Every finding on record at Clearview Nursing Center

Based on observation, interview, and record review, the facility failed to ensure staff used acceptable infection control procedures and practices for wound care for two residents (Residents #1 and #55) out of two sampled residents, one resident (Resident #4) for catheter (a flexible tube placed in the bladder to drain urine) care out of one sampled resident, and one resident (Resident #6) with a gastrostomy tube (g-tube - a medical device surgically placed through the abdomen directly into the stomach to deliver nutrition, fluids, and medication when oral intake is unsafe or insufficient) out of one sampled resident. The facility also failed to ensure laundry was processed in a way to limit the spread of infections. This practice could potentially affect all residents. The facility census was 62. Review of the facility's policy titled, Enhanced Barrier Precautions, revised March 2024, showed:- To prevent broader transmission of multi-drug resistance organisms (MDROs) and to help protect patients with chronic wounds and indwelling devices, enhanced barrier precautions (EBP) should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed;- Residents who require EBP: are those known to be infected or colonized with MDRO, with an indwelling medical device including the following: central venous catheter, urinary catheter, feeding tube (PEG tube, G-tube), tracheostomy/ventilator regardless of their MDRO status, and wounds, regardless of their MDRO status;- Use EBP when providing high-contact resident care activities such as those listed: bathing/showering, transferring residents from one position to another, providing hygiene, changing bed linens, changing briefs or assisting with toileting, caring for or using indwelling medical device, performing wound care. The facility did not provide a policy regarding infection control practices in laundry services. 1. Observation on 03/03/26 at 1:25 P.M., of Resident #6's medication administration via g-tube showed:- No EBP signage on the resident's door;- No personal protective equipment (PPE) available outside of the resident room;- Licensed Practical Nurse (LPN) G performed hand hygiene, put on gloves, and did not put on a gown;- LPN G performed the medication administration. 2. Observation on 03/04/26 at 8:20 A.M., of Resident #55's wound care showed:- No EBP signage on the resident's door;- No PPE available outside of the resident room;- LPN G and LPN I gathered supplies for the wound care at the resident's door;- LPN G and LPN I did not perform hand hygiene, put on gloves, did not put on a gown, and entered the room; - LPN G performed the wound care. 3. Observation on 03/04/26 at 8:50 A.M., of Resident #1's wound care showed:- No EBP signage on the resident's door;- No PPE available outside of the resident room;- LPN I performed hand hygiene, put on gloves, did not put on a gown, and entered the resident's room;- LPN I provided wound care for the resident. 4. Observation on 03/04/26 at 9:06 A.M., of Resident #4's catheter care showed:- No EBP signage on the resident's door;- No PPE available outside of the resident room;- Certified Nurse Aide (CNA) L and CNA M entered the resident's room, performed hand hygiene, put on gloves, and did not put on a gown;- CNA L provided catheter care for the resident. During an interview on 03/04/26 at 3:50 P.M., LPN P said the EBP was new and not sure what it was for. It was maybe something for the CNAs to use. During an interview on 03/04/26 at 3:55 P.M., CNA Q said he/she put on PPE before going into resident rooms to provide care. The PPE was for infection control. The supplies weren't out there before today. CNA Q was unsure why Resident #6 and Resident #55 required supplies and other residents did not. During an interview on 03/05/26 at 11:52 A.M., LPN I said staff should be wearing gloves and gowns when entering a resident's room where there was a catheter, wound, or g-tube tube. He/She did not know what happened to the containers with the PPE and they had been outside the resident's room in the past. LPN I thought someone cleaned house and placed all of the containers with PPE in storage. During an interview on 03/05/26 at 11:55 A.M., the Director of Nursing (DON) said she had no idea what happened to the containers of PPE and the signs that had previously been on the residents' door. Staff should be wearing gloves and gowns when entering a resident's room with catheters, g-tubes, wounds or anything with a device entering the body. During an interview on 03/05/26 at 11: 55 A.M., the Infection Preventionist said she was not aware the PPE storage drawers were not outside of the residents' rooms. She would expect staff to come to her and let her know the supplies were not readily available. During an interview on 03/05/26 1:55 P.M., Registered Nurse (RN) R said if a resident had a catheter, staff only needed to wear gloves. If a resident had a wound with Staphylococcus (a common bacteria found on the surface of the skin and in the nose), then gown and gloves needed to be worn. If a wound had eschar (a thick layer of dead tissue) or was a skin tear, only gloves needed to be worn. During an interview on 03/05/26 at 2:35 P.M., the Administrator said residents with any opening of their skin, such as a catheter, wound or a g-tube should have EBP in place. Staff should wear a gown and gloves whenever providing care to residents on EBP. 5. Observation on 03/04/25 at 2:49 P.M., of the laundry room showed:- The laundry building with one door to enter/exit the laundry room;- Dirty laundry barrels sat in the entry of the laundry room;- The washing machines located at the front area of the laundry building;- Dryers, a folding table, and wheeled clothing racks located at the rear area of the laundry building;- Clean linen carts located in the back of the laundry room;- No physical separation between the dirty laundry at the entrance and clean laundry at the back of the room;- Anyone entering or exiting the laundry room had to pass through the dirty laundry holding area;- All clean laundry and linen carts had to pass the dirty linen barrels and the soiled area to exit the laundry room building to be distributed to the residents and facility. During an interview on 03/04/25 at 2:49 P.M., Laundry Aide (LA) O said the dirty laundry came to the laundry room in barrels from each hall. He/She wore gloves when separating the dirty laundry. Once the laundry was dried, staff either hung or folded the laundry and put it on the cart to take to the residents. The laundry was delivered through the same door it entered the laundry room. During an interview on 03/04/26 at 2:55 P.M., LA O said he/she was not aware of any certain way the dirty linens and clean linens should enter and exit the laundry room. During an interview on 03/04/26 at 3:01 P.M., the Laundry Supervisor said the clean linens exited the laundry room through the same door the dirty laundry entered. During an interview on 03/04/26 at 3:21 P.M., the IP said he/she was not aware of any certain way the dirty linens and clean linens should enter and exit the laundry room. During a phone interview on 03/12/26 at 8:57 A.M., the IP said he/she was aware the laundry room only had one entrance/exit, but was not aware of any certain way the dirty linens and clean linens should enter and exit the laundry room. During a phone interview on 03/12/26 at 9:00 A.M., the Administrator said there was only one entrance/exit to the laundry room.

Based on observation, interview, and record review, the facility failed to ensure staff maintained or enhanced the quality of life for two residents (Residents #8 and #54) and failed to maintain the dignity of one resident (Resident #55) when left exposed during care out of 16 sampled residents. The facility's census was 62. The facility did not provide a dignity policy. 1. Observation on 03/02/26 at 12:11 P.M., of Resident #8 showed:- The resident sat in the hall and asked two different staff that passed by for a cup of coffee; - No staff acknowledged the resident. Observation on 03/02/26 at 12:31 P.M., showed:- The resident asked Certified Nursing Assistant (CNA) J if he/she could have a cup of coffee as CNA J walked by;- CNA J responded in a loud and stern voice, No, the kitchen is closed. CNA J continued to walk past the resident without offering another option or redirecting the resident. During an interview on 03/02/26 at 12:32 P.M., CNA J said the staff try not to give the resident coffee because it caused the resident to be anxious and then the resident wanted to get out of bed. The kitchen was not actually closed and would get the resident a drink when he/she was finished with his/her task. During an interview on 03/05/26 at 2:32 P.M., the Director of Nursing (DON) said he/she would expect staff to acknowledge the resident's requests. She would expect staff to offer the resident another option to drink or redirect the resident. 2. Observation on 03/03/26 at 12:23 P.M., of Resident #54 showed:- The resident lay in bed with his/her eyes open and his/her call light and water sat out of reach of the resident on the nightstand;- The resident said he/she had not had lunch yet and was hungry. During an interview on 03/03/26 at 12:25 P.M., CNA E said he/she was unsure why the resident was not up for lunch. Observation on 03/03/26 at 12:37 P.M., showed:- At 12:33 P.M., CNA E and CNA F transferred the resident from the bed into his/her wheelchair;- At 12:37 P.M., the resident sat at the dining room table, asked for water, and quickly ate his/her lunch. The resident ate 90% of the meal, drank one cup of water and one cup of chocolate milk. During an interview on 03/03/26 on 1:04 P.M., Licensed Practical Nurse (LPN) G said the resident refused to get out of bed earlier. When the resident refused to get up for lunch, he/she left the resident alone because he/she was on hospice. Sometimes staff would put a tray back and check on the resident later. If a tray was put back for the resident, LPN G would have to stay in the dining room later and that put him/her behind in his/her duties. During an interview on 03/05/26 at 1:32 P.M., the Administrator said he would expect staff to make sure residents were up every day for lunch, and the call lights to be in reach to ensure the residents were able to get up at their liberty. During an interview on 03/05/26 at 2:34 P.M., the DON said staff should make sure residents were up for meals, and if the residents refused to get up, the staff should re-visit a short time later and ensure the residents were fed. She would expect staff to notify him/her if this continued. 3. Observation on 03/04/26 at 8:20 A.M., of Resident #55 showed:- LPN G and LPN I performed wound care for the resident without the privacy curtain pulled and/or the door closed;- The resident's bare backside was exposed to the hallway;- Two unknown persons passed by the resident's door during his/her care. During an interview on 03/04/26 8:34 A.M., LPN I said normally staff closed the door when providing wound care or treatments. LPN G said he/she normally pulled the curtain when doing wound care or treatments. During an interview on 03/05/26 at 2:34 P.M., the DON said she would expect staff to provide privacy during any wound care or treatments, including closing the privacy curtain and/or closing the door.

Based on observation and interview, the facility failed to ensure call lights were placed within reach to meet resident needs for five residents (Residents #5, #6, #52, #54 and #67) out of 16 sampled residents and one resident (Resident #12) outside the sample. The facility census was 62.The facility did not provide a call light policy. 1. Observations on 03/02/26 at 9:56 A.M., and 2:13 P.M., 03/03/26 at 8:33 A.M., and 12:47 P.M., and 03/04/26 at 2:28 P.M., of Resident #67 showed:- The resident lay in bed and the call light out lay on the floor out of the resident's reach;- The resident sat in a Geri-chair (a specialized, heavy padded recliner) and the call light lay on the floor out of the resident's reach. 2. Observations on 03/02/26 at 9:59 A.M., and 2:17 P.M., and 03/03/26 at 8:25 A.M., and 2:31 P.M., of Resident #52 showed:- The resident lay in bed and the call light lay on the floor out of the resident's reach. 3. Observations on 03/02/26 at 1:26 P.M., and 3:45 P.M., 03/03/26 at 8:25 A.M., 10:08 A.M., and 1:17 P.M., and 03/04/26 at 12:44 P.M., of Resident #5 showed:- The resident lay in bed and the call light lay on the floor out of the resident's reach;- The resident sat in a Geri-chair at the head of his/her bed and the call light was attached to a privacy curtain at the foot of his/her bed out of the resident's reach. 4. Observations on 03/02/26 at 2:38 P.M., 03/03/26 at 12:23 P.M., and 03/05/26 at 8:52 A.M., of Resident #54 showed:- The resident lay in bed and the call light lay on the nightstand out of the resident's reach;- The resident lay in bed and the call light lay inside a trash can on the floor beside the nightstand out of the resident's reach. 5. Observations on 03/02/26 at 2:39 P.M., and 03/03/26 at 10:03 A.M., of Resident #6 showed:- The resident lay in bed and the call light was attached to a privacy curtain at the foot of his/her bed out of the resident's reach. 6. Observations on 03/02/26 at 2:40 P.M., 03/04/26 at 8:15 A.M., and 03/04/26 at 2:18 P.M., of Resident #12 showed:- The resident lay in bed and the call light hung from a metal frame attached to the wall at the foot of his/her bed out of the resident's reach;- The resident sat beside his/her bed in a wheelchair and the call light hung from a metal frame attached to the wall at the foot of his/her bed out of the resident's reach. During an interview on 03/05/26 at 1:15 P.M., the Administrator said he would expect staff to make sure call lights were always within the residents' reach. During an interview on 03/05/26 at 2:06 P.M., Certified Nurse Assistant (CNA) A said staff should make sure a call light was placed within a resident's reach before leaving his/her room. During an interview on 03/05/26 at 2:09 P.M., Licensed Practical Nurse (LPN) B said a resident should have a call light always placed within reach while in his/her room. During an interview on 03/05/26 at 2:27 P.M., the Director of Nursing (DON) said call lights should always be in reach for residents. She expected staff to check periodically and when entering and exiting a resident's room to make sure the call lights were within reach of the resident.

Based on observation, interview, and record review, the facility failed to conduct inspections of all bed frames, mattresses, and side rails as part of a regular maintenance program for four residents (Residents #1, #6, #52 and #55) out of four sampled residents. The facility census was 62. The facility did not provide a side rail inspection policy. 1. Review of Resident #1's medical record showed:- admitted on [DATE];- Diagnoses of fracture (broken bone) of the left leg, pain, muscle weakness, and chronic obstruction pulmonary disease (COPD - a long-term chronic airway disease);- No maintenance inspection for the side rail. Observations on 03/02/26 at 1:10 P.M., and 03/03/26 at 10:00 A.M., of the resident's bed showed:- A side rail in the upright position on both half sides of the resident's bed and moved with minimal effort. Observation on 03/04/26 at 8:50 A.M., and 03/05/26 at 9:00 A.M, showed:- The resident lay in bed with both half side rails in an upright position. 2. Review of Resident #6's medical record showed:- admitted on [DATE];- Diagnoses of autistic disorder (developmental disability), pervasive developmental disorder (delays in developing communication), seizures (sudden, uncontrolled movement, behavior, sensations, or consciousness), and unspecified intellectual disabilities;- No maintenance inspection for the side rail. Observation on 03/02/26 at 10:53 A.M., 03/03/2026 at 8:45 A.M., 03/04/26 at 9:48 A.M., and 03/05/26 at 9:21 A.M., showed:- A side rail in the upright position on both half sides of the resident's bed and moved with minimal effort. Observations on 03/02/26 at 2:41 P.M., 03/03/26 at 3:21 PM., and 03/05/26 at 11:04 A.M., showed:- The resident lay in bed with both half side rails in an upright position. 3. Review of Resident #52's medical record showed:- admitted on [DATE];- Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), history of falls, urinary tract infection (UTI - an infection anywhere in the urinary tract), hypertension (high blood pressure) and history of falls;- No maintenance inspection for the side rail. Observations on 03/02/26 at 9:59 A.M., and 2:17 P.M., and 03/03/26 at 8:25 A.M., and 2:31 P.M., of the resident's bed showed:- A side rail in the upright position on both half sides of the resident's bed and moved with minimal effort. 4. Review of Resident #55's medical record showed:- admitted on [DATE];- Diagnoses of spinal stenosis cervical region (narrowing of the spine in the neck region), multiple sclerosis (breakdown of the protective covering of nerves), heart failure, and acute respiratory failure with hypoxia (lungs cannot get enough oxygen to the blood);- No maintenance inspection for the side rail. Observations on 03/02/26 at 11:14 A.M., 03/02/26 at 3:11 P.M., 03/04/26 at 10:42 A.M., and 03/05/26 at 1:41 P.M., of the resident's bed showed:- A side rail in the upright position on both half sides of the resident's bed and moved with minimal effort. During an interview on 03/04/26 at 2:32 P.M., the Director of Nursing (DON) said if there were side rails on a resident's bed, then maintenance should be inspecting the side rails at least monthly. During an interview on 03/05/26 at 9:32 A.M., the DON said she spoke to the maintenance staff and the maintenance staff had not completed any inspections on the side rails. During an interview on 03/05/26 at 1:00 P.M., the Maintenance Staff said he/she placed the rails on the resident's bed when the nursing department requested it. If staff had not placed anything in the maintenance log about the side rails, then he/she knew nothing about the side rails until staff notified him/her. The side rails had not been inspected. During an interview on 03/05/26 at 2:30 P.M., the Administrator said he expected staff to inspect side rails on resident beds at least quarterly.

Based on observation and interview, the facility staff failed to post the required daily nurse staffing information in a prominent location readily accessible to residents and visitors for four out of four days. The facility census was 62.The facility did not provide a policy on nurse staff posting. Observations on 03/02/26 at 12:05 P.M., 03/03/26 at 9:00 A.M., 03/04/26 at 8:45 A.M., and 03/05/26 at 12:30 P.M., showed:- Daily nurse staffing posted on the east end of the facility near the nurses' station;- No daily nurse staffing posted at the main entrance of the facility or at the west end area of the facility;- Daily nurse staffing not posted in a prominent place readily accessible to all residents and visitors. During an interview on 03/05/26 at 1:30 P.M., Certified Nurse Aide (CNA) K said the nursing staff information had always been posted on the east end of the facility. He/she had never known of the staffing posted anywhere else in the facility. During an interview on 03/05/26 at 1:33 P.M., the Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff) Coordinator said the charge nurse that worked the east end was usually the nurse that filled out the daily staff and posted it. The nurse staff posting had never been anywhere other than the east end of the facility near the nurses' station. During an interview on 03/05/26 at 1:34 P.M., Licensed Practical Nurse (LPN) G said the charge nurse on the east end was responsible for filling out the daily staff sheet and posted it every morning. The staffing sheet had always been posted by the nurses' station on the east end of the facility. During an interview on 03/05/26 at 1:45 P.M., the Director of Nursing (DON) said she was not sure who was responsible for posting the nurse staffing, however it was always completed and hung near the bulletin board on the east end of the facility. During an interview on 03/05/26 at 2:20 P.M., the Administrator said the east end of the facility was the only place the nurse staffing had ever been posted.

Based on observation, interview, and record review, the facility failed to assess for the risk of entrapment, review the possible risks and benefits of the side rails prior to installation or use, and the facility failed to obtain informed consent of the side rails prior to use for four residents (Residents #1, #6, #52, and #55) out of four sampled residents. The facility census was 62. The facility did not provide a side rail assessment policy. 1.Review of Resident #1's medical record showed:- admitted on [DATE];- Diagnoses of fracture (broken bone) of the left leg, pain, muscle weakness, and chronic obstruction pulmonary disease (COPD - a long-term chronic airway disease);- Cognition moderately impaired;- No documentation of a side rail assessment or informed consent for the use of side rails. Observation on 03/02/26 at 1:10 P.M., 03/03/26 at 10:00 A.M., 03/04/26 at 8:50 A.M., and 03/05/26 at 9:00 A.M., showed:- The resident's bed with both half side rails in an upright position. Observation on 03/04/26 at 8:50 A.M., and 03/05/26 at 9:00 A.M., showed:- The resident lay in bed with both half side rails in an upright position. During an interview on 03/04/26 at 8:55 A.M., the resident said he/she used the side rails to turn side to side while in bed. The rails were already on the bed upon his/her admission. 2. Review of Resident #6's medical record showed:- admitted on [DATE];- Diagnoses of autistic disorder (developmental disability), pervasive developmental disorder (delays in developing communication), seizures (sudden, uncontrolled movement, behavior, sensations, or consciousness), and unspecified intellectual disabilities;- Cognition severely impaired-never/rarely made decisions;- The resident with a legal guardian;- No documentation of a side rail assessment or informed consent for the use of the side rails. Observations on 03/02/26 at 10:53 A.M., 03/03/26 at 8:45 A.M., 03/04/26 at 9:48 A.M., and 03/05/26 at 9:21 A.M., showed:- The resident's bed with both half rails in an upright position. Observations on 03/02/26 at 2:41 P.M., 03/03/26 at 3:21 PM., and 03/05/26 at 11:04 A.M., showed:- The resident lay in bed with both half side rails in an upright position. 3. Review of Resident #52's medical record showed:- admitted on [DATE];- Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), history of falls, urinary tract infection (UTI - an infection anywhere in the urinary tract), hypertension (high blood pressure) and history of falls;- Cognition severely impaired;- The resident with a legal guardian;- No documentation of a side rail assessment or informed consent for the use of the side rails. Observations on 03/02/26 at 1:30 P.M., 03/03/26 at 9:32 A.M., 03/04/26 at 1:39 P.M., and 03/05/26 at 10:34 A.M., showed:- The resident lay in bed with both half side rails in an upright position. 4. Review of Resident #55's medical record showed:- admitted on [DATE];- Diagnoses of spinal stenosis cervical region (narrowing of the spine in the neck region), multiple sclerosis (breakdown of the protective covering of nerves), heart failure, and acute respiratory failure with hypoxia (lungs cannot get enough oxygen to the blood);- Cognition intact;- No documentation of a side rail assessment or informed consent for the use of the side rails. Observations on 03/02/26 at 11:14 A.M., 03/02/26 at 3:11 P.M., 03/04/26 at 10:42 A.M., and 03/05/26 at 1:41 P.M., showed:- The resident's bed with both half rails in an upright position. During an interview on 03/02/26 at 3:11 P.M., the resident said he/she couldn't physically use the side rails right now but had in the past. During an interview on 03/04/26 at 2:00 P.M., the Director of Nursing (DON) said when a resident was admitted with a concern of side rail use, nursing would complete an initial side rail assessment. After the initial admission assessment, the side rail assessments were supposed to be completed quarterly thereafter. She thought the side rail assessments had been missed because they were not included in the admission packet. During an interview on 03/04/26 at 2:30 P.M., the Administrator said he would expect an assessment to be completed before the side rails were put on a resident's bed and be assessed quarterly.

Based on observation, interview, and record review, the facility failed to assess for the risk of entrapment, review the possible risks and benefits of the side rails prior to installation or use, and the facility failed to obtain informed consent of the side rails prior to use for four residents (Residents #1, #6, #52, and #55) out of four sampled residents. The facility census was 62. Review of the facility's policy titled, Minimum Data Sets (MDS - a federally mandated assessment completed by the facility) and Care Planning Guidelines, dated September 2013, showed:- It is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) Manual, any published interim RAI manual errata (error) documents, and applicable federal guidelines as the authoritative guide for completion of MDS, care area assessments (CAA), and resident care planning. 1.Review of Resident #1's medical record showed:- admitted on [DATE];- Diagnoses of fracture (broken bone) of the left leg, pain, muscle weakness, and chronic obstruction pulmonary disease (COPD - a long-term chronic airway disease);- Cognition moderately impaired. Observations on 03/02/26 at 1:10 P.M, 03/03/26 at 10:00 A.M., 03/04/26 at 8:50 A.M., and 03/05/26 at 9:00 A.M., showed:- The resident's bed with both half side rails in an upright position. Observations on 03/04/26 at 8:50 A.M., and 03/05/26 at 9:00 A.M., showed:- The resident lay in bed with both half side rails in an upright position. During an interview on 03/04/26 at 8:55 A.M., the resident said he/she used the half side rails to turn side to side while in bed. The resident said the half side rails were already on his/her bed upon admission. Review of the resident's Care Plan, revised on 02/26/26, showed:- Did not address the resident's both half side rail use. 2. Review of Resident #6's medical record showed:- admitted on [DATE];- Diagnoses of autistic disorder (developmental disability), pervasive developmental disorder (delays in developing communication), seizures (sudden, uncontrolled movement, behavior, sensations, or consciousness), and unspecified intellectual disabilities;- Cognition severely impaired-never/rarely made decisions. Observations on 03/02/26 at 10:53 A.M., 03/03/26 at 8:45 A.M., 03/04/26 at 9:48 A.M., and 03/05/26 at 9:21 A.M., showed:- The resident's bed with both half rails in an upright position. Observations on 03/02/26 at 2:41 P.M., 03/03/26 at 3:21 P.M., and 03/05/26 at 11:04 A.M., showed:- The resident lay in bed with both half side rails in an upright position. Review of the resident's Care Plan, dated 01/09/26, showed:- Did not address the resident's both half side rail use. 3. Review of Resident #52's medical record showed:- admitted on [DATE];- Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), history of falls, urinary tract infection (UTI - an infection anywhere in the urinary tract), hypertension (high blood pressure) and history of falls;- An unwitnessed fall with no injury on 01/15/26;- An unwitnessed fall with no injury on 01/21/26. Observations on 03/02/26 at 1:30 P.M., 03/03/26 at 9:32 A.M., 03/04/26 at 1:39 P.M., and 03/05/26 at 10:34 A.M., of the resident showed:- Resident lay in bed with both side rails in an upright position;- A fall mat lay on the floor on the left-side of his/her bed. Review of the resident's Care Plan, revised 01/08/26, showed:- Falls on 08/16/25, 08/24/25, 09/9/25, 09/19/25, 10/09/25, and 10/14/25 with no specific interventions put in place for safety measures;- No documentation of falls on 01/15/25 and 01/26/26 with no specific interventions put in place for safety measures;- Did not address the resident's both half side rail use. 4. Review of Resident #55's medical record showed:- admitted on [DATE];- Diagnoses of spinal stenosis cervical region (narrowing of the spine in the neck region), multiple sclerosis (breakdown of the protective covering of nerves), heart failure, and acute respiratory failure with hypoxia (lungs cannot get enough oxygen to the blood);- Cognition intact. Observations on 03/02/26 at 11:14 A.M., 03/02/26 at 3:11 P.M., 03/04/26 at 10:42 A.M., and 03/05/26 at 1:41 P.M., showed:- The resident's bed with both half rails in an upright position. Review of the resident's Care Plan, revised, 01/16/26, showed:- Did not address the resident's both half side rail use. During an interview on 03/05/26 at 2:00 P.M., the Director of Nursing (DON) said she would expect resident falls and side rail use to be addressed on the care plan. During an interview on 03/05/26 at 2:30 P.M., the Administrator said he would expect falls and side rail use to be on the care plan. During an interview on 03/11/26 at 12:00 P.M., the MDS Coordinator said he/she would expect falls and side rails to be addressed on the care plan.

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year and failed to provide the required annual competencies of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions), Abuse (infliction of physical, sexual or emotional injury/harm), and Neglect (failure to provide necessary services for an adult's safety or health) prevention for two Certified Nurse Aides (CNA) (CNA C and CNA D) out of two sampled CNAs. The facility census was 62.The facility did not provide a nurse aide in-service education policy. Review of the facility's 2026 Quality Assurance and Performance Improvement (QAPI) Plan showed:- The facility will provide the necessary training to enable staff to perform their jobs effectively;- Ongoing training includes mandatory all-staff competency updates addressing topics such as changes in policies and procedures and regulatory requirements. Review of the Facility Assessment, revised 01/21/26, showed:- Topics to be trained at hire and annually thereafter for a CNA; - Required in-service training for nurse aides: a. Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; b. Include dementia management training and resident abuse prevention; c. Address areas of weakness as determined by facility assessment and may address the special needs of residents as determined by the facility staff; d. For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. 1. Review of the facility's December 2024 through December 2025 in-service records showed:- CNA C's hire date of 12/12/24 ;- CNA C attended three in-services;- CNA C did not attend the annual competency in-service on Dementia Care, Abuse, and Neglect;- No documentation of times for each in-service on the monthly in-service sheets;- The facility failed to provide CNA C with the required twelve hours of in-service education for December 2024 through December 2025 and failed to provide annual competency in-services on Dementia Care and Abuse and Neglect. 2. Review of the facility's November 2024 through November 2025 in-service records showed:- CNA D's hire date of 11/01/24;- CNA D attended five in-services;- CNA D did not attend the annual competency in-service on Dementia Care, Abuse, and Neglect;- No documentation of times for each in-service on the monthly in-service sheets;- The facility failed to provide CNA D with the required twelve hours of in-service education for November 2024 through November 2025 and failed to provide annual competency in-services on Dementia Care and Abuse and Neglect. During an interview on 03/05/26 at 10:02 A.M., the Director of Nursing (DON) said CNAs should have 12 hours of in-services annually. Abuse, neglect, and dementia training should be topics covered and included in the in-services. There should be a time duration on each in-service given to the facility staff. All staff were required to attend the monthly in-services. During an interview on 03/05/26 at 2:20 P.M., the Administrator said CNAs should have the required in-services annually. He was not aware of staff not having the required in-services.

Based on interview and record review, the facility failed to respond or act upon grievances, and failed to keep documentation of inventory for two residents (Residents #23 and #48) out of 15 sampled residents. The facility census was 59. Review of the facility's policy titled, Grievance Protocol, undated, showed: - The purpose of the grievance/complaint report and grievance log is to provide a written record of each resident and family concern and to insure proper follow-up through the appropriate discipline; - The Social Service Director (SSD) is responsible for the program, although the Administrator is ultimately responsible for the proper implementation; - Grievance complaint should be filled out for resident articles that are lost or cannot be located; - Social Services and Administrator evaluate the monthly grievance log for trends or patterns and devise an action plan to correct issues. A new log should be completed each month. The facility did not provide an inventory policy. Review of the facility's Grievance Log showed an empty binder with no documentation of any reported resident grievances. During an interview on 12/03/24 at 1:59 P.M., Resident #48 said he/she was missing an electronic tablet and a cell phone. The items went missing within the last two - three weeks. He/She made the SSD and the Administrator aware of the missing items, but they were not doing anything about it. During an interview on 12/04/24 at 9:16 A.M., the SSD said he/she was not aware of Resident #48's missing items until 12/02/24, and did not initiate a grievance related to the incident. He/She helped the resident look through his/her room for the missing items, but they were not found. The facility did not have inventory sheets for the resident's belongings, but he/she did normally try to get inventory lists completed for the residents. SSD had not been initiating or completing grievances. During an interview on 12/04/24 at 10:11 A.M., Resident #23 said he/she was missing a cereal cup full of quarters and two electronic tablets. One tablet had been missing longer than a year, but the second tablet and cup of quarters were missing within the past two months. He/She told the SSD about the missing items and had never heard anything else about them. During an interview on 12/04/24 at 10:42 A.M., the SSD said he/she did remember hearing about the missing money for Resident #23, but did not remember anything about a missing tablet. The SSD told the resident it was safer to keep money in the front business office. The SSD did not initiate or complete a grievance for the reported incident and did not have an inventory sheet for Resident #23. SSD said there should be a grievance form filled out when a resident reports a concern and an inventory sheet completed for each resident at the facility. During an interview on 12/04/24 at 11:15 A.M., Certified Nursing Assistant (CNA) G said he/she did know about the items missing for Resident #48. Any time items were reported missing by a resident, he/she will help search and then notify the charge nurse on duty. During an interview on 12/04/24 at 11:01 A.M., Registered Nurse (RN) F said he/she was aware that Resident #48 had missing items. When staff were told items were missing, he/she will help search and make the Director of Nursing (DON) aware. During an interview on 12/04/24 at 11:08 A.M., the DON said she was aware of the missing items for Resident #23 and Resident #48. When items were reported missing, there should be an investigation started immediately and inventory sheets reviewed. During an interview on 12/04/24 at 10:45 A.M., the Administrator said he was unsure about the grievance policy, but they did work together as a team to try and handle missing items. He had never replaced items for residents in the past.

Based on interview and record review, the facility failed to obtain a physician's order for code status for two residents (Residents #14 and #38) and consistently document a resident's code status with Full Code (cardiopulmonary resuscitation (CPR - an emergency procedure consisting of chest compressions if the heart stops beating or the person stops breathing) or Do Not Resuscitate (DNR - does not want CPR) for one resident (Resident #35) out of 15 sampled residents. The facility census was 59. Review of the facility's policy titled, DNR Protocol, not dated, showed: - The Social Services Designee (SSD) will be responsible to print all DNR order forms on lavender paper to be placed in the admission packet; - Once the DNR form is signed by the resident or legal representative it is to be signed by the physician; - The SSD will then complete the following: a green paper with Full Code or a red paper with DNR will be placed in the very front of the medical record in a plastic sheet protector; on the Physician Order Sheet (POS) in the menu section located in the right upper corner of the POS, the SSD will add the heading of Code Status; - The resident's code status will be periodically reviewed and renewed with the resident and/or legal representative, no less than quarterly during care plan review with the resident or resident's representative signing the care plan; - The SSD will monitor the resident code status monthly, with new admission, readmissions, and as a resident's code status is changed to ensure all components of the program are current. 1. Review of Resident #14's medical record showed: - admitted [DATE]; - Face sheet with Full Code status; - Full Code written on spine of the hard chart. Review of the resident's [DATE] Physician Order Sheet (POS) showed: - No order for the resident's code status. Review of the resident's revised care plan, dated [DATE], showed: - Full Code status. 2. Review of Resident #35's medical record showed: - admitted [DATE]; - Face sheet with DNR code status; - A red dot for DNR on the spine of the hard chart. Review of the resident's [DATE] POS showed: - An order for Full Code status. Review of the resident's revised care plan, dated [DATE], showed: - Full Code status. 3. Review of Resident #38's medical record showed: - An admitted [DATE]; - Face sheet with Full Code status; - A green dot for Full Code on the spine of the hard chart. Review of the resident's [DATE] POS showed: - No order for the resident's code status. Review of the resident's revised care plan, dated [DATE], showed: - Full Code status. During an interview on [DATE] at 10:20 A.M., the Director of Nursing (DON) said the Social Service Director (SSD) made sure what the code status was at admission. An order should be obtained for the code status. She would expect the code status to match anywhere it was documented. During an interview on [DATE] at 10:25 A.M., Licensed Practical Nurse (LPN) I said if there was a code called, he/she would look at the hard chart and see what the code status was. A green dot on the spine of the binder meant the resident was a Full Code. A red dot on the spine of the binder meant the resident was a DNR. The face sheet and a purple sheet should be in the chart when the resident was a DNR. During an interview on [DATE] at 10:33 A.M., the MDS (a federally mandated assessment instrument completed by the facility staff) Coordinator said the SSD will let staff know if a resident had changed his/her mind and/or if the code status changed. The SSD would change the face sheet, however the SSD couldn't write an order. The resident was a full code until the DNR paperwork had been signed by the physician. During an interview on [DATE] at 10:40 A.M., the Quality Assurance (QA) Nurse and the DON said they would expect the orders for the code status to be on the physician orders. 45872 48532

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service and failed to provide the required annual competencies of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions) for two certified nurse assistants (CNA) (CNA A and CNA B) of two nurse aides sampled. The facility census was 59. The facility did not provide a nurse aide in-service policy. Review of the facility assessment, revised 02/06/24, showed: - Required in-service training for nurse's aides: 1. Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; 2. Include dementia management training and resident abuse preventions training; 3. Address areas of weakness as determined by the facility assessment and address the special needs of residents to as determined by the facility staff; 4. For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. 1. Review of the facility's August 2023 - July 2024 in-service records showed: - CNA A's hire date of 08/13/22; - CNA A attended a total of seven monthly in-services; - No time duration documented on the monthly in-service sheets; - CNA A did not attend an annual competency in-service on Dementia Care. 2. Review of the facility's November 2023 - October 2024 in-service records showed: - CNA B's hire date of 11/02/21; - CNA B attended a total of six monthly in-services; - No time duration documented on the monthly in-service sheets; - CNA B did not attend an annual competency in-service on Dementia Care. During an interview on 12/06/24 at 10:50 A.M., the Director of Nursing (DON) said nurse aid education training should include Dementia Care. Nurse-aides should receive 12 hours of education training to meet the annual in-service requirement. During an interview on 12/06/24 at 10:56 A.M., the Administrator said nurse aid education training should include Dementia Care. Nurse-aides should receive 12 hours of education training to meet the annual in-service requirement.

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 37 opportunities with three errors made, resulting in an error rate of 8.11% for three residents (Residents #20, #34 and #38) out of eleven sampled residents. The facility's census was 59. Review of the facility's policy titled, Specific Medication Administration Procedures, dated July 2021, showed: - Prime insulin pen prior to use; - Dial up two units; - Hold pen upright and push the button on the end of the pen so a small drop of insulin appears; - Dial insulin to the desired insulin dose to be administered to the resident. Review of the Humalog/lispro (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Kwik Pen (Insulin in a pen-type device) instructions, revised, July 2023, showed: - Prime the pen by turning the dose knob to two units; - Hold the pen with the needle pointing up; - Tap the cartridge holder gently to collect air bubbles at the top; - Push the dose knob in until it stops, and zero is seen in the dose window, count to five slowly, insulin will be visible at the tip of the needle; - Select the dose; - Give the injection after selecting the area and cleaning the site with an alcohol swab. Review of the Novolog/Fiasp/aspart (fast-acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen administration instructions, dated September 2021, showed: - Prime the pen by turning the dose selector to two units; - Keep the needle upwards and press the push-button until the dose selector reads zero; - Turn the dose selector to select the number of prescribed units. 1. Review of Resident #20's Physician Order Sheet (POS), dated December 2024, showed: - An order for Humalog insulin pen 100 units per milliliter (ml) subcutaneous (injection under the skin) with meals per a sliding scale if blood sugar is 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units, 401-450=12 units, blood sugar greater than 450, call the physician, dated 06/10/24. Observation of Resident #20's medication administration on 12/04/24 at 11:16 A.M., showed: - Registered Nurse (RN) J administered 12 units of Humalog subcutaneously per order of the sliding scale for a blood sugar of 433 with the resident's Humalog Kwik Pen; - RN J failed to prime the Humalog Kwik Pen per the manufacturer's instructions prior to the administration to the resident. 2. Review of Resident #34's POS, dated December 2024, showed: - An order for ondansetron (anti-nausea medication) 4 milligrams (mg) disintegrating tablet three times daily with meals for weight loss, dated 04/10/23. Observation of Resident #34's medication administration on 12/05/24 at 11:30 A.M., showed: - Certified Medication Technician (CMT) K administered the tablet with water; - CMT K failed to instruct the resident to hold the medication on or underneath the tongue for medication to be effective; - The resident swallowed the tablet instead of it disintegrating. 3. Review of Resident #38's POS, dated December 2024, showed: - An order for Novolog Flex insulin pen 100 units per ml subcutaneous with meals per a sliding scale if blood sugar is 150-175=1 unit, 176-200=2 units, 201-225=3 units, 226-250=4 units, 251-275=5 units, 276-300=6 units, 301-325=7 units, 326-350=8 units, 351-375=9 units, 376-400=10 units, if greater than 400, call nurse practitioner (NP)/physician's assistant (PA), dated 10/16/24. Observation of Resident #38's medication administration on 12/04/24 at 11:23 A.M., showed: - RN J administered 9 units of Novolog subcutaneously per order of the sliding scale for a blood sugar of 249 with the resident's Novolog Flex pen; - RN J failed to prime the Novolog Flex Pen per the manufacturer's instructions prior to the administration to the resident. During an interview on 12/04/24 at 11:45 A.M., RN J said he/she thought the insulin pens only needed to be primed when the pen was new, not for each insulin administration. During an interview on 12/06/24 at 9:30 A.M., the Director of Nursing (DON) said staff should prime insulin pens with two units of insulin with every insulin administration. During an interview on 12/06/24 at 10:55 A.M., the Quality Assurance (QA) Nurse said the facility followed the insulin manufacturer's recommendations.

Based on interview and record review, the facility failed to provide a Preadmission Screening and Resident Review (PASARR - a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder, to determine the level of care needed) for two residents (Residents #4 and #43) out of two sampled residents. The facility census was 59. The facility did not provide a policy for a PASARR. 1. Review of Resident #4's medical record showed: - An admitted [DATE]; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) and post traumatic stress disorder (PTSD - psychological distress following a traumatic event); - No documentation of the required level one PASARR screening upon admission to the facility. 2. Review of Resident #43's medical record showed; - An admitted [DATE]; - Diagnoses of bipolar (a mental disorder that causes unusual shifts in mood) and schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations); - No documentation of the required level one PASARR screening upon admission to the facility. During an interview on 12/05/24 at 11:15 A.M., the Social Service Director (SSD) said a level one PASARR should be completed on a resident prior to admission to the facility. Resident #4's level one screening still needed to be completed and submitted. Resident #43's level one screening was rejected due to no psychiatric documentation that wasn't sent. During an interview on 12/06/24 at 1:05 P.M., the Administrator said he would expect a resident to have a level one PASARR completed prior to the resident being admitted to the facility.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) for two residents (Residents #4 and #51) out of 15 sampled residents. The facility census was 59. Review of the facility's policy titled, MDS and Care Planning Guidelines, revised 10/01/15, showed: - It is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI - a tool used to assist facility staff to gather defined information on a resident's strengths and needs) Manual, any published interim RAI manual errata (error) documents, and applicable federal guidelines as the authorative guide for completion of MDS, care area assessments (CAAs) and resident care planning; - The policy did not address the accuracy of MDS assessments. 1. Review of Resident #4's annual MDS, dated [DATE], showed: - The resident did not receive an anticoagulant (medication to prevent and treat blood clots in the blood vessels and the heart). Review of the resident's December 2024 Physician Order Sheet (POS) showed: - Diagnosis of personal history of thrombophlebitis (vein inflammation that happens in connection with one or more blood clots); - An order for desmopressin (an anticoagulant) 0.1 milligram (mg) 1/2 tablet oral twice daily, dated 12/05/22; Review of the resident's care plan, revised 02/12/24, showed: - The resident received anticoagulant therapy. 2. Review of Resident #51's annual MDS, dated [DATE], showed: - The resident received an anticoagulant. Review of the resident's December 2024 POS showed: - Diagnosis of stroke; - An order for aspirin (a nonsteroidal anti-inflammatory drug) 325 mg oral daily, dated 12/28/22. Review of the resident's care plan, revised 10/24/24, showed: - The resident received anticoagulant therapy. During an interview on 12/06/24 at 9:12 A.M. , the MDS Coordinator said if a resident took an anticoagulant, it should be indicated on the resident's MDS assessment. If a resident didn't take an anticoagulant, it should not be indicated as an anticoagulant on the resident's MDS assessment. During an interview on 12/06/24 at 10:18 A.M. , the Director of Nursing (DON) said if a resident took an anticoagulant, it should be indicated on the resident's MDS assessment. If a resident didn't take an anticoagulant, it should not be indicated as an anticoagulant on the resident's MDS assessment.

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 59. The facility did not provide a homelike environment policy. 1. Observations on 12/03/24 at 2:42 P.M., and 12/04/24 at 9:20 A.M., of the 100 Hall showed: - A seat cushion cover worn with several peeled areas on a chair next to the bed near the door in room [ROOM NUMBER]; - Several areas of wallpaper peeled with exposed sheetrock located behind the bed near the window in room [ROOM NUMBER]; - A seat cushion cover worn with several peeled areas on a chair next to the bed near the door in room [ROOM NUMBER]; - Dark scuff marks and a three inch (in.) area of exposed sheetrock and peeled paint on the wall next to the door in room [ROOM NUMBER]. 2. Observations on 12/05/24 at 10:37 A.M., of the 300 Hall showed: - A loose and cracked piece of molding on the right side of the door frame in room [ROOM NUMBER]; - A cracked piece and a missing piece of molding on the left side of the door frame in room [ROOM NUMBER]; - An area of loose sheetrock tape on the ceiling by the privacy curtain track near the bed by the door in room [ROOM NUMBER]; - A seat cushion cover worn with a large area of peeled material on a chair next to the bed near the door in room [ROOM NUMBER]. 3. Observations on 12/06/24 at 12:45 P.M., of the Spa Room next to the mechanical room showed: - Several bed mattresses stacked against the wall by the toilet; - Several cupcake pans stacked on top of the left side clothes cabinet; - A mattress, step ladder and other miscellaneous items stacked against the left side of the clothes cabinet; - Cluttered shower chairs, a red trash can with lid, and miscellaneous debris inside and on the shower stall floor. Review of the Maintenance Log Book, dated 09/20/24 - 12/02/24, showed no documentation of areas of concern addressed. During an interview on 12/03/24 at 10:23 A.M., the resident in room [ROOM NUMBER] said he/she would like for his/her chair to be either replaced or fixed. He/She doesn't know why staff would take a good chair out of his/her room and replace it with one that looked so bad because he/she had visitors that sit in the chair and it's not very appealing to look at. During an interview on 12/06/24 at 9:05 A.M., Housekeeper C said he/she verbally told the maintenance department if there was something that needed to be fixed. He/She did not know if there was a maintenance log and had not seen anything recently to report other than a toilet not working. During an interview on 12/06/24 at 9:20 A.M., Housekeeper D said if he/she noticed something that needed fixed, he/she let someone know on the hall. He/She had not seen anything to report and was not aware of a maintenance log to write down any environment concerns. During an interview on 12/06/24 at 9:32 A.M., the Maintenance Supervisor (MS) said it would be easier to keep up with environmental issues if staff would write the concerns found on the maintenance log. MS had asked staff to write down the environment concerns because it made it hard to remember things throughout the day when staff didn't write environmental concerns down to be addressed and prioritized in a timely manner. During an interview on 12/06/24 at 10:50 A.M., the Quality Assurance (QA) nurse said the facility had several chairs in storage that could replace the worn chairs. He/She would let the Administrator know. During an interview on 12/06/24 at 12:41 P.M., the Administrator said he would expect staff to use the maintenance log book located at the nurses' station to write down any environmental concerns in addition to verbally telling the MS.

Based on observation, interview, and record review, the facility failed to implement, monitor, and modify interventions to maintain acceptable parameters of nutritional status for one resident(Resident #14) out of two sampled residents. The facility census was 59. Review of the facility's policy titled, Weight Champion Program, not dated, showed: - Each community should designate a weight champion to assist in the oversight and monitoring of residents that have or are at risk for weight loss; - The purpose of this program is to take a proactive stance against weight loss and collaborate to decrease weight loss numbers; - The weight champion will be responsible for keeping the weight variance report from Matrix, as well being custodian of the daily, weekly and monthly facility weight lists; - The champion will review for completion during the next stand up meeting. The champion will request and monitor re-weights of residents; - Weights should be reviewed weekly in our Interdisciplinary Team (IDT) meeting; - Weights should be assessed by the IDT at the time that the loss is noted. If a supplement is necessary, food items should be tried first, the exception is that of those resident drinking is more feasible for the resident. This must be documented; - Examples of food interventions are snacks, fortified (a fortified food used to provide extra calories, proteins and vitamins) milk , fortified soups, extra portions, supercereal (a fortified cereal used to provide extra calories, proteins and vitamins), smaller more frequent meals, super pudding (a fortified pudding used to provide extra calories, proteins and vitamins), fortified food program. Review of the facility's policy titled, Registered Consultant Dietitian (RD), dated May 2015, showed: - Monthly visits to each facility to assist in compliance of regulatory requirements in food service and residents' dietary care with a report of findings; - Consultation with the Director of Nursing (DON) on all residents who are at risk for poor nutrition, have significant weight loss, have pressure sores, or that are fed per tube. 1. Review of Resident #14's Physician Order Sheet (POS), dated December 2024, showed: - An order for Level 7 Regular diet (easy to chew), reduced concentrated sweets (RCS), dated 06/21/24; - An order for Boost very high calorie drink (VHC) 120 millimeters (ml) with supper meal, dated 12/03/24; - An order for a referral to gastroenterologist (specialist in organs of the digestive system), dated 12/04/24; - No order for a multivitamin as recommended by the RD on 06/18/24; - No order for weekly weights as recommended by the RD on 12/03/24. Review of the resident's Weight Variance Report, dated 06/15/24 through 12/04/24, showed: - On 06/15/24, the resident weighed 235.8 pounds (lbs); - On 06/20/24, the resident weighed 235.8 lbs; - On 06/25/24, the resident weighed 233.7 lbs; - On 07/02/24, the resident weighed 233.7 lbs; - On 07/09/24, the resident weighed 230.4 lbs; - On 08/02/24, the resident weighed 228.0 lbs; - On 09/03/24, the resident weighed 221.0 lbs; - On 10/01/24, the resident weighed 216.9 lbs; - On 11/04/24, the resident weighed 210.4 lbs; - On 12/04/24, the resident weighed 206.6 lbs; - From 06/15/24 - 08/02/24, the resident had a 4.98% weight loss in 3 months; - From 06/15/24 - 12/04/24, the resident had a 10.38% weight loss in 6 months. Review of the Dietary assessments showed: - An initial assessment completed on 06/18/24, with a regular diet,restricted concentrated sweets, and recommendations to add a multivitamin; - A quarterly nutrition review completed on 09/12/24, with a regular diet and restricted concentrated sweets. Notes weight was down six pounds in 30 days, edema (swelling) contributing; - A significant weight change in status completed on 12/03/24, with greater than 7.5% wt. loss in 90 days. Resident with significant weight change for 90 days and 180 days. Recommended to add VHC 120 ml to supper meal and monitor weekly weights; - No documentation the RD assessed the resident in October and November 2024. Review of the resident's Care Plan, last reviewed, 09/23/24, showed: - A regular diet, no concentrated sweets; - Did not address weight loss with interventions. Observations of the resident on 12/03/24, 12/05/24, and 12/06/24, during the lunch meal showed: - The resident ate in the main dining room. The resident #14 ate approximately 50-100% of his/her meals. During an interview on 12/03/24 at 2:14 P.M., Resident #14 said he/she was not trying to lose weight and was not on any medications to aid in weight loss. During an interview on 12/05/24 at 3:25 P.M., the Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) Coordinator said the Restorative Nurse Aide (RNA) weighed the residents. The MDS Coordinator and the DON received a copy of the weight variance report and reviewed it. The facility did not have meetings where they discussed residents weights. During an interview on 12/05/24 at 3:34 P.M. the Quality Assurance (QA) Nurse said the RD needed to be reviewing any weight loss in the facility. The weight variance report should be reviewed by the DON and any resident with weight loss should be seen by the RD. During an interview on 12/11/24 at 9:53 A.M., the RD said it would be good if the facility held weight meetings within the facility on a bi-weekly basis. During an interview on 12/11/24 at 10:30 A.M., the MDS Coordinator said Resident #14's family brought it to the attention of the facility of the resident's weight loss. 48532

Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for one resident (Resident #6) out of one sampled resident. The facility failed to use proper hand hygiene during blood sugar testing for four residents (Residents #3, #10, #20 and #38) out of four sampled residents. This deficient practice had the potential to affect all residents in the facility. The facility census was 59. Review of the facility's policy, titled, Enhanced Barrier Precautions to Infection Control Guidelines, updated 2024, showed: -To prevent broader transmissions of multi-drug resistance organisms (MDROs) and to help protect patients with chronic wounds and indwelling devices. EBP should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed; - Examples of MDROs include, but are not limited to, methicillin-resistant staphylococcus aureas (MRSA), vancomycin-resistant enterococci (VRE), extended spectrum beta-lactamase (ESBL-producing enterobacterais) and drug-resistant streptococcus pneumoniae; - Who requires EBP, residents known to be infected or colonized with a MDRO, residents with an indwelling medical device, and residents with a wound, regardless of their MDRO status; - When to use EBP, during high-contact resident care activities, such as, performing wound care; - Gown and gloves are required when conducting high-contact resident care activities, such as wound care. Review of the facility's policy titled, Diabetic Infection Control, undated, showed: - Gloves are to be worn when performing finger sticks and changed between resident contacts; - Remove and discard gloves in appropriate receptacles after each procedure that involves potential exposure to blood or body fluids, including finger stick blood sampling; - Perform hand hygiene (i.e., hand washing with soap and water or use an alcohol-based hand rub) immediately after removal of gloves and before touching other medical supplies intended for use on another resident. 1. Observation on 12/05/24 at 1:28 P.M., of Resident #6's wound care showed: - No EBP signage posted outside of the resident's room; - Registered Nurse (RN) J did not put on isolation gown, did not perform hand hygiene, put on gloves, and entered the resident's room; - RN J removed the saturated dressing from the resident's left neck area; - RN J performed hand hygiene and changed gloves; - RN J used wound cleanser and gauze to clean the wound, did not perform hand hygiene, did not change gloves, and patted the wound dry with clean gauze; - RN J performed hand hygiene and put on clean gloves; - RN J applied a 2x2 gauze dressing and secured with medical tape; - RN J took the biohazard bag outside of the resident room and disposed of the bag in the trash can attached to the treatment cart; - RN J removed the gloves and did not perform hand hygiene. During an interview on 12/03/24 at 10:01 A.M., Resident #6 said he/she didn't know why they had a dressing applied to his/her neck. 2. Observation on 12/04/24 at 11:10 A.M., of Resident #10's blood sugar testing showed: - RN J did not perform hand hygiene and put on gloves; - RN J performed the resident's blood sugar testing; - RN J removed the gloves and did not perform hand hygiene. 3. Observation on 12/04/24 at 11:16 A.M., of Resident #20's blood sugar testing showed: - RN J did not perform hand hygiene and put on gloves; - RN J performed the resident's blood sugar testing; - RN J removed the gloves and did not perform hand hygiene. 4. Observation on 12/04/24 at 11:23 A.M., of Resident #38's blood sugar testing showed: - RN J did not perform hand hygiene and put on gloves; - RN J performed the resident's blood sugar testing; - RN J removed the gloves and did not perform hand hygiene. 5. Observation on 12/04/24 at 11:26 A.M., of Resident #3's blood sugar testing showed: - RN J did not perform hand hygiene and put on gloves; - RN J performed the resident's blood sugar testing; - RN J removed the gloves and did not perform hand hygiene. During an interview on 12/06/24 at 9:30 AM, the Director of Nursing (DON) said Resident #6 should have been on EBP. With EBP, staff should be putting on a gown and gloves and removing the gown and gloves within the resident's room. She said nurses should be performing hand hygiene prior to putting on gloves and after removing gloves for any procedure, including blood sugar testing.

Based on interview and record review, the facility failed to ensure at least one person had completed specialized training in infection prevention and control for the Infection Preventionist (IP) (a professional who assures healthcare workers and residents are doing everything possible to prevent infection) position. This had the potential to affect all residents in the facility. The facility census was 52. Review of the facility's policy titled, Infection Prevent and Control Program, dated 02/07/23 showed the IP is qualified to conduct infection prevention and control activities as a result of education, training and experience (he/she will complete the Centers for Disease Control and Prevention (CDC) Long Term Care Infection Preventionist module). The facility did not provide documentation for any staff members that had completed the specialized training for the IP position. During an interview at 10/19/23 at 9:20 A.M., the Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff) Coordinator said he/she and the Director of Nursing (DON) were taking classes for the IP position. They were both enrolled in the IP classes but had not completed the class. He/She had been in the current position since October 2022. During an interview on 10/19/23 at 10:20 A.M., the DON said he/she and the MDS Coordinator share the responsibility for the IP position. They were both enrolled in the IP classes but had not completed the classes. He/She had been the DON since May 2023. During an interview on 10/20/23, at 12:45 P.M., the Administrator said both the DON and MDS Coordinator were taking classes for the IP position but had not finished the program yet.

Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs for six residents (Residents #13, #14, #18, #21, #31, and #38) out of 13 sampled residents. The facility census was 52. Review of the facility's policy titled, Care Plan Comprehensive, undated, showed: - An individualized comprehensive care plan includes measurable goals and time frames that meet the resident's highest practicable physical, mental, and psychosocial well-being; - The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff); - A well-developed care plan will be oriented to managing risk factors, applying current standards of practice in the care planning process, assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs; - The comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment. 1. Review of Resident #13's medical record showed: - An admitted [DATE]; - Diagnoses of chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing related problems), hypertension (high blood pressure), major depressive disorder (MDD) (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (a disorder characterized by feelings of worry, anxiety or fear that is strong enough to interfere with one's daily activities). Review of the resident's Physician Order Sheet (POS), dated 10/20/23, showed an order for oxygen at 2 liters (L) per nasal cannula (NC) (a device used to deliver supplemental oxygen to an individual in need of respiratory help), dated 10/20/23. Observations of the resident showed: - On 10/18/23 at 8:41 A.M., the resident lay in bed with oxygen on at 2 L per NC; - On 10/19/23 at 7:59 A.M., the resident lay in bed with oxygen on at 2 L per NC. Review of the resident's care plan, last reviewed on 08/17/23, showed it did not address the resident's oxygen with specific interventions. During an interview on 10/18/23 at 8:41 A.M., the resident said he/she only used oxygen when it was needed. During an interview on 10/19/23 at 10:12 A.M., Certified Medication Technician (CMT) A said Resident #13 wore oxygen when needed. During an interview on 10/19/23 at 10:15 A.M., Licensed Practical Nurse (LP) B said Resident #13 had oxygen on when needed. The oxygen should be care planned. 2. Review of Resident #14's medical record showed: - An admitted [DATE]; - Diagnosis of low back pain; - Resident assessed as a safe smoker on 08/07/2023. Review of the resident's POS, dated 10/04/23, showed: - An order for hydrocodone-acetaminophen (an opioid for pain control) 7.5 - 325 milligram (mg) every 6 hours as needed (PRN), dated 04/05/23; - An order for acetaminophen (a medication used to relieve mild or chronic pain and to reduce fever) 325 mg two tablets every 6 hours PRN, dated 02/24/23. Review of the resident's care plan, last reviewed on 08/22/23, showed: - Did not address the resident's smoking with specific interventions; - Did not address the resident's pain with specific interventions. Observations of the resident showed on 10/19/23 at 11:00 A.M., the resident smoked in the designated smoking area unsupervised. During an interview on 10/17/23 at 12:45 P.M., Resident #14 said he/she only used medications when needed for pain and had smoked without supervision since being assessed as a safe smoker soon after being placed in the facility. 3. Review of Resident #18's medical record showed: - admitted [DATE]; - Diagnoses of end stage renal disease (ESRD) (when the kidneys are no longer able to work at a level needed for day-to-day life), non-ST elevation myocardial infarction (NSTEMI) (a type of heart attack that usually happens when your heart's need for oxygen can't be met), hypertension ((high blood pressure), hypotension (low blood pressure), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), atherosclerotic heart disease of native coronary artery (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery); and acute kidney failure (a sudden episode of kidney failure or kidney damage). Review of the resident's Physician Order Sheet (POS), dated 10/2023, showed: - An order for 1 Liter (L) fluid restriction every day, evening, and night shift, dated 09/25/23; - An order for daily weights every morning and record results daily, dated 09/23/23; - An order for a renal, 2 gram sodium diet, dated 09/22/23; - No documentation of an order for dialysis; - No documentation of an order to assess and monitor the dialysis access site; - No documentation of an order to assess and monitor the resident before and after dialysis treatments. Review of the resident's care plan, last reviewed on 10/03/23, showed: - Dialysis with specific interventions not addressed; - The dialysis access site(s) not addressed. During an interview on 10/17/23 at 3:36 P.M., Resident #18 said he/she received dialysis on Monday, Wednesday and Friday. 4. Review of Resident #21's medical record showed: - admitted to the facility on [DATE]; - Diagnoses of post-traumatic stress disorder (PTSD) (a mental health condition triggered by a terrifying event), anxiety disorder, depression, personality disorder (a mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that cause problems), and traumatic brain injury (TBI) (an injury that affects how the brain works); - No documentation of a PTSD assessment. Review of the resident's care plan, last revised on 10/12/23, showed: - PTSD not addressed; - No documentation the resident had past trauma or any triggers that would cause behaviors; - No interventions for how the facility would address these behaviors if they occurred or how the facility would provide support to the resident. During an interview on 10/19/23 at 11:15 A.M., the MDS Coordinator said there wasn't a PTSD assessment used. The resident's PTSD should be care planned. During an interview on 10/19/23 at 2:05 P.M., Resident #21 said he/she could not recall what diagnoses he/she had. The resident did not see a psychiatrist and didn't feel like he/she needed to. The medication he/she was on worked good. During an interview on 10/19/23 at 2:13 P.M., the MDS Coordinator said the PTSD for Resident #21 was due to a motor vehicle accident that resulted in his/her TBI. 5. Review of Resident #31's medical record showed: - admitted [DATE]; - Diagnoses of end stage renal disease, dependence on renal dialysis and hypertension. Review of Resident #31's POS, dated 10/04/23, showed: - The resident received dialysis three times a week on Tuesday, Thursday, and Saturday, dated 11/22/22; - No documentation of an order to assess and monitor the resident's dialysis access site; - No documentation of an order to assess and monitor the resident before and after dialysis treatments. Review of the resident's care plan, dated 10/04/23, showed: - Dialysis with specific interventions not addressed; - The dialysis access site(s) not addressed. During an interview on 10/20/23 at 11:17 A.M., Resident #31 said he/she rode a transit bus to dialysis on Tuesday, Thursday and Saturday. 6. Review of Resident #38's medical record showed: - admitted on [DATE]; - Diagnoses of PTSD, major depressive disorder severe with psychotic (severe mental disorder that causes abnormal thinking and perceptions) symptoms, and anxiety disorder; - No documentation of a PTSD Assessment; - Resident assessed as a safe smoker on 08/07/2023. Review of the resident's POS, dated 10/04/23, showed an order for Lamictal (an anticonvulsant) one tablet 25 mg twice a day for major depressive disorder severe with psychotic symptoms, dated 03/30/23. Review of the resident's care plan, initiated on 02/22/23, showed: - PTSD and smoking not addressed in care plan; - No documentation showing the resident had past trauma or any triggers that would cause behaviors; - No interventions for how the facility would address these behaviors if they occurred or how the facility would provide support to the resident. During an interview on 10/17/23 at 2:30 P.M., Resident #38 said he/she was a safe smoker and was allowed to smoke at will without supervision. The resident said he/she had seen a psychiatrist in the past and would like a chance to visit again. During an interview on 10/19/23 at 10:10 A.M., the MDS Coordinator said care plans should reflect the care required by the residents, should be accurate, and should be updated as needed. During an interview on 10/20/23 at 10:45 A.M., the Director of Nursing (DON) said specific care requirements should be care planned individually for each resident to include oxygen, PTSD, dialysis, and smoking. During an interview on 10/20/23 at 12:45 P.M., the Administrator said he would expect care plans to reflect the care required by each individual resident. 46521 47445

Based on interview and record review, the facility failed to provide documentation of a Level I Preadmission Screening and Resident Review (PASARR) (a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder to determine the level of care needed) for two residents (Residents #38 and #41) out of four sampled residents. The facility's census was 52. The facility did not provide a policy regarding PASARR. 1. Review of Resident #38's medical record showed: - An admitted [DATE]; - Diagnoses of major depressive disorder severe with psychotic symptoms (a serious medical illness that negatively affects how you feel, the way you think and how you act), generalized anxiety disorder (persistent worry and fear about everyday situations), and post-traumatic stress disorder (PTSD) (a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event); - No documentation of a Level I PASARR. Review of Resident #38's Quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, dated 08/03/23, showed the PASARR not documented. During an interview on 10/19/23 at 2:47 P.M., the Social Service Director (SSD) said Resident #38 had not had a Level I PASARR screening since being admitted to the facility. The resident transferred from another long term care facility. The resident should have had a new Level I completed. Review of Resident #41's medical record showed: - An admitted [DATE]; - Diagnoses of bipolar disorder (a mental disorder that causes unusual shifts in mood), depression, anxiety disorder, and schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations); - No documentation of a Level I PASARR. Review of Resident #41's quarterly MDS, dated [DATE], showed the PASARR not documented. During an interview on 10/18/23 at 4:52 P.M., the SSD said Resident #41 had not had a Level I PASARR completed since he/she had been admitted to the facility. The resident transferred from another facility and the prior Level I PASARR wasn't received from the previous facility. During an interview on 10/20/23 at 12:45 P.M., the Administrator said he would expect the facility to have completed or ensured a copy of the Level I PASARR followed the residents from a previous facility. 47445