Every finding on record at Colonel Glenn Health and Rehab, LLC

Number of residents sampled: Number of residents cited: Based on observations, interviews, and facility policy review, the facility failed to store and prepare foods under sanitary conditions in one of one kitchen. The findings include: Incident #1 During an observation in the kitchen on 08/11/2026 at 11:20 AM, this surveyor observed the Dietary Manager (DM) washing the blender in the three-compartment sink. The DM picked up the plunger from the floor and plunged the sink until water receded. The DM then picked up a wet rag off of the sink and wiped out the wash compartment, then used the same rag to wash the blender.During an interview on 08/11/2026 at 2:00 PM, the DM stated, we usually send the plunger through the dishwasher after we use it, it is supposed to be stored on the rack off the floor. The DM also stated that the sinks should have been sanitized correctly after she used the plunger in the sink. The DM stated, this could have caused cross contamination. Incident #2During an observation on 08/11/2026 at 11:45 AM, this surveyor observed [NAME] #5 prepare dessert with gloved hands, [NAME] #5 retrieved a bag of whipped topping from the refrigerator, contaminating the gloves. [NAME] #5, with contaminated gloves, used scissors to cut the tip of the bag and applied the topping to the dessert. [NAME] #5 then picked up cookie topping, cut the tip off the bag with scissors and poured the cookie topping over his fingers, onto the dessert. [NAME] #5 did not change gloves or perform hand hygiene during this process.During an interview on 08/11/2026 at 2:00 PM, the DM stated she expected staff to change gloves when the gloves were physically dirty and between clean and soiled task, to prevent food borne illness.During an interview on 08/11/2026 at 2:15 PM, [NAME] #5 stated their hands needed to be washed before gloving and when taking gloves off. [NAME] #5 also stated touching dirty items and then food could cause cross contamination. Incident #3 During an observation on 08/11/2026 at 12:05 PM, in the kitchen prep area, the air conditioner vent, above the shelving where the bread was stored was dripping liquid down onto the bread on the shelf in the manufacturer's packaging. The liquid was pooling around the bread package.During an interview on 08/11/2026 at 2:00 PM, the DM stated it was not best practice for the air conditioner to be leaking on the bread. The DM stated, this does not usually happen, and the bread has been moved. Incident #4 During an observation with [NAME] #6 on 08/11/2026 at 12:20 PM, this surveyor observed [NAME] #6 obtain the following temperatures for the foods on the cold food serving bar:-the cookie dessert temped at 48 degrees Fahrenheit - the salad temped at 52 degrees Fahrenheit. During an observation on 08/11/2026 at 12:55 PM, this surveyor observed the DM place the cookie dessert on a resident's tray. The DM was shown the temperature reading for the dessert. The DM stated the dessert was not safe to serve to the residents. During an interview on 08/11/2025 at 2:00 PM, the DM stated that the food on the cold food line needed to be kept under 41 degrees Fahrenheit to prevent food borne illness. During an interview on 08/11/2026 at 2:25 PM, [NAME] #6 stated, hot food items needed to be at 140 degrees [Fahrenheit] and the cold food items needed to be at 41 degrees [Fahrenheit] to prevent food born illness.During an interview on 08/11/2026 at 2:56 PM, the Administrator stated that the sink should have been sanitized properly after using the plunger to prevent food borne illness. The Administrator stated they expected staff to use clean gloves between clean and soiled [tasks] and when they are physically dirty. The Administrator continued that they expected food to be served at the appropriate temperature; If food was served at the wrong temperature it could cause a food borne illness. Review of the facility policy titled Infection Control, dated 11/02/2017, revealed equipment and counters will be cleaned and sanitized after each use. Review of a facility policy titled Food Storage, dated 11/25/19, revealed Food is stored away from all sewer and water lines, drains and dripping pipes. Review of a facility policy titled Hand Washing/Hand Hygiene, dated 11/22/17, revealed that All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors.Review of an in-service dated 08/09/2026 with a subject of handwashing revealed, wash often before and after glove use. [NAME] #5 had signed the sign-in sheet for the in-service indicating they were present for the training.

Number of residents sampled:Number of residents cited: Based on record review and interviews the facility failed to ensure two (Resident #4, Resident #82) of two residents were free from misappropriation of resident owned trust fund money. The findings include: Resident #4 Review of Resident #4's Medical Diagnosis Report revealed Resident #4 had diagnoses that included dementia, scalp and neck cancer and stroke. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/10/2026, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #4 had no cognitive impairment. Resident #82 Review of Resident #82's Medical Diagnosis Report revealed Resident #82 had diagnoses that included dementia, kidney disease stage II and atrial fibrillation. Review of the quarterly MDS with an ARD of 05/09/2026, revealed Resident #82 had a BIMS score of 11, which indicated Resident #82 had moderate cognitive impairment. Review of an Office of Long-Term Care (OLTC) Reportable revealed that on 07/07/2026 at 2:30 PM, the facility discovered $750.00 had been withdrawn from Resident #82's trust account for shopping, and a reportable was submitted to the OLTC on 07/08/2026 at 12:04 PM. The reportable indicated a check had been written out to cash in the amount of $750.00 with no supporting documentation. Resident #82's family stated they had no recollection of asking for cash in the amount of $750.00. Police were notified, and a request to process $750.00 to replace the money was made to the main office of the facility. Review of a Police Report dated 07/08/2026 at 11:20 AM, revealed that the Assistant Administrator reported theft /misappropriation of resident trust funds in the amount of $750.00 for Resident #82 in the form of a check made out to cash and later added that another check made out to cash in the amount of $800.00 was missing from Resident #4's trust fund. During an interview on 08/11/2026 at 10:55 AM, the Business Office Manager (BOM) stated that Resident #82's family reported $750.00 missing from the residents' trust. The BOM stated an audit and reportable was completed. The BOM also stated that an investigative audit revealed that Resident #4 also had $800.00 missing from their trust account, and we replaced both residents' funds immediately. During an interview on 08/12/2026 at 2:07 PM, the BOM indicated BOM #8 had been responsible for trust accounts from 4/2025-6/29/2026 The BOM stated, I mailed out quarterly statements when I returned from a leave of absence. The BOM stated that on 07/09/2026 the Assistant Administrator called the BOM and revealed that Resident #82's family had questioned why over $700.00 had come out of Resident 82's trust as a cash withdrawal. The Assistant Administrator reported to the BOM that a check had been made out to cash on Resident #82's trust account without any receipts on 05/06/2026. The BOM stated the Administrator also indicated that Resident #4 had a check in the amount of $800.00 written to cash on 06/11/2026. The BOM stated, checks are never to be made out to cash. During a follow-up interview on 08/13/2026 at 2:15 PM, the BOM stated Resident #4's friend was going to make an $800.00 payment on a burial policy, so I called their friend to see if the friend had picked up the $800.00 and if BOM #8 just forgotten to get Resident #4 to sign for the cash. Resident #4's friend stated they did not have time to come by and pick up the money for the burial policy and stated that Resident #4 only needed to pay $400.00 not $800.00. The BOM stated to prevent misappropriation from reoccurring in the future, money request for cash now must be signed by the resident, then the resident must sign again indicating they received the money with a witness. During an interview 08/12/2026 at 2:32 PM, the Administrator confirmed that BOM #8 left on maternity leave on 06/26/2026. The Administrator stated, I had the code on the BOM office door changed when we found out the money was missing, removed computer access and removed BOM #8 from our bank accounts, we interviewed all the residents to see if anyone had taken money from them or prevented them from receiving their 40.00 a month. The Administrator stated that she called BOM #8 after becoming aware of the misappropriation of funds and BOM #8 had denied signing the checks and stated that receipts were received. The Administrator stated, I asked her why the checks were written out to cash because that is not our procedure and she said that was how the family representatives wanted them to be written. The Administrator also stated that someone forged her name on both checks. During a telephone interview on 08/12/2026 at 3:40 PM, the Assistant Administrator stated that he became aware that $750.00 was withdrawn from Resident #82's trust when family came to the office and stated there was cash taken out of Resident #82's trust account without their knowledge. The Assistant Administrator stated there were no supporting documents to go with the withdrawal. The Assistant Administrator stated, BOM #8 had gone on maternity leave, and she told me there were supporting documents with receipts. BOM #8 was told the documents or receipts to support why money was removed from the account could not be found. The Assistant Administrator stated the facility's procedure was to only write cash on a check if the facility did not have the money on hand and would write a cash check and reference the residents' name on the memo of the check. The cash would then be given to the resident with witness signatures. There were no signatures from the resident or the resident's family requesting this money. The Assistant Administrator stated, The BOM, the Administrator and I reconcile trust accounts every month. During reconciliation we check cash going in and cash going out. If it does not reconcile, we do a 'deep dive line by line.' We do representative payee reviews that are done yearly (not necessarily every 12 months) for each resident and look line by line and we would have caught the missing funds at that time. The Assistant Administrator revealed that only the Administrator, Assistant Administrator or a BOM would have known the door code and known where the drawer keys were hidden for the Business Office. During an interview on 08/13/2026 at 4:15 PM, Resident #4 stated that last week someone told them money was taken out of their trust account without their knowledge, and the money was paid back to the account by the facility. Resident #4 stated they could ask for cash but had to sign for it. Resident #4 confirmed that they had not signed for or received $800.00 in cash. During a telephone interview on 08/13/2026 at 10:01 AM, BOM #8 stated she did not need receipts for Resident #4's transaction because the cash was to be given to the resident's spouse. BOM #8 stated that Resident #82's family brought in receipts and that she had to wait on a third receipt before giving the resident cash. BOM #8 stated that the resident had three receipts from a retail store adding up to $750.00. The BOM #8 stated that the resident was saying they did not get the money, but BOM #8 stated she knew that there were three receipts stapled to a document for the distribution of the funds. BOM #8 stated she did not normally have residents sign for cash unless it was for the monthly allowance money and residents had to turn in receipts, and administration would staple the receipts to a copy of the check BOM #8 would write and put the paperwork in a trust folder. BOM #8 stated, it is weird as soon as I leave money disappears from the trust and other staff had access to that office. BOM #8 stated she spoke with Resident #4, and the resident wanted $800.00 to give to their friend to pay on a burial policy. BOM #8 denied knowledge of any missing funds and stated, the only thing I did wrong was signing those checks to cash. During a telephone interview on 08/14/2026 at 9:33 AM, Resident #82's family stated they got a statement that showed Resident #82 had $400.00 and something dollars remaining and that $750.00 had been deducted. The family member stated that the Assistant Administrator told the family member that the family had been given money to spend on Resident #82 in the amount of $750.00. The family member stated, I told the Assistant Administrator that I did not get $750.00 cash for my parent. The family member stated that the Assistant Administrator was looking for receipts and stated he could not find receipts, but he did find where the $750.00 was deducted out. The family revealed that the facility immediately put the money back into Resident #82's account. During a telephone interview on 08/14/2026 at 1:30 PM, Resident #4's friend was asked if they had picked up $800.00 to pay on burial expenses? The friend stated, I have not had a chance to come by yet. The friend stated that she had to come pick it up so that she and Resident #4 could sign for the funds. The friend stated she was notified that Resident #4's funds were taken out of the trust and replaced by the facility. Review of a policy titled Abuse Neglect Misappropriation investigating and reporting policy, revised on 11/20/2017, revealed that the facility does everything possible to protect residents from abuse. They will provide criminal background checks and not knowingly hire anyone that has been convicted of abuse. Any known or alleged suspicions of misappropriation should be reported to the administrator right aways and the allegations investigated to determine if anything has occurred, the extent and by whom. All residents should be protected. Reviewed a policy titled Resident Accounts Procedure, from the admissions packet revealed that the facility will manage personal funds when requested by the resident or responsible party. Review of an Employee File for BOM #8 revealed a criminal background check and write ups including no-call-no-show, work not done in a timely manner, including: room and board not posted on a check written on 01/12/2026, deposited checks into trust but did not write a check for room and board, did not run credit card payments and three residents had over $2000.00 in their trust because checks were not written for room and board.

Number of residents sampled: Number of residents cited: Based on observations, record review, interviews, and facility policy review, the facility failed to ensure the resident's environment remained free of accident hazards and each resident received adequate supervision and assistance to prevent accidents for two (Resident #39, Resident #43) of two residents reviewed. The findings include: Resident #39 Review of Resident #39's admission Record revealed that the facility admitted Resident #39 on 07/13/2026 with diagnoses that included type 2 diabetes mellitus, glaucoma, and chest pain. Review of a Care Plan revealed Resident #39 had an Activities of Daily Living (ADL) self-care performance deficit related to impaired balance and benign neoplasm of colon with an initiated date of 07/29/2026. Interventions included that the resident required partial assistance by one staff with bathing/showering three times a week and as necessary. Use short, simple instructions such as hold your washcloth in your hand; put soap on your washcloth; wash your face; to promote independence. Review of Resident #39's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/2026, revealed that Resident #39 had a Brief Interview for Mental Status (BIMS) score of 08 which indicated the resident had moderate cognitive impairment. A review of Resident #39's Care Area Assessment (CAA) worksheet revealed a potential problem related to visual function of diseases and conditions of the eye: glaucoma, visual field deficit, diabetic retinopathy, and decreased visual acuity. Complications of immobility such as contractures. ADL problem: Bathing: mental errors: sequencing problems, incomplete performance, anxiety limitations. Physical limitations: weakness, limited range of motion, poor coordination, poor balance, visual impairment, pain. Falls triggering condition. Resident received antidepressant medication, resident on antidepressants. Internal Risk factors: Neuromuscular/functional: Loss of arm or leg movement. A review of Resident #39's Physician Orders revealed Resident #39 had orders for occupational therapy dated 07/13/2026 and physical therapy dated 07/13/2026 with a focus of gait training, speech therapy dated 07/16/2026 with a focus on cognition and individual treatment for dysphagia, insulin, a medication for chest pain, eye drops for glaucoma, a medication to treat nausea, and a prescription opioid pain medication for pain. During an observation on 08/10/2026 at 10:42 AM, this surveyor observed that the shower room on Hall 1-D was ajar. The door was unlocked and unsecured. The door opened easily by pushing on the door. A tall plastic gray storage cabinet was observed in the corner of the room. The cabinet doors were open and this surveyor observed shampoos and conditioners, body cleansers, cornstarch powder, a bottle of facial cleanser, a container of [Name Brand] wipes, six new razors, boxes of gloves, and a bag of cotton balls. This surveyor observed a used razor lying on top of one of the boxes of gloves. During a concurrent observation and interview on 08/10/2026 at 10:48 AM, the Director of Nursing (DON) observed that the shower room door on Hall 1-D was not locked or secured and that the storage cabinet was not locked. The DON stated, we do not keep the door to the shower room or the storage cabinet locked. The DON observed the contents of the storage cabinet and stated that the residents stored their private stuff in the cabinet. The DON confirmed the contents and stated, there is a concern with the used razor being open just lying there. The DON acknowledged that she did not know how long the used razor had been in the cabinet. The DON stated, these are single use razors and should be disposed of after they are used. The DON confirmed that they did not have any residents who could take themselves to the shower room. The DON stated it had to be a staff member who put the used razor on the box. During an observation on 08/10/2026 at 11:50 AM, this surveyor observed that the shower room on Hall 1-D was unlocked and unsecured. This surveyor heard water running and observed the shower curtain closed. This surveyor announced themselves and Resident #39 stated their name and replied, I'm in here. There was no one in the shower with the resident. Resident #39 stated that they were taking their shower and that they could shower alone. Certified Nursing Assistant (CNA) #2 was observed down the hallway entering Resident #39's room. During an interview on 08/10/2026 at 12:11 PM in Resident #39's room with CNA #2 present, Resident #39 stated they had been living in the facility for 2-3 weeks and CNA # 2 confirmed that Resident #39 had been at the facility for about 3 weeks. Resident #39 stated that they shower themselves every other day. CNA #2 confirmed that staff sets up everything and the resident showered themselves. During an observation on 08/12/2026 at 10:53 AM, the shower room on Hall 1-D was unlocked and unsecured. During an interview on 08/12/2026 at 11:37 AM, the Restorative CNA (RCNA) #1 stated the shower rooms were kept locked and there was a keypad with a code to get into them. RCNA #1 stated residents were allowed to give themselves their own showers and be in the shower room without supervision. RCNA #1 stated some residents want their privacy, and staff would provide set up and then the residents would give their own showers. RCNA #1 stated there were two residents on Hall 1-D that would give themselves their own showers. RCNA stated Resident #39 gave themselves a shower. During an interview on 08/12/2026 at 12:08 PM, the DON stated that razors were to be kept in the cabinet in the shower room and it had a locking mechanism that should be locked when not in use. The DON stated there were no residents who resided on Hall 1-D who should be in the shower room without supervision. The DON stated that residents should never be left in the shower room unattended. The DON reviewed the Electronic Health Record (EHR) Care Plan for Resident #39, and stated Resident #39's supervision level for showers was partial assistance by one staff. The DON stated that meant the resident needed help washing some parts of their body. The DON stated Resident #39 should not be left alone in the shower due to concerns of a fall, injury or of water getting in their face and nose. The DON stated, in the event of injury the resident may not be able to yell out for anyone. During an interview on 08/12/2026 at 1:23 PM, CNA #2 stated she had left Resident #39 in the shower room with the shower running and went down the hall to the resident's room to retrieve the resident's bag. During an observation on 08/13/2026 at 4:12 PM, the shower room door on Hall 1-D was unlocked and unsecured. Review of a facility policy titled Standard Precautions, dated 11/22/2016, revealed that standard Precautions will be used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. The policy also revealed to place used disposable .sharp items in appropriate puncture-resistant containers. Review of the Safety Data Sheet (SDS) for [Name Brand] Germicidal Disposable Wipes revealed: Causes serious eye irritation, may cause drowsiness or dizziness. Precautionary statements included Prevention. Keep the container tightly closed. Store in a well-ventilated place, keep container tightly closed. The SDS also revealed handling and storage included to avoid contact with eyes, wash hands after handling. Resident #43 Review of Resident #43's admission Record revealed that the facility admitted Resident #43 on 03/17/2022 with diagnoses that included cerebral palsy, history of falling, urinary tract infection, hematuria, pain, and essential (primary) hypertension. Review of Resident #43's quarterly MDS with an ARD of 08/01/2026 revealed Resident #43 had a BIMS score of 07, which indicated the resident had severe cognitive impaired. The MDS also revealed that Resident #43 was mobile via manual wheelchair pushed by staff and that Resident #43 needed supervision/or touching assistance with eating and partial/moderate assistance with oral hygiene. Resident #43 was dependent on staff for toileting, shower/bathing self, lower body dressing and putting on and taking off footwear. Resident #43 required substantial/maximal assistance with upper body dressing and personal hygiene. The MDS revealed that Resident #43 was incontinent of bowel and bladder and at risk for developing pressure ulcers/injuries. The MDS also revealed pressure reducing device in chair and bed and turning and repositioning program. Review Resident #43's Physician Orders revealed Resident #43 had an order to admit to hospice home care with an order date of 06/29/2026. The Physician Orders also revealed an order dated 07/16/2026 for a low air loss mattress related to pressure injury. Review of Resident #43's Care Plan with a last reviewed date of 05/25/2026, revealed Resident #43 had an ADL self-care performance deficit. Resident #43 was dependent on one staff for mobility in a medical reclining chair. Resident #43 required extensive assistance from two staff for repositioning and turning in bed every two hours as needed. Resident #43 had contractures of the right lower extremity and left arm. Interventions included to provide skin care daily to keep clean and prevent skin breakdown. The Care Plan also revealed that Resident #43 required mechanical lift with two staff assistance utilizing a purple lift pad for transfers. During an observation on 08/10/2026 at 12:09 PM, Resident #43 was sitting in room in a medical reclining chair with a lift sling beneath the resident. The lift sling was observed to have frayed trim and torn material; specifically, the trim was not intact around the areas that supported the resident's head, shoulders, and buttocks. The area around the lifting straps attached was also frayed and not intact. During a follow-up observation on 08/11/2026 at 9:45 AM, Resident #43 was sitting in room in a medical reclining chair after breakfast. The lift sling under Resident #43 was observed to have frayed trim and torn material. During an interview on 08/12/2026 at 1:42 PM, CNA# 9 stated that they reported changes in resident condition to the charge nurse. CNA #9 stated residents were checked for incontinence and repositioned at least every two hours. CNA#9 stated if a lift sling was frayed or torn they would change it out for a sling in good repair, notify the charge nurse, and discard the damaged one. During an interview on 08/12/2026 at 2:01 PM, CNA #10 stated residents were checked for incontinence and repositioned at least every two hours, and more often if needed. CNA #10 stated if a frayed or torn lift sling was observed they would throw away the damaged one. CNA #10 stated a frayed or torn lift sling could cause an accident. During an interview on 08/12/2025 at 2:11 PM, CNA #11 stated, how to care for each individual resident is in their care plan. CNA #11 stated that if a lift sling was in poor repair and being used for a resident, he would discard that sling immediately. During an interview on 08/12/2026 at 12:43 PM, Laundry Personnel #12 was asked if they ever observed lift slings that were frayed and the trim was no longer intact. Laundry Personnel #12 stated, yes and I report it to administration when they are seen and they are immediately destroyed. During an interview on 08/13/2026 at 3:30 PM, the DON stated, usually damaged lift slings are destroyed in laundry but if it makes it to the floor, the CNAs will discard it. The DON stated that if a damaged lift sling was used for a resident it could cause an accident or injury. This surveyor requested the DON accompany to Resident #43's room to view the damaged lift sling. Upon entering the room Resident #43 was sitting up in a medical reclining chair at bedside. This surveyor observed that the lift sling had been changed. This Surveyor provided pictures of the damaged lift sling for the DON and noted the time/date that the pictures were taken. The DON was able to describe the lift sling as worn and confirmed that the lift sling needed to be replaced. During an interview on 8/13/2026 at 4:08 PM, the Administrator denied ever seeing a damaged lift sling and stated, if seen, it would only be once, because the CNAs know to discard the sling if in poor condition. This Surveyor informed the Administrator that the surveyor had observed the damaged sling being used for Resident #43 for three days and that it had been changed now. Photos of damaged sling shown to the Administrator with time/date stamp. The Administrator stated that if a damaged lift sling was used on a resident, the resident could sustain a fall or injury. Review of a General Guidelines, Owner's Operator and Maintenance Manual for the lift sling revised on 12/31/2013, revealed that after laundering inspect sling(s) for wear, tear, and loose stitching. Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately.

Based on observation, interviews, and record review, it was determined the facility failed to ensure care planned interventions were implemented for one (Resident #19) of one resident reviewed. Specifically, four observations were made of a call device not being made readily accessible for Resident #19, who had a history of falls and care planned interventions for staff to ensure a call device be kept readily accessible at the bedside to allow the resident to alert staff when assistance was needed. The findings include: A review of the admission Record revealed that the facility admitted Resident #19 with diagnoses that included restless and agitation, unspecified glaucoma, and unsteadiness on feet. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2026, revealed Resident #72 had experienced falls since admission. Resident #19 required supervision for lying to sitting on side of the bed, sitting to stand, rolling left to right, sitting to lying, and toilet transfers. A review of Resident #19's Care Plan, initiated on 02/10/2025, revealed Resident #19 had an Activities of Daily Living (ADL) self-care performance deficit related to weakness and impaired mobility. Interventions included to encourage the resident to use the call light for assistance. -The care plan included a focus area, initiated on 07/19/2026 and revised on 8/10/2026, that indicated Resident #19 was at moderate risk for falls related to impaired mobility. -Resident #19 had actual falls on 10/28/2025, 11/22/2025, 11/23/2025, 02/23/2026, 04/06/2026, 07/07/2026, and 07/19/2026. -Resident #19 had a fall with an injury that required the resident to be sent to the emergency room on [DATE].-Interventions included ensuring the resident's call light was within reach and encouraging the resident to use the call light for assistance as needed. The care plan revealed that Resident #19 required prompt response to answering the call light. During an observation on 08/10/2026 at 1:30 PM, Resident #19's call light was observed lying on the floor of the room, out of reach of the resident. During an observation on 08/12/2026 at 10:28 AM, Resident #19 was observed sitting on the side of the bed. An empty 8-ounce cup was observed on the bed table. Resident #19 indicated needing water and was directed to use the call light to alert staff by the surveyor. The call light was observed on the floor behind the head of the bed, out of reach of the resident. An interview was attempted with Resident #19, who was unable to understand the surveyor's questions.During an observation on 08/12/2026 at 3:05 PM, Resident #19 was observed sitting on the side of the bed. The call light was on the floor behind the head of the bed, out of reach of the resident. During an interview on 08/12/2026 at 3:16 PM, Certified Nurse Aide (CNA) #7 stated that Resident #19 was able to use the call light. CNA #7 confirmed that Resident #19's call light was currently positioned on the floor behind the bed and should be positioned on the side of the bed as to be within reach. During an interview on 08/12/2026 at 4:20 PM, the Administrator stated the facility did not have a policy for call lights. During an interview on 08/13/2026 at 10:32 AM, the Director of Nursing (DON) indicated that Resident #19 was able to use the call light. During a second interview on 08/13/2026 at 10:45 AM, the Administrator indicated that Resident #19's call light should be kept within reach. Review of an Inservice Training Report titled Call Lights dated 08/07/2026, revealed that all call lights are to be answered in a timely manner.

Based on record review, observation, interviews, facility documentation review, and facility policy review, it was determined that the facility failed to prevent a rash from spreading between residents in different rooms, on two different halls and two separate floors when reviewed for infection control and prevention for one of one infection control plan The findings include: Resident #1Review of an admission Record, indicated the facility admitted Resident #1 on 11/01/2024, with diagnoses which included Alzheimer's disease and stroke. Resident #1 resided on the first floor of the facility. Review of a Medical Diagnosis report indicated Resident #1 was diagnosed with rash and other nonspecific skin eruptions on 11/10/2025, scabies on 11/15/2025, and unspecified skin changes on 11/22/2025. Review of an Orders Summary, indicated Resident #1 had orders for the following: -An antihistamine to be started on 08/05/2025, - An antibiotic due to elevated white blood cells ordered on 10/31/2024, -An oral antifungal ,ordered on 11/09/2025 for a rash, - -An antifungal cream ,ordered for a rash and other nonspecific skin eruptions on 11/10/2025. - Contact isolation for scabies on 11/14/2025, -A steroidal cream, ordered 11/22/2025. - An anti-parasitic, ordered 11/14/2025. Review of a significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2025 revealed Resident #1 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident's cognitive skills for daily decision making were severely impaired. Review of Resident #1's Care Plan dated 11/14/2025 indicated the resident had a rash to the right flank, right shoulder, right underarm and upper back. The Care Plan also included interventions to avoid scratching, keep hands and body parts from excessive moisture, use high quality moisturizer, use anti-pruritic medications, increase out of bed activity as directed, monitor rash for spreading, and treat the area as ordered. Review of Resident #1's NSG [Nursing] Weekly Skin Audit dated 11/07/2025, indicated a rash was present on assessment. Review of Resident #1's Medication Administration Record/Treatment Administration Record (MAR/TAR) for 11/2025 revealed the resident had an antiparasitic cream administered on the following dates: 11/15/2025, 11/18/2025, and 11/21/2025. Resident #2 Review of an admission Record indicated the facility admitted Resident #2 on 05/01/2025 with diagnoses which included dementia, psychotic mood disturbance, anxiety, and Alzheimer's disease. Resident #2 resided on the first floor of the facility Review of a Medical Diagnosis report indicated Resident #2 was diagnosed with urticaria (hives) on 08/22/2025, and allergic contact dermatitis on 10/31/2025. Review of an Orders Summary, indicated Resident #2 had orders for the following: -An antihistamine, to start on 08/22/2025 for itching. -A steroid, ordered for urticaria (hives) on 08/22/2025. -A Topical steroid cream, ordered for rash on 08/26/2025. -A second topical steroid cream, ordered for rash on 08/26/2025. -A third topical cream, ordered for rash and itching on 09/23/2025. -Steroids, ordered for urticaria (hives) on 09/23/2025. -An antifungal cream, ordered for urticaria (hives) on 11/18/2025. -An antiparasitic cream, ordered on five separate dates: 09/11/2025, 09/30/2025, 10/01/2025, 10/31/2025, and 11/18/2025. The quarterly MDS, with an ARD of 11/14/2025, revealed Resident #2 had a SAMS score of 3 which indicated the resident's cognitive skills for daily decision making were severely impaired. Review of Resident #2's Care Plan revealed the Care Plan did not address a rash. Review of a NSG Weekly Skin Audit dated10/30/2025, revealed the first skin assessment which indicated a rash was present. Review of Resident #2'sMAR/TAR for 09/2025, revealed the resident had an antiparasitic cream administered on 09/13/2025. Review of Resident #2's MAR/TAR for 10/2025, revealed the resident had an antiparasitic cream administered on 10/01/2025. Review of Resident #2's AR/TAR for 11/2025, revealed the resident had an antiparasitic cream administered on 11/01/2025 and 11/07/2025. Resident #3Review of Resident #3's admission Record, indicated the facility admitted Resident #3 on 08/08/2024 with diagnoses which included insomnia, recurrent depressive disorder, and cellulitis. The admission Record also indicated a diagnoses of rash and other nonspecific skin eruptions on 10/14/2025. Resident #3 resided on the second floor of the facility Review of a Medical Diagnosis report indicated Resident #3 was diagnosed with pruritus (itchy skin on 09/18/2025, and rash and other nonspecific skin eruptions on 10/14/2025. Review of Resident #3's Orders Summary, indicated the resident had orders for the following: -Medication for itching/rash started 09/18/2025 -Steroids on 10/14/2025. -A referral for dermatology on 10/16/2025. -An antiparasitic cream on 10/29/2025. Review of the VA [Veteran Affairs] Visit notes dated 10/29/2025, indicated Resident #3 had significant itching and rash for two months and revealed the rash was most likely scabies. Orders for an antiparasitic cream were given with further instructions for prevention such as cleaning sheets and clothing in boiling water. Review of Provider visit notes dated 11/11/2025 indicated Resident #3 complained of ongoing itching and diffuse rash all over the body. Resident #3 stated the rash negatively affected, causing increased anxiety and irritability. Review of the [Clinic name] Visit notes dated 10/23/2025, indicated Resident #3 was seen for a skin problem/rash with multiple attempts for treatment of the rash and itching. The visit note also indicated none of the treatments were successful. Review of a quarterly MDS, with an ARD of 11/13/2025, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. Review of Resident #3's Care plan with an initiation date of10/29/2025, revealed the resident had a rash to the chest, abdomen, back, both arms and both legs. The Care Plan included interventions initiated on 10/29/2025, to avoid scratching, keep hands and body parts from excessive moisture, use high quality moisturizer, use anti-pruritic medications, to increase out of bed activity as directed, monitor rash for spreading, and treat area as ordered. Review of the NSG Weekly Skin Audit, dated 09/30/2025 indicated a rash described as dry and flaky redness observed to both lower extremities. Review of [Clinic name] visit notes dated 10/23/2025, revealed Resident #3 had a rash throughout their body. Review Resident #3's MAR/TAR for 10/2025, revealed the resident was administered an antiparasitic cream on 10/29/2025 Review of Resident #3's Order Summary, indicated the resident was placed on contact isolation on 11/19/2025. During a concurrent interview and observation of Resident #3 on 12/02/2025 at 9:37 AM, Resident #3 reported the rash was present for four to five months. Resident #3 indicated they were eventually given a bath in a special body wash/soap, and a lotion was applied a few times. Resident #4 Review of an admission Record indicated the facility admitted Resident #4 on 03/17/2025, with diagnoses which included cerebral palsy and anxiety disorder. Resident #4 resided on the first floor of the facility. Review on a Medical Diagnosis Report indicated Resident #4 was diagnosed with pruritus on 09/05/2025, and allergic contact dermatitis on 10/31/2025. Review of Resident #4's Order Summary, indicated Resident #4 was admitted to hospice on 04/26/2023 and had orders for the following: - An antihistamine cream, ordered on 08/21/2025 for urticaria. -An oral antihistamine, ordered for rash on 08/26/2025 and -steroids, ordered on 08/26/2025 for a rash. -An antihistamine, ordered on 09/02/2025 for itching. -Steroid cream, ordered for pruritus on 09/03/2025. -An oral antiparasitic, for pruritus (itchy skin) for prophylactic measures, unspecified and allergic contact dermatitis on 10/31/2025. -The oral antiparasitic was reordered for a rash 11/12/2025. -An antiparasitic cream, ordered on two separate dates 10/31/2025 and 11/14/2025. - Contact isolation to start on 11/14/2025. Review of a quarterly MDS, with an ARD of 09/22/2025, revealed Resident #4 had a BIMS score of 7 which indicated the resident had severe cognitive impairment. Review of Resident #4'sCare Plan, with a revision date of 08/26/2025, revealed the resident had a rash to the left lateral thigh, upper and lower back, chest, bilateral arms, and right knee. The Care Plan also included interventions to avoid scratching, keep hands and body parts from excessive moisture, use high quality moisturizer, using anti-pruritic medications, increase out of bed activity as directed, monitor rash for spreading or signs of infection and treat area as ordered. Review of Resident #4's NSG Weekly Skin Audit dated 09/19/2025, indicated a rash was present. Review of provider visit notes dated 11/18/2025, revealed Resident #4 was seen for a skin problem/rash. The provider note also indicated a ring worm to left lower extremity with raised small pruritic rash to left lower extremity. Review MAR/TAR for 09/2025, revealed Resident #4 was administered a steroid cream for pruritus (itchy skin) on 09/04/2025 thru 09/17/2025 and 09/24/2025 thru 09/30/2025. The MAR/TAR for 09/2025 also indicated a second steroid cream for itching: Rash was administered on 09/02/2025. Review MAR/TAR for 10/2025, revealed Resident #4 was administered an antihistamine seventeen times from 10/01/2025 thru 10/29/2025 for itching. A steroid cream was administered 10/1/2025 thru 10/31/2025 for pruritus (itchy skin)'. Review MAR/TAR for 11/2025, revealed Resident #4 was administered an oral antiparasitic on 11/01/2025, 11/02/2025, 11/08/2025, 11/09/2025, 11/12/2025, 11/13/2025, 11/19/2025, 11/20/2025 and 11/26/2025 for a rash. An antiparasitic cream administered on 11/7/2025 and 11/14/2025 for rash, urticaria (hives) pruritus (itchy skin), and allergic contact dermatitis. An antiparasitic was administered on 11/15/2025, 11/18/2025, and 11/21/2025 for a rash. A steroid cream was applied on 11/1/2025 through 11/30/2025 for pruritus (itchy skin). Review of Resident #4's Orders Summary, indicated the resident was placed on contact isolation on 11/14/2025. During an interview on 12/02/2025 at 11:41 AM, Resident #4's power of attorney (POA) stated Resident #4 was itching frantically. The POA stated they received a call that the facility was treating a rash and was advised that someone on Resident #4's hall had scabies, and the staff were treating everyone on the hall. Resident #5A review of the admission record, indicated Resident #5 was admitted to the facility on [DATE] with diagnoses of stroke, urticaria (hives), impulsiveness, restlessness and agitation, anxiety, reduced mobility, and other signs and symptoms involving cognitive functions and awareness. Resident #5 was discharged on 10/29/2025 to another facility. A review of the MAR/TAR 09/2025 indicated Resident #5 resided on the 1st floor, Unit 1A. Report indicated Resident #5 was on an anticonvulsant medication for impulsiveness on 07/17/2025, 09/02/2025, and 09/18/2025, an anti-fungal shampoo started on 09/23/2025, oral steroids on 08/24/2025 for atopic dermatitis, an anti-psychotic medication for impulsiveness on 09/25/2025, an anti-psychotic for restlessness and agitation on 09/11/2025, an allergy medication for rash related to itching, an antihistamine for itching related to a rash on 08/29/2025, and antibiotic on 09/16/2025 for a rash, an anti-anxiety medication on 09/25/2025, topical steroid to be applied to the both arms, stomach, back and shoulder due to a rash on 09/3/2025, topical steroid for itching and rash on 08/26/2025 A review of the receiving facility's admission record dated 10/29/2025 indicated scabies was included in the diagnoses upon entry to the facility. A review of the Admit Skin Audit for 10/29/2025 indicated Resident #5 entered the facility with a rash present. The progress notes reported a rash that appeared to be scabies. Resident immediately put on isolation, MD notified, clothes bagged for 14 days, and anti-parasitic cream applied. During an interview on 12/02/2025 at 4:08 PM, the Resident #5's receiving facility representative contacted the sending facility and reported that the resident was transferred with a rash and was diagnosed and treated for scabies. The receiving facility representative stated they were not informed prior to transfer of the rash and possible scabies concerns. Resident #6 A review of admission Record, indicated Resident #6 was admitted to the facility on [DATE] with diagnoses of stroke, altered mental status, recurrent depressive disorder, and impair vision to both eyes. Resident #6 resided on the 2nd floor, Unit 2B. A review on the Medical Diagnosis, indicated Resident #6 was diagnosed with allergic contact dermatitis unspecified cause on 08/01/2025 and encounter for prophylactic measures unspecified on 09/17/2025. A review of the Nsg Weekly Skin Audit 09/04/2025, indicated a rash was identified on the skin assessment for Resident #6. The quarterly MDS, with an ARD of 08/05/2025, revealed Resident #6 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. A review MAR/TAR for 09/2025, revealed Resident #6 was administered a broad-spectrum antibiotic on 09/16/2025 through 09/23/2025 for a rash related to allergic contact dermatitis. An antiparasitic cream was administered on 09/04/2025. A steroid cream was administered on 09/19/2025, 09/22/2025, 09/24/2025, 09/26/2025, and 09/29/2025. A topical antibiotic cream was applied 09/1/2025, 09/02/2025 and 09/03/2025 for a rash. A steroid cream was applied 09/18/2025 through 09/30/2025 for rash, irritation, and allergic contact dermatitis. A review of the MAR/TAR for 10/2025 revealed Resident #6 was administered an oral antiparasitic on 10/10/2025, 10/11/2025, 10/17/2025, 10/18/2025, and 10/24/2025 for allergic contact dermatitis, encountered prophylactic measures. An antifungal shampoo was administered 10/01/2025 through 10/17/2025 on odd days. An antiparasitic cream was ordered to administer two consecutive doses weekly on Wednesday it was administered on 10/08/2025 with the second dose due for administration on 10/22/2025. No documentation was provided to indicate the second dose was administered. A steroid was administered on 10/01/2025 through 10/24/2025. A review of Resident #6's Progress Notes indicated the resident was transferred to a different facility on 10/24/2025. During an interview on 12/01/2025 at 12:41 PM, Healthcare Provider #7 stated, Resident #3 was the first resident known with a rash, followed by Resident #1, and then Resident #4. Resident #5 had a rash and was transferred to another facility with the rash. Healthcare Provider #7 stated the rash had been present in the facility since September of 2025 and staff was originally instructed not to use perfumes, body washes, or air refresheners, but the rash kept going on and kept getting worse. During an interview on 12/01/2025 at 1:03 PM, Healthcare Provider #8 stated they had developed a rash, was seen in the emergency room and diagnosed with scabies in November of 2025. Healthcare Provider #8 stated the following residents in the facility had a rash: Resident # 2, Resident #3, Resident # 4, and Resident # 5. Healthcare Provider #8 stated it had been present for a while. Resident #5 had dementia and was combative, the rash made it worse. Healthcare Provider #8 stated prior to 11/14/2025 there were no interventions or instruction given by the facility to stop the spread of the rash. During an interview on 12/02/2025 at 10:20 AM, Certified Nursing Assistant (CNA) #2 recalled rashes started to appear on residents in July 2025. During an interview on 12/02/2025 at 10:35 AM, Licensed Practical Nurse (LPN) #3 reported she worked mostly on the second floor in Units A and B, and that everybody was treated with cream and showers in the middle of November. The entire hall of both A and B halls were quarantined and everyone had to wear PPE. During an interview with LPN #4 on 12/02/2025 at 1:24 PM, LPN #4 stated Resident #2 was the first to present with a rash. LPN #4 reported the treatments did not seem to help Resident #2. LPN #2 reported the rash had been present in the facility as early as September 2025. LPN #4 then reported noticing a rash on Resident #1 about one month ago. LPN#4 stated Resident #1 went to the emergency room and returned with a diagnosis of scabies. LPN #2 reported she then noticed a rash on Resident #4. LPN #4 reported at first they were thinking the rash came from an allergy to laundry soap but that they were treating the residents with multiple different medications, but it was not going away, and it was just getting worse. LPN #4 reported being told it was a viral rash. LPN #4 reported after the return of Resident #1 with the diagnosis of scabies the staff started wearing PPE, housekeeping started cleaning more, and the facility implemented contact isolation. During an interview on 12/02/2025 at 9:30 AM, Housekeeper #5 revealed no residents were ever in isolation and no special cleaning instructions were ever given. During an interview on 12/02/2025 at 9:45 AM, Housekeeper #6 revealed a lot of residents had a rash. Housekeeper #6 listed seven different rooms that were affected. Housekeeper #6 reported they were never advised to do anything different until November of 2025 During an interview on 12/02/2025 at 1:48 PM, the Infection Preventionist (IP) reported in July of 2025 that a resident with a rash was moved from the first floor of the facility to the second floor. The IP stated the rash started in a small area of the facility but became more systemic. The IP reported more rashes were present in September of 2025 and the locations/residents seemed to be sporadic. The IP stated there was 28 cases by November. The IP indicated that the first resident was diagnosed on [DATE] with scabies and contact isolation was started on 11/14/2025. A record review of the Order Listing Report dated 12/02/2025 generated by the IP as a rash tracking tool revealed a rash on three residents in September, eight residents in the month of October, and 26 residents in the month of November. During an interview on 12/02/2025 at 2:30 PM, the Treatment Nurse reported each resident's rash presented a little different. The facility treated residents with different things and reported to the doctor after every treatment. Isolation and treatment of residents did not start until after Resident #1 was diagnosed with scabies. During an interview on 12/03/2025 at 9:08 AM, the Advanced Practice Registered Nurse (APRN) stated, Resident #5 presented with a rash in July of 2025 and was treated with an anti-parasitic in mid-October. The APRN reported treating the residents for a rash; they would improve and then get worse; the rash did not go away. The APRN reported a few residents were sent out to have the rash tested, but no definitive diagnosis was given. The APRN confirmed residents on the first floor on hall A and residents on the second floor on hall B had a rash. Transmission based precautions did not start until after Resident #1 returned from the hospital with the diagnosis of scabies and did not start with the first round of antiparasitic given. The APRN stated, You treat your resident based off how the symptoms present. During an interview on 12/03/2025 at 9:30 AM, the Director of Nursing (DON) reported the rash was in the facility since July 2025, and after it was discovered more than one resident had a rash on more than one hall multiple medications were tried to treat the rash. The DON stated, after the diagnosis of scabies was given to Resident #1 on 11/14/2025 the facility did body audits on all residents, isolation was initiated for any resident with a rash, treatment with an antiparasitic was given to any resident with symptoms, in-services were completed, and prophylactic treatment was offered to the staff During an interview on 12/03/2025 at 10:35 AM, the Medical Director (MD) reported a rash was present on and off in the facility for a couple of months. She had a weekly meeting with the facility's department heads and the APRN. The MD initially treated the rash as an allergic reaction or contact dermatitis. She did entertain the idea of scabies and treated some residents with anti-parasitic, but she wanted a definitive diagnosis, however the hospital never identified the rash, and no new orders were ever received. The MD believed only three to four residents in the facility had a rash at one time. When asked about treatment for unconfirmed diagnoses the MD stated, You manage your resident symptoms. During an interview on 12/03/2025 at 11:45 AM, the Administrator stated the rash was on and off in the facility with the first rash starting in July 2025, with Resident #3 and then Resident #5's rash beginning in August. The rash would seem to go away and then come back. The facility originally treated the rash as an allergic reaction trying multiple medications such as antibiotics, creams, and steroids it depended on the resident how the facility treated it and who was sent out. The MD was made aware of all findings in the monthly quality assurance meetings. The Administrator stated the rash did not present as scabies, and there were no confirmed scrapings. She reported when Resident #3 returned from their appointment with the VA a diagnosis of possible scabies was mentioned. Resident #3 was given medication and was isolated. When Resident #1 returned from the hospital with the diagnosis of scabies, different measures began such as, resident was placed on isolation, the whole building was assessed, and everyone that had a symptom was treated. She stated all interventions started after Resident #1 returned and the facility then followed the CDC guidelines and the facility's scabies policy. Mattresses were replaced, all linens and clothes were washed in hot water, and prophylactic treatment for all residents and staff with symptoms. A review of a facility policy titled, Infection Prevention and Control Program, dated 11/22/2017, indicated, The facility will have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. Standard precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infectious status. Transmission base precautions shall be used when caring for residents who are documented or expected to have communicable disease or infections that can be transmitted to others. A review an undated, facility policy titled, Scabies, Treatment and Prevention indicated, Scabies is an itching skin irritation caused by the microscopic human itch mite, which burrows in the skin's upper layers and eventually causes itching, tiny irregular red lines just above the skin and an allergic reaction. Scabies is spread by skin-to-skin contact with the affected area, or through contact with bedding, clothing, privacy curtains and some furniture. Prevention is possible with good hygiene and restricting sharing clothing. Individuals who come on contact with the infected resident or potentially infected bedding or clothing should wear a gown or other protective clothing as established by the facility's infection and exposure control program. Failure to identify scrapings as positive does not necessarily exclude the diagnosis. And Note: Negative scrapings do not exclude the diagnosis. Treatment should be administered if symptoms are present. Indicated, Often diagnosis is made from signs and symptoms and treatment followed without scraping. Indicated, Persons who have been previously infested develop more rapid symptoms. Symptoms may sometime include severe itching. Indicated, Infected residents should remain in contact isolation until 24 hours after the last treatment. A review of the CDC guidelines title Scabies- clinical overview of Crusted Scabies dated 12/18/2023 indicated, people who have an increased risk of developing scabies include the elderly. Also, Patients with crusted scabies may not show the usual signs and symptoms, or lesions distribution seen in classic scabies. Patients may not have the classic rash or pruritus (itchy skin)pruritus (itchy skin) (itchy skin)pruritus (itchy skin) (itchy skin) (itchy skin). Prevention is quick detection. Diagnosis is Early detection and appropriate treatment is key to preventing further scabies infestations. A review of the CDC guidelines title, Clinical Care of Scabies dated 12/18/2023, indicated first line of medications are oral anti-parasitic and topical parasitic.

42569 46724 51814 Based on record review and interview, the facility failed to ensure minimum data set (MDS) assessments were transmitted after completion for 8 (Residents #4, #32, #47, #49, #55, #58, #76, #88) of 8 sampled residents reviewed for resident assessments. The findings are: On 04/23/25, the following issues were identified: 1. A review of Resident #4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/10/2025, status indicated Export Ready but had not been sent. The Completed MDS was dated 03/24/2025, and the Batch Accepted date was 04/24/2025. 2. A review of Resident #32 ' s record revealed that Resident #32 ' s quarterly MDS assessment completed on 03/10/2025 status indicated ready to export. 4. A review of Resident #47 ' s record revealed that Resident #47 ' s quarterly MDS assessment completed on 03/17/2025 status indicated ready to export. 5. On 04/24/2025 a review of Resident #49's MDS assessment history screen revealed a quarterly assessment dated [DATE], status was Export Ready, but the assessment was never added to a batch to be submitted. Review of the MDS screen revealed the last assessment accepted was an admission with an ARD of 12/10/2024. 6. On 04/24/2025, a review of Resident #55's MDS assessment history screen revealed an annual MDS dated [DATE], status was Export Ready, but the assessment was never added to a batch to be submitted. Review of the MDS screen revealed the last MDS accepted was a quarterly MDS with an ARD of 12/13/2024. 7. A review of Resident #58's quarterly MDS with an ARD of 03/08/2025, status indicated Export Ready but had not been sent. The completed MDS was dated 03/22/2025, and the Batch Number 1068 accepted date was 04/24/2025. 8. Review of Resident #76 ' s quarterly MDS with an ARD of 03/16/2025, signed as completed on 03/30/2025, revealed it should have been submitted 04/13/2025, an entry MDS with an ARD of 03/12/2025 not signed by the registered nurse, revealed it should have been submitted 03/26/2025 and a discharge return anticipated MDS with an ARD of 03/09/25, signed as completed on 03/23/25, revealed it should have been submitted 04/06/2025. 9. A review of Resident #88's MDS screen revealed the quarterly MDS with an ARD of 03/18/2025, status was Export Ready and had not been transmitted. Review of the assessment history screen revealed the quarterly assessment dated [DATE], was never added to a batch to be submitted. On 04/24/2025 at 3:04 PM, the MDS Coordinator was interviewed and stated she completed the MDS assessments for the facility. She stated she used the resident assessment instrument (RAI) version 3.0 dated October 2024, to complete the assessments and the time frame for submitting an MDS after completion was 7 days. She reviewed Resident #55's annual MDS with an ARD of 03/13/2025, in the electronic health record and stated the assessment was not submitted because of not being selected with the batch to be submitted. She stated the reason Resident #49's quarterly MDS with an ARD of 03/12/2025, was not submitted was the same answer as Resident #55, it had not been selected with the batch to be submitted. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 manual required assessment summary provided by the Director of Nursing (DON) on 04/24/2025, revealed the transmission date should not be later than the Care Plan completion date plus 14 calendar days for an admission, annual, significant change in status, and significant correction to prior comprehensive MDS assessment. The transmission date should not be later than the MDS completion date plus 14 calendar days for a quarterly, significant correction to prior quarterly, discharge assessment-return and return not anticipated MDS assessment. On 04/24/2025 at 4:56 PM, the DON was asked who was responsible for ensuring that MDS reports were submitted in a timely manner. The DON responded that she was. On 04/24/2025 at 4:59 PM, the MDS Coordinator was asked who was responsible for submitting the MDS in a timely manner, she asked if she could confirm and get back to this surveyor. At 5:00 PM, the MDS Coordinator confirmed she was responsible. 52085

Based on observation, record review, interview, and facility policy review, the facility failed to ensure expired food items were promptly removed / discarded on or before the expiration or use by date; Dietary staff washed their hands between dirty and clean tasks and before handling clean equipment; Cold food items were at 41 degrees Fahrenheit or below on ice while awaiting service for 2 of 2 meals observed; ensure meals were served at a safe and appetizing temperature to prevent possible food born illnesses for 1 (Resident #84) of 1 sampled resident. The findings include: 1.On [DATE] at 9:28 AM, the following observation was made in the walk-in refrigerator: A carton of half and half was on a shelf with an expiration date of [DATE]. 2. On [DATE] at 9:50 AM, the following observations were made in the first storage room: A box of cheese peanut butter crackers that contained 80 counts of crackers were on a shelf with an expiration date of [DATE]. A box of saltine crackers on a shelf had an expiration date of [DATE]. 3. On [DATE] at 10:25 AM, the following observations were made in the second storage room: Nine coffee bags were on a shelf with an expiration date of [DATE]. Ten boxes of unsweetened milk were on a shelf with an expiration date of [DATE]. During an interview on [DATE] at 8:30 AM, the Dietary Manager stated the food items were expired and would be discarded. 4. On [DATE] at 11:19 AM, a carton of melted vanilla ice cream was on a shelf in the freezer. During an interview with the Dietary Manager, she was asked if the ice cream had melted. She stated it was thawed, and she could not understand why someone would put thawed ice cream back in the freezer to refreeze. 5. On [DATE] at 12:28 PM, Dietary [NAME] (DC) #2 touched his hair bead and without washing his hands, he picked up slices of bacon and placed them on the saucepan to be cooked. During an interview with DC #2 he was asked what he should have done after touching dirty objects and before handling clean equipment. DC #2 stated he should have washed his hands. 6. On [DATE] at 12:47 PM, second floor food temperatures on the steam table when taken and read by the Dietary [NAME] (DC) #3 were: Turkey sandwich on ice 47 degrees Fahrenheit. Ham and cheese salad 49.8 degrees. During an interview with the Dietary aide (DA) #4, she was asked if a glass of house shake on the tray on the shelf over the steam table was ready to be served to the residents. She stated yes. DA #4 was asked if she would mind checking the temperature. DC #3 checked the temperature and stated it was 63 degrees Fahrenheit and that it was warm to the touch. DA #4 stated she would throw it away and make a new one. During an interview on [DATE] at 8:30 AM the Dietary Manager was asked what a safe temperature for the cold food was to be held at prior to serving, and she stated the food temperature was not in the safe range for serving to residents and the quality of food would not be at its highest. 7. A review of facility policy titled, Handwashing and glove usage in food service reviewed indicated hands should be washed before starting work, after leaving and returning to the kitchen prep area and after touching anything else such as dirty equipment and work surfaces. 8. A review of the Admission Record, indicated the facility admitted Resident #84 with diagnoses that included dementia (disease affecting memory) with mood disturbance and depressive disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #84 had a Staff Interview for Mental Status (SAMS) score, which indicated the resident had severe cognitive impairment. Resident #84 was totally dependent on staff for eating, transfers and bed mobility. Review of Resident #84's Care Plan, revised on [DATE], revealed the resident had an activities of daily living (ADL) self-care performance deficit related to dementia. Interventions included Resident #84 was dependent on staff for eating and to give a house shake with all meals. A review of Resident #84's physician ' s orders, revealed Resident #84 had a Regular-Enhanced diet; Pureed texture. A review of an Activity of Daily living task - Eating & Percentage, revealed Resident #84 had eaten between 0% to 50 % most meals from [DATE] and [DATE]. During an observation on [DATE] at 9:59 AM, Resident # 84's breakfast tray was sitting on an overbed table at the end of the resident's bed. Breakfast service began at 7:30 AM, per facility schedule, and trays were taken down each hall one at a time to resident rooms. Resident #84 was in bed with eyes closed, the tray card indicated pureed regular diet with enhanced foods, and written on tray card in marker was super cereal and milk. The utensils on the tray were not open, items on the breakfast tray had not been uncovered, and the milk was unopened. During a concurrent observation and interview on [DATE] at 1:05 PM, a Certified Nursing Assistant (CNA) took a lunch tray into Resident #84's room then came out without the tray. At 1:10 PM, a female, who identified herself as a family friend, and later was identified as a family paid care giver (PCG) #8 reported she came in every day around 10 o'clock to feed the resident. PCG #8 stated Resident #84 ate well for her because the resident knew her as she had been a family friend for a long time. PCG #8 reported she had a staff member heat the breakfast tray prior to feeding it to Resident #84. PCG #8 then stated, due to Resident #84 recently eating 90% of the breakfast tray, she was going to wait to feed the resident lunch. On [DATE] at 8:36 AM, a breakfast tray, which was served between 7:30 AM and 8:00 AM, was again observed sitting on an overbed table at the end of Resident #84's bed, the resident was in bed with eyes closed. On [DATE] at 10:51 AM, PCG #8 arrived at the facility and was observed transferring Resident #84 into a Geri chair without assistance of facility staff. PCG # 8 reported she was going to feed Resident #84 breakfast, turned on Resident #84's call light, and when CNA#9 arrived, asked her to heat up the breakfast tray. CNA #9 took the breakfast tray and left the room. On [DATE] at 10:55 AM, CNA #9, who had worked at the facility for two weeks, stated it was in Resident 84 ' s Care Plan to leave breakfast in the resident's room at breakfast so PCG #8 could feed the resident when she arrived. When asked how Resident #84 ' s trays were warmed, CNA #9 replied they were warmed up either in the microwave in the pantry or taken to kitchen to be put in the warmer. On [DATE] at 11:15 AM, Dietary Cook/Dietary Manager Assistant (DC/DMA) #1 was asked how resident's trays that are sent to the floor are reheated. She stated that there were microwaves on each floor. When asked if items are brought to the kitchen to be reheated, she replied no, but the kitchen could prepare something fresh if needed. On [DATE] at 10:13 AM, DC/DMA #1 accompanied this surveyor to Resident #84's room and was asked to check the temperatures of the food items on Resident #84's breakfast tray using her digital thermometer. The results were: oatmeal-92 degrees Fahrenheit; pancake-75.2 degrees Fahrenheit; sausage 79.9 degrees Fahrenheit; eggs-78.4 degrees Fahrenheit; and house shake which contained milk products- 63.1 degrees Fahrenheit. DC/DMA #1 stated, A lot of stuff could happen if food is consumed outside of safe temperature range and in the danger zone. It would be better to make it fresh. When asked how the food could be heated, she replied, by using the microwave in the break room. When asked how the temperature would be checked prior to serving, DC/CMA #1 stated, I don't guess it could be, it would be better to have something fresh made when the caregiver arrives. At this time the Director of Nursing (DON) came into Resident #84's room. She related that Resident #84's family member had requested food be left in room so PCG #8 could feed the resident when she arrived. The DON confirmed food could be unsafe to feed to residents after sitting for an extended period. The DON went on to say the food could be heated. When asked how the temperature would be checked to ensure it was reheated to the proper temperature, she agreed the CNAs had no way to check the temperature of the food if microwaved to ensure it was at an acceptable range. The DON was asked if there was documentation that Resident #84 ' s family member had requested trays be left in the resident's room. She stated, no and that it had been a conversation she had with the family member and she related it to staff in the morning stand up meeting. The DON also agreed this should have been placed in Resident #84's Care Plan. On [DATE] at 12.52 PM, Resident #84's family member was contacted via telephone. The family member reported the facility ' s policy was unknown but that the family member did not want Resident #84 taken to the dining room at mealtimes due to having to get up so early and being distracted from eating by other residents. Resident #84 ' s family member stated the facility had not, to the family member ' s knowledge, attempted to feed Resident #84 in the room, and the family member had been told if Resident #84 was dependent on staff for eating the resident would have to be fed in the dining room so the family member had instructed the facility to leave the tray in the room so the PCG #8 would be able to feed the resident when she arrived. A review of nutritional services facility policies titled, Holding Foods dated [DATE], and Resident Dining Services dated [DATE], indicated foods would be held at proper temperatures to avoid bacterial growth, and remain palatable. Temperatures must meet or exceed 140 degrees Fahrenheit for hot foods and at or below 41 degrees Fahrenheit for cold foods. The facility will have a process in place to ensure residents receive meals in a timely manner with appropriate assistance.

Based on observation, record review, interview, policy review, and the review of the menu, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents during 1 of 2 meals observed being prepared in the kitchen. The findings are: 1. A review of the 4/22/2025 Breakfast Meal Menu indicated the residents on a regular diet and the residents on a mechanically soft diet were to receive 3/4 cup of cereal, residents on pureed diets were to receive a #8 scoop (1/2 cup) of cereal, and residents on enhanced diets were to receive 1 cup of cereal. a. During an observation of the breakfast meal in the kitchen on 4/22/25 at 7:35 AM, the Dietary [NAME] (DC) #1 used a 4-ounce (oz.) ladle spoon (1/2 cup) to serve a single portion of regular oatmeal to the residents on regular diets and residents on mechanical soft diets, instead of 3/4 cup as specified on the menu. b. During an interview on 4/22/25 at 8:00 AM, DC #1 stated she looked at the menu but did not know why she had used a 4 oz. ladle spoon (1/2 cup) to serve a serving of oatmeal to the residents on regular and mechanical soft diets, instead of 3/4 cup as specified on the menu. c. During an observation on 4/22/25 at 7:37 AM, DC #1 used a 3 oz. ladle spoon (3/8 cup) to serve a single portion of pureed oatmeal to the residents on pureed diets, instead of a #8 scoop (1/2 cup) of pureed cereal as specified on the menu. d. During an observation on 4/22/25 at 7:42 AM, DC #1 used a 4 oz. ladle spoon (1/2 cup) to serve a single portion of super cereal to the residents on enhanced food diets, instead of 1 cup as specified on the menu. 2. During an interview on 4/22/25 at 8:00 AM, DC #1 stated she used 3 oz. ladle spoon (3/8 cup) to serve a serving of oatmeal to the residents on pureed diets, instead of a #8 scoop as specified on the menu. DC #1 stated she looked at the menu but did not know why she had used 3 oz. ladle spoon (1/2 cup) to serve a serving of enhanced oatmeal to the residents on enhanced diets, instead of 1 cup as specified on the menu. 3. During an interview on 4/22/25 at 8:00 AM, DC #1 stated she looked at the menu but did not know why she had used a 4 oz. ladle spoon (1/2 cup) to serve a serving of enhanced oatmeal to the residents on enhanced diets, instead of 1 cup as specified on the menu. DC #1 stated if a resident was not receiving the right portions as specified on the menu it could cause weight loss. 4. During an interview on 4/22/25 at 8:30 AM, the Dietary Manager stated if a resident was not receiving the right portions as specified on the menu it could cause weight loss. 5. A review of facility policy titled, Portion Control indicated staff should serve portions according to the menu spreadsheet.

Based on observation, interview, record review, and facility document review, the facility failed to implement fall prevention interventions for 1 resident (Resident #58) of 3 residents reviewed for fall prevention. The findings include: A review of the Admission Record, indicated the facility admitted Resident #58 with diagnoses that included spastic diplegic cerebral palsy which primarily affects the legs with stiffness and difficulty with walking, abnormality of gait and mobility, communication deficit, anxiety disorder, and muscle wasting and atrophy (muscle shrinking). The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 03/08/2025, revealed Resident #58 had a Brief Interview of Mental Status (BIMS) of 5 which indicated the resident had severe cognitive impairment. The MDS revealed the resident had two or more falls since the prior assessment and required moderate assistance with toileting hygiene, sit to stand, and toilet transfer. An intervention for transfer indicated the resident required extensive assistance by one staff to move between surfaces. The MDS also indicated the resident was chairfast and could not bear own weight or must be assisted into wheelchair. The functional section indicated that the resident was able to understand reminders and ask for assistance. A review of Resident #58's Care Plan Report, revealed the resident had high risk for falls related to history of falls and weak gait. An intervention dated 07/05/2024, indicated staff should attempt to determine possible cause of falls and record root causes. A review of Residents #58's Care Plan Report, revealed the resident had 13 actual falls on 07/05/2024, 08/12/2024, 09/06/2024, 11/18/2024, 11/25/2024, 12/24/2024, 01/02/2025, 01/09/2025, 02/02/2025, 02/13/2025, 02/19/2025, and 03/21/2025. An intervention dated 10/19/2022 indicated fall mat to the left at side of bed. An intervention dated 01/09/2025 indicated the resident's bathroom door to be closed. An intervention dated 03/21/2025 indicated toileting checks every one hour. An intervention dated 02/24/2023 indicated urinal within reach to left side of bed. An intervention dated 02/03/2025 indicated sensor alarm applied to bathroom door. During an observation on 04/21/25 at 10:20 AM, Resident #58 was sitting in a wheelchair watching television. The bathroom door was open, and a mesh stop sign was across the bathroom door entry. Resident #58 indicated the staff do not want me to walk in the bathroom without the assistance of staff so they put the stop sign in place to remind me to ask for assistance when going into the bathroom. The resident stated, I have had some falls. The bed was in low position and no fall mats were present in the room. An observation on 04/23/25 at 7:51 AM, revealed Resident #58 was not in the resident's room. A mesh stop sign was in place across the entry of the bathroom; the bathroom door was open. The bed was in low position and no fall mats were present in the room. An observation on 04/23/25 at 9:35 AM, revealed Resident #58 was in resident's room. There were no fall mats in the room, nor in the bathroom. A mesh stop sign was across the bathroom door; the bathroom door was open. The resident was sitting in a wheelchair and had on non-skid shoes. On 04/23/2025 at 9:30 AM, during an interview Resident #58's family member reported Resident #58 has had some falls, and the facility placed a mesh stop sign up across the bathroom door because the resident usually falls when trying to use the bathroom without assistance. During an interview on 04/23/25 9:53 AM, with Licensed Practical Nurse (LPN) #5 she reported the facility did not have bed or chair alarms. LPN #5 explained Resident #58 had an alarm on the wall to the left when walking into the resident's bathroom. She indicated the alarm was present so when the resident walked through the door the alarm would sound, and the staff would know to come assist the resident. LPN #5 walked in front of the alarm on the wall several times with no alarm sounding. The LPN verified there was no sensor alarm on the resident's bathroom door and the alarm on the wall was not working and therefore was not doing what it was supposed to do. LPN #5 verified there were no fall mats in the resident's room. The LPN stated the bathroom door must remain open for the resident to view the stop sign so the resident would be prompted to seek assistance. During an interview on 04/23/25 at 9:53 AM, Registered Nurse (RN) #6 was present with LPN #5 in Resident #5's room and verified the alarm on the left side of the wall, inside the resident's bathroom was not working. RN #6 verified there were not any fall mats in the resident's room and the bathroom door was open. During an interview on 04/23/25 at 12:00 PM, Certified Nursing Assistant (CNA) #7 reported he usually works Hall C from Monday to Friday, 7:00 AM to 3:00 PM. He verified there was not an alarm on Resident #58's bathroom door but reported there was an alarm on the left side of the wall just inside the resident's bathroom. CNA #7 indicated that the alarm did not work but he checked on the resident at least every hour while he was working. The CNA verified there were no fall mats in the resident's room and the mesh stop sign was to remind the resident to ask for assistance before going to the bathroom. On 04/23/25 at 3:05 PM, an interview with the Director of Nursing (DON) revealed that Resident #58 has had several falls over the past year. She indicated the interventions related to the resident's Care Plan should be followed to keep the resident safe. The DON reported that the department heads have a daily meeting to discuss resident needs, and a root cause analysis of Resident #58's falls had been discussed but there was no documentation as to the results. The DON indicated, per the resident's interventions for high risk of falls, in the resident's room there should be fall mats on the floor, a mesh stop sign should be across the bathroom entryway, there should be an alarm on the door that does alarm when the resident walks in front of the sensor and the bathroom door should be closed. On 04/24/25 at 8:02 AM, during an interview inside Resident #58's room, Social revealed she was familiar with the resident and attended the care plan meetings for the resident. Social verified there were no fall mats in room, a mesh stop sign was attached only to the right side of the door entry and the bathroom door was partially open. Social verified the alarm did not work by verbalization and by walking in front of the alarm with no sound resulting. She verified the resident's urinal was in the bathroom in a plastic bag near the toilet. On 04/24/25 at 8:12 AM, during an interview, the Administrator reported that the alarm in Resident #58's bathroom did work, but the staff turned it off and on each time the resident was in and out of the room. She reported to her knowledge the resident has had at least 10 falls over the past year. She reported there were no fall mats in the room because they were causing the resident to be unsteady. She verified the resident's urinal was in a bag next to the toilet in the bathroom.

Based on facility record review and interview, it was determined that the facility failed to update resident care plans to reveal an accurate code status (Full Code status changed to a Do Not Resuscitate (DNR) status) for 1 (Resident #5) of 2 residents sampled for revisions or updates to the care plan. The findings are: Review of Resident #5 ' s Admission Record face sheet revealed Resident #5 ' s admitted was [DATE], and that Resident #5 ' s code status was Full Code. Review of Resident #5 ' s Hospice Admission Record, completed on [DATE] revealed Resident #5 ' s code status had been changed to Universal Do Not Resuscitate (DNR), instructing providers not to do CPR (cardiopulmonary resuscitation) if a patient's breathing stops or if the patient's heart stops beating. Review of Resident #5 ' s Care Plan, initiated on [DATE], revealed Resident #5 ' s code status was Full Code (Full code indicates cardiopulmonary resuscitation (CPR) is requested if the resident has no heartbeat and is not breathing). Interventions included to check to make sure that full code status was listed as resident's code status on the resident's profile face sheet, to review code status with the resident or responsible party annually or as needed. The Care Plan had not been updated to display the current, accurate code status for Resident #5. On [DATE] at 3:16 PM, during an interview, the Director of Nursing (DON) stated Care Plans should be updated any time there was a change for a resident and quarterly. A delay in care would be the outcome for the wrong care plan. On [DATE] at 3:04 PM, during an interview the Minimum Data Set Coordinator (MDS) stated she normally updates Care Plans when the MDS was done or when the resident had a change in condition or order.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure a urinary catheter drainage bag was not directly touching the floor for 1 (Resident #216) of 1 sampled resident reviewed for urinary catheter care. The findings are: Review of the Admission Record revealed Resident #216 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood properly). Review of the Order Summary Report revealed [brand name] catheter: 16 French (FR) with 10 cubic centimeters (cc) balloon every night shift starting on the 15th and ending every month with an order date of 04/19/2025. Review of a Nursing Baseline Care Plan with a signed date of 04/18/2025, revealed for bowel and bladder, Resident #216 had an indwelling catheter. On 04/21/2025 at 2:13 PM, Resident #216 was observed lying in bed with eyes closed. On the right side of the bed, there was a urinary catheter drainage bag observed, and the bottom of the drainage bag was directly on the floor on the right side of the bed. There was a green spout on the collection chamber of the urinary drainage bag directly touching the floor. On 04/21/2025 at 4:15 PM, Resident #216 was observed lying in bed on back with the head of bed slightly elevated. The bottom of a urinary drainage bag was observed directly touching the floor. On 04/22/2025 at 2:34 PM, Resident #216 was lying in bed with the head of bed elevated. A urinary drainage bag was hooked inside the bend of a bed rail and the bottom of the bag was directly touching the floor. On 04/23/2025 at 11:05 AM, Resident #216 was lying in bed with the head of bed elevated. A urinary drainage bag was hooked on the lower part of the bed frame and the bottom of the drainage bag was directly on the floor. On 04/23/2025 at 2:34 PM, Certified Nursing Assistant (CNA) #10 and this surveyor entered Resident #216's room, and the bed was elevated and not in the lowest position. CNA #10 lowered the bed down to the lowest position and at 2:37 PM, the bottom of the urinary drainage bag was observed directly on the floor. CNA #10 was interviewed and stated the urinary drainage bag should not be on the floor. On 04/23/2025 at 2:39 PM, CNA #11 was interviewed and stated the urinary drainage bag should not be on the floor for sanitary purposes due to possible contamination. CNA #11 stated the CNA or the nurse was responsible for ensuring the urinary drainage bag was off the floor. On 04/23/2025 at 4:34 PM, the Director of Nursing (DON) was interviewed and stated the urinary drainage bag should be positioned under the bed in a privacy bag and not on the floor. She stated the urinary drainage bag should be positioned off the floor for infection prevention and the CNAs and nurses were responsible for ensuring the urinary drainage bag was not on the floor. Review of a Perineal/Catheter Care policy dated as revised 11/22/2016, revealed for catheter care, extra tubing should be in a coiled position and (drainage bag below the bladder level) with privacy covering. Review of an Infection Prevention and Control Program policy dated 11/22/2017, revealed standard precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator and storage area were covered or sealed to maintain freshness and prevent potential cross contamination of food and beverages, that expired food items were promptly remove/discarded by the expiration or use by dates, that kitchen vents and ceiling tiles were cleaned to provide a sanitary environment for food preparation, and that baseboards were not missing and were free of chips, debris, rust, and dirt, that 1 of 2 ice scoop ice machines was maintained in clean and sanitary condition to prevent food and beverages contamination, that staff washed hands before handling clean equipment or food items to minimize the potential for contaminating food items for residents who received meals from 1 of 1 kitchen, and that hot food items were maintained at or above 135 degrees Fahrenheit while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 94 residents who received food from the kitchen. The findings are. 1. On [DATE] 09:40 AM, the ice machine panel in a room leading to the kitchen had wet, black residue on it. The surveyor asked the Dietary Supervisor to wipe the panel of the inside of the ice machine. She used a tissue to wipe the panel inside of the ice machine which had a black substance on it that had easily transferred from the ice machine onto the tissue. The surveyor asked Dietary Supervisor to describe the residue found inside the ice machine that showed on the tissue. Who uses the ice machine from the machine and how often do you clean it? She stated, It has black dirt, we use it to fill beverages served to the residents at mealtimes. That's the ice the CNAs (Certified Nursing Assistants) use to fill the water pitchers in the resident's rooms. 2. On [DATE] at 09:49 AM, the following observations were made in the kitchen: a. An open box of sausage on a shelf in the refrigerator. The box was not covered or completely sealed. b. Two of 2 opened boxes of bacon were on a shelf in the refrigerator. The boxes were not covered or sealed. c. An open box of chocolate chip cookies was on a shelf in the refrigerator. The box was not covered or sealed. d. An opened gallon of coleslaw dressing was on a shelf in the refrigerator. There was no date when opened on the gallon. e. A bottle of chocolate syrup, bottle of grape jelly, gallon of soy sauce, brown and seasoning sauce on a shelf in the refrigerator were opened with no opening date on them. f. A container of strawberry filling was on a shelf in the refrigerator with an expiration date of [DATE]. g. An opened plastic bag that contained hot dogs was on shelf in the refrigerator. The bag was not sealed. 3. On [DATE] at 09:59 AM, the following observations were made in the walk-in freezer: a. An opened box of sugar cookies. The box was not covered or sealed. b. An opened box of scones was on a shelf in the freezer. The box was not covered or sealed. c. An opened box of pepperoni was on shelf in the freezer. The box was not covered or sealed. d. An opened box of sausage links was on a shelf in the freezer. The box was not covered or sealed. e. An opened box of diced sausage was on a shelf in the freezer. The box was not covered or sealed. 4. [DATE] 10:07 AM, the following observations were made on the shelf in the storage room, there were no dates of when the species were opened. a. A container of onion powder, no open date on the container. b. A container of grated Parmesan cheese, no open date on it. c. A container of black pepper, no open date on it. d. A plastic bag that contained potato flakes, no open or received date. 5. [DATE] 10:19 AM, the following observations were made on a shelf above the food preparation counter, there were no dates of when the spices were opened: a. A container of jerk, no open date. b. Poultry seasonings, no open date. c, Montreal seasoning, no open date d. Ground mustard, no open date. e. Chicken seasoning, no open date. f. Rotisserie chicken seasoning, no open date. g. An open bottle of lemon juice was on a shelf above the food preparation counter. Some of the juice had been used from it. The manufacturer's instructions on the bottle specified to refrigerator after opening. The surveyor asked the Dietary Employee (DE) #1, what do you use lemon juice for? DE #1 said We use it to cook and to clean grill. 6. On [DATE] 10:30 AM the following observations were made in the emergency storage room: a. Two of 2 unopened boxes that contained 8 counts each of 32 fluid ounces of Ensure plus on a shelf had an expiration date of ,d+[DATE]. b. Two of 2 unopened boxes that contained 8 counts each of 32 fluid ounces of Ensure plus on a shelf had an expiration date of [DATE]. c. Three of 3 unopened boxes that contained 8 counts each of 32 fluid ounces of thick and easy nectar milk were on a shelf with an expiration date of [DATE]. d. An unopened box that contained 8 counts of nectar milk on a shelf had an expiration date of [DATE]. e. An unopened box of silk almond milk on a shelf had an expiration date of [DATE]. f. Three of 3 unopened cartons that contained 96 counts each of 4 ounces of grape juice had an expiration date of [DATE]. g. An unopened carton that contained 96 counts each of 4 ounce apple juice on a shelf had an expiration date of [DATE]. h. Two of 2 unopened cartons that contained 96 counts each of 4 ounce cans of orange juice on a shelf had an expiration date of [DATE]. i. Unopened carton that contained 24 counts of 8 fluid ounce each of Pivot 1.5 cal, was on shelf with an expiration date of [DATE]. J. Two of 2 cartons that contained 24 counts each of 8 fluid ounce nutritional supplement were on a shelf with an expiration date of [DATE]. k. Two of 2 unopened cartons that contained 24 counts each of 8 fluid ounce nutritional supplement 1.5 calorie were on shelf with expiration date of [DATE]. Two other cartons of nutritional supplement 1.5 calorie had an expiration date of [DATE]. l. A carton that contained 12 counts of unopened 46 fluid ounce cans of vegetable drink was on shelf with an expiration date of [DATE]. m. Unopened carton that contained cranberry juice was on a shelf with expiration date of [DATE]. Four of 4 unopened containers of peanut butter were on shelf with an expiration date of [DATE]. n. [DATE] 08:30 AM, the air vent in the food preparation area had rust and grayish stains on it. 7. On [DATE] at 11:57 AM, the following observations were made in the kitchen: a. Three of the 3 air vents in the dish room had rust on them. b. There were greasy lint's on the ceiling tiles around the vents. The ceiling tile had stains on it. c. There were missing baseboards on the right side of the wall in the dish washing machine. The area where the tiles were missing, exposes the concert. d. The left side wall leading to the dish washing machine was chipped, exposing the metal. The air vent by the steam table, between the milk refrigerator and the steam table, between the stove and food preparation sink, by the upright refrigerator, by the grill, by the mechanical room, by the door leading to the storage room, between the walk-in refrigerator and walk-in freezer, above the shelf of food preparation sink where bags of buns and bread were kept had built up rust deposit. There was dust on the ceiling tiles around the vents. e. The air vent above the hand washing sink had rust on it. The ceiling tile by the air vent was chipped exposing the concert. The area that was chipped had stain on it. There was black dust around the ceiling tile. f. The ceiling tile above the walk-in freezer had brown/black stains on it. There was a hole in the ceiling tile that had fiber hanging out from it. The ceiling tile was cracked and was loose. 8. On [DATE] at 12:08 PM, Dietary Employee (DE) #2 picked up a container of peanut butter, a bottle of grape jelly from the storage room and placed them on the counter. He untied a bag of bread, picked up gloves and placed them on his hands contaminating the gloves in the process. Without changing gloves and washing his hands, he used his contaminated gloved hands to remove slices of bread from the bag and placed them on a pan liner laid on the counter. Before DE #2 spread peanut butter on the bread. The surveyor asked DE #2 what should you have done after touching dirty objects and before handling food items? DE #2 stated, I should have washed my hands. 9. On [DATE] at 12:10 PM, DE #3 picked up the water hose with his bare hand, used it to spray leftover food from inside of the dishes, contaminating his hands. He placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, he moved to the clean side of the dishwasher area and picked up the clean pan and placed them on the clean rack to be used in cooking foods items to be served to the residents for supper meal with his fingers inside the pan. The Surveyor asked him what you should have done after touching dirty objects or before handling clean Equipment? DE #3 stated, I should have washed my hands. 10. On [DATE] at 01:11 PM, the temperatures of the food items when checked and read by the DE #2 were with the following results: a. Broccoli with cheese 128 degrees Fahrenheit. b. Pureed steak 133 degrees Fahrenheit. c. Pasta 131 degrees Fahrenheit. d. The above food items were not reheated before being served to the residents. The surveyor asked DE #2, What should do when food items are not hot enough on the steam table. DE #2 stated, I should have reheated them. 11. A facility policy titled . Hand Washing provided the Dietary Surveyor on [DATE] at 04:13 PM documented, To remove contamination after, handling soiled utensils or equipment, during food preparation, before donning gloves for working with food and after engaging in other activities that contaminates the hands.

Based on record review and interview, the facility failed to ensure that a call light was in reach for 1 Resident #3 of 4 sampled residents (Residents #69; #86; #91) who utilize the call light on unit 1-D. The facility failed to ensure that call lights located in the resident's bathroom were equipped with a device that would enable them to reach the call light should they fall for 1 Resident #34 who resides on unit 1-B and 2 Residents #86 and #399 sampled residents who reside on unit 1-D. The findings are: 1) Resident #3 has a diagnosis of shortness of breath, genetic causes of short stature, and glaucoma. On the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of December 23, 2023. The resident received a score of 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS). a) On 02/12/2024 10:54 AM, Resident #3 stated Sometimes I have a hard time getting my call button when it falls to the floor. It doesn't stay clipped. I have to beat on the table to get them. The Resident's call light was noted to be lying on the floor. b) On 02/13/2024 11:22 AM, the surveyor made observations of Resident #3 ' s call light lying on the floor. The Surveyor pushed the button to alert the staff. Certified Nursing Assistant (CNA) #4 came into the room to check Resident #3. The Surveyor asked CNA #4 where the call light should be. The CNA stated, Within reach of the resident. CNA #4 was asked why should the call light be in reach of the resident. CNA #4 stated So they can call us. 2. Resident #86 has a diagnosis Diabetes mellitus, Glaucoma, and Cerebral infarction. On the quarterly MDS with an ARD of 12/6/23 the resident received a score of 9 (8-12 indicates moderate cognitive impairment) on the BIMS. a. On 02/12/2024 at 10:50 AM, Resident #86 ' s bathroom was observed to not have a string extending from the call light. Resident #86, was ambulating freely around the room. The Surveyor asked if the resident utilized the bathroom. Resident #86 stated, All the time. Resident #86 was asked if they would be able to reach the call light if a fall occurred in the bathroom. Resident #86 stated, I would do my best to sit up and reach it, but I would rather have a string. 3. Resident #399 had diagnoses of Hypertension, Diabetes mellitus, and Acquired absence of right leg below knee. On the quarterly MDS with an ARD of 10/27/23 the resident received a score of 13 (13-15 indicates cognitively intact) on the BIMS. a. On 02/12/2024 at 11:24 AM, Resident #399 ' s bathroom was observed to not have a string extending from the call light. Resident #399 stated that despite having had a stroke they could still use the bathroom and that the staff helped with transfers to the toilet. At 1:25 PM, the Resident was asked if they could reach the call light if a fall occurred from the toilet. Resident #399 stated, I would do my best, but since I can't use my right side, it would be hard. I really need a string. 4. Resident #34 had diagnoses of Diabetes mellitus with diabetic Polyneuropathy and Orthopedic aftercare following surgical amputation. On the quarterly MDS with an ARD of 12/13/23 the resident received a score of 15 on the BIMS. a. On the On 02/12/2024 on 12:19 PM, Resident #34's bathroom was observed to not have a string extending from the call light. Resident #34 was asked if they utilized the bathroom. The Resident stated, Yes, I use it in the daytime. Resident #3 described wearing a brief at night due to their prosthesis being removed and it being too hard for the staff to assist with transfers to the bathroom. When asked about the ability to reach the call light if a fall occurred in the bathroom the Resident stated, It would take some time for me to get over there. My string broke about 2 or 3 months ago and I told the maintenance man. I still don't have one. 5. On 2/12/2024 at 3:35 PM, a Maintenance Director was asked how he was made aware of maintenance issues in the facility. He reported that requests for maintenance forms were at each nurses' station. The Maintenance Director was asked if a resident could reach the call light button if they were to fall. He stated, I think some of them could, but not all of them. Some of them would have to have a string. 6. On 2/13/2024 at approximately 1:49 PM, CNA #5 was asked residents could reach their call light in their bathroom if it didn't have a pull string. CNA #5 stated, I think it would be hard. I mean they really need a string. 7. On 2/14/2024 at approximately 11:30 AM, the Administrator was asked if a resident could reach the call light if they were to fall in their bathroom if the call light device did not have a string which extended down the wall. The Administrator stated, I bet I could. 8. On 2/16/2024 at 8:30 AM, the Assistant Administrator (AA) was asked if the facility had a policy concerning call lights. AA reported that he would ask the Administrator upon their return. No policy was available. 49596

Based on record review and interview, the facility failed to ensure that a call light was in reach for 1 Resident #3 of 4 sampled residents (Residents #69; #86; #91) who utilize the call light on unit 1-D. The facility failed to ensure that call lights located in the resident's bathroom were equipped with a device that would enable them to reach the call light should they fall for 1 Resident #34 who resides on unit 1-B and 2 Residents #86 and #399 sampled residents who reside on unit 1-D. The findings are: 1) Resident #3 has a diagnosis of shortness of breath, genetic causes of short stature, and glaucoma. On the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of December 23, 2023. The resident received a score of 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS). a) On 02/12/2024 10:54 AM, Resident #3 stated Sometimes I have a hard time getting my call button when it falls to the floor. It doesn't stay clipped. I have to beat on the table to get them. The Resident's call light was noted to be lying on the floor. b) On 02/13/2024 11:22 AM, the surveyor made observations of Resident #3 ' s call light lying on the floor. The Surveyor pushed the button to alert the staff. Certified Nursing Assistant (CNA) #4 came into the room to check Resident #3. The Surveyor asked CNA #4 where the call light should be. The CNA stated, Within reach of the resident. CNA #4 was asked why should the call light be in reach of the resident. CNA #4 stated So they can call us. 2. Resident #86 has a diagnosis Diabetes mellitus, Glaucoma, and Cerebral infarction. On the quarterly MDS with an ARD of 12/6/23 the resident received a score of 9 (8-12 indicates moderate cognitive impairment) on the BIMS. a. On 02/12/2024 at 10:50 AM, Resident #86 ' s bathroom was observed to not have a string extending from the call light. Resident #86, was ambulating freely around the room. The Surveyor asked if the resident utilized the bathroom. Resident #86 stated, All the time. Resident #86 was asked if they would be able to reach the call light if a fall occurred in the bathroom. Resident #86 stated, I would do my best to sit up and reach it, but I would rather have a string. 3. Resident #399 had diagnoses of Hypertension, Diabetes mellitus, and Acquired absence of right leg below knee. On the quarterly MDS with an ARD of 10/27/23 the resident received a score of 13 (13-15 indicates cognitively intact) on the BIMS. a. On 02/12/2024 at 11:24 AM, Resident #399 ' s bathroom was observed to not have a string extending from the call light. Resident #399 stated that despite having had a stroke they could still use the bathroom and that the staff helped with transfers to the toilet. At 1:25 PM, the Resident was asked if they could reach the call light if a fall occurred from the toilet. Resident #399 stated, I would do my best, but since I can't use my right side, it would be hard. I really need a string. 4. Resident #34 had diagnoses of Diabetes mellitus with diabetic Polyneuropathy and Orthopedic aftercare following surgical amputation. On the quarterly MDS with an ARD of 12/13/23 the resident received a score of 15 on the BIMS. a. On the On 02/12/2024 on 12:19 PM, Resident #34's bathroom was observed to not have a string extending from the call light. Resident #34 was asked if they utilized the bathroom. The Resident stated, Yes, I use it in the daytime. Resident #3 described wearing a brief at night due to their prosthesis being removed and it being too hard for the staff to assist with transfers to the bathroom. When asked about the ability to reach the call light if a fall occurred in the bathroom the Resident stated, It would take some time for me to get over there. My string broke about 2 or 3 months ago and I told the maintenance man. I still don't have one. 5. On 2/12/2024 at 3:35 PM, a Maintenance Director was asked how he was made aware of maintenance issues in the facility. He reported that requests for maintenance forms were at each nurses' station. The Maintenance Director was asked if a resident could reach the call light button if they were to fall. He stated, I think some of them could, but not all of them. Some of them would have to have a string. 6. On 2/13/2024 at approximately 1:49 PM, CNA #5 was asked residents could reach their call light in their bathroom if it didn't have a pull string. CNA #5 stated, I think it would be hard. I mean they really need a string. 7. On 2/14/2024 at approximately 11:30 AM, the Administrator was asked if a resident could reach the call light if they were to fall in their bathroom if the call light device did not have a string which extended down the wall. The Administrator stated, I bet I could. 8. On 2/16/2024 at 8:30 AM, the Assistant Administrator (AA) was asked if the facility had a policy concerning call lights. AA reported that he would ask the Administrator upon their return. No policy was available. 49596

Based on observation, record review, and interview, the facility failed to accurately assess the Minimum Data Set [MDS] accurately reflected on Section J1800, any falls since Admission/Entry or Reentry or Prior Assessment, a history of falls affecting 1 sampled (Resident #68) of 4 residents with falls on 2A. The facility failed to update the Minimum Data Set [MDS] with a discharge with anticipation to return in a timely manner for 1 (Resident #32) of 46 residents discharged in the last 120 days. The findings are: 1. Resident #68 with a diagnosis of ALZHEIMER ' S DISEASE, Dementia, CHRONIC OBSTRUCTIVE PULMONARY DISEASE and OBSTRUCTIVE AND REFLUX UROPATHY. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 07/21/2023 shows a Brief Interview for Mental Status (BIMS) of 99 (99 means unable to complete the interview). Resident #68 required extensive one person assistance for bed mobility, transfers dressing, eating, toileting and personal hygiene. a. A Care Plan (Revised, 01/05/2024) for Resident #68 documented, .The resident is High risk for falls r/t past medical history of falls, multiple dx noted in chart .1/19/23 Actual fall without injury .01/20/23 Actual fall without injury .01/20/23 Actual fall without injury .01/29/23 Actual fall without injury .02/17/23 Actual fall without injury . 02/18/23- Actual fall without injury .3/3/23- Actual fall without injury .3/10/23- Actual fall without injury .3/17/23- Actual fall with right femur fracture .08/14/23 - Actual fall without injury .09/12/23 Actual fall with injury .12/2/23: actual fall with no injury . b. On 02/14/2024 at 09:06 PM, The Surveyor reviewed the 04/20/2023, 07/21/2023, and 10/21/2023 Quarterly Minimum Data Set [MDS] and Section J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent is answered 0 (0 means no falls). c. 02/15/2024 10:09 AM, the Surveyor asked the MDS Coordinator to check section J1800, on the Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 10/21/2023 and see if Resident #68 had been coded for falls. The MDS Coordinator said, I did not code it right. The Surveyor asked what she meant by saying it was not coded right and the MDS Coordinator said it meant she answered 0 no falls. The MDS nurse was asked why it was important to code correctly to the MDS, and if miscoding could affect resident care. The MDS nurse said it is important for accuracy but did not affect care because resident #68's falls were in the care plan anyway. d. 02/15/2024 10:15 AM, the Surveyor asked the Administrator if staff were expected to chart accurately to the MDS, and she yes, because we get accurate information. The Surveyor asked if coding incorrectly to the MDS could affect resident care and the Administrator said that it can affect resident care when MDS information is not accurate. The Surveyor asked for an MDS policy and the Administrator said they use the Resident Assessment Instrument [RAI] manual and would bring section J1800 to the surveyor. e. On 02/15/2024 10:30 AM, the Nursing Consultant provided section J1800 of the Resident Assessment Instrument [RAI] manual titled J1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent documenting, . Planning for Care identification of residents who are at high risk of falling is a top priority for care planning. A previous fall is the most important predictor of risk for future falls .A fall should stimulate evaluation of the resident's need for rehabilitation, ambulation aids, modification of the physical environment, or additional monitoring . Steps for Assessment .2. If this is not the first assessment/entry or reentry (A0310E=1), the review period is from the day after the ARD of the last MDS assessment to the ARD of the current assessment. 3. Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment. 4. Review nursing home incident reports, fall logs and the medical record (physician, nursing, therapy, and nursing assistant notes). 5. Ask the resident and family about falls during the look-back period. Resident and family reports of falls should be captured here whether or not these incidents are documented in the medical record . Code 1, yes: If the resident has fallen since the last assessment. Continue to Number of Falls Since Admission/Entry or Prior Assessment (OBRA or Schedule PPS) . 2. Resident #32 with a diagnosis of Metabolic encephalopathy, CVA and chronic kidney disease. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 9/26/2023 a Brief Interview of Mental Status score of 03( 0-3 indicates severe cognitive impairment). Per closed record review MDS 120 days overdue. The Surveyor reviewed the MDS records and Nursing Notes and did not find discharge information. a. On 02/15/2024 9:15 AM, during interview LPN #3 said Resident #32 ' s skin beginning to mottle. If she had been with Hospice, we wouldn't have sent her to the hospital. She was very sick. LPN #3 referred to a nursing progress note she had written on 12/1/2023 describing the Resident's condition. She also described how the e-interact assessment on 12/2/2023 was never finished. add. b. On 02/15/2024 at 02:20 PM, the Surveyor asked the MDS coordinator concerning Resident #32 transfer on 12/3/2024. She stated she does not remember her she doesn't believe she was working with her at that time. She did look up Residents in electronic health record to answer questions. The surveyor asked, What is MDS process when someone is transferred or discharged ? MDS replied Well, if they go to the emergency room (ER) we do a discharge with anticipated return form. The surveyor asked, Was that done? MDS stated No it was not done. The surveyor asked, If they do not return what is the process?. MDS stated, If it's before midnight we do a discharge not anticipating a return form, but if it's after midnight we don't, we don't need to do anything. c. 02/16/2024 at 09:41 AM, Surveyor requested RAI policy with a discharge anticipating the return Nurse consultant provided the copy. d. On 02/16/2024 at 09:41 AM, the Nurse Consultant provided a policy titled Death in Facility Tracking Record OBRA Discharge Assessments Documenting, .10 OBRA Discharge Assessment-Return Anticipated. Must be completed when the resident is discharged from the facility and the resident is expected to return to the facility within 30 days. Must be completed within 14 days after the discharge date + 14 calendar days .

49596 Based on observation, record review and interview, the facility failed to ensure the environment was free of accident hazards by making sure lift pads or shower slings were free of fraying, loose threads, and missing trim to prevent accidents. This failed practice had the potential to affect 1 (Resident #249) of 4 residents on 2 A requiring shower sling assistance, and to ensure an accident/hazard free environment was provided for 1 Resident (#10) resident in the case mix. This failed practice had the potential to affect 7 ambulatory residents who resided on hall 1-D. The findings are: 1. Resident #249 had diagnoses of Cerebral palsy, Cerebrovascular disease, and Bladder disorder. The Medicare 5 Day Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 02/04/2024 suggests a Brief Interview for Mental Status [BIMS] score of 15 (13-15 indicates cognitively intact). Resident #249 requires maximal assistance for eating and dressing, dependent for self-care, bathing, indoor mobility, and functional cognition. Resident #249 requires a wheelchair and mechanical lift. a. A Care Plan documented, .The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t [related to] disease process functional quadriplegia (Revised, 02/12/2024) .TRANSFER: The resident requires Mechanical Lift with x2 staff assistance for transfers . b. On 02/12/2024 at 12:20 PM, the Surveyor observed a mesh shower sling in Resident #249's closet and inspected the trim and found loose threads, and missing border trim. c. On 02/12/24 at 12:28 PM, the Surveyor asked LPN #2 to accompany her to room [ROOM NUMBER] A 212-A. Licensed Practical Nurse (LPN) #2 was asked to look at the lift pad in the closet and to identify any concerns. LPN #2 identified the lift pad as being mesh, and one that we use in the shower. LPN #2 said the lift pad is worn and needs to be replaced. The Surveyor asked what the process was for replacing and laundering lift pads. LPN #2 said the Certified Nursing Assistants (CNA)'s should tell nursing when they find a worn lift pad, and the Director of Nursing (DON) would need to be told so that a new lift pad could be ordered to replace the worn pad. LPN #2 said the resident could use the worn pad until a new one came in to replace it, and they are laundered when soiled. The Surveyor asked if there was a procedure for removing worn lift pads from laundry services and LPN #2 said she did not know. d. On 02/15/2024 at 10:45 AM, the Surveyor required a lift policy on shower slings. The Administrator was asked for the process the facility utilized for assessing the shower sling or lift pad. The Administrator reported that the CNAs should inspect the pad before use, and it should be inspected when laundered as well. Laundry staff are not healthcare trained, so she relies on the CNAs to let the nurses know and it will be removed. Residents that need a lift get one shower sling, and 2 lift pads. The Administrator agreed that slings and lift pads with loose strings, missing trim and fraying should be removed for resident safety. e. On 02/14/2023 at 12:01 PM, The Administrator provided a policy titled Invacare Slings documentation did not apply. 2. Resident #10 has Diagnoses: EDEMA, CHRONIC KIDNEY DISEASE. On the Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of January 26, 2024, the resident received a score of 13 (Cognition is intact) on the brief interview for mental status (BIMS). a. On 2/12/24 at 12:02 PM, the Surveyor noted a bottle of rubbing alcohol sitting on the floor beside Resident #10 ' s room. When asked if she used the rubbing alcohol Resident #10 stated, Yes, I put it on my legs and then I put the Vaseline on my legs to keep them well. b. On 2/12/2024 at 12:05 PM, the Surveyor interviewed Licensed Practical Nurse (LPN) #1 and asked if a resident could keep rubbing alcohol at their bedside or beside their chair, LPN #1 stated No, it is not permissible. They can ingest it. LPN #1 was informed of the rubbing alcohol at Resident #10 ' s bedside and immediately went and removed the bottle, stating We have to watch her because she has a lot of family and friends who will bring her things. c. On 02/15/2024 at 02:00 PM, the Administrator was asked what is your policy for residents who have rubbing alcohol in the room. The Administrator said If they have it, they have it put up in their closets. If we see it, we take it out of their room. If we are aware of it, we would ask the doctor if they could have it and get it on their Medication Administration Record MAR. The Surveyor asked, what is your policy for family and friends bringing rubbing alcohol to their resident? The Administrator stated We asked them not to bring it. The Surveyor asked, what could be a potential negative outcome to a resident? The Administrator stated, Some demented resident could drink it, spill it, get it in their eyes and they could get sick. d. On 02/15/2023 at 2:57 PM, the Safety Data Sheet provided by the Administrator documented, Danger! Flammable liquid. May form explosive peroxides. May cause respiratory and digestive tract irritation. Causes eye irritation. May cause skin irritation. May cause central nervous system depression. Target Organs: Eyes, skin, respiratory system, central nervous system. Potential Health Effects . Chronic: Prolonged or repeated skin contact may cause defatting and dermatitis. May cause allergic skin reaction in some individuals .Section 4 .Section 16.

Based on observations, interviews and record reviews, the facility failed to ensure that residents received adequate hydration. This failed practice had the potential to cause dehydration (lack of total body water) and hypernatremia (occur when there is a too much water loss or too much sodium gain in the body). This failed practice affected 2 Residents (#18, #75) of 4 sampled Residents on 2 B who were unable to get up and get water independently. The findings are: 1. Resident #18 had diagnoses of Dementia, Hyperosmolality (dehydration) and Hypernatremia (increased sodium). Resident #18 was taking Furosemide (a medication used to remove water from the body) one time a day. A progress noted dated 1/25/2024 at 10:34 documented that an order was received to provide resident with 8 ounces of water every 4 hours during the day due to hyperosmolality and hypernatremia. According to a Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/11/2024 a Brief Interview of Mental Status (BIMS) score of 99 was entered due to the Resident being unable to complete the interview. According to their care plan Resident #18 had dehydration or potential fluid deficit related to the use of diuretic daily, Dementia, and cognitive communication deficit. One of the interventions in place on the care plan stated, encourage the resident to drink fluids of choice frequently and with each care interaction. a. On 02/12/2024 at 10:22 AM, the Surveyor observed Resident #18 lying in bed. The water pitcher was not within reach of Resident #18. b. On 02/14/2024 at 10:50 AM, the Surveyor observed Resident #18 lying in bed. The water pitcher was on the bed side of table out of the reach of Resident #18. c. On 02/14/2024 at 12:45 PM, the Surveyor observed Resident #18 lying in bed. The water pitcher was on bed side table out of reach of Resident #18. d. On 02/14/2024 at 12:50 PM, the Surveyor asked Certified Nursing Assistant (CNA) #3 Can Resident #18 get their own water? CNA #3 stated [Resident #18] can when [the resident] wants to. The Surveyor asked CNA #3, is Resident #18 able to reach their water pitcher now? CNA #3 stated No [the resident] is not able to. e. On 02/14/2024 at 01:15 PM, the Administrator stated, We do not have a hydration policy we follow standard procedures. 2. Resident #75 had a diagnosis of Poly osteoarthritis, Malignant neoplasm of lungs and was on hospice. According to a Significant Change MDS with ARD of 1/9/24 Resident #75 score 07 (0-7 indicates severely impaired cognition) on a BIMS. According to the care plan Resident #75 had a history of Urinary tract infection and one of the interventions stated, encourage adequate fluid intake .deficit related to the use of diuretic daily, Dementia, cognitive communication deficit .encourage the resident to drink fluids of choice frequently and with each care interaction. a. On 02/14/2024 at 10:50 AM, the Surveyor observed Resident #75 lying in bed with a water pitcher on the bedside table outside of the reach of the Resident. b. On 02/14/24 at 12:45 PM, the Surveyor observed Resident #75 lying in bed with eyes closed. The water pitcher was on the bedside table out of reach of the Resident. c. On 02/14/2024 at 12:52 PM, the Surveyor asked Certified Nursing Assistant (CNA) #3 can Resident #75 get her own water? CNA #3 stated, If she raises her head she can. The Surveyor asked Resident #75, can we raise the head of your bed? Resident 75 stated sure. CNA #3 raised the head of bed then stated, No she cannot reach her water. d. On 02/14/2024 at 12:55 PM, the Surveyor asked LPN #2, why is it important for Resident to have their water pitcher near them? LPN #2 stated, So they can get them a drink and hydration the only time we don't keep at the bedside is if there are on fluid restriction or NPO (nothing by mouth). The Surveyor asked LPN #2, is Resident 75 NPO or on fluid restriction? LPN stated No. e. On 02/14/2024 at 01:00 PM, the Surveyor asked the Administrator, why is it important to have water near the Resident? Administrator stated, Keep them hydrated.

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for respiratory complications for 2 (Resident #33, and #73) of 5 sampled residents. The facility failed to store oxygen tubing appropriately when not in use to prevent possible respiratory complications for 1(Resident #27) of 5 sampled residents. This failed practice had the potential to affect 15 residents that had physicians' orders for Oxygen as documented on a list provided by the Director of Nursing on 02/15/24 at 3:50 PM. The findings are: 1. Resident #33 had diagnoses of Pulmonary fibrosis, Chronic obstructive pulmonary disease, and Heart failure. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/24 documented that the resident scored 7 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS) and received oxygen therapy. a. The physician's order dated 8/3/23 documented, .O2 (Oxygen) at 3L/M(Liters per Minute) via NC (Nasal Cannula) continuously. May remove for ADLs (Activities of Daily Living). every shift related to Chronic obstructive pulmonary disease, unspecified . b. The care plan with a revision date of 1/11/24 documented, .Focus: (Resident #33) has oxygen therapy r/t (related to) emphysema, Pulmonary fibrosis, COPD (Chronic Obstructive Pulmonary Disease), and Mucopurulent chronic bronchitis .Goal: Resident will have no s/sx (signs or symptoms) of poor oxygen absorption .Interventions/Tasks: . OXYGEN SETTINGS: O2 (Oxygen at) 3 L/M (liters per minute) via nasal prongs . c. The care plan with a revision date of 1/11/23 documented, .Focus: Resident has Asthma r/t emphysema, Pulmonary fibrosis, COPD, and chronic bronchitis .Goal: (Resident #33) will remain free of complications of Asthma .Interventions/Tasks: .o Give nebulizer treatments and oxygen therapy as ordered. OXYGEN SETTINGS: O2 via nasal prongs @ 3LPM . d. On 02/12/2024 at 10:21 AM, Resident #33 was sitting up in recliner with oxygen in use between 2.0 and 2.5 liters per nasal cannula. e. On 02/12/2024 at 02:50 PM, Resident #33 was sitting up in recliner with oxygen in use between 2.0 to 2.5 liters per nasal cannula. Resident #33 said she uses her oxygen all the time. Also said she sleeps in her recliner because it is easier to breathe that way. f. On 02/13/2024 at 08:56 AM, Resident #33 was sitting up in recliner with eyes closed. Oxygen was in use between 2.0 and 2.5 liters per nasal cannula. g. On 02/14/2024 at 10:16 AM, Resident #33 was sitting up in recliner with eyes closed. Oxygen was in use between 2.0 and 2.5 liters per nasal cannula. h. On 02/15/2024 at 08:20 AM, Resident #33 was sitting up in recliner watching television. Oxygen was in use at 2.0 and 2.5 liters per nasal cannula. i. On 2/15/2023 at 10:10 am, the Surveyor asked Licensed Practical Nurse (LPN) #4 to accompany her to Resident #33's room. Upon entering the room LPN #4 was asked, What is (Resident #33's) oxygen flow rate set at? LPN #4 looked at Resident #33 oxygen concentrator and flow rate and stated, It is set at 2.5 liters. LPN #4 was asked, What should (Resident #33's) Oxygen flow rate be set at? LPN #4 stated, It should be set at 3 liters. LPN #4 was asked, Who is responsible for ensuring oxygen is set at the correct rate? LPN #4 stated, The Nurse. LPN #4 was asked, How often should the oxygen flow rate be checked? LPN #4 stated, I usually check the rate by noon, but I check it at least twice a shift. LPN #4 was asked, Does Resident #33 alter her oxygen flow rate? LPN #4 stated, no. She would not but her family might. LPN #4 was asked, Should doctor's orders for oxygen flow rate be followed? LPN #4 stated, yes. LPN #4 was asked, why is it important that the oxygen is set at the correct flow rate? It is important because it helps improve her breathing. LPN #4 was asked, If a resident is altering their oxygen flow rate should the doctor be notified? LPN #4 stated, yes. 2. Resident #73 had diagnoses of COPD Acute on chronic respiratory failure with hypoxia, and Heart failure. The Quarterly MDS with an ARD of 1/4/24 documented that the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and used oxygen therapy. a. A physician's order dated 11/8/23 documented, .O2 (Oxygen) at 3 LPM via nasal cannula for SOB (Shortness of Breath) and / or pulse ox (Oximetry) less than 90% every shift related to Acute and chronic respiratory failure with hypoxia and Chronic obstructive pulmonary disease with (acute) exacerbation. b. The care plan with a revision date of 12/29/23 documented, .Focus: (Resident #73) has oxygen therapy r/t(related to) COPD . Goal: o (Resident #73) will have no s/sx (signs or symptoms) of poor oxygen absorption .Interventions/Tasks: . OXYGEN SETTINGS: O2 via nasal prongs @ 3LPM c. On 02/12/2024 at 10:37 AM, Resident #73 was sitting up in bed watching television and knitting. Oxygen was in use at 2 liters per nasal cannula. d. On 02/13/2024 at 08:59 AM, Resident #73 was lying in bed with eyes closed. Oxygen was in use at 2 liters per nasal cannula. e. On 02/13/2024 at 10:33 AM, Resident #73 was sitting up in bed. Oxygen was in use at 2 liters per nasal cannula. f. On 02/14/2024 at 01:00 PM, Resident #73 was sitting up in wheelchair in room with oxygen in use at 2 liters per nasal cannula. g. On 2/14/2024 at 1:45 PM, LPN #1 was asked by the Surveyor to accompany her to Resident #73's room. Upon entering room LPN #1 was asked, What flow rate is (Resident #73's) oxygen set at? LPN #1 looked at Resident #73 oxygen concentrator and the flow rate and stated, It is set at 2 liters. The Surveyor and LPN #1 then exited the room and LPN #1 was asked, What should (Resident #73's) oxygen flow rate be set at? LPN #1 stated, I will have to look at the record to be sure. LPN #1 looked at Resident #73's electronic record and stated, It should be set at 3 liters. I will get that changed right now. LPN #1 was asked, Who is responsible for ensuring the oxygen is set at the correct flow rate? LPN #1 stated, It would be the nurse. LPN #1 was asked, How often should the oxygen flow rate be checked? LPN #1 stated, Once a shift. LPN #1 was asked, Does (Resident #73) alter her oxygen flow rate herself? LPN #1 stated, Yes. LPN #1 was asked, Is it care planned that the Resident alters her oxygen flow rate? LPN #1 stated, I am not sure. LPN #1 looked at Resident #73 electronic record and stated, It is not care planned that she alters the rate. LPN #1 was asked, Should doctors order for oxygen flow rate be followed? LPN #1 stated, Yes, the orders should always be followed. LPN #1 was asked, Why is it important that the doctor's orders for oxygen flow rate are followed? LPN #1 stated, If the resident has COPD the flow rate should not go over a certain amount. Oxygen is a medication and as nurses we should not alter without a doctor's order. LPN #1 was asked, If a resident is altering the flow rate of their oxygen should the doctor be notified? LPN #1 stated, Yes, the doctor should be notified. LPN #1 was asked, Has Resident #73's doctor been notified that she alters her oxygen flow rate? LPN #1 stated, Not that I know of. I would have to go through the progress notes to see if he has been notified. h. On 12/14/2024 at 2:00 PM, the Surveyor reviewed Resident #73's nursing progress notes for 1/15/24 to 2/14/24 and there was no documentation that the doctor had been notified regarding the resident altering her oxygen flow rate. i. On 2/15/2024 at 2:40 PM, the Surveyor asked the Director of Nursing (DON), Who is responsible for ensuring that a resident's oxygen is set at the correct flow rate? The DON stated, The nurses are responsible. The DON was asked, How often should the nurse check to ensure the oxygen is at the correct flow rate? The DON stated, Every time that they go into the residents room. The DON was asked, Should doctor's orders for oxygen flow rate be followed? The DON stated, Yes. The DON was asked, Why is it important that the oxygen is set at the rate ordered by the doctor? The DON stated, Because the doctor has assessed the resident, they know what flow rate is safe for the resident. The DON was asked, Should the doctor be notified if a resident is adjusting the flow rate of their oxygen? The DON stated, Yes, the nurses should call the doctor and let him know. I was not aware that (Resident #73) changed the flow rate. j. On 2/15/2024 at 3:45 PM, the policy title Oxygen Safety provided by the Administrator documented, .Policy: The facility will properly handle oxygen and other flammable gases. Procedure: 1. Oxygen therapy is administered to the resident only upon the written order of a licensed physician . 3. Resident #27 had a diagnosis of acute respiratory failure with Hypoxia and COPD. Resident 27 has an order for oxygen continuous at 3 liters via nasal cannula. According to the order oxygen tubing was to be changed every Sunday night on 11-7 shift and dated. Quarterly MDS with ARD of 11/14/23 documented that Resident scored 15 (13-15 cognitively intact) on a BIM and used oxygen therapy while a Resident. a. On 02/12/2024 at 10:56 AM, the Surveyor observed Resident #27 sitting on the side of bed with feet on the floor. Resident #27 had oxygen in place via nasal cannula from concentrator at 3 liters. There was a wheelchair next to Resident's bed with a portable oxygen tank attached and tubing bundled up in the seat of the wheelchair uncovered. b. On 02/12/2024 at 10:56 AM, Resident #27 said she uses the chair and oxygen when she travels with family and goes to the dining room. c. On 02/13/2024 at 10:46 AM, the Surveyor observed Resident #27 was in the restroom with oxygen noted in place via nasal cannula from to the concentrator. There was oxygen tubing bundle in seat of wheelchair uncovered. d. On 02/14/2024 at 10:41 AM, the Surveyor observed Resident #27 sitting on side of bed with Surveyor observed oxygen tubing bundled up in the wheelchair uncovered. e. On 02/14/2024 at 11:56 AM, Surveyor observed Resident #27 in wheelchair being pushed by family with oxygen being delivered via nasal cannula from portable oxygen tank attached to wheelchair. f. On 02/14/2024 at 11:56 AM, Surveyor asked Resident #27 is that new oxygen tubing you have on? Resident #27 stated, yes ma'am. Surveyor asked Resident #27 was it changed today? Resident #27 stated, No, not today. Surveyor asked Resident #27 when was the tubing changed? Resident #27 stated Christmas when I was last in the chair. g. On 02/14/2024 at 12:55 PM, the Surveyor asked LPN #2, what is the proper way to store oxygen that is not in use? LPN #2 stated In a plastic with the date that the tubing was changed. h. On 02/14/2024 01:00 PM, the Surveyor asked Administrator, what is the proper way to store oxygen tubing when not in use? Administrator stated, In a bag on the back of a chair. 48977

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with Respiratory/Tracheostomy Care. These failed practices had the potential to affect all 15 residents with physician ' s orders for oxygen therapy, the facility failed to prevent repeat deficiencies in transmitting the Minimum Data Set (MDS) within 14 days of the Completion Date for 1 (Resident #32) of 46 residents discharged in the last 120 days and failed to ensure residents had fluids readily available to them. The findings are: 1. A Recertification survey was conducted on 12/22/2022 at the facility. During this survey, the team identified concerns with respiratory care regarding ensure an oxygen nasal cannula tubing was stored in accordance with professional standards of practice when not in use. The team identified concerns with the facility failing to transmit discharge information to the Minimum Data Set (MDS) within 14 days of the completion date, and there were concerns with fluids being readily accessible to promote adequate hydration. 2. A review of the facility's Plan of Correction indicated: On 12/20/22, the facility was notified by the State Survey team that Discharge MDS assessments had not been transmitted per RAI (Resident Assessment Instrument) guidelines timely. On 12/22/2022, the Administrator reviewed with the MDS Coordinator the RAI Guidelines Chapter 5 and in-serviced the MDS Coordinator on the importance of timely transmittal of MDS data. Monitoring: The Director of Nursing (DON) will review weekly for 4 weeks and monthly thereafter to ensure all completed MDS assessments are transmitted within proper timeframes per RAI guidelines Chapter 5, and negative findings will be corrected at the time of discovery and reported to the Administrator at the next daily QA meeting Monday-Friday for continued education, monitoring and retraining to ensure continued compliance. The Administrator will review any negative findings at the Quarterly QA meeting for continued monitoring and training requirements. 3. A review of the facility's Plan of Correction indicated: On 12/21/2022, the facility was notified by the State Survey Team that 3 residents did not have fluids readily available to them. On 12/21/2022, the Lead Certified Nursing Assistant (CAN) and DON in-serviced all available nursing staff regarding the importance of ensuring all Resident not ordered by the Physician to be maintained NPO (nothing by mouth) had fluids readily accessible to promote adequate hydration. On 01/04/2022, the DON completed an all-staff in-service that included ensuring the Residents had fluids readily accessible to promote adequate nutrition. Monitoring: The Lead CNA will monitor to ensure that all Residents (that do not have Physician Orders for NPO) have fluids readily accessible to them 3 times a week for 4 weeks then 2 times a week for 4 weeks and weekly thereafter to ensure on-going compliance. Any negative findings will be corrected at the time of discovery and reported to the DON who will complete in-servicing and retraining as indicated. The DON will notify the Administrator at the next daily QA (Quality Assurance) meeting Monday -Friday of any negative findings for continued monitoring and training needs. The Administrator will report all negative findings to the Quarterly QA meeting with the Medical Director present to ensure on-going compliance. 4. A review of the facility's Plan of Correction, with a completion date of x/xx/2023 indicated: On 12/21/2022, the DON in-serviced all available nursing staff regarding ensuring Oxygen Nasal Cannula Tubing was stored per professional standards when not in use. On 01/04/2023, the DON held an all-staff in-service which included training ensuring oxygen Nasal Cannula Tubing was stored per professional standards when not in use. The DON and ADON will monitor all residents that require Oxygen per Physicians Orders per the Order listing report 2 times a week for 1 month and weekly thereafter to ensure oxygen Nasal Cannula Tubing was stored per professional standards when not in use: The DON will report any negative findings to the Administrator at the next daily QA meeting M-F for further training and education needs. The Administrator will report any negative findings to the quarterly QA committee with the Medical Director present to ensure on-going compliance. 5. A Recertification survey was conducted on 2/12/2024-2/16/2024. During the survey the team identified concerns with respiratory/tracheostomy care, transmitting discharge information to the Minimum Data Set (MDS) in a timely manner, ensuring fluids were readily accessible to promote adequate hydration, Cross Reference F641, F692, F695. On 02/16/2024 at 09:51 AM, the Surveyor asked the Administrator, How does the QAA Committee know when an issue arises in any department? She stated, We get together and do morning rounds, we discuss issues, or we may have complaints. 1. The Surveyor asked, How does the QAA Committee know when a deviation from performance or a negative trend is occurring? She stated, Through tracking/trending, morning meetings with data collection. 2 The Surveyor asked, How does the QAA Committee decide which issues to work on? She stated, According to what you all say a trend of two or more then we need an action plan. 3. The Surveyor asked, How long will the QAA Committee monitor an issue that it has corrected? She stated, Depends on what the issue is. Usually 6 to 12 months. 4. The Surveyor asked, Is the QAA Committee aware of repeated survey deficiencies? She stated, yes. 5. The Surveyor asked, If aware, did the Committee implement corrective action? She stated, Yes we have plans on correct monitoring, in service, training, continue monitoring, reeducating or terminations. 6. The Surveyor asked, Is the Committee monitoring to ensure corrective action has been implemented? She stated, Yes, we monitor. The surveyor asked for an example of when something similar happened. The Administrator stated, Well, sure a while back our census boomed, we went from 70 to 0 residents quickly and we started having a lot of complaints on one hall, complaints from family. We had a new certified nursing assistant we monitored to see what was happening. She was doing well but didn't have enough seasoned help. We did an acuity check and adjusted the schedule to have more help. The complaints stopped.

Based on record review and interview the facility failed to coordinate with state designated authority to ensure that resident received any care and therapy that could have been recommended and deemed essential for the highest practicable functioning for 1 (Resident #27) of 27 sampled Residents. The findings are: 1. Resident #27 had diagnoses of Bipolar disorder, Current episode depressed, mild or moderate severity. According to a Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/14/23 Resident #27 scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS). a. On 02/13/24 10:57 AM, review of records showed Resident #27 had a diagnosis of Bipolar disorder with current episode depression and was prescribed Venlafaxine 75mg. Surveyor unable to locate any documentation that a Pre-admission Screening and Resident Review (PASRR) Level I was completed. b. On 02/14/2024 at 09:05 AM, the Surveyor requested documentation of a Level I screening and Level II evaluation if Level I recommended it to be completed for Resident #27. c. On 02/14/2024 at 10:00 AM, the Administrator provided the Surveyor with documentation that stated Resident #27 was NON-PASRR from State Designated Professional Associates dated 8/23/22. d. On 02/14/2024 10:50 AM, the Surveyor requested DMS-787 form for Resident #27 from the Administrator. The Administrator voiced that Resident #27 did not receive the diagnosis bi-polar at the hospital, the Resident received the diagnosis at the facility due to her mental condition. e. On 02/14/2024 10:55 AM, the Administrator provided a 787 application dated 8/23/22 that documented Resident #27 did not have a diagnosis or history of mental illness. f. On 02/14/2024 at 11:00 AM, the Surveyor stated to the Administrator the 787 application provided documented that Resident #27 did not have a mental illness. The Administrator replied, I don't know. The Surveyor asked the Administrator who was responsible for the PASRRs. The Administrator voiced that no one person is the responsible for PASSRR but the Social and Business Office Manager (BOM) submit them. g. On 02/14/2024 at 11:05 AM, the Surveyor asked the Business Office Manager (BOM), do you complete the PASARRs applications? The BOM stated No the nurses fill them out and I submit them. The Surveyor stated to the BOM, I was provided this 787 that does not address the bipolar diagnosis for Resident #27, do you have one that does? The BOM stated, I will look to see if we do. h. On 02/14/2024 at 11:30 AM, the BOM provided the Surveyor with a 787 dated 6/2/23 that documented Resident #27 did not have a diagnosis or history of mental illness but had Bi-Polar checked. The Surveyor brought this error to the attention of the BOM who stated The nurses just use the original form and whited out what needed changed and the (Advance Practice Nurse) APN signed off on it. She just missed that box. The Surveyor asked, do you have the response to this 787? The BOM stated No. The Surveyor asked the BOM, without the response to the 787 how do you know if the Resident required a level II evaluation? The BOM stated I don't. The BOM stated All I know is I get the packet and the nurses go over. The Surveyor asked the BOM, do you have the packet? The BOM stated I do not no ma'am. i. On 02/14/2024 at 12:20 PM, the Administrator stated, As of October the regulation stated that we don't have to re-submit the 787 if the Resident has not received treatment within the last 2 years from mental hospital. The Surveyor stated to the Administrator that Resident #27 received the diagnosis before October, with a created date of 6/1/23. j. On 02/14/2024 01:00 PM, the Surveyor asked the Administrator, why is it important to follow through and get the response from the proper designated State Authority? The Administrator stated, So that we know if they need additional care. k. On 2/15/2024 at 4:30 PM, the Administrator had not provided the Surveyor with a policy on PASRR.