms dated between 4/5/22-07/19/23, did not reveal a maintenance request form for room [ROOM NUMBER]A or room [ROOM NUMBER]. Record review of the facility's policy titled, Resident Rights, date reviewed 02/20/2021, indicated, . The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely .